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• What Is a Research Design | Types, Guide & Examples

What Is a Research Design | Types, Guide & Examples

Published on June 7, 2021 by Shona McCombes . Revised on November 20, 2023 by Pritha Bhandari.

A research design is a strategy for answering your   research question  using empirical data. Creating a research design means making decisions about:

• Your overall research objectives and approach
• Whether you’ll rely on primary research or secondary research
• Your sampling methods or criteria for selecting subjects
• Your data collection methods
• The procedures you’ll follow to collect data
• Your data analysis methods

A well-planned research design helps ensure that your methods match your research objectives and that you use the right kind of analysis for your data.

Table of contents

Step 1: consider your aims and approach, step 2: choose a type of research design, step 3: identify your population and sampling method, step 4: choose your data collection methods, step 5: plan your data collection procedures, step 6: decide on your data analysis strategies, other interesting articles, frequently asked questions about research design.

• Introduction

Before you can start designing your research, you should already have a clear idea of the research question you want to investigate.

There are many different ways you could go about answering this question. Your research design choices should be driven by your aims and priorities—start by thinking carefully about what you want to achieve.

The first choice you need to make is whether you’ll take a qualitative or quantitative approach.

Qualitative research designs tend to be more flexible and inductive , allowing you to adjust your approach based on what you find throughout the research process.

Quantitative research designs tend to be more fixed and deductive , with variables and hypotheses clearly defined in advance of data collection.

It’s also possible to use a mixed-methods design that integrates aspects of both approaches. By combining qualitative and quantitative insights, you can gain a more complete picture of the problem you’re studying and strengthen the credibility of your conclusions.

Practical and ethical considerations when designing research

As well as scientific considerations, you need to think practically when designing your research. If your research involves people or animals, you also need to consider research ethics .

• How much time do you have to collect data and write up the research?
• Will you be able to gain access to the data you need (e.g., by travelling to a specific location or contacting specific people)?
• Do you have the necessary research skills (e.g., statistical analysis or interview techniques)?
• Will you need ethical approval ?

At each stage of the research design process, make sure that your choices are practically feasible.

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Within both qualitative and quantitative approaches, there are several types of research design to choose from. Each type provides a framework for the overall shape of your research.

Types of quantitative research designs

Quantitative designs can be split into four main types.

• Experimental and   quasi-experimental designs allow you to test cause-and-effect relationships
• Descriptive and correlational designs allow you to measure variables and describe relationships between them.

With descriptive and correlational designs, you can get a clear picture of characteristics, trends and relationships as they exist in the real world. However, you can’t draw conclusions about cause and effect (because correlation doesn’t imply causation ).

Experiments are the strongest way to test cause-and-effect relationships without the risk of other variables influencing the results. However, their controlled conditions may not always reflect how things work in the real world. They’re often also more difficult and expensive to implement.

Types of qualitative research designs

Qualitative designs are less strictly defined. This approach is about gaining a rich, detailed understanding of a specific context or phenomenon, and you can often be more creative and flexible in designing your research.

The table below shows some common types of qualitative design. They often have similar approaches in terms of data collection, but focus on different aspects when analyzing the data.

Your research design should clearly define who or what your research will focus on, and how you’ll go about choosing your participants or subjects.

In research, a population is the entire group that you want to draw conclusions about, while a sample is the smaller group of individuals you’ll actually collect data from.

Defining the population

A population can be made up of anything you want to study—plants, animals, organizations, texts, countries, etc. In the social sciences, it most often refers to a group of people.

For example, will you focus on people from a specific demographic, region or background? Are you interested in people with a certain job or medical condition, or users of a particular product?

The more precisely you define your population, the easier it will be to gather a representative sample.

• Sampling methods

Even with a narrowly defined population, it’s rarely possible to collect data from every individual. Instead, you’ll collect data from a sample.

To select a sample, there are two main approaches: probability sampling and non-probability sampling . The sampling method you use affects how confidently you can generalize your results to the population as a whole.

Probability sampling is the most statistically valid option, but it’s often difficult to achieve unless you’re dealing with a very small and accessible population.

For practical reasons, many studies use non-probability sampling, but it’s important to be aware of the limitations and carefully consider potential biases. You should always make an effort to gather a sample that’s as representative as possible of the population.

Case selection in qualitative research

In some types of qualitative designs, sampling may not be relevant.

For example, in an ethnography or a case study , your aim is to deeply understand a specific context, not to generalize to a population. Instead of sampling, you may simply aim to collect as much data as possible about the context you are studying.

In these types of design, you still have to carefully consider your choice of case or community. You should have a clear rationale for why this particular case is suitable for answering your research question .

For example, you might choose a case study that reveals an unusual or neglected aspect of your research problem, or you might choose several very similar or very different cases in order to compare them.

Data collection methods are ways of directly measuring variables and gathering information. They allow you to gain first-hand knowledge and original insights into your research problem.

You can choose just one data collection method, or use several methods in the same study.

Survey methods

Surveys allow you to collect data about opinions, behaviors, experiences, and characteristics by asking people directly. There are two main survey methods to choose from: questionnaires and interviews .

Observation methods

Observational studies allow you to collect data unobtrusively, observing characteristics, behaviors or social interactions without relying on self-reporting.

Observations may be conducted in real time, taking notes as you observe, or you might make audiovisual recordings for later analysis. They can be qualitative or quantitative.

Other methods of data collection

There are many other ways you might collect data depending on your field and topic.

If you’re not sure which methods will work best for your research design, try reading some papers in your field to see what kinds of data collection methods they used.

Secondary data

If you don’t have the time or resources to collect data from the population you’re interested in, you can also choose to use secondary data that other researchers already collected—for example, datasets from government surveys or previous studies on your topic.

With this raw data, you can do your own analysis to answer new research questions that weren’t addressed by the original study.

Using secondary data can expand the scope of your research, as you may be able to access much larger and more varied samples than you could collect yourself.

However, it also means you don’t have any control over which variables to measure or how to measure them, so the conclusions you can draw may be limited.

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As well as deciding on your methods, you need to plan exactly how you’ll use these methods to collect data that’s consistent, accurate, and unbiased.

Planning systematic procedures is especially important in quantitative research, where you need to precisely define your variables and ensure your measurements are high in reliability and validity.

Operationalization

Some variables, like height or age, are easily measured. But often you’ll be dealing with more abstract concepts, like satisfaction, anxiety, or competence. Operationalization means turning these fuzzy ideas into measurable indicators.

If you’re using observations , which events or actions will you count?

If you’re using surveys , which questions will you ask and what range of responses will be offered?

You may also choose to use or adapt existing materials designed to measure the concept you’re interested in—for example, questionnaires or inventories whose reliability and validity has already been established.

Reliability and validity

Reliability means your results can be consistently reproduced, while validity means that you’re actually measuring the concept you’re interested in.

For valid and reliable results, your measurement materials should be thoroughly researched and carefully designed. Plan your procedures to make sure you carry out the same steps in the same way for each participant.

If you’re developing a new questionnaire or other instrument to measure a specific concept, running a pilot study allows you to check its validity and reliability in advance.

Sampling procedures

As well as choosing an appropriate sampling method , you need a concrete plan for how you’ll actually contact and recruit your selected sample.

That means making decisions about things like:

• How many participants do you need for an adequate sample size?
• What inclusion and exclusion criteria will you use to identify eligible participants?
• How will you contact your sample—by mail, online, by phone, or in person?

If you’re using a probability sampling method , it’s important that everyone who is randomly selected actually participates in the study. How will you ensure a high response rate?

If you’re using a non-probability method , how will you avoid research bias and ensure a representative sample?

Data management

It’s also important to create a data management plan for organizing and storing your data.

Will you need to transcribe interviews or perform data entry for observations? You should anonymize and safeguard any sensitive data, and make sure it’s backed up regularly.

Keeping your data well-organized will save time when it comes to analyzing it. It can also help other researchers validate and add to your findings (high replicability ).

On its own, raw data can’t answer your research question. The last step of designing your research is planning how you’ll analyze the data.

Quantitative data analysis

In quantitative research, you’ll most likely use some form of statistical analysis . With statistics, you can summarize your sample data, make estimates, and test hypotheses.

Using descriptive statistics , you can summarize your sample data in terms of:

• The distribution of the data (e.g., the frequency of each score on a test)
• The central tendency of the data (e.g., the mean to describe the average score)
• The variability of the data (e.g., the standard deviation to describe how spread out the scores are)

The specific calculations you can do depend on the level of measurement of your variables.

Using inferential statistics , you can:

• Make estimates about the population based on your sample data.
• Test hypotheses about a relationship between variables.

Regression and correlation tests look for associations between two or more variables, while comparison tests (such as t tests and ANOVAs ) look for differences in the outcomes of different groups.

Your choice of statistical test depends on various aspects of your research design, including the types of variables you’re dealing with and the distribution of your data.

Qualitative data analysis

In qualitative research, your data will usually be very dense with information and ideas. Instead of summing it up in numbers, you’ll need to comb through the data in detail, interpret its meanings, identify patterns, and extract the parts that are most relevant to your research question.

Two of the most common approaches to doing this are thematic analysis and discourse analysis .

There are many other ways of analyzing qualitative data depending on the aims of your research. To get a sense of potential approaches, try reading some qualitative research papers in your field.

If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

A research design is a strategy for answering your   research question . It defines your overall approach and determines how you will collect and analyze data.

A well-planned research design helps ensure that your methods match your research aims, that you collect high-quality data, and that you use the right kind of analysis to answer your questions, utilizing credible sources . This allows you to draw valid , trustworthy conclusions.

Quantitative research designs can be divided into two main categories:

• Correlational and descriptive designs are used to investigate characteristics, averages, trends, and associations between variables.
• Experimental and quasi-experimental designs are used to test causal relationships .

Qualitative research designs tend to be more flexible. Common types of qualitative design include case study , ethnography , and grounded theory designs.

The priorities of a research design can vary depending on the field, but you usually have to specify:

• Your research questions and/or hypotheses
• Your overall approach (e.g., qualitative or quantitative )
• The type of design you’re using (e.g., a survey , experiment , or case study )
• Your data collection methods (e.g., questionnaires , observations)
• Your data collection procedures (e.g., operationalization , timing and data management)
• Your data analysis methods (e.g., statistical tests  or thematic analysis )

A sample is a subset of individuals from a larger population . Sampling means selecting the group that you will actually collect data from in your research. For example, if you are researching the opinions of students in your university, you could survey a sample of 100 students.

In statistics, sampling allows you to test a hypothesis about the characteristics of a population.

Operationalization means turning abstract conceptual ideas into measurable observations.

For example, the concept of social anxiety isn’t directly observable, but it can be operationally defined in terms of self-rating scores, behavioral avoidance of crowded places, or physical anxiety symptoms in social situations.

Before collecting data , it’s important to consider how you will operationalize the variables that you want to measure.

A research project is an academic, scientific, or professional undertaking to answer a research question . Research projects can take many forms, such as qualitative or quantitative , descriptive , longitudinal , experimental , or correlational . What kind of research approach you choose will depend on your topic.

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Chapter 2. Research Design

Getting started.

When I teach undergraduates qualitative research methods, the final product of the course is a “research proposal” that incorporates all they have learned and enlists the knowledge they have learned about qualitative research methods in an original design that addresses a particular research question. I highly recommend you think about designing your own research study as you progress through this textbook. Even if you don’t have a study in mind yet, it can be a helpful exercise as you progress through the course. But how to start? How can one design a research study before they even know what research looks like? This chapter will serve as a brief overview of the research design process to orient you to what will be coming in later chapters. Think of it as a “skeleton” of what you will read in more detail in later chapters. Ideally, you will read this chapter both now (in sequence) and later during your reading of the remainder of the text. Do not worry if you have questions the first time you read this chapter. Many things will become clearer as the text advances and as you gain a deeper understanding of all the components of good qualitative research. This is just a preliminary map to get you on the right road.

Research Design Steps

Before you even get started, you will need to have a broad topic of interest in mind. [1] . In my experience, students can confuse this broad topic with the actual research question, so it is important to clearly distinguish the two. And the place to start is the broad topic. It might be, as was the case with me, working-class college students. But what about working-class college students? What’s it like to be one? Why are there so few compared to others? How do colleges assist (or fail to assist) them? What interested me was something I could barely articulate at first and went something like this: “Why was it so difficult and lonely to be me?” And by extension, “Did others share this experience?”

Once you have a general topic, reflect on why this is important to you. Sometimes we connect with a topic and we don’t really know why. Even if you are not willing to share the real underlying reason you are interested in a topic, it is important that you know the deeper reasons that motivate you. Otherwise, it is quite possible that at some point during the research, you will find yourself turned around facing the wrong direction. I have seen it happen many times. The reason is that the research question is not the same thing as the general topic of interest, and if you don’t know the reasons for your interest, you are likely to design a study answering a research question that is beside the point—to you, at least. And this means you will be much less motivated to carry your research to completion.

Researcher Note

Why do you employ qualitative research methods in your area of study? What are the advantages of qualitative research methods for studying mentorship?

Qualitative research methods are a huge opportunity to increase access, equity, inclusion, and social justice. Qualitative research allows us to engage and examine the uniquenesses/nuances within minoritized and dominant identities and our experiences with these identities. Qualitative research allows us to explore a specific topic, and through that exploration, we can link history to experiences and look for patterns or offer up a unique phenomenon. There’s such beauty in being able to tell a particular story, and qualitative research is a great mode for that! For our work, we examined the relationships we typically use the term mentorship for but didn’t feel that was quite the right word. Qualitative research allowed us to pick apart what we did and how we engaged in our relationships, which then allowed us to more accurately describe what was unique about our mentorship relationships, which we ultimately named liberationships ( McAloney and Long 2021) . Qualitative research gave us the means to explore, process, and name our experiences; what a powerful tool!

How do you come up with ideas for what to study (and how to study it)? Where did you get the idea for studying mentorship?

Coming up with ideas for research, for me, is kind of like Googling a question I have, not finding enough information, and then deciding to dig a little deeper to get the answer. The idea to study mentorship actually came up in conversation with my mentorship triad. We were talking in one of our meetings about our relationship—kind of meta, huh? We discussed how we felt that mentorship was not quite the right term for the relationships we had built. One of us asked what was different about our relationships and mentorship. This all happened when I was taking an ethnography course. During the next session of class, we were discussing auto- and duoethnography, and it hit me—let’s explore our version of mentorship, which we later went on to name liberationships ( McAloney and Long 2021 ). The idea and questions came out of being curious and wanting to find an answer. As I continue to research, I see opportunities in questions I have about my work or during conversations that, in our search for answers, end up exposing gaps in the literature. If I can’t find the answer already out there, I can study it.

—Kim McAloney, PhD, College Student Services Administration Ecampus coordinator and instructor

When you have a better idea of why you are interested in what it is that interests you, you may be surprised to learn that the obvious approaches to the topic are not the only ones. For example, let’s say you think you are interested in preserving coastal wildlife. And as a social scientist, you are interested in policies and practices that affect the long-term viability of coastal wildlife, especially around fishing communities. It would be natural then to consider designing a research study around fishing communities and how they manage their ecosystems. But when you really think about it, you realize that what interests you the most is how people whose livelihoods depend on a particular resource act in ways that deplete that resource. Or, even deeper, you contemplate the puzzle, “How do people justify actions that damage their surroundings?” Now, there are many ways to design a study that gets at that broader question, and not all of them are about fishing communities, although that is certainly one way to go. Maybe you could design an interview-based study that includes and compares loggers, fishers, and desert golfers (those who golf in arid lands that require a great deal of wasteful irrigation). Or design a case study around one particular example where resources were completely used up by a community. Without knowing what it is you are really interested in, what motivates your interest in a surface phenomenon, you are unlikely to come up with the appropriate research design.

These first stages of research design are often the most difficult, but have patience . Taking the time to consider why you are going to go through a lot of trouble to get answers will prevent a lot of wasted energy in the future.

There are distinct reasons for pursuing particular research questions, and it is helpful to distinguish between them.  First, you may be personally motivated.  This is probably the most important and the most often overlooked.   What is it about the social world that sparks your curiosity? What bothers you? What answers do you need in order to keep living? For me, I knew I needed to get a handle on what higher education was for before I kept going at it. I needed to understand why I felt so different from my peers and whether this whole “higher education” thing was “for the likes of me” before I could complete my degree. That is the personal motivation question. Your personal motivation might also be political in nature, in that you want to change the world in a particular way. It’s all right to acknowledge this. In fact, it is better to acknowledge it than to hide it.

There are also academic and professional motivations for a particular study.  If you are an absolute beginner, these may be difficult to find. We’ll talk more about this when we discuss reviewing the literature. Simply put, you are probably not the only person in the world to have thought about this question or issue and those related to it. So how does your interest area fit into what others have studied? Perhaps there is a good study out there of fishing communities, but no one has quite asked the “justification” question. You are motivated to address this to “fill the gap” in our collective knowledge. And maybe you are really not at all sure of what interests you, but you do know that [insert your topic] interests a lot of people, so you would like to work in this area too. You want to be involved in the academic conversation. That is a professional motivation and a very important one to articulate.

Practical and strategic motivations are a third kind. Perhaps you want to encourage people to take better care of the natural resources around them. If this is also part of your motivation, you will want to design your research project in a way that might have an impact on how people behave in the future. There are many ways to do this, one of which is using qualitative research methods rather than quantitative research methods, as the findings of qualitative research are often easier to communicate to a broader audience than the results of quantitative research. You might even be able to engage the community you are studying in the collecting and analyzing of data, something taboo in quantitative research but actively embraced and encouraged by qualitative researchers. But there are other practical reasons, such as getting “done” with your research in a certain amount of time or having access (or no access) to certain information. There is nothing wrong with considering constraints and opportunities when designing your study. Or maybe one of the practical or strategic goals is about learning competence in this area so that you can demonstrate the ability to conduct interviews and focus groups with future employers. Keeping that in mind will help shape your study and prevent you from getting sidetracked using a technique that you are less invested in learning about.

STOP HERE for a moment

I recommend you write a paragraph (at least) explaining your aims and goals. Include a sentence about each of the following: personal/political goals, practical or professional/academic goals, and practical/strategic goals. Think through how all of the goals are related and can be achieved by this particular research study . If they can’t, have a rethink. Perhaps this is not the best way to go about it.

You will also want to be clear about the purpose of your study. “Wait, didn’t we just do this?” you might ask. No! Your goals are not the same as the purpose of the study, although they are related. You can think about purpose lying on a continuum from “ theory ” to “action” (figure 2.1). Sometimes you are doing research to discover new knowledge about the world, while other times you are doing a study because you want to measure an impact or make a difference in the world.

Basic research involves research that is done for the sake of “pure” knowledge—that is, knowledge that, at least at this moment in time, may not have any apparent use or application. Often, and this is very important, knowledge of this kind is later found to be extremely helpful in solving problems. So one way of thinking about basic research is that it is knowledge for which no use is yet known but will probably one day prove to be extremely useful. If you are doing basic research, you do not need to argue its usefulness, as the whole point is that we just don’t know yet what this might be.

Researchers engaged in basic research want to understand how the world operates. They are interested in investigating a phenomenon to get at the nature of reality with regard to that phenomenon. The basic researcher’s purpose is to understand and explain ( Patton 2002:215 ).

Basic research is interested in generating and testing hypotheses about how the world works. Grounded Theory is one approach to qualitative research methods that exemplifies basic research (see chapter 4). Most academic journal articles publish basic research findings. If you are working in academia (e.g., writing your dissertation), the default expectation is that you are conducting basic research.

Applied research in the social sciences is research that addresses human and social problems. Unlike basic research, the researcher has expectations that the research will help contribute to resolving a problem, if only by identifying its contours, history, or context. From my experience, most students have this as their baseline assumption about research. Why do a study if not to make things better? But this is a common mistake. Students and their committee members are often working with default assumptions here—the former thinking about applied research as their purpose, the latter thinking about basic research: “The purpose of applied research is to contribute knowledge that will help people to understand the nature of a problem in order to intervene, thereby allowing human beings to more effectively control their environment. While in basic research the source of questions is the tradition within a scholarly discipline, in applied research the source of questions is in the problems and concerns experienced by people and by policymakers” ( Patton 2002:217 ).

Applied research is less geared toward theory in two ways. First, its questions do not derive from previous literature. For this reason, applied research studies have much more limited literature reviews than those found in basic research (although they make up for this by having much more “background” about the problem). Second, it does not generate theory in the same way as basic research does. The findings of an applied research project may not be generalizable beyond the boundaries of this particular problem or context. The findings are more limited. They are useful now but may be less useful later. This is why basic research remains the default “gold standard” of academic research.

Evaluation research is research that is designed to evaluate or test the effectiveness of specific solutions and programs addressing specific social problems. We already know the problems, and someone has already come up with solutions. There might be a program, say, for first-generation college students on your campus. Does this program work? Are first-generation students who participate in the program more likely to graduate than those who do not? These are the types of questions addressed by evaluation research. There are two types of research within this broader frame; however, one more action-oriented than the next. In summative evaluation , an overall judgment about the effectiveness of a program or policy is made. Should we continue our first-gen program? Is it a good model for other campuses? Because the purpose of such summative evaluation is to measure success and to determine whether this success is scalable (capable of being generalized beyond the specific case), quantitative data is more often used than qualitative data. In our example, we might have “outcomes” data for thousands of students, and we might run various tests to determine if the better outcomes of those in the program are statistically significant so that we can generalize the findings and recommend similar programs elsewhere. Qualitative data in the form of focus groups or interviews can then be used for illustrative purposes, providing more depth to the quantitative analyses. In contrast, formative evaluation attempts to improve a program or policy (to help “form” or shape its effectiveness). Formative evaluations rely more heavily on qualitative data—case studies, interviews, focus groups. The findings are meant not to generalize beyond the particular but to improve this program. If you are a student seeking to improve your qualitative research skills and you do not care about generating basic research, formative evaluation studies might be an attractive option for you to pursue, as there are always local programs that need evaluation and suggestions for improvement. Again, be very clear about your purpose when talking through your research proposal with your committee.

Action research takes a further step beyond evaluation, even formative evaluation, to being part of the solution itself. This is about as far from basic research as one could get and definitely falls beyond the scope of “science,” as conventionally defined. The distinction between action and research is blurry, the research methods are often in constant flux, and the only “findings” are specific to the problem or case at hand and often are findings about the process of intervention itself. Rather than evaluate a program as a whole, action research often seeks to change and improve some particular aspect that may not be working—maybe there is not enough diversity in an organization or maybe women’s voices are muted during meetings and the organization wonders why and would like to change this. In a further step, participatory action research , those women would become part of the research team, attempting to amplify their voices in the organization through participation in the action research. As action research employs methods that involve people in the process, focus groups are quite common.

If you are working on a thesis or dissertation, chances are your committee will expect you to be contributing to fundamental knowledge and theory ( basic research ). If your interests lie more toward the action end of the continuum, however, it is helpful to talk to your committee about this before you get started. Knowing your purpose in advance will help avoid misunderstandings during the later stages of the research process!

The Research Question

Once you have written your paragraph and clarified your purpose and truly know that this study is the best study for you to be doing right now , you are ready to write and refine your actual research question. Know that research questions are often moving targets in qualitative research, that they can be refined up to the very end of data collection and analysis. But you do have to have a working research question at all stages. This is your “anchor” when you get lost in the data. What are you addressing? What are you looking at and why? Your research question guides you through the thicket. It is common to have a whole host of questions about a phenomenon or case, both at the outset and throughout the study, but you should be able to pare it down to no more than two or three sentences when asked. These sentences should both clarify the intent of the research and explain why this is an important question to answer. More on refining your research question can be found in chapter 4.

Chances are, you will have already done some prior reading before coming up with your interest and your questions, but you may not have conducted a systematic literature review. This is the next crucial stage to be completed before venturing further. You don’t want to start collecting data and then realize that someone has already beaten you to the punch. A review of the literature that is already out there will let you know (1) if others have already done the study you are envisioning; (2) if others have done similar studies, which can help you out; and (3) what ideas or concepts are out there that can help you frame your study and make sense of your findings. More on literature reviews can be found in chapter 9.

In addition to reviewing the literature for similar studies to what you are proposing, it can be extremely helpful to find a study that inspires you. This may have absolutely nothing to do with the topic you are interested in but is written so beautifully or organized so interestingly or otherwise speaks to you in such a way that you want to post it somewhere to remind you of what you want to be doing. You might not understand this in the early stages—why would you find a study that has nothing to do with the one you are doing helpful? But trust me, when you are deep into analysis and writing, having an inspirational model in view can help you push through. If you are motivated to do something that might change the world, you probably have read something somewhere that inspired you. Go back to that original inspiration and read it carefully and see how they managed to convey the passion that you so appreciate.

At this stage, you are still just getting started. There are a lot of things to do before setting forth to collect data! You’ll want to consider and choose a research tradition and a set of data-collection techniques that both help you answer your research question and match all your aims and goals. For example, if you really want to help migrant workers speak for themselves, you might draw on feminist theory and participatory action research models. Chapters 3 and 4 will provide you with more information on epistemologies and approaches.

Next, you have to clarify your “units of analysis.” What is the level at which you are focusing your study? Often, the unit in qualitative research methods is individual people, or “human subjects.” But your units of analysis could just as well be organizations (colleges, hospitals) or programs or even whole nations. Think about what it is you want to be saying at the end of your study—are the insights you are hoping to make about people or about organizations or about something else entirely? A unit of analysis can even be a historical period! Every unit of analysis will call for a different kind of data collection and analysis and will produce different kinds of “findings” at the conclusion of your study. [2]

Regardless of what unit of analysis you select, you will probably have to consider the “human subjects” involved in your research. [3] Who are they? What interactions will you have with them—that is, what kind of data will you be collecting? Before answering these questions, define your population of interest and your research setting. Use your research question to help guide you.

Let’s use an example from a real study. In Geographies of Campus Inequality , Benson and Lee ( 2020 ) list three related research questions: “(1) What are the different ways that first-generation students organize their social, extracurricular, and academic activities at selective and highly selective colleges? (2) how do first-generation students sort themselves and get sorted into these different types of campus lives; and (3) how do these different patterns of campus engagement prepare first-generation students for their post-college lives?” (3).

Note that we are jumping into this a bit late, after Benson and Lee have described previous studies (the literature review) and what is known about first-generation college students and what is not known. They want to know about differences within this group, and they are interested in ones attending certain kinds of colleges because those colleges will be sites where academic and extracurricular pressures compete. That is the context for their three related research questions. What is the population of interest here? First-generation college students . What is the research setting? Selective and highly selective colleges . But a host of questions remain. Which students in the real world, which colleges? What about gender, race, and other identity markers? Will the students be asked questions? Are the students still in college, or will they be asked about what college was like for them? Will they be observed? Will they be shadowed? Will they be surveyed? Will they be asked to keep diaries of their time in college? How many students? How many colleges? For how long will they be observed?

Recommendation

Take a moment and write down suggestions for Benson and Lee before continuing on to what they actually did.

Have you written down your own suggestions? Good. Now let’s compare those with what they actually did. Benson and Lee drew on two sources of data: in-depth interviews with sixty-four first-generation students and survey data from a preexisting national survey of students at twenty-eight selective colleges. Let’s ignore the survey for our purposes here and focus on those interviews. The interviews were conducted between 2014 and 2016 at a single selective college, “Hilltop” (a pseudonym ). They employed a “purposive” sampling strategy to ensure an equal number of male-identifying and female-identifying students as well as equal numbers of White, Black, and Latinx students. Each student was interviewed once. Hilltop is a selective liberal arts college in the northeast that enrolls about three thousand students.

How did your suggestions match up to those actually used by the researchers in this study? It is possible your suggestions were too ambitious? Beginning qualitative researchers can often make that mistake. You want a research design that is both effective (it matches your question and goals) and doable. You will never be able to collect data from your entire population of interest (unless your research question is really so narrow to be relevant to very few people!), so you will need to come up with a good sample. Define the criteria for this sample, as Benson and Lee did when deciding to interview an equal number of students by gender and race categories. Define the criteria for your sample setting too. Hilltop is typical for selective colleges. That was a research choice made by Benson and Lee. For more on sampling and sampling choices, see chapter 5.

Benson and Lee chose to employ interviews. If you also would like to include interviews, you have to think about what will be asked in them. Most interview-based research involves an interview guide, a set of questions or question areas that will be asked of each participant. The research question helps you create a relevant interview guide. You want to ask questions whose answers will provide insight into your research question. Again, your research question is the anchor you will continually come back to as you plan for and conduct your study. It may be that once you begin interviewing, you find that people are telling you something totally unexpected, and this makes you rethink your research question. That is fine. Then you have a new anchor. But you always have an anchor. More on interviewing can be found in chapter 11.

Let’s imagine Benson and Lee also observed college students as they went about doing the things college students do, both in the classroom and in the clubs and social activities in which they participate. They would have needed a plan for this. Would they sit in on classes? Which ones and how many? Would they attend club meetings and sports events? Which ones and how many? Would they participate themselves? How would they record their observations? More on observation techniques can be found in both chapters 13 and 14.

At this point, the design is almost complete. You know why you are doing this study, you have a clear research question to guide you, you have identified your population of interest and research setting, and you have a reasonable sample of each. You also have put together a plan for data collection, which might include drafting an interview guide or making plans for observations. And so you know exactly what you will be doing for the next several months (or years!). To put the project into action, there are a few more things necessary before actually going into the field.

First, you will need to make sure you have any necessary supplies, including recording technology. These days, many researchers use their phones to record interviews. Second, you will need to draft a few documents for your participants. These include informed consent forms and recruiting materials, such as posters or email texts, that explain what this study is in clear language. Third, you will draft a research protocol to submit to your institutional review board (IRB) ; this research protocol will include the interview guide (if you are using one), the consent form template, and all examples of recruiting material. Depending on your institution and the details of your study design, it may take weeks or even, in some unfortunate cases, months before you secure IRB approval. Make sure you plan on this time in your project timeline. While you wait, you can continue to review the literature and possibly begin drafting a section on the literature review for your eventual presentation/publication. More on IRB procedures can be found in chapter 8 and more general ethical considerations in chapter 7.

Once you have approval, you can begin!

Research Design Checklist

Before data collection begins, do the following:

• Write a paragraph explaining your aims and goals (personal/political, practical/strategic, professional/academic).
• Define your research question; write two to three sentences that clarify the intent of the research and why this is an important question to answer.
• Review the literature for similar studies that address your research question or similar research questions; think laterally about some literature that might be helpful or illuminating but is not exactly about the same topic.
• Find a written study that inspires you—it may or may not be on the research question you have chosen.
• Consider and choose a research tradition and set of data-collection techniques that (1) help answer your research question and (2) match your aims and goals.
• Define your population of interest and your research setting.
• Define the criteria for your sample (How many? Why these? How will you find them, gain access, and acquire consent?).
• If you are conducting interviews, draft an interview guide.
•  If you are making observations, create a plan for observations (sites, times, recording, access).
• Acquire any necessary technology (recording devices/software).
• Draft consent forms that clearly identify the research focus and selection process.
• Create recruiting materials (posters, email, texts).
• Apply for IRB approval (proposal plus consent form plus recruiting materials).
• Block out time for collecting data.
• At the end of the chapter, you will find a " Research Design Checklist " that summarizes the main recommendations made here ↵
• For example, if your focus is society and culture , you might collect data through observation or a case study. If your focus is individual lived experience , you are probably going to be interviewing some people. And if your focus is language and communication , you will probably be analyzing text (written or visual). ( Marshall and Rossman 2016:16 ). ↵
• You may not have any "live" human subjects. There are qualitative research methods that do not require interactions with live human beings - see chapter 16 , "Archival and Historical Sources." But for the most part, you are probably reading this textbook because you are interested in doing research with people. The rest of the chapter will assume this is the case. ↵

One of the primary methodological traditions of inquiry in qualitative research, ethnography is the study of a group or group culture, largely through observational fieldwork supplemented by interviews. It is a form of fieldwork that may include participant-observation data collection. See chapter 14 for a discussion of deep ethnography. 

A methodological tradition of inquiry and research design that focuses on an individual case (e.g., setting, institution, or sometimes an individual) in order to explore its complexity, history, and interactive parts.  As an approach, it is particularly useful for obtaining a deep appreciation of an issue, event, or phenomenon of interest in its particular context.

The controlling force in research; can be understood as lying on a continuum from basic research (knowledge production) to action research (effecting change).

In its most basic sense, a theory is a story we tell about how the world works that can be tested with empirical evidence.  In qualitative research, we use the term in a variety of ways, many of which are different from how they are used by quantitative researchers.  Although some qualitative research can be described as “testing theory,” it is more common to “build theory” from the data using inductive reasoning , as done in Grounded Theory .  There are so-called “grand theories” that seek to integrate a whole series of findings and stories into an overarching paradigm about how the world works, and much smaller theories or concepts about particular processes and relationships.  Theory can even be used to explain particular methodological perspectives or approaches, as in Institutional Ethnography , which is both a way of doing research and a theory about how the world works.

Research that is interested in generating and testing hypotheses about how the world works.

A methodological tradition of inquiry and approach to analyzing qualitative data in which theories emerge from a rigorous and systematic process of induction.  This approach was pioneered by the sociologists Glaser and Strauss (1967).  The elements of theory generated from comparative analysis of data are, first, conceptual categories and their properties and, second, hypotheses or generalized relations among the categories and their properties – “The constant comparing of many groups draws the [researcher’s] attention to their many similarities and differences.  Considering these leads [the researcher] to generate abstract categories and their properties, which, since they emerge from the data, will clearly be important to a theory explaining the kind of behavior under observation.” (36).

An approach to research that 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 ). Contrast with quantitative research .

Research that contributes knowledge that will help people to understand the nature of a problem in order to intervene, thereby allowing human beings to more effectively control their environment.

Research that is designed to evaluate or test the effectiveness of specific solutions and programs addressing specific social problems.  There are two kinds: summative and formative .

Research in which an overall judgment about the effectiveness of a program or policy is made, often for the purpose of generalizing to other cases or programs.  Generally uses qualitative research as a supplement to primary quantitative data analyses.  Contrast formative evaluation research .

Research designed to improve a program or policy (to help “form” or shape its effectiveness); relies heavily on qualitative research methods.  Contrast summative evaluation research

Research carried out at a particular organizational or community site with the intention of affecting change; often involves research subjects as participants of the study.  See also participatory action research .

Research in which both researchers and participants work together to understand a problematic situation and change it for the better.

The level of the focus of analysis (e.g., individual people, organizations, programs, neighborhoods).

The large group of interest to the researcher.  Although it will likely be impossible to design a study that incorporates or reaches all members of the population of interest, this should be clearly defined at the outset of a study so that a reasonable sample of the population can be taken.  For example, if one is studying working-class college students, the sample may include twenty such students attending a particular college, while the population is “working-class college students.”  In quantitative research, clearly defining the general population of interest is a necessary step in generalizing results from a sample.  In qualitative research, defining the population is conceptually important for clarity.

A fictional name assigned to give anonymity to a person, group, or place.  Pseudonyms are important ways of protecting the identity of research participants while still providing a “human element” in the presentation of qualitative data.  There are ethical considerations to be made in selecting pseudonyms; some researchers allow research participants to choose their own.

A requirement for research involving human participants; the documentation of informed consent.  In some cases, oral consent or assent may be sufficient, but the default standard is a single-page easy-to-understand form that both the researcher and the participant sign and date.   Under federal guidelines, all researchers "shall seek such consent only under circumstances that provide the prospective subject or the representative sufficient opportunity to consider whether or not to participate and that minimize the possibility of coercion or undue influence. The information that is given to the subject or the representative shall be in language understandable to the subject or the representative.  No informed consent, whether oral or written, may include any exculpatory language through which the subject or the representative is made to waive or appear to waive any of the subject's rights or releases or appears to release the investigator, the sponsor, the institution, or its agents from liability for negligence" (21 CFR 50.20).  Your IRB office will be able to provide a template for use in your study .

An administrative body established to protect the rights and welfare of human research subjects recruited to participate in research activities conducted under the auspices of the institution with which it is affiliated. The IRB is charged with the responsibility of reviewing all research involving human participants. The IRB is concerned with protecting the welfare, rights, and privacy of human subjects. The IRB has the authority to approve, disapprove, monitor, and require modifications in all research activities that fall within its jurisdiction as specified by both the federal regulations and institutional policy.

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

Qualitative research is a type of research methodology that focuses on exploring and understanding people’s beliefs, attitudes, behaviors, and experiences through the collection and analysis of non-numerical data. It seeks to answer research questions through the examination of subjective data, such as interviews, focus groups, observations, and textual analysis.

Qualitative research aims to uncover the meaning and significance of social phenomena, and it typically involves a more flexible and iterative approach to data collection and analysis compared to quantitative research. Qualitative research is often used in fields such as sociology, anthropology, psychology, and education.

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

This method involves conducting an interview with a single participant to gain a detailed understanding of their experiences, attitudes, and beliefs. One-to-one interviews can be conducted in-person, over the phone, or through video conferencing. The interviewer typically uses open-ended questions to encourage the participant to share their thoughts and feelings. One-to-one interviews are useful for gaining detailed insights into individual experiences.

Focus Groups

This method involves bringing together a group of people to discuss a specific topic in a structured setting. The focus group is led by a moderator who guides the discussion and encourages participants to share their thoughts and opinions. Focus groups are useful for generating ideas and insights, exploring social norms and attitudes, and understanding group dynamics.

Ethnographic Studies

This method involves immersing oneself in a culture or community to gain a deep understanding of its norms, beliefs, and practices. Ethnographic studies typically involve long-term fieldwork and observation, as well as interviews and document analysis. Ethnographic studies are useful for understanding the cultural context of social phenomena and for gaining a holistic understanding of complex social processes.

Text Analysis

This method involves analyzing written or spoken language to identify patterns and themes. Text analysis can be quantitative or qualitative. Qualitative text analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Text analysis is useful for understanding media messages, public discourse, and cultural trends.

This method involves an in-depth examination of a single person, group, or event to gain an understanding of complex phenomena. Case studies typically involve a combination of data collection methods, such as interviews, observations, and document analysis, to provide a comprehensive understanding of the case. Case studies are useful for exploring unique or rare cases, and for generating hypotheses for further research.

Process of Observation

This method involves systematically observing and recording behaviors and interactions in natural settings. The observer may take notes, use audio or video recordings, or use other methods to document what they see. Process of observation is useful for understanding social interactions, cultural practices, and the context in which behaviors occur.

Record Keeping

This method involves keeping detailed records of observations, interviews, and other data collected during the research process. Record keeping is essential for ensuring the accuracy and reliability of the data, and for providing a basis for analysis and interpretation.

This method involves collecting data from a large sample of participants through a structured questionnaire. Surveys can be conducted in person, over the phone, through mail, or online. Surveys are useful for collecting data on attitudes, beliefs, and behaviors, and for identifying patterns and trends in a population.

Qualitative data analysis is a process of turning unstructured data into meaningful insights. It involves extracting and organizing information from sources like interviews, focus groups, and surveys. The goal is to understand people’s attitudes, behaviors, and motivations

Qualitative Research Analysis Methods

Qualitative Research analysis methods involve a systematic approach to interpreting and making sense of the data collected in qualitative research. Here are some common qualitative data analysis methods:

Thematic Analysis

This method involves identifying patterns or themes in the data that are relevant to the research question. The researcher reviews the data, identifies keywords or phrases, and groups them into categories or themes. Thematic analysis is useful for identifying patterns across multiple data sources and for generating new insights into the research topic.

Content Analysis

This method involves analyzing the content of written or spoken language to identify key themes or concepts. Content analysis can be quantitative or qualitative. Qualitative content analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Content analysis is useful for identifying patterns in media messages, public discourse, and cultural trends.

Discourse Analysis

This method involves analyzing language to understand how it constructs meaning and shapes social interactions. Discourse analysis can involve a variety of methods, such as conversation analysis, critical discourse analysis, and narrative analysis. Discourse analysis is useful for understanding how language shapes social interactions, cultural norms, and power relationships.

Grounded Theory Analysis

This method involves developing a theory or explanation based on the data collected. Grounded theory analysis starts with the data and uses an iterative process of coding and analysis to identify patterns and themes in the data. The theory or explanation that emerges is grounded in the data, rather than preconceived hypotheses. Grounded theory analysis is useful for understanding complex social phenomena and for generating new theoretical insights.

Narrative Analysis

This method involves analyzing the stories or narratives that participants share to gain insights into their experiences, attitudes, and beliefs. Narrative analysis can involve a variety of methods, such as structural analysis, thematic analysis, and discourse analysis. Narrative analysis is useful for understanding how individuals construct their identities, make sense of their experiences, and communicate their values and beliefs.

Phenomenological Analysis

This method involves analyzing how individuals make sense of their experiences and the meanings they attach to them. Phenomenological analysis typically involves in-depth interviews with participants to explore their experiences in detail. Phenomenological analysis is useful for understanding subjective experiences and for developing a rich understanding of human consciousness.

Comparative Analysis

This method involves comparing and contrasting data across different cases or groups to identify similarities and differences. Comparative analysis can be used to identify patterns or themes that are common across multiple cases, as well as to identify unique or distinctive features of individual cases. Comparative analysis is useful for understanding how social phenomena vary across different contexts and groups.

Applications of Qualitative Research

Qualitative research has many applications across different fields and industries. Here are some examples of how qualitative research is used:

• Market Research: Qualitative research is often used in market research to understand consumer attitudes, behaviors, and preferences. Researchers conduct focus groups and one-on-one interviews with consumers to gather insights into their experiences and perceptions of products and services.
• Health Care: Qualitative research is used in health care to explore patient experiences and perspectives on health and illness. Researchers conduct in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education: Qualitative research is used in education to understand student experiences and to develop effective teaching strategies. Researchers conduct classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work : Qualitative research is used in social work to explore social problems and to develop interventions to address them. Researchers conduct in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : Qualitative research is used in anthropology to understand different cultures and societies. Researchers conduct ethnographic studies and observe and interview members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : Qualitative research is used in psychology to understand human behavior and mental processes. Researchers conduct in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy : Qualitative research is used in public policy to explore public attitudes and to inform policy decisions. Researchers conduct focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

• Identify your research question: Qualitative research starts with a research question or set of questions that you want to explore. This question should be focused and specific, but also broad enough to allow for exploration and discovery.
• Select your research design: There are different types of qualitative research designs, including ethnography, case study, grounded theory, and phenomenology. You should select a design that aligns with your research question and that will allow you to gather the data you need to answer your research question.
• Recruit participants: Once you have your research question and design, you need to recruit participants. The number of participants you need will depend on your research design and the scope of your research. You can recruit participants through advertisements, social media, or through personal networks.
• Collect data: There are different methods for collecting qualitative data, including interviews, focus groups, observation, and document analysis. You should select the method or methods that align with your research design and that will allow you to gather the data you need to answer your research question.
• Analyze data: Once you have collected your data, you need to analyze it. This involves reviewing your data, identifying patterns and themes, and developing codes to organize your data. You can use different software programs to help you analyze your data, or you can do it manually.
• Interpret data: Once you have analyzed your data, you need to interpret it. This involves making sense of the patterns and themes you have identified, and developing insights and conclusions that answer your research question. You should be guided by your research question and use your data to support your conclusions.
• Communicate results: Once you have interpreted your data, you need to communicate your results. This can be done through academic papers, presentations, or reports. You should be clear and concise in your communication, and use examples and quotes from your data to support your findings.

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

• Customer Feedback: A company may conduct qualitative research to understand the feedback and experiences of its customers. This may involve conducting focus groups or one-on-one interviews with customers to gather insights into their attitudes, behaviors, and preferences.
• Healthcare : A healthcare provider may conduct qualitative research to explore patient experiences and perspectives on health and illness. This may involve conducting in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education : An educational institution may conduct qualitative research to understand student experiences and to develop effective teaching strategies. This may involve conducting classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work: A social worker may conduct qualitative research to explore social problems and to develop interventions to address them. This may involve conducting in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : An anthropologist may conduct qualitative research to understand different cultures and societies. This may involve conducting ethnographic studies and observing and interviewing members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : A psychologist may conduct qualitative research to understand human behavior and mental processes. This may involve conducting in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy: A government agency or non-profit organization may conduct qualitative research to explore public attitudes and to inform policy decisions. This may involve conducting focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

Purpose of Qualitative Research

The purpose of qualitative research is to explore and understand the subjective experiences, behaviors, and perspectives of individuals or groups in a particular context. Unlike quantitative research, which focuses on numerical data and statistical analysis, qualitative research aims to provide in-depth, descriptive information that can help researchers develop insights and theories about complex social phenomena.

Qualitative research can serve multiple purposes, including:

• Exploring new or emerging phenomena : Qualitative research can be useful for exploring new or emerging phenomena, such as new technologies or social trends. This type of research can help researchers develop a deeper understanding of these phenomena and identify potential areas for further study.
• Understanding complex social phenomena : Qualitative research can be useful for exploring complex social phenomena, such as cultural beliefs, social norms, or political processes. This type of research can help researchers develop a more nuanced understanding of these phenomena and identify factors that may influence them.
• Generating new theories or hypotheses: Qualitative research can be useful for generating new theories or hypotheses about social phenomena. By gathering rich, detailed data about individuals’ experiences and perspectives, researchers can develop insights that may challenge existing theories or lead to new lines of inquiry.
• Providing context for quantitative data: Qualitative research can be useful for providing context for quantitative data. By gathering qualitative data alongside quantitative data, researchers can develop a more complete understanding of complex social phenomena and identify potential explanations for quantitative findings.

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

• Exploring a new area: If little is known about a particular topic, qualitative research can help to identify key issues, generate hypotheses, and develop new theories.
• Understanding complex phenomena: Qualitative research can be used to investigate complex social, cultural, or organizational phenomena that are difficult to measure quantitatively.
• Investigating subjective experiences: Qualitative research is particularly useful for investigating the subjective experiences of individuals or groups, such as their attitudes, beliefs, values, or emotions.
• Conducting formative research: Qualitative research can be used in the early stages of a research project to develop research questions, identify potential research participants, and refine research methods.
• Evaluating interventions or programs: Qualitative research can be used to evaluate the effectiveness of interventions or programs by collecting data on participants’ experiences, attitudes, and behaviors.

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

• Focus on subjective experience: Qualitative research is concerned with understanding the subjective experiences, beliefs, and perspectives of individuals or groups in a particular context. Researchers aim to explore the meanings that people attach to their experiences and to understand the social and cultural factors that shape these meanings.
• Use of open-ended questions: Qualitative research relies on open-ended questions that allow participants to provide detailed, in-depth responses. Researchers seek to elicit rich, descriptive data that can provide insights into participants’ experiences and perspectives.
• Sampling-based on purpose and diversity: Qualitative research often involves purposive sampling, in which participants are selected based on specific criteria related to the research question. Researchers may also seek to include participants with diverse experiences and perspectives to capture a range of viewpoints.
• Data collection through multiple methods: Qualitative research typically involves the use of multiple data collection methods, such as in-depth interviews, focus groups, and observation. This allows researchers to gather rich, detailed data from multiple sources, which can provide a more complete picture of participants’ experiences and perspectives.
• Inductive data analysis: Qualitative research relies on inductive data analysis, in which researchers develop theories and insights based on the data rather than testing pre-existing hypotheses. Researchers use coding and thematic analysis to identify patterns and themes in the data and to develop theories and explanations based on these patterns.
• Emphasis on researcher reflexivity: Qualitative research recognizes the importance of the researcher’s role in shaping the research process and outcomes. Researchers are encouraged to reflect on their own biases and assumptions and to be transparent about their role in the research process.

Advantages of Qualitative Research

Qualitative research offers several advantages over other research methods, including:

• Depth and detail: Qualitative research allows researchers to gather rich, detailed data that provides a deeper understanding of complex social phenomena. Through in-depth interviews, focus groups, and observation, researchers can gather detailed information about participants’ experiences and perspectives that may be missed by other research methods.
• Flexibility : Qualitative research is a flexible approach that allows researchers to adapt their methods to the research question and context. Researchers can adjust their research methods in real-time to gather more information or explore unexpected findings.
• Contextual understanding: Qualitative research is well-suited to exploring the social and cultural context in which individuals or groups are situated. Researchers can gather information about cultural norms, social structures, and historical events that may influence participants’ experiences and perspectives.
• Participant perspective : Qualitative research prioritizes the perspective of participants, allowing researchers to explore subjective experiences and understand the meanings that participants attach to their experiences.
• Theory development: Qualitative research can contribute to the development of new theories and insights about complex social phenomena. By gathering rich, detailed data and using inductive data analysis, researchers can develop new theories and explanations that may challenge existing understandings.
• Validity : Qualitative research can offer high validity by using multiple data collection methods, purposive and diverse sampling, and researcher reflexivity. This can help ensure that findings are credible and trustworthy.

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

• Subjectivity : Qualitative research relies on the subjective interpretation of researchers, which can introduce bias into the research process. The researcher’s perspective, beliefs, and experiences can influence the way data is collected, analyzed, and interpreted.
• Limited generalizability: Qualitative research typically involves small, purposive samples that may not be representative of larger populations. This limits the generalizability of findings to other contexts or populations.
• Time-consuming: Qualitative research can be a time-consuming process, requiring significant resources for data collection, analysis, and interpretation.
• Resource-intensive: Qualitative research may require more resources than other research methods, including specialized training for researchers, specialized software for data analysis, and transcription services.
• Limited reliability: Qualitative research may be less reliable than quantitative research, as it relies on the subjective interpretation of researchers. This can make it difficult to replicate findings or compare results across different studies.
• Ethics and confidentiality: Qualitative research involves collecting sensitive information from participants, which raises ethical concerns about confidentiality and informed consent. Researchers must take care to protect the privacy and confidentiality of participants and obtain informed consent.

Also see Research Methods

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How to use and assess qualitative research methods

Loraine busetto.

1 Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany

Wolfgang Wick

2 Clinical Cooperation Unit Neuro-Oncology, German Cancer Research Center, Heidelberg, Germany

Christoph Gumbinger

Associated data.

Not applicable.

This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.

The aim of this paper is to provide an overview of qualitative research methods, including hands-on information on how they can be used, reported and assessed. This article is intended for beginning qualitative researchers in the health sciences as well as experienced quantitative researchers who wish to broaden their understanding of qualitative research.

What is qualitative research?

Qualitative research is defined as “the study of the nature of phenomena”, including “their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived” , but excluding “their range, frequency and place in an objectively determined chain of cause and effect” [ 1 ]. This formal definition can be complemented with a more pragmatic rule of thumb: qualitative research generally includes data in form of words rather than numbers [ 2 ].

Why conduct qualitative research?

Because some research questions cannot be answered using (only) quantitative methods. For example, one Australian study addressed the issue of why patients from Aboriginal communities often present late or not at all to specialist services offered by tertiary care hospitals. Using qualitative interviews with patients and staff, it found one of the most significant access barriers to be transportation problems, including some towns and communities simply not having a bus service to the hospital [ 3 ]. A quantitative study could have measured the number of patients over time or even looked at possible explanatory factors – but only those previously known or suspected to be of relevance. To discover reasons for observed patterns, especially the invisible or surprising ones, qualitative designs are needed.

While qualitative research is common in other fields, it is still relatively underrepresented in health services research. The latter field is more traditionally rooted in the evidence-based-medicine paradigm, as seen in " research that involves testing the effectiveness of various strategies to achieve changes in clinical practice, preferably applying randomised controlled trial study designs (...) " [ 4 ]. This focus on quantitative research and specifically randomised controlled trials (RCT) is visible in the idea of a hierarchy of research evidence which assumes that some research designs are objectively better than others, and that choosing a "lesser" design is only acceptable when the better ones are not practically or ethically feasible [ 5 , 6 ]. Others, however, argue that an objective hierarchy does not exist, and that, instead, the research design and methods should be chosen to fit the specific research question at hand – "questions before methods" [ 2 , 7 – 9 ]. This means that even when an RCT is possible, some research problems require a different design that is better suited to addressing them. Arguing in JAMA, Berwick uses the example of rapid response teams in hospitals, which he describes as " a complex, multicomponent intervention – essentially a process of social change" susceptible to a range of different context factors including leadership or organisation history. According to him, "[in] such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect" [ 8 ] . Instead of limiting oneself to RCTs, Berwick recommends embracing a wider range of methods , including qualitative ones, which for "these specific applications, (...) are not compromises in learning how to improve; they are superior" [ 8 ].

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 – 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

Given that qualitative research is characterised by flexibility, openness and responsivity to context, the steps of data collection and analysis are not as separate and consecutive as they tend to be in quantitative research [ 13 , 14 ]. As Fossey puts it : “sampling, data collection, analysis and interpretation are related to each other in a cyclical (iterative) manner, rather than following one after another in a stepwise approach” [ 15 ]. The researcher can make educated decisions with regard to the choice of method, how they are implemented, and to which and how many units they are applied [ 13 ]. As shown in Fig.  1 , this can involve several back-and-forth steps between data collection and analysis where new insights and experiences can lead to adaption and expansion of the original plan. Some insights may also necessitate a revision of the research question and/or the research design as a whole. The process ends when saturation is achieved, i.e. when no relevant new information can be found (see also below: sampling and saturation). For reasons of transparency, it is essential for all decisions as well as the underlying reasoning to be well-documented.

Iterative research process

While it is not always explicitly addressed, qualitative methods reflect a different underlying research paradigm than quantitative research (e.g. constructivism or interpretivism as opposed to positivism). The choice of methods can be based on the respective underlying substantive theory or theoretical framework used by the researcher [ 2 ].

Data collection

The methods of qualitative data collection most commonly used in health research are document study, observations, semi-structured interviews and focus groups [ 1 , 14 , 16 , 17 ].

Document study

Document study (also called document analysis) refers to the review by the researcher of written materials [ 14 ]. These can include personal and non-personal documents such as archives, annual reports, guidelines, policy documents, diaries or letters.

Observations

Observations are particularly useful to gain insights into a certain setting and actual behaviour – as opposed to reported behaviour or opinions [ 13 ]. Qualitative observations can be either participant or non-participant in nature. In participant observations, the observer is part of the observed setting, for example a nurse working in an intensive care unit [ 18 ]. In non-participant observations, the observer is “on the outside looking in”, i.e. present in but not part of the situation, trying not to influence the setting by their presence. Observations can be planned (e.g. for 3 h during the day or night shift) or ad hoc (e.g. as soon as a stroke patient arrives at the emergency room). During the observation, the observer takes notes on everything or certain pre-determined parts of what is happening around them, for example focusing on physician-patient interactions or communication between different professional groups. Written notes can be taken during or after the observations, depending on feasibility (which is usually lower during participant observations) and acceptability (e.g. when the observer is perceived to be judging the observed). Afterwards, these field notes are transcribed into observation protocols. If more than one observer was involved, field notes are taken independently, but notes can be consolidated into one protocol after discussions. Advantages of conducting observations include minimising the distance between the researcher and the researched, the potential discovery of topics that the researcher did not realise were relevant and gaining deeper insights into the real-world dimensions of the research problem at hand [ 18 ].

Semi-structured interviews

Hijmans & Kuyper describe qualitative interviews as “an exchange with an informal character, a conversation with a goal” [ 19 ]. Interviews are used to gain insights into a person’s subjective experiences, opinions and motivations – as opposed to facts or behaviours [ 13 ]. Interviews can be distinguished by the degree to which they are structured (i.e. a questionnaire), open (e.g. free conversation or autobiographical interviews) or semi-structured [ 2 , 13 ]. Semi-structured interviews are characterized by open-ended questions and the use of an interview guide (or topic guide/list) in which the broad areas of interest, sometimes including sub-questions, are defined [ 19 ]. The pre-defined topics in the interview guide can be derived from the literature, previous research or a preliminary method of data collection, e.g. document study or observations. The topic list is usually adapted and improved at the start of the data collection process as the interviewer learns more about the field [ 20 ]. Across interviews the focus on the different (blocks of) questions may differ and some questions may be skipped altogether (e.g. if the interviewee is not able or willing to answer the questions or for concerns about the total length of the interview) [ 20 ]. Qualitative interviews are usually not conducted in written format as it impedes on the interactive component of the method [ 20 ]. In comparison to written surveys, qualitative interviews have the advantage of being interactive and allowing for unexpected topics to emerge and to be taken up by the researcher. This can also help overcome a provider or researcher-centred bias often found in written surveys, which by nature, can only measure what is already known or expected to be of relevance to the researcher. Interviews can be audio- or video-taped; but sometimes it is only feasible or acceptable for the interviewer to take written notes [ 14 , 16 , 20 ].

Focus groups

Focus groups are group interviews to explore participants’ expertise and experiences, including explorations of how and why people behave in certain ways [ 1 ]. Focus groups usually consist of 6–8 people and are led by an experienced moderator following a topic guide or “script” [ 21 ]. They can involve an observer who takes note of the non-verbal aspects of the situation, possibly using an observation guide [ 21 ]. Depending on researchers’ and participants’ preferences, the discussions can be audio- or video-taped and transcribed afterwards [ 21 ]. Focus groups are useful for bringing together homogeneous (to a lesser extent heterogeneous) groups of participants with relevant expertise and experience on a given topic on which they can share detailed information [ 21 ]. Focus groups are a relatively easy, fast and inexpensive method to gain access to information on interactions in a given group, i.e. “the sharing and comparing” among participants [ 21 ]. Disadvantages include less control over the process and a lesser extent to which each individual may participate. Moreover, focus group moderators need experience, as do those tasked with the analysis of the resulting data. Focus groups can be less appropriate for discussing sensitive topics that participants might be reluctant to disclose in a group setting [ 13 ]. Moreover, attention must be paid to the emergence of “groupthink” as well as possible power dynamics within the group, e.g. when patients are awed or intimidated by health professionals.

Choosing the “right” method

As explained above, the school of thought underlying qualitative research assumes no objective hierarchy of evidence and methods. This means that each choice of single or combined methods has to be based on the research question that needs to be answered and a critical assessment with regard to whether or to what extent the chosen method can accomplish this – i.e. the “fit” between question and method [ 14 ]. It is necessary for these decisions to be documented when they are being made, and to be critically discussed when reporting methods and results.

Let us assume that our research aim is to examine the (clinical) processes around acute endovascular treatment (EVT), from the patient’s arrival at the emergency room to recanalization, with the aim to identify possible causes for delay and/or other causes for sub-optimal treatment outcome. As a first step, we could conduct a document study of the relevant standard operating procedures (SOPs) for this phase of care – are they up-to-date and in line with current guidelines? Do they contain any mistakes, irregularities or uncertainties that could cause delays or other problems? Regardless of the answers to these questions, the results have to be interpreted based on what they are: a written outline of what care processes in this hospital should look like. If we want to know what they actually look like in practice, we can conduct observations of the processes described in the SOPs. These results can (and should) be analysed in themselves, but also in comparison to the results of the document analysis, especially as regards relevant discrepancies. Do the SOPs outline specific tests for which no equipment can be observed or tasks to be performed by specialized nurses who are not present during the observation? It might also be possible that the written SOP is outdated, but the actual care provided is in line with current best practice. In order to find out why these discrepancies exist, it can be useful to conduct interviews. Are the physicians simply not aware of the SOPs (because their existence is limited to the hospital’s intranet) or do they actively disagree with them or does the infrastructure make it impossible to provide the care as described? Another rationale for adding interviews is that some situations (or all of their possible variations for different patient groups or the day, night or weekend shift) cannot practically or ethically be observed. In this case, it is possible to ask those involved to report on their actions – being aware that this is not the same as the actual observation. A senior physician’s or hospital manager’s description of certain situations might differ from a nurse’s or junior physician’s one, maybe because they intentionally misrepresent facts or maybe because different aspects of the process are visible or important to them. In some cases, it can also be relevant to consider to whom the interviewee is disclosing this information – someone they trust, someone they are otherwise not connected to, or someone they suspect or are aware of being in a potentially “dangerous” power relationship to them. Lastly, a focus group could be conducted with representatives of the relevant professional groups to explore how and why exactly they provide care around EVT. The discussion might reveal discrepancies (between SOPs and actual care or between different physicians) and motivations to the researchers as well as to the focus group members that they might not have been aware of themselves. For the focus group to deliver relevant information, attention has to be paid to its composition and conduct, for example, to make sure that all participants feel safe to disclose sensitive or potentially problematic information or that the discussion is not dominated by (senior) physicians only. The resulting combination of data collection methods is shown in Fig.  2 .

Possible combination of data collection methods

Attributions for icons: “Book” by Serhii Smirnov, “Interview” by Adrien Coquet, FR, “Magnifying Glass” by anggun, ID, “Business communication” by Vectors Market; all from the Noun Project

The combination of multiple data source as described for this example can be referred to as “triangulation”, in which multiple measurements are carried out from different angles to achieve a more comprehensive understanding of the phenomenon under study [ 22 , 23 ].

Data analysis

To analyse the data collected through observations, interviews and focus groups these need to be transcribed into protocols and transcripts (see Fig.  3 ). Interviews and focus groups can be transcribed verbatim , with or without annotations for behaviour (e.g. laughing, crying, pausing) and with or without phonetic transcription of dialects and filler words, depending on what is expected or known to be relevant for the analysis. In the next step, the protocols and transcripts are coded , that is, marked (or tagged, labelled) with one or more short descriptors of the content of a sentence or paragraph [ 2 , 15 , 23 ]. Jansen describes coding as “connecting the raw data with “theoretical” terms” [ 20 ]. In a more practical sense, coding makes raw data sortable. This makes it possible to extract and examine all segments describing, say, a tele-neurology consultation from multiple data sources (e.g. SOPs, emergency room observations, staff and patient interview). In a process of synthesis and abstraction, the codes are then grouped, summarised and/or categorised [ 15 , 20 ]. The end product of the coding or analysis process is a descriptive theory of the behavioural pattern under investigation [ 20 ]. The coding process is performed using qualitative data management software, the most common ones being InVivo, MaxQDA and Atlas.ti. It should be noted that these are data management tools which support the analysis performed by the researcher(s) [ 14 ].

From data collection to data analysis

Attributions for icons: see Fig. ​ Fig.2, 2 , also “Speech to text” by Trevor Dsouza, “Field Notes” by Mike O’Brien, US, “Voice Record” by ProSymbols, US, “Inspection” by Made, AU, and “Cloud” by Graphic Tigers; all from the Noun Project

How to report qualitative research?

Protocols of qualitative research can be published separately and in advance of the study results. However, the aim is not the same as in RCT protocols, i.e. to pre-define and set in stone the research questions and primary or secondary endpoints. Rather, it is a way to describe the research methods in detail, which might not be possible in the results paper given journals’ word limits. Qualitative research papers are usually longer than their quantitative counterparts to allow for deep understanding and so-called “thick description”. In the methods section, the focus is on transparency of the methods used, including why, how and by whom they were implemented in the specific study setting, so as to enable a discussion of whether and how this may have influenced data collection, analysis and interpretation. The results section usually starts with a paragraph outlining the main findings, followed by more detailed descriptions of, for example, the commonalities, discrepancies or exceptions per category [ 20 ]. Here it is important to support main findings by relevant quotations, which may add information, context, emphasis or real-life examples [ 20 , 23 ]. It is subject to debate in the field whether it is relevant to state the exact number or percentage of respondents supporting a certain statement (e.g. “Five interviewees expressed negative feelings towards XYZ”) [ 21 ].

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 – 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

Three common mixed methods designs

In the convergent parallel design, a qualitative study is conducted in parallel to and independently of a quantitative study, and the results of both studies are compared and combined at the stage of interpretation of results. Using the above example of EVT provision, this could entail setting up a quantitative EVT registry to measure process times and patient outcomes in parallel to conducting the qualitative research outlined above, and then comparing results. Amongst other things, this would make it possible to assess whether interview respondents’ subjective impressions of patients receiving good care match modified Rankin Scores at follow-up, or whether observed delays in care provision are exceptions or the rule when compared to door-to-needle times as documented in the registry. In the explanatory sequential design, a quantitative study is carried out first, followed by a qualitative study to help explain the results from the quantitative study. This would be an appropriate design if the registry alone had revealed relevant delays in door-to-needle times and the qualitative study would be used to understand where and why these occurred, and how they could be improved. In the exploratory design, the qualitative study is carried out first and its results help informing and building the quantitative study in the next step [ 26 ]. If the qualitative study around EVT provision had shown a high level of dissatisfaction among the staff members involved, a quantitative questionnaire investigating staff satisfaction could be set up in the next step, informed by the qualitative study on which topics dissatisfaction had been expressed. Amongst other things, the questionnaire design would make it possible to widen the reach of the research to more respondents from different (types of) hospitals, regions, countries or settings, and to conduct sub-group analyses for different professional groups.

How to assess qualitative research?

A variety of assessment criteria and lists have been developed for qualitative research, ranging in their focus and comprehensiveness [ 14 , 17 , 27 ]. However, none of these has been elevated to the “gold standard” in the field. In the following, we therefore focus on a set of commonly used assessment criteria that, from a practical standpoint, a researcher can look for when assessing a qualitative research report or paper.

Assessors should check the authors’ use of and adherence to the relevant reporting checklists (e.g. Standards for Reporting Qualitative Research (SRQR)) to make sure all items that are relevant for this type of research are addressed [ 23 , 28 ]. Discussions of quantitative measures in addition to or instead of these qualitative measures can be a sign of lower quality of the research (paper). Providing and adhering to a checklist for qualitative research contributes to an important quality criterion for qualitative research, namely transparency [ 15 , 17 , 23 ].

Reflexivity

While methodological transparency and complete reporting is relevant for all types of research, some additional criteria must be taken into account for qualitative research. This includes what is called reflexivity, i.e. sensitivity to the relationship between the researcher and the researched, including how contact was established and maintained, or the background and experience of the researcher(s) involved in data collection and analysis. Depending on the research question and population to be researched this can be limited to professional experience, but it may also include gender, age or ethnicity [ 17 , 27 ]. These details are relevant because in qualitative research, as opposed to quantitative research, the researcher as a person cannot be isolated from the research process [ 23 ]. It may influence the conversation when an interviewed patient speaks to an interviewer who is a physician, or when an interviewee is asked to discuss a gynaecological procedure with a male interviewer, and therefore the reader must be made aware of these details [ 19 ].

Sampling and saturation

The aim of qualitative sampling is for all variants of the objects of observation that are deemed relevant for the study to be present in the sample “ to see the issue and its meanings from as many angles as possible” [ 1 , 16 , 19 , 20 , 27 ] , and to ensure “information-richness [ 15 ]. An iterative sampling approach is advised, in which data collection (e.g. five interviews) is followed by data analysis, followed by more data collection to find variants that are lacking in the current sample. This process continues until no new (relevant) information can be found and further sampling becomes redundant – which is called saturation [ 1 , 15 ] . In other words: qualitative data collection finds its end point not a priori , but when the research team determines that saturation has been reached [ 29 , 30 ].

This is also the reason why most qualitative studies use deliberate instead of random sampling strategies. This is generally referred to as “ purposive sampling” , in which researchers pre-define which types of participants or cases they need to include so as to cover all variations that are expected to be of relevance, based on the literature, previous experience or theory (i.e. theoretical sampling) [ 14 , 20 ]. Other types of purposive sampling include (but are not limited to) maximum variation sampling, critical case sampling or extreme or deviant case sampling [ 2 ]. In the above EVT example, a purposive sample could include all relevant professional groups and/or all relevant stakeholders (patients, relatives) and/or all relevant times of observation (day, night and weekend shift).

Assessors of qualitative research should check whether the considerations underlying the sampling strategy were sound and whether or how researchers tried to adapt and improve their strategies in stepwise or cyclical approaches between data collection and analysis to achieve saturation [ 14 ].

Good qualitative research is iterative in nature, i.e. it goes back and forth between data collection and analysis, revising and improving the approach where necessary. One example of this are pilot interviews, where different aspects of the interview (especially the interview guide, but also, for example, the site of the interview or whether the interview can be audio-recorded) are tested with a small number of respondents, evaluated and revised [ 19 ]. In doing so, the interviewer learns which wording or types of questions work best, or which is the best length of an interview with patients who have trouble concentrating for an extended time. Of course, the same reasoning applies to observations or focus groups which can also be piloted.

Ideally, coding should be performed by at least two researchers, especially at the beginning of the coding process when a common approach must be defined, including the establishment of a useful coding list (or tree), and when a common meaning of individual codes must be established [ 23 ]. An initial sub-set or all transcripts can be coded independently by the coders and then compared and consolidated after regular discussions in the research team. This is to make sure that codes are applied consistently to the research data.

Member checking

Member checking, also called respondent validation , refers to the practice of checking back with study respondents to see if the research is in line with their views [ 14 , 27 ]. This can happen after data collection or analysis or when first results are available [ 23 ]. For example, interviewees can be provided with (summaries of) their transcripts and asked whether they believe this to be a complete representation of their views or whether they would like to clarify or elaborate on their responses [ 17 ]. Respondents’ feedback on these issues then becomes part of the data collection and analysis [ 27 ].

Stakeholder involvement

In those niches where qualitative approaches have been able to evolve and grow, a new trend has seen the inclusion of patients and their representatives not only as study participants (i.e. “members”, see above) but as consultants to and active participants in the broader research process [ 31 – 33 ]. The underlying assumption is that patients and other stakeholders hold unique perspectives and experiences that add value beyond their own single story, making the research more relevant and beneficial to researchers, study participants and (future) patients alike [ 34 , 35 ]. Using the example of patients on or nearing dialysis, a recent scoping review found that 80% of clinical research did not address the top 10 research priorities identified by patients and caregivers [ 32 , 36 ]. In this sense, the involvement of the relevant stakeholders, especially patients and relatives, is increasingly being seen as a quality indicator in and of itself.

How not to assess qualitative research

The above overview does not include certain items that are routine in assessments of quantitative research. What follows is a non-exhaustive, non-representative, experience-based list of the quantitative criteria often applied to the assessment of qualitative research, as well as an explanation of the limited usefulness of these endeavours.

Protocol adherence

Given the openness and flexibility of qualitative research, it should not be assessed by how well it adheres to pre-determined and fixed strategies – in other words: its rigidity. Instead, the assessor should look for signs of adaptation and refinement based on lessons learned from earlier steps in the research process.

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 – 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

While some authors argue that randomisation can be used in qualitative research, this is not commonly the case, as neither its feasibility nor its necessity or usefulness has been convincingly established for qualitative research [ 13 , 27 ]. Relevant disadvantages include the negative impact of a too large sample size as well as the possibility (or probability) of selecting “ quiet, uncooperative or inarticulate individuals ” [ 17 ]. Qualitative studies do not use control groups, either.

Interrater reliability, variability and other “objectivity checks”

The concept of “interrater reliability” is sometimes used in qualitative research to assess to which extent the coding approach overlaps between the two co-coders. However, it is not clear what this measure tells us about the quality of the analysis [ 23 ]. This means that these scores can be included in qualitative research reports, preferably with some additional information on what the score means for the analysis, but it is not a requirement. Relatedly, it is not relevant for the quality or “objectivity” of qualitative research to separate those who recruited the study participants and collected and analysed the data. Experiences even show that it might be better to have the same person or team perform all of these tasks [ 20 ]. First, when researchers introduce themselves during recruitment this can enhance trust when the interview takes place days or weeks later with the same researcher. Second, when the audio-recording is transcribed for analysis, the researcher conducting the interviews will usually remember the interviewee and the specific interview situation during data analysis. This might be helpful in providing additional context information for interpretation of data, e.g. on whether something might have been meant as a joke [ 18 ].

Not being quantitative research

Being qualitative research instead of quantitative research should not be used as an assessment criterion if it is used irrespectively of the research problem at hand. Similarly, qualitative research should not be required to be combined with quantitative research per se – unless mixed methods research is judged as inherently better than single-method research. In this case, the same criterion should be applied for quantitative studies without a qualitative component.

The main take-away points of this paper are summarised in Table ​ Table1. 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

Take-away-points

Acknowledgements

Abbreviations, authors’ contributions.

LB drafted the manuscript; WW and CG revised the manuscript; all authors approved the final versions.

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Qualitative Research: Characteristics, Design, Methods & Examples

Lauren McCall

MSc Health Psychology Graduate

MSc, Health Psychology, University of Nottingham

Lauren obtained an MSc in Health Psychology from The University of Nottingham with a distinction classification.

Learn about our Editorial Process

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

“Not everything that can be counted counts, and not everything that counts can be counted“ (Albert Einstein)

Qualitative research is a process used for the systematic collection, analysis, and interpretation of non-numerical data (Punch, 2013). 

Qualitative research can be used to: (i) gain deep contextual understandings of the subjective social reality of individuals and (ii) to answer questions about experience and meaning from the participant’s perspective (Hammarberg et al., 2016).

Unlike quantitative research, which focuses on gathering and analyzing numerical data for statistical analysis, qualitative research focuses on thematic and contextual information.

Characteristics of Qualitative Research 

Reality is socially constructed.

Qualitative research aims to understand how participants make meaning of their experiences – individually or in social contexts. It assumes there is no objective reality and that the social world is interpreted (Yilmaz, 2013). 

The primacy of subject matter 

The primary aim of qualitative research is to understand the perspectives, experiences, and beliefs of individuals who have experienced the phenomenon selected for research rather than the average experiences of groups of people (Minichiello, 1990).

Variables are complex, interwoven, and difficult to measure

Factors such as experiences, behaviors, and attitudes are complex and interwoven, so they cannot be reduced to isolated variables , making them difficult to measure quantitatively.

However, a qualitative approach enables participants to describe what, why, or how they were thinking/ feeling during a phenomenon being studied (Yilmaz, 2013). 

Emic (insider’s point of view)

The phenomenon being studied is centered on the participants’ point of view (Minichiello, 1990).

Emic is used to describe how participants interact, communicate, and behave in the context of the research setting (Scarduzio, 2017).

Why Conduct Qualitative Research? 

In order to gain a deeper understanding of how people experience the world, individuals are studied in their natural setting. This enables the researcher to understand a phenomenon close to how participants experience it. 

Qualitative research allows researchers to gain an in-depth understanding, which is difficult to attain using quantitative methods. 

An in-depth understanding is attained since qualitative techniques allow participants to freely disclose their experiences, thoughts, and feelings without constraint (Tenny et al., 2022). 

This helps to further investigate and understand quantitative data by discovering reasons for the outcome of a study – answering the why question behind statistics. 

The exploratory nature of qualitative research helps to generate hypotheses that can then be tested quantitatively (Busetto et al., 2020).

To design hypotheses, theory must be researched using qualitative methods to find out what is important in order to begin research. 

For example, by conducting interviews or focus groups with key stakeholders to discover what is important to them. 

Examples of qualitative research questions include: 

• How does stress influence young adults’ behavior?
• What factors influence students’ school attendance rates in developed countries?
• How do adults interpret binge drinking in the UK?
• What are the psychological impacts of cervical cancer screening in women?
• How can mental health lessons be integrated into the school curriculum? 

Collecting Qualitative Data

There are four main research design methods used to collect qualitative data: observations, interviews,  focus groups, and ethnography.

Observations

This method involves watching and recording phenomena as they occur in nature. Observation can be divided into two types: participant and non-participant observation.

In participant observation, the researcher actively participates in the situation/events being observed.

In non-participant observation, the researcher is not an active part of the observation and tries not to influence the behaviors they are observing (Busetto et al., 2020). 

Observations can be covert (participants are unaware that a researcher is observing them) or overt (participants are aware of the researcher’s presence and know they are being observed).

However, awareness of an observer’s presence may influence participants’ behavior. 

Interviews give researchers a window into the world of a participant by seeking their account of an event, situation, or phenomenon. They are usually conducted on a one-to-one basis and can be distinguished according to the level at which they are structured (Punch, 2013). 

Structured interviews involve predetermined questions and sequences to ensure replicability and comparability. However, they are unable to explore emerging issues.

Informal interviews consist of spontaneous, casual conversations which are closer to the truth of a phenomenon. However, information is gathered using quick notes made by the researcher and is therefore subject to recall bias. 

Semi-structured interviews have a flexible structure, phrasing, and placement so emerging issues can be explored (Denny & Weckesser, 2022).

The use of probing questions and clarification can lead to a detailed understanding, but semi-structured interviews can be time-consuming and subject to interviewer bias. 

Focus groups 

Similar to interviews, focus groups elicit a rich and detailed account of an experience. However, focus groups are more dynamic since participants with shared characteristics construct this account together (Denny & Weckesser, 2022).

A shared narrative is built between participants to capture a group experience shaped by a shared context. 

The researcher takes on the role of a moderator, who will establish ground rules and guide the discussion by following a topic guide to focus the group discussions.

Typically, focus groups have 4-10 participants as a discussion can be difficult to facilitate with more than this, and this number allows everyone the time to speak.

Ethnography

Ethnography is a methodology used to study a group of people’s behaviors and social interactions in their environment (Reeves et al., 2008).

Data are collected using methods such as observations, field notes, or structured/ unstructured interviews.

The aim of ethnography is to provide detailed, holistic insights into people’s behavior and perspectives within their natural setting. In order to achieve this, researchers immerse themselves in a community or organization. 

Due to the flexibility and real-world focus of ethnography, researchers are able to gather an in-depth, nuanced understanding of people’s experiences, knowledge and perspectives that are influenced by culture and society.

In order to develop a representative picture of a particular culture/ context, researchers must conduct extensive field work. 

This can be time-consuming as researchers may need to immerse themselves into a community/ culture for a few days, or possibly a few years.

Qualitative Data Analysis Methods

Different methods can be used for analyzing qualitative data. The researcher chooses based on the objectives of their study. 

The researcher plays a key role in the interpretation of data, making decisions about the coding, theming, decontextualizing, and recontextualizing of data (Starks & Trinidad, 2007). 

Grounded theory

Grounded theory is a qualitative method specifically designed to inductively generate theory from data. It was developed by Glaser and Strauss in 1967 (Glaser & Strauss, 2017).

 This methodology aims to develop theories (rather than test hypotheses) that explain a social process, action, or interaction (Petty et al., 2012). To inform the developing theory, data collection and analysis run simultaneously. 

There are three key types of coding used in grounded theory: initial (open), intermediate (axial), and advanced (selective) coding. 

Throughout the analysis, memos should be created to document methodological and theoretical ideas about the data. Data should be collected and analyzed until data saturation is reached and a theory is developed. 

Content analysis

Content analysis was first used in the early twentieth century to analyze textual materials such as newspapers and political speeches.

Content analysis is a research method used to identify and analyze the presence and patterns of themes, concepts, or words in data (Vaismoradi et al., 2013). 

This research method can be used to analyze data in different formats, which can be written, oral, or visual. 

The goal of content analysis is to develop themes that capture the underlying meanings of data (Schreier, 2012). 

Qualitative content analysis can be used to validate existing theories, support the development of new models and theories, and provide in-depth descriptions of particular settings or experiences.

The following six steps provide a guideline for how to conduct qualitative content analysis.

• Define a Research Question : To start content analysis, a clear research question should be developed.
• Identify and Collect Data : Establish the inclusion criteria for your data. Find the relevant sources to analyze.
• Define the Unit or Theme of Analysis : Categorize the content into themes. Themes can be a word, phrase, or sentence.
• Develop Rules for Coding your Data : Define a set of coding rules to ensure that all data are coded consistently.
• Code the Data : Follow the coding rules to categorize data into themes.
• Analyze the Results and Draw Conclusions : Examine the data to identify patterns and draw conclusions in relation to your research question.

Discourse analysis

Discourse analysis is a research method used to study written/ spoken language in relation to its social context (Wood & Kroger, 2000).

In discourse analysis, the researcher interprets details of language materials and the context in which it is situated.

Discourse analysis aims to understand the functions of language (how language is used in real life) and how meaning is conveyed by language in different contexts. Researchers use discourse analysis to investigate social groups and how language is used to achieve specific communication goals.

Different methods of discourse analysis can be used depending on the aims and objectives of a study. However, the following steps provide a guideline on how to conduct discourse analysis.

• Define the Research Question : Develop a relevant research question to frame the analysis.
• Gather Data and Establish the Context : Collect research materials (e.g., interview transcripts, documents). Gather factual details and review the literature to construct a theory about the social and historical context of your study.
• Analyze the Content : Closely examine various components of the text, such as the vocabulary, sentences, paragraphs, and structure of the text. Identify patterns relevant to the research question to create codes, then group these into themes.
• Review the Results : Reflect on the findings to examine the function of the language, and the meaning and context of the discourse. 

Thematic analysis

Thematic analysis is a method used to identify, interpret, and report patterns in data, such as commonalities or contrasts. 

Although the origin of thematic analysis can be traced back to the early twentieth century, understanding and clarity of thematic analysis is attributed to Braun and Clarke (2006).

Thematic analysis aims to develop themes (patterns of meaning) across a dataset to address a research question. 

In thematic analysis, qualitative data is gathered using techniques such as interviews, focus groups, and questionnaires. Audio recordings are transcribed. The dataset is then explored and interpreted by a researcher to identify patterns. 

This occurs through the rigorous process of data familiarisation, coding, theme development, and revision. These identified patterns provide a summary of the dataset and can be used to address a research question.

Themes are developed by exploring the implicit and explicit meanings within the data. Two different approaches are used to generate themes: inductive and deductive. 

An inductive approach allows themes to emerge from the data. In contrast, a deductive approach uses existing theories or knowledge to apply preconceived ideas to the data.

Phases of Thematic Analysis

Braun and Clarke (2006) provide a guide of the six phases of thematic analysis. These phases can be applied flexibly to fit research questions and data. 

Template analysis

Template analysis refers to a specific method of thematic analysis which uses hierarchical coding (Brooks et al., 2014).

Template analysis is used to analyze textual data, for example, interview transcripts or open-ended responses on a written questionnaire.

To conduct template analysis, a coding template must be developed (usually from a subset of the data) and subsequently revised and refined. This template represents the themes identified by researchers as important in the dataset. 

Codes are ordered hierarchically within the template, with the highest-level codes demonstrating overarching themes in the data and lower-level codes representing constituent themes with a narrower focus.

A guideline for the main procedural steps for conducting template analysis is outlined below.

• Familiarization with the Data : Read (and reread) the dataset in full. Engage, reflect, and take notes on data that may be relevant to the research question.
• Preliminary Coding : Identify initial codes using guidance from the a priori codes, identified before the analysis as likely to be beneficial and relevant to the analysis.
• Organize Themes : Organize themes into meaningful clusters. Consider the relationships between the themes both within and between clusters.
• Produce an Initial Template : Develop an initial template. This may be based on a subset of the data.
• Apply and Develop the Template : Apply the initial template to further data and make any necessary modifications. Refinements of the template may include adding themes, removing themes, or changing the scope/title of themes. 
• Finalize Template : Finalize the template, then apply it to the entire dataset. 

Frame analysis

Frame analysis is a comparative form of thematic analysis which systematically analyzes data using a matrix output.

Ritchie and Spencer (1994) developed this set of techniques to analyze qualitative data in applied policy research. Frame analysis aims to generate theory from data.

Frame analysis encourages researchers to organize and manage their data using summarization.

This results in a flexible and unique matrix output, in which individual participants (or cases) are represented by rows and themes are represented by columns. 

Each intersecting cell is used to summarize findings relating to the corresponding participant and theme.

Frame analysis has five distinct phases which are interrelated, forming a methodical and rigorous framework.

• Familiarization with the Data : Familiarize yourself with all the transcripts. Immerse yourself in the details of each transcript and start to note recurring themes.
• Develop a Theoretical Framework : Identify recurrent/ important themes and add them to a chart. Provide a framework/ structure for the analysis.
• Indexing : Apply the framework systematically to the entire study data.
• Summarize Data in Analytical Framework : Reduce the data into brief summaries of participants’ accounts.
• Mapping and Interpretation : Compare themes and subthemes and check against the original transcripts. Group the data into categories and provide an explanation for them.

Preventing Bias in Qualitative Research

To evaluate qualitative studies, the CASP (Critical Appraisal Skills Programme) checklist for qualitative studies can be used to ensure all aspects of a study have been considered (CASP, 2018).

The quality of research can be enhanced and assessed using criteria such as checklists, reflexivity, co-coding, and member-checking. 

Co-coding 

Relying on only one researcher to interpret rich and complex data may risk key insights and alternative viewpoints being missed. Therefore, coding is often performed by multiple researchers.

A common strategy must be defined at the beginning of the coding process  (Busetto et al., 2020). This includes establishing a useful coding list and finding a common definition of individual codes.

Transcripts are initially coded independently by researchers and then compared and consolidated to minimize error or bias and to bring confirmation of findings. 

Member checking

Member checking (or respondent validation) involves checking back with participants to see if the research resonates with their experiences (Russell & Gregory, 2003).

Data can be returned to participants after data collection or when results are first available. For example, participants may be provided with their interview transcript and asked to verify whether this is a complete and accurate representation of their views.

Participants may then clarify or elaborate on their responses to ensure they align with their views (Shenton, 2004).

This feedback becomes part of data collection and ensures accurate descriptions/ interpretations of phenomena (Mays & Pope, 2000). 

Reflexivity in qualitative research

Reflexivity typically involves examining your own judgments, practices, and belief systems during data collection and analysis. It aims to identify any personal beliefs which may affect the research. 

Reflexivity is essential in qualitative research to ensure methodological transparency and complete reporting. This enables readers to understand how the interaction between the researcher and participant shapes the data.

Depending on the research question and population being researched, factors that need to be considered include the experience of the researcher, how the contact was established and maintained, age, gender, and ethnicity.

These details are important because, in qualitative research, the researcher is a dynamic part of the research process and actively influences the outcome of the research (Boeije, 2014). 

Reflexivity Example

Who you are and your characteristics influence how you collect and analyze data. Here is an example of a reflexivity statement for research on smoking. I am a 30-year-old white female from a middle-class background. I live in the southwest of England and have been educated to master’s level. I have been involved in two research projects on oral health. I have never smoked, but I have witnessed how smoking can cause ill health from my volunteering in a smoking cessation clinic. My research aspirations are to help to develop interventions to help smokers quit.

Establishing Trustworthiness in Qualitative Research

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability.

Credibility in Qualitative Research

Credibility refers to how accurately the results represent the reality and viewpoints of the participants.

To establish credibility in research, participants’ views and the researcher’s representation of their views need to align (Tobin & Begley, 2004).

To increase the credibility of findings, researchers may use data source triangulation, investigator triangulation, peer debriefing, or member checking (Lincoln & Guba, 1985). 

Transferability in Qualitative Research

Transferability refers to how generalizable the findings are: whether the findings may be applied to another context, setting, or group (Tobin & Begley, 2004).

Transferability can be enhanced by giving thorough and in-depth descriptions of the research setting, sample, and methods (Nowell et al., 2017). 

Dependability in Qualitative Research

Dependability is the extent to which the study could be replicated under similar conditions and the findings would be consistent.

Researchers can establish dependability using methods such as audit trails so readers can see the research process is logical and traceable (Koch, 1994).

Confirmability in Qualitative Research

Confirmability is concerned with establishing that there is a clear link between the researcher’s interpretations/ findings and the data.

Researchers can achieve confirmability by demonstrating how conclusions and interpretations were arrived at (Nowell et al., 2017).

This enables readers to understand the reasoning behind the decisions made. 

Audit Trails in Qualitative Research

An audit trail provides evidence of the decisions made by the researcher regarding theory, research design, and data collection, as well as the steps they have chosen to manage, analyze, and report data. 

The researcher must provide a clear rationale to demonstrate how conclusions were reached in their study.

A clear description of the research path must be provided to enable readers to trace through the researcher’s logic (Halpren, 1983).

Researchers should maintain records of the raw data, field notes, transcripts, and a reflective journal in order to provide a clear audit trail. 

Discovery of unexpected data

Open-ended questions in qualitative research mean the researcher can probe an interview topic and enable the participant to elaborate on responses in an unrestricted manner.

This allows unexpected data to emerge, which can lead to further research into that topic. 

Flexibility

Data collection and analysis can be modified and adapted to take the research in a different direction if new ideas or patterns emerge in the data.

This enables researchers to investigate new opportunities while firmly maintaining their research goals. 

Naturalistic settings

The behaviors of participants are recorded in real-world settings. Studies that use real-world settings have high ecological validity since participants behave more authentically. 

Limitations

Time-consuming .

Qualitative research results in large amounts of data which often need to be transcribed and analyzed manually.

Even when software is used, transcription can be inaccurate, and using software for analysis can result in many codes which need to be condensed into themes. 

Subjectivity 

The researcher has an integral role in collecting and interpreting qualitative data. Therefore, the conclusions reached are from their perspective and experience.

Consequently, interpretations of data from another researcher may vary greatly. 

Limited generalizability

The aim of qualitative research is to provide a detailed, contextualized understanding of an aspect of the human experience from a relatively small sample size.

Despite rigorous analysis procedures, conclusions drawn cannot be generalized to the wider population since data may be biased or unrepresentative.

Therefore, results are only applicable to a small group of the population. 

Extraneous variables

Qualitative research is often conducted in real-world settings. This may cause results to be unreliable since extraneous variables may affect the data, for example:

• Situational variables : different environmental conditions may influence participants’ behavior in a study. The random variation in factors (such as noise or lighting) may be difficult to control in real-world settings.
• Participant characteristics : this includes any characteristics that may influence how a participant answers/ behaves in a study. This may include a participant’s mood, gender, age, ethnicity, sexual identity, IQ, etc.
• Experimenter effect : experimenter effect refers to how a researcher’s unintentional influence can change the outcome of a study. This occurs when (i) their interactions with participants unintentionally change participants’ behaviors or (ii) due to errors in observation, interpretation, or analysis. 

What sample size should qualitative research be?

The sample size for qualitative studies has been recommended to include a minimum of 12 participants to reach data saturation (Braun, 2013).

Are surveys qualitative or quantitative?

Surveys can be used to gather information from a sample qualitatively or quantitatively. Qualitative surveys use open-ended questions to gather detailed information from a large sample using free text responses.

The use of open-ended questions allows for unrestricted responses where participants use their own words, enabling the collection of more in-depth information than closed-ended questions.

In contrast, quantitative surveys consist of closed-ended questions with multiple-choice answer options. Quantitative surveys are ideal to gather a statistical representation of a population.

What are the ethical considerations of qualitative research?

Before conducting a study, you must think about any risks that could occur and take steps to prevent them. Participant Protection : Researchers must protect participants from physical and mental harm. This means you must not embarrass, frighten, offend, or harm participants. Transparency : Researchers are obligated to clearly communicate how they will collect, store, analyze, use, and share the data. Confidentiality : You need to consider how to maintain the confidentiality and anonymity of participants’ data.

What is triangulation in qualitative research?

Triangulation refers to the use of several approaches in a study to comprehensively understand phenomena. This method helps to increase the validity and credibility of research findings. 

Types of triangulation include method triangulation (using multiple methods to gather data); investigator triangulation (multiple researchers for collecting/ analyzing data), theory triangulation (comparing several theoretical perspectives to explain a phenomenon), and data source triangulation (using data from various times, locations, and people; Carter et al., 2014).

Why is qualitative research important?

Qualitative research allows researchers to describe and explain the social world. The exploratory nature of qualitative research helps to generate hypotheses that can then be tested quantitatively.

In qualitative research, participants are able to express their thoughts, experiences, and feelings without constraint.

Additionally, researchers are able to follow up on participants’ answers in real-time, generating valuable discussion around a topic. This enables researchers to gain a nuanced understanding of phenomena which is difficult to attain using quantitative methods.

What is coding data in qualitative research?

Coding data is a qualitative data analysis strategy in which a section of text is assigned with a label that describes its content.

These labels may be words or phrases which represent important (and recurring) patterns in the data.

This process enables researchers to identify related content across the dataset. Codes can then be used to group similar types of data to generate themes.

What is the difference between qualitative and quantitative research?

Qualitative research involves the collection and analysis of non-numerical data in order to understand experiences and meanings from the participant’s perspective.

This can provide rich, in-depth insights on complicated phenomena. Qualitative data may be collected using interviews, focus groups, or observations.

In contrast, quantitative research involves the collection and analysis of numerical data to measure the frequency, magnitude, or relationships of variables. This can provide objective and reliable evidence that can be generalized to the wider population.

Quantitative data may be collected using closed-ended questionnaires or experiments.

What is trustworthiness in qualitative research?

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability. 

Credibility refers to how accurately the results represent the reality and viewpoints of the participants. Transferability refers to whether the findings may be applied to another context, setting, or group.

Dependability is the extent to which the findings are consistent and reliable. Confirmability refers to the objectivity of findings (not influenced by the bias or assumptions of researchers).

What is data saturation in qualitative research?

Data saturation is a methodological principle used to guide the sample size of a qualitative research study.

Data saturation is proposed as a necessary methodological component in qualitative research (Saunders et al., 2018) as it is a vital criterion for discontinuing data collection and/or analysis. 

The intention of data saturation is to find “no new data, no new themes, no new coding, and ability to replicate the study” (Guest et al., 2006). Therefore, enough data has been gathered to make conclusions.

Qualitative Research

What is qualitative research.

Qualitative research is the methodology researchers use to gain deep contextual understandings of users via non-numerical means and direct observations. Researchers focus on smaller user samples—e.g., in interviews—to reveal data such as user attitudes, behaviors and hidden factors: insights which guide better designs.

“ There are also unknown unknowns, things we don’t know we don’t know.” — Donald Rumsfeld, Former U.S. Secretary of Defense

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See how you can use qualitative research to expose hidden truths about users and iteratively shape better products.

Qualitative Research Focuses on the “Why”

Qualitative research is a subset of user experience (UX) research and user research . By doing qualitative research, you aim to gain narrowly focused but rich information about why users feel and think the ways they do. Unlike its more statistics-oriented “counterpart”, quantitative research , qualitative research can help expose hidden truths about your users’ motivations, hopes, needs, pain points and more to help you keep your project’s focus on track throughout development. UX design professionals do qualitative research typically from early on in projects because—since the insights they reveal can alter product development dramatically—they can prevent costly design errors from arising later. Compare and contrast qualitative with quantitative research here:

Qualitative research

Quantitative Research

You Aim to Determine

The “why” – to get behind how users approach their problems in their world

The “what”, “where” & “when” of the users’ needs & problems – to help keep your project’s focus on track during development

Loosely structured (e.g., contextual inquiries) – to learn why users behave how they do & explore their opinions

Highly structured (e.g., surveys) – to gather data about what users do & find patterns in large user groups

Number of Representative Users

Often around 5

Ideally 30+

Level of Contact with Users

More direct & less remote (e.g., usability testing to examine users’ stress levels when they use your design)

Less direct & more remote (e.g., analytics)

Statistically

You need to take great care with handling non-numerical data (e.g., opinions), as your own opinions might influence findings

Reliable – given enough test users

Regarding care with opinions, it’s easy to be subjective about qualitative data, which isn’t as comprehensively analyzable as quantitative data. That’s why design teams also apply quantitative research methods, to reinforce the “why” with the “what”.

Qualitative Research Methods You Can Use to Get Behind Your Users

You have a choice of many methods to help gain the clearest insights into your users’ world – which you might want to complement with quantitative research methods. In iterative processes such as user-centered design , you/your design team would use quantitative research to spot design problems, discover the reasons for these with qualitative research, make changes and then test your improved design on users again. The best method/s to pick will depend on the stage of your project and your objectives. Here are some:

Diary studies – You ask users to document their activities, interactions, etc. over a defined period. This empowers users to deliver context-rich information. Although such studies can be subjective—since users will inevitably be influenced by in-the-moment human issues and their emotions—they’re helpful tools to access generally authentic information.

Structured – You ask users specific questions and analyze their responses with other users’.

Semi-structured – You have a more free-flowing conversation with users, but still follow a prepared script loosely.

Ethnographic – You interview users in their own environment to appreciate how they perform tasks and view aspects of tasks.

Usability testing

Moderated – In-person testing in, e.g., a lab.

Unmoderated – Users complete tests remotely: e.g., through a video call.

Guerrilla – “Down-the-hall”/“down-and-dirty” testing on a small group of random users or colleagues.

User observation – You watch users get to grips with your design and note their actions, words and reactions as they attempt to perform tasks.

Qualitative research can be more or less structured depending on the method.

Qualitative Research – How to Get Reliable Results

Some helpful points to remember are:

Participants – Select a number of test users carefully (typically around 5). Observe the finer points such as body language. Remember the difference between what they do and what they say they do.

Moderated vs. unmoderated – You can obtain the richest data from moderated studies, but these can involve considerable time and practice. You can usually conduct unmoderated studies more quickly and cheaply, but you should plan these carefully to ensure instructions are clear, etc.

Types of questions – You’ll learn far more by asking open-ended questions. Avoid leading users’ answers – ask about their experience during, say, the “search for deals” process rather than how easy it was. Try to frame questions so users respond honestly: i.e., so they don’t withhold grievances about their experience because they don’t want to seem impolite. Distorted feedback may also arise in guerrilla testing, as test users may be reluctant to sound negative or to discuss fine details if they lack time.

Location – Think how where users are might affect their performance and responses. If, for example, users’ tasks involve running or traveling on a train, select the appropriate method (e.g., diary studies for them to record aspects of their experience in the environment of a train carriage and the many factors impacting it).

Overall, no single research method can help you answer all your questions. Nevertheless, The Nielsen Norman Group advise that if you only conduct one kind of user research, you should pick qualitative usability testing, since a small sample size can yield many cost- and project-saving insights. Always treat users and their data ethically. Finally, remember the importance of complementing qualitative methods with quantitative ones: You gain insights from the former; you test those using the latter.

Learn More about Qualitative Research

Take our course on User Research to see how to get the most from qualitative research.

Read about the numerous considerations for qualitative research in this in-depth piece.

This blog discusses the importance of qualitative research , with tips.

Explore additional insights into qualitative research here .

Literature on Qualitative Research

Here’s the entire UX literature on Qualitative Research by the Interaction Design Foundation, collated in one place:

Learn more about Qualitative Research

Take a deep dive into Qualitative Research with our course User Research – Methods and Best Practices .

How do you plan to design a product or service that your users will love , if you don't know what they want in the first place? As a user experience designer, you shouldn't leave it to chance to design something outstanding; you should make the effort to understand your users and build on that knowledge from the outset. User research is the way to do this, and it can therefore be thought of as the largest part of user experience design .

In fact, user research is often the first step of a UX design process—after all, you cannot begin to design a product or service without first understanding what your users want! As you gain the skills required, and learn about the best practices in user research, you’ll get first-hand knowledge of your users and be able to design the optimal product—one that’s truly relevant for your users and, subsequently, outperforms your competitors’ .

This course will give you insights into the most essential qualitative research methods around and will teach you how to put them into practice in your design work. You’ll also have the opportunity to embark on three practical projects where you can apply what you’ve learned to carry out user research in the real world . You’ll learn details about how to plan user research projects and fit them into your own work processes in a way that maximizes the impact your research can have on your designs. On top of that, you’ll gain practice with different methods that will help you analyze the results of your research and communicate your findings to your clients and stakeholders—workshops, user journeys and personas, just to name a few!

By the end of the course, you’ll have not only a Course Certificate but also three case studies to add to your portfolio. And remember, a portfolio with engaging case studies is invaluable if you are looking to break into a career in UX design or user research!

We believe you should learn from the best, so we’ve gathered a team of experts to help teach this course alongside our own course instructors. That means you’ll meet a new instructor in each of the lessons on research methods who is an expert in their field—we hope you enjoy what they have in store for you!

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Types Of Qualitative Research Designs And Methods

Qualitative research design comes in many forms. Understanding what qualitative research is and the various methods that fall under its…

Qualitative research design comes in many forms. Understanding what qualitative research is and the various methods that fall under its umbrella can help determine which method or design to use. Various techniques can achieve results, depending on the subject of study.

Types of qualitative research to explore social behavior or understand interactions within specific contexts include interviews, focus groups, observations and surveys. These identify concepts and relationships that aren’t easily observed through quantitative methods. Figuring out what to explore through qualitative research is the first step in picking the right study design.

Let’s look at the most common types of qualitative methods.

What Is Qualitative Research Design?

Types of qualitative research designs, how are qualitative answers analyzed, qualitative research design in business.

There are several types of qualitative research. The term refers to in-depth, exploratory studies that discover what people think, how they behave and the reasons behind their behavior. The qualitative researcher believes that to best understand human behavior, they need to know the context in which people are acting and making decisions.

Let’s define some basic terms.

Qualitative Method

A group of techniques that allow the researcher to gather information from participants to learn about their experiences, behaviors or beliefs. The types of qualitative research methods used in a specific study should be chosen as dictated by the data being gathered. For instance, to study how employers rate the skills of the engineering students they hired, qualitative research would be appropriate.

Quantitative Method

A group of techniques that allows the researcher to gather information from participants to measure variables. The data is numerical in nature. For instance, quantitative research can be used to study how many engineering students enroll in an MBA program.

Research Design

A plan or outline of how the researcher will proceed with the proposed research project. This defines the sample, the scope of work, the goals and objectives. It may also lay out a hypothesis to be tested. Research design could also combine qualitative and quantitative techniques.

Both qualitative and quantitative research are significant. Depending on the subject and the goals of the study, researchers choose one or the other or a combination of the two. This is all part of the qualitative research design process.

Before we look at some different types of qualitative research, it’s important to note that there’s no one correct approach to qualitative research design. No matter what the type of study, it’s important to carefully consider the design to ensure the method is suitable to the research question. Here are the types of qualitative research methods to choose from:

Cluster Sampling

This technique involves selecting participants from specific locations or teams (clusters). A researcher may set out to observe, interview, or create a focus group with participants linked by location, organization or some other commonality. For example, the researcher might select the top five teams that produce an organization’s finest work. The same can be done by looking at locations (stores in a geographic region). The benefit of this design is that it’s efficient in collecting opinions from specific working groups or areas. However, this limits the sample size to only those people who work within the cluster.

Random Sampling

This design involves randomly assigning participants into groups based on a set of variables (location, gender, race, occupation). In this design, each participant is assigned an equal chance of being selected into a particular group. For example, if the researcher wants to study how students from different colleges differ from one another in terms of workplace habits and friendships, a random sample could be chosen from the student population at these colleges. The purpose of this design is to create a more even distribution of participants across all groups. The researcher will need to choose which groups to include in the study.

Focus Groups

A focus group is a small group that meets to discuss specific issues. Participants are usually recruited randomly, although sometimes they might be recruited because of personal relationships with each other or because they represent part of a certain demographic (age, location). Focus groups are one of the most popular styles of qualitative research because they allow for individual views and opinions to be shared without introducing bias. Researchers gather data through face-to-face conversation or recorded observation.

Observation

This technique involves observing the interaction patterns in a particular situation. Researchers collect data by closely watching the behaviors of others. This method can only be used in certain settings, such as in the workplace or homes.

An interview is an open-ended conversation between a researcher and a participant in which the researcher asks predetermined questions. Successful interviews require careful preparation to ensure that participants are able to give accurate answers. This method allows researchers to collect specific information about their research topic, and participants are more likely to be honest when telling their stories. However, there’s no way to control the number of unique answers, and certain participants may feel uncomfortable sharing their personal details with a stranger.

A survey is a questionnaire used to gather information from a pool of people to get a large sample of responses. This study design allows researchers to collect more data than they would with individual interviews and observations. Depending on the nature of the survey, it may also not require participants to disclose sensitive information or details. On the flip side, it’s time-consuming and may not yield the answers researchers were looking for. It’s also difficult to collect and analyze answers from larger groups.

A large study can combine several of these methods. For instance, it can involve a survey to better understand which kind of organic produce consumers are looking for. It may also include questions on the frequency of such purchases—a numerical data point—alongside their views on the legitimacy of the organic tag, which is an open-ended qualitative question.

Knowledge of the types of qualitative research designs will help you achieve the results you desire.

With quantitative research, analysis of results is fairly straightforward. But, the nature of qualitative research design is such that turning the information collected into usable data can be a challenge. To do this, researchers have to code the non-numerical data for comparison and analysis.

The researcher goes through all their notes and recordings and codes them using a predetermined scheme. Codes are created by ‘stripping out’ words or phrases that seem to answer the questions posed. The researcher will need to decide which categories to code for. Sometimes this process can be time-consuming and difficult to do during the first few passes through the data. So, it’s a good idea to start off by coding a small amount of the data and conducting a thematic analysis to get a better understanding of how to proceed.

The data collected must be organized and analyzed to answer the research questions. There are three approaches to analyzing the data: exploratory, confirmatory and descriptive.

Explanatory Data Analysis

This approach involves looking for relationships within the data to make sense of it. This design can be useful if the research question is ambiguous or open-ended. Exploratory analysis is very flexible and can be used in a number of settings. But, it generally looks at the relationship between variables while the researcher is working with the data.

Confirmatory Data Analysis

This design is used when there’s a hypothesis or theory to be tested. Confirmatory research seeks to test how well past findings apply to new observations by comparing them to statistical tests that quantify relationships between variables. It can also use prior research findings to predict new results.

Descriptive Data Analysis

In this design, the researcher will describe patterns that can be observed from the data. The researcher will take raw data and interpret it with an eye for patterns to formulate a theory that can eventually be tested with quantitative data. The qualitative design is ideal for exploring events that can’t be observed (such as people’s thoughts) or when a process is being evaluated.

With careful planning and insightful analysis, qualitative research is a versatile and useful tool in business, public policy and social studies. In the workplace, managers can use it to understand markets and consumers better or to study the health of an organization.

Businesses conduct qualitative research for many reasons. Harappa’s Thinking Critically course prepares professionals to use such data to understand their work better. Driven by experienced faculty with real-world experience, the course equips employees on a growth trajectory with frameworks and skills to use their reasoning abilities to build better arguments. It’s possible to build more effective teams. Find out how with Harappa.

Explore Harappa Diaries to learn more about topics such as What is Qualitative Research , Quantitative Vs Qualitative Research , Examples of Phenomenological Research and Tips For Studying Online to upgrade your knowledge and skills.

• Open access
• Published: 08 April 2024

Transformational nurse leadership attributes in German hospitals pursuing organization-wide change via Magnet® or Pathway® principles: results from a qualitative study

• Joan Kleine   ORCID: orcid.org/0009-0005-1727-3683 1 ,
• Julia Köppen   ORCID: orcid.org/0000-0001-7941-641X 1 , 2 ,
• Carolin Gurisch   ORCID: orcid.org/0009-0008-3763-7220 3 &
• Claudia B. Maier   ORCID: orcid.org/0000-0002-7734-2258 2  

BMC Health Services Research volume  24 , Article number:  440 ( 2024 ) Cite this article

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Metrics details

Budget constraints, staff shortages and high workloads pose challenges for German hospitals. Magnet® and Pathway® are concepts for implementing organization-wide change and redesigning work environments. There is limited research on the key elements that characterize nurse leaders driving the implementation of Magnet®/Pathway® principles outside the U.S. We explored the key attributes of nurse leaders driving organization-wide change through Magnet®/Pathway® principles in German hospitals.

Using a qualitative study design, semi-structured interviews ( n  = 18) were conducted with nurse leaders, managers, and clinicians, in five German hospitals known as having started implementing Magnet® or Pathway® principles. The interviews were recorded and transcribed verbatim. Data were analyzed in Atlas.ti using content analysis. For the analysis, a category system was created using a deductive-inductive approach.

Five leadership attributes and eleven sub-attributes were identified as main themes and sub-themes: Visionary leaders who possess and communicate a strong vision and serve as role models to inspire change. Strategic leaders who focus on strategic planning and securing top management support. Supportive leaders who empower, emphasizing employee motivation, individualized support, and team collaboration. Stamina highlights courage, assertiveness, and resilience in the face of challenges. Finally, agility which addresses a leader’s presence, accessibility, and rapid responsiveness, fostering adaptability.

Conclusions

The study demonstrates leadership attributes explicitly focusing on instigating and driving organization-wide change through Magnet®/Pathway® principles in five German hospitals. The findings suggest a need for comprehensive preparation and ongoing development of nurse leaders aimed at establishing and sustaining a positive hospital work environment.

Peer Review reports

European hospitals are facing multiple challenges, including economic pressure, cost containment strategies, technological advancements, and shortages of healthcare professionals, which require constant adaptation [ 1 , 2 , 3 , 4 ]. Particularly concerning is the high burden of mental distress reported by nurses and other healthcare professionals [ 5 , 6 ]. It is increasingly recognized that the root causes of increased stress and burnout among nurses are linked to the work environment in hospitals and other healthcare settings, that is why hospitals should strive to change their working conditions [ 7 , 8 ].

The Magnet Recognition Program® (Magnet) and the Pathway to Excellence® Program (Pathway), both originating in the United States (U.S.) and held at the American Nurses Credentialing Center (ANCC), are designed to facilitate organizational-wide change of work environments, enhancing employee well-being, retention, productivity, and patient outcomes [ 9 , 10 , 11 ]. These concepts can provide a structured approach for European hospitals to tackle the challenges of the future effectively.

Research on Magnet hospitals, primarily conducted in the U.S., suggests that Magnet can enhance working conditions, job satisfaction, and nurse well-being in hospitals [ 12 , 13 , 14 , 15 ], while also improving patient outcomes [ 14 , 15 , 16 ]. However, findings across studies and outcomes vary. In contrast, the impact of Pathway has received less attention in research. Nevertheless, some studies have indicated that Pathway promotes increased nurse autonomy and decision-making authority, fosters leadership development, improves safety and quality standards, enhances employee well-being, and supports professional growth [ 17 , 18 ].

As of December 2023, 591 organizations worldwide had Magnet designation [ 19 ], and 214 had Pathway designation [ 20 ], with the majority in the U.S. Internationally, only 17 hospitals hold Magnet designation [ 19 ] and 16 have Pathway designation [ 20 ]. While none of them are in Germany, some German hospitals have proactively started implementing Magnet/Pathway principles to drive organization-wide changes aiming at enhancing job satisfaction, attracting and retaining healthcare professionals [ 21 , 22 , 23 , 24 ]. Hence, the inclusion of Magnet and Pathway principles as comparable case examples of organization-wide change in the current study is justified by the growing proactive adoption of these concepts by some German hospitals.

Magnet and Pathway focus on promoting nurse engagement and supporting professional nursing practice environments. The difference lies in their specific objectives: Magnet emphasizes sustained quality patient care, nursing excellence, and innovations in professional practice, while Pathway highlights creating supportive practice environments that empower and engage staff and is known for having less stringent data requirements [ 25 , 26 ]. However, both aim to cultivate a culture of nursing care excellence, supported by a transformational leadership style [ 25 ], which is the central focus of the present study.

Leadership skills do play a crucial role in successfully promoting organization-wide change [ 27 , 28 , 29 ] and has also been shown to have a profound impact on employee stress and emotional well-being [ 30 ]. Transformational leadership was identified as one effective leadership style in healthcare settings [ 29 , 31 , 32 , 33 ]. Transformational leaders motivate employees towards an organizational vision by inspiring and empowering them to continuously develop themselves and addressing their individual needs [ 34 , 35 ]. The theoretical framework for transformational leadership was first conceptualized in the 1970s, defining it as a relationship between leaders and employees who motivate, empower, and elevate each other’s moral values in pursuit of fulfilling common interests [ 36 ]. Further expansion by Bass and Avolio introduced four subcategories that represent the characteristics of transformational leaders: Idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration [ 34 , 35 ].

Several U.S. studies have analyzed the relationship between transformational leadership and the implementation of Magnet principles [ 37 , 38 , 39 ]. In a southern U.S. nonprofit acute care hospital seeking Magnet designation, a survey of 115 staff nurses showed that transformational leadership style was positively associated with nurses’ job satisfaction and satisfaction with promotion opportunities [ 37 ]. Magnet hospital CNOs rated their transformational leadership practices highly and reported a strong positive correlation between engagement and leadership practice, with empowering others as the most important practice [ 38 ]. A study of clinical nurse leaders, who attended the 2016 Magnet Conference in Orlando, Florida, showed a positive relationship between transformational leadership practices and work engagement, but observed differences in leadership practices and work engagement based on varying levels of education [ 39 ].

The majority of research conducted outside of the U.S. has focused on investigating the impact of transformational leadership style within healthcare settings, with no focus on the implementation of Magnet/Pathway [ 29 , 31 , 32 , 33 , 37 , 40 , 41 , 42 , 43 , 44 , 45 ]. Several studies found that forms of transformational leadership styles resulted in positive organizational performance, such as improved staff retention, lower turnover, and better quality of care [ 31 , 32 , 33 , 37 , 40 , 41 ]. A systematic review including 12 studies from the US, Canada, Saudi Arabia, China, Ethiopia, Italy, and Jordan, showed a positive correlation between transformational leadership and nurses’ job satisfaction in the hospital setting [ 29 ].

To date, most of the qualitative studies analyzed transformational leadership style from the nurse leaders’ perspective. A study from Finland used a qualitative design to examine nurses’ leadership skills in leading change [ 44 ]. They identified three main roles: First, ‘leading interpersonal relationships’ including competencies of being a team player, coach, and parental figure. Second, ‘leading processes’ including competencies such as organizing, coordinating, and being a conductor based on the organization’s mission. And third, ‘leading a culture’ is defined as advocating values and norms and creating an open, resilient, and evidence-based culture [ibid.]. Another study from 2016 explored senior nurses’ experiences of organization-wide change leadership in three NHS acute hospitals in England through in-depth interviews [ 43 ]. The aspect of leadership was frequently discussed in relation to organization-wide change. An effective nurse leader was characterized as a strong, inspiring, and supportive leader with novel and heroic approaches [ibid.]. Weak leaders were those who did not encourage their teams, had poor presence and were unresponsive to the need for change [ibid]. Another qualitative study used a grounded theory approach to examine the processes nursing management uses to promote change on their wards in five hospitals in Japan [ 45 ]. According to the interviewees, the change management process led by nurse managers consists of having beliefs and being able to empathize with the nursing staff to achieve common goals [ibid.]. Four characteristics of nurse leaders were reported as indispensable factors for change: having both a micro and macro perspective; respecting their own beliefs and external standards; being proactive; having empathy for nursing staff [ibid.]. A 2020 study conducted in a university hospital in Brazil, examined the challenges of exercising transformational leadership and strategies nurses leaders used to address these challenges include being role models for the team, proactively maintaining dialogue with co-workers, and building empathetic relationships [ 42 ].

In German hospitals, a cross-sectional study investigated nursing leadership styles, analyzing the self-assessment of 93 ward managers and the external evaluation of 1,567 employees with the multifactorial leadership questionnaire (MLQ-5X), revealing the presence of transformational leadership practices [ 46 ]. The ward management consistently achieved mean values above the scale mean in all dimensions of transformational leadership, both in the self-assessment and in the external evaluation [ibid.]. However, despite the acknowledged existence of transformational leadership practices in nursing within German hospitals, research on the attributes of nurse leaders that support organization-wide change through implementation of Magnet/Pathway principles remains scarce. This study aims to identify beneficial attributes of nurse leaders from German hospitals, shedding light on their role in driving organization-wide change through Magnet/Pathway and advancing the understanding of leadership practices’ impact within the German healthcare systems. Research on this topic is critical to fill a gap in the literature regarding nurse leader attributes that facilitate organization-wide change and can provides insights that could inform nursing leadership development initiatives tailored to the needs of German hospitals seeking Magnet/Pathway designation.

Design and setting

This study was conducted as part of the German Magnet pioneer study, based on a qualitative research design in five pioneer hospitals. Semi-structured interviews were conducted between March and October 2020 with nurse leaders, managers, and clinicians involved in introducing Magnet or Pathway principles in five German hospitals. Inclusion criteria were as follows: (i) hospitals known as pioneers, defined as early adopters of the Magnet or Pathway principles, (ii) having started the implementation on their own initiative prior to 2020. For the purposes of this study, the primary focus was on the leadership attributes of nurses driving organization-wide change using Magnet/Pathway principles. The research protocol was approved by the Ethics Committee of the Charité (No. EA4/185/19). This study used the consolidated qualitative research reporting criteria (COREQ) [ 47 ].

The semi-structured interview guide contained a total of nine question with a set of probing questions. Topics covered motivation and rationale for implementing Magnet/Pathway, the identification of facilitators and barriers, of which one question was specifically on the role of leadership. However, interviewees referred to leadership attributes and practices throughout the interview in various instances. All interviewees filled out a short questionnaire on demographic characteristics and information about their role in the hospital, position, and years of work experience.

Sample recruitment

The purposive sample consisted of 18 persons from the five hospitals. Hospital size ranged between 200 and 2000 beds. Interviewees were nurse leaders, managers, and clinicians who had gained experience with the implementation of Magnet/Pathway. All requested interview partners agreed to be interviewed.

Data collection and analysis

Interviews were conducted in German and face-to-face by three members of the research team, following the semi-structured interview guide. The interviews lasted between 30 and 135 min. The interviews were anonymized and transcribed verbatim and were coded with ID01-ID18. The analysis of the anonymized transcripts was carried out in a multi-stage procedure based on content analysis, with a content structuring and summarising approach according to Mayring [ 48 ].

A deductive-inductive approach was chosen. The transcripts were coded using the data analysis software ATLAS.ti. For the deductive coding a coding guide was developed prior to the analysis based on the five components of the Magnet model [ 10 ]. Subsequently, the content of the deductive code leadership was re-analyzed in-depth inductively to answer the research question.

Several measures were applied to ensure transparency and quality. This involved investigator triangulation whereby the three researchers were involved in the data collection, analysis, and interpretation of the study [ 49 ].

Prior to the interviews, the three researchers conducted pilot interviews among themselves to ensure consistency. The coding of the interviews was performed by the three researchers who also conducted the interviews. Each coder was familiar with all 18 transcripts. After a pilot analysis phase with three interviews which were coded together and discussed at length to achieve high interrater agreement, the transcripts were randomly allocated. In regularly scheduled meetings, the coders reported the interim status and discussed problems or questions regarding the analysis and reviewed sample content of the codes together. In the next step, themes and sub-themes were formed by the researchers and discussed. Examples of quotes from interviewees are provided in the results section to enhance understanding of the interpretation of the results.

Interviewee characteristics

The 18 interviewees had a mean age of 48.9 (SD: 10.0) years, seven were female and eleven male. The majority ( n  = 16) had a degree in nursing and two a degree in medicine. Leadership and/or staff responsibilities had 17 interviewees and on average they had five (SD: 2.8) years of experience with implementing Magnet/Pathway (see Table  1 ).

All 18 transcripts were included in the analysis, regardless of whether direct quotes are shown in this study. Five main leadership attributes (subsequently referred to as main themes) driving organization-wide change using the Magnet/Pathway principles were identified: visionary, strategic, supportive, stamina, and agility. The main themes consist of eleven sub-themes (see Table  2 ).

Main theme 1: Visionary

Two sub-themes were clustered as the main theme visionary. It emerged that having a vision and acting as a role model were identified as requirement to implement organization-wide change.

Having a vision

Most interviewees agreed that leaders need a vision that they carry with conviction and strive to realize with high motivation. Interviewees suggested that a leader who is visionary would inspire employees for the change process. Furthermore, some interviewees mentioned that it is beneficial if leaders communicate well their vision of the future to their employees.

“With a vision I can inspire people. So, I need something that is strong enough, that really radiates energy, that […] gives people courage.” (ID9) .

It was seen as essential that the visions should be catchy, based on clinical practice and reflect the needs of clinical practitioners. One of the interviewees also mentioned the involvement of employees in the practical elaboration of the vision.

“So, I […] presented the vision to my team. […] And we went into working groups on how we can implement it, how we can live it. We have three keywords in there: human, competent, pioneering.” (ID14) .

The interviewees described the need for people who serve as role models that adhere to their vision, ideals, and values and stand up for them. Leaders acting as role models were identified as being less concerned with fulfilling specific criteria for maintaining a label or certificate but focused on improving the well-being of employees and quality of care. Interviewees explained a role model function of leaders as beneficial when employees could identify with their leaders, as this makes it easier to formulate and accept the vision and values as common goals. One interviewee stressed the importance of the personality of the leader and their manner of communicating with their staff.

“I would almost reduce it to the personalities that drive the whole thing. So, it always depends on how you transmit something, how do you communicate, how do you deal with your staff.” (ID4) .

A role model as an inspiration was suggested to increase the motivation of the employees to develop themselves and eventually to work towards the achievement of common goals.

“For me it was […] exciting to have a nursing director who brought special knowledge and an enthusiasm that I sometimes missed in the nursing field. […] just ahead of the times and […] powerful with motivation and of course that caught me.” (ID2) .

Main theme 2: Strategic

Two sub-themes were identified under the main theme strategic: Critical attributes as strategic planning and convincing top management contribute to effective implementation of positive change.

Strategic planning

Interviewees mentioned that leadership attributes included the ability to plan strategically to meet the goals of the hospital. For example, one of the interviewees described that the implementation of transformational leadership had been the key to driving further changes in the direction of Magnet.

“I think that the key component to live the Magnet concept is transformational leadership. […] I first must manage through leadership to keep people and attract new ones. And if that succeeds, […] then I can bring the other components into life […].” (ID9) .

Some interviewees highlighted the relevance of strategic resource allocation to be able to initiate and sustain the hospital-wide change via Magnet/Pathway principles. This included investing in human resources, e.g. nursing scientists or project coordinators, and in structural development, e.g. data management or digitalization. One interviewee described the strategy of providing budget or other cost-related information for the top management and the board required for Magnet/Pathway implementation.

“There needs to be at least […] an overarching Magnet project manager or director. […] last year I made an initial rough calculation for the board […] as a template, what it would cost the hospital. […] because that is of course indispensable.” (ID7) .

Convincing top management

Most interviewees addressed the importance of seeking and gaining the support of top management to advance change processes.

“The first step, […], was to convince the executive director, because the combination is simply necessary to do anything at all.” (ID4) .

One interviewee underscored the importance of active involvement and dedication from top-level decision makers and management in driving organization-wide change processes.

“So, I think you definitely need […] - the decision makers, the management - they must commit themselves clearly to it, and they must have a vision in this direction […].” (ID5) .

Main theme 3: Supportive

Three sub-themes were clustered under the main theme supportive. To be a supportive leader who fosters an empowering workplace to meet Magnet/Pathway principles, it was described as important to inspire and motivate employees to evolve professionally, support employees individually in developing themselves and their ideas further and cultivate a strong team spirit as a team player to pursue common goals.

Inspiration and motivation

Some of the interviewees talked about encouraging and inspiring employees to go beyond themselves. Increasing employees’ self-confidence enabled them to make their own decisions and motivated them to evolve professionally. This increased the motivation to drive positive change within the organization. One of the interviewees further explained that the higher the motivation in the team, the faster positive changes could be implemented.

“The half of it is […] that you get moving forward and, of course, the more motivated you are, the faster and the better you get moving forward. So, it’s about strengthening motivation and this for the whole team and making sure that you get better professionally.” (ID2) .

A leader should have a passion for the intended changes to persuade and motivate all employees and should take into account the time component of implementing organization-wide change using the Magnet/Pathway concept.

“And you have to be passionate about the topic, otherwise the concept won’t work either. That takes time at first. And then the biggest task is to get all the employees on board.” (ID4) .

Individual support of employees

The individual support of employees by leaders was recognized as indispensable when it comes to empowering them. According to the interviewees it was important to create a trusting working environment and to make employees feel that they are supported in developing themselves and their ideas further.

“[T]he employees must feel something is getting better for me. Managers are standing up for me, they are behind me. That is what is important for employees.” (ID9) .

However, finding the right support for each employee required individual consultation. Only in this way special circumstances and needs could be considered in a targeted manner. In particular, support for the academic training of bedside nurses is mentioned by interviewees as an example which underscores the significance of management’s role in facilitating and encouraging such endeavors.

“[…] there was […] a young [male nurse] sitting there […] who says, ‘Yeah, did I get this right, you want us all to have academic degrees?’ And he says, ‘Listen, I’m 35, I have three kids, I can’t afford to give up one euro right now at all.’ And [the CNO] understands, of course, there are priorities. But then you must see how you can support someone like that. […] If someone wants the [bachelor in nursing] […] then there is massive support, especially at the management level.” (ID7) .

Team player

The interviewees shared the idea that inspiration, motivation, and support of staff succeed more effectively when leaders are perceived as team players. According to the interviewees, a strong team spirit strengthens motivation to pursue common goals and helps not to give up. It also supports the well-being of all employees in their daily work.

“The team spirit is so important because if you motivate a team, if you win a team, and if you, as the leader of such a team, ensure that people enjoy working together and that the day-to-day problems can be sorted out, and if it says at the top and at the front: We are a team, we do this together, and together we are strong, Then you have already won half of everything that can be won.” (ID2) .

An interviewee at a higher managerial level additionally stated that it is important to always maintain a friendly atmosphere and show appreciation to receive important information about current issues and concerns in the teams. Decisions should not be made alone, but should always be considered with the teams, as they know more about the day-to-day matters of the staff members.

“We have […] a very, very friendly interaction, because I think that they are not my subordinates, they are my ward managers and they are the most important source of work for me, so to speak. Without them, I wouldn’t need to show up here to work, without my ward managers interacting with their teams, knowing exactly what’s going on here right now […], where’s the tension right now? What’s going well right now, what’s not going well right now?” (ID17) .

Main theme 4: Stamina

Two of the sub-themes were clustered as the main theme stamina. It emerged that implementing organization-wide change requires leaders who have strong personalities with courage and assertiveness.

The interviews showed that courage and a willingness to take risks in a context of uncertainty, which requires change, is experienced as a beneficial leader attribute. For the interviewees, courage meant being committed to the community and pursuing a vision and goals and being persistent about them. The step of opting for the implementation of organization-wide change with the Magnet/Pathway is described by some interviewees as a dare and leaders should be prepared for negative effects and to face resistance.

“I would say: Yes, you can always change something. And I didn’t let myself be discouraged […]. Sometimes people have said that we can’t really implement the Magnet concept here. And for me it was always important which ideas from the concept can be implemented and this I want to implement […], but I don’t let that stop me. […] And of course you also need leaders who are strong enough to say: ‘I know, even if it sounds crazy, we’re going in that direction now’.” (ID9) .

Nevertheless, especially in times of nursing shortages and high workload, it was important to have a sense of achievement to summon up courage. One of the CNOs interviewed reported that due to a high number of applicants to study nursing in the interviewee’s initial phase at the hospital, the interviewee had gained the courage to believe in the change concept and continued to pursue the interviewee’s vision despite high workloads and poor moods among the nursing staff and continued to pursue their vision.

“[…] despite reports of work overload, which reached me in droves at that time in my starting phase […], and then I was talking about academic training, actually I almost got a slap in the face, but at the same time [many] applied [to study nursing]. And then that was again the point where I had confidence: ‘You’re sticking to it; you have the courage’.” (ID3) .

Assertiveness

Interviewees agreed that implementing organization-wide change requires a high level of commitment and that leaders should have assertiveness. It was mentioned that it is important to prepare for the long term and to be aware of the length of time required to drive change processes using the Magnet/Pathway concept.

“I think the concepts themselves are very, very complex and take an incredible amount of time to implement. But it is possible. You just need someone who has stamina and who stands there and says, ‘So, and I want this, and this is the way, and this is my way, and I’m going to follow through.‘” (ID14) .

A sufficient individual resilience of leaders in hospitals was described as crucial to be able to overcome past failures, learn from them and stay positive. An interviewee described that initial rejection of new intervention plans by employees was initially perceived as a setback, but the leaders remained strong and learned from it.

“Well, that certainly took its time. [The CNO] came back [from U.S.] to the hospital with lots of new ideas and everyone who hears something new first says: ‘Stop, hold this. […], English words, now we only use English words. What does Magnet mean at all?’ and there was already a lot of distance from the employees […]. But then [the CNO] was able to convince […] at least the mangement level.” (ID4) .

Convincing top management was also described as an endeavor and requires the attributes of assertiveness and courage. One example is to advocate for one’s employees.

“And my job as a CNO, of course, is to fight to make sure that my nurse leaders have the resources, from time, to space, to other things, to be able to do good leadership.” (ID9) .

Main theme 5: Agility

In the context of this study, agility means the ability to adapt flexibly and quickly to changing tasks, circumstances, and demands as well as fostering a sense of team spirit. Two of the sub-themes were clustered as the main theme agility; showing presence and demonstrate well and fast accessibility and responsiveness.

Showing presence

It emerged from the statements of the interviewees that showing presence and direct personal contact of the leaders towards the employees was an important competence to keep up the commitment of the employees for implementing positive change within the hospital.

“Of course, I’m also in favour of the director of nursing not working at the bedside anymore […], but they should also not forget the direct contact to those who do the frontline work.“(ID2) .

With personal presence the leader’s appreciation of frontline workers and the interest in their well-being could become more tangible. It would also be a better way to transmit enthusiasm for the overarching, common goal to employees. Likewise, communication lines would be shortened, and employee concerns and needs could be addressed quicker. One of the interviewees shared a key moment when the CNO introduced himself unannounced at a staff meeting, and this sparked a sense of optimism among the employees.

“And I don’t think there’s ever been anything like this before, where a team meets for a dialogue and all of a sudden the CNO comes in and introduces himself and also says something about his philosophy and how he would like it to be. […] And that was the first jolt, because the employees realized, there’s someone who’s not untouchable, but there’s someone who’s like us.” (ID14) .

Another interviewee stated that they were expected as a nurse leader to know as many of the employees personally as possible. This was an essential factor for equal interaction between the professional groups.

“I know a lot of our nurses […], I know all the academic nurses, […] people expect me to take an interest in them. The whole eye-level system means that you really give everyone a name as well, not just a number anymore.” (ID1) .

One of the interviewees acknowledged that a lack of presence at the frontline work, as well as a lack of interest in the processes by the leader, had negatively impacted the success of implementing change processes.

“He [CNO] wasn’t on the wards; he didn’t see that as his responsibility either. It was more like; he gives the strategy and then the others are supposed to do the implementation. That just didn’t work out well. […] it was certainly a barrier that the [CNO] had little understanding of the daily operational problems. […] It would still have been easier if the employees had experienced him as being a little closer to the employees.” (ID10) .

Accessibility and responsiveness

In addition, interviewees explained that by showing presence outside of their own office, leaders should also cultivate an “open door”-culture and be available to meet with employees at short notice. This includes accessibility via various communication channels but also quick responsiveness.

“My door is open all day. I am not the leader who is available once a year for one hour […], but I am permanently there for dialogue, I do have time.” (ID6) . “We do a topical hour with the nursing directorate where they can come and get in touch with science here. [AND] Cappuccino with the nursing directors; where everyone can come without an appointment and also have individual talks […].” (ID3) .

Another interviewee used a current occurrence to stress the importance of responding to employee requests as soon as possible to keep them motivated.

“Right before you came in, there was a colleague who asked me […] if he could do a work shadowing. Within three minutes he got his answer […]. What use has a rigid structure, if you let someone like him wait for two weeks and say ‘Well, I was overworked’? You have to address these things.” (ID2) .

The findings of this study shed light on the attributes of nurse leaders in German hospitals that drive organization-wide change using Magnet/Pathway, which are aimed at improving employee well-being, productivity, and patient outcomes. A key component of the concepts is the practice of transformational leadership [ 9 ]. The results highlight five main themes that encompass beneficial leadership attributes: visionary, strategic, supportive, stamina, and agility.

The theme of visionary underscores the significance of visionary leadership in driving organization-wide change towards Magnet/Pathway. Having a clear and compelling vision that is communicated effectively to employees emerged as a key factor. The role of leaders as role models who embody vision and values was also emphasized. This aligns with existing literature on transformational leadership, which emphasizes the importance of idealized influence and inspirational motivation [ 34 , 35 ]. Leaders who serve as role models and inspire others create a sense of identification and motivation among employees to work towards common goals.

The theme of strategic highlights the role of strategic planning and resource allocation in Magnet/Pathway implementation. Several studies confirmed that strategic thinkers are among the most effective leaders. People with the ability to think strategically are more likely to ensure the sustainable success of an organization and are better able to put existing strategic plans into execution [ 50 , 51 , 52 , 53 ]. Furthermore, this study emphasizes the importance of leaders advocating for Magnet/Pathway principles to gain the support and commitment of the top management. Convincing the top management was seen as crucial for the success of change efforts.

The supportive theme emphasizes the significance of individualized support for employees’ development and well-being. This includes empowering employees to pursue further education, addressing their unique needs, and fostering a trusting work environment. This study highlights the role of leaders in providing resources and support for academic advancement, which aligns with the Magnet key component on structural empowerment. Furthermore, the importance of team spirit and collaboration was emphasized, echoing the Magnet/Pathway principle of exemplary professional practice and a collaborative work environment. Supportive leaders act as team players and inspire and motivate their staff to perform beyond the norm [ 38 , 54 ]. They support staff nurses to assessing their own performance, working out their goals and defining their responsibilities [ 38 , 43 , 44 ]. As a result, nurse leaders can promote knowledge building, intrinsic motivation and innovative work behavior among nurses [ 54 ].

In the German healthcare system, it is noteworthy that not every nursing director automatically holds a position on the hospital’s executive board, underscoring the importance of engaging top management in organizational change initiatives. Additionally, given that lifelong learning and continuous professional development are not standard practices in nursing in Germany, contrasting with the conditions required for Magnet/Pathway implementation, it highlights the crucial role of CNOs in empowering their staff and fostering a culture of lifelong learning and professional growth.

Results of previous qualitative studies analyzing transformational leadership style from the nurse leaders’ perspective confirm these findings. They include competencies such as a strong, inspiring, and supportive leader with novel approaches. The leaders serve as role models and are able to empathize with nursing staff to achieve common goals [ 42 , 43 , 44 , 45 ]. By cultivating a visionary outlook and a supportive stance, nurse leaders can effectively foster work engagement, address burnout, and create a motivating environment for healthcare professionals. Importantly, these leadership qualities can be learned and improved over time among nurses through targeted educational interventions, training, mentoring, and hands-on experiences [ 55 , 56 , 57 ]. Nevertheless, while some leadership skills can be developed through training and experience, certain innate character traits may provide an inherent advantage in the cultivation of effective leadership [ 58 ]. For instance, personality traits such as emotional intelligence, empathy, and authenticity have been linked to leadership effectiveness [ibid.]. Although these traits may not be directly teachable, they may serve as foundational elements that contribute to the development of successful transformational leadership practices.

The alignment between the findings of this study and those from various international contexts raises important implications for both the Magnet/Pathway implementation process and the broader understanding of transformational leadership. The resemblance between the identified leadership attributes and those found in studies conducted in different countries suggests a level of universality in the leadership qualities required for successful organization-wide change, particularly in healthcare settings. Furthermore, the consensus between the leadership attributes identified in this study and those from international research may imply that studies solely focused on transformational leadership can offer relevant insights for organizations pursuing Magnet/Pathway designation.

Given the diversity of leadership approaches across other sectors (including industry), it is important to recognize the contextual relativity of specific leadership traits. While the leadership attributes identified in this study are tailored specifically to nursing within hospitals, they may be relevant in other sectors, but require further evaluations in different contexts. While a leader’s ability to communicate a clear vision and motivate employees is as crucial in the business sector as in healthcare, the best way of communication and motivation may vary.

New insights that expand the understanding of the role of leadership in driving organization-wide change that emerge from this study is the perspective on the themes of stamina and agility in the context of transformational leadership and Magnet/Pathway implementation.

The theme of stamina reflects the perseverance and resilience required for implementing Magnet/Pathway principles. Leaders need courage to navigate uncertainty and take calculated risks. Leaders should want to make changes and push them forward with stamina and assertiveness, and who are not afraid to speak up and ask for support from higher authorities. In the context of transformational leadership, stamina has often been discussed as a leader’s perseverance, determination, and resilience in the face of challenges [ 34 ]. However, the findings of this study emphasize a more profound dimension of stamina as the leader’s ability not only to persevere, but also to inspire and sustain momentum during complex, long-term endeavors such as Magnet/Pathway implementation.

The concept of agility as an essential leadership skill has gained attention in recent years and refers to a leader’s ability to adapt quickly to changing circumstances. This aligns with the dynamic nature of healthcare settings, where leaders must respond to changing demands [ 59 ]. Interviewees in this study emphasized the positive impact of agile leadership, which enables leaders to respond rapidly, purposefully, and individually to different situations [ 59 , 60 , 61 ]. By adapting task structures and difficulty levels to match employees’ needs and commitment, leaders can prevent both under- and over-challenging their team members, thereby facilitating their professional development [ 59 , 60 , 61 ]. With the sub-themes showing presence as well as accessibility and responsiveness, it became clear that leaders should be in regular exchange with their employees to be able to react agilely to the requirements and needs [ 62 ]. In contrast, the findings confirm that the lack of frontline presence as well as the leader’s lack of interest in the processes negatively impacted the success of Magnet/Pathway implementation. However, in the context of Magnet/Pathway implementation, agility goes beyond flexibility to include a dynamic responsiveness to evolving healthcare challenges. The results show that leaders need to be flexible not only in their decision-making, but also in their accessibility and responsiveness to employees. This reflects a proactive approach that not only supports the implementation of the Magnet/Pathway principles, but also ensures that employees remain engaged and motivated throughout the transformation process.

Limitations

This study has several limitations. Firstly, the interviews were conducted in only five German hospitals, yet they were the first ones known to have started introducing Magnet or Pathway in Germany. While these hospitals provided valuable insights into the implementation process, the perspectives shared by leaders and staff are not representative of all hospitals in Germany, limiting the generalizability of the findings. Secondly, the majority of interviewees in this study were nurse managers or individuals with leadership responsibilities. As a result, the findings primarily reflect the management and leadership perspective, potentially overlooking the viewpoints and experiences of frontline nurses. It is important to consider a wider range of perspectives to gain a comprehensive understanding of the challenges and opportunities associated with leadership while implementing Magnet/Pathway principles.

This study provides in-depth insights into the leadership attributes that drives the implementation of organization-wide change through Magnet/Pathway principles in German. It offers guidance for nurse leaders seeking to drive positive organization-wide change and enhance employee well-being.

The interviewees in this study emphasized the importance of leadership competencies such as visionary direction, strategic planning, personalized support, resolute stamina, and adaptive agility. The themes of stamina and agility offer new insights, showcasing the need for courage, assertiveness, and adaptability in leaders driving long-term organization-wide change towards Magnet/Pathway.

Given the vital role of transformational leadership in driving organization-wide change, as well as the fact that transformational leadership skills can be trained, a comprehensive preparation and ongoing development of nurse leaders toward transformational leadership skills may support establishing and sustaining a positive work environment in hospitals.

Data availability

A 32-item checklist for interviews and focus groups (COREQ) and the coding tree are provided as supplementary material. The transcripts used and analyzed during the Magnet pioneer study are available from the corresponding author on reasonable request.

Abbreviations

American Nurses Association

American Nurses Credentialing Center

Chief Nursing Officer

Consolidated Criteria for Reporting Qualitative

Interviewee Identification

Multifactor Leadership Questionnaire

National Health Service

Standard deviation

United Sates of America

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Acknowledgements

We extend our thanks to the 18 interviewees for their time and valuable insights, especially considering the challenges posed by the COVID-19 pandemic during the interview data collection period. Their willingness to participate in this study is greatly appreciated and has significantly contributed to our research. We also thank the consortium of the Magnet4Europe study.

The Magnet pioneer study was funded by the B. Braun Foundation (Grant No. 18001021). Additional time on the study was funded by a grant from Robert Bosch Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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CBM was the PI of the Magnet pioneer study and planned the study and its methodology. CBM and JuK contributed to the study’s design. CBM, JuK and JoK performed data collection and conducted the deductive analysis of the data. JoK conducted the main inductive analyses for the purpose of the current study. CBM and JuK provided critical review and discussion of inductive coding. JoK wrote the first draft manuscript, and prepared tables. CBM, JuK and CG were involved in subsequent iterations and conducted critical review of the manuscript.

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This research has been performed in accordance with the Declaration of Helsinki with ethics approval through the Ethics Committee of the Charité (No. EA4/185/19). Written informed consent was obtained from all interviewees prior to the interviews. For interviewees, neither advantages nor disadvantages resulted from participation or non-participation in the study. Participation could be withdrawn at any time without consequences till anonymizations.

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Kleine, J., Köppen, J., Gurisch, C. et al. Transformational nurse leadership attributes in German hospitals pursuing organization-wide change via Magnet® or Pathway® principles: results from a qualitative study. BMC Health Serv Res 24 , 440 (2024). https://doi.org/10.1186/s12913-024-10862-y

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Women’s experiences of attempted suicide in the perinatal period (ASPEN-study) – a qualitative study

• Kaat De Backer   ORCID: orcid.org/0000-0001-5202-2808 1 ,
• Alexandra Pali   ORCID: orcid.org/0009-0009-5817-156X 1 , 2 ,
• Fiona L. Challacombe   ORCID: orcid.org/0000-0002-3316-8155 3 ,
• Rosanna Hildersley   ORCID: orcid.org/0000-0002-1850-6101 3 ,
• Mary Newburn   ORCID: orcid.org/0000-0001-9471-0908 4 ,
• Sergio A. Silverio   ORCID: orcid.org/0000-0001-7177-3471 5 , 6 ,
• Jane Sandall   ORCID: orcid.org/0000-0003-2000-743X 1 ,
• Louise M. Howard   ORCID: orcid.org/0000-0001-9942-744X 3 &
• Abigail Easter   ORCID: orcid.org/0000-0002-4462-6537 1  

BMC Psychiatry volume  24 , Article number:  255 ( 2024 ) Cite this article

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Suicide is a leading cause of maternal death during pregnancy and the year after birth (the perinatal period). While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK [ 1 ], the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth [ 2 ]. Qualitative research into perinatal suicide attempts is crucial to understand the experiences, motives and the circumstances surrounding these events, but this has largely been unexplored.

Our study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt.

Through iterative feedback from a group of women with lived experience of perinatal mental illness and relevant stakeholders, a qualitative study design was developed. We recruited women and birthing people ( N  = 11) in the UK who self-reported as having undertaken a suicide attempt. Interviews were conducted virtually, recorded and transcribed. Using NVivo software, a critical realist approach to Thematic Analysis was followed, and themes were developed.

Three key themes were identified that contributed to the perinatal suicide attempt. The first theme ‘Trauma and Adversities’ captures the traumatic events and life adversities with which participants started their pregnancy journeys. The second theme, ‘Disillusionment with Motherhood’ brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women’s mental health. The third theme, ‘Entrapment and Despair’, presents a range of factors that leads to a significant deterioration of women’s mental health, marked by feelings of failure, hopelessness and losing control.

Conclusions

Feelings of entrapment and despair in women who are struggling with motherhood, alongside a background of traumatic events and life adversities may indicate warning signs of a perinatal suicide. Meaningful enquiry around these factors could lead to timely detection, thus improving care and potentially prevent future maternal suicides.

Peer Review reports

Pregnancy, childbirth, and the postnatal period are a positive and empowering experience for many women and birthing people Footnote 1 . Yet it is widely accepted that the perinatal period is also a time of significant stress, with one in four women experiencing mental health difficulties during this time [ 3 ]. Evidence on the impact of perinatal mental ill-health on the mother [ 4 ], her children [ 5 ], the wider family [ 6 ] and society [ 7 ] has grown in the last decade and worldwide, maternal suicide has been identified as a global public health issue [ 8 ]. In European countries with enhanced surveillance systems for maternal mortality maternal suicide has been identified as one of the leading causes of maternal death [ 9 ]. In the UK, the Confidential Enquiries into Maternal Deaths (MBRRACE-UK) have repeatedly highlighted similar findings, leading to the development and expansion of specialist perinatal mental health services in the UK [ 10 ]. Despite this, there has been no sign of a reduction in suicide rates [ 11 , 12 , 13 , 14 ]. The UK Government has therefore identified pregnant women and new mothers for the first time as a priority group in the recent Suicide Prevention Strategy [ 15 ].

While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births (95% CI 2.55–5.55) in the UK [ 1 ], many more women will attempt suicide during pregnancy and the year after birth. Worldwide, the pooled prevalence of perinatal suicide attempts has been estimated to be 680 per 100,000 (95% CI 0.10–4.69%) during pregnancy and 210 per 100,000 (95% CI 0.01–3.21%) during the first-year postpartum [ 2 ]. As well as distressing in their own right, perinatal suicide attempts are known to increase the risk of future fatal acts [ 16 ]. Antenatal [ 17 ] and postnatal suicide attempts [ 18 ] are also associated with increased maternal and neonatal morbidity, adverse birth outcomes, and further suicide attempts.

It is important to note that terminology in suicide research has been a contentious issue and a wide range of definitions have been used in various contexts. The US National Center for Injury and Control issued guidance on uniform definitions in the context of self-directed violence’ [ 19 ], which has informed our study definition of ‘suicide attempt’: “a non-fatal, self-directed, potentially injurious behaviour with intent to die as a result of the behaviour. A suicide attempt might not result in injury”. This definition contains three components worth highlighting, i.e. (1) suicidal ideation, (2) suicidal intent and (3) suicidal behaviour. ‘Suicidal ideation’, also known as ‘suicidality’ (i.e. thoughts of engaging in suicide-related behaviour) [ 19 ] is a known risk factor for suicide [ 20 ] but does not necessarily lead to suicidal behaviours (e.g., behaviour that is self-directed and deliberately results in injury or the potential for injury to oneself, with implicit or explicit evidence of suicidal intent’) [ 19 ]. ‘Suicide attempt’ must also be distinguished from ‘near-fatal deliberate self-harm’, which was defined by Douglas et al (2004) as ‘an act of self-harm using a method that would usually lead to death, or self-injury to a “vital” body area, or self-poisoning that requires admission to an intensive care unit or is judged to be potentially lethal [ 21 ]’. This definition does not contain an element of ‘suicidal intent’, ie. explicit or implicit evidence that at the time of injury the individual intended to kill self or wished to die, and that the individual understood the probable consequences of his or her actions [ 19 ].

To date, perinatal suicide research has predominately been based on case note reviews [ 1 ], retrospective cohort studies [ 22 ], or qualitative studies focussing on suicidal ideation [ 23 ]. Research into suicide attempts in the perinatal period is therefore acutely needed, to gain a better understanding of the circumstances surrounding maternal suicide, the support available to perinatal women and how future deaths can be avoided. To our knowledge, no studies in the UK have used qualitative methods to explore the experiences of women who undertook a suicide attempt in pregnancy or during the postnatal period, yet survived. A better understanding of these events could help refine support and early interventions for women and birthing people at risk.

Aim of the study

The aim of this study was to explore the experiences of women and birthing people who had undertaken one or more suicide attempts during the perinatal period.

Study design

The ASPEN-study (Attempted Suicide during the PEriNatal period) utilised a qualitative design, using semi-structured interviews, to allow for an in-depth understanding of the contextual factors of perinatal suicide attempts, and to demystify the taboos and misunderstanding that are enshrouding this phenomenon [ 24 ]. Qualitative methods are particularly helpful to study sensitive topics [ 25 ] and can facilitate a deeper understanding of suicide attempts, beyond merely explaining [ 26 ]. We adopted a critical realist ontology, meaning participants’ accounts were seen as ‘truths’, even when their reported recall might have been impacted by serious mental illness and/or distress at the time of events [ 27 ]. We also adopted an objectivist epistemological stance meaning our belief system of how we acquire knowledge is one of reality existing and not being constructed, thus enabling an approach to participants’ narratives with no preconceived notions of how the participants may experience the phenomenon of interest [ 28 ]. Drawing on our epistemological and ontological positions, a critical realist approach to Thematic Analysis was best aligned with our philosophical underpinnings. Critical realist TA is an alternative approach to Thematic Analysis, that differs from codebook TA with its positivistic assumptions [ 29 ], or reflexive TA that is grounded in philosophical constructivism [ 30 , 31 ]. Critical realist TA is an explanatory approach that aims to produce causal knowledge through qualitative research on phenomena in the world around us [ 32 , 33 ]. We wanted to go beyond merely ‘exploring’ the phenomenon of perinatal suicide attempt, but aimed to understand what women had experienced during this time, such as any significant life course events they identified as relevant to their perinatal suicide attempt, the specific circumstances in the lead-up to the suicide attempt, their views of motherhood and how this impacted their mental health and any key elements or milestones that made a substantial difference on their journey to recovery. As such, this approach informed our development and structure of the interview schedule and analysis of the data to ensure that this was captured.

Participants and recruitment

The study was advertised through social media and third sector organisations in the field of perinatal mental health and suicide prevention (see Acknowledgements). Interested participants were included if they: (1) were 18 years of age or older; (2) had one or more suicide attempts during the perinatal period (i.e. from pregnancy up to the first year after giving birth), including when the attempt was prevented by self, a loved one or a member of the public; (3) and this happened less than 10 years ago; (4) were residing in the UK; and (5) were not receiving inpatient psychiatric care or experiencing an acute episode of a psychiatric disorder at the time of recruitment. The latter exclusion criterium was adopted in line with our safety protocol, to prevent delays in recovery by addressing such a difficult event outside a therapeutic environment. We used both convenience sampling and purposive sampling techniques: we interviewed anyone who responded to our recruitment materials, met the inclusion criteria and wanted to participate in the study after reading the participant information sheet (convenience sampling). Simultaneously, we also made concerted efforts through intense collaboration with community leaders and third sector organisations to recruit a diverse sample of women and birthing people from different ethnic, cultural, socio-economic and religious backgrounds (purposive sampling). A total of twelve women and birthing people contacted the research team with an interest in the study. Eligibility for the study was explored in a sensitive way, against the overall inclusion criteria and the three components of the study’s definition of ‘suicide attempt’ (suicidal ideation, intent and behaviour). Where in doubt, eligibility was discussed with the wider supervision team. In total, eleven interviews were conducted. A twelfth interested participant did not attend the (online) interview and did not respond to any follow-up emails. Recruitment was finalised when no new themes were being generated from data analysis of the last two interviews [ 34 ]. Participants received reimbursement of £50 for their time to complete the interview and a short demographic survey.

Data collection and analysis

Semi-structured interviews lasted between 38 and 115 min ( MTime  = 65 min) and were conducted via video-conference software (Microsoft Teams) by one researcher (KDB) between October 2022 and April 2023. Interviews were audio-recorded, transcribed and de-identified by a professional transcription company. Field notes were taken during the interview. Transcriptions were checked for accuracy by two researchers (KDB, AP). The interview schedule, which was co-designed with a panel of women with lived experience of perinatal mental illness, aimed to explore experiences of mental health difficulties prior to and during the perinatal period, the circumstances in the lead-up to the suicide attempt, and those following the suicide attempt. The interview schedule was used flexibly and did not prevent participants from sharing their story in the order they preferred, but instead, was used as an aid to prompt where required. Interview data was so rich that a secondary analysis focusing on social support prior and after women’s suicide attempts was undertaken, to be published separately.

Thematic Analysis (TA) [ 30 , 31 , 33 ] of the interview data was conducted using NVivo software while adopting a critical realist approach to Thematic Analysis [ 30 , 31 , 33 ]. The process of data analysis is rarely a linear event, and guided by Fryer’s previous work on critical realist TA [ 33 ], our approach to data analysis is presented in Fig.  1 and can best be described as follows:

Display of critical realist approach to thematic analysis

Public and patient involvement and engagement (PPIE)

An established advisory panel of women with lived experience of perinatal mental illness was consulted during different phases of the study with additional feedback sought from key stakeholders in the field of perinatal mental illness (see Acknowledgements). The process of PPIE during the study design and data collection phase of this study has been documented elsewhere [ 35 ]. A draft manuscript was shared with research participants to sense-check findings and comment on the manuscript. Participants were also given the opportunity to select a pseudonym of their choice. A total of 8 participants reviewed the draft manuscript and their feedback was incorporated in the final version of this paper.

The study team and reflexivity

The research team are a multidisciplinary team of researchers and clinical academics, with backgrounds in psychology (FLC, AE, RH, SAS, AP), psychiatry (LMH), and midwifery (KDB, JS), and several had clinical experience of supporting women who attempted suicide during the perinatal period (KDB, FLC, LMH). Within the research team, there was a balance between those who were parents and those who did not have children and researchers were at different stages of their life, spanning nearly three generations. The phenomenon of suicidality in the perinatal period was familiar to most of the research team, through extensive clinical experience and/or previous research in the field of perinatal mental health. Our positionality is therefore best described as ‘hybrid’, concordant with our critical realist ontology, as we aimed to align our existing knowledge and understanding (i.e. being embedded in the data) with the uniqueness and unfamiliarity of each individual story that was shared with us as a ‘truth’ (i.e. being an objective onlooker), in order to analyse the data in a coherent and sensitive matter [ 36 ]. Data were collected by one researcher (KDB) who was trained in advanced qualitative research techniques as well as having clinical experience as a perinatal mental health midwife. Analysis was conducted by the same researcher and a MSc Student with a background in clinical psychology (AP). Regular team meetings were held throughout the data collection and analysis phase to discuss and sense-check the developing themes and sub-themes.

Participant safety and researcher wellbeing

The safety and emotional wellbeing of all participants was key throughout the study. Thus, we adopted key elements of trauma-informed care into our study design [ 37 ]. A robust safety protocol, with clear pathways for escalation if required, was developed with the input of the PPIE advisory panel [ 38 ]. The study team undertook bespoke training in trauma-informed interviewing and the interview schedule was developed with this in mind. A safety check prior and after the interview was carried out by the same researcher (KDB), either via email or by phone and all participants were offered a confidential de-brief session with an independent clinical psychologist. The psychological safety of the researchers was also considered [ 25 ] and supported by access to regular reflective supervision sessions provided by a clinical psychologist and regular debrief sessions with supervisors to process any difficult emotions arising from conducting the interviews [ 39 ]. We were acutely aware of the potentially triggering content of the audio files and raised this with the transcription company [ 40 ]. When sending audio recordings for transcription, a summary of triggering content was provided to ensure the transcription would be appropriately allocated.

The majority of our sample ( N  = 11) were White British women ( n  = 10), with one woman from a mixed ethnic background. Participants were predominantly married ( n  = 8) and had higher education qualifications ( n  = 7). All but one participant had received a mental health diagnosis by a doctor or other healthcare professional in the past although the demographic survey did not allow to ascertain when this diagnosis had been given. More than half of the participants in our sample were given multiple diagnoses, indicating a high level of complexity in mental health presentation. In most cases, pregnancies had been planned ( n  = 9). All but two women were multiparous, with half of the sample having two children ( n  = 6), and three participants having three or more children. Two women were first-time mothers at the time of the attempt. Four women undertook their suicide attempt during pregnancy, with a fifth woman being pregnant whilst her older child was still under the age of one. The remaining six women undertook a suicide attempt within the year after giving birth. Four participants had a stay in an inpatient psychiatric Mother and Baby Unit (MBU), and for three of them the admission was preceded by their suicide attempt. For one participant, the admission in the Mother and Baby Unit was subsequently followed by an admission in a general psychiatric hospital, where she undertook the actual suicide attempt. A full table of demographic and clinical information can be found in Table  1 .

Qualitative analysis resulted in the identification of three key themes that played a significant role in the deterioration of women’s mental health during the perinatal period, ultimately culminating into a suicide attempt. Saturation for all themes and sub-themes was achieved after nine interviews when no new themes or subthemes were generated. Data from the remaining two interviews confirmed our analysis and provided additional depth and detail [ 34 ]. The three overarching themes are presented in Fig.  2 : Theme 1 ‘Trauma and Adversities’ , consisting of family history of perinatal mental illness and psycho-social adversities, including grief and trauma; Theme 2 ‘Disillusionment with Motherhood’ , marked by a variety of challenges that arose during pregnancy or the postnatal period; and Theme 3 ‘Entrapment and Despair’ , where multiple stressors piled up with no respite or support available, leading to a severe deterioration of mental ill-health, and ultimately, the suicide attempt.

Display of themes and sub-themes

Qualitative data is presented below, with the most representative quotations in text and an additional table of supplementary of quotations included in Supplementary Material 1 .

Theme 1: trauma and adversities

All respondents in our sample started their pregnancy journeys with a range of vulnerabilities, such as previous mental health difficulties, loss, trauma, or social risk factors including domestic abuse and substance misuse. Nevertheless, participants were not always aware of the profound impact these would have on their mental health later in pregnancy and in the postnatal period. Subthemes contributing to this were:

Psycho-social adversities

Many women had experienced mental health difficulties at some point in their life, and most were fully aware of their potentially devastating impact. Some had experienced poor mental health during adolescence and young adulthood and anticipated mental health problems during the perinatal period.

“I’ve had some terrible things happen in my life about failed marriage and fertility problems. Big, big things that I’ve sort of managed with a strength of mine that I perhaps didn’t have in my late teens or early 20s to overcome. So I guess it was always on my radar knowing the stats around you are more likely to have perinatal mental health problems if you’ve had bouts of depression in the past.” – Rosy .

In contrast, others had dealt with traumatic experiences in their life, but could not see how this would be relevant to their mental health during pregnancy and the postnatal period. They started their pregnancy unaware of any potential risks to their mental health.

“I lost my brother when he was 18. […] And I didn’t get a lot of time off work, I was kind of straight back into work. I’m a [professional role in mental health], so I was working in acute psychiatry. Back to work, dealing with other people’s trauma and I don’t think I really dealt with my own particularly well. And it was kind of I think eight months later I had an episode of depression, just very low mood, apathy, poor motivation, poor concentration, was treated briefly with antidepressants and then just kind of did okay after that. So there had been nothing.” – Simone .

Previous trauma was reported by almost all respondents, whether it being through a bereavement, or traumatic life experiences, such as miscarriage and infertility, domestic abuse, fractured relationships, or suicide of a loved one. Two women reported having experienced domestic abuse. One of them reported the abuse, which she described as a ‘punishment’, only started after informing her partner of the pregnancy.

“It was a punishment actually that I dared to be pregnant even though he knew I wasn’t on any contraception or anything. And it really shocked me because he had never ever been like that before.” – Lauren .

For the other respondent, the domestic abuse had been long-lasting and led her to seek coping strategies to deal with the trauma and pain. Being in an abusive relationship created the worst possible start for pregnancy, with no support available.

“Well, it was my first pregnancy. I was 24 so I still hadn’t grown up properly, and I was in a really bad domestic violence relationship so there was a lot going on around that. I was getting no support [for] my pregnancy. I was also using as well which I regret profoundly, but I was drinking, like I drank occasionally because of my mental health, and my mental health was just all over the place; I was really, really unwell.” – Selina .

For some, their previous mental health difficulties were related to an earlier pregnancy or birth experience:

“I had huge amounts of birth trauma from my first, which I had a debrief for from the hospital, which was incredibly unhelpful. And it ended in emergency caesarean [section], after nine days of labour, and being in hospital, as a very naïve 19-year-old, having her first baby; looking back on it, feeling quite coerced by doctors, but not realising at the time that that’s what was happening. And that has impacted me for the rest of my life.” – Sam .

The severity of previous perinatal mental health problems was varied, with one woman having experienced postpartum psychosis after the birth of her first child. Going into the second pregnancy, the risk of relapse was hanging over her like a dark cloud:

“I remember sort of going to the 12-week scan with [second pregnancy] and getting the picture and thinking like shit, it’s really real now and it could all happen again. So I was really scared about that. Because the reccurrence rates are quite high for psychosis, so it’s quite likely that I was going to become unwell. So I was worried, yes, I was really concerned.” – Marie .

This feeling of worry was also reported by women with mild to moderate mental health difficulties and was compounded by a fear of being dismissed and not being able to access support if they would require it.

“I think there was something about the anxiousness of doing it all again, because I think I had some prenatal depression with my first, that wasn’t picked up, and then postnatal anxiety through the roof, that was also never picked up, and was told that was normal.” – Sam .

Family history of perinatal mental illness

Several respondents had a family history of perinatal mental illness and were vigilant that they might experience something similar. To mitigate this risk, they actively sought perinatal mental health support at the earliest opportunity.

“My mum had severe perinatal mental illness, she was hospitalised after my older brother for a year without him […]. At the time they didn’t really have Mother and Baby Units. Then I came [a few] years later and she was hospitalised again but with me for six months, and she passed away […] So my dad said she was saying the same things as each time she’d been sectioned; she would present with very religious ideation and stuff like this, so it was exactly the same stuff, and she died by suicide. So because of that collective history, when we were trying to get pregnant we thought “We need to let someone know we’re trying to get pregnant,” and so I was referred then to a Perinatal Psychiatrist before we got pregnant” - Sarah .

For others, this family history was not something which was spoken about prior to their own experiences of perinatal mental illness. One respondent mentioned she had never been aware of her mother’s history of postnatal depression until she herself started to experience postnatal depression.

“I didn’t know that my mum had postnatal depression. That’s not anything that she’d shared until… I knew that my brother cried a lot and I think he had a cows’ milk protein intolerance, but I didn’t know that my mum…” – Rosy .

Theme 2: disillusionment with motherhood

While previous mental health challenges or trauma were present in the background, all women were profoundly disillusioned with motherhood which contributed to a deterioration in their mental health. This theme of ‘Disillusionment with Motherhood’ captures three sub-themes that reflect a discrepancy between what women thought or hoped motherhood would be like, and the crushing reality they found themselves in. Together, these sub-themes compounded each other and became a catalyst for worsening mental health. The following sub-themes address the various areas of disillusionment that women in our sample reported: in their bodies, in their identity and in the bond with their baby.

The physical and mental struggle of pregnancy and birth

All participants held hopes and expectations of what their pregnancy, birth or the postnatal period would be like. For some first-time mothers, it soon became clear that the societal rosy-hued image of pregnancy was very far removed from their own experience of pregnancy. As they came to grips with how pregnancy was unfolding, the harsh contrast between expectation and reality was so high that many struggled to adjust to this:

“There’s all this thing about pregnancy you’re supposed to be glowing and it’s all marvellous and you’ve got these wonderful hormones, but I was just beached on the sofa feeling hot and sweaty thinking when is this baby going to come out, when’s it going to come out?” – Simone .

For those who had been pregnant before, the reality of another pregnancy, knowing full well what was in store, started to dawn on them:

“I don’t know, it hit me like a ton of bricks. Like oh shit, I’m doing this again. I’m pregnant again.” – Liv .

In addition to these psychological adjustments to reality, respondents mentioned how the physical toll of pregnancy and childbirth played a significant role in the deterioration of their mental health. This close correlation between physical issues and mental health decline was abundantly clear across the sample.

“I was horribly, horribly sick [hyperemesis]; that got worse each pregnancy. I don’t know if that’s normal; I’d heard it is. But horribly sick, which makes you absolutely miserable anyway.” – Sam . “I just sort of couldn’t wait for it [the pregnancy] to end. Yes, I just wanted to give birth. So when they said that they were going to induce me at 40 weeks I thought thank goodness, because my sickness started again quite late on. Again, I don’t know if it was because of the pre-eclampsia. But yes, I was just very ready, very ready to have little one.” – Hannah .

In the most extreme cases, pregnancy was not viewed as something to be enjoyed, but something that left women feeling repulsive.

“So since the pregnancy, just my life fell apart really, I was unemployed, and I just felt the whole way through not just sick and ill, absolutely physically repulsive, like I just felt like an absolute filthy animal. I can’t describe the disgust I felt for myself and the bigger my bump grew, the more disgusting I felt. And I don’t know, it’s just everything was awful, every day was awful.” – Lauren .

For other women physical injuries as a result of childbirth left them unable to function and to enjoy the things they were looking forward to as a new mother.

“I had some tearing and I’d had an episiotomy and they hadn’t healed, so my episiotomy had opened up and there were lots of A&E [Accidents and Emergency] visits and an operation eventually, but I think that really didn’t help my mental health because obviously if you’re in pain all the time then, it just drags you down, doesn’t it? So I wasn’t able to do my normal stuff, I wasn’t able to just carry on with life because I was in pain, I couldn’t sit and I felt like I couldn’t do mummy things.” – Mel .

Apart from the physical repercussions of pregnancy and childbirth, it was the trauma of giving birth and its psychological sequalae which triggered a marked deterioration in the mental health of several women in our sample.

“It was just sort of like you couldn’t expect it to happen, it was like a poor pregnancy and sort of felt like, you know, the birth went wrong as well.” – Hannah . “I had a premature baby. And I went on, I don’t know, like trauma response. Like totally numb. I suppose the adrenalin, the shock, everything…” – Liv .

Invalidation of identity and self-sacrifice

Almost all respondents encountered negative experiences with healthcare professionals at some point during pregnancy or the postnatal period and felt invalidated and dismissed by these. Women reported they were not seen as a person, with a complete identity, but reduced to a vessel for their baby, with little consideration given to their own feelings. This led to a profound loss of identity, exacerbating feelings of being invisible, inadequate and unimportant.

“It was never about me. And I know it’s not all about me, but when I’m wanting to commit suicide, it is very much about me and not one person asked me if I was alright, they were more concerned if the baby was alright, which I was as well, but they just completely bypassed that there was any reason I would do it.“ – Selina .

There seemed to be a lack of professional inquisitiveness to understand why a mother(-to-be) would consider suicide. Instead, all attention was directed towards the well-being of the baby, leading to multiple missed opportunities for timely care and support. In some cases, women reached out but their calls for help were simply ignored while their mood was rapidly deteriorating. These experiences would have devastating consequences on their further help-seeking behaviour.

“What really killed me, what was like the punch in the face that I needed was when I had my midwife appointment at, I don’t know, eight, ten weeks, something like that, and I told her ‘you know what, I’m not feeling right. There’s something bubbling inside me that is not alright, is not correct. I feel more anxious than normal, I can’t sleep, it’s all very weird’. And she just said ‘okay, I’m going to pin that down here to talk about in your next appointment. But we’re not going to do anything right now’. I never saw her again, by the way.” – Liv .

Invalidating encounters like the one described above would have a profound impact on how women viewed healthcare professionals as a source of support and whether they would reach out to them and share the extent of their mental health problems.

“I just felt like nobody was listening at all, just not heard one bit.” – Anna .

For some, the invalidating experience would almost become a motivator to succeed in their suicide plans, as they felt the severity of their mental health problems was brushed under the carpet. One participant sought help after a first suicide attempt through a medication overdose and shared the following:

“So then I think a few more weeks went by and I went back to the doctor’s. I said to the doctor, ’I want to kill myself’. My medication and stuff, I was honest with him, I said the medications and stuff that he was put… I think he tried me on Zopiclone as well with not sleeping and he said, ‘Well if you wanted to kill yourself, you would have done it by now’. I was just… I sort of felt then I’ve got something to prove.” – Hannah .

The loss of identity made respondents feel invisible to healthcare professionals and went hand in hand with exhausting themselves to be the best possible mother for their baby. Women described feelings of total self-sacrifice to meet this perceived standard of ‘the perfect mother’.

“I think I sort of went into supermum mode when I came home, like I had something to prove, and again, it’s that background of failure. I think I’m quite hard on myself anyway and I’m quite… If something goes wrong, I’m probably harder on myself in my head than somebody else would be and I maybe got a bit of a perfectionist trait, so I really didn’t want to rely on anybody, I didn’t ask for help with anything regarding my little boy, and I had a really, really strong bond with him which was really positive, but I think I was sort of going like overkill with not asking for help.” – Hannah .

However, as women started to experience the hard reality of caring for a newborn, they felt unable to meet this impossible standard. The perceived pressure to achieve (unrealistic) goals as well as their feelings of failure to do so started to take a significant strain on their mental health.

“No one had ever told me that before. No one had ever said that you don’t just have to drop everything and run to your child. Because I thought that that was what a secure bond was; and obviously now I’ve learnt about attachment theory and things. I thought that, for her to be securely bonded with me, I had to give every last drop of myself to be her mum.” – Sam .

‘It wasn’t like starry-eyed love’

Closely linked with the previous sub-theme, was the realisation for many women that they did not feel an instant rush of love for their baby. Several women reported feeling unsettled and flawed as a mother when they felt distant and detached from their baby. Women tried their very best to ‘act as a mother’ and do whatever their baby required, but this did not mean they also ‘felt like a mother’.

“So, at the beginning it was very strange. It, because like I said, I was determined to do anything in my power to get that baby out of NICU [Neonatal Intensive Care Unit]. Like whatever it takes, whatever the cost. So it never felt like oh, it’s my baby. I would have jumped in front of a train for him but it was not like a starry-eyed love. And that kept going.” – Liv . “In terms of motherhood, yes, I don’t know whether I just felt I was failing at it or… [pause] I don’t know, I felt very not connected to the baby. I had felt very, very bonded and very connected, and then I wasn’t at all.” – Sarah .

Sadly, for some, this lack of bonding with their baby persisted for a long time, with enduring consequences on their mental health and family happiness, leading to feelings of guilt and shame with which they still are coming to terms with.

“I had no attachment to him probably for about five years, nothing at all, just this ongoing sense of regret and I remember thinking daily I’ve made such a massive mistake in my life and almost this like realisation you are never going to get back what you had before, so just this real hopelessness actually at life.” – Lauren . “I just couldn’t, I couldn’t bond with, I couldn’t. Even still now I love her to pieces but we’re not like mother and daughter, we’re not.” – Anna .

Theme 3: entrapment and despair

In the final phase leading up to the suicide attempt, women experienced an accumulation of stressors, unleashing an overwhelming feeling of hopelessness and entrapment, with seemingly no way out of the situation they found themselves in. The sub-themes identified under this theme of ‘Entrapment and Despair’ left women no breathing space or respite. A perfect storm was brewing, for which women only started to see one way out, and that was by taking their own life.

Feeling like a failure

All respondents expressed a pervasive feeling of utter failure, intersecting their different identifies as a woman, mother and partner. Their perceived inability to meet expectations, whether this related to giving birth, feeding their baby, or functioning as a mother and partner stood in sharp contrast with how they viewed other mothers, who seemed to be effortlessly successful in doing so.

“You sort of just blame yourself. So I can just remember looking at him when he was asleep thinking like, ’Oh you’ve failed, I can’t do this, I’ve already failed at being a mum, but I can’t do this’, and I can just remember just thinking that, looking at him. So I think even though I know it wasn’t my fault, you really felt like a failure and I felt like it was me, like there was something wrong with me, because a lot of women around me, like even family, they never really had experiences like that, they would have like a good pregnancy, like a vaginal birth, a normal birth, so I really felt like I had failed and I really blamed myself for that.” – Hannah .

This feeling of being a total failure created a sense of dread, leaving them fearful every day that their inability and incompetence as a mother would be further exposed.

“I remember seeing the light coming in through the curtains in the morning and just thinking “Oh my god, no, I can’t, I can’t do another day,” like my heart would go, and it was that dread, that whole dread would come over me and I’d think “I can’t do another day today, I just can’t do it. I can’t do it.” It was like a… Yes, it was really hard. I just felt like I don’t know, it felt like I just wasn’t good enough for her, I wasn’t good enough. […] It just felt like I wasn’t good enough to be her mum.” – Mel .

This overwhelming sense of incompetence erased feelings of love, enjoyment or hope and instilled a feeling that their baby and loved ones would be better off without them.

“So it just escalated. This what was going on in my head about, you know, me not being good enough, a failure, just escalated even more, that now I was thinking they are going to take him away, everyone will know how rubbish I am. So it was later that week where I still wasn’t sleeping and I just thought, do you know what, the both of them would be better off without me, because I’ve just failed, I’m just a failure. They will be better off without me.” – Simone . “…That just made me feel so, so low that I think that spiral of internalised feelings and negativity compounded with this sort of isolation and lack of sleep just led me to think they’d be better off without me around, they’d have a parent maybe or a family that would be able to meet their needs.” – Rosy .

Intense intrusive thoughts and abnormal experiences

More than half of the women in our sample reported intrusive ideas or unsettling experiences in the period preceding their suicide attempt. For many, this came as a total surprise as they were unaware this could happen and they felt unable to express the extent of their intrusive thoughts to anyone.

“I remember getting up and going to the bathroom to brush my teeth and then started hearing voices. So this voice, I didn’t recognise it, was just chanting, ‘stinky [name of baby], stinky [name of baby]’, which is my baby’s name and I was like why’s that happening? I don’t understand. Where’s that coming from? And then later that day I remember looking at my husband and thinking you’re the father of this baby, but I’m not its mother. It was a really odd thought, because I was like I know I’ve been pregnant and I know I’ve just been through all that labour, but I look at this baby and it’s not mine, but I know you are the dad. It was really odd.”- Simone . “They [the intrusive thoughts] were really, really scary. And totally uncontrollable as well. They were so vivid and they used to make me feel really upset because they happened quite early on, probably when she was only a few weeks old and I remembering googling them and reading loads of things about it didn’t mean that you were not coping, it didn’t meant that you were going to hurt your baby, it didn’t mean that you were depressed, but I think maybe I should have perhaps seen that as a bit of a sign that I needed to get some help because it was weeks and weeks later that I finally did. But yes, they did upset me and I only told my mum, I didn’t tell anybody else because I just felt as though are people going to think that I’m going to hurt her? Am I going to hurt her if I talk about it more? Yes, they were really scary.” – Rosy .

For some, these ideas were extremely horrific and a symptom of their psychotic illness at the time. Unfortunately, this was left undiagnosed and untreated, leaving them totally desperate and isolated while these unsettling thoughts became their lived reality.

“[…] I started to think ‘oh I’ve committed all these awful crimes in my life’ and I was kind of struggling to process what they were and I was thinking have I killed people and maybe buried them and I don’t know where they are or have I kind of done a big theft or something but not been able to quite work out where I’d stolen the money from. But I was kind of panicking that I’d either buried these bodies or hidden this money and I couldn’t remember where they were, so I was panicking someone else is going to find them and then I’m going to be put in prison. So I had this kind of I want to die because I’m scared I’m going to go to prison because I’ve done all these awful things. And I just felt absolutely desperate.” – Lauren .

Alone in this world

While these distressing experiences of failure and intrusive thoughts invaded women’s mindset, women felt profoundly alone and isolated. Social isolation was reported as a catalyst for their suicide attempt by every woman in the sample. For some, it was a continuation of the situation they had already been in, but during this stage everything felt more desperate, more alone.

“I think by that point I wasn’t talking to anybody at all, not family, certainly not the kids’ dad. The kids’ dad… […] I just totally blocked his number and I wasn’t seeing anybody else. And actually, in some ways, I don’t think anybody wanted to see me because they were just like, “Why have you had another kid?” So the only people that I saw were my own kids, maybe the odd school teacher at pickup but that was it. No one from work. No friends really.” – Lauren .

For others, it was the absence of their partner, who had to return to work after paternity leave, that served as a lever for an acute deterioration of their mental health.

“Everything was fine until about three weeks after the birth and we were back at home, and my husband went back to work; it was him going back to work and I just, yes, fell apart.” – Sarah .

Some respondents had their baby during one of the COVID-19 pandemic lockdowns, when social restrictions meant they were unable to meet with friends or family or seek peer support from other mothers. Instead, they felt cooped up inside their house, alone and isolated, with their suicidal thoughts.

“Completely isolated. Not being able to, like I could have been going to, I don’t know, prenatal yoga. Or breastfeeding groups or toddler groups. Anything else that would take me out of that loop. So I think obviously that made it a lot worse. I don’t think that it would have been… – I don’t know.” – Liv . “So she was three or four months old when Covid hit and it was the whole lockdown and yes, everything just got ten times worse because I couldn’t do anything then; I couldn’t go and talk to my mum, I couldn’t go out, I couldn’t even have doctor’s appointments, I couldn’t have hospital appointments which made me worry even more, and my husband’s a key worker so I was just on my own all the time. Yes, and I think that’s when it got to the point where I just felt like I couldn’t cope anymore.” – Mel .

Several respondents recalled how this feeling of loneliness instilled a determination in them to retreat into isolation further. This meant they no longer wanted to speak to or be around others, even when they had a supportive network in place. An unstoppable cycle of isolation and socially avoidant behaviour was set in motion.

“I just stopped talking to people. That’s when I stopped talking to anybody and I got really ill with my mental health because of it, but I thought “Well, why am I going to talk to people when they don’t listen to me anyway?”- Selina . “I knew exactly what I was doing. I knew how I was going to do it. I just wanted it done. So I thought I have to tell him. I have to tell him. But I couldn’t tell him that I was off to kill myself.” – Simone .

‘Tired’ and ‘wired’

All but two respondents mentioned sleep deprivation as a major contributing factor to the accumulation of despair in the days or weeks before the suicide attempt. The sheer exhaustion they felt prevented them from thinking clearly or having the energy to face their circumstances and get better.

“My little boy slept really well from, gosh, about three weeks, maybe less than that, he would sleep through the night which was really, really lucky, but I couldn’t sleep and I think, yes, the problems of not sleeping had a snowball effect.” – Hannah .

This level of hypervigilance and restlessness was for many women the reason why they were unable to sleep. While women reported to feel exhausted on one hand, they also reported to experience an unhealthy level of drive, anger or arousal, leaving them ‘tired and wired’.

“I stopped sleeping entirely; I was so angry all the time – it’s all the textbook depression symptoms, but I was so angry all the time. I was so tired all the time, but just wired, couldn’t sleep.”- Sam . “I remember thinking I’m just so tired, I just want to go to sleep. I just want to be asleep and not be disturbed. But my mind was just so busy.” – Simone .

Some displayed agitated and manic behaviour to such an extent that they struggled to understand how this went unnoticed.

“I live three miles from the hospital and after they sent me home the next day, I walked back to the hospital with [the] kids and I was mowing the lawn five days after he was born and cleaning the house from top to bottom and driving all over the city after a [caesarean] section and you kind of just think like why did nobody notice? How can you think that that’s normal behaviour? Because I just felt this constant need, like I’ve got to be constantly doing things, constantly cleaning things, constantly walking places or doing things, alongside this absolute anger.” – Lauren .

The irreversibility of motherhood

A majority of respondents described they came to a very agonising realisation that they were unable to get out of being a mother and that they found themselves in an irreversible situation, with no going back. The feeling of being ‘stuck’ was so pervasive, that many expressed they wanted either the pregnancy to end, or to not wake up. The irreversibility of motherhood was surrounded by feelings of deep regret and an admission that this had been their own fault and responsibility.

“I remember actually hoping he would be stillborn towards the end, I think after the bridge. I just really wanted for him to be stillborn because if he was then it would all be over but it wouldn’t be my fault, and then I couldn’t go back. I think there was this constant sense of wanting to go back before any of it had happened and I just have my [older] children and I was working and I was happy and I kept seeking these ways just to go back and there weren’t any and I just got more and more desperate as time went on.” – Lauren .

Many respondents shared their conflicting emotions towards their baby, who they viewed as the cause of their distress on the one hand, and as the reason to stay alive on the other.

“[…] I simply could not do it anymore. Help, or don’t help. Whatever. I’m just not going to be around. And it’s almost like this feeling of, you want someone to take the baby off you, so that the baby’s not around, or that’s how I felt. The baby is your reason to stay alive, but the baby’s also the thing that’s causing you so much anguish. And that conflict is just so hard.” – Sam .

Women were desperate to get a grip on the situation, yet it all felt in vain, with no improvement in sight. An overwhelming feeling of hopelessness took over, leaving women with no light at the end of the tunnel and only one option: taking their own life.

“I don’t know how to explain it. I was feeling like all the things that I had to do were like water in my hands. I could see it. I could feel it. I could hold it. But it was coming through my fingers and I couldn’t do anything about it.” – Liv .

Our study identified three overarching themes, marking different phases during which women’s mental health gradually deteriorated. Whilst not all sub-themes under these themes were necessarily reported by every respondent, they paint a comprehensive picture of the distressing feelings and contributing factors that women experienced in the days and weeks prior to their suicide attempt. Nearly half of our sample undertook a suicide attempt during pregnancy. This is in line with evidence suggesting antepartum suicide attempts are an important complication of pregnancy [ 2 ] and act as a strong predictor for postnatal suicidal behaviour, including completed suicide [ 41 ]. In addition, participants in our sample whose suicide attempt occurred during the postnatal period reported suicidal ideation had started during pregnancy, making the antenatal period a critical period for both antenatal and postnatal suicide prevention.

Our first theme, ‘Trauma and adversities’, captures vulnerabilities prior to conception and during pregnancy and has two key elements: (1) psycho-social adversities, including grief and trauma and (2) having a family history of perinatal mental health difficulties. Women with previous mental health difficulties, in particular those with a history of depression and mood disorders, are known to have an increased risk of fatal and non-fatal perinatal suicide attempts [ 3 , 42 , 43 ]. In addition, previous adverse life events and abuse, especially when these occurred during childhood, [ 44 , 45 ], perinatal bereavement and infertility [ 46 ], comorbid substance use disorders and intimate partner violence [ 47 ], have also been associated with an increased risk of perinatal suicidal thoughts and suicidal behaviour. While the need for trauma-informed maternity services has become a public health priority [ 37 ], it is not always matched by a general awareness of the importance to raise these issues during pregnancy or the postnatal period [ 48 ]. This is reflected in our findings, where several of the respondents had experienced significant trauma and adverse life events prior to becoming pregnant but did not feel this was particularly relevant. Similarly, for some respondents a significant family history of perinatal mental health problems was unbeknown to them until their own mental health deteriorated. In contrast, those respondents who started pregnancy with an alertness of the risk of perinatal mental health problems in light of their own previous mental health difficulties or those of close relatives, reported to have prophylactic support measures in place, for instance by accessing a community perinatal mental health service during pregnancy. While this did not prevent their mental health from deteriorating, it did shorten the referral and escalation times when they reached a point of crisis. Having meaningful conversations about the prevalence of perinatal mental ill-health early on in pregnancy and undertaking a thorough assessment of mental health-related risk factors, such as previous mental health history, domestic abuse, substance misuse, previous trauma, among others, at every contact with maternity services is therefore essential to mitigate these pre-existing vulnerabilities [ 49 ].

In our second theme, ‘Disillusionment with Motherhood’, we identified a range of triggering factors that caused women’s mental health to decline. A first and often overlooked sub-theme that we identified was the impact of a physically and mentally challenging pregnancy and birth and their role in a subsequent mental health deterioration. This was often exacerbated when women received unkind, disrespectful care, which made them feel invisible. Whilst there are no studies to our knowledge that directly associate birth trauma with an increased risk of perinatal suicide, the association between birth trauma and postpartum post-traumatic stress disorder (PTSD) is well established [ 50 , 51 , 52 , 53 ]. Postpartum PTSD in turn is associated with poor coping and stress and highly co-morbid with depression [ 50 ]. Less evidence is available on the association between pregnancy and birth complications and perinatal suicide risk. One study found no association between maternal complications in pregnancy and during birth with hospitalisation for a suicide attempt [ 54 ]. Yet, as illustrated by our study sample, not all suicide attempts will result in an admission to a general hospital for medical treatment. Thus, further evidence is needed to understand the role of physical health complications, both during pregnancy, childbirth and the postnatal period, and their role in mood deterioration.

The subsequent sub-themes of ‘Invalidation of identify and self-sacrifice’ and ‘It wasn’t like starry-eyed love’ are closely intertwined and bring the complexity of women’s conflicting emotions towards motherhood to light [ 55 ]. The desire to be a good mother as a newly found identify often came to the detriment of their own personal self, with many women reporting situations of total self-sacrifice [ 56 ]. These daily struggles, of trying to be the perfect mother on the one hand, while trying to bond with their baby on the other hand, was in many cases fertile soil to start feeling obsolete as a person and feeling disillusioned in motherhood. Our findings build on previous work from Reid et al. (2022), who identified key factors in the context of a perinatal suicide attempt, such as a strained mother-infant bond, lack of social support, loneliness and hopelessness [ 44 ]. This resonates with our sub-themes of “Feeling like a failure”, “Alone in this world” and “Irreversibility of motherhood”. Our final theme “Entrapment and Despair” is in line with Reid et al. (2022)’s final phase, called ‘Darkness Descends’ [ 23 ] and is marked by pervasive feelings of hopelessness and failed motherhood. Under this theme, a turbulent accumulation of negative factors resulting in a fast deterioration of their mental health was reported by all respondents. These feelings of hopelessness and being totally entrapped were so all-encompassing, that participants felt no other way out than by attempting to take their own life. However, in this third stage, women did not just feel disillusioned, they felt totally incompetent as a mother, to a point they believed their baby and family would be better off without them. The finality of motherhood, with no way to turn back time or to escape their fate (‘Irreversibility of Motherhood’), drove them further to despair [ 55 ]. The MBRRACE-UK reports have repeatedly raised such feelings of incompetence as a mother and estrangement of the infant as a ‘red flag’ which should be taken seriously to prevent future maternal deaths by suicide [ 1 , 13 , 57 ].

Another factor we identified in this phase was the occurrence of intrusive thoughts and unsettling (psychotic) experiences, brought together in the subtheme ‘Intense intrusive thoughts and abnormal experiences’. The majority of our respondents reported abnormal experiences that were very unsettling to them. For some, these could be described as intrusive thoughts in the context of Obsessive Compulsive Disorder. Although intrusive thoughts are common among new parents, such experiences are often misunderstood, surrounded by stigma, and sometimes being misdiagnosed or over-normalised and dismissed, preventing timely and effective intervention [ 58 ]. For others in our sample, these experiences may have been delusions or hallucinations as part of a psychotic presentation. For all respondents who had them, the experiences were intense, frightening and difficult to understand at the time. Practitioner knowledge, sensitive risk assessment and careful diagnostic consideration about the nature and type of internal experiences is fundamental to appropriately treat women experiencing these upsetting experiences [ 59 ]. Yet equally important is increased public awareness on the occurrence and impact of such experiences, so women can seek timely support when they experience these frightening thoughts or delusions.

A third common factor we identified was sleep deprivation during pregnancy and the postnatal period and its profound impact on women’s mental health. Sleep disturbance is very common in relation to mental illness, and was highlighted in the most recent MBRRACE-UK report as marked and persistent in those women who died by suicide, even when treated with hypnotic medication [ 1 ]. A recent systematic review by Palagini et al. (2023) showed insomnia and poor sleep quality increased the odds of suicidal risk in pregnant and postpartum women by more than threefold, independently from psychiatric comorbidity [ 60 ]. Especially in a context of onset of psychotic illness, such as bipolar disorder, insomnia often precipitates other psychotic symptoms such as restlessness, irritability and rapid mood changes [ 61 ]. Unfortunately, as sleep loss is generally accepted as a common ‘side effect’ of pregnancy and having a newborn baby, its severity and potential devastating consequences are poorly understood and often minimised. Overall, the theme of ‘Entrapment and Despair’ captures the sheer hopelessness and inability to gain control over a rapidly escalating situation, in line with Klonsky and May’s Three-Step-Theory of suicide [ 62 ]. This theoretical model of suicide considers three steps to suicide. Being in pain and hopelessness leads to suicidal ideation (Step 1), which can be exacerbated by isolation or countered by connectedness (Step 2). The final step is marked by one’s capability of attempting suicide (Step 3). The pervasive feeling of hopelessness and lack of control gradually paved the way for a solid belief it would be better to no longer be here. Participants in our sample shared how they accepted this belief and waited for an opportunity to carry out their suicide plan. This combination of hopelessness and rejection of motherhood, a belief that death would be preferred and an opportunity to act on these thoughts has been previously theorised as a culmination of factors for perinatal suicide [ 23 ]. In line with findings from previous MBRRACE-UK reports, the vast majority of respondents in our sample turned to violent methods for suicide, such as jumping, hanging, suffocation, using sharp objects or stepping in front of traffic, reflecting the high level of distress women found themselves in and the determination with which they wanted to carry out their plan.

Strengths and limitation

Our study is the first to our knowledge to focus on suicide attempts during the perinatal period and offers a rich understanding of women’s experiences surrounding these highly distressing events. A strength of this study is the recruitment of participants across the UK, rather than one geographical area, with diversity in the sample regarding age, parity, psychiatric morbidity, social support, educational attainment and socio-economic status. Significant efforts were made to recruit women from diverse ethnic, cultural, and religious backgrounds, through invitations and meetings with community leaders and designated support groups. Despite our efforts, we did not achieve diversity regarding ethnic and cultural background, one of the limitations of this study. Ethnicity data from the latest MBRRCACE-UK report showed that women who died by suicide were predominately white (86%), with no further ethnicity details on the remaining 14% [ 1 ]. As a result, although this was never our intention, we are aware our study findings are focusing on the experiences of White women in the UK and not transferrable to an ethnically and culturally more diverse sample, or to other countries across the globe. In addition, our sample consisted predominantly of participants with higher educational qualification, in positions of employment. Therefore, our analysis was unable to explore the impact of poverty on women’s suicidality, which is known to be an important driver of poor (perinatal) mental health [ 63 , 64 ]. We are aware a more ethnically, culturally, religiously and socio-economically heterogenous sample is likely to represent a diversity of perspectives, highlighting these issues. Another limitation was the design of the demographic survey, which did not specifically differentiate between mental health diagnosis given during the life course or specifically at the time of the suicide attempt. Suicide research, especially in a perinatal context, is notorious for its recruitment challenges. Saturation for all themes and sub-themes was achieved well within the available sample and is one of the strengths of this study. Another strength of our study is the sensitivity and rigour of patient and public involvement throughout the various phases of the study. This was crucial to do justice to the courage which participants had shown by sharing their stories and to keep respondents safe throughout their research participation.

Implications for clinical practice and care and future research

Our study highlights the importance of routine inquiry of previous mental health difficulties and family history of perinatal mental health problems at the first encounter during pregnancy. Yet, such an assessment needs to be more comprehensive than a tick-box exercise and should be accompanied by a personalised conversation about prevalence of perinatal mental health problems and potential triggers, including trauma and grief. Professionals should be given adequate time during antenatal encounters to explore this in depth and, where required, receive additional training in perinatal mental health to build confidence in doing so. The perinatal period is often described as a ‘window of opportunity’, but this goes both ways: While every encounter creates opportunity for screening, detection and support, it also has the potential for invoking or deepening trauma. Our study revealed the devastating and long-lasting impact of unkind, careless and dismissive remarks by healthcare professionals on women’s mental health, thus instilling a feeling of failure by throw-away comments that would ripple on weeks and months after they were uttered. Perinatal healthcare professionals need to understand the weight of their words, how they can provide hope when women are struggling, but equally how they can push women further into isolation and despair. Culturally aware and trauma-informed clinical practice is essential to achieve this, whilst also recognising the impact of burn-out and carer’s fatigue in an overstretched and under-resourced healthcare service. Healthcare professionals need to be cautious about the difference between normalising and dismissing distressing feelings. In addition, professionals need to fully understand the profound impact of physical, social and psychological risk factors as identified by our study. The physical and mental challenge of pregnancy and childbirth, often in combination with a traumatic birth experience should not be underestimated. An impaired mother-infant dyad, feelings of resentment of motherhood, and the discrepancy between women’s expectations and their lived reality are all key triggers that should be discussed, identified and addressed at the earliest opportunity, in a non-judgemental and sensitive way to avoid further escalation. Women need to be validated and reassured by professionals when disclosing these feelings, and be informed that support is available to help them transition into motherhood. Continuity of care throughout the perinatal period, if done with sensitivity and person-centredness, can foster trusting relationship so women feel safe and supported to disclose distressing feelings. Similarly, insomnia and sleep disturbance, albeit in combination with restlessness and irritability, intrusive thoughts and feelings of lack of control and failure are red flags for severe and rapid mental health deterioration that required prompt and effective action. More than anything, women need to feel safe and listened to, so they can share their feelings with healthcare professionals without fear of judgement, shame and stigma. Our study showed that women will often retreat into silence prior to a suicide attempt and in that moment more than ever rely on attentive, educated and compassionate support networks to avoid a suicide attempt.

Future research into perinatal suicide attempt should focus on developing effective preventative interventions and public health strategies, both in an antenatal and postnatal context, with their distinct healthcare professionals’ involvement and resource challenges. By using implementation science methods, these interventions should be tested and evaluated on their efficacy and effectiveness, in order to reduce future maternal suicides.

This study is the first UK-based qualitative study looking at suicide attempts during the perinatal period. Our findings identified three themes with several contributing factors which led women to undertake a suicide attempt. It is important to understand the impact of previous trauma and life adversity when going through pregnancy and the postnatal period. Feelings of disillusionment with motherhood and feeling entrapped in a hopeless situation were key phases women experienced in the lead-up to their suicide attempt. Our study findings have important implications for clinical practice and healthcare professionals should be aware of warning signs, to improve timely detection and facilitate meaningful inquiry, in order to improve care and prevent future maternal suicide deaths.

Data availability

The datasets generated and analysed during the current study are not publicly available due to the privacy of the participants in the study and the sensitive nature of the data. Further inquiries can be directed to the corresponding author ([email protected]).

We acknowledge not all people who give birth and go through the perinatal period identity as women, female or mothers. While this paper utilises predominantly the terms women and mothers, we aim to include also those who identify as transgender, non-binary or any other gender identity.

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Acknowledgements

We would like to thank all the women and birthing people who took part in this study, for their time, their bravery and the honesty with which they shared their story. Their commitment to improve care for others who find themselves in a similar position was a privilege to witness. We thank Dr Clare Dolman, the Patient Advisory Group at the Section for Women’s Mental Health at King’s College London, the South London Applied Research Collaboration Maternity and Perinatal Mental Health theme Patient and Public Involvement and Engagement group for their suggestions and feedback throughout the different stages of this study. We also like to thank the third sector partners that were closely involved in the study journey, such as Maternal Mental Health Alliance, Mothers for Mothers, the Institute of Health Visiting, the Motherhood Group, REFORM, National Childbirth Trust (NCT), and Maternity Action.

This work was supported by the National Institute for Health and Care Research (NIHR) South London Applied Research Collaboration (NIHR200152). Patient and public involvement engagement activities undertaken for this study were funded through a King’s Engaged Research Network (KERN) Public Engagement Small Grant Award. Kaat De Backer, Sergio A. Silverio, Professor Jane Sandall and Dr Abigail Easter are supported by the NIHR Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. Kaat De Backer (King’s College London) is also in receipt of an NIHR Doctoral Research Fellowship (NIHR302565). Sergio A. Silverio (King’s College London) is currently in receipt of a Personal Doctoral Fellowship from the NIHR ARC South London Capacity Building Theme [NIHR-INF-2170]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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AE, LMH, JS, RH, KDB conceived the work and designed the study. SAS and MN contributed to the development of the design. MN led the Public and Patient Involvement and Engagement. KDB, AP, AE, FLC contributed to data acquisition. KDB, AP, AE, FLC interpreted the data. KDB drafted the manuscript and incorporated revisions from all other authors. All authors read and approved the final manuscript.

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De Backer, K., Pali, A., Challacombe, F.L. et al. Women’s experiences of attempted suicide in the perinatal period (ASPEN-study) – a qualitative study. BMC Psychiatry 24 , 255 (2024). https://doi.org/10.1186/s12888-024-05686-3

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Patients’ Experiences With Digitalization in the Health Care System: Qualitative Interview Study

Authors of this article:

Original Paper

• Christian Gybel Jensen 1 * , MA   ; 
• Frederik Gybel Jensen 1 * , MA   ; 
• Mia Ingerslev Loft 1, 2 * , MSc, PhD  

1 Department of Neurology, Rigshospitalet, Copenhagen, Denmark

2 Institute for People and Technology, Roskilde University, Roskilde, Denmark

*all authors contributed equally

Corresponding Author:

Mia Ingerslev Loft, MSc, PhD

Department of Neurology

Rigshospitalet

Inge Lehmanns Vej 8

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Email: [email protected]

Background: The digitalization of public and health sectors worldwide is fundamentally changing health systems. With the implementation of digital health services in health institutions, a focus on digital health literacy and the use of digital health services have become more evident. In Denmark, public institutions use digital tools for different purposes, aiming to create a universal public digital sector for everyone. However, this digitalization risks reducing equity in health and further marginalizing citizens who are disadvantaged. Therefore, more knowledge is needed regarding patients’ digital practices and experiences with digital health services.

Objective: This study aims to examine digital practices and experiences with public digital health services and digital tools from the perspective of patients in the neurology field and address the following research questions: (1) How do patients use digital services and digital tools? (2) How do they experience them?

Methods: We used a qualitative design with a hermeneutic approach. We conducted 31 semistructured interviews with patients who were hospitalized or formerly hospitalized at the department of neurology in a hospital in Denmark. The interviews were audio recorded and subsequently transcribed. The text from each transcribed interview was analyzed using manifest content analysis.

Results: The analysis provided insights into 4 different categories regarding digital practices and experiences of using digital tools and services in health care systems: social resources as a digital lifeline, possessing the necessary capabilities, big feelings as facilitators or barriers, and life without digital tools. Our findings show that digital tools were experienced differently, and specific conditions were important for the possibility of engaging in digital practices, including having access to social resources; possessing physical, cognitive, and communicative capabilities; and feeling motivated, secure, and comfortable. These prerequisites were necessary for participants to have positive experiences using digital tools in the health care system. Those who did not have these prerequisites experienced challenges and, in some cases, felt left out.

Conclusions: Experiences with digital practices and digital health services are complex and multifaceted. Engagement in digital practices for the examined population requires access to continuous assistance from their social network. If patients do not meet requirements, digital health services can be experienced as exclusionary and a source of concern. Physical, cognitive, and communicative difficulties might make it impossible to use digital tools or create more challenges. To ensure that digitalization does not create inequities in health, it is necessary for developers and institutions to be aware of the differences in digital health literacy, focus on simplifying communication with patients and next of kin, and find flexible solutions for citizens who are disadvantaged.

Introduction

In 2022, the fourth most googled question in Denmark was, “Why does MitID not work?” [ 1 ]. MitID (My ID) is a digital access tool that Danes use to enter several different private and public digital services, from bank accounts to mail from their municipality or the state. MitID is a part of many Danish citizens’ everyday lives because the public sector in Denmark is digitalized in many areas. In recent decades, digitalization has changed how governments and people interact and has demonstrated the potential to change the core functions of public sectors and delivery of public policies and services [ 2 ]. When public sectors worldwide become increasingly digitalized, this transformation extends to the public health sectors as well, and some studies argue that we are moving toward a “digital public health era” that is already impacting the health systems and will fundamentally change the future of health systems [ 3 ]. While health systems are becoming more digitalized, it is important that both patients and digitalized systems adapt to changes in accordance with each other. Digital practices of people can be understood as what people do with and through digital technologies and how people relate to technology [ 4 ]. Therefore, it is relevant to investigate digital practices and how patients perceive and experience their own use of digital tools and services, especially in relation to existing digital health services. In our study, we highlight a broad perspective on experiences with digital practices and particularly add insight into the challenges with digital practices faced by patients who have acute or chronic illness, with some of them also experiencing physical, communicative, or cognitive difficulties.

An international Organization for Economic Cooperation and Development report indicates that countries are digitalized to different extents and in different ways; however, this does not mean that countries do not share common challenges and insights into the implementation of digital services [ 2 ].

In its global Digital Government Index, Denmark is presented as one of the leading countries when it comes to public digitalization [ 2 ]. Recent statistics indicate that approximately 97% of Danish families have access to the internet at home [ 5 ]. The Danish health sector already offers many different digital services, including web-based delivery of medicine, e-consultations, patient-related outcome questionnaires, and seeking one’s own health journal or getting test results through; “Sundhed” [ 6 ] (the national health portal) and “Sundhedsjournalen” (the electronic patient record); or the apps “Medicinkortet” (the shared medication record), “Minlæge” (My Doctor, consisting of, eg, communication with the general practitioner), or “MinSP” (My Health Platform, consisting of, eg, communication with health care staff in hospitals) [ 6 - 8 ].

The Danish Digital Health Strategy from 2018 aims to create a coherent and user-friendly digital public sector for everyone [ 9 ], but statistics indicate that certain groups in society are not as digitalized as others. In particular, the older population uses digital services the least, with 5% of people aged 65 to 75 years and 18% of those aged 75 to 89 years having never used the internet in 2020 [ 5 ]. In parts of the literature, it has been problematized how the digitalization of the welfare state is related to the marginalization of older citizens who are socially disadvantaged [ 10 ]. However, statistics also indicate that the probability of using digital tools increases significantly as a person’s experience of using digital tools increases, regardless of their age or education level [ 5 ].

Understanding the digital practices of patients is important because they can use digital tools to engage with the health system and follow their own health course. Researching experiences with digital practices can be a way to better understand potential possibilities and barriers when patients use digital health services. With patients becoming more involved in their own health course and treatment, the importance of patients’ health literacy is being increasingly recognized [ 11 ]. The World Health Organization defines health literacy as the “achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions” [ 12 ]. Furthermore, health literacy can be described as “a person’s knowledge and competencies to meet complex demands of health in modern society, ” and it is viewed as a critical step toward patient empowerment [ 11 , 12 ]. In a digitalized health care system, this also includes the knowledge, capabilities, and resources that individuals require to use and benefit from eHealth services, that is, “digital health literacy (eHealth literacy)” [ 13 ]. An eHealth literacy framework created by Norgaard et al [ 13 ] identified that different aspects, for example, the ability to process information and actively engage with digital services, can be viewed as important facets of digital health literacy. This argument is supported by studies that demonstrate how patients with cognitive and communicative challenges experience barriers to the use of digital tools and require different approaches in the design of digital solutions in the health sector [ 14 , 15 ]. Access to digital services and digital literacy is becoming increasingly important determinants of health, as people with digital literacy and access to digital services can facilitate improvement of health and involvement in their own health course [ 16 ].

The need for a better understanding of eHealth literacy and patients’ capabilities to meet public digital services’ demands as well as engage in their own health calls for a deeper investigation into digital practices and the use of digital tools and services from the perspective of patients with varying digital capabilities. Important focus areas to better understand digital practices and related challenges have already been highlighted in various studies. They indicate that social support, assessment of value in digital services, and systemic assessment of digital capabilities are important in the use and implementation of digital tools, and they call for better insight into complex experiences with digital services [ 13 , 17 , 18 ]. Therefore, we aimed to examine digital practices and experiences with public digital health services and digital tools from the perspective of patients, addressing the following research questions: how do patients use digital services and digital tools, and how do they experience them?

We aimed to investigate digital practices and experiences with digital health services and digital tools; therefore, we used a qualitative design and adopted a hermeneutic approach as the point of departure, which means including preexisting knowledge of digital practices but also providing room for new comprehension [ 19 ]. Our interpretive approach is underpinned by the philosophical hermeneutic approach by Gadamer et al [ 19 ], in which they described the interpretation process as a “hermeneutic circle,” where the researcher enters the interpretation process with an open mind and historical awareness of a phenomenon (preknowledge). We conducted semistructured interviews using an interview guide. This study followed the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist [ 20 ].

Setting and Participants

To gain a broad understanding of experiences with public digital health services, a purposive sampling strategy was used. All 31 participants were hospitalized or formerly hospitalized patients in a large neurological department in the capital of Denmark ( Table 1 ). We assessed whether including patients from the neurological field would give us a broad insight into the experiences of digital practices from different perspectives. The department consisted of, among others, 8 inpatient units covering, for example, acute neurology and stroke units, from which the patients were recruited. Patients admitted to a neurological department can have both acute and transient neurological diseases, such as infections in the brain, stroke, or blood clot in the brain from which they can recover completely or have persistent physical and mental difficulties, or experience chronic neurological and progressive disorders such as Parkinson disease and dementia. Some patients hospitalized in neurological care will have communicative and cognitive difficulties because of their neurological disorders. Nursing staff from the respective units helped the researchers (CGJ, FGJ, and MIL) identify patients who differed in terms of gender, age, and severity of neurological illness. Some patients (6/31, 19%) had language difficulties; however, a speech therapist assessed them as suitable participants. We excluded patients with severe cognitive difficulties and those who were not able to speak the Danish language. Including patients from the field of neurology provided an opportunity to study the experience of digital health practice from various perspectives. Hence, the sampling strategy enabled the identification and selection of information-rich participants relevant to this study [ 21 ], which is the aim of qualitative research. The participants were invited to participate by either the first (CGJ) or last author (MIL), and all invited participants (31/31, 100%) chose to participate.

All 31 participants were aged between 40 to 99 years, with an average age of 71.75 years ( Table 1 ). Out of the 31 participants, 10 (32%) had physical disabilities or had cognitive or communicative difficulties due to sequela in relation to neurological illness or other physical conditions.

Data Collection

The 31 patient interviews were conducted over a 2-month period between September and November 2022. Of the 31 patients, 20 (65%) were interviewed face-to-face at the hospital in their patient room upon admission and 11 (35%) were interviewed on the phone after being discharged. The interviews had a mean length of 20.48 minutes.

We developed a semistructured interview guide ( Table 2 ). The interview questions were developed based on the research aim, findings from our preliminary covering of literature in the field presented in the Introduction section, and identified gaps that we needed to elaborate on to be able to answer our research question [ 22 ]. The semistructured interview guide was designed to support the development of a trusting relationship and ensure the relevance of the interviews’ content [ 22 ]. The questions served as a prompt for the participants and were further supported by questions such as “please tell me more” and “please elaborate” throughout the interview, both to heighten the level of detail and to verify our understanding of the issues at play. If the participant had cognitive or communicative difficulties, communication was supported using a method called Supported Communication for Adults with Aphasia [ 23 ] during the interview.

The interviews were performed by all authors (CGJ, FGJ, and MIL individually), who were skilled in conducting interviews and qualitative research. The interviewers are not part of daily clinical practice but are employed in the department of neurology from where the patients were recruited. All interviews were audio recorded and subsequently transcribed verbatim by all 3 authors individually.

a PRO: patient-related outcome.

Data Analysis

The text from each transcribed interview was analyzed using manifest content analysis, as described by Graneheim and Lundman [ 24 ]. Content analysis is a method of analyzing written, verbal, and visual communication in a systematic way [ 25 ]. Qualitative content analysis is a structured but nonlinear process that requires researchers to move back and forth between the original text and parts of the text during the analysis. Manifest analysis is the descriptive level at which the surface structure of the text central to the phenomenon and the research question is described. The analysis was conducted as a collaborative effort between the first (CGJ) and last authors (MIL); hence, in this inductive circular process, to achieve consistency in the interpretation of the text, there was continued discussion and reflection between the researchers. The transcriptions were initially read several times to gain a sense of the whole context, and we analyzed each interview. The text was initially divided into domains that reflected the lowest degree of interpretation, as a rough structure was created in which the text had a specific area in common. The structure roughly reflected the interview guide’s themes, as guided by Graneheim and Lundman [ 24 ]. Thereafter, the text was divided into meaning units, condensed into text-near descriptions, and then abstracted and labeled further with codes. The codes were categorized based on similarities and differences. During this process, we discussed the findings to reach a consensus on the content, resulting in the final 4 categories presented in this paper.

Ethical Considerations

The interviewees received oral and written information about the study and its voluntary nature before the interviews. Written informed consent was obtained from all participants. Participants were able to opt of the study at any time. Data were anonymized and stored electronically on locked and secured servers. The Ethics Committee of the Capitol Region in Denmark was contacted before the start of the study. This study was registered and approved by the ethics committee and registered under the Danish Data Protection Agency (number P2021-839). Furthermore, the ethical principles of the Declaration of Helsinki were followed for this study.

The analysis provided insights into 4 different categories regarding digital practices and experiences of using digital tools and services in health care systems: social resources as a digital lifeline, possessing the necessary capabilities, big feelings as facilitators or barriers, and life without digital tools.

Social Resources as a Digital Lifeline

Throughout the analysis, it became evident that access to both material and social resources was of great importance when using digital tools. Most participants already possessed and had easy access to a computer, smartphone, or tablet. The few participants who did not own the necessary digital tools told us that they did not have the skills needed to use these tools. For these participants, the lack of material resources was tied particularly to a lack of knowledge and know-how, as they expressed that they would not know where to start after buying a computer—how to set it up, connect it to the internet, and use its many systems.

However, possessing the necessary material resources did not mean that the participants possessed the knowledge and skill to use digital tools. Furthermore, access to material resources was also a question of having access to assistance when needed. Some participants who had access to a computer, smartphone, and tablet and knew how to use these tools still had to obtain help when setting up hardware, updating software, or getting a new device. These participants were confident in their own ability to use digital devices but also relied on family, friends, and neighbors in their everyday use of these tools. Certain participants were explicitly aware of their own use of social resources when expressing their thoughts on digital services in health care systems:

I think it is a blessing and a curse. I think it is both. I would say that if I did not have someone around me in my family who was almost born into the digital world, then I think I would be in trouble. But I feel sorry for those who do not have that opportunity, and I know quite a few who do not. They get upset, and it’s really frustrating. [Woman, age 82 years]

The participants’ use of social resources indicates that learning skills and using digital tools are not solely individual tasks but rather continuously involve engagement with other people, particularly whenever a new unforeseen problem arises or when the participants want a deeper understanding of the tools they are using:

If tomorrow I have to get a new ipad...and it was like that when I got this one, then I had to get XXX to come and help me move stuff and he was sweet to help with all the practical stuff. I think I would have cursed a couple of times (if he hadn’t been there), but he is always helpful, but at the same time he is also pedagogic so I hope that next time he showed me something I will be able to do it. [Man, age 71 years]

For some participants, obtaining assistance from a more experienced family member was experienced as an opportunity to learn, whereas for other participants, their use of public digital services was even tied directly to assistance from a spouse or family member:

My wife, she has access to mine, so if something comes up, she can just go in and read, and we can talk about it afterwards what (it is). [Man, age 85 years]

The participants used social resources to navigate digital systems and understand and interpret communication from the health care system through digital devices. Another example of this was the participants who needed assistance to find, answer, and understand questionnaires from the health care department. Furthermore, social resources were viewed as a support system that made participants feel more comfortable and safer when operating digital tools. The social resources were particularly important when overcoming unforeseen and new challenges and when learning new skills related to the use of digital tools. Participants with physical, cognitive, and communicative challenges also explained how social resources were of great importance in their ability to use digital tools.

Possessing the Necessary Capabilities

The findings indicated that possessing the desire and knowing how to use digital tools are not always enough to engage with digital services successfully. Different health issues can carry consequences for motor skills and mobility. Some of these consequences were visibly affecting how our participants interacted with digital devices, and these challenges were somewhat easy to discover. However, our participants revealed hidden challenges that posed difficulties. In some specific cases, cognitive and communicative inabilities can make it difficult to use digital tools, and this might not always be clear until the individual tries to use a device’s more complex functions. An example of this is that some participants found it easy to turn on a computer and use it to write but difficult to go through security measures on digital services or interpret and understand digital language. Remembering passwords and logging on to systems created challenges, particularly for those experiencing health issues that directly affect memory and cognitive abilities, who expressed concerns about what they were able to do through digital tools:

I think it is very challenging because I would like to use it how I used to before my stroke; (I) wish that everything (digital skills) was transferred, but it just isn’t. [Man, age 80 years]

Despite these challenges, the participants demonstrated great interest in using digital tools, particularly regarding health care services and their own well-being. However, sometimes, the challenges that they experienced could not be conquered merely by motivation and good intentions. Another aspect of these challenges was the amount of extra time and energy that the participants had to spend on digital services. A patient diagnosed with Parkinson disease described how her symptoms created challenges that changed her digital practices:

Well it could for example be something like following a line in the device. And right now it is very limited what I can do with this (iPhone). Now I am almost only using it as a phone, and that is a little sad because I also like to text and stuff, but I also find that difficult (...) I think it is difficult to get an overview. [Woman, age 62 years]

Some participants said that after they were discharged from the hospital, they did not use the computer anymore because it was too difficult and too exhausting , which contributed to them giving up . Using digital tools already demanded a certain amount of concentration and awareness, and some diseases and health conditions affected these abilities further.

Big Feelings as Facilitators or Barriers

The findings revealed a wide range of digital practices in which digital tools were used as a communication device, as an entertainment device, and as a practical and informative tool for ordering medicine, booking consultations, asking health-related questions, or receiving email from public institutions. Despite these different digital practices, repeating patterns and arguments appeared when the participants were asked why they learned to use digital tools or wanted to improve their skills. A repeating argument was that they wanted to “follow the times, ” or as a participant who was still not satisfied with her digital skills stated:

We should not go against the future. [Woman, age 89 years]

The participants expressed a positive view of the technological developments and possibilities that digital devices offered, and they wanted to improve their knowledge and skills related to digital practice. For some participants, this was challenging, and they expressed frustration over how technological developments “moved too fast ,” but some participants interpreted these challenges as a way to “keep their mind sharp. ”

Another recurring pattern was that the participants expressed great interest in using digital services related to the health care system and other public institutions. The importance of being able to navigate digital services was explicitly clear when talking about finding test answers, written electronic messages, and questionnaires from the hospital or other public institutions. Keeping up with developments, communicating with public institutions, and taking an interest in their own health and well-being were described as good reasons to learn to use digital tools.

However, other aspects also affected these learning facilitators. Some participants felt alienated while using digital tools and described the practice as something related to feelings of anxiety, fear, and stupidity as well as something that demanded “a certain amount of courage. ” Some participants felt frustrated with the digital challenges they experienced, especially when the challenges were difficult to overcome because of their physical conditions:

I get sad because of it (digital challenges) and I get very frustrated and it takes a lot of time because I have difficulty seeing when I look away from the computer and have to turn back again to find out where I was and continue there (...) It pains me that I have to use so much time on it. [Man, age 71 years]

Fear of making mistakes, particularly when communicating with public institutions, for example, the health care system, was a common pattern. Another pattern was the fear of misinterpreting the sender and the need to ensure that the written electronic messages were actually from the described sender. Some participants felt that they were forced to learn about digital tools because they cared a lot about the services. Furthermore, fears of digital services replacing human interaction were a recurring concern among the participants. Despite these initial and recurring feelings, some participants learned how to navigate the digital services that they deemed relevant. Another recurring pattern in this learning process was repetition, the practice of digital skills, and consistent assistance from other people. One participant expressed the need to use the services often to remember the necessary skills:

Now I can figure it out because now I’ve had it shown 10 times. But then three months still pass... and then I think...how was it now? Then I get sweat on my forehead (feel nervous) and think; I’m not an idiot. [Woman, age 82 years]

For some participants, learning how to use digital tools demanded time and patience, as challenges had to be overcome more than once because they reappeared until the use of digital tools was more automatized into their everyday lives. Using digital tools and health services was viewed as easier and less stressful when part of everyday routines.

Life Without Digital Tools: Not a Free Choice

Even though some participants used digital tools daily, other participants expressed that it was “too late for them.” These participants did not view it as a free choice but as something they had to accept that they could not do. They wished that they could have learned it earlier in life but did not view it as a possibility in the future. Furthermore, they saw potential in digital services, including digital health care services, but they did not know exactly what services they were missing out on. Despite this lack of knowledge, they still felt sad about the position they were in. One participant expressed what she thought regarding the use of digital tools in public institutions:

Well, I feel alright about it, but it is very, very difficult for those of us who do not have it. Sometimes you can feel left out—outside of society. And when you do not have one of those (computers)...A reference is always made to w and w (www.) and then you can read on. But you cannot do that. [Woman, age 94 years]

The feeling of being left out of society was consistent among the participants who did not use digital tools. To them, digital systems seemed to provide unfair treatment based on something outside of their own power. Participants who were heavily affected by their medical conditions and could not use digital services also felt left out because they saw the advantages of using digital tools. Furthermore, a participant described the feelings connected to the use of digital tools in public institutions:

It is more annoying that it does not seem to work out in my favour. [Woman, age 62 years]

These statements indicated that it is possible for individuals to want to use digital tools and simultaneously find them too challenging. These participants were aware that there are consequences of not using digital tools, and that saddens them, as they feel like they are not receiving the same treatment as other people in society and the health care system.

Principal Findings

The insights from our findings demonstrated that our participants had different digital practices and different experiences with digital tools and services; however, the analysis also highlighted patterns related to how digital services and tools were used. Specific conditions were important for the possibility of digital practice, including having access to social resources; possessing the necessary capabilities; and feeling motivated, secure, and comfortable . These prerequisites were necessary to have positive experiences using digital tools in the health care system, although some participants who lived up to these prerequisites were still skeptical toward digital solutions. Others who did not live up to these prerequisites experienced challenges and even though they were aware of opportunities, this awareness made them feel left out. A few participants even viewed the digital tools as a threat to their participation in society. This supports the notion of Norgaard et al [ 13 ] that the attention paid to digital capability demands from eHealth systems is very important. Furthermore, our findings supported the argument of Hjeltholt and Papazu [ 17 ] that it is important to better understand experiences related to digital services. In our study, we accommodate this request and bring forth a broad perspective on experiences with digital practices; we particularly add insight into the challenges with digital practices for patients who also have acute or chronic illness, with some of them also experiencing physical, communicative, and cognitive difficulties. To our knowledge, there is limited existing literature focusing on digital practices that do not have a limited scope, for example, a focus on perspectives on eHealth literacy in the use of apps [ 26 ] or intervention studies with a focus on experiences with digital solutions, for example, telemedicine during the COVID-19 pandemic [ 27 ]. As mentioned by Hjeltholt et al [ 10 ], certain citizens are dependent on their own social networks in the process of using and learning digital tools. Rasi et al [ 28 ] and Airola et al [ 29 ] argued that digital health literacy is situated and should include the capabilities of the individual’s social network. Our findings support these arguments that access to social resources is an important condition; however, the findings also highlight that these resources can be particularly crucial in the use of digital health services, for example, when interpreting and understanding digital and written electronic messages related to one’s own health course or when dealing with physical, cognitive, and communicative disadvantages. Therefore, we argue that the awareness of the disadvantages is important if we want to understand patients’ digital capabilities, and the inclusion of the next of kin can be evident in unveiling challenges that are unknown and not easily visible or when trying to reach patients with digital challenges through digital means.

Studies by Kayser et al [ 30 ] and Kanoe et al [ 31 ] indicated that patients’ abilities to interpret and understand digital health–related services and their benefits are important for the successful implementation of eHealth services—an argument that our findings support. Health literacy in both digital and physical contexts is important if we want to understand how to better design and implement services. Our participants’ statements support the argument that communication through digital means cannot be viewed as similar to face-to-face communication and that an emphasis on digital health literacy demonstrates how health systems are demanding different capabilities from the patients [ 13 ]. We argue that it is important to communicate the purposes of digital services so that both the patient and their next of kin know why they participate and how it can benefit them. Therefore, it is important to make it as clear as possible that digital health services can benefit the patient and that these services are developed to support information, communication, and dialogue between patients and health professionals. However, our findings suggest that even after interpreting and understanding the purposes of digital health services, some patients may still experience challenges when using digital tools.

Therefore, it is important to understand how and why patients learn digital skills, particularly because both experience with digital devices and estimation of the value of digital tools have been highlighted as key factors for digital practices [ 5 , 18 ]. Our findings indicate that a combination of these factors is important, as recognizing the value of digital tools was not enough to facilitate the necessary learning process for some of our participants. Instead, our participants described the use of digital tools as complex and continuous processes in which automation of skills, assistance from others, and time to relearn forgotten knowledge were necessary and important facilitators for learning and understanding digital tools as well as becoming more comfortable and confident in the use of digital health services. This was particularly important, as it was more encouraging for our participants to learn digital tools when they felt secure, instead of feeling afraid and anxious, a point that Bailey et al [ 18 ] also highlighted. The value of digital solutions and the will to learn were greater when challenges were viewed as something to overcome and learn from instead of something that created a feeling of being stupid. This calls for attention on how to simplify and explain digital tools and services so that users do not feel alienated. Our findings also support the argument that digital health literacy should take into account emotional well-being related to digital practice [ 32 ].

The various perspectives that our participants provided regarding the use of digital tools in the health care system indicate that patients are affected by the use of digital health services and their own capabilities to use digital tools. Murray et al [ 33 ] argued that the use of digital tools in health sectors has the potential to improve health and health delivery by improving efficacy, efficiency, accessibility, safety, and personalization, and our participants also highlighted these positive aspects. However, different studies found that some patients, particularly older adults considered socially vulnerable, have lower digital health literacy [ 10 , 34 , 35 ], which is an important determinant of health and may widen disparities and inequity in health care [ 16 ]. Studies on older adult populations’ adaptation to information and communication technology show that engaging with this technology can be limited by the usability of technology, feelings of anxiety and concern, self-perception of technology use, and the need for assistance and inclusive design [ 36 ]. Our participants’ experiences with digital practices support the importance of these focus areas, especially when primarily older patients are admitted to hospitals. Furthermore, our findings indicate that some older patients who used to view themselves as being engaged in their own health care felt more distanced from the health care system because of digital services, and some who did not have the capabilities to use digital tools felt that they were treated differently compared to the rest of society. They did not necessarily view themselves as vulnerable but felt vulnerable in the specific experience of trying to use digital services because they wished that they were more capable. Moreover, this was the case for patients with physical and cognitive difficulties, as they were not necessarily aware of the challenges before experiencing them. Drawing on the phenomenological and feministic approach by Ahmed [ 37 ], these challenges that make patients feel vulnerable are not necessarily visible to others but can instead be viewed as invisible institutional “walls” that do not present themselves before the patient runs into them. Some participants had to experience how their physical, cognitive, or communicative difficulties affected their digital practice to realize that they were not as digitally capable as they once were or as others in society. Furthermore, viewed from this perspective, our findings could be used to argue that digital capabilities should be viewed as a privilege tied to users’ physical bodies and that digital services in the health care system are indirectly making patients without this privilege vulnerable. This calls for more attention to the inequities that digital tools and services create in health care systems and awareness that those who do not use digital tools are not necessarily indifferent about the consequences. Particularly, in a context such as the Danish one, in which the digital strategy is to create an intertwined and user-friendly public digital sector for everyone, it needs to be understood that patients have different digital capabilities and needs. Although some have not yet had a challenging experience that made them feel vulnerable, others are very aware that they receive different treatment and feel that they are on their own or that the rest of the society does not care about them. Inequities in digital health care, such as these, can and should be mitigated or prevented, and our investigation into the experiences with digital practices can help to show that we are creating standards and infrastructures that deliberately exclude the perspectives of those who are most in need of the services offered by the digital health care system [ 8 ]. Therefore, our findings support the notions that flexibility is important in the implementation of universal public digital services [ 17 ]; that it is important to adjust systems in accordance with patients’ eHealth literacy and not only improve the capabilities of individuals [ 38 ]; and that the development and improvement of digital health literacy are not solely an individual responsibility but are also tied to ways in which institutions organize, design, and implement digital tools and services [ 39 ].

Limitations

This qualitative study provided novel insights into the experiences with public digital health services from the perspective of patients in the Danish context, enabling a deeper understanding of how digital health services and digital tools are experienced and used. This helps build a solid foundation for future interventions aimed at digital health literacy and digital health interventions. However, this study has some limitations. First, the study was conducted in a country where digitalization is progressing quickly, and people, therefore, are accustomed to this pace. Therefore, readers must be aware of this. Second, the study included patients with different neurological conditions; some of their digital challenges were caused or worsened by these neurological conditions and are, therefore, not applicable to all patients in the health system. However, the findings provided insights into the patients’ digital practices before their conditions and other challenges not connected to neurological conditions shared by patients. Third, the study was broad, and although a large number of informants was included, from a qualitative research perspective, we would recommend additional research in this field to develop interventions that target digital health literacy and the use of digital health services.

Conclusions

Experiences with digital tools and digital health services are complex and multifaceted. The advantages in communication, finding information, or navigating through one’s own health course work as facilitators for engaging with digital tools and digital health services. However, this is not enough on its own. Furthermore, feeling secure and motivated and having time to relearn and practice skills are important facilitators. Engagement in digital practices for the examined population requires access to continuous assistance from their social network. If patients do not meet requirements, digital health services can be experienced as exclusionary and a source of concern. Physical, cognitive, and communicative difficulties might make it impossible to use digital tools or create more challenges that require assistance. Digitalization of the health care system means that patients do not have the choice to opt out of using digital services without having consequences, resulting in them receiving a different treatment than others. To ensure digitalization does not create inequities in health, it is necessary for developers and the health institutions that create, design, and implement digital services to be aware of differences in digital health literacy and to focus on simplifying communication with patients and next of kin through and about digital services. It is important to focus on helping individuals meet the necessary conditions and finding flexible solutions for those who do not have the same privileges as others if the public digital sector is to work for everyone.

Acknowledgments

The authors would like to thank all the people who gave their time to be interviewed for the study, the clinical nurse specialists who facilitated interviewing patients, and the other nurses on shift who assisted in recruiting participants.

Conflicts of Interest

None declared.

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Abbreviations

Edited by A Mavragani; submitted 14.03.23; peer-reviewed by G Myreteg, J Eriksen, M Siermann; comments to author 18.09.23; revised version received 09.10.23; accepted 27.02.24; published 11.04.24.

©Christian Gybel Jensen, Frederik Gybel Jensen, Mia Ingerslev Loft. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 11.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.