research article qualitative

About Journal

American Journal of Qualitative Research (AJQR)  is a quarterly peer-reviewed academic journal that publishes qualitative research articles from a number of social science disciplines such as psychology, health science, sociology, criminology, education, political science, and administrative studies. The journal is an international and interdisciplinary focus and greatly welcomes papers from all countries. The journal offers an intellectual platform for researchers, practitioners, administrators, and policymakers to contribute and promote qualitative research and analysis.

ISSN: 2576-2141

Call for Papers- American Journal of Qualitative Research

American Journal of Qualitative Research (AJQR) welcomes original research articles and book reviews for its next issue. The AJQR is a quarterly and peer-reviewed journal published in February, May, August, and November.

We are seeking submissions for a forthcoming issue published in February 2024. The paper should be written in professional English. The length of 6000-10000 words is preferred. All manuscripts should be prepared in MS Word format and submitted online: https://www.editorialpark.com/ajqr

For any further information about the journal, please visit its website: https://www.ajqr.org

Submission Deadline: November 15, 2023

Announcement 

Dear AJQR Readers, 

Due to the high volume of submissions in the American Journal of Qualitative Research , the editorial board decided to publish quarterly since 2023.

Volume 8, Issue 2

Current issue - in progress.

The COVID-19 pandemic has highlighted and exacerbated the difficult juggling act women in the U.S. have to do between parenting their children and working outside the home. The pandemic has also led to a decline in maternal mental health, particularly among mothers with young children, mothers of color, and those with previous mental health issues. The authors noted these experiences in their own lives as mothers with children and observed them in the lives of the women around them. These observations informed the design of this narrative inquiry study, in which we used semi-structured interviews to explore mothers’ shifting ideas and experiences of mothering, work, and family life during a global pandemic. We used creative analytic practice (CAP) to compose reflexive researcher conversations around the interview data that enabled us to highlight nuances in the data, show more transparently our meaning-making, make visible our researcher subjectivities, show uncertainties about aspects of data interpretation, and create a more accessible data representation.

Keywords: Mothering, COVID-19 pandemic, U.S. women, Narrative inquiry, Creative analytic practice.

The COVID-19 pandemic put France’s healthcare system under extreme tension and led to significant levels of stress among healthcare professionals in general and nurses in particular. Research has shown how these elements affected nurses’ physical and psychological health and manifested as insomnia, anxiety, and depressive syndromes. The present qualitative study aimed to explore the lived experiences of France’s nurses as a function of their level of exposure to the virus and whether they worked in the hospital sector or practiced privately in the community during the pandemic’s first wave. It also sought to describe the resources nurses used to maintain their overall health. We administered 19 qualitative interviews to 19 nurses in the autumn of 2021. The present study revealed that nurses were subjected to significant stress during the pandemic. Our data analysis enabled us to draw out three principal themes: 1) Being on the edge in stormy period ; 2) Personal impact on several levels and 3) Floating together and learning. There were no significant differences between the groups that were subjected to different levels of exposure to COVID-19. All the groups were affected by the pandemic that struck a healthcare system that was already systematically fragile. Nurses were severely tested by the COVID-19 pandemic, but their consciousness of the importance of their role grew, despite questioning what meaning there was to their profession, perhaps even to their lives . The trauma still felt fresh 18 months later, during the interviews, and this cannot be ignored in future healthcare policymaking .

Keywords: COVID-19, nurses, salutogenesis, stressors, health resources.

Annual mammography screening is recommended by the US Preventive Services Task Force (USPSTF) and American Cancer Society (ACS) to reduce mortality through early detection of breast cancer. In rural Appalachia, rates of later-stage breast cancer incidence and mortality are higher than national averages. We explored the ways that providers and staff at breast cancer screening facilities employed novel approaches to overcome patient- and facility-level barriers to access to breast cancer screening in the Appalachian region. We conducted 23 semi-structured interviews with 28 clinical providers and staff of breast health facilities in Appalachia. Themes reflect how limiting features of breast screening facilities influenced access to care; the way patient-level barriers presented challenges to access to breast screening; and that external and regulatory forces presented obstacles to access to care. In addition, the unique geographical and geographical attributes of the Appalachian region shaped access and adherence to mammography screening recommendations. Thematic findings highlight that facilities implemented patient-centered strategies to overcome access-related barriers. Results may inform the ways breast cancer screening facilities address suboptimal access to breast health screening. They may also inform future resource allocations to enable facilities to reach breast cancer screening performance goals.

Keywords: rural health, breast cancer, preventive health care, women’s health.

Paternal parenting affects child development; hence, the father’s absence has a deleterious effect on the male child. The literature on parenting shows limited focus on how parenting impacts children by gender. This qualitative hermeneutic phenomenological study investigated the key question, “How does a father’s absence during childhood influence a man’s subsequent parenting of his son(s)?” An integrated theoretical framework was used to guide the study: Parenting Style Theory, Social-Cognitive Theory, and Bioecological Systems Theory. Nine Trinidadian males aged 20 to 35 years who were parenting sons were recruited to participate using snowball sampling. Data on men’s adverse childhood experiences were gathered using semi-structured interviews. Content and thematic analyses were done using DELVE software. Key findings include the influence of stereotypical cultural constructs, the church’s critical role in addressing childhood trauma, the transmission of father absence across generations, and the relationship between neurodevelopment and adverse childhood experiences. Implications of these findings will benefit child and adolescent advocacy, inform policymaking, aid professional intervention in mental health and education, and strengthen familial systems and ecclesiastical contexts. Future research should explore the lived experiences of men who crave emotional connection with their sons yet struggle with the stereotypical cultural perception of manhood.

Keywords: father absence, brain development, childhood trauma, intergenerational, the transmission of behavior.

The purpose of this qualitative transcendental phenomenological study was to understand the essence of the shared lived experiences of undergraduate college students with anxiety disorders at two universities in the Southeastern United States. Ellis’s cognitive theory, rational emotive behavior therapy, guided the study which took place at a mid-sized, public nonsectarian university and a small, private liberal arts college. The central research question elicited rich data regarding the shared lived experiences of the study participants. The four research sub-questions address participants’ perceptions regarding the impact of their disorders on their lifestyles and academic performance. A purposeful criterion sample was used to select the participants who completed a questionnaire, open-ended individual interviews, a single focus group interview, and participant journals. Phenomenological reduction was used to create a composite integration of meaning and the essence of the lived experience of the participants. Data results identified five themes: (a) social fears, (b) stressor issues, (c) generational issues, (d) academic performance barriers, and (e) institutional education and accommodation preferences.

Keywords: Alexithymia, anxiety, disorder, qualitative, stressors

School shootings are traumatic events that can lead to anxiety, depression, and post-traumatic stress disorder among students who experience these events. It is important to find effective strategies to help students cope with their return to school, as well as their anxiety and stress levels while on campus. There exists a gap in the literature on the effects of therapy dogs on students who have witnessed a school shooting. This current study used a retrospective mixed-methods survey that was sent to recent graduates of Marjory Stoneman Douglas High School (located in Parkland, Florida) who witnessed the February 2018 shooting. Data were collected to assess how the therapy dogs affected students' willingness to return to school and their stress/anxiety levels while on campus. Identified themes indicated that the therapy dogs helped with anxiety levels, stress levels, and overall moods of Marjory Stoneman Douglas High School students. These findings provide important implications for community leaders and school administrators who want to promote healing and well-being in a community that has experienced violence.

Keywords: Therapy dog, school shooting, community violence.

Identifying the relation between the processes of programming and foreign language writing may lead to new directions for programming language and natural language focused instructional design. The present qualitative case study supported by quantitative data investigated foreign language writing experiences of computer engineering students taking an object-oriented programming course. Forty-five sophomores learning programming and academic English simultaneously in a foundation university in Ankara, Turkey, were selected purposefully for the case study. There were two data sources (students’ opinions and documents) and three data collection tools (a semi-structured interview, a short diary, and a composition. In terms of the findings of the research, four themes were obtained; however, only the use of metacognitive strategies will be explained in detail due to the length of the study. Participants stated that they feel the positive effects of programming experience on the use of self-evaluation strategy and that there are similarities and differences between the processes of programming and foreign language writing. Participants’ views on the effect of programming on foreign language writing did not differ according to their writing and programming performance scores. Participants stated that programming experience may have an effect on the use of metacognitive language learning strategies in the writing process. Upon analyzing participants’ comments, it is understood that programming experience does not hinder the use of metacognitive strategies but has a role in supporting and reinforcing their use. It is suggested that multiple case studies be done for similar views on the effects of programming and that each finding be proven by quantitative studies.

Keywords: programming, foreign language writing, metacognitive strategies.

The significance of participatory decision-making in educational institutions is widely acknowledged as essential in school management and administration. This study aimed to determine how involved teachers are in making decisions in their schools and what role they think they play in shaping different parts of school policies and procedures. It also looked at their perspectives on how decisions made by others are carried out in schools. Semi-structured interviews with 10 secondary school teachers focused on teachers' role in decision-making related to their routine school tasks, strategic decision-making, participatory role in making school decisions, and their willingness to participate in decision-making. This study showed that teachers' low participation is attributed to their shared desire to be involved in school management and administration-related decisions. Teachers expressed that participatory school-based decision-making can promote collaboration and collectivism among the school staff, and it plays a significant role in shaping their work satisfaction and motivation. By gaining insights into teachers' perspectives, this study aims to contribute to the broader understanding of participatory school decision-making in the Rwandan secondary education system and communicate potential improvements for fostering a more collaborative and inclusive educational environment.

Keywords: teachers’ perceptions, qualitative research, decision-making, secondary schools.

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• Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

• P. Gill 1 &
• J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

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Introduction.

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

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Qualitative Study

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

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

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

Examples of Qualitative Research Approaches

Ethnography

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

Grounded Theory

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

Phenomenology

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

Narrative Research

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

Research Paradigm

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

Positivist vs Postpositivist

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

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

Constructivist

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

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

Data Sampling

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

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

Criterion sampling-selection based on pre-identified factors.

Convenience sampling- selection based on availability.

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

Extreme case sampling- targeted selection of rare cases.

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

Data Collection and Analysis

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

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

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

Dissemination

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

Examples of Application

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

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

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

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

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

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

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

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

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

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

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

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• Published: 14 June 2021

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice

• Jannine van Schothorst–van Roekel 1 ,
• Anne Marie J.W.M. Weggelaar-Jansen 1 ,
• Carina C.G.J.M. Hilders 1 ,
• Antoinette A. De Bont 1 &
• Iris Wallenburg 1  

BMC Nursing volume  20 , Article number:  97 ( 2021 ) Cite this article

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Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.

A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.

Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.

Conclusions

Conducting small-change experiments, anchored by action and appraisal rather than by design , clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

Peer Review reports

The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [ 1 , 2 ]. Nurses play an important role in facing these contemporary challenges [ 3 , 4 ]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [ 5 , 6 ]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [ 7 , 8 ]. This issue has sparked renewed interest in nursing role development [ 9 , 10 , 11 ]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [ 12 , 9 ].

New nursing roles usually arise through task specialization [ 13 , 14 ] and the development of advanced nursing roles [ 15 , 16 ]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [ 17 , 18 ]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [ 19 , 20 ]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [ 21 , 22 , 23 ].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [ 24 , 25 ] but also in Australia [ 26 , 27 ], Singapore [ 20 ] and the United States of America [ 28 , 29 ]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [ 30 ]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [ 31 ].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [ 32 ]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [ 33 , 34 , 35 , 36 ], based on nurses’ thorough knowledge of professional practices [ 37 ] and leadership role [ 38 , 39 , 40 ].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [ 41 ]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [ 42 , 43 , 44 ]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [ 31 ]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.

The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.

We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [ 45 , 46 ]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [ 47 , 48 ]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table  1 . The project team, comprising nursing policy staff, coaches and HR staff ( N  = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers ( N  = 4), and the CEO ( N  = 1) in the meetings.

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [ 45 ] (see Table  2 ).

Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [ 49 , 50 ], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [ 46 ].

Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams ( n  = 2); (2) bi-monthly meetings ( n  = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed ( n  = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice ( n  = 15). Minutes and detailed notes also produced thick descriptions [ 51 ]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [ 52 ]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO ( n  = 1), middle managers ( n  = 4), VNs ( n  = 6), BNs ( n  = 9, including four senior nurses), paramedics ( n  = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards ( N  = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Data analysis

Data collection and inductive thematic analysis took place iteratively [ 45 , 53 ]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file ). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [ 54 ]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.

Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [ 48 ]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [ 55 ]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [ 56 , 57 ]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [ 54 ]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [ 48 ]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.

Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [ 32 ]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is , is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [ 58 ] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [ 59 ]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [ 49 ]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [ 1 , 60 ]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [ 61 ]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [ 62 ] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [ 63 ], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [ 64 ]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [ 65 ]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [ 1 ], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [ 66 ] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.

This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [ 49 ]. Usually, invisible work gets no formal recognition, for example in policy documents [ 55 ], whereas it is crucial in daily routines and organizational structures [ 49 , 60 ]. Second, experimenting triggers an accumulation of small changes [ 33 , 35 ] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [ 37 ]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [ 43 ] resulting in a subordinate position, power inequity and lack of autonomy [ 44 ]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [ 12 ] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [ 9 , 10 , 11 ] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [ 41 ] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [ 42 ] and Abbott [ 67 ] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [ 37 , 39 , 40 ]. Adding to Mannix et al. [ 38 ], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [ 64 , 65 ]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [ 34 , 68 ] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.

Limitations

Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.

This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design , the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

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The authors would like to thank all participants for their contribution to this study.

The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

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van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20 , 97 (2021). https://doi.org/10.1186/s12912-021-00613-3

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Reflexivity in pharmacy practice qualitative research: systematic review of twelve peer-reviewed journals

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J Tomlinson, K Medlinskiene, Reflexivity in pharmacy practice qualitative research: systematic review of twelve peer-reviewed journals, International Journal of Pharmacy Practice , Volume 32, Issue Supplement_1, April 2024, Pages i5–i6, https://doi.org/10.1093/ijpp/riae013.007

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Reflexivity is named as an important component for establishing trustworthiness and authenticity within qualitative research. Depending on the philosophical stance of the researcher, subjectivity is often intertwined with qualitative research, thus engagement in reflexivity accounts for how this subjectivity shapes the study and aids to increase its rigor. Walsh’s typology [1] proposed personal, interpersonal, methodological, and contextual dimensions of reflexivity, which are overlapping and interacting, and was endorsed by the International Association for Medical Education (AMEE). [2] As pharmacy professionals conducting research, we bring many aspects (personal and professional experiences, beliefs, values) that can help us develop deeper and richer insights into our work; if not considered through reflexivity, this may have unrealised impacts which can bring the findings under scrutiny.

This systematic review aimed to explore reflexivity reporting, type, and strategies in qualitative studies published in peer-reviewed pharmacy journals.

Two reviewers screened twelve pharmacy related peer-reviewed journals from inception to 1 st August 2023 for qualitative studies; these were identified as the ‘top’ pharmacy practice journals in JANE (Journal/Author Name Estimator). Then, studies were independently reviewed against inclusion criteria. Any disagreements were discussed to reach a consensus. Qualitative studies discussing reflexivity, having dedicated reflexivity sections in the manuscript, or providing quality checklists with reflexivity were included. Quantitative, mixed methods, and educational research studies were excluded. Two reviewers completed data extraction: reflexivity methods, where discussed in the paper and to what extent, and type of reflexivity as per Walsh’s typology to determine the dimension of reflexivity. [1] Data were synthesised narratively. Quality appraisal of study conduct was not completed and all eligible papers were included.

452 qualitative studies were reviewed and 102 were included from seven journals. Thirty-four studies provided quality checklists and 18 had personal ( n= 10), interpersonal ( n= 2), methodological ( n= 1), or multi-type ( n= 5) reflexivity. In the remaining 68 articles, reflexivity was personal ( n= 20), interpersonal ( n= 3), methodological ( n= 16), multi-type ( n= 28), or unclear ( n= 1). Where reflexivity was presented, it was mostly reported in the manuscript’s methods section or within limitations sections of discussions; some had reflexivity named sections. However, reviewed studies lacked true reflexive comments, and often descriptions of research team backgrounds were provided without consideration of the impact on the study, or the focus was on minimising study bias. Twelve studies alluded to the use of reflexive diaries, journals, or note sheets but lacked detail in how they were implemented.

This is the first systematic review, to our best knowledge, focused on reflexivity reporting in pharmacy practice qualitative studies. It highlighted that reflexivity reporting was poor, often misunderstood, and use of the quality checklist did not increase appropriate reporting. Reflexivity was often described as something researchers ‘did’ to minimise bias, rather than something to embrace and explore as part of qualitative research process. We posit that this could be due to a lack of understanding of what true reflexivity is, unclear quality checklist instructions and limited potential to include it meaningfully in the final manuscript. The review was limited to twelve pharmacy practice journals and articles published in English.

1. Walsh R. The methods of reflexivity. Humanist Psychol. 2003; 31(4): 51–66.

2. Olmos-Vega FM, Stalmeijer RE, Varpio L et al . A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Medical Teacher 2023; 45(3): 241-251.

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What is Qualitative in Qualitative Research

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• Published: 27 February 2019
• Volume 42 , pages 139–160, ( 2019 )

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

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What is Qualitative in Research

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

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

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

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

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

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

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

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

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

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

Towards a Definition of Qualitative Research

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

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

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

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

Qualitative research is multimethod in focus, involving an interpretative, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives. (Denzin and Lincoln 2005 :2)

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

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

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

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

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

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

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

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

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

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

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

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

Analysis – What is Qualitative Research?

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

Qualitative and Quantitative

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

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

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

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

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

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

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

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

Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

Grounded Theory

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

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

Defining Qualitative Research

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

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

Distinctions

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

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

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

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

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

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

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

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

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

Improved Understanding

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

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

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

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

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

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

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

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

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

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

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

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

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

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Acknowledgements

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

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Transcending borders with human-centric qualitative research

Generative AI can greatly impact qualitative research. This article will explain how to conduct qualitative research on a global scale, from understanding cultural nuances to leveraging cutting-edge technologies like gen AI.

How to master qualitative research with gen AI

Editor’s note: Jim Longo is the co-founder and chief strategy officer at Discuss.

Businesses are recognizing the importance of understanding consumer behavior on a global scale. Human centricity, a philosophy placing consumers at the heart of business strategies, has shifted the focus from quantitative data to the nuanced insights provided by qualitative research. However, conducting qualitative research on a global scale presents unique challenges. 

Yet, with rapidly evolving innovations in technology, particularly gen AI, conducting next-gen qualitative research on a global scale has become not only feasible but also essential for businesses striving to stay competitive.

How gen AI is revolutionizing global qualitative research 

Gen AI serves as the cornerstone of next-gen qual on a global scale. It’s the unlock for scaling unstructured data, extracting meaningful insights efficiently and enhancing consumer understanding. By accelerating insight generation and improving accuracy, gen AI empowers businesses to make informed decisions swiftly, seamlessly and globally.

As businesses expand their global footprint, the ability to conduct qualitative market research on a global scale becomes imperative. By embracing human centricity, leveraging advanced technology like gen AI and implementing comprehensive strategies, businesses can navigate the complexities of global markets with confidence, empathy and agility.

Enhancing consumer empathy on a global scale

Consumer empathy transcends being merely a function; it's a strategic mind-set woven into the fabric of organizations. It requires strong partnerships, advanced technology and comprehensive services to drive empathy initiatives forward effectively.

Cross-cultural training

Cross-cultural training is pivotal in enabling researchers to conduct research on a global scale. Understanding cultural nuances and sensitivities is essential for designing research methodologies that resonate with diverse audiences. Without adequate cross-cultural training, researchers risk misinterpreting consumer behaviors and preferences, leading to biased or inaccurate insights. By investing in cross-cultural training, organizations will ensure that their research efforts are culturally sensitive and relevant across various markets. As stated by Erin Meyer, author of "The Culture Map: Breaking Through the Invisible Boundaries of Global Business," "Without proper cultural understanding, your good intentions may be misconstrued."

Cross-cultural training fosters empathy and cultural competence among researchers, enabling them to approach their work with a genuine understanding of and appreciation for the perspectives of others. This empathetic approach is crucial for building authentic connections with consumers and gaining deeper insights into their needs, preferences and behaviors. 

Multilingual research materials

Language diversity is a defining feature of many markets today, and ignoring linguistic differences can lead to overlooking valuable insights and perspectives. Translating research materials into local languages ensures inclusivity and accessibility, allowing all consumers to participate in the research process and share their experiences in their native language. This not only demonstrates respect for cultural diversity but also facilitates deeper engagement and understanding among participants.

According to a report by CSA Research , "72.4% of consumers are more likely to buy a product with information in their own language." By catering to consumers' language preferences, researchers can enhance the relevance and impact of their research efforts, ultimately leading to more informed decision-making and customer-centric strategies. By breaking down language barriers, researchers can foster trust and rapport with participants, leading to more open and candid responses during interviews and focus groups. 

Gen AI tools

Gen AI tools represent a game-changing technology that empowers researchers to conduct research on a global scale with unprecedented efficiency and depth. There's a growing recognition of AI's pivotal role in gaining insights into consumer behavior and preferences, especially in the qualitative research realm. These AI-powered tools, such as gen AI summaries and thematic analysis, offer a never-before-seen capability in analyzing consumer interactions. They provide researchers, regardless of their qualitative analysis expertise, with a means to uncover key trends and themes from diverse consumer conversations. By automating repetitive tasks and streamlining the analysis process, gen AI tools free up researchers' time to focus on more strategic aspects of qualitative research. This not only enhances productivity but also allows researchers to deliver more value to their organizations by uncovering nuanced consumer insights that drive innovation and competitive advantage in global markets.

Virtual workshops and sessions

Albeit obvious, virtual platforms offer a convenient and efficient means of engaging global teams in empathy-building workshops and sessions. These virtual gatherings provide an opportunity for researchers to immerse themselves in diverse consumer sentiments and preferences from around the world. Through interactive discussions and activities, teams can gain valuable insights into the varying needs and aspirations of consumers across different regions, fostering a culture of empathy and understanding within the organization.

Digital platforms for collaboration

Digital platforms play a crucial role in facilitating collaboration among global teams. By leveraging digital tools, researchers can easily share insights, collaborate on projects and communicate with colleagues across different time zones. These platforms enable seamless knowledge sharing and foster a culture of collaboration, driving innovation and creativity in empathy initiatives. Whether it's sharing research findings, collaborating on strategy development or discussing consumer insights, digital platforms provide a centralized hub for global teams to connect and collaborate effectively. Additionally, digital platforms enable researchers to overcome logistical challenges associated with traditional in-person collaboration, such as travel restrictions and scheduling conflicts. This ensures greater participation and engagement from team members across the globe, ultimately leading to more comprehensive and nuanced insights into global consumer behavior and preferences. Digital platforms provide a centralized repository for storing and accessing research materials, ensuring that global teams have easy access to the latest insights and data, further enhancing collaboration and decision-making processes. Digital platforms foster a culture of collaboration and innovation that transcends geographical boundaries.

Continuous feedback loop and regular updates

A continuous feedback loop enables ongoing improvement and refinement in empathy initiatives. By gathering insights, sharing best practices and adapting strategies based on real-time feedback from global teams, researchers ensure the relevance and impact of empathy programs in an ever-evolving market landscape. This iterative approach fosters collaboration, continuous learning and swift responses to emerging trends and consumer preferences on a global scale. Additionally, it promotes transparency and accountability within the research process, fostering trust and engagement among team members while driving innovation and creativity in empathy initiatives. By incorporating feedback loops into their methodologies, organizations identify and address potential blind spots or biases, ensuring robust and actionable insights across diverse cultural contexts.

Regular check-ins and updates play a vital role in supporting global qualitative market research by providing a structured framework to monitor empathy programs and align them with organizational goals. These meetings serve as essential forums for sharing insights, discussing challenges and celebrating successes, fostering a culture of collaboration and accountability among global teams. Transparent communication channels keep team members informed and engaged, reinforcing the importance of empathy initiatives and driving momentum across the organization.

By staying agile and responsive to feedback, organizations adapt and refine empathy strategies to meet the evolving needs of global consumers, ensuring continuous improvement and innovation. 

Navigating the landscape of global qualitative research

• Cultural sensitivity and context:  Understanding the intricate nuances of cultural norms, customs and values in each target region is fundamental to conducting meaningful qualitative research. Businesses must invest in gaining cultural sensitivity to ensure their research resonates with diverse audiences worldwide.
• Translation and localization : Accurate translation of research materials is crucial for maintaining cultural relevance and inclusivity. Leveraging gen AI tools that support multiple languages ensures seamless communication and understanding across global markets.
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• Virtual research technology : Embracing video conferencing, online communities or mobile apps for remote interviews and focus groups in local languages, with live translation capabilities, facilitates real-time interaction and engagement.
• Time zone considerations:  Flexibility in scheduling research activities helps accommodate different time zones and ensures broader participation and comprehensive insights.
• Ethical compliance: Adhering to ethical guidelines and regulations specific to each country is paramount to maintaining the integrity and confidentiality of research activities.
• Data security:  Partnering with vendors that prioritize data security and compliance with international data protection laws is essential to safeguard sensitive information. When utilizing a vendor that uses gen AI, ensure they employ a closed-loop system to ensure that any data sent to the engine for processing is not shared or accessible to any entity. No outside data should be introduced, and none of OpenAI's learning models should be informed by or utilizing that data in any way.

The key to improving qualitative marketing research

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By embracing human-centricity, leveraging advanced technology and implementing comprehensive strategies, businesses can elevate the quality and relevance of their qualitative research efforts, ultimately gaining a competitive edge in global business.

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• Open access
• Published: 17 April 2024

Breaking down barriers to mental healthcare access in prison: a qualitative interview study with incarcerated males in Norway

• Line Elisabeth Solbakken 1 , 2 ,
• Svein Bergvik 3 &
• Rolf Wynn 1 , 4  

BMC Psychiatry volume  24 , Article number:  292 ( 2024 ) Cite this article

456 Accesses

Metrics details

Mental health problems are highly prevalent in prison populations. Incarcerated persons generally come from disadvantaged backgrounds and are living under extraordinary conditions while in prison. Their healthcare needs are complex compared to the general population. Studies have found that incarcerated individuals are reluctant to seek help and that they experience challenges in accessing mental healthcare services. To some extent, seeking treatment depends on the degree of fit between potential users and health services, and actual use might be a better indication of accessibility than the fact that services are available. This study aimed to explore individual and systemic facilitators and barriers to accessing mental healthcare in a prison context.

An analytical approach drawing on elements of constructivist Grounded theory was the methodological basis of this study. Fifteen male participants were recruited from three prisons in Northern Norway. Data was collected through in-depth interviews on topics such as help-seeking experiences, perceived access to services and availability of health information.

We found that distrust in the system, challenges with the referral routines, worries about negative consequences, and perceived limited access to mental healthcare were barriers to help-seeking among incarcerated individuals. How prison officers, and healthcare personnel respond to incarcerated persons reporting mental distress could also be critical for their future willingness to seek help. Providing information about mental health and available services, initiating outreaching mental health services, and integrating mental health interventions into treatment programs are examples of efforts that might reduce barriers to accessing services.

Conclusions

Facilitating access to mental health services is crucial to accommodate the mental health needs of those incarcerated. This study provides insights into the complex interplay of individual, social and systemic factors that may contribute to the utilization of mental health care among incarcerated persons. We suggest that correctional and healthcare systems review their practices to facilitate access to healthcare for people in prison.

Peer Review reports

Mental health of people in prison

The rates of mental disorders are considerably higher among incarcerated individuals than in the general population [ 1 , 2 , 3 , 4 ]. Co-morbidities are common, and around 20% of incarcerated individuals have concurrent mental and substance use disorders [ 5 ]. They are at increased risk for all-cause mortality, self-harm, violence, and victimization, and suicide rates are about 3–6 times higher among incarcerated males relative to males in the broader population [ 6 ]. Adverse life experiences and disadvantaged living conditions from an early age may explain the observed accumulation of mental health problems in prison populations worldwide [ 7 , 8 ]. Genetic predispositions combined with environmental stressors are implicated in the development of mental disorders [ 9 , 10 ]. People in prison generally experience low educational achievements, low income, and unstable housing. Thus, the poor mental health of prison populations is caused by a complex interplay of social, environmental, and genetic factors [ 7 , 11 ]. In addition to the pre-existing burdens, incarcerated individuals are facing prison–specific challenges such as loss of autonomy, social isolation, bullying and violence that may exacerbate mental health issues [ 12 , 13 , 14 , 15 ]. Considering the elevated rates of mental health problems in prison, facilitating access to mental health services is crucial to accommodate the needs of those incarcerated.

Access to mental health services

The treatment gap refers to the proportion of individuals with mental health problems within a specific community that require treatment without receiving it [ 16 ]. Variable access to mental healthcare and high levels of unmet mental health needs are universal challenges in communities across the world [ 17 , 18 ]. Even when health services are available, individual and systemic barriers may hinder their use. In a narrow sense, access to healthcare may be considered equivalent to available services. However, some argue that a more meaningful way to define access is the “degree of fit” between the potential users and health services [ 19 ]. For instance, if services are accessible in terms of transportation and treatment costs and whether they are compatible with potential users’ personal attitudes, beliefs and preferences. “Having access” can be understood as the potential for using available mental health services. “Gaining access”, is the individual process of choosing to use those services [ 20 ]. Within this frame of reference, access to services is more precisely defined by the actual use of services.

Mental health help-seeking

Across settings and populations, the majority of those suffering from mental health problems do not seek treatment [ 21 , 22 , 23 ]. The literature on help-seeking gives insight into the intrapersonal factors involved in accessing mental health care. Within this context, help-seeking has been defined as: " an adaptive coping process that is the attempt to obtain external assistance to deal with a mental health concern” [ 24 ]. The process of seeking help involves becoming aware of a mental health problem that may require intervention; articulating the psychological challenges in a way that can be understood by others; awareness of help sources that are available and accessible; and a willingness to talk about the mental health problem to available help sources [ 25 ]. Throughout the help-seeking process, personal thoughts and feelings become increasingly interpersonal as an individual confides in and seeks support from others. It is not uncommon to share mental health concerns with informal sources of support such as friends and family prior to, or even instead of, seeking professional help [ 26 ]. Moreover, informal networks are found to facilitate but may also discourage professional formal help-seeking for mental health problems [ 27 , 28 ].

The theory of planned behavior (TPB), a well-known model within behavior change research, may also provide a framework for understanding how personal attitudes and social influences are implicated in accessing healthcare. Subjective norms, attitudes, and perceived behavioral control are elements of TPB that are particularly important for understanding the help-seeking process [ 29 ]. In this context, subjective norms refer to a person’s beliefs about other peoples’ practice or approval of help-seeking and are related to expectations of social support in pursuing professional help. Attitudes refer to appraisals of seeking professional mental help as beneficial or harmful and a judgement of whether help-seeking would be constructive compared to alternative behaviors. Perceived behavioral control can be divided into self-efficacy (the confidence that one can seek help), and controllability (the extent of personal control in the help-seeking process). A recent review found that attitudes and perceived behavioral control predict help-seeking intentions across different population groups and cultures [ 30 ].

Access to mental health services in prison

Equity is essential in healthcare to ensure that the health system meets the needs of different groups of people and individuals [ 20 ]. “The principle of equivalence” is a widely endorsed standard for healthcare in correctional settings [ 31 ]. This principle is laid down in the United Nations´ Nelson Mandela Rules. Rule number 24 states that: “Prisoners should enjoy the same standards of health care that are available in the community, and should have access to necessary health-care services free of charge without discrimination on the grounds of their legal status” [ 32 ] (p.8) However, some argue that equal standards are not sufficient to meet the complex needs of incarcerated individuals and that mental healthcare in prison must be more intensive and integrative than services provided in the community [ 33 , 34 , 35 ]. In reality there are several reports of shortcomings in the delivery of mental healthcare in prison in many countries across the world, as mental disorders in incarcerated persons are underdiagnosed and undertreated [ 6 , 34 ]. Studies from Canada, the US, and the UK indicate that a significant proportion of incarcerated people with mental health problems have not received adequate treatment [ 36 , 37 , 38 , 39 ]. Suggested explanations for unmet needs are underfunding, failure in screening procedures and quality at reception, demand for more mental health knowledge among prison staff, and possible underrating of the severity of mental health problems by the prison administrations to reduce treatment costs [ 36 , 37 , 38 , 39 , 40 ]. Taken together these reports suggest that mental health services do not fit the complex needs of incarcerated persons in high-income countries. There is less knowledge about the situation in low- and middle-income countries. However, the elevated rates of mental disorders in these countries suggest that unmet needs among incarcerated persons are a widespread challenge [ 1 ].

Mental health help-seeking in prison

Evidence suggests that the immense burden of mental disorders among people in prison is not matched by a proportional use of mental healthcare [ 41 ]. Several reports from various correctional settings have documented that incarcerated persons are reluctant to seek help for mental health problems [ 41 ]. Among the reported barriers to help-seeking in prison are confidentiality concerns [ 42 ], fear of stigma associated with a diagnosis [ 43 ], a preference for self-management or informal support [ 44 ], lack of knowledge of psychological services [ 42 , 44 ] and distrust in the system [ 45 ]. In addition, systemic factors may influence access to healthcare in prison. The culture in all-male prisons typically demands that those imprisoned mask their vulnerabilities by adopting a tough and dominant demeanor [ 46 ]. Experiencing mental illness and receiving professional mental health treatment is also associated with an increased risk of victimization in incarcerated individuals [ 47 ].

Mental health literacy (MHL) is a concept that includes the knowledge and attitudes that influence how people manage their mental health needs [ 48 ]. Having sufficient knowledge and access to information about mental health and mental health services can be a prerequisite for seeking professional help [ 49 ]. For people living in the community, seeking online information and advice is an important strategy for gaining knowledge about how to cope with mental health challenges [ 50 , 51 , 52 ]. For security reasons, access to the Internet is typically severely limited for those imprisoned [ 53 , 54 ]. Hence, this essential mental health information source is largely unavailable to them. Accordingly, incarcerated individuals are reliant on finding mental health information through information pamphlets, books, TV programs, newspapers or consulting healthcare professionals [ 55 ]. Some argue that limited access to online information and digital health services may have consequences for the well-being and successful rehabilitation of those incarcerated [ 53 , 56 , 57 ]. Thus, there are reasons to believe that restricted access to mental health information may also affect help-seeking and access to healthcare for incarcerated individuals.

The rationale for the current study

Fostering health-promoting environments and adequate access to mental healthcare within prisons is a public health imperative increasingly acknowledged in the literature [ 33 ]. Moreover, the mental health of incarcerated persons is a matter of public safety since untreated severe mental disorders are associated with a higher risk of recidivism [ 58 , 59 ]. People in prison retain their right to health services, and in principle, incarcerated persons have access to mental health services. A vital question, however, is how incarcerated persons experience gaining access and how this affects their actual use of services. Existing research on the provision of mental healthcare in prisons, particularly within a Scandinavian context, is sparse, leaving significant knowledge gaps. The question of access to health information for incarcerated persons is similarly understudied. This study aimed to investigate how incarcerated persons experience individual and systemic factors that facilitate or impede access to mental healthcare in prison.

The Helsinki Declaration of Medical Research involving human subjects and services laid the basis of the ethical considerations of this study [ 60 ]. The study was approved by the Data Protection Officer of the University Hospital of North Norway (No. 02415). The Norwegian Correctional system, which is responsible for the welfare of incarcerated individuals, approved of the study (Ref. 200900463-347). The Regional Health Research Ethics Committee concluded that the project was outside their mandate (Ref. 40,701).

The principles of voluntariness and informed consent are central to human subject research. Individuals in prison are considered vulnerable due to their restricted freedom and autonomy, poor health status, higher incidence of learning disabilities, and lower literacy levels. Consequently, additional precautions are required to ensure that research with incarcerated participants is conducted ethically [ 61 ]. User participation in designing research that includes vulnerable groups is crucial to achieving this objective [ 61 , 62 ]. Measures in accordance with recommendations were taken to ensure consent information that is complete, relevant, and understandable [ 63 ]. A user representative from Way-Back, an organization that supports incarcerated persons with reentry to their communities, contributed to the project’s planning. The user representative provided input on information about the study, research questions, the interview guide and how to conduct the interviews. The input was used to tailor information and for conducting the interviews in accordance with the constraints of the prison contexts and the needs of the incarcerated individuals. The choice of whether to reimburse participants in prison studies is debated. Because of the relative deprivation of prison life, some argue that even small incentives could potentially result in undue influence for participation in research [ 64 ]. For this reason, we chose to abstain from offering reimbursement for the participants in this study.

Study context

At any given time, about 3000 persons are serving a sentence in Norway, of which 5.6% are women and 26.2% are non-Norwegian citizens [ 65 ]. A recent study found that almost 60% of incarcerated persons in Norway had a diagnosed mental disorder, together with a 33% rise in the one-year prevalence of mental disorders between the years 2010–2019 [ 66 ]. Thus, the proportion of people with mental disorders entering prison has been increasing. In Norway, access to necessary healthcare is considered a basic human right and is legislated in the Patient’s Rights Act section 2 [ 67 ]. Healthcare is primarily tax-funded, with a nominal service fee and a relatively low cap on yearly individual costs [ 68 ]. Norway has committed to “the principle of equivalence” meaning that those imprisoned retain their right to healthcare equal to that of the general population [ 31 ]. Prison health services serve incarcerated persons with milder mental health problems and are accessible by self-referral through a paper-based request system. The prison health services can refer those who experience moderate to severe mental disorders to specialist mental health services, and treatment is often provided in prison by mental health professionals from local hospitals For people imprisoned in Norway, healthcare and medications are free of charge [ 69 ], eliminating one significant barrier to mental healthcare access [ 70 ]. Furthermore, as the municipalities and local hospitals provide health services - the importation of services promotes equity and that services are independent of the correctional system, thereby strengthening the rights of people in prison [ 71 ].

A study found that incarcerated persons in Norway were reluctant to seek help for mental health problems from prison health services unless they had concurrent sleep or substance use problems [ 72 ]. A survey by Bjørngaard et al. [ 73 ] found lower patient satisfaction with prison health services compared to people using community health services and that those with mental health problems were less satisfied compared to incarcerated patients with other health challenges. A survey representative of the Norwegian prison population found that 20% of incarcerated males sample reported that they had received mental health services, while 25% reported that they had been in need of mental health services in prison but had not received any [ 11 ]. More recent reports suggest that mental health services are insufficient to meet the needs of those imprisoned in Norway and that incarcerated individuals referred due to their severe mental illness may not be admitted to specialist services for in-patient assessment and treatment [ 74 , 75 ]. These reports indicate that mental health services do not fit the complex needs of incarcerated persons in Norway and that there are potential obstacles in their access to mental healthcare.

Study design

This study was underpinned by relativist epistemology which is based on the assumption of multiple individual realities that allow for different understandings of the same phenomenon [ 76 ]. The study design was suitable for exploring and explaining commonly experienced individual, social, cultural and structural factors that influence help-seeking and access to mental healthcare for incarcerated individuals. The study incorporates vital Grounded Theory (GT) components, including initial coding, categorizing data, constant comparative methods involving inductive and abductive reasoning, and memoing [ 77 ]. The use of theoretical sampling, which is rare in prison research due to ethical and practical constraints [ 78 ], was not employed in this study. Data collection concluded once additional data no longer contributed new insights or further elaborated the developed categories.

Preconceptions

The first author, a clinical community psychologist and a PhD student, worked part-time as a prison officer for two years during her psychology education. This experience gave her an insider’s view of the correctional system, inevitably influencing her initial perceptions. Before conducting the interviews, she held a somewhat optimistic view of the correctional system’s capacity to support and enhance the mental health of those incarcerated. However, this perspective was challenged through the narratives of the study participants, who conveyed powerful personal accounts that highlighted substantial barriers to obtaining mental health services within the prison environment. The other two authors, serving as supervisors, are also researchers and mental health professionals with considerable clinical experience. Their diverse backgrounds contributed to a supervisory dynamic that adresssed the research topic’s complexities. Throughout the study, the authors engaged in a process of collaborative reflection, concerned with maintaining a balance between engaging with participant stories and sustaining a critical stance towards the data. These discussions were essential in helping the first author navigate an empathetic understanding of the participant’s experiences with the necessary analytical objectivity required for rigorous qualitative research.

Participants and study settings

Fifteen males serving a prison sentence were recruited from three prisons in Northern Norway. Thirteen of the participants served a sentence at a high security level, while two served at lower security. The participants’ age ranged from the early twenties to the late sixties (M: 43.6 years). Two participants had other nationalities, while the rest were Norwegian citizens. Further details about the participants must be withheld to preserve their privacy. When citing individual participants, they are anonymized by using pseudonyms.

Recruitment

Participants were recruited through posters in the prison ward that conveyed basic information, including the fact that the interviews were confidential and would be recorded. The posters encouraged those interested in participating to approach a contact person for more information. A prison officer, a social worker or a reintegration coordinator were assigned the role as contact persons in the selected prisons. Those who actively approached the contact person were given more comprehensive written information about the study. Requiring an active choice by incarcerated individuals was done to enhance their experience of self-determination and autonomy in their decision to participate. The contact person scheduled appointments with the participants, and the interviewer had no prior knowledge of the participants other than what they presented in the interviews. One potential participant cancelled the interview appointment due to health issues on the interview day and withdrew from the study.

The first author conducted face-to-face, in-depth interviews. The interviews took place in prison visitation rooms or in an office in the health wards. Before the interview, the participants were given information about the study and their rights as research participants and signed a written consent form. The interviewer was alone with the participants during the interview and had a personal alarm as a safety precaution. The interview guide covered topics on knowledge of mental health and available services, help-seeking experiences, and access to mental health information (sample questions provided in Table  1 ). The participants were asked open-ended questions and were invited to speak freely on these topics. Thus, the order and framing of questions varied depending on where they fit into the participants’ narratives. This allowed for following up on the participants’ experiences and may have given the participants an increased sense of control in the interview. The first author who conducted the interviews was attentive to signs of emotional discomfort in participants and avoided pressure on sensitive topics. After the interviews, the participants were encouraged to ask questions and comment on their experience and reminded of their right to withdraw from the study. Nearly all the participants expressed that the experience of participating in the study was positive and that they appreciated the chance to contribute to the research project.

The first author transcribed the audio-recorded interviews in Norwegian, ensuring a verbatim account of the participants’ narratives. The initial eight interviews were transcribed before initiating data analysis. This early examination of the data facilitated a refinement of the interview guide, which was then applied to the subsequent seven interviews to deepen the inquiry. Data collection and analysis were concurrent as the study progressed from the ninth interview, which allowed for immediate integration of new data into the evolving analytical framework. The data was examined using the NVivo 12 software, which supported the systematic organization and analysis of the data. The data was analyzed line-by-line, searching for incidents in the form of recurring beliefs, actions, experiences, and explanations [ 79 ]. The constant comparison method was applied throughout the analysis. In the initial coding phase, incidents were compared to incidents, and through this process underlying recurring concepts and similarities were identified and assigned codes. Subsequently, codes were then compared to codes, and related codes were organized into conceptual categories, reflecting both common features and divergent viewpoints [ 77 ]. In the intermediate coding phase, the data was abstracted into categories which were compared to each other, and relationships between categories were developed and refined. The authors engaged in a collaborative and reflective dialogue throughout this process, meeting regularly to deliberate on preconceptions, the emerging categories and their interpretations. This dynamic exchange was informed by memos that captured analytical decisions, insights, and evolving interpretations, thus guiding the reflective process. In the last stage, advanced coding, a core category which binds the other categories and sub-categories together was developed. Through a collaborative process the categories were substantiated with representative quotes, which, upon completion of the analysis, were translated from Norwegian to English for inclusion in the report. This resulted in a nuanced understanding grounded in the participants’ experiences and the researchers’ interpretative lens.

The data analysis yielded four main categories illustrating the participants’ active engagement in identifying challenges and facilitators for mental healthcare access within the prison environment. The first category, “Mental health awareness,” captures how beliefs and knowledge concerning mental health were influenced by the experiences and constraints inherent to prison life, potentially affecting the pursuit of help and access to healthcare services. The second main category reveals how systemic sub-cultural values can obstruct healthcare access, whereas, on a personal level, fellow inmates served as vital support for obtaining mental health services. The third main category, “Access to mental health care,” examines how organizational and systemic barriers impede access to mental healthcare. The final main category, “Enhancing access to services,” delineates factors that lowered the bar for mental healthcare access. The core category, “Breaking down barriers,” encapsulates the dynamic interplay between incarcerated individuals and the contextual factors that influenced their ability and willingness to access mental healthcare in prison. This central theme also recognizes the collaborative effort between participants and researchers in identifying problem areas and solutions to mental healthcare access, thereby “breaking down barriers”. An outline of these categories is presented in Table  2 .

Mental health awareness

An information void.

Seeking information can be an essential first step for recognizing symptoms of mental illness that may require intervention. Prior to imprisonment, visiting their general practitioner or using online search engines were the preferred methods for finding health information for the participants in this study. In prison, however, access to the Internet is severely limited:

Where can we get information? We do not have access to computers or anything. So, I would have to call someone on the outside to get them to print articles and send them to me by post. So, no. We don’t know our rights, we don’t know about the services available to us, as a matter of fact we know very little. There’s an information void. Stuart

A few of the participants referred to the prison library as a source of information. Some also said that they could talk to health care professionals, correctional officers, or other staff members like the priest, to get mental health information. Fellow incarcerated individuals who had experienced mental health problems and received health services were also mentioned by some participants. The common thread in all suggestions was a dependency on others to access information about mental health. Only a couple of participants had tried to find mental health information during their time in prison. However, they found it difficult to obtain:

The only choice I have is to ask the prison officers to print it [mental health information], but sometimes they don’t want to do it because they think it’s bad. And I have tried to search for psychosis and such in school [in prison], but then the teachers ask why I would seek out such a gloomy subject. It feels a bit complicated to obtain information. Larry

Participants from all three prisons also pointed out the need for more information about mental healthcare in prison:

We have a notice board on the ward (…). The information should be hung there for people to see, that there is a psychologist here, and that you can talk to her. ‘cause I’ve seen little of that sort in here. Liam

One participant underscored that information about available mental health services is particularly important for those with no experience from such services prior to imprisonment:

It [information] must tell you about your opportunities. To normalize it [seeking help] in a way. And the threshold must be low. I think many experience that it is too high. If I hadn’t been in contact with mental health services before I came here, the threshold for seeking help would have been sky high for me as well. Neil

Awareness of mental health issues

Factors in the prison context were fundamental to the participants’ explanations of mental health problems. Many participants attributed the onset or worsening of mental health problems to the shock of imprisonment and to the continuous hardships of prison life. Understanding symptoms as primarily caused by external stressors such as prison hardship may have influenced their appraisals about the need to seek help. As Frank stated:

I’ve always had good mental health. Until I came here, inside these walls. Frank

Frank reported considerable symptoms of post-traumatic stress. Understanding his symptoms as something triggered by the prison living conditions, he did not see how seeking professional help could benefit him. Like many other participants, he insisted that the correctional system needed to change and had lost hope that he could improve his own situation.

In contrast, other participants who attributed their mental health problems to external stressors concluded that they indeed needed help to cope. The suffering they experienced during their first weeks in prison motivated them to seek formal help:

I asked to talk to a psychologist in here. ‘Cause, I felt that I needed to. ‘Cause in the beginning when I came here, it all seemed dark. No matter how hard I tried to do the right thing, there was some sort of dark force that was just pushing on, and the obstacles were piling up. Travis

For some, their main motivation for seeking help was to receive professional validation from healthcare personnel regarding the negative health consequences of their prison experiences. Some also hoped that healthcare professionals could advocate for better living conditions:

And it is good that others [psychologists] can take part in these things. So that it is manifested what prisons actually do to people. Jack

Social influences on help-seeking

Prison culture and mental health stigma.

The participants described how the culture within prison influenced their willingness to talk about mental health issues. The importance of appearing strong and dominant within the prison setting was emphasized by many. According to several participants, the talk at the wards was characterized by attempts to one-up the others’ stories about criminal activities to appear tough. Many also explained that hiding vulnerabilities was critical in the prison community, and some also underlined the potential for victimization for those who were not able to conform to the prison norms:

You are wearing a prison mask. You cannot show weakness. ‘Cause then you’ll soon be a victim, a sitting duck. I have experienced inmates that have, eh mostly stayed in their cells. They have been harassed so badly that they are sitting there crying. The prison milieu can be tough. Neil

Choosing to confide in and seek advice from peers can also have negative consequences. Several of the participants said that it was wise to be careful with who you chose to share mental health related issues with:

Let’s say you talk about your personal feelings, and about your sentence and stuff, right. They can be very nice to you there and then, before they stab you in the back later on, spreading everything you’ve said to destroy you. It is a cynical game. Bobby

Bobby went on to explain that a fellow incarcerated individual could use personal information for harassing, blackmailing and threatening the family of someone who has confided in them, if a conflict should arise. Some of the participants also addressed directly how the prison climate may influence willingness to seek mental health treatment:

They do not want to go to a psychologist and talk. Because then they are seen as weak and not able to cope. Because in prison everyone should be tough. Drug lords and such. But, on the inside they are not like that. Nicky

The role of peers in accessing mental health services

Despite the clear barriers, fellow incarcerated appeared to be an important informal help source for mental health problems. Many of the participants had observed signs of emotional distress among their incarcerated peers and described how they had given them advice and encouragement. According to several participants, those imprisoned also had an essential role in recognizing mental health problems in their peers:

There is no-one who talks to us regularly to check on how we are doing. That’s not a priority here. So, unless some of the inmates take on the role of an officer or a psychologist, then there’s no-one who reports concern (…) There are many inmates who are taking on a role as a social worker, but it’s kinda wrong. They are neither paid for it, nor qualified. They do it because no-one else does. Stuart

Although none of the participants said that they themselves had been prompted to seek help by peers, they told stories of how they had pushed their peers to seek formal help:

A fellow inmate. I could tell he was struggling because he talked to me as the only person. In a way, I was his psychologist. The days when he was down in the dumps, I tried to talk to him (…) And I said, listen up. It’s for your own good. I will write a request form, and we will arrange contact with a psychologist (…) and it will help. Nicky

Experiencing fellow incarcerated people in distress appeared to be common, and participants also explained how they reported to prison officers their concerns about peers with self-harm and suicide plans:

There was a fella’ who told me that he knew exactly how to take his own life (…). “I’ll just do it like this and this and this”. And, uhm. Then he said he was going to do it. And I thought that I would have to report it, and I did. Roy

Roy went on to describe in detail how his reported concern led to a prison officer interrupting the suicide attempt by the fellow incarcerated, thereby saving his life. Several other participants shared similar stories, indicating that peers played a significant role in recognizing and getting help for mental health related problems in prison.

Access to mental healthcare

Self-referral and disempowerment.

In order to access prison healthcare, those imprisoned must write and deliver a paper-based request form. All the participants in this study were aware that this is the way to contact prison healthcare, and most of them knew that the general practitioner working at the prison could refer them to a psychologist or to a psychiatric hospital. Unfortunately, the request form system seemed to amplify the participants’ perceptions of disempowerment. Rather than seeing themselves as agents taking charge of their own situation and health, they were left passively waiting to be contacted after filling out the forms:

You are pacified when you must write a request form to talk to someone. Then you don’t know when they are coming to talk to you. And then it’s like, the problem may be swept under the rug when they finally get to you. Tommy

According to the participants, many of these request forms seemed to disappear, and it could take an exceedingly long time before they got any response to their request:

Many times, when you write a request form it disappears. Nothing happens. Those request forms are worthless most of the time. Keith

There were also several participants who voiced concern over the confidentiality of the request forms even when the forms were delivered in closed envelopes:

We can see for ourselves that they [prison officers] open and read, uhm, confidential information, [lowers his voice] and to put it mildly, uhm, breaches in confidentiality are all too common. It is alarming! Neil

One of the informants also explained that incarcerated persons who had mother tongues other than Norwegian could have problems with understanding and filling out request forms to health, and that forms that were not filled out correctly were of no value. According to Roy and other participants, the correctional system did not give sufficient information and guidance about the request forms:

They might not know how to write, or understand what it [the form] says, you know? Potentially it is severe for that guy, right. It’s garbage! Garbage, that request form. They haven’t received any request from him. Roy

The perceived availability of mental healthcare

The perceptions of accessibility of mental health care varied between the participants. A few of the participants were in active treatment with a psychologist at the time of the interviews, and they had experienced the access as unproblematic. Common for some of these participants was that they had been in treatment before they entered prison:

From sending my request and to receiving an acceptance letter it took one and a half weeks. Less than three weeks later I was in treatment. It was efficient. Much quicker than I’ve ever experienced before. Neil

However, many participants said that they could not access secondary mental health services. There were two notable sub-groups among the participants who perceived that access to specialized psychological treatment was limited. The first group shared stories about living unstructured lives at the edge of society. They seemed to have little confidence in health care and correctional services, and were less hopeful of their own potential of being rehabilitated:

I have tried for several years now, but I didn’t get help. They can say whatever they want about how easy it is to access a psychologist and prison healthcare and everything, but it is not true. Ronny

Two of the participants explained how they would have to take drastic measures such as performing violent acts or acting weird to get help for their mental health problems When Marlon was asked how he could access mental health services he responded:

You would have to either hurt yourself, or someone else, so that they end up in hospital. Marlon

The interviewer asked if it was possible to access mental health services by using less drastic measures, Marlon answered:

Uhm. Naaah. I don’t know. I do not think so. Not from my experience. Marlon

Another sub-group having difficulties accessing mental health services was those in prison for the first time. Most had led more typical lives with stable employment and housing conditions before imprisonment. When they sought mental health services, they were told that these adjustment problems were normal in prison:

I’ve been struggling for several periods here and have said that I wanted to talk to a nurse or a psychologist. And then I was referred to a psychologist. And the psychologist assessed me, and said that: “Nothing’s wrong with you, you are just having a hard time, I cannot help you”. So, you do not get anyone to talk to, unless you- I don’t know what you must have really, but I sure ain’t got it. The nurses say that they haven’t got the time, and the psychologist says that I am not ill. And then I am left to feel bad. In my case, there is no service really. Stuart

Prison officers’ role in mental healthcare and accessing services

Several participants stated that mental health problems and well-being were not high on the prison agenda. Many would have appreciated it if correctional officers on a more regular basis had asked how they were doing and believed that this would have facilitated them to open up and talk about mental health issues.

In my opinion, mental health is forgotten here in a way. Physical activity, movement, workouts, yes. Since I arrived here some months ago, only twice I’ve been asked: “Hi, how are you? Is there something you want to talk about?” Travis

Some also said that they knew people in prison who were unaware of their own need for mental health care or unable to access help, and argued that the correctional system should do more to help these people to access care:

You have the type where people do not get help because they themselves are not able to request help from the prison health services and the prison officers do not see to that they get the help they need. Neil

Some were concerned about how acute health problems were handled in the weekends and evenings when prison health services were unavailable. In these situations, prison officers were left to decide whether or not to contact emergency healthcare services. Several of the participants were not satisfied by this arrangement:

(…) they think that they can make a doctor’s judgement. That they can decide that it is not that important. It is rude. It is trespassing norms. Jack

Some participants told stories of how their peers in prison did not seem to get the help they needed even though it was apparent that they were in a bad state mentally:

I have reported concern about people, before they started cutting themselves and f***ing themselves up. But what worries me, is that even though I voiced my concern to both prison health services and prison officers, no measures were taken. Before it was too late. Stuart

Asking for help from correctional officers could also have consequences. Ronny served at a lower security level. He experienced that his requests to see a psychologist were met by suggestions of transferring him to a higher security level:

I have written request forms: “I need to speak to a psychologist. Immediately”. And then they [the prison officers] are threatening me by saying that they are going to transfer me to a higher security level. They ask if I am going to hurt myself. No, I tell them. I’m not going to hurt myself. I just need to talk to a psychologist. Ronny

Another participant described how he had sometimes cut himself by shards from plates and drinking glass to suppress mental suffering. He explained how he on one occasion used the intercom to notify the officers that they needed to come and pick up a glass that was triggering an urge to self-harm. The participant said that initially a single officer came to his cell to pick up the glass:

A few minutes later there were four officers, and they unlocked the cell door, and there were a lot of questions. I guess they were worried about my mental state, and I said that I appreciated the concern. Then I reminded them that I had asked them to pick up the glass so I would NOT cut myself, so if they were to use that against me, it would be unfair. Tommy

He reassured that the situation had been resolved with the conversation. However, he had the impression that disclosing mental distress to officers could increase the risk for being transferred to a higher security level, or to a security cell.

Enhancing access to services

The perceived advantages of seeking professional help.

There were some commonly experienced benefits of seeking mental healthcare among the participants. Coming off drugs and living under stable conditions in prison provided some participants an opportunity to reflect on their lives and to gather motivation to work on their addiction and mental health problems:

I have been thinking a lot about treatment in an institution. I know how it went the last few times I got out [of prison]. Within half an hour I was sitting there with the needle. And if I don’t do anything before I get out, the same will happen again. I’m trying to prevent it (…) I’ve had treatment for drug and alcohol use before. And back then there was a psychologist who said that, once you’ve been clean for a year, then the brain is back to normal. I can feel it, like, my mindset is already changing . Kurt

For about half of the participants, seeking professional help was related to their motivation for living a law-abiding life after prison. The participants linked substance use to both mental health problems and a criminal lifestyle, and getting treatment was seen as essential for preventing recidivism:

I have lived a rough life, and I have no-one, NO-ONE. How long am I going to live? One doesn’t know. But I’ll be fifty soon. So, I must make it now. I really have to make it now [his voice bursts]. And it depends on many psychological factors. So, I’m choosing to use all the things that I have access to in prison, like treatment for drug addiction. Roy

Although many had previous experience of treatment for their substance use, they still had hopes that treatment could help them. Liam had previously experienced that consultations with a psychologist brought up subjects that was difficult for him to talk about:

I regret that I quit, because it could have done me good. But I guess it got too personal, and it stirred up things. Liam

He also explained that at the time he was more interested in doing drugs than going to therapy. However, he still believed that treatment could help him:

I will probably contact a psychologist, now that I’m about to get treatment for my addictions. It is easier to open up when there are no substances involved. Liam

In summary, seeking professional help for mental health problems was perceived to promote in-prison coping, rehabilitation, and preparation for life outside of prison for most of the participants.

Lowering the bar for accessing mental health services .

Many of the participants expressed skepticism towards ‘the system’. They described how they had been let down and disappointed by the child welfare services, the criminal justice system, and healthcare professionals. Experiences from childhood to adult life had led to a lack of confidence that healthcare personnel and the correctional system and society had their best interest at heart. For them, it was important that healthcare professionals were perceived as genuine and “on their side”:

The experience of being believed and listened to… They do not have to relate, to say that they understand so damn much, ‘cause that’s not really important. Marlon

Several participants said that barriers for talking about mental health were reduced when healthcare personnel reached out in the prison ward. One of the prisoners described two nurses who used to visit the prison wing every day at lunch-hour. He appreciated that it was possible to request a private conversation in the cell, and that he was taken seriously:

They were highly skilled. And they listened. They listened to what you had to say, and they understood you. Tommy

Having previous positive experiences of mental health treatment and knowledge of what to expect from mental health services also seemed to reduce barriers for in-prison help-seeking from some of the participants:

I saw a psychologist on a regular basis, once a week (…). And after six consultations I was past the worst in some sense. I was provided with the tools I needed to cope. Bobby .

This participant had experience with psychological treatment outside of prison and had tried to access mental health services for months in prison. However, he believed his challenges were too mild to get help from a psychologist. He emphasized the need for available low-threshold services for those who suffer from milder mental health problems:

It should be available for everyone who wants it. It should not be embarrassing, it should not be taboo, it should be… A natural part of it, really. Bobby

In addition, when services were provided as standard procedure and a natural part of rehabilitation, they were perceived as less stigmatizing. Nicky described how he was placed on a prison ward that was specialized in substance use treatment:

And when you are placed in that ward, then you are automatically assigned to a psychologist from the substance use clinic, that you can have weekly consultations with. Nicky .

Some also suggested that the systematic screening and assessment of health and social problems also could facilitate access to mental health services and this was suggested as an integral part of healthcare and rehabilitation in prison by some of the participants. Ronny underscored the importance of proper assessment:

What is this person’s problem? Why did he come back? Is there something happening to him on the outside? Could he need help with anything? Maybe someone should ask him? Ronny

Ronny went on describing the nice brochures of the correctional system, with promises of assessment of strengths and needs of individuals, but he claimed that this did not happen in reality. This view was shared by several of the other participants, as they called for more assessment to benefit the mental health and rehabilitation of incarcerated individuals.

Mental health support from different sources

The participants had different preferences regarding where to get help. Support from friends and family was seen as important for most of the participants. However, health professionals could sometimes be preferred over informal or semi-formal sources because of their role in advocating for better living conditions in prison:

I get visits from my family, but I’d like to talk to someone here in prison, so that they could gain awareness of the actual problem. If I’m spitting venom to some random lady that is here as a volunteer with the Red Cross, it’s useless, I think. If I talk to a nurse who works here at this establishment, she could perhaps do something about some of our challenges. Stuart

The cultural competency of health care personnel could also be a key factor in promoting help-seeking and forming a therapeutic alliance with people in prison. Many incarcerated individuals have lived on the edge of society, while most health care personnel, and particularly doctors and psychologists, are from the upper middle class. These cultural differences may form an abyss between the incarcerated individuals and mental healthcare personnel:

A psychologist does not have a criminal record. Now I’m generalizing. But they have performed well in school. Have passed through the system. Highly educated. Their lives have been smooth sailing (…) They have not experienced the shadow side of life. Tommy

This participant had one prior positive experience with a psychologist, but his general impression of psychologists was that they were of no help. He did not feel a connection with any of the others and had written them off completely. He preferred talking to a representative from a user organization who have led a similar life to himself:

I know that they know exactly how I’m feeling. They have served a prison sentence. And they… They have lived experience, and then it’s much easier to listen to what they have to say, because I know it’s not knowledge that they have acquired through reading. Tommy

Prison officers can also be of help to incarcerated people who experience mental health problems. Nicky said that while he was at a lower security level, he had been to a sports event outside prison with an officer and some fellow incarcerated. He had a panic attack because of all the people who kept arriving at the venue and he had to go outside for some fresh air. The prison officer followed him and was understanding, and told Nicky that he had seen many incarcerated people with similar reactions:

He was understanding and said: It will be OK. After that day at the match, coincidently, he ended up being my primary contact officer. And to socialize me back to society he fixed it so that every weekend he was working we could go to a shopping mall, to try. Little by little, by little. (…) It helped. It did. Yes. Nicky

Although Nicky had no plan to seek help for his anxiety symptoms, he appreciated the support he received from his primary contact officer.

Bobby, on the other hand, had some informal support from fellow incarcerated and had also talked with a priest. He said that he often ruminated when he had time alone in his cell and emphasized his need for sharing his thoughts with others and receiving advice. He explained why he preferred to get help from formal sources:

So, to have someone who is an outsider. Who’s not an inmate. Who has got a sensible outlook on life, that can guide you– I think that’s important. (…) Because when you talk to a fellow inmate, then… It can go in the opposite direction, right. Because many have been through major crises, they have lost friends, they have lost family, maybe they have lost their girlfriend and wife, their children won’t speak to them, right? Bobby

Most participants also held the prison priests in high regard and appreciated the availability of the service. However, talking with a priest was not seen as a replacement for a consultation with a psychologist:

It was peculiar, when I asked for someone to talk with, the priest was offered first. For me it is alright, I go to church. But I’m thinking, if someone is not a Christian. I’m like: a priest? Or if you’re not religious. A session with the priest is more like a consultation towards God and his will. He can be a good listener [the priest], but you might not get the help you need in a mental sense. So, a psychologist, a “talking person” in prison is necessary. That could check on you sometimes.

This study’s findings demonstrate that many of the factors deciding access to mental healthcare are firmly rooted at the organizational level of the correctional and healthcare systems. Prisons in the Scandinavian countries, including Norway, are presumptuously humane compared to harsher correctional settings in other parts of the world. One could assume that these favorable conditions would be more conducive to mental healthcare access. However, the systemic barriers we found largely overlapped with challenges reported in other countries [ 42 , 43 , 44 ]. In addition, we found that individual beliefs, attitudes and aspirations also influence willingness to seek mental healthcare. Interestingly, most of these intrapersonal factors are tightly interwoven with the participant’s appraisals of how the prison conditions influence their mental health. This study also addresses an important knowledge gap in the literature, namely how restrictions on access to mental health information could influence mental health help-seeking for people in prison. The identified core category, “Breaking down barriers”, reflects an overarching focus on solutions to improving mental healthcare access based on the experiences of the participants in this study.

Access to health information

Knowledge of available services and how to access them is a prerequisite for mental health help-seeking [ 80 ]. The participants in our study claimed that information about mental health services was unsatisfactory, and lack of such information has also been noted as a barrier to help-seeking in other prison-based studies [ 44 ]. Moreover, sufficient levels of mental health literacy are positively associated with increased intentions for help-seeking from both informal and formal sources [ 81 ]. The participants in our study reported severely restricted access to their preferred sources of health information and a dependency on others to obtain such information. Since information seeking may occur before individuals are ready to share their health concerns with others, having to rely on others for accessing information is a potential barrier for recognizing mental health problems [ 25 ]. Thus, it is likely that the limited access to mental health information negatively impacts incarcerated persons capacity to manage their own mental health needs. The potential consequences of restrictions on access to health information among people in prison need more research attention. However, findings from other populations suggest that closing the apparent health information gap could be an important intervention for improving help-seeking for mental health problems [ 82 , 83 ].

The social influences on accessing mental healthcare

The participants reported that prison culture reduced their willingness to seek support from fellow incarcerated and the use of professional help for mental health problems. The TBP element “subjective norms” posits that beliefs about the opinions of others may influence the willingness to seek help [ 29 ]. Attributing mental health problems to personal weakness may reflect a stereotyped attitude involved in stigmatizing mental disorders [ 84 ]. Stigma may lead to concerns about what others might think if one were to seek help, and may delay or hinder help-seeking efforts [ 80 , 85 ]. It also seemed to be an important constraint to mental healthcare access in our study. This corresponds with findings from other studies [ 45 , 46 , 47 ] and suggests that fear of appearing weak is also a significant barrier to help-seeking in a Scandinavian prison context. Based on our findings and recommendations, we advise that focus on health education and normalization of mental health problems are measures that could decrease stigma [ 86 ], and increase willingness to seek mental health support and treatment among people in prison.

Although the culture among those incarcerated was perceived to discourage seeking support for mental health problems, fellow incarcerated also played a key role in supporting those who experienced mental health problems. They were more available than other help sources and had lived experience with distress related to imprisonment. Since information about available services was insufficient, fellow incarcerated were also perceived as an important source of information. Thus, naturally occurring peer support seemed to normalize mental health problems, possibly reducing stigma and lowering the threshold for mental health help-seeking. From the literature, we know that peer-based health interventions is effective in correctional settings [ 87 ], and formalizing peer-based health information and support could be beneficial in interventions aiming to increase the use of mental health services.

Beliefs and motivations for help-seeking

The prison environment was embedded in the participants’ beliefs: attributing the onset and worsening of mental health problems to the prison conditions was common among the participants. According to the Theory of Planned Behavior (TPB), attitudes about the potential benefits of help-seeking and alignment with individual goals affect the readiness and willingness to seek professional help [ 29 ]. Our data supported this notion. Some participants abstained from seeking professional help as they did not see how it might benefit them in their goal of improving their living conditions. For others, a prominent motive for seeking professional help was to receive validation and help managing their challenging life situations and the everyday stressors of prison life. A few participants also framed mental health help-seeking as a mission to document the consequences of imprisonment. By sharing their experiences with professionals, they hoped healthcare personnel could help them advocate for better conditions in prison. Obtaining sufficient knowledge about essential aspects of prison life is essential for health professionals working in a prison setting [ 88 ]. Based on our findings we propose that the ability of healthcare staff to communicate their understanding of the influence of prison living conditions on mental health is crucial for gaining trust and building an alliance with their incarcerated patients.

Another important motivator for many participants seeking help was their aspirations to live a law-abiding life after being released. It has been increasingly recognized that the relationship between mental disorders and criminal activity is complex and that integrated treatment that addresses both criminogenic factors (i.e. antisocial attitudes and behavior, substance use, criminal network, family issues and low educational/vocational engagement) and mental health issues is a must to prevent recidivism [ 89 ]. This view corresponds with the beliefs and preferences for rehabilitation and healthcare of several participants in our study. They were worried about their reintegration into society, which motivated them to seek professional help. Substance use treatment, in particular, was seen as essential to attaining rehabilitative goals. However, some participants who had served multiple sentences were less positive towards help-seeking. They had more negative experiences and seemed less hopeful that mental healthcare could improve their situation. Their low expectations for potential gain combined with a perceived lack of personal control in the help-seeking process, appeared to stall help-seeking for these participants. We suggest that implementing health services with a concurrent focus on addressing both criminogenic needs and mental disorders could be especially important for fostering healthcare utilization for people with a history of reoffending.

Organizational barriers to accessing mental healthcare

The perceived challenges with the paper-based request system were considered a significant barrier to healthcare access. TPB postulates that behavioral control and self-efficacy are important in help-seeking [ 29 ]. In a system where autonomy is limited, one could assume that a self-referral system can be empowering for those seeking help. However, the participants seemed to experience the opposite as they were left passively waiting for an answer to their request. Some also expressed confidentiality concerns, as they believed that prison officers read the request notes. Thus, the process of accessing health services seemed to diminish, rather than enhance their notions of control and self-efficacy. Improving the reliability of responses to requests and ensuring confidentiality could increase the experience of control in the self-referral process and may also empower imprisoned persons to seek help.

A barrier rooted in the interactions between the individual and the helping services was found in various expressions of skepticism towards “the system” by many participants. Earlier studies have also reported distrust in the system as a barrier to help-seeking [ 41 , 44 ]. Our results elaborate on these findings as the participants spoke of how suicides and severe self-harm by fellow incarcerated people contributed to diminished faith in the system. Some had voiced concern over the health and welfare of peers and had experienced that they were not listened to by the prison officers. According to the participants, many of their fellow incarcerated people had more severe symptoms of mental health problems and did not seem to have access to the help they needed. This confirmed their beliefs that the system took little interest in their mental health, and for some of them this led to a growing feeling of hopelessness and resentment. In addition, the high prevalence of mental disorders in prison implies that incarcerated persons witness people in severe distress regularly and for prolonged periods. This issue is largely unexplored and unrecognized in prison research, and the impact of these experiences on mental well-being and recovery should be investigated further.

Participants who experienced mental distress and adjustment problems had difficulties in accessing mental health services. They needed someone to talk to about their situation that could give them advice on how to cope, however they did not fulfil the criteria for secondary mental health services. Minor mental health problems in Norwegian prisons are to be handled by the prison healthcare services. However, according to the participants their capacity is very limited. This finding corresponds to other studies [ 90 ] documenting that access to integrated mental health services was limited for those with milder mental health problems. In the community, the establishment of low threshold services for people with mental health problems has been an important commitment as early intervention can prevent the development of more serious conditions. This may be even more important for those imprisoned, since coping strategies such as physical activity and seeking social support are less accessible [ 91 ].

Prison officer’s influence on access to mental healthcare

Prison officers were perceived to have a key role as gatekeepers to healthcare. Officers can facilitate access to healthcare by encouraging help-seeking or directly contacting healthcare services based on observations and conversations with incarcerated individuals [ 39 , 41 , 92 ]. The participants in our study pointed out the need for prison officers to take their health concerns more seriously, and that the threshold for contacting healthcare services by their request was too high. In addition, being asked directly about their psychological state by staff members was seen to ease talks about mental health by the participants. Our results support the notion that prison officers that are responsive to the mental healthcare needs of incarcerated persons could build confidence that these needs would be attended to when required [ 92 ]. Thus, ensuring sufficient mental health knowledge and awareness among prison officers of their role in mental healthcare access is an essential task for correctional systems.

Previous studies have found that the correctional systems´ procedures for managing suicidal risk is a potential obstacle for help-seeking. The fear of being moved or placed in a safety cell without personal belongings was identified as a barrier to disclosing suicidal thoughts [ 39 , 93 ]. In Norway, the risk of self-harm and suicide is ideally handled by increasing social contact, activities, monitoring and healthcare. However, in the face of acute mental crisis and severe suicide risk, placing persons in solitary confinement is not an uncommon practice [ 94 ]. Challenges with having incarcerated persons admitted and treated in specialized health care institutions, understaffing, and a lack of central guidelines for handling suicide risk may contribute to the use of solitary confinement for incarcerated persons in acute mental distress in the Norwegian correctional system [ 94 ]. The Norwegian Parliamentary Ombudsman reports that fear of solitary confinement and being placed in a security cell is a barrier to seeking help for suicidal ideations and plans [ 95 ]. In our study, participants who had asked for help when they were in acute distress experienced that the officers assumed that they intended to harm themselves. They were faced with the potential of being transferred to a higher security level or being placed in solitary confinement. Thus, how prison officers respond to incarcerated persons’ reports of acute mental distress could be of critical importance for their willingness to seek help for mental health issues in the future. However, more research on the perceived and actual consequences of disclosing mental distress and suicidal ideations in prison is needed to inform interventions to promote help-seeking.

Enhancing access to mental healthcare in prison

The participants underscore some conditions that may lower the bar mental healthcare utilization. Earlier positive experiences with mental healthcare in the community was mentioned by participants as important for their willingness to seek such services in prison, which also corresponds with findings in earlier studies [ 42 , 96 ]. In addition, the participants saw mental health services that were outreaching and integrated as positive. A few participants also highlighted mental health screening at reception to discover mental disorders that may need intervention. Screening at intake, and outreaching and integrated services are also recommended in the prison research literature [ 88 ]. Our findings show that these recommended measures may also make intuitive sense to incarcerated persons - common for all of them are that they seem to reduce stigma related to utilizing mental healthcare.

Our results indicate that incarcerated persons with both milder and more severe mental disorders experience barriers to accessing mental healthcare. These results are in line with studies from other correctional settings reporting unmet needs due to challenges with access and delivery of mental healthcare [ 37 , 38 , 39 ]. The underutilization of mental health services by incarcerated persons suggests that the ‘degree of fit’ between their needs and the available mental healthcare requires improvement. The World Health Organization (WHO) advocates for correctional systems with health and well-being as an integrated part of their core business and culture [ 33 ]. Along these lines, we found that participants called for a correctional system with mental health higher on the agenda. Some also preferred to seek help for mental health problems from other sources than mental health professionals. This finding supports the recommendation of the WHO that it is important to build mental health competency in all staff members in contact with those imprisoned. As many of the barriers to mental healthcare utilization are rooted in the wider correctional setting, we also suggest that the correctional and healthcare systems, in collaboration, should review their practices to enhance perceived efficacy in accessing healthcare.

Limitations

The data in this study are based on interviews with fifteen participants from three prisons. The participants were self-selected and may have had more knowledge, interest, and willingness to talk about mental health issues than the average person in prison. We cannot claim that the results represent a complete account of access to mental healthcare and help-seeking among incarcerated persons in Norway. However, our findings were consistent with findings from other studies from Norway and correctional settings in some other countries. We have presented details about the participants, method, data, and context to allow others to consider the potential transferability of the results. We hope our findings encourage further research on access to mental healthcare for people in prison.

Mental healthcare that is outreaching and integrated is perceived to facilitate access and decrease stigma. The correctional system should address access to health information, the referral system, and their responses to incarcerated persons who disclose distress to facilitate access to healthcare. Our results also indicate that mental healthcare extends beyond the scope of health services, suggesting that sufficient mental health knowledge and agency is needed at all levels of the correctional system.

Data availability

The data produced in the course of this research is not openly accessible owing to considerations regarding privacy. However, they can be obtained from the corresponding author upon a reasonable request.

Abbreviations

Theory of planned behavior

Mental health literacy

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Acknowledgements

The authors thank the study participants and the correctional facilities for their cooperation.

Open access funding provided by UiT The Arctic University of Norway (incl University Hospital of North Norway). The study was supported by a grant from the North Norway Regional Health Authority (Helse Nord RHF). The funding body had no role in study design, data collection, analysis, or writing of the manuscript. The study was supported by the Publication Fund of UiT The Arctic University of Norway.

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All authors contributed to the conception and design of the study. LES conducted the interviews and their transcription. All authors analyzed the data. LES drafted the manuscript. All authors participated in revising the manuscript and approved the final version.

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Solbakken, L.E., Bergvik, S. & Wynn, R. Breaking down barriers to mental healthcare access in prison: a qualitative interview study with incarcerated males in Norway. BMC Psychiatry 24 , 292 (2024). https://doi.org/10.1186/s12888-024-05736-w

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The experiences and needs of older adults receiving voluntary services in Chinese nursing home organizations: a qualitative study

• Qin Shen 1 &
• Junxian Wu 1  

BMC Health Services Research volume  24 , Article number:  547 ( 2024 ) Cite this article

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Older adults living in nursing home organizations are eager to get voluntary help, however, their past experiences with voluntary services are not satisfactory enough. To better carry out voluntary services and improve the effectiveness of services, it is necessary to have a deeper understanding of the experiences and needs of older adults for voluntary services.

The purposive sampling method was used to select 14 older adults from two nursing home organizations in Hangzhou and conduct semi-structured interviews, Collaizzi’s seven-step method was used to analyze the data.

Older adults in nursing home organizations have both beneficial experiences and unpleasant service experiences in the process of receiving voluntary services; Beneficial experiences include solving problems meeting needs and feeling warmth and care, while unpleasant service experiences include the formality that makes it difficult to benefit truly, lack of organization, regularity, sustainability, and the mismatch between service provision and actual demands. The needs for voluntary services mainly focuses on emotional comfort, Cultural and recreational, and knowledge acquisition.

Older adults in nursing home organizations have varied voluntary experiences, and their voluntary service needs are diversified. Voluntary service needs of older adults should be accurately assessed, and voluntary service activities should be focused upon.

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Introduction

As a result of advancements in medical technology and improved sanitation conditions, the average life expectancy of Chinese people has increased significantly from 60 years in 1970 to 77.3 years in 2023. However, this has led to a growing number of older adults in China. According to the seventh population census conducted by the National Bureau of Statistics of China, there are now 260 million people over the age of 60 living in the country [ 1 ], The aging population in China is growing, and population balance is becoming a core challenge for the country in the long term. The increasing aging population has posed significant challenges and burdens to the state and society [ 2 ], China’s aging population challenges the current security system, requiring significant efforts from the state and society for improvement [ 3 ].

There are three main modes of old-age care in China: family old-age care, community old-age care, and institutionalized old-age care. Family old-age care is the most traditional form of old-age care in China, due to the reduction in family size and the formation of the “4-2-1” family model - which consists of four older adults, one couple, and one child - the traditional family model is no longer able to meet the growing demand for older adults care [ 4 ]; China’s community old-age care is still in the exploratory stage, facing challenges such as slow construction, insufficient staff, and lack of professional knowledge. As a result, it cannot provide meticulous care services for older adults [ 5 ]. Against this background, institutionalized older adult care has gradually become popular, it refers to older adults in social service organizations such as senior citizen apartments, welfare homes, and homes for older adults to spend their later life [ 6 ]. The challenges of population aging and the inadequacies of family and community support for older adults have resulted in a growing number of older adults opting to reside in nursing home organizations. This has undoubtedly placed additional burdens and challenges on these nursing home organizations. Due to multiple challenges such as late start, low quality, and lack of professional and technical talents, China’s nursing home organizations are still a long way from meeting the comprehensive needs of older adults in terms of health management, skilled nursing care, rehabilitation training, cultural and recreational services, psychological counseling, and social interaction [ 7 ]. To tackle the issue of an aging population in China and ensure that older adults have a high quality of life when choosing nursing home organizations, it is necessary to enhance the quality of older adult care services by engaging social forces, such as volunteer teams [ 8 ]. Voluntary services refer to the voluntary, unpaid public service offered by individuals, organizations, and voluntary service organizations to society or other organizations. The forms of voluntary services are diverse and can be either formal, planned, and long-term, or informal, spontaneous, and intermittent [ 9 ]. At present, volunteer groups in China’s nursing home organizations are mostly informal and consist of university students, healthcare workers, art workers, social workers, and others. These groups are invited by nursing home organizations or come to these institutions on their initiative to provide services for older adults. These services include a wide range of activities such as haircutting, cultural performances, spiritual comfort, hobby learning (e.g., paper-cutting, flower arranging), organizing festive activities (e.g., making rice dumplings on-site at Dragon Boat Festival, making mooncakes at Mid-Autumn Festival, etc.).

Voluntary services are a crucial aspect of long-term care and greatly complement the resources provided by the government,these nursing home organizations welcome volunteers who perform various non-medical activities associated with the daily lives of older adults [ 10 , 11 , 12 ]. Volunteers offer additional assistance and companionship to residents, provide support to employees such as nurses, nutritionists, and physical therapists, and potentially improve the overall quality of care, in China, these services have become increasingly popular and play a crucial role [ 13 , 14 ]. However, some problems have emerged in voluntary services, The voluntary services provided by volunteer organizations for older adults have certain functional defects and efficiency dilemmas, such as an unsound volunteer management system, high mobility of volunteers, and lack of a corresponding volunteer training system, which leads to the inability to provide high-quality services [ 13 ]. The above problems have undermined the effectiveness of voluntary services and affected the regular operation of nursing home organizations [ 15 ].

For effective services for older adults, it’s critical to understand the needs and experiences of older adults in nursing home organizations, there have been limited studies on how older adults feel about receiving voluntary services and if such services are suitable for their actual needs. One qualitative study documented the experiences of older adults who were helped by volunteers, but it was mainly focused on the volunteers themselves [ 16 ]. Another study looked into the benefits and experiences of receiving voluntary services, but it specifically focused on older adults who were confined to their homes [ 17 ]. There is no research available that sheds light on the emotions and requirements of older adults who receive voluntary services in nursing home organizations. To bridge this gap, we conducted interviews with older adults who have been accepted for voluntary services in two nursing home organizations in Hangzhou. The objective of this study is to gain a deeper understanding of the actual needs and experiences of older adults and use this information to guide promoting the effective growth of voluntary services and establishing a voluntary service system that is suitable for older adults in nursing home organizations.

This study adopts a qualitative descriptive approach to examine the experiences and expectations of older adults in nursing home organizations when receiving voluntary services. This study aims to gain a comprehensive understanding of the actual experiences and needs of older adults residing in nursing home organizations regarding receiving voluntary services and explore the types of voluntary services that are most suitable for the needs of older adults. To ensure accuracy and transparency, the authors followed the Consolidated Standards for Reporting Qualitative Research (COREQ) guidelines when reporting their findings [ 18 ].

Participants

During June-August 2023, the authors used purposive sampling to sample older adults residing in two nursing home organizations in Hangzhou, the inclusion criteria for the interview subjects were as follows:

they had to have resided in the nursing home organizations for more than a year;

they had to have received voluntary services;

they had to be conscious and able to express themselves effectively;

they had to have given informed consent and voluntarily agreed to participate in the study.

The number of people participating in the study was decided based on information saturation, this means the interviews were conducted until no new topics emerged and responses were repeated, the data from the twelfth interview indicated that saturation had been reached as confirmed by the other two interviews. This research principle was based on previous qualitative research studies [ 19 ]. A total of 14 older adults, coded N1-N14, were included in this study. All older adults who participated in the study agreed to the interview process, and none withdrew during the study. Detailed information can be found in Table  1 .

Interview outline

We developed an interview outline after thoroughly reviewing the literature sources and consulting with the research group [ 20 , 21 ]. We selected two older adults living in nursing home organizations to conduct pre-interviews, we adjusted the interview outline based on the feedback we received from the pre-interviews.

The interview will cover the following topics:

Please describe the voluntary services you have received in detail. How do you feel about receiving these services?

Are you satisfied with the voluntary service you have received? What aspects of the service make you satisfied?

What are your dissatisfactions with the voluntary service? Why do you feel that way?

What are your expectations and needs for the voluntary service’s content, form, and volunteers?

Is there anything else you would like to add to the discussion?

Data collection

A semi-structured interview method was utilized to gather data for this study. The main researcher, (a master’s degree nursing student) has been trained in qualitative research methods and has mastered the semi-structured interview techniques required to conduct interviews independently. Additionally, the researcher has participated in various volunteer activities in nursing organizations and has established a trustworthy relationship with the interviewees. Before conducting the interviews, the main researcher explained the study’s purpose and methodology to the interviewees and, after acquiring their consent, scheduled an appointment in advance. Face-to-face interviews were conducted with the respondents in a quiet, private, comfortable conference room. During the interview, the researcher recorded the entire process with the respondent’s consent without interrupting the respondent unnecessarily. The researcher confirmed the key concerns and the content that the respondent could not express clearly by repeating, asking follow-up questions, and asking rhetorical questions. The researcher also promptly recorded the respondent’s non-verbal information, such as movements, expressions, and tone of voice. Each interview lasted 30–45 min, and after conducting 14 interviews, no new information was obtained, indicating data saturation and ending the interview process. At the end of the interview, each interviewee was given a small token of appreciation.

Data analysis

The audio recordings of the interviews were transcribed into text within 24 h of completion, non-verbal information was noted in the transcript at relevant places. The transcribed information was then entered into the NVIVO 11.0 software (QST International, Cambridge, MA, USA) for data extraction, coding, and integration. Two researchers independently analyzed and coded the data, and the results were compared to identify common themes. Any discrepancies were resolved after the research team had discussed them to ensure that the data was complete and the analysis was accurate. Colaizzi’s seven-step analysis method was used to refine the themes from the interviews, which involved the following steps [ 22 ]:

Carefully read all the transcriptions of the interviews.

Analyze the significant statements made by the interviewees.

Code the recurring and meaningful ideas discussed in the interviews.

Gather the coded ideas and form the theme clusters.

Define and describe the themes from the coded ideas.

Identify similar ideas and sublimate the theme concepts.

Return the results to the interviewees for verification, and revision, and add the results based on the feedback from the interviewees. For detailed coding results, please see Table  2 .

After the data analysis was summarized, two main themes were identified: Experiences and Needs for volunteerism.

Theme 1: experiences

Beneficial experiences, solving problems and meeting needs.

Many older adults currently reside in nursing home organizations that are situated far away from their children and friends, they often face difficulties in getting help promptly when they encounter problems, which can affect their daily lives. For instance, in today’s rapidly developing society, many older adults own smartphones but lack the necessary knowledge to use them effectively. This, in turn, reduces their social participation and increases their sense of isolation. However, voluntary services have been instrumental in assisting them in overcoming these hurdles and leading a more fulfilling life.

N11: “When the volunteers come to teach me how to use computers, I ask them something that I don’t understand, and the teacher will explain it to me immediately.” N1: “I don’t know how to buy things online. Volunteers taught me little by little, and after a few teaching sessions, I learned how to do it so I don’t have to bother the caregiver every time. I can also do online shopping by myself, and I feel that life is much more convenient.”

Some respondents stated that volunteers could fulfill their needs. Professional volunteers also taught older adults Chinese medicine and health care and assisted with self-care.

N12: “I’m interested in Chinese medicine health care knowledge, and when students from the University of Traditional Chinese Medicine come over, and I ask them What are the functions of different acupoints, they tell me how to press them to make them work.”

Feel warmth and care

Many older adults live in nursing home organizations, away from their familiar environment and social network. This isolation can generate a sense of loneliness, making them more eager for emotional support. Volunteers provide services to add joy to the lives of older adults so that they feel cared for. Interviewees have mentioned that being taken care of on their initiative makes them feel warm and touched, increasing their overall sense of well-being.

N10: “I am delighted when I participate in volunteering, I feel that I have a group life again, I am pleased, I feel that someone cares about us.” N8: “Volunteers come to serve us, feel that people still care about us older adults, and now the country also cares about us, and society also cares about us, I am thrilled.”

Some respondents said that having someone to talk to and greet them would make them feel happy and that they were willing to communicate with young people and accept their new ideas.

N2: “As soon as I see you young people, I am happy, I feel the atmosphere of youth, my mood is different, I feel less lonely.”

Unpleasant service experiences

A formality that makes it difficult to benefit truly.

According to the interviewees, there are certain formalized phenomena in the domain of volunteering. Some volunteers engage in volunteering activities to obtain a certificate, such certificates can help them get extra points at work. Some volunteers participated in volunteering based on the mentality of the herd under the organizational arrangements of their schools or enterprises. These volunteers lack initiative, violate the principle of voluntarism, and cannot provide services that genuinely benefit older adults due to their single-mindedness and formalism during the service process. As a result, older adults have a poorer sense of experience.

N7: “Some volunteers are asked to serve by their companies, and they have to finish the job; some just go through a process.” N13: “Many volunteers come over to perform a show, then take photos and leave; the service time is very short, just like completing a task.” N5: “Some volunteers are very perfunctory; they come for a while and leave quickly.”

Lack of organization, regularity, sustainability

Many volunteers offer their services without compensation, while they have their formal jobs, which makes it difficult for them to provide services consistently. Additionally, volunteers may be more mobile, which can result in a lack of continuity in the services that are provided and the target groups that are served. However, older adults living in nursing home organizations often have monotonous and lonely lives, and occasional voluntary services may not be enough to meet their needs. As a result, some older adults may feel dissatisfied with the irregular and unsustainable nature of voluntary services.

N12: “Volunteers come on an ad hoc basis; they are not regular. Recently, a school teacher came to teach us how to sing, but unfortunately, they had to leave due to commitments and have not been able to come back.’’ N5: “Volunteers can’t come regularly; they come once in a while or not regularly and don’t have a plan.” N7: “Volunteers come to the nursing home occasionally, so they don’t want to bother them.”

The mismatch between service provision and actual demand

The voluntary services provided to older adults in nursing institutions were not able to match their real needs as the volunteers had no prior knowledge of their needs and did not make any advance preparations.

N4: “Last time, a volunteer came and asked me if I needed help with cleaning. However, I declined their kind offer because caregivers in the nursing home clean rooms every day, and the volunteers could not address the specific things I needed help with.”

The needs of older adults for volunteering can vary significantly based on their experiential backgrounds, and physiological and psychological conditions. Therefore, providing the same services to all older adults can lead to negative feelings towards volunteering among them.

N10: “Some volunteers come just to dance and sing, it feels very noisy. I don’t want to participate, I want the volunteers to talk to me peacefully and quietly.” N14: “I am not very good with my legs, so it is difficult for me to participate in activities organized by the volunteers downstairs. I would like to find activities I can participate in in my room, such as playing games or doing crafts.”

Theme 2 needs for volunteerism

Needs for emotional comfort.

Many older adults live in semi-closed institutions where they lack long-term support from their families and struggle to find someone to talk to. During the epidemic, nursing home organizations prohibited visitors to prevent the spread of the virus, leaving many seniors alone and cut off from the outside world. As a result, many older adults experience feelings of loneliness and depression. To help combat these negative emotions, volunteers can provide companionship and support, which can effectively reduce feelings of loneliness and promote emotional well-being.

N1: “I hope someone will come and chat with us; many older adults have no way to contact the outside world, so they have psychological barriers, they need psychological counseling, they need someone to come and chat with them to relieve their loneliness.” N10: “It’s better to have volunteers to come over to the service, to come and chat with me, to visit me.” N12: “I would like volunteers to communicate with us, tell us what is happening outside, tell us something new.”

Cultural and recreational needs

As people age, their social interactions tend to decrease, and they gradually tend to withdraw from daily life. This results in older adults having more free time after their retirement. Nursing home organizations can provide basic living care and medical assistance for older adults, which relieves them of the burden of cooking, cleaning, and shopping. This also means they have more free time than those who live at home or in the community. Many older adults wish to participate in cultural and recreational activities, such as singing, dancing, sports, and watching performances, to add excitement to their lives. They hope that volunteers can organize such activities to help them reduce their loneliness and spend their time in a meaningful way.

N14: “It’s good for volunteers to come and teach us how to dance, sing, and sing opera, and time passes a little faster when we all get together and learn.” N2: “It is popular for volunteers to bring cultural performances to our nursing home, we love to see young people performing programs, singing some classic old songs or Peking Opera, it is very popular.” N9: “We would like to play tai chi, it is a very suitable sport for us as it strengthens the body and the movements are softer, it would be nice if a teacher could teach us.”

Knowledge acquisition needs

According to Maslow’s Hierarchy of Needs Theory, individuals will naturally shift their focus toward higher-level pursuits once their basic and low-level needs are met. In the case of older adults residing in nursing home organizations, their basic material needs are taken care of, and as a result, their need for knowledge and learning becomes increasingly important. Many older adults require assistance in learning how to use electronic equipment, which can help facilitate their communication with the outside world and reduce feelings of isolation.

N1: “It’s become very convenient to buy things online, but I don’t know how to operate it myself and would like someone to teach me.” N2: “My daughter bought me an expensive Apple phone, but I am unfamiliar with how to use it. It would be great if someone could systematically instruct me on how to use the smartphone.” N8: “I don’t know how to use my smartphone, I don’t understand many functions, so I would benefit from having a teacher to guide me.”

As individuals age, their bodily and cognitive functions may deteriorate, adversely affecting their quality of life. Basic healthcare knowledge can be critical for older adults to maintain good health. Many older adults have a strong desire to learn about nutritional diets, rational exercise, and traditional Chinese medicine physiotherapy as a means of improving their health.

N9: “Volunteers can come and talk to us about medicine and how to predict dementia.” N13: “I have high blood pressure and cholesterol. I need advice on what to eat and what to avoid.”

To prevent any disagreements regarding the distribution of their assets among their heirs after they pass away, older adults seek the help of volunteers to assist them in drafting a will that is by national policies and regulations and has legal validity.

N12: “Volunteers can help us learn how to write a will effectively and can avoid unnecessary trouble and conflicts in the future.”

The current situation of voluntary experiences of older adults in nursing home organizations

Analysis of beneficial experiences.

The study’s findings indicate that individuals residing in nursing home organizations who are of advanced age have mixed experiences when it comes to receiving voluntary services. Most respondents conveyed the warmth and care emanating from the volunteers and the society towards older adults. Furthermore, they shared that volunteering offered them a means to engage in activities actively, create connections with fellow older adults, and foster mutual support and camaraderie. This social participation has the potential to enhance the mental well-being of older adults, thereby decreasing feelings of loneliness and depression [ 17 ]. Voluntary activities like smartphone training can help older adults acquire the necessary needed skills and adapt better to modern technology and life. Competent skills are crucial for older adults, particularly in today’s fast-developing technological society, where electronic devices such as smartphones are becoming increasingly popular. However, many older adults need more skills to operate these devices and thus cannot fully utilize them. Through training, older adults can learn how to use smartphones, including sending text messages, browsing the web, using social media, downloading applications, and more. Learning these skills not only improves the quality of life of older adults but also helps them stay connected with family and friends, thereby reducing loneliness.

Improved skills can assist older adults in accessing and utilizing health information, including online medical advice and health apps. This information can aid in managing their health status, preventing and managing chronic illnesses, and ultimately improving their quality of life. Volunteering is crucial in nursing home organizations. It provides numerous benefits to older adults, including enhancing their mental health and quality of life and receiving the necessary support and care by participating in voluntary activities [ 23 ].

Analysis of unpleasant experiences

During the interviews, some older adults shared negative experiences regarding the content, form, and frequency of voluntary services. They pointed out that volunteers did not understand their needs in advance, focusing too much on material assistance and neglecting their psychological and intellectual needs. Additionally, the service process is often too process-oriented and formalized, with less interaction with older adults, resulting in voluntary services failing to meet their expectations.

Research suggests that negative experiences of receiving voluntary services may impact older adults’ willingness to seek help and the effectiveness of voluntary services. Therefore, when providing voluntary services to older adults, it is essential to take the initiative to understand their experiences and continuously optimize the voluntary program. This approach is crucial to improving the quality of voluntary services [ 24 ].

The current situation of the demands for voluntary services by older adults

The study results show that nursing home organizations can provide comprehensive life care services to older adults, meaning they do not require many voluntary services for life care. However, this does not imply that older adults’ needs are met. Their need for emotional support, cultural recreation, and knowledge-seeking and learning is highly concentrated.

When older adults leave their familiar family environment to move into care institutions, they may experience feelings of loneliness and boredom due to the lack of regular interaction with their children, family members, and friends. This sense of isolation can harm their mental health, and they may seek more opportunities to communicate and interact with younger individuals to gain emotional comfort [ 25 ].

As people age, cultural entertainment and knowledge learning become essential for spiritual growth. After their basic living needs are taken care of, older adults desire more fulfilling recreational activities, such as calligraphy, painting, and singing, these activities enrich the spiritual life of older adults and benefit their physical and mental health [ 26 ].

In today’s rapidly developing society, the widespread use of smartphones and the popularity of online shopping have led to a digital divide among older adults. This phenomenon has, to some extent, hindered their social participation and increased their sense of isolation. Consequently, there is a growing demand for voluntary services that assist with smartphone use and can help them enjoy a convenient and fulfilling digital life.

The need for voluntary services for older adults has changed over time. While they still require help with their daily living, they also need emotional support, cultural engagement, and opportunities to learn new things. We should focus on meeting these needs to ensure our voluntary services are beneficial. By doing so, we can help older adults live fulfilling, healthy, and happy lives in their later years [ 27 ].

Suggestions and strategies for optimizing volunteerism

Accurately assessing older adults’ voluntary service needs.

The study results reveal that some older adults have negative experiences with voluntary services that fail to meet their actual needs, leading to unsatisfactory service outcomes. This highlights the need to accurately identify the real service needs of older adults to improve the quality and effectiveness of voluntary services.

To achieve our goal, we need to take a series of steps. Firstly, we must create appropriate tools for evaluating the needs of older adults for voluntary services. We should also clarify the assessment methods and strategies for assessing these needs, before launching voluntary services, relevant organizations and volunteers must understand older adults’ service experience and needs through qualitative and quantitative assessment methods [ 28 ].

To improve the quality and effectiveness of voluntary services for older adults, we can utilize big data technology to carry out precise reforms. This involves building a unified information platform for voluntary services that enables a quick match between the needs of older adults and the specialties of volunteers through the co-construction, sharing, and everyday use of resource information [ 29 ]. By doing so, we can provide multi-level, multi-category, and personalized voluntary services that cater to the actual needs of older adults, thus achieving the purpose of “precise service.”

In conclusion, we must prioritize the actual needs of older adults and provide them with more personalized and intimate voluntary services by continuously improving the assessment tools and information platforms with the orientation of precise services, the use of big data technology will play a key role in helping us realize the goal of efficient and accurate services.

Improving the quality management system of voluntary services

Volunteering quality refers to the quality of services volunteers provide, as perceived by the direct recipients. Research has shown that low-quality voluntary services fail to achieve their intended goals, moreover, negative experiences of receiving voluntary services may discourage older adults from seeking help in the future. The study highlights a significant gap between older adults’ experience of volunteering quality and their expectations, therefore, it is necessary to strengthen the management of volunteering quality to ensure that expectations are met.

To enhance the quality of volunteering, we need to implement measures. Firstly, we must optimize the recruitment and selection system for volunteers, this entails formulating recruitment plans and selection requirements that align with the voluntary services needs of older adults. We aim to create a stable and committed volunteer team skilled in services knowledge and job skills and willing to participate in voluntary services for an extended period [ 30 ].

To enhance the level and quality of service, it is important to provide regular and standardized training to volunteers. Volunteers should receive professional information support services, such as training on volunteer spirit, etiquette, communication skills, and the physiological and psychological characteristics of older adults. The main forms of training include information consultation, professional knowledge, technology lectures, sharing of previous volunteer experiences, summarizing stage-by-stage voluntary services, and experiential services. Volunteers should be provided with face-to-face or online interaction to help them improve their ability to assist older adults. The training for volunteering encompasses theoretical knowledge about volunteering, including its characteristics and principles, the rights and interests of service users, and respect for them. It also includes basic knowledge of social work, such as interpersonal communication methods and skills, as well as knowledge of health care for older adults. The latter includes the introduction of general knowledge about daily life care for older adults, such as diet, hygiene, and exercise, and the evaluation of the training’s effectiveness. Both voluntary service organizations and nursing home organizations should participate in the training process, only volunteers who have completed the training and assessment can engage in service activities [ 31 ]. It is essential to improve the evaluation mechanism of voluntary service quality. This can be done by creating a scientific evaluation index system involving older adults in evaluating their satisfaction with the voluntary service program and conducting a comprehensive analysis of the evaluation results. This analysis can help to optimize and improve the service program, additionally, tracking and evaluating the effectiveness of optimization measures to continuously enhance service quality is crucial [ 32 ].

Improving the quality of voluntary services is a comprehensive project that enhances various aspects, such as volunteer recruitment, training, and service quality evaluation. This systematic approach can help serve the nursing home organizations better and improve their overall quality of life.

Strengths and limitations

The paper’s strength lies in its focus on the experience of older adults in nursing institutions when receiving voluntary services and their need for such services. This study’s understanding of the real feelings and needs of older adults is beneficial for various organizations in society to provide better services in a targeted manner. However, the study’s limitation is that it mainly focuses on the more developed areas of Hangzhou, which affects the sample’s representativeness and makes it challenging to reflect the general situation of older adults in nursing home organizations. Additionally, the author’s subjective viewpoints may affect the analysis of the material during the data analysis process. Finally, the sample size of this study is relatively small, and there may be individual differences in personality, physical condition, and economic situation, among others. Therefore, expanding the sample size and the region’s scope to carry out more in-depth research is necessary.

This research explored the experiences and requirements of older adults who receive voluntary services in Chinese care homes. The study categorized their experiences into two groups: beneficial experiences and unpleasant service experiences, the needs of older adults who receive voluntary services include emotional comfort, cultural and recreational, and knowledge acquisition. It is crucial to have a timely and comprehensive understanding of the experiences and needs of older adults to create a targeted voluntary service model, standardized management, and training of volunteers in nursing home organizations.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. The datasets are not publicly available due to confidentiality and ethical restrictions.

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Acknowledgements

We want to express our heartfelt appreciation to the 14 older adults who participated in the interview and shared their experiences. We are also grateful to the administrators of nursing home organizations in Hangzhou, Zhejiang Province, for granting us access and allowing us to conduct the interviews at their facility. Their cooperation was invaluable in gaining insights into the needs of older adults.

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Li, L., Shen, Q. & Wu, J. The experiences and needs of older adults receiving voluntary services in Chinese nursing home organizations: a qualitative study. BMC Health Serv Res 24 , 547 (2024). https://doi.org/10.1186/s12913-024-11045-5

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Reconfiguring european industry for net-zero: a qualitative review of hydrogen and carbon capture utilization and storage benefits and implementation challenges †.

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Based on a rich corpus of original mixed-methods research, this paper explores the benefits, barriers, and justice impacts of industrial decarbonization via hydrogen and carbon capture utilization and storage (CCUS) via European industrial firms located in UK clusters. It asks: (1) what are the technology dynamics and drivers of both hydrogen and CCUS in a real-world deployment context, including the state of deployment plans? (2) what are the possible benefits of CCUS and hydrogen deployment? (3) What are the most significant barriers and challenges facing CCUS and hydrogen implementation? (4) Who stands to “win” the most from deployment, who stands to “lose,” what possible inequitable community impacts could emerge, and what impact will deployment have on vulnerable groups? We offer answers to these four questions based on extensive semi-structured research interviews ( N = 111) triangulated with site visits to industrial clusters ( N = 52) as well as an extensive secondary review of the academic literature. We conclude with clear policy insights that are now prevalent across UK and European industrial clusters as well as emerging and context-specific recommendations concerning the adoption of hydrogen and CCUS to achieve net-zero industry globally.

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Qualitative study.

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• Introduction

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

Qualitative research at its core, ask open-ended questions whose answers are not easily put into numbers such as ‘how’ and ‘why’. [2] Due to the open-ended nature of the research questions at hand, qualitative research design is often not linear in the same way quantitative design is. [2] One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. [3] Phenomena such as experiences, attitudes, and behaviors can be difficult to accurately capture quantitatively, whereas a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a certain time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify and it is important to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore ‘compete’ against each other and the philosophical paradigms associated with each, qualitative and quantitative work are not necessarily opposites nor are they incompatible. [4] While qualitative and quantitative approaches are different, they are not necessarily opposites, and they are certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined that there is a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated together.

Examples of Qualitative Research Approaches

Ethnography

Ethnography as a research design has its origins in social and cultural anthropology, and involves the researcher being directly immersed in the participant’s environment. [2] Through this immersion, the ethnographer can use a variety of data collection techniques with the aim of being able to produce a comprehensive account of the social phenomena that occurred during the research period. [2] That is to say, the researcher’s aim with ethnography is to immerse themselves into the research population and come out of it with accounts of actions, behaviors, events, etc. through the eyes of someone involved in the population. Direct involvement of the researcher with the target population is one benefit of ethnographic research because it can then be possible to find data that is otherwise very difficult to extract and record.

Grounded Theory

Grounded Theory is the “generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior.” [5] As opposed to quantitative research which is deductive and tests or verifies an existing theory, grounded theory research is inductive and therefore lends itself to research that is aiming to study social interactions or experiences. [3] [2] In essence, Grounded Theory’s goal is to explain for example how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.

Phenomenology

Phenomenology is defined as the “study of the meaning of phenomena or the study of the particular”. [5] At first glance, it might seem that Grounded Theory and Phenomenology are quite similar, but upon careful examination, the differences can be seen. At its core, phenomenology looks to investigate experiences from the perspective of the individual. [2] Phenomenology is essentially looking into the ‘lived experiences’ of the participants and aims to examine how and why participants behaved a certain way, from their perspective . Herein lies one of the main differences between Grounded Theory and Phenomenology. Grounded Theory aims to develop a theory for social phenomena through an examination of various data sources whereas Phenomenology focuses on describing and explaining an event or phenomena from the perspective of those who have experienced it.

Narrative Research

One of qualitative research’s strengths lies in its ability to tell a story, often from the perspective of those directly involved in it. Reporting on qualitative research involves including details and descriptions of the setting involved and quotes from participants. This detail is called ‘thick’ or ‘rich’ description and is a strength of qualitative research. Narrative research is rife with the possibilities of ‘thick’ description as this approach weaves together a sequence of events, usually from just one or two individuals, in the hopes of creating a cohesive story, or narrative. [2] While it might seem like a waste of time to focus on such a specific, individual level, understanding one or two people’s narratives for an event or phenomenon can help to inform researchers about the influences that helped shape that narrative. The tension or conflict of differing narratives can be “opportunities for innovation”. [2]

Research Paradigm

Research paradigms are the assumptions, norms, and standards that underpin different approaches to research. Essentially, research paradigms are the ‘worldview’ that inform research. [4] It is valuable for researchers, both qualitative and quantitative, to understand what paradigm they are working within because understanding the theoretical basis of research paradigms allows researchers to understand the strengths and weaknesses of the approach being used and adjust accordingly. Different paradigms have different ontology and epistemologies . Ontology is defined as the "assumptions about the nature of reality” whereas epistemology is defined as the “assumptions about the nature of knowledge” that inform the work researchers do. [2] It is important to understand the ontological and epistemological foundations of the research paradigm researchers are working within to allow for a full understanding of the approach being used and the assumptions that underpin the approach as a whole. Further, it is crucial that researchers understand their own ontological and epistemological assumptions about the world in general because their assumptions about the world will necessarily impact how they interact with research. A discussion of the research paradigm is not complete without describing positivist, postpositivist, and constructivist philosophies.

Positivist vs Postpositivist

To further understand qualitative research, we need to discuss positivist and postpositivist frameworks. Positivism is a philosophy that the scientific method can and should be applied to social as well as natural sciences. [4] Essentially, positivist thinking insists that the social sciences should use natural science methods in its research which stems from positivist ontology that there is an objective reality that exists that is fully independent of our perception of the world as individuals. Quantitative research is rooted in positivist philosophy, which can be seen in the value it places on concepts such as causality, generalizability, and replicability.

Conversely, postpositivists argue that social reality can never be one hundred percent explained but it could be approximated. [4] Indeed, qualitative researchers have been insisting that there are “fundamental limits to the extent to which the methods and procedures of the natural sciences could be applied to the social world” and therefore postpositivist philosophy is often associated with qualitative research. [4] An example of positivist versus postpositivist values in research might be that positivist philosophies value hypothesis-testing, whereas postpositivist philosophies value the ability to formulate a substantive theory.

Constructivist

Constructivism is a subcategory of postpositivism. Most researchers invested in postpositivist research are constructivist as well, meaning they think there is no objective external reality that exists but rather that reality is constructed. Constructivism is a theoretical lens that emphasizes the dynamic nature of our world. “Constructivism contends that individuals’ views are directly influenced by their experiences, and it is these individual experiences and views that shape their perspective of reality”. [6] Essentially, Constructivist thought focuses on how ‘reality’ is not a fixed certainty and experiences, interactions, and backgrounds give people a unique view of the world. Constructivism contends, unlike in positivist views, that there is not necessarily an ‘objective’ reality we all experience. This is the ‘relativist’ ontological view that reality and the world we live in are dynamic and socially constructed. Therefore, qualitative scientific knowledge can be inductive as well as deductive.” [4]

So why is it important to understand the differences in assumptions that different philosophies and approaches to research have? Fundamentally, the assumptions underpinning the research tools a researcher selects provide an overall base for the assumptions the rest of the research will have and can even change the role of the researcher themselves. [2] For example, is the researcher an ‘objective’ observer such as in positivist quantitative work? Or is the researcher an active participant in the research itself, as in postpositivist qualitative work? Understanding the philosophical base of the research undertaken allows researchers to fully understand the implications of their work and their role within the research, as well as reflect on their own positionality and bias as it pertains to the research they are conducting.

Data Sampling 

The better the sample represents the intended study population, the more likely the researcher is to encompass the varying factors at play. The following are examples of participant sampling and selection: [7]

• Purposive sampling- selection based on the researcher’s rationale in terms of being the most informative.
• Criterion sampling-selection based on pre-identified factors.
• Convenience sampling- selection based on availability.
• Snowball sampling- the selection is by referral from other participants or people who know potential participants.
• Extreme case sampling- targeted selection of rare cases.
• Typical case sampling-selection based on regular or average participants. 

Data Collection and Analysis

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

While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or in the environment of the participants, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed which may then be coded manually or with the use of Computer Assisted Qualitative Data Analysis Software or CAQDAS such as ATLAS.ti or NVivo. [8] [9] [10]

After the coding process, qualitative research results could be in various formats. It could be a synthesis and interpretation presented with excerpts from the data. [11] Results also could be in the form of themes and theory or model development.

Dissemination

To standardize and facilitate the dissemination of qualitative research outcomes, the healthcare team can use two reporting standards. The Consolidated Criteria for Reporting Qualitative Research or COREQ is a 32-item checklist for interviews and focus groups. [12] The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a wider range of qualitative research. [13]

Examples of Application

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

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

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

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

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

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

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

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

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

The researcher could try to have the parks department reassess the shady areas to make them less conducive to the smokers or identify how to limit the sales of cigarettes to underage individuals by the convenience store. The researcher would then cycle back to qualitative methods of asking at-risk population their perceptions of the changes, what factors are still at play, as well as quantitative research that includes teen smoking rates in the community, the incidence of new teen smokers, among others. [14] [15]

Qualitative research functions as a standalone research design or in combination with quantitative research to enhance our understanding of the world. Qualitative research uses techniques including structured and unstructured interviews, focus groups, and participant observation to not only help generate hypotheses which can be more rigorously tested with quantitative research but also to help researchers delve deeper into the quantitative research numbers, understand what they mean, and understand what the implications are.  Qualitative research provides researchers with a way to understand what is going on, especially when things are not easily categorized. [16]

• Issues of Concern

As discussed in the sections above, quantitative and qualitative work differ in many different ways, including the criteria for evaluating them. There are four well-established criteria for evaluating quantitative data: internal validity, external validity, reliability, and objectivity. The correlating concepts in qualitative research are credibility, transferability, dependability, and confirmability. [4] [11] The corresponding quantitative and qualitative concepts can be seen below, with the quantitative concept is on the left, and the qualitative concept is on the right:

• Internal validity--- Credibility
• External validity---Transferability
• Reliability---Dependability
• Objectivity---Confirmability

In conducting qualitative research, ensuring these concepts are satisfied and well thought out can mitigate potential issues from arising. For example, just as a researcher will ensure that their quantitative study is internally valid so should qualitative researchers ensure that their work has credibility.  

Indicators such as triangulation and peer examination can help evaluate the credibility of qualitative work.

• Triangulation: Triangulation involves using multiple methods of data collection to increase the likelihood of getting a reliable and accurate result. In our above magic example, the result would be more reliable by also interviewing the magician, back-stage hand, and the person who "vanished." In qualitative research, triangulation can include using telephone surveys, in-person surveys, focus groups, and interviews as well as surveying an adequate cross-section of the target demographic.
• Peer examination: Results can be reviewed by a peer to ensure the data is consistent with the findings.

‘Thick’ or ‘rich’ description can be used to evaluate the transferability of qualitative research whereas using an indicator such as an audit trail might help with evaluating the dependability and confirmability.

• Thick or rich description is a detailed and thorough description of details, the setting, and quotes from participants in the research. [5] Thick descriptions will include a detailed explanation of how the study was carried out. Thick descriptions are detailed enough to allow readers to draw conclusions and interpret the data themselves, which can help with transferability and replicability.
• Audit trail: An audit trail provides a documented set of steps of how the participants were selected and the data was collected. The original records of information should also be kept (e.g., surveys, notes, recordings).

One issue of concern that qualitative researchers should take into consideration is observation bias. Here are a few examples:

• Hawthorne effect: The Hawthorne effect is the change in participant behavior when they know they are being observed. If a researcher was wanting to identify factors that contribute to employee theft and tells the employees they are going to watch them to see what factors affect employee theft, one would suspect employee behavior would change when they know they are being watched.
• Observer-expectancy effect: Some participants change their behavior or responses to satisfy the researcher's desired effect. This happens in an unconscious manner for the participant so it is important to eliminate or limit transmitting the researcher's views.
• Artificial scenario effect: Some qualitative research occurs in artificial scenarios and/or with preset goals. In such situations, the information may not be accurate because of the artificial nature of the scenario. The preset goals may limit the qualitative information obtained.
• Clinical Significance

Qualitative research by itself or combined with quantitative research helps healthcare providers understand patients and the impact and challenges of the care they deliver. Qualitative research provides an opportunity to generate and refine hypotheses and delve deeper into the data generated by quantitative research. Qualitative research does not exist as an island apart from quantitative research, but as an integral part of research methods to be used for the understanding of the world around us. [17]

• Enhancing Healthcare Team Outcomes

Qualitative research is important for all members of the health care team as all are affected by qualitative research. Qualitative research may help develop a theory or a model for health research that can be further explored by quantitative research.  Much of the qualitative research data acquisition is completed by numerous team members including social works, scientists, nurses, etc.  Within each area of the medical field, there is copious ongoing qualitative research including physician-patient interactions, nursing-patient interactions, patient-environment interactions, health care team function, patient information delivery, etc. 

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Disclosure: Steven Tenny declares no relevant financial relationships with ineligible companies.

Disclosure: Janelle Brannan declares no relevant financial relationships with ineligible companies.

Disclosure: Grace Brannan declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Tenny S, Brannan JM, Brannan GD. Qualitative Study. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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