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What is phenomenology in qualitative research?

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7 February 2023

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Take a closer look at this type of qualitative research along with characteristics, examples, uses, and potential disadvantages.

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• What is phenomenological qualitative research?

Phenomenological research is a qualitative research approach that builds on the assumption that the universal essence of anything ultimately depends on how its audience experiences it .

Phenomenological researchers record and analyze the beliefs, feelings, and perceptions of the audience they’re looking to study in relation to the thing being studied. Only the audience’s views matter—the people who have experienced the phenomenon. The researcher’s personal assumptions and perceptions about the phenomenon should be irrelevant.

Phenomenology is a type of qualitative research as it requires an in-depth understanding of the audience’s thoughts and perceptions of the phenomenon you’re researching. It goes deep rather than broad, unlike quantitative research . Finding the lived experience of the phenomenon in question depends on your interpretation and analysis.

• What is the purpose of phenomenological research?

The primary aim of phenomenological research is to gain insight into the experiences and feelings of a specific audience in relation to the phenomenon you’re studying. These narratives are the reality in the audience’s eyes. They allow you to draw conclusions about the phenomenon that may add to or even contradict what you thought you knew about it from an internal perspective.

• How is phenomenology research design used?

Phenomenological research design is especially useful for topics in which the researcher needs to go deep into the audience’s thoughts, feelings, and experiences.

It’s a valuable tool to gain audience insights, generate awareness about the item being studied, and develop new theories about audience experience in a specific, controlled situation.

• Examples of phenomenological research

Phenomenological research is common in sociology, where researchers aim to better understand the audiences they study.

An example would be a study of the thoughts and experiences of family members waiting for a loved one who is undergoing major surgery. This could provide insights into the nature of the event from the broader family perspective.

However, phenomenological research is also common and beneficial in business situations. For example, the technique is commonly used in branding research. Here, audience perceptions of the brand matter more than the business’s perception of itself.

In branding-related market research, researchers look at how the audience experiences the brand and its products to gain insights into how they feel about them. The resulting information can be used to adjust messaging and business strategy to evoke more positive or stronger feelings about the brand in the future.

• The 4 characteristics of phenomenological research design

The exact nature of phenomenological research depends on the subject to be studied. However, every research design should include the following four main tenets to ensure insightful and actionable outcomes:

A focus on the audience’s interpretation of something . The focus is always on what an experience or event means to a strictly defined audience and how they interpret its meaning.

A lack of researcher bias or prior influence . The researcher has to set aside all prior prejudices and assumptions. They should focus only on how the audience interprets and experiences the event.

Connecting objectivity with lived experiences . Researchers need to describe their observations of how the audience experienced the event as well as how the audience interpreted their experience themselves.

• Types of phenomenological research design

Each type of phenomenological research shares the characteristics described above. Social scientists distinguish the following three types:

Existential phenomenology —focuses on understanding the audience’s experiences through their perspective. 

Hermeneutic phenomenology —focuses on creating meaning from experiences through the audience’s perspective.

Transcendental phenomenology —focuses on how the phenomenon appears in one consciousness on a broader, scientific scale.

Existential phenomenology is the most common type used in a business context. It’s most valuable to help you better understand your audience.

You can use hermeneutic phenomenology to gain a deeper understanding of how your audience perceives experiences related to your business.

Transcendental phenomenology is largely reserved for non-business scientific applications.

• Data collection methods in phenomenological research

Phenomenological research draws from many of the most common qualitative research techniques to understand the audience’s perspective.

Here are some of the most common tools to collect data in this type of research study:

Observing participants as they experience the phenomenon

Interviewing participants before, during, and after the experience

Focus groups where participants experience the phenomenon and discuss it afterward

Recording conversations between participants related to the phenomenon

Analyzing personal texts and observations from participants related to the phenomenon

You might not use these methods in isolation. Most phenomenological research includes multiple data collection methods. This ensures enough overlap to draw satisfactory conclusions from the audience and the phenomenon studied.

Get started collecting, analyzing, and understanding qualitative data with help from quickstart research templates.

• Limitations of phenomenological research

Phenomenological research can be beneficial for many reasons, but its downsides are just as important to discuss.

This type of research is not a solve-all tool to gain audience insights. You should keep the following limitations in mind before you design your research study and during the design process:

These audience studies are typically very small. This results in a small data set that can make it difficult for you to draw complete conclusions about the phenomenon.

Researcher bias is difficult to avoid, even if you try to remove your own experiences and prejudices from the equation. Bias can contaminate the entire outcome.

Phenomenology relies on audience experiences, so its accuracy depends entirely on how well the audience can express those experiences and feelings.

The results of a phenomenological study can be difficult to summarize and present due to its qualitative nature. Conclusions typically need to include qualifiers and cautions.

This type of study can be time-consuming. Interpreting the data can take days and weeks.

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Qualitative study design: Phenomenology

• Qualitative study design

Phenomenology

• Grounded theory
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• Observation
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Used to describe the lived experience of individuals.

• Now called Descriptive Phenomenology, this study design is one of the most commonly used methodologies in qualitative research within the social and health sciences.
• Used to describe how human beings experience a certain phenomenon. The researcher asks, “What is this experience like?’, ‘What does this experience mean?’ or ‘How does this ‘lived experience’ present itself to the participant?’
• Attempts to set aside biases and preconceived assumptions about human experiences, feelings, and responses to a particular situation.
• Experience may involve perception, thought, memory, imagination, and emotion or feeling.
• Usually (but not always) involves a small sample of participants (approx. 10-15).
• Analysis includes an attempt to identify themes or, if possible, make generalizations in relation to how a particular phenomenon is perceived or experienced.

Methods used include:

• participant observation
• in-depth interviews with open-ended questions
• conversations and focus workshops. 

Researchers may also examine written records of experiences such as diaries, journals, art, poetry and music.

Descriptive phenomenology is a powerful way to understand subjective experience and to gain insights around people’s actions and motivations, cutting through long-held assumptions and challenging conventional wisdom.  It may contribute to the development of new theories, changes in policies, or changes in responses.

Limitations

• Does not suit all health research questions.  For example, an evaluation of a health service may be better carried out by means of a descriptive qualitative design, where highly structured questions aim to garner participant’s views, rather than their lived experience.
• Participants may not be able to express themselves articulately enough due to language barriers, cognition, age, or other factors.
• Gathering data and data analysis may be time consuming and laborious.
• Results require interpretation without researcher bias.
• Does not produce easily generalisable data.

Example questions

• How do cancer patients cope with a terminal diagnosis?
• What is it like to survive a plane crash?
• What are the experiences of long-term carers of family members with a serious illness or disability?
• What is it like to be trapped in a natural disaster, such as a flood or earthquake? 

Example studies

• The patient-body relationship and the "lived experience" of a facial burn injury: a phenomenological inquiry of early psychosocial adjustment . Individual interviews were carried out for this study.
• The use of group descriptive phenomenology within a mixed methods study to understand the experience of music therapy for women with breast cancer . Example of a study in which focus group interviews were carried out.
• Understanding the experience of midlife women taking part in a work-life balance career coaching programme: An interpretative phenomenological analysis . Example of a study using action research.
• Holloway, I. & Galvin, K. (2017). Qualitative research in nursing and healthcare (Fourth ed.): John Wiley & Sons Inc.
• Rodriguez, A., & Smith, J. (2018). Phenomenology as a healthcare research method . Journal of Evidence Based Nursing , 21(4), 96-98. doi: 10.1136/eb-2018-102990
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• Next: Grounded theory >>
• Last Updated: Apr 8, 2024 11:12 AM
• URL: https://deakin.libguides.com/qualitative-study-designs

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Phenomenology

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Phenomenology helps us to understand the meaning of people's lived experience.  A phenomenological study explores what people experienced and focuses on their experience of a phenomenon.  As phenomenology has a strong foundation in philosophy, it is recommended that you explore the writings of key thinkers such as Husserl, Heidegger, Sartre and Merleau-Ponty before embarking on your research. Duquesne's Simon Silverman Phenomenology Center maintains a collection of resources connected to phenomenology as well as hosting lectures, and is a good place to start your exploration.

• Simon Silverman Phenomenology Center
• Husserl, Edmund, 1859–1938
• Heidegger, Martin, 1889–1976
• Sartre, Jean Paul, 1905–1980
• Merleau-Ponty, Maurice, 1908–1961

Books and eBooks

Online Resources

• Phenomenology Stanford Encyclopedia of Philosophy entry.

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• Last Updated: Aug 18, 2023 11:56 AM
• URL: https://guides.library.duq.edu/qualitative_research

• Open access
• Published: 27 April 2024

Exploring health care providers’ engagement in prevention and management of multidrug resistant Tuberculosis and its factors in Hadiya Zone health care facilities: qualitative study

• Bereket Aberham Lajore 1   na1   nAff5 ,
• Yitagesu Habtu Aweke 2   na1   nAff6 ,
• Samuel Yohannes Ayanto 3   na1   nAff7 &
• Menen Ayele 4   nAff5  

BMC Health Services Research volume  24 , Article number:  542 ( 2024 ) Cite this article

42 Accesses

Metrics details

Engagement of healthcare providers is one of the World Health Organization strategies devised for prevention and provision of patient centered care for multidrug resistant tuberculosis. The need for current research question rose because of the gaps in evidence on health professional’s engagement and its factors in multidrug resistant tuberculosis service delivery as per the protocol in the prevention and management of multidrug resistant tuberculosis.

The purpose of this study was to explore the level of health care providers’ engagement in multidrug resistant tuberculosis prevention and management and influencing factors in Hadiya Zone health facilities, Southern Ethiopia.

Descriptive phenomenological qualitative study design was employed between 02 May and 09 May, 2019. We conducted a key informant interview and focus group discussions using purposely selected healthcare experts working as directly observed treatment short course providers in multidrug resistant tuberculosis treatment initiation centers, program managers, and focal persons. Verbatim transcripts were translated to English and exported to open code 4.02 for line-by-line coding and categorization of meanings into same emergent themes. Thematic analysis was conducted based on predefined themes for multidrug resistant tuberculosis prevention and management and core findings under each theme were supported by domain summaries in our final interpretation of the results. To maintain the rigors, Lincoln and Guba’s parallel quality criteria of trustworthiness was used particularly, credibility, dependability, transferability, confirmability and reflexivity.

Total of 26 service providers, program managers, and focal persons were participated through four focus group discussion and five key informant interviews. The study explored factors for engagement of health care providers in the prevention and management of multidrug resistant tuberculosis in five emergent themes such as patients’ causes, perceived susceptibility, seeking support, professional incompetence and poor linkage of the health care facilities. Our findings also suggest that service providers require additional training, particularly in programmatic management of drug-resistant tuberculosis.

The study explored five emergent themes: patient’s underlying causes, seeking support, perceived susceptibility, professionals’ incompetence and health facilities poor linkage. Community awareness creation to avoid fear of discrimination through provision of support for those with multidrug resistant tuberculosis is expected from health care providers using social behavioral change communication strategies. Furthermore, program managers need to follow the recommendations of World Health Organization for engaging healthcare professionals in the prevention and management of multidrug resistant tuberculosis and cascade trainings in clinical programmatic management of the disease for healthcare professionals.

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Introduction

Mycobacterium tuberculosis, the infectious agent that causes multi-drug resistant tuberculosis (MDR-TB), is resistant to at least rifampicin and isoniazid. Direct infection can cause the disease to spread, or it can develop secondary to improper management of tuberculosis among drug susceptible tuberculosis cases and associated poor adherence [ 1 ].

Multidrug-resistant strains of mycobacterium tuberculosis have recently emerged, which makes achieving “End TB Strategy” more difficult [ 2 ]. Multi drug resistant tuberculosis (MDR-TB) has been found to increasingly pose a serious threat to global and Ethiopian public health sector. Despite the fact that a number of risk factors for MDR-TB have been identified through various research designs, the epidemiology of this disease is complex, contextual, and multifaceted [ 1 ]. Quantitative studies demonstrate that prior treatment history [ 3 , 4 , 5 , 6 , 7 ], interrupted drug supply [ 8 ], inappropriate treatments and poor patient compliance [ 3 , 7 , 9 ], poor quality directly observed treatment short course (DOTS), poor treatment adherence [ 10 ], age [ 5 ], and malnutrition [ 11 ] were factors associated with multi drug resistant TB.

Globally, an estimated 20% of previously treated cases and 3.3% of new cases are thought to have MDR-TB; these levels have essentially not changed in recent years. Globally, 160,684 cases of multidrug-resistant TB and rifampicin-resistant TB (MDR/RR-TB) were notified in 2017, and 139,114 cases were enrolled into treatment in 2017 [ 12 ]. A systematic review in Ethiopia reported 2% prevalence of MDR-TB [ 3 ] that is higher than what is observed in Sub-Saharan Africa, 1.5% [ 13 ]. The prevalence of MDR-TB, according to the national drug-resistant tuberculosis (DR-TB) sentinel report, was 2.3% among newly diagnosed cases of TB and 17.8% among cases of TB who had already received treatment,. This suggests a rising trend in the prevalence of TB drug resistance compared to the results of the initial drug-resistant TB survey carried out in Ethiopia from 2003 to 2005 [ 14 ].

Ethiopia has placed strategies into place that emphasize political commitment, case finding, appropriate treatment, a continuous supply of second-line anti-TB medications of high quality, and a recording system. Due to other competing health priorities, the nation is having difficulty accelerating the scale-up of the detection, enrollment and treatment of drug-resistant TB patients [ 15 , 16 ]. To address these issues, the nation switched from a hospital-based to a clinic-based ambulatory model of care, which has allowed MDR-TB services to quickly decentralize and become more accessible. Accordingly, the nation has set up health facilities to act as either treatment initiating centers (TIC) or treatment follow-up centers (TFC) or both for improved referral and communication methods [ 15 ].

One of the key components of the “End TB strategy” is engagement of health care professionals in the prevention and management of multidrug resistant tuberculosis [ 17 ]. Inadequate engagement of healthcare providers is one aspect of the healthcare system that negatively influences MDR-TB prevention and control efforts [ 17 ]. This may be manifested in a number of ways, including inadequate understanding of drug-resistant tuberculosis, improper case identification, failure to initiate treatment again, placement of the wrong regimens, improper management of side effects and poor infection prevention [ 1 ]. These contributing factors are currently being observed in Ethiopia [ 18 ], Nigeria [ 7 , 19 , 20 ] and other countries [ 21 , 22 ]. According to a study conducted in Ethiopia, MDR-TB was linked to drug side effects from first-line treatments, being not directly observed, stopping treatment for at least a day, and retreating with a category II regimen [ 17 ].

This may be the result of a synergy between previously investigated and other contextual factors that have not yet been fully explored, such as professional engagement, beliefs, and poor preventive practices. The engagement of health professionals in MDR-TB prevention and control is assessed using a number of composite indicators. Health professionals may interact primarily inside the healthcare facilities. Typically, they play a significant role in connecting healthcare services with neighborhood-based activities [ 17 ]. One of the main research areas that have not sufficiently addressed is evidence indicating the status of healthcare professionals’ engagement and contextual factors in MDR-TB prevention and management.

It is increasingly urgent to identify additional and existing factors operating in a particular context that contribute to the development of the disease in light of the epidemic of drug resistance, including multi-drug resistance (MDR-TB) and extensively drug resistant TB (XDR-TB) in both new and previously treated cases of the disease [ 23 ]. In order to develop and implement control measures, it is therefore essential to operationally identify a number of contextual factors operating at the individual, community, and health system level.

Therefore, the overall purpose of this study was to explore the level of engagement of health care providers and contextual factors hindering/enabling the prevention and provision of patient-centered care for MDR-TB in health facilities, DOTS services centers and MDR-TB treatment initiation center [TIC], in Hadiya Zone, Southern Ethiopia.

Qualitative approach and research paradigm

Descriptive phenomenological qualitative study design was employed to explore factors influencing engagement of health professionals in MDR-TB prevention and management and thematic technique was employed for the analysis of the data.

Researchers’ characteristics and reflexivity

Three Principal investigators conducted this study. Two of them had Masters of public health in Epidemiology and Reproductive health and PhD candidates and the third one had Bachelor’s degree in public health with clinical experience in the area of Tuberculosis prevention and management and MPH in Biostatistics. The principal investigators have research experience with published articles in different reputable journals. There were no prior contacts between researchers and participants before the study whereas researchers have built positive rapport with study participants during data collection to foster open communication and trust and had no any assumptions and presuppositions about the research topic and result.

Context/ study setting and period

The study was conducted between 2 and 9 May, 2019 in Hadiya Zone with more than 1.7 million people residing in the Zone. There are 300 health posts, 63 health centers, 3 functional primary hospitals and 1 comprehensive specialized hospital in the Zone. Also, there are more than 350 private clinics and 1 private hospital in the Zone. All of the public health facilities and some private health facilities provide directly observed short course treatment (DOTS) service for tuberculosis patients. There are more than eight treatment initiation centers (TICs) for MDR-TB patients in Hadiya Zone. MDR-TB (Multidrug-resistant tuberculosis) treatment initiation centers are specialized facilities that provide comprehensive care, diagnosis and treatment initiation, psychosocial support, and follow up services to individuals with MDR-TB. The linkage between MDR-TB treatment initiation centers and other healthcare facilities lies in the coordination of care, referral pathways, and collaboration to ensure comprehensive and integrated care for individuals with MDR-TB. Overall, healthcare providers play a crucial role in the management of MDR-TB by providing specialized care, ensuring treatment adherence, monitoring progress and outcomes, and supporting individuals in achieving successful treatment outcomes and improved health.

Units of study and sampling strategy

Our study participants were health care professionals working in MDR-TB TICs in both private and public health facilities, and providing DOTS services, MDR-TB program leaders in treatment initiation centers, as well as TB focal persons, disease prevention and health promotion focal person, and project partners from district health offices. The study involved four focus group discussion (FGDs) and five key informants’ interview (KII) with a total of 26 participants to gather the necessary information. Expert purposive sampling technique was employed and sample size was determined based on the saturation of idea required during data collection process.

Data collection methods and instruments

Focus group discussion and face to face key informants’ interviews were employed to collect the data. We conducted a total of four FGD and five key informants’ interviews with participants chosen from DOTS providing health facilities and MDR-TB program leaders in treatment initiation centers, as well as TB focal persons and project partners from district health offices and disease prevention and health promotion focal person. One of the FGDs was conducted among health professionals from the public MDR-TB treatment initiation centers. Three FGDs were conducted among disease prevention and health promotion focal persons, TB focal persons and DOTS providers in public health facilities (health centers).

An observation checklist was developed to assess the general infection prevention and control measures used by specific healthcare facilities in the study area. We used unstructured FGD guide, key informant interview guide, observation checklist and audio recorders to collect primary data and it was collected using local language called Amharic. Prior to data collection, three people who are not among principal investigators with at least a master’s degree in public health and prior experience with qualitative research were trained by principal investigators. Three of them acts as a tape recorder, a moderator, and as a note taker alternatively. The length of FGD ranged from 58 to 82 min and that of key informants’ interview lasted from 38 to 56 min.

Data processing and data analysis

Memos were written immediately after interviews followed by initial analysis. Transcription of audio records was performed by principal investigators. The audio recordings and notes were refined, cleaned and matched at the end of each data collection day to check for inconsistencies, correct errors, and modify the procedures in response to evolving study findings for subsequent data collection. Transcribed interviews, memos, and notes from investigator’s observation were translated to English and imported to Open Code 4.02 [ 2 ] for line by line coding of data, and categorizing important codes (sub theming). The pre-defined themes for MDR-TB prevention and control engagement were used to thematize the line-by-line codes, categories, and meanings using thematic analysis. Finally, the phenomenon being studied was explained by emerging categories and themes. Explanations in themes were substantiated by participants’ direct quotations when necessary.

Trustworthiness

Phone calls and face to face briefing were requested from study participants when some expressions in the audio seems confusing while transcripts were performed. To ensure the credibility of the study, prolonged engagement was conducted, including peer debriefing with colleagues of similar status during data analysis and inviting available study participants to review findings to ensure as it is in line with their view or not. Memos of interviews and observation were crosschecked while investigator was transcribing to ensure credibility of data as well as to triangulate investigator’s categorizing and theming procedures. For transferability, clear outlines of research design and processes were provided, along with a detailed study context for reader judgment. Dependability was ensured through careful recording and transcription of verbal and non-verbal data, and to minimize personal bias, scientific procedures were followed in all research stages. Conformability was maintained by conducting data transcription, translation, and interpretation using scientific methods. Researchers did all the best to show a range of realities, fairly and faithfully. Finally, an expert was invited to put sample of codes and categories to emerged corresponding categories and themes respectively.

Demographic characteristics of study participants

Four focus group discussions and five key informants’ interviews were conducted successfully. There were 26 participants in four focus group discussions, and key informants’ interview. Ages of participants ranges from 20 to 50 years with an average age of 33.4  ±  6.24 SD years. Participants have five to ten years of professional experience with DOTS services (Table  1 ).

Emergent themes and subthemes

The study explored how health care providers’ engagement in MDR-TB prevention and management was influenced. The investigation uncovered five major themes. These themes were the patient’s underlying causes, seeking support, perceived susceptibility, healthcare providers’ incompetence, and poor linkage between health facilities. Weak community TB prevention, health system support, and support from colleagues were identified subthemes in the search for help by health professionals whereas socioeconomic constraints, lack of awareness, and fear of discrimination were subthemes under patients underlying factors (Fig.  1 ).

Themes and subthemes emerged from the analysis of health professionals’ engagement in MDR-TB prevention and management study in Hadiya zone’s health facilities, 2019

The patient’s underlying causes

This revealed why TB/MDR-TB treatment providers believe health professionals are unable to provide standard MDR-TB services. The subthemes include TB/MDR-TB awareness, fear of discrimination, and patients’ socioeconomic constraints.

Socioeconomic constraints

According to our research, the majority of healthcare professionals who provided directly observed short-course treatment services mentioned socioeconomic constraints as barriers to engage per standard and provide MDR-TB prevention and management service. More than half of the participants stated that patients’ primary reasons include lack of money for house rental close to the treatment centers, inability to afford food and other expenses, and financial constraints to cover transportation costs.

In addition to this, patients might have additional responsibilities to provide food and cover other costs for their families’ need. The majority of health care professionals thought that these restrictions led to their poor engagement in MDR-TB prevention and management. One of the focus groups’ discussants provided description of the scenario in the following way:

“…. I have many conversations with my TB/MDR-TB patients. They fail to complete DOTS or treatment intensive care primarily as a result of the requirement of prolonged family separation. They might provide most of the family needs, including food and other expenses” (FGD-P01).

Lack of awareness about MDR-TB

This subtheme explains how MDR-TB patients’ knowledge of the illness can make it more difficult for health professionals to provide DOTS or TICs services. The majority of DOTS providers stated that few TB or MDR-TB patients were aware of how MDR-TB spreads, how it is treated, and how much medication is required. Additionally, despite the fact that they had been educated for the disease, majority of patients did not want to stop contact with their families or caregivers. A health care provider stated,

“…. I provided health education for MDR-TB patients on how the disease is transmitted and how they should care for their family members. They don’t care; however, give a damn about their families .” (FGD-P05).

Some healthcare professionals reported that some patients thought that MDR-TB could not be cured by modern medication. One medical professional described the circumstance as follows:

“…. I noticed an MDR-TB patient who was unwilling to be screened. He concluded that modern medication is not effective and he went to spiritual and traditional healers” (FGD-P02).

As a result, almost all participants agreed on the extent to which patient knowledge of TB and MDR-TB can influence a provider’s engagement to MDR-TB services. The majority suggested that in order to improve treatment outcomes and preventive measures, the media, community leaders, health development armies, one-to-five networks, non-governmental organizations, treatment supporters, and other bodies with access to information need to put a lot of efforts.

Fear of discrimination

According to our research, about a quarter of healthcare professionals recognized that patients’ fear of discrimination prevents them from offering MDR-TB patients the DOTS services they need, including counseling index cases and tracing contact histories.

HEWs, HDAs, and 1-to-5 network members allegedly failed to monitor and counsel the index cases after their immediate return to their homes, according to the opinions from eight out of twenty-six healthcare professionals. The patients began to engage in routine social and political activities with neighbors while hiding their disease status. A healthcare professional described this situation as follows:

“…. I understood from my MDR-TB patient’s words that he kept to himself and avoided social interaction. He made this decision as a result of stigmatization by locals, including health extension workers. As a result, the patient can’t attend social gatherings. …. In addition, medical professionals exclude MDR-TB patients due to fear of exposures. As a result, patients are unwilling to undergo early screening” (FGD-P04).

Professionals’ perceived risk of occupational exposure

This theme highlights the anxiety that healthcare workers experience because of MDR-TB exposure when providing patient care. Our research shows that the majority of health professionals viewed participation as “taking coupons of death.” They believed that regardless of how and where they engaged in most healthcare facilities, the risk of exposure would remain the same. According to our discussion and interview, lack of health facility’s readiness takes paramount shares for the providers’ risk of exposures and their susceptibility.

According to the opinion from the majority of FGD discussants and in-depth interviewees, participants’ self-judgment score and our observation, the majority of healthcare facilities that offer DOTS for DS-TB and MDR-TB did not create or uphold standards in infection prevention in the way that could promote better engagement. These include poor maintenance of care facilities, lack of personal protective equipment, unsuitable facility design for service provision, lack of patient knowledge regarding the method of MDR-TB transmission, and lack of dedication on the part of health care staff.

As one of our key informant interviewees [District Disease Prevention Head], described health professionals’ low engagement has been due to fear of perceived susceptibility. He shared with us what he learned from a community forum he moderated.

Community forum participant stated that “… There was a moment a health professional run-away from the TB unit when MDR-TB patient arrived. At least they must provide the necessary service, even though they are not willing to demonstrate respectful, compassionate, or caring attitude to MDR-TB patients” (KII-P01). Besides , one of the FGD discussants described the circumstance as follows:

“…. Emm…. Because most health facilities or MDR-TB TIC are not standardized, I am concerned about the risk of transmission. They are crammed together and poor ventilation is evident as well as their configuration is improper. Other medical services are causing the TICs to become overcrowded. Most patients and some medical professionals are unconcerned with disease prevention ” (FGD-P19).

Participants’ general fear of susceptibility may be a normal psychological reaction and may serve as a motivation for taking preventative actions. However, almost all participants were concerned that the main reasons for their fear were brought up by the improper application of programmatic management and MDR-TB treatment standards and infection prevention protocols in healthcare facilities.

Health care providers’ incompetence

This theme illustrates how professionalism and dedication impact participation in MDR-TB prevention and management. The use of DS-TB prevention and management by health professionals was also taken into account because it is a major factor in the development of MDR-TB. This theme includes the participants’ perspectives towards other healthcare workers involved in and connected to MDR-TB.

Nearly all of the participants were aware of the causes and danger signs of MDR-TB. The majority of the defined participants fit to the current guidelines. However, participants in focus groups and key informant interviews have brought up shortcomings in MDR-TB service delivery practice and attitude. We looked at gaps among healthcare professionals’ knowledge, how they use the national recommendations for programmatic management and prevention of MDR-TB, prevent infections, take part in community MDR-TB screenings, and collaborate with other healthcare professionals for better engagement.

More than half of the participants voiced concerns about their attitudes and skill sets when using MDR-TB prevention and management guideline. When asked about his prior experiences, one of the focus group participants said:

“…. Ok, let me tell you my experience, I was new before I attended a training on MDR-TB. I was unfamiliar with the MDR-TB definition given in the recommendations. When I was hired, the health center’s director assigned me in the TB unit. I faced difficulties until I received training” (FGD-P24). Furthermore , one of the key informant interview participants shared a story: “…. In my experience, the majority of newly graduated health professionals lack the required skill. I propose that pre-service education curricula to include TB/MDR-TB prevention and management guideline trainings” (KII-P01).

The majority of participants mentioned the skill gap that was seen among health extension workers and laboratory technicians in the majority of healthcare facilities. Some of the participants in the in-depth interviews and FGD described the gaps as follows:

“…. According to repeated quality assurance feedbacks, there are many discordant cases in our [ District TB Focal Person ] case. Laboratory technicians who received a discrepant result (KII-P01) are not given training which is augmented by shared story from FGD discussants, “According to the quality assurance system, laboratory technicians lack skill and inconsistent results are typical necessitating training for newly joining laboratory technicians” (FGD-P20).

Through our discussions, we explored the level of DOTS providers’ adherence to the current TB/MDR-TB guideline. As a result, the majority of participants pointed out ineffective anti-TB management and follow-up care. One of the participants remembered her practical experience as follows:

“…. In my experience, the majority of health professionals fail to inform patients about the drug’s side effects, follow-up procedures, and other techniques for managing the burden of treatment. Only the anti-TB drug is provided, and the patient is left alone. The national treatment recommendation is not properly implemented by them” (FGD-P04).

Many barriers have been cited as reasons that might have hindered competencies for better engagement of health professionals. Training shortage is one of the major reasons mentioned by many of the study participants. One of discussants from private health facility described the problem as

“…. We are incompetent, in my opinion. Considering that we don’t attend update trainings. Many patients who were diagnosed negative at private medical facilities turned out to be positive, and vice versa which would be risky for drug resistance” (FGD-P14) which was supported by idea from a participant in our in-depth interview: “…. We [Program managers] are running short of training for our health care providers at different health centers and revealed that four out of every five healthcare professionals who work in various health centers are unaware of the TB/MDR-TB new guideline” (KII-P02).

Seeking support

This theme focuses on the significance and effects of workplace support in the engagement of MDR-TB prevention and control. This also explains the enabling and impeding elements in the engagement condition of health professionals. Three elements make up the theme: coworkers (other health professionals) in the workplace, support from community TB prevention actors, and a healthcare system.

Support from community TB prevention actors

This subtheme includes the assistance provided to study participants by important parties such as community leaders, the health development army, and other stakeholders who were involved in a community-based TB case notification, treatment adherence, and improved patient outcomes.

Many of the study participants reported that health extension workers have been poorly participating in MDR-TB and TB-related community-based activities like contact tracing, defaulter tracing, community forums, health promotion, and treatment support. One study participant described their gap as follows:

“…. I understood that people in the community were unaware of MDR-TB. The majority of health extension workers do not prioritize raising community awareness of MDR-TB” (FGD-P13). This was supported by idea from a district disease prevention head and stated as: “…. There is no active system for contacts tracing. Health educators send us information if they find suspected cases. However, some patients might not show up as expected. We have data on three family members who tested positive for MDR-TB” (KII-P3).

Support from a health system

The prime focus of this subtheme is on the enabling elements that DOTS providers require assistance from the current healthcare system for better engagement. All study participants expressed at least two needs to be met from the health system in order for them to effectively participate in MDR-TB prevention, treatment, and management. All study participants agreed that issues with the health system had a negative impact on their engagement in the prevention, treatment, diagnosis, and management of MDR-TB in almost all healthcare facilities. Poor conditions in infrastructure, resources (supplies, equipment, guidelines, and other logistics), capacity building (training), supportive supervision, establishment of public-private partnerships, and assignment of motivated and trained health professionals are some of the barriers that needs to be worked out in order to make them engage better. One of the participants pronounces supplies and logistics problems as:

“…. The health center I worked in is listed as a DOTS provider. However, it lacks constant electricity, a working microscope, lab supplies, medications, etc, and we refer suspected cases to nearby health centers or district hospitals for AFB-examination and, “Sometimes we use a single kit for many patients and wait for the medication supply for three or more weeks and patients stops a course of therapy that might induce drug resistance” (FGD-PI04) which was augmented by statement from FGD participant who works at a treatment initiation center: “…. We faced critical shortage of supplies and hospital administrators don’t care about funding essential supplies for patient care. For instance, this hospital (the hospital in which this FGD was conducted) can easily handle N-95 masks. Why then they (hospital administrators working in some TIC) can’t do it?” (FGD-P18).”

Regarding in-service training on MDR-TB, almost all participants pointed out shortage of on-job training mechanisms. One of our FGD participants said:

“…. I missed the new training on MDRTB programmatic management guidelines. I’ve heard that new updates are available. I still work using the old standard” (FGD-PI05). A health professional working in private clinic heightens the severity of training shortage as: “…. We have not participated in TB/MDR-TB guidelines training. You know, most of for-profit healthcare facilities do not provide any training for their staff. I’m not sure if I’m following the (TB/MDR-TB) guideline” (FGD-P14). One of our key informant interview participants; MDR-TB center focal person suggested the need for training as: “…. I’ve received training on the MDR-TB services and public-private partnership strategy. It was crucial in my opinion for better engagement. It is provided for our staff [MDRTB center focal person]. However, this has not yet been expanded to other health facilities” (KII-P04).

Concerning infrastructures, transportation problem was one of the frequently mentioned obstacles by many participants that hinder engagement in MDR-TB/TB service. This factor had a negative impact to both sides (health professionals and patients). One of discussants said:

“…. I face obstacles such as transport cost to perform effective TB/MDR-TB outreach activities like health education, tracing family contacts and defaulters and community mobilization. Rural kebeles are far apart from each other. How can I support 6 rural Kebeles?” (FGD-P01). One of the participants; MDR-TB treatment centers supervisor/program partner seconded the above idea as: “…. I suggest government must establish a system to support health professionals working in remote health care facilities in addition to MDR-TB centers. I guess there are more than 30 government health centers and additional private clinics. We can’t reach them all due to transportation challenges” (KII-P05). One of the participants , a district disease prevention head added: “…. Our laboratory technicians take sample from MDR-TB suspects to the post office and then, the post office sends to MDR-TB site. Sometimes, feedback may not reach timely. There is no any system to cover transportation cost. That would make case detection challenging” (FGD-P02).

Support from colleagues

Study participants stated the importance of having coworker with whom they could interconnect. However, eight participants reported that they were discriminated by their workmates for various reasons, such as their perceived fear of exposure to infection and their perception as if health professionals working in TB/MDR-TB unit get more training opportunities and other incentives. One of the focus group discussants said:

“…. My colleagues [health professional working out of MDR-TB TICs] stigmatize us only due to our work assignment in MDR-TB clinic. I remember that one of my friends who borrowed my headscarf preferred to throw it through a window than handing-over it back safely. Look, how much other health professionals are scared of working in MDR-TB unit. This makes me very upset. I am asking myself that why have I received such training on MDR-TB?” (FGD-P04).

Some of the participants also perceived that, health professionals working in MDR-TB/TB unit are the only responsible experts regarding MDR-TB care and treatment. Because, other health professionals consider training as if it is an incentive to work in such units. One of the FGD discussants described:

“… Health professionals who work in other service units are not volunteer to provide DOTS if TB focal person/previously trained staffs are not available. Patients wait for longer time” (FGD-P11).

Health facilities’ poor linkage

This theme demonstrates how various healthcare facilities, including private and public healthcare facilities such as, health posts, health care centers and hospitals, and healthcare professionals working at various levels of the healthcare system in relation to TB/MDR-TB service, are inter-linked or communicating with one another.

Many study participants noted a lack of coordination between higher referral hospitals, TB clinics, health posts, and health centers. Additionally, the majority of the assigned healthcare professionals had trouble communicating with patients and their coworkers. A focus group discussant also supported this idea as

“…. There is a lack of communication between us [DOTS providers at treatment initiation centers] and health posts, health centers, and private clinics. We are expected to support about 30 public health facilities. It’s of too much number, you know. They are out of our reach. We only took action when a problem arose” (FGD-P16).

Significant number of participants had raised the problem of poor communication between health facilities and treatment initiation centers. One of the interviewees [program manager] said:

“…. I see that one of our challenges is the weak referral connections between treatment initiation centers and health centers. As a result, improper sample transfer to Gene- Xpert sites and irregular postal delivery are frequent” . “Our; DOTS staff at the MDR-TB center, DOTS staff at the health center, and health extension workers are not well connected to one another. Many patients I encountered came to this center [MDR-TB center] after bypassing both health post and health center. Poor linkage and communication, in my opinion, could be one of the causes. The same holds true for medical facilities that are both public and private ” (KII-P02).

Engagement of individual healthcare providers is one of the peculiar interventions to achieve the goal of universal access to drug resistance tuberculosis care and services [ 17 ]. Healthcare providers engagement in detecting cases, treating and caring for multidrug resistant tuberculosis (MDR-TB) may be influenced by various intrinsic (individual provider factors) and extrinsic (peer, health system, political and other factors) [ 15 ]. Our study explored engagement of individual DOTS providers and factors that influence their engagement in MDR-TB prevention and management service. This is addressed through five emergent themes and subthemes as clearly specified in our results section.

The findings showed patients’ socioeconomic constraints were important challenges that influence health professionals’ engagement, and provision of MDR-TB prevention and management services. Although approaches differ, studies in Ethiopia [ 24 ], South Africa [ 25 ] and India [ 26 , 27 ] documented that such factors influence health providers’ engagement in the prevention and management of multi drug resistant tuberculosis. Again, the alleviation of these factors demands the effort from patients, stakeholders working on TB, others sectors, and the healthcare system so that healthcare providers can deliver the service more effectively in their day-to-day activities and will be more receptive to the other key factors.

We explored participants’ experiences on how patients’ awareness about drug sensitive or multi drug resistant tuberculosis influenced their engagement. Accordingly, participants encountered numerous gaps that restricted their interactions with TB/MDR-TB patients. In fact, our study design and purposes vary, studies [ 28 , 29 , 30 ] indicated that patients awareness influenced providers decision in relation to MDR-TB services and patients’ awareness status is among factors influencing healthcare providers’ decision making about the care the MDR-TB patient receives. As to our knowledge, patients’ perceived fear of discrimination was not documented whether it had direct negative impact on reducing providers’ engagement. Therefore, patients’ awareness creation is an important responsibility that needs to be addressed by the community health development army, health extension workers, all other healthcare providers and stakeholder for better MDR-TB services and patient outcomes.

Our study indicates that healthcare providers perceived that they would be exposed to MDR-TB while they are engaged. Some of the participants were more concerned about the disadvantages of engagement in providing care to MDR-TB patients which were predominantly psychological and physical pressure. In this context, the participants emphasized that engagement in MDR-TB patient care is “always being at risk” and expressed a negative attitude. This finding is similar to what has been demonstrated in a cross-sectional study conducted in South Africa in which majority of healthcare providers believed their engagement in MDR-TB services would risk their health [ 21 ].

However, majority of the healthcare providers demonstrated perceived fear of exposures mainly due to poor infection prevention practices and substandard organization of work environment in most TB/MDR-TB units. This is essentially reasonable fear, and needs urgent intervention to protect healthcare providers from worsening/reducing their effective engagement in MDR-TB patient care. On the other side of the coin, perceived risk of occupational exposure to infection could be source for taking care of oneself to combat the spread of the infection.

In our study, healthcare provider’s capability (competence) also had an impact on their ability to engage in prevention and management of MDR-TB. Here, participants had frequently raised their and other healthcare providers’ experience regarding skill gaps, negative attitude towards the service unit they were working in, ineffective use of MDR-TB guideline, poor infection prevention practices and commitment. In addition, many health professionals report serious problems regarding case identification and screening, drug administration, and side effect management. These findings were supported by other studies in Ethiopia [ 7 ] and in Nigeria [ 19 , 20 ]. This implies an urgent need for training of health care worker on how to engage in prevention and management of multidrug resistant TB.

Moreover, our findings provide insights into the role of community TB prevention actors, currently functioning health system, and colleagues and other stakeholders’ regarding healthcare providers’ engagement. Participants emphasized that support from community TB prevention actors is a key motivation to effectively engage on management and prevention roles towards MDR-TB. Evidence shows that community TB prevention is one of the prominent interventions that study participants would expect in DOTS provision as community is the closest source of information regarding the patients [ 31 , 32 ].

Similarly, all participants had pointed out the importance of support from a health system directly or indirectly influence their engagement in the prevention, diagnosis, treatment, and management of MDR-TB. Researches indicated that health system supports are enabling factors for healthcare providers in decision making regarding TB/MDR-TB prevention and treatment [ 33 ]. This problem is documented by the study done in Ethiopia [ 22 ]. In addition, support from colleagues and other stakeholders was also a felt need to engage in MDR-TB which was supported by the World Health Organization guideline which put engagement in preventing MDR-TB and providing patients centered care needs collaborative endeavor among healthcare providers, patients, and other stakeholders [ 17 ].

Participants showed that there were poor linkage among/within DOTS providers working in health post (extension workers), health centers, hospitals and MDRTB treatment initiation centers. Our finding is consistent with a research in South Africa which shows poor health care attitude is linked to poor treatment adherence [ 34 ]. Our study implies the need for further familiarization especially on clinical programmatic management of drug resistant tuberculosis. Moreover, program managers need to follow health professionals’ engagement approaches recommended by the World Health Organization: End TB strategy [ 17 ].

Limitations of the study

There are some limitations that must be explicitly acknowledged. First, participants from private health facilities were very few, which might have restricted the acquisition and incorporation of perspectives from health care providers from private health care facilities. Second, healthcare providers’ engagement was not measured from patient side given that factors for engagement may differ from what has been said by the healthcare provides. Third, power relationships especially among focus group discussant in MDR-TB treatment initiation centers might have influenced open disclosures of some sensitive issues.

The study showed how healthcare provider’s engagement in MDR-TB management and prevention was influenced. Accordingly, patient’s underlying causes, seeking support, perceived occupational exposure, healthcare provider’s incompetence and health facilities poor linkage were identified from the analysis. Weak community TB prevention efforts, poor health system support and support from colleagues, health care providers’ incompetence and health facilities poor linkage were among identified factors influencing engagement in MDR – TB prevention and management. Therefore, measures need to be in place that avert the observed obstacles to health professionals’ engagement including further quantitative studies to determine the effects of the identified reasons and potential factors in their engagement status.

Furthermore, our findings pointed out the need for additional training of service providers, particularly in clinical programmatic management of drug-resistant tuberculosis. Besides, program managers must adhere to the World Health Organization’s recommendations for health professional engagement. Higher officials in the health sector needs to strengthen the linkage between health facilities and service providers at different levels. Community awareness creation to avoid fear of discrimination including provision of support for those with MDR-TB is expected from health experts through implementation of social behavioral change communication activities.

Abbreviations

Directly observed treatment short-course

Drug susceptible tuberculosis

Millennium development goals

Multidrug resistant tuberculosis

Sustainable development goals

Tuberculosis

Treatment initiation center

World Health Organization

Extensively drug resistant TB

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Acknowledgements

We would like to acknowledge Hosanna College of Health Sciences Research and community service directorate for providing us the opportunity and necessary fund to conduct this research. Our appreciation also goes to heads of various health centers, hospitals, district health and Hadiya Zone Health office for unreserved cooperation throughout data collection.

The authors declare that this study received funding from Hosanna College of Health Sciences. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

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Bereket Aberham Lajore & Menen Ayele

Present address: Hossana College of Health Sciences, Hosanna, SNNPR, Ethiopia

Yitagesu Habtu Aweke

Present address: College of Health Sciences, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia

Samuel Yohannes Ayanto

Present address: College of Health Sciences, Institute of Public Health, Department of -Population and Family Health, Jimma University, Jimma, Ethiopia

Bereket Aberham Lajore, Yitagesu Habtu Aweke and Samuel Yohannes Ayanto contributed equally to this work.

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Department of Family Health, Hossana College of health sciences, Hossana, Ethiopia

Bereket Aberham Lajore

Department of Health informatics, Hossana College of Health Sciences, Hossana, Ethiopia

Department of Midwifery, Hossana College of Health Sciences, Hossana, Ethiopia

Department of Clinical Nursing, Hossana College of Health Sciences, Hossana, Ethiopia

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Bereket Aberham Lajore, Yitagesu Habtu Aweke, and Samuel Yohannes Ayanto conceived the idea and wrote the proposal, participated in data management, analyzed the data and drafted the paper and revised the analysis and subsequent draft of the paper. Menen Ayele revised and approved the proposal, revised the analysis and subsequent draft of the paper. Yitagesu Habtu and Bereket Aberham Lajore wrote the main manuscript text and prepared all tables. All authors reviewed and approved the final manuscript.

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Ethical approval was obtained from Institutional review board [IRB] of Hossana College of health sciences after reviewing the protocol for ethical issues and provided a formal letter of permission to concerned bodies in the health system. Accordingly, permission to conduct this study was granted by respective health facilities in Hadiya zone. Confidentiality of the information was assured and participants’ autonomy not to participate or to opt-out at any stage of the interview were addressed. Finally, informed consent was obtained from the study participants after detailed information.

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Lajore, B.A., Aweke, Y.H., Ayanto, S.Y. et al. Exploring health care providers’ engagement in prevention and management of multidrug resistant Tuberculosis and its factors in Hadiya Zone health care facilities: qualitative study. BMC Health Serv Res 24 , 542 (2024). https://doi.org/10.1186/s12913-024-10911-6

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Factors influencing the development of nursing professionalism: a descriptive qualitative study

• Xingyue He 1 ,
• Huili Cao 2 ,
• Linbo Li 1 ,
• Yanming Wu 1 &
• Hui Yang 1 , 3  

BMC Nursing volume  23 , Article number:  283 ( 2024 ) Cite this article

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The shortage of nurses threatens the entire healthcare system, and nursing professionalism can improve nurse retention and enhance the quality of care. However, nursing professionalism is dynamic, and the factors influencing its development are not fully understood.

A qualitative descriptive study was conducted. Using maximum variation and purposive sampling, 14 southern and northern China participants were recruited. Semi-structured interviews were conducted from May 2022 to August 2023 in face-to-face conversations in offices in the workplace or via voice calls. The interviews were transcribed verbatim and analyzed via thematic analysis.

Three main themes emerged: (1) nourishment factors: promoting early sprouting; (2) growth factors: the power of self-activation and overcoming challenges; and (3) rootedness factors: stability and upward momentum. Participants described the early acquisition of nursing professionalism as derived from personality traits, family upbringing, and school professional education, promoting the growth of nursing professionalism through self-activation and overcoming challenges, and maintaining the stable and upward development of nursing professionalism through an upward atmosphere and external motivation.

We revealed the dynamic factors that influence the development of nursing professionalism, including “nourishment factors”, “growth factors”, and “rootedness factors”. Our findings provide a foundation for future development of nursing professionalism cultivation strategies. Nursing administrators can guide the development of nurses’ professionalism from many angles according to the stage they are in, and the development of professionalism deserves more attention. In the future, we can no longer consider the development of nursing professionalism solely as the responsibility of individual nurses; the power of families, organizations, and society is indispensable to jointly promoting nursing professionalism among nurses.

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Introduction

The number of nurses leaving hospitals has been increasing, and the shortage of nurses is a significant problem faced globally [ 1 , 2 ]. According to earlier studies, professionalism improves nurses’ clinical performance [ 3 ] and positively affects their adaptability (Park et al. 2021), reducing nurses’ burnout and turnover rates. Therefore, fostering professionalism in nurses and the factors that influence the development of professionalism are essential to producing effective nurses.

Nurses comprise the largest group of healthcare providers [ 4 ]. Nurses are a vital part of the healthcare system, with 27.9 million caregivers worldwide, according to the World Health Organisation’s Global Status of Nursing Report 2020 [ 5 ]. However, an unbalanced number of nurses and patients, high work pressure, and the fact that nurses face patients’ suffering, grief, and death each day have exacerbated burnout and led to the resignation of many nurses [ 6 ]. The COVID-19 outbreak has further exposed the shortage of nursing staff, especially in low- and middle-income countries where the scarcity of nurses remains acute. The lack of nurses not only has direct negative impacts on patients but also poses a threat to the entire healthcare system.

Nursing professionalism is closely associated with nurse retention and nursing practice [ 7 , 8 , 9 ]. Nursing professionalism is defined as providing individuals care based on the principles of professionalism, caring, and altruism [ 6 ]. As a belief in the profession, nursing professionalism is a systematic view of nursing that represents the practice standards and value orientation nurses utilize [ 10 , 11 ]. According to previous research, nursing professionalism can enhance nurses’ clinical performance and positively impact their adaptability, reducing job burnout and turnover rates [ 6 ]. Furthermore, as nurses are the ones who provide “presence” care, cultivating nursing professionalism among nurses can promote interactions between nurses and patients, further improving the quality of nursing care and patient outcomes and injecting new vitality and hope into the entire healthcare system [ 12 ].

However, nursing professionalism is dynamic, and the cultural context also shapes nursing professionalism to some extent, leading to ambiguity in the factors influencing nursing professionalism. Initially perceived as mere “caregivers,” nurses have transformed into “professional practitioners,” emphasizing the nursing field’s seriousness and distinct professional characteristics [ 13 , 14 ]. Nursing professionalism is also the foundation for developing the nursing profession [ 15 ]. Focusing on the factors influencing the development of nursing professionalism is one of the essential elements in providing an optimal environment for nurses’ professional growth and development in clinical practice [ 16 ]. Although some scales, such as the Hall Professionalism Inventory (HPI) [ 17 ], Miller’s Wheel of Professionalism in Nursing (BIPN) [ 18 ], Hwang’s Nurse Professional Values Scale (NPVS) [ 19 ], and Fantahun’s Nursing Professionalism Questionnaire [ 20 ] have been used to measure factors influencing the awareness, attitudes, and behaviors, they have their limitations. They struggle to encompass professionalism’s multidimensionality and complexity fully, overlook multilayered background factors, are constrained by standardization issues, may not account for individual differences, and often fail to capture dynamic changes over time [ 21 , 22 , 23 ].Compared with quantitative research methods, qualitative research can provide insights into the “unique phenomenology and context of the individual being tested,” which can help the researcher stay close to nurses’ professional lives during the research process and understand the personal, familial, and societal factors that influence nursing professionalism [ 24 ].Additionally, the understanding of nursing professionalism varies across different cultural and social contexts. In Western countries, research on nursing professionalism tends to incorporate professionalism across the entire nursing industry. In contrast, within China, research on professionalism tends to focus more on the individual level, with less attention to the perspectives of groups or the industry [ 25 ]. Therefore, through qualitative research, we can present nursing professionalism in a deeper, more affluent, and more transparent manner. Secondly, it is more authentic to understand the factors influencing nursing professionalism by directly obtaining relevant information from the perspective of nurses through dialogue with research participants as mutual subjects.

Given these considerations, we aim to answer the question of what factors influence the development of nursing professionalism. To provide more targeted strategies and recommendations for optimizing the nursing professional environment, enhancing nurses’ job satisfaction, improving t nursing quality, and contributing sustainably to patients’ and nurses’ health and well-being.

To explore the factors influencing the development of nursing professionalism. By incorporating nurses’ perspectives, we aim to improve our understanding of professionalism as individual, family, and socio-cultural influences. With this knowledge, we can inform strategies for developing nursing professionalism.

Study design

A descriptive qualitative approach was adopted based on naturalistic inquiry [ 26 , 27 ] and analyzed using the thematic analysis method described by Braun and Clarke [ 28 ]. Semi-structured interviews were conducted between May 2022 and August 2023 with nurses in southern and northern China hospitals. Furthermore, the research findings were reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) (Supplementary Material S1 ) [ 29 ].

Participants and settings

We chose hospital nurses as study participants based on considerations of their nursing experience. Firstly, the Chinese government has implemented a policy of accountable holistic care, whereby registered nurses take on the entire cycle of a patient’s physical, mental, and spiritual care [ 30 ]. Secondly, new nurses must undergo two weeks to one month of basic training and a 12–24 month specialty rotation (for most new nurses who graduated before 2016, their training was completed by their departments). During this time, they are under the supervision of a superior nurse for holistic and responsible care [ 31 ].

We used maximum variance purposive sampling to recruit a heterogeneous sample of information-rich key participants [ 32 ]. Participant selection considered variations in role classification, years of experience, and educational levels of Chinese nurses [ 33 ]. The purposive variation allowed the discovery of Chinese nurses’ unique perceptions of nursing professionalism. Inclusion criteria: (1) registered nurses (providing direct services to patients within the unit), nurse managers (directly supervising and guiding the clinical work of registered nurses), nursing department managers (managing nurse managers throughout the hospital), with at least one year of nursing experience; (2) voluntary participation. Exclusion criteria: (1) nurses not working during the hospital’s study period (holidays, maternity leave, or sick leave); (2) refresher nurses.

Data collection

The same researcher conducted each interview to ensure consistency. Before the interviews, the interviewers systematically conducted in-depth theoretical research on relevant studies. The interviewer received guidance from professors with rich experience in qualitative research and undertook practice interviews to improve her interviewing skills. Interviewers encouraged interviewees to talk freely about their perceptions and used an interview guide (Supplementary Material S2 ), which was based on the findings of previous research on the conceptual analysis of nursing professionalism [ 6 ]. The questions were open-ended and general; ample space was left between questions to respond to interviewees’ comments. Semi-structured interviews began with a brief introduction to the topic (e.g., definition and explanation of nursing professionalism). Although the interviewer had an agenda for discussion, this format allowed the interviewee to deviate from this agenda and direct follow-up questions [ 34 ].

All interviews were conducted from May 2022 to August 2023 in face-to-face conversations in offices in the workplace or via voice calls and lasted between 35 and 94 min. Participants were asked to complete the main demographic questionnaire at the end of the interviews. The researcher recorded participants’ expressions, body language, and pauses during the interviews. Memos written by the researcher during the study were also used as analytical material.

Data analysis

For rigorous qualitative sampling and data saturation, Braun et al. [ 35 ] propose that qualitative researchers require a sample appropriate to the research questions and the theoretical aims of the study and that can provide an adequate amount of data to answer the question and analyze the issue entirely. We reached thematic saturation after 14 interviews when no new codes or themes emerged.

A thematic analysis approach was used, following the phases described by Braun and Clarke [ 28 ]. The analysis comprised six stages: (1) immersing in the data; (2) creating initial codes; (3) identifying themes; (4) reviewing; (5) defining and labeling these themes; and (6) finally, composing the analysis report. Two researchers transcribed and analyzed the textual data. In the first stage, the researchers carefully read the interview transcripts to familiarize themselves with the depth and breadth of the content. In the second stage, preliminary codes were generated based on the research questions, initial interpretation of the data, and discussion of initial emerging patterns. At this stage, ensuring that all actual data extracts were coded and organized within each code was necessary. In addition, the following principles were used as guidelines: (1) code for as many potential themes/patterns as possible; (2) code extracts of data inclusively, i.e., preserve small sections of the surrounding data when relevant; and (3) code individual extracts of data for as many different “themes” as appropriate [ 36 ]. In the third phase, the two authors analyzed the initial codes, sorted them into potential themes, and debated their meanings and emerging patterns to reach a consensus. This phase, which refocused the analysis on the broader level of themes rather than that of codes, involved sorting the different codes into potential themes. In the fourth stage, reviewing themes ensures that the data supports the themes and allows an iterative process between different levels of abstraction without losing grounding in the raw data. Finally, defining the “essence” of each theme during the development of the main themes by identifying the “story” as consistent with the data and the research question while ensuring that the themes did not overlap but still fit together in the overall “story” of the data. It told the “story” by writing analytical narratives with illustrative quotes.

This study achieved credibility by selecting a heterogeneous sample, performing member checks, and taking field notes [ 37 ]. This study ensured dependability by verifying the findings with the researchers and participants, appropriately numbering the direct quotations (e.g., DN1), and comparing the results with the previous literature. This study established confirmability via audit trails [ 38 ] and the comprehensive reporting of all research processes. This study ensured transferability by describing the data collection process and seeking a heterogeneous sample.

Fourteen participants were interviewed (the demographic information is presented in Table  1 ). The thematic analysis identifies three major themes (Fig.  1 ). These interconnected topics illuminate the growth process and factors influencing nursing professionalism. The first theme, “nourishment factors: promoting early sprouting,” includes personal traits, family upbringing, and professional education at school and emphasizes early factors influencing nursing professionalism. The second theme, “growth factors: the power of self-activation and overcoming challenges,” included self-activation and overcoming difficulties, focusing on the dual attributes of the growth process of nursing professionalism. The final theme, “rootedness factors: stability and upward momentum,” includes an upward atmosphere and external motivation and explores the factors that maintain the stability and sustainability of nursing professionalism.

Factors influencing the development of nursing professionalism

Nourishment factors: promoting early sprouting

Personal traits.

Personal traits are called “nature” [ 23 ]. There exists a close connection between personal traits and professional behavior. When nurses confront patients’ physiological and emotional needs, innate qualities like kindness and compassion predispose them to be more sensitive to patients’ suffering and needs. Nursing professionalism transcends mere task fulfillment; this inner emotional drive compels nurses to fulfill their duties and engage in nursing work out of a genuine desire and sense of responsibility, practicing the nursing mission nobly. Thus, whether individual traits align with the nursing mission profoundly influences the nursing professionalism of nurses in their work.

“At 32, I became a head nurse, full of vitality and boundless enthusiasm, particularly compassion. I have no idea where this compassion comes from.” (ND1) .

Family upbringing

Education begins in the family, and it is through family education that nurses develop an early sense of professionalism. China has a “family culture” that defines the responsibility of family education. The study participants recalled that in childhood, the “living” nature of family education shaped early professionalism, in which the concepts of “kindness” and “altruism” were acquired through interactions with family members.

“My mother was an early childhood educator, and when she told me fairy tales, it was to promote kindness. Loving others and being selfless, you can’t be a bad person. That’s what altruistic education is about.” (ND1) .

The impact of family education on the acquisition of nursing professionalism extends into adulthood. In Chinese Confucianism and collectivism, family members usually have close emotional ties, and this “strong bond” family structure promotes nurses’ understanding and care for others and their ability to be wiser and more caring in the nursing profession. This strong bonding plays a catalytic role in the emergence of nursing professionalism.

“Some nurses are very adept at expressing care, perhaps because grandparents and parents live together. Since childhood, parents have taught them how to express care.” (N4) .

School professional education

Nursing professionalism is further acquired through professional education in schools. Nursing professional education emphasizes respect and care for patients, adherence to social responsibility, and the integration of traditional Chinese oriental medical thought and Western nursing concepts, internalized into behaviors to form the concept of professional nursing spirit. Participants indicated that the virtues of dedication, responsibility, respect, and caring that permeate school professional education are incorporated by nurses into nursing practice.

“The best nursing comes from the heart. When I was administering injections, I thought about how to alleviate the patient’s pain. Later, I learned that if I entered the needle quickly, it would be less painful, so I often practiced in the operating room.” (N8) .

Other participants also shared that they felt positively guided by professional education at school, constructing a comprehensive nursing philosophy system within the educational context. They realized that nursing is a multidisciplinary field encompassing human care, social responsibility, and ethical values.

“University was my most unforgettable learning experience. I studied 36 courses here, including nursing aesthetics, literature, sociology, ethics, education, etc. I realized that the nursing work we engage in has such rich depth! has become an invaluable treasure in my nursing career.” (ND1) .

Growth factors: the power of self-activation and overcoming challenges

Self-activation, professional benefits.

Professional benefit perception refers to the advantages nurses perceive while engaging in nursing work, acknowledging that their involvement in nursing promotes their holistic personal growth [ 39 ]. Consistent with traditional perspectives, this study finds that nurses generate a sense of professional benefit through both “tangible benefits” and “spiritual benefits,” recognizing the value and significance of nursing work, thereby furthering the development of nursing professionalism.

The dynamic updating achieves “tangible benefits.” Nurses require outstanding professional competence and ongoing continuing education. Participants mentioned that nurses utilize their professional knowledge and clinical experience to save patients’ lives, and exceptional professional competence can rekindle their enthusiasm for work. Continuous and dynamic continuing education, supplementing the latest technology and knowledge in the nursing field, can generate positive professional emotions.

“There’s only one doctor on duty at night, and nurses are the first responders when we encounter emergencies. Even before the doctor arrives in the ward, I must act quickly and urgently. Every time I bring a patient back from the brink of death, I feel excited throughout the night.” (N6) . “Experience is und oubtedly important. I’ve been working for over a decade, and I undergo training every year. No one likes stagnation; we can forge ahead only by continually moving forward.” (NM3) .

Self-worth realization through “spiritual benefits.” Experiencing a sense of value in nursing practice provides nurses with positive reinforcement, enhancing nursing professionalism behavior. Moreover, as healthcare practitioners, the ability of relatives and family members to benefit from it distinguishes Chinese nurses’ unique approach to self-worth realization from nurses in other countries. This unexpected feedback, whether in material or spiritual forms, enables nurses to fulfill their sense of worth.

“Sometimes, friends and relatives ask me about hospitalization-related questions, and I am more than willing to help them.” (N2) . “ I changed my mother’s gastric tube without any complications.” (NM3) .

Professional identity

Nursing professional identity refers to nurses acknowledging their work and affirming their self-worth [ 40 ]. This study defines professional identity as a gradual “process” and a “state.”

One participant mentioned that professional identity is a psychological “process” that nurses develop and confirm their professional roles through their personal experiences. It is closely related to the individual experiences of nurses. Nurses’ gradual recognition of their work prompts them to progress and develop a positive work attitude and professionalism.

“Gradually, I discovered that being a nurse makes me realize my significance, which keeps me moving forward, time and time again.” (ND2) .

Simultaneously, as a “state,” professional identity represents the degree to which nurses identify with the nursing profession. This “state” of professional identity reflects nursing professionalism’s long-term accumulation and formation. It indicates nurses’ long-standing dedication and emotional involvement in nursing, leading to higher professional competence and a sense of responsibility in their work.

“It’s not just a job to make a living; it’s about wholeheartedly identifying with this profession, unleashing one’s potential, which results in better professional conduct.”(N5) .

Overcoming challenges

Balancing roles.

Balancing roles refers to the equilibrium individuals establish between their roles in the nursing profession, family, and organization. Nursing professional roles are inherently multifaceted, and when faced with multiple responsibilities, such as family demands and organizational tasks, nurses must balance these roles. The tension and complexity between personal and organizational roles can potentially inhibit their emotions and professional motivation. However, in China, families are tightly knit, and strong family support can help reconcile this tension.

“To be a good nursing department manager, you need strong family support. The commitment to one’s career and the dedication to family don’t always align. For instance, my job keeps me busy regarding family matters, and I have limited time to care for my children. My parents-in-law take care of them more. I do rounds every Sunday, and the phone never stops ringing, even on my days off. There’s no way around it; this is the role I’ve taken on. Family support allows me to work with peace of mind.” (ND3) .

Adaptation organization

Nurses also face challenges in adapting to organizational systems. These adaptability challenges include rapidly learning new technologies, processes, and the culture of practice in different departments. This “unfamiliarity” impedes the manifestation of nursing professionalism. Participants indicated that the inability to adapt to clinical work quickly affects new graduate nurses’ transition into practice. Initially, there is a “honeymoon period” when becoming a registered nurse, but as actual capabilities do not align with expected performance, the excitement gradually wanes.

“I didn’t know the routine procedures in ophthalmology, I couldn’t measure eye pressure, and I didn’t know how to perform eye injections. I was terrified, which brought various challenges when I started working.” (N4) .

Furthermore, nurses must adapt to the practice culture of “this is how things are done” and “it’s always been done this way” in their workplace. Due to the promotion and title system requirements in Chinese hospitals, nurses with several years of experience often need to rotate through departments such as Intensive Care Unit and emergency for a period. The differences in operations and management between different departments also frustrate these nurses during rotations. However, a certain social prestige is attached, making it challenging for the nurses from the original department to provide direct guidance to the rotating nurses, leading to isolation for the latter in new departments.

“A blank slate regarding the department’s hierarchy, administrative procedures, and so on.” (N3) . “Although there’s a set of procedures, mostly similar, it’s the slight differences that always set me apart.” (N6) .

Rootedness factors: stability and upward momentum

Upward atmosphere, peer support.

Peer support has a positive impact on nursing professionalism. Peers are individuals of the same age group who have formed a connection due to shared experiences in similar socio-cultural environments, with emotional support, mutual assistance, and understanding constituting the core elements of peer support [ 41 ]. Firstly, nursing work often involves highly stressful situations, including heavy workloads, complex patient conditions, and urgent medical cases. Peer support provides emotional support, allowing nurses to find comfort and encouragement when facing stress and difficulties. Secondly, peer support cultivates a positive work atmosphere and team spirit. In a mutually supportive, trusting, and cooperative team, nurses are more likely to experience a sense of accomplishment in their work. They feel they are not isolated but part of a united and collaborative whole. Furthermore, peer support also promotes professional development and knowledge exchange among nurses. In an open and supportive team environment, nurses are more willing to share their experiences and knowledge, learn from each other, and grow.

“The spirit influences the spirit, especially those of my age group who have left a deep impression on me with their admirable qualities in their work. It makes me reflect on my shortcomings in my work and constantly strive to improve and adjust myself.” (N2) .

Intergenerational role models

Inter-generational refers to the relationships between generations [ 42 ]. In nursing practice, inter-generational relationships exist, such as those among nurses of different ages and levels of experience. This study’s inter-generational role models include managerial role models and senior nurses.

Participants believe that managers’ professionalism influences subordinate nurses’ attitudes and performance. The professionalism of managers not only plays a guiding and leadership role in daily work but, more importantly, sets an example, inspiring and encouraging subordinate nurses who are willing to follow and inherit professionalism.

“The department’s leadership has a significant impact on professionalism. When managers have a strong sense of professionalism, the nurses they oversee follow suit. Because leadership represents the management level and higher things, it’s difficult for things at the bottom to go well if it’s not well-controlled at the top.” (N8) .

On the other hand, senior nurses, as role models within the nursing generation, also significantly impact the upward development of professionalism. Senior nurses’ rich experience and professional competence guide new nurses to maintain a rigorous attitude at work. New nurses often draw from and learn senior nurses’ work attitudes and behaviors, catalyzing the elevation of nursing professionalism.

“Senior nurses have a role model effect because new nurses learn from the older ones. If senior nurses work rigorously and new nurses make mistakes or lack a sense of dedication, they will immediately point it out. Over time, you also become more rigorous.” (NM3) .

Perceived professional respect

Societal respect for nursing work creates an atmosphere of care and emphasis on nursing. Nurses within this atmosphere become aware of the importance of nursing work and the profound significance of patient care. They are inclined to exhibit positive nursing professionalism behaviors to meet the expectations of society and the general public.

“The nursing industry has experienced the COVID-19 pandemic, and during the anti-epidemic efforts, nurses were at the forefront, risking their lives to care for patients, receiving acclaim from patients, doctors, and the public.” (N2) .

Professional respect is the manifestation of nurses’ self-acknowledgment of nursing values. It is more than an external acknowledgment; it is an internal affirmation. This mutual respect aligns nurses’ professional and societal worth, catalyzing increased potential and motivation.

External motivation

The stability of nursing professionalism relies on external resources, including the diverse support from nursing managers and the guidance of national healthcare policies. Nursing managers are the frontline leaders who interact with nurses, and their support serves as a management tool and a direct means to sustain nursing professionalism. This multifaceted support encompasses economic incentives such as compensation and reward mechanisms. It extends to non-material motivations such as career advancement opportunities, adequate staffing, modern equipment provision, and fair and equitable treatment form crucial aspects of managerial support. Providing nurses with stable external support creates a space to focus on their professional mission and responsibilities, thus maintaining the stability of nursing professionalism.

“Economic foundation determines the superstructure(spiritual world)).” (NM1) .

Furthermore, the guidance of national healthcare policies serves as a beacon for the development of the nursing profession. At the national level, healthcare policies can regulate the organization and operation of healthcare systems and services, providing nurses with a more stable and favorable working environment. This environment allows nurses to fulfill their professional roles better and maximize their value. The environmental changes brought about by policy guidance offer nurses more favorable professional conditions, effectively promoting the upward development of nursing professionalism.

“Government documents summarize the needs of our society, and nursing will continue to improve in the direction of policy guidance.” (NM3) .

Discussions

This study provides insights for understanding the factors that influence the development of nursing professionalism. We emphasize the themes of early nourishment factors that promote the emergence of nursing professionalism, growth factors associated with self-activation and overcoming challenges, and rootedness factors that stabilize upward, which reveal the dynamic factors that influence the development of nursing professionalism.

We added the early influence of personality traits, family upbringing, and school professional education in the development of nursing professionalism, which is similar to the pathway through which nurses’ foundational values are acquired [ 43 , 44 ]. Building on previous research, we highlight the sequential order of socialization in family education and school professional education, with individual socialization within the family achieving individual socialization before school professional education, emphasizing the importance of intergenerational family transmission on the development of nursing professionalism [ 45 ]. Education commences within the family, a social organization with an educational function. China values its “family culture” and emphasizes defining parental responsibilities for family education based on blood relations. It is a common folk law in China that parents are regarded as the first teachers. In addition, Chinese society promotes Confucianism, which emphasizes instilling the concept of “self-improvement” through “educational living” [ 46 ], as mentioned in our study, the interpersonal interactions such as “altruism” and “caring” arising from family interactions can help nurses establish a deeper emotional connection with their patients. Therefore, future consideration could be given to incorporating programs that foster culture and emotions into professional education. Similar studies are necessary in East Asian countries and other countries with similar cultures to broaden the results of factors influencing nursing professionalism.

The growth of nursing professionalism requires real work scenarios. Our results present the dual factors of nursing professionalism upon entering the workplace. Regarding self-activation factors, we delve into the significance of “professional identity” and, for the first time from the perspective of Chinese collectivism, explain the unique influence of “professional benefits” on nursing professionalism. Our study aligns with previous research, viewing professional identity as an ongoing “process” [ 47 ]. By developing a professional identity, nurses can exhibit “stateful” self-satisfaction and self-motivation, contributing to their job satisfaction and professionalism [ 48 ]. The “professional benefits” involve integrating rational and emotional aspects. The “tangible benefits” of professionalism and technical competence at work lead to positive experiences and emotions among nurses. Nurses voluntarily invest more passion and energy in their work [ 49 ]. In addition, what sets our results apart is how Chinese nurses obtain ‘spiritual benefits,’ which come from the convenience of medical access that their relatives enjoy due to their work. Some studies have shown that “spiritual benefits” are more apparent among nurses aged 40 and above and those with higher professional titles [ 50 ]. The accumulation of clinical experience and the harmonious interpersonal relationships achieved through medical collaboration can help family members access reliable medical resources, leading to greater professional gain. This phenomenon is closely related to the collective consciousness of Chinese nurses, revealing that people are not always “self-interested and rational”; their behavior is influenced by more complex factors such as intuition, emotions, and attitudes [ 49 ].

In terms of the challenges faced, on the one hand, we emphasized the supportive role of intergenerational relationships in nurses’ work-family conflicts. Previous studies have shown that Chinese nurses perceive nursing work as a means to fulfill family responsibilities rather than the ultimate goal, reflecting a prioritization of family over work [ 51 ]. Consequently, nurses are more likely to resign during work-family conflicts, reallocating their resources from work to family [ 52 ]. Compared with previous studies, we found that China is a highly connected society, and multi-generational households are relatively common [ 53 ]. Hence, the importance of maintaining good intergenerational relationships cannot be ignored in Chinese society and culture, substantially impacting nursing professionalism. On the other hand, we reveal the underlying reasons for the restricted development of nursing professionalism among nurses during the transition period. Newly graduated nurses face negative experiences such as incompetence, lack of preparation, exhaustion, and disappointment in their work, hindering the development of nursing professionalism, which is especially evident in departments such as obstetrics and gynecology, ophthalmology, and emergency, where teaching hours for these specialties fall significantly below those for general internal medicine and surgical nursing [ 54 ]. The educational experiences of nurses are insufficient to meet clinical demands [ 55 ]. Moreover, this is compounded by differences in the structure and content of the 12–24 month “standardized training” for new nurses that has already begun in most cities in China, further exacerbating the experience of separation of new nurses from their organizations [ 56 ]. The development of rotational nurses is often neglected, and transfer systems are a mere formality [ 57 ]. Therefore, developing nursing adaptability and creating a supportive work environment should be incorporated into the content and structure of different organizational transition programs to make a positive work environment and promote nurses’ engagement, enhancing nursing professionalism.

It is worth noting that the rootedness factor involves individual, organizational, and societal dimensions. At the personal level, peer support and intergenerational role models integrate the demonstration of actual “peers” and “role models” with nurses’ self-awareness and agency to achieve upward mobility in nursing professionalism [ 58 ]. However, while peer support offers emotional and social cognitive consistency based on age, background, and learning experiences, it may lack experiential depth [ 59 ]. In contrast, intergenerational role models involving a “superior-subordinate” relationship can initially lead to “nurturing” relationships, potentially leading to lateral violence and bullying [ 60 ]. At the organizational level, our findings highlight that professional respect in the workplace is more relevant to nurses’ professionalism than social appraisal. Professional respect is the nurses’ perception of their subjective social status within the profession and an analysis of the social value associated with the nursing profession [ 61 ]. However, nurses are not always respected, especially as insults and disregard from patients, superiors, or physicians can lead to negative emotions, professional burnout, and a desire to quit [ 62 , 63 , 64 ]. Regarding the societal dimension, providing external motivation tailored to nurses’ specific backgrounds and needs is beneficial for the stable development of nursing professionalism. Financial incentives are often considered a common strategy to improve nurses’ motivation and retention in motivation management [ 65 ]. However, the effectiveness of incentives is, more importantly, dependent on the response of nurses after implementation, and it is crucial to understand the needs and preferences of nurses in terms of incentives as well as the level of nurses’ participation in policy development, in addition to material rewards [ 66 , 67 ].Therefore, maintaining the stability of nursing professionalism is therefore complex, and nursing managers should consider ways to deepen peer support and reduce workplace bullying through “intergenerational parenting”, and should develop policies that support nurses, have zero-tolerance for disruptive behaviours, uphold the professional dignity of nurses, and ensure that their voices are heard and valued, which contributes to a more positive, fulfilling, and motivating nursing work environment.

Limitations

Given the persistently low number of men in nursing, all participants recruited for our study were female. However, considering the relatively narrow focus of the research, The purposive variation, and the richness of the generated data, the sample size was deemed sufficient to achieve our objectives. In addition, although the study results reveal dynamic influences on the development of nursing professionalism, they do not differentiate between nurses at different career stages, such as novice and expert nurses. We consider these factors as “common characteristics” for them, intertwined with each other, which can be further clarified in future research.

Conclusions

This study is an important addition to previous research in that we reveal the dynamics of factors that influence the development of nursing professionalism, including the “nourishment factor,” “growth factor,” and “rootedness factor.” Our findings provide contextual factors that can be changed during the development of nursing professionalism and lay the foundation for future strategies to foster nursing professionalism.

Relevance to clinical practice

The findings of this study have important implications for exploring the development of nursing professionalism. Nursing managers can support nurses’ professionalism from various perspectives, depending on the stage of the nurse’s life, such as valuing nurses’ family relationships, focusing on nurses in transition, listening to nurses’ voices, and creating a “magnetic nursing” work environment. These measures will not only positively impact the careers of individual nurses but will also help improve the standard and quality of health care in general. In the future, we should no longer view the development of nursing professionalism as solely the responsibility of individual nurses; the influence of family, organizations, and society is indispensable in collectively promoting the development of nurses’ nursing professionalism.

Data availability

Data used to support the findings of this study are available from the corresponding author upon request.

Abbreviations

The Hall Professionalism Inventory

Miller’s Wheel of Professionalism in Nursing

SHwang’s Nurse Professional Values Scale

The consolidated criteria for reporting qualitative research

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Xingyue He, Ya Mao, Linbo Li, Yanming Wu & Hui Yang

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How phenomenology can help us learn from the experiences of others

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Introduction

As a research methodology, phenomenology is uniquely positioned to help health professions education (HPE) scholars learn from the experiences of others. Phenomenology is a form of qualitative research that focuses on the study of an individual’s lived experiences within the world. Although it is a powerful approach for inquiry, the nature of this methodology is often intimidating to HPE researchers. This article aims to explain phenomenology by reviewing the key philosophical and methodological differences between two of the major approaches to phenomenology: transcendental and hermeneutic. Understanding the ontological and epistemological assumptions underpinning these approaches is essential for successfully conducting phenomenological research.

This review provides an introduction to phenomenology and demonstrates how it can be applied to HPE research. We illustrate the two main sub-types of phenomenology and detail their ontological, epistemological, and methodological differences.

Conclusions

Phenomenology is a powerful research strategy that is well suited for exploring challenging problems in HPE. By building a better understanding of the nature of phenomenology and working to ensure proper alignment between the specific research question and the researcher’s underlying philosophy, we hope to encourage HPE scholars to consider its utility when addressing their research questions.

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A Qualitative Space highlights research approaches that push readers and scholars deeper into qualitative methods and methodologies. Contributors to A Qualitative Space may: advance new ideas about qualitative methodologies, methods, and/or techniques; debate current and historical trends in qualitative research; craft and share nuanced reflections on how data collection methods should be revised or modified; reflect on the epistemological bases of qualitative research; or argue that some qualitative practices should end. Share your thoughts on Twitter using the hashtag: #aqualspace

Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so.—Douglas Adams

Despite the fact that humans are one of few animals who can learn from the experiences of others, we are often loath to do so. Perhaps this is because we assume that similar circumstances could never befall us. Perhaps this is because we assume that, if placed in the same situation, we would make wiser decisions. Perhaps it is because we assume the subjective experience of an individual is not as reliably informative as objective data collected from external reality. Regardless of the assumptions grounding this apprehension, it is essential for scholars to learn from the experiences of others. In fact, it is a foundational premise of research. Research involves the detailed study of a subject (i. e., an individual, groups of individuals, societies, or objects) to discover information or to achieve a new understanding of the subject [ 1 ]. Such detailed study often requires understanding the experiences of others so that we can glean new insights about a particular phenomenon. Scholars in health professions education (HPE) are savvy to the need to learn from the experiences of others. To maximize the effectiveness of feedback, of workplace-based learning, of clinical reasoning, or of any other of a myriad of phenomena, HPE researchers need to be able to carefully explore and learn from the experiences of others. What often curtails these efforts is a lack of methodology. In other words: HPE researchers need to know how to learn from the experiences of others.

Phenomenology is a qualitative research approach that is uniquely positioned to support this inquiry. However, as an approach for engaging in HPE research, phenomenology does not have a strong following. It is easy to see why: To truly understand phenomenology requires developing an appreciation for the philosophies that underpin it. Those philosophies theorize the meaning of human experience. In other words, engaging in phenomenological research requires the scholar to become familiar with the philosophical moorings of our interpretations of human experience. This may be a daunting task, but Douglas Adams never said learning from the experiences of others would be easy.

The questions that phenomenology can answer, and the insights this kind of research can provide, are of foundational importance to HPE: What is the experience of shame and the impact of that experience for medical learners [ 2 ]? What does it mean to be an empathetic clinician [ 3 ]? What is the medical learner’s experience of failure on high stakes exams [ 4 ]? How do experienced clinicians learn to communicate their clinical reasoning in professional practice [ 5 ]? Answers to such questions constitute the underpinnings of our field. To answer such questions, we can use phenomenology to learn from the experiences of others.

In this manuscript, we delve into the philosophies and methodologies of two varieties of phenomenology: hermeneutic and transcendental. Our goal is not to simplify the complexities of phenomenology, nor to argue that all HPE researchers should use phenomenology. Instead, we suggest that phenomenology is a valuable approach to research that needs to have a place in HPE’s body of research. We will place these two approaches in the context of their philosophical roots to illustrate the similarities and differences between these ways of engaging in phenomenological research. In so doing, we hope to encourage HPE researchers to thoughtfully engage in phenomenology when their research questions necessitate this research approach.

What is phenomenology?

In simple terms, phenomenology can be defined as an approach to research that seeks to describe the essence of a phenomenon by exploring it from the perspective of those who have experienced it [ 6 ]. The goal of phenomenology is to describe the meaning of this experience—both in terms of what was experienced and how it was experienced [ 6 ]. There are different kinds of phenomenology, each rooted in different ways of conceiving of the what and how of human experience. In other words, each approach of phenomenology is rooted in a different school of philosophy. To choose a phenomenological research methodology requires the scholar to reflect on the philosophy they embrace. Given that there are many different philosophies that a scientist can embrace, it is not surprising that there is broad set of phenomenological traditions that a researcher can draw from. In this manuscript, we highlight the transcendental and the hermeneutic approaches to phenomenology, but a broader phenomenological landscape exists. For instance, the Encyclopedia of Phenomenology, published in 1997, features articles on seven different types of phenomenology [ 7 ]. More contemporary traditions have also been developed that bridge the transcendental/hermeneutic divide. Several of these traditions are detailed in Tab.  1 [ 8 , 9 , 10 ].

To understand any of these approaches to phenomenology, it is useful to remember that most approaches hold a similar definition of phenomenology’s object of study. Phenomenology is commonly described as the study of phenomena as they manifest in our experience, of the way we perceive and understand phenomena, and of the meaning phenomena have in our subjective experience [ 11 ]. More simply stated, phenomenology is the study of an individual’s lived experience of the world [ 12 ]. By examining an experience as it is subjectively lived, new meanings and appreciations can be developed to inform, or even re-orient, how we understand that experience [ 13 ].

From this shared understanding, we now address how transcendental (descriptive) phenomenology and hermeneutic (interpretive) phenomenology approach this study in different ways. These approaches are summarized in Tab.  2 .

• Transcendental phenomenology

Phenomenology originates in philosophical traditions that evolved over centuries; however, most historians credit Edmund Husserl for defining phenomenology in the early 20th century [ 14 ]. Understanding some of Husserl’s academic history can provide insight into his transcendental approach to phenomenology. Husserl’s initial work focused on mathematics as the object of study [ 15 ], but then moved to examine other phenomena. Husserl’s approach to philosophy sought to equally value both objective and subjective experiences, with his body of work ‘culminating in his interest in “pure phenomenology” or working to find a universal foundation of philosophy and science [ 13 ].’ Husserl rejected positivism’s absolute focus on objective observations of external reality, and instead argued that phenomena as perceived by the individual’s consciousness should be the object of scientific study. Thus, Husserl contended that no assumptions should inform phenomenology’s inquiry; no philosophical or scientific theory, no deductive logic procedures, and no other empirical science or psychological speculations should inform the inquiry. Instead, the focus should be on what is given directly to an individual’s intuition [ 16 ]. As Staiti recently argued, this attitude towards phenomenology is akin to that of ‘a natural scientist who has just discovered a previously unknown dimension of reality [ 17 ].’ This shift in focus requires the researcher to return ‘to the self to discover the nature and meaning of things [ 18 ].’ As Husserl asserted: ‘Ultimately, all genuine and, in particular, all scientific knowledge, rests on inner evidence [ 19 ].’ Inner evidence—that is, what appears in consciousness—is where a phenomenon is to be studied. What this means for Husserl is that subjective and objective knowledge are intimately intertwined. To understand the reality of a phenomenon is to understand the phenomenon as it is lived by a person. This lived experience is, for Husserl, a dimension of being that had yet to be discovered [ 17 ]. For Husserl, phenomenology was rooted in an epistemological attitude; for him, the critical question of a phenomenological investigation was ‘What is it for an individual to know or to be conscious of a phenomenon [ 20 ]?’ In Husserl’s conception of phenomenology, any experienced phenomenon could be the object of study thereby pushing analysis beyond mere sensory perception (i. e. what I see, hear, touch) to experiences of thought, memory, imagination, or emotion [ 21 ].

Husserl contended that a lived experience of a phenomenon had features that were commonly perceived by individuals who had experienced the phenomenon. These commonly perceived features—or universal essences—can be identified to develop a generalizable description. The essences of a phenomenon, according to Husserl, represented the true nature of that phenomenon. The challenge facing the researcher engaging in Husserl’s phenomenology, then, is:

To describe things in themselves, to permit what is before one to enter consciousness and be understood in its meanings and essences in the light of intuition and self-reflection. The process involves a blending of what is really present with what is imagined as present from the vantage point of possible meanings; thus, a unity of the real and the ideal [ 18 ] .

In other words, the challenge is to engage in the study of a person’s lived experience of a phenomenon that highlights the universal essences of that phenomenon [ 22 ]. This requires the researcher to suspend his/her own attitudes, beliefs, and suppositions in order to focus on the participants’ experience of the phenomenon and identify the essences of the phenomenon. One of Husserl’s great contributions to philosophy and science is the method he developed that enables researchers ‘to suspend the natural attitude as well as the naïve understanding of what we call the human mind and to disclose the realm of transcendental subjectivity as a new field of inquiry [ 17 ].’

In Husserl’s’ transcendental phenomenology (also sometimes referred to as the descriptive approach), the researcher’s goal is to achieve transcendental subjectivity —a state wherein ‘the impact of the researcher on the inquiry is constantly assessed and biases and preconceptions neutralized, so that they do not influence the object of study [ 22 ].’ The researcher is to stand apart, and not allow his/her subjectivity to inform the descriptions offered by the participants. This lived dimension of experience is best approached by the researcher who can achieve the state of the transcendental I —a state wherein the objective researcher moves from the participants’ descriptions of facts of the lived experience, to universal essences of the phenomenon at which point consciousness itself could be grasped [ 23 ]. In the state of the transcendental I , the researcher is able to access the participants’ experience of the phenomenon pre-reflectively—that is ‘without resorting to categorization on conceptualization, and quite often includes what is taken for granted or those things that are common sense [ 13 ].’ The transcendental I brings no definitions, expectations, assumption or hypotheses to the study; instead, in this state, the researcher assumes the position of a  tabula rasa, a blank slate, that uses participants’ experiences to develop an understanding of the essence of a phenomenon.

This state is achieved via a series of reductions. The first reduction, referred to as the transcendental stage , requires transcendence from the natural attitude of everyday life through epoche , also called the process of bracketing . This is the process through which the researchers set aside—or bracket off as one would in a mathematical equation—previous understandings, past knowledge, and assumptions about the phenomenon of interest. The previous understandings that must be set aside include a wide range of sources including: scientific theories, knowledge, or explanation; truth or falsity of claims made by participants; and personal views and experiences of the researcher [ 24 ]. In the second phase, transcendental-phenomenological reduction , each participant’s experience is considered individually and a complete description of the phenomenon’s meanings and essences is constructed [ 18 ]. Next is reduction via imaginative variation wherein all the participants’ descriptions of conscious experience are distilled to a unified synthesis of essences through the process of free variation [ 25 ]. This process relies on intuition and requires imagining multiple variations of the phenomenon in order to arrive at the essences of the phenomenon [ 25 ]. These essences become the foundation for all knowledge about the phenomenon.

The specific processes followed to realize these reductions vary across researchers engaging in transcendental phenomenology. One commonly used transcendental phenomenological method is that of psychologist Clark Moustakas, and other approaches include the works of: Colaizzi [ 26 ], Giorgi [ 27 ], and Polkinghorne [ 28 ]. Regardless of the approach used, to engage rigorously in transcendental phenomenology, the researcher must be vigilant in his/her bracketing work so that the researcher’s individual subjectivity does not bias data analysis and interpretations. This is the challenge of reaching the state of the transcendental I where the researcher’s own interpretations, perceptions, categories, etc. do not influence the processes of reduction. It is important to note that modern philosophers continue to wrestle with Husserl’s notions of bracketing. If bracketing is successfully achieved, the researcher sets aside the world and the entirety of its content—including the researcher’s physical body [ 17 ]. While dedication to this bracketing is challenging to maintain, Husserl asserts that it is necessary. Suspending reliance on and foundations in physical reality is the only way to abandon our human experiences in such a way as to find the transcendent I. Researchers might borrow [ 29 ] practices from other qualitative research methods to achieve this goal. For instance, a study could be designed to have multiple researchers triangulate [ 30 ] their reductions to confirm appropriate bracketing was maintained. Alternatively, a study could involve validation of data [ 18 ] via member checking [ 31 ] to ensure that the identified essences resonated with the participants’ experiences.

Husserl’s transcendental phenomenology has been employed by HPE researchers. For example, in 2012, Tavakol et al. studied medical students’ understanding of empathy by engaging in transcendental phenomenological research [ 32 ]. The authors note that medial students’ loss of empathy as they transition from pre-clinical to clinical training is well documented in the medical literature [ 33 ], and has been found to negatively impact patients and the quality of healthcare provided [ 34 ]. Tavakol et al. [ 32 ] used a descriptive phenomenological approach (i. e. using the methodology of Colaizzi and Giorgi) to report on the phenomenon of empathy as experienced by medical students during the course of their training. The authors identified two key factors impacting empathic ability: innate capacity for empathy and barriers to displaying empathy [ 32 ].

• Hermeneutic phenomenology

Hermeneutic phenomenology, also known as interpretive phenomenology, originates from the work of Martin Heidegger. Heidegger began his career in theology, but then moved into academia as a student of philosophy. While Heidegger’s philosophical inquiry began in alignment with Husserl’s work, he later challenged several key aspects of Husserl’s transcendental phenomenology. A foundational break from his predecessor was the focus of phenomenological inquiry. While Husserl was interested in the nature of knowledge (i. e., an epistemological focus), Heidegger was interested in the nature of being and temporality (i. e., an ontological focus) [ 21 ]. With this focus on human experience and how it is lived, hermeneutic phenomenology moves away from Husserl’s focus on ‘acts of attending, perceiving, recalling and thinking about the world [ 13 ]’ and on human beings as knowers of phenomenon. In contrast, Heidegger is interested in human beings as actors in the world and so focuses on the relationship between an individual and his/her lifeworld. Heidegger’s term lifeworld referred to the idea that ‘individuals’ realities are invariably influenced by the world in which they live [ 22 ].’ Given this orientation, individuals are understood as always already having an understanding of themselves within the world, even if they are not constantly, explicitly and/or consciously aware of that understanding [ 17 ]. For Heidegger, an individual’s conscious experience of a phenomenon is not separate from the world, nor from the individual’s personal history. Consciousness is, instead, a formation of historically lived experiences including a person’s individual history and the culture in which he/she was raised [ 22 ]. An individual cannot step out of his/her lifeworld. Humans cannot experience a phenomenon without referring back to his/her background understandings. Hermeneutic phenomenology, then, seeks ‘to understand the deeper layers of human experience that lay obscured beneath surface awareness and how the individual’s lifeworld, or the world as he or she pre-reflectively experiences it, influences this experience [ 35 ].’ Hermeneutic phenomenology studies individuals’ narratives to understand what those individuals experience in their daily lives, in their lifeworlds.

But the hermeneutic tradition pushes beyond a descriptive understanding. Hermeneutic phenomenology is rooted in interpretation—interpreting experiences and phenomena via the individual’s lifeworld. Here, Heidegger’s background in theology can be seen as influencing his approach to phenomenology. Hermeneutics refers to the interpretation of texts, to theories developed from the need to translate literature from different languages and where access to the original text (e. g., the Bible) was problematic [ 36 ]. If all human experience is informed by the individual’s lifeworld, and if all experiences must be interpreted through that background, hermeneutic phenomenology must go beyond description of the phenomenon, to the interpretation of the phenomenon. The researcher must be aware of the influence of the individual’s background and account for the influences they exert on the individual’s experience of being.

This is not to say that the individual’s subjective experience—which is inextricably linked with social, cultural, and political contexts—is pre-determined. Heidegger argued that individuals have situated freedom. Situated freedom is a concept that asserts that ‘individuals are free to make choices, but their freedom is not absolute; it is circumscribed by the specific conditions of their daily lives [ 22 ].’ Hermeneutic phenomenology studies the meanings of an individual’s being in the world, as their experience is interpreted through his/her lifeworld, and how these meanings and interpretations influence the choices that the individual makes [ 13 ]. This focus requires the hermeneutic phenomenologist to interpret the narratives provided by research participants in relation to their individual contexts in order to illuminate the fundamental structures of participants’ understanding of being and how that shaped the decisions made by the individual [ 37 ].

Another key aspect that distinguishes hermeneutic phenomenology is the role of the researcher in the inquiry. Instead of bracketing off the researcher’s subjective perspective, hermeneutic phenomenology recognizes that the researcher, like the research subject, cannot be rid of his/her lifeworld. Instead, the researcher’s past experiences and knowledge are valuable guides to the inquiry. It is the researcher’s education and knowledge base that lead him/her to consider a phenomenon or experience worthy of investigation. To ask the research to take an unbiased approach to the data is inconsistent with hermeneutic phenomenology’s philosophical roots. Instead, researchers working from this tradition should openly acknowledge their preconceptions, and reflect on how their subjectivity is part of the analysis process [ 16 ].

The interpretive work of hermeneutic phenomenology is not bound to a single set of rule-bound analytical techniques; instead, it is an interpretive process involving the interplay of multiple analysis activities [ 35 ]. In general, this process:

Starts with identifying an interesting phenomenon that directs our attention towards lived experience. Members of the research team then investigate experience as it is lived, rather than as it is conceptualized, and reflect on the essential [phenomenological] themes that characterize the participant’s experience with the phenomenon, simultaneously reflecting on their own experiences. Researchers capture their reflections in writing and then reflect and write again, creating continuous, iterative cycles to develop increasingly robust and nuanced analyses. Throughout the analysis, researchers must maintain a strong orientation to the phenomenon under study (i.   e., avoid distractions) and attend to the interactions between the parts and the whole. This last step, also described as the hermeneutic circle, emphasizes the practice of deliberately considering how the data (the parts) contribute to the evolving understanding of the phenomena (the whole) and how each enhances the meaning of the other [ 35 ] .

In the hermeneutic approach to phenomenology, theories can help to focus inquiry, to make decisions about research participants, and the way research questions can be addressed [ 22 ]. Theories can also be used to help understand the findings of the study. One scholar whose engagement with hermeneutic phenomenology is widely respected is Max van Manen [ 38 ]. Van Manen acknowledges that hermeneutic phenomenology ‘does not let itself be deceptively reduced to a methodical schema or an interpretative set of procedures [ 39 ].’ Instead, this kind of phenomenology requires the researcher to read deeply into the philosophies of this tradition to grasp the project of hermeneutic phenomenological thinking, reading, and writing.

A recent study published by Bynum et al. illustrates how hermeneutic phenomenology may be employed in HPE [ 2 ]. In this paper, Bynum et al. explored the phenomenon of shame as an emotion experienced by medical residents and offer insights into the effects of shame experiences on learners. As a means in scholarly inquiry, this study demonstrates how hermeneutic phenomenology can provide insight into complex phenomena that are inextricably entwined in HPE.

Incorporating phenomenological research methodologies into HPE scholarship creates opportunities to learn from the experiences of others. Phenomenological research can broaden our understanding of the complex phenomena involved in learning, behaviour, and communication that are germane to our field. But success in these efforts is dependent upon both improved awareness of the potential value of these approaches, and enhanced familiarization with the underlying philosophical orientation and methodological approaches of phenomenology. Perhaps most critically, HPE scholars must construct research processes that align with the tenets of the methodology chosen and the philosophical roots that underlie it. This alignment is the cornerstone for establishing research rigour and trustworthiness.

Following a specific checklist of verification activities or mandatory processes cannot buoy the quality and rigour of a particular phenomenological study. Instead, beyond maintaining fidelity between research question, paradigm, and selected methodology, robust phenomenological research involves deep engagement with the data via reading, reflective writing, re-reading and re-writing. In Moustakas’s approach to transcendental phenomenology, the researcher reads the data, reduces the data to meaning units, re-reads those reductions to then engage in thematic clustering, compares the data, writes descriptions, and so on in an ongoing process of continually engaging with the data and writing reflections and summaries until the researcher can describe the essence of the lived experience [ 18 ]. In hermeneutic phenomenology, scholars describe engaging in a hermeneutic circle wherein the researcher reads the data, constructs a vague understanding, engages in reflective writing, then re-engages with the text with revised understandings [ 40 ]. In cycles of reading and writing, of attending to the whole of the text and the parts, the hermeneutic researcher constructs an understanding of the lived experience. In both traditions, deep engagement with the data via reading, writing, re-reading and re-writing is foundational. While this engagement work is not standardized, Polkinghorne suggests that rich descriptions of phenomenological research might be characterized by qualities such as vividness, richness, accuracy, and elegance [ 41 ]. While we question how these qualities might be evaluated in a qualitative study, they confirm that attention to the depth of engagement in reading and writing of the phenomenological data is a necessary condition for rigour.

Phenomenology is a valuable tool and research strategy. For those who are not familiar with its philosophical underpinnings or methodological application, it can seem challenging to apply to HPE scholarship. We hope this manuscript will serve to relieve some of the apprehension in considering the use of phenomenology in future work. We believe that the appropriate application of phenomenology to HPE’s research questions will help us to advance our understanding by learning from the experiences of others.

The views expressed herein are those of the authors and do not necessarily reflect those of the Uniformed Services University of the Health Sciences, the United States Department of Defense or other federal agencies.

Cambridge Online Dictionary. 2019. https://dictionary.cambridge.org/us/dictionary/english/research . Accessed 24 Feb 2019, Research.

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Neubauer, B.E., Witkop, C.T. & Varpio, L. How phenomenology can help us learn from the experiences of others. Perspect Med Educ 8 , 90–97 (2019). https://doi.org/10.1007/s40037-019-0509-2

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Published : 05 April 2019

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DOI : https://doi.org/10.1007/s40037-019-0509-2

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