literature review qualitative method

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Qualitative research: literature review .

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Exploring the literature review 

Literature review model: 6 steps.

Adapted from The Literature Review , Machi & McEvoy (2009, p. 13).

Your Literature Review

Step 2: search, boolean search strategies, search limiters, ★ ebsco & google drive.

1. Select a Topic

"All research begins with curiosity" (Machi & McEvoy, 2009, p. 14)

Selection of a topic, and fully defined research interest and question, is supervised (and approved) by your professor. Tips for crafting your topic include:

• Be specific. Take time to define your interest.
• Topic Focus. Fully describe and sufficiently narrow the focus for research.
• Academic Discipline. Learn more about your area of research & refine the scope.
• Avoid Bias. Be aware of bias that you (as a researcher) may have.
• Document your research. Use Google Docs to track your research process.
• Research apps. Consider using Evernote or Zotero to track your research.

Consider Purpose

What will your topic and research address?

In The Literature Review: A Step-by-Step Guide for Students , Ridley presents that literature reviews serve several purposes (2008, p. 16-17).  Included are the following points:

• Historical background for the research;
• Overview of current field provided by "contemporary debates, issues, and questions;"
• Theories and concepts related to your research;
• Introduce "relevant terminology" - or academic language - being used it the field;
• Connect to existing research - does your work "extend or challenge [this] or address a gap;" 
• Provide "supporting evidence for a practical problem or issue" that your research addresses.

★ Schedule a research appointment

At this point in your literature review, take time to meet with a librarian. Why? Understanding the subject terminology used in databases can be challenging. Archer Librarians can help you structure a search, preparing you for step two. How? Contact a librarian directly or use the online form to schedule an appointment. Details are provided in the adjacent Schedule an Appointment box.

2. Search the Literature

Collect & Select Data: Preview, select, and organize

AU Library is your go-to resource for this step in your literature review process. The literature search will include books and ebooks, scholarly and practitioner journals, theses and dissertations, and indexes. You may also choose to include web sites, blogs, open access resources, and newspapers. This library guide provides access to resources needed to complete a literature review.

Books & eBooks: Archer Library & OhioLINK

Databases: Scholarly & Practitioner Journals

Review the Library Databases tab on this library guide, it provides links to recommended databases for Education & Psychology, Business, and General & Social Sciences.

Expand your journal search; a complete listing of available AU Library and OhioLINK databases is available on the Databases  A to Z list . Search the database by subject, type, name, or do use the search box for a general title search. The A to Z list also includes open access resources and select internet sites.

Databases: Theses & Dissertations

Review the Library Databases tab on this guide, it includes Theses & Dissertation resources. AU library also has AU student authored theses and dissertations available in print, search the library catalog for these titles.

Did you know? If you are looking for particular chapters within a dissertation that is not fully available online, it is possible to submit an ILL article request . Do this instead of requesting the entire dissertation.

Newspapers:  Databases & Internet

Consider current literature in your academic field. AU Library's database collection includes The Chronicle of Higher Education and The Wall Street Journal .  The Internet Resources tab in this guide provides links to newspapers and online journals such as Inside Higher Ed , COABE Journal , and Education Week .

The Chronicle of Higher Education has the nation’s largest newsroom dedicated to covering colleges and universities.  Source of news, information, and jobs for college and university faculty members and administrators

The Chronicle features complete contents of the latest print issue; daily news and advice columns; current job listings; archive of previously published content; discussion forums; and career-building tools such as online CV management and salary databases. Dates covered: 1970-present.

Offers in-depth coverage of national and international business and finance as well as first-rate coverage of hard news--all from America's premier financial newspaper. Covers complete bibliographic information and also subjects, companies, people, products, and geographic areas. 

Comprehensive coverage back to 1984 is available from the world's leading financial newspaper through the ProQuest database. 

Newspaper Source provides cover-to-cover full text for hundreds of national (U.S.), international and regional newspapers. In addition, it offers television and radio news transcripts from major networks.

Provides complete television and radio news transcripts from CBS News, CNN, CNN International, FOX News, and more.

Search Strategies & Boolean Operators

There are three basic boolean operators:  AND, OR, and NOT.

Used with your search terms, boolean operators will either expand or limit results. What purpose do they serve? They help to define the relationship between your search terms. For example, using the operator AND will combine the terms expanding the search. When searching some databases, and Google, the operator AND may be implied.

Overview of boolean terms

About the example: Boolean searches were conducted on November 4, 2019; result numbers may vary at a later date. No additional database limiters were set to further narrow search returns.

Database Search Limiters

Database strategies for targeted search results.

Most databases include limiters, or additional parameters, you may use to strategically focus search results.  EBSCO databases, such as Education Research Complete & Academic Search Complete provide options to:

• Limit results to full text;
• Limit results to scholarly journals, and reference available;
• Select results source type to journals, magazines, conference papers, reviews, and newspapers
• Publication date

Keep in mind that these tools are defined as limiters for a reason; adding them to a search will limit the number of results returned.  This can be a double-edged sword.  How? 

• If limiting results to full-text only, you may miss an important piece of research that could change the direction of your research. Interlibrary loan is available to students, free of charge. Request articles that are not available in full-text; they will be sent to you via email.
• If narrowing publication date, you may eliminate significant historical - or recent - research conducted on your topic.
• Limiting resource type to a specific type of material may cause bias in the research results.

Use limiters with care. When starting a search, consider opting out of limiters until the initial literature screening is complete. The second or third time through your research may be the ideal time to focus on specific time periods or material (scholarly vs newspaper).

★ Truncating Search Terms

Expanding your search term at the root.

Truncating is often referred to as 'wildcard' searching. Databases may have their own specific wildcard elements however, the most commonly used are the asterisk (*) or question mark (?).  When used within your search. they will expand returned results.

Asterisk (*) Wildcard

Using the asterisk wildcard will return varied spellings of the truncated word. In the following example, the search term education was truncated after the letter "t."

Explore these database help pages for additional information on crafting search terms.

• EBSCO Connect: Searching with Wildcards and Truncation Symbols
• EBSCO Connect: Searching with Boolean Operators
• EBSCO Connect: EBSCOhost Search Tips
• EBSCO Connect: Basic Searching with EBSCO
• ProQuest Help: Search Tips
• ERIC: How does ERIC search work?

★ EBSCO Databases & Google Drive

Tips for saving research directly to Google drive.

Researching in an EBSCO database?

It is possible to save articles (PDF and HTML) and abstracts in EBSCOhost databases directly to Google drive. Select the Google Drive icon, authenticate using a Google account, and an EBSCO folder will be created in your account. This is a great option for managing your research. If documenting your research in a Google Doc, consider linking the information to actual articles saved in drive.

EBSCO Databases & Google Drive

EBSCOHost Databases & Google Drive: Managing your Research

This video features an overview of how to use Google Drive with EBSCO databases to help manage your research. It presents information for connecting an active Google account to EBSCO and steps needed to provide permission for EBSCO to manage a folder in Drive.

About the Video:  Closed captioning is available, select CC from the video menu.  If you need to review a specific area on the video, view on YouTube and expand the video description for access to topic time stamps.  A video transcript is provided below.

• EBSCOhost Databases & Google Scholar

Defining Literature Review

What is a literature review.

A definition from the Online Dictionary for Library and Information Sciences .

A literature review is "a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works" (Reitz, 2014). 

A systemic review is "a literature review focused on a specific research question, which uses explicit methods to minimize bias in the identification, appraisal, selection, and synthesis of all the high-quality evidence pertinent to the question" (Reitz, 2014).

Recommended Reading

About this page

EBSCO Connect [Discovery and Search]. (2022). Searching with boolean operators. Retrieved May, 3, 2022 from https://connect.ebsco.com/s/?language=en_US

EBSCO Connect [Discover and Search]. (2022). Searching with wildcards and truncation symbols. Retrieved May 3, 2022; https://connect.ebsco.com/s/?language=en_US

Machi, L.A. & McEvoy, B.T. (2009). The literature review . Thousand Oaks, CA: Corwin Press: 

Reitz, J.M. (2014). Online dictionary for library and information science. ABC-CLIO, Libraries Unlimited . Retrieved from https://www.abc-clio.com/ODLIS/odlis_A.aspx

Ridley, D. (2008). The literature review: A step-by-step guide for students . Thousand Oaks, CA: Sage Publications, Inc.

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Methodology

• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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

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

 Statistics

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

Research bias

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

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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McCombes, S. (2023, September 11). How to Write a Literature Review | Guide, Examples, & Templates. Scribbr. Retrieved August 21, 2024, from https://www.scribbr.com/dissertation/literature-review/

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Chapter 9. Reviewing the Literature

What is a “literature review”.

No researcher ever comes up with a research question that is wholly novel. Someone, somewhere, has asked the same thing. Academic research is part of a larger community of researchers, and it is your responsibility, as a member of this community, to acknowledge others who have asked similar questions and to put your particular research into this greater context. It is not simply a convention or custom to begin your study with a review of previous literature (the “ lit review ”) but an important responsibility you owe the scholarly community.

Too often, new researchers pursue a topic to study and then write something like, “No one has ever studied this before” or “This area is underresearched.” It may be that no one has studied this particular group or setting, but it is highly unlikely no one has studied the foundational phenomenon of interest. And that comment about an area being underresearched? Be careful. The statement may simply signal to others that you haven’t done your homework. Rubin ( 2021 ) refers to this as “free soloing,” and it is not appreciated in academic work:

The truth of the matter is, academics don’t really like when people free solo. It’s really bad form to omit talking about the other people who are doing or have done research in your area. Partly, I mean we need to cite their work, but I also mean we need to respond to it—agree or disagree, clarify for extend. It’s also really bad form to talk about your research in a way that does not make it understandable to other academics.…You have to explain to your readers what your story is really about in terms they care about . This means using certain terminology, referencing debates in the literature, and citing relevant works—that is, in connecting your work to something else. ( 51–52 )

A literature review is a comprehensive summary of previous research on a topic. It includes both articles and books—and in some cases reports—relevant to a particular area of research. Ideally, one’s research question follows from the reading of what has already been produced. For example, you are interested in studying sports injuries related to female gymnasts. You read everything you can find on sports injuries related to female gymnasts, and you begin to get a sense of what questions remain open. You find that there is a lot of research on how coaches manage sports injuries and much about cultures of silence around treating injuries, but you don’t know what the gymnasts themselves are thinking about these issues. You look specifically for studies about this and find several, which then pushes you to narrow the question further. Your literature review then provides the road map of how you came to your very specific question, and it puts your study in the context of studies of sports injuries. What you eventually find can “speak to” all the related questions as well as your particular one.

In practice, the process is often a bit messier. Many researchers, and not simply those starting out, begin with a particular question and have a clear idea of who they want to study and where they want to conduct their study but don’t really know much about other studies at all. Although backward, we need to recognize this is pretty common. Telling students to “find literature” after the fact can seem like a purposeless task or just another hurdle for completing a thesis or dissertation. It is not! Even if you were not motivated by the literature in the first place, acknowledging similar studies and connecting your own research to those studies are important parts of building knowledge. Acknowledgment of past research is a responsibility you owe the discipline to which you belong.

Literature reviews can also signal theoretical approaches and particular concepts that you will incorporate into your own study. For example, let us say you are doing a study of how people find their first jobs after college, and you want to use the concept of social capital . There are competing definitions of social capital out there (e.g., Bourdieu vs. Burt vs. Putnam). Bourdieu’s notion is of one form of capital, or durable asset, of a “network of more or less institutionalized relationships of mutual acquaintance or recognition” ( 1984:248 ). Burt emphasizes the “brokerage opportunities” in a social network as social capital ( 1997:355 ). Putnam’s social capital is all about “facilitating coordination and cooperation for mutual benefit” ( 2001:67 ). Your literature review can adjudicate among these three approaches, or it can simply refer to the one that is animating your own research. If you include Bourdieu in your literature review, readers will know “what kind” of social capital you are talking about as well as what kind of social scientist you yourself are. They will likely understand that you are interested more in how some people are advantaged by their social capital relative to others rather than being interested in the mechanics of how social networks operate.

The literature review thus does two important things for you: firstly, it allows you to acknowledge previous research in your area of interest, thereby situating you within a discipline or body of scholars, and, secondly, it demonstrates that you know what you are talking about. If you present the findings of your research study without including a literature review, it can be like singing into the wind. It sounds nice, but no one really hears it, or if they do catch snippets, they don’t know where it is coming from.

Examples of Literature Reviews

To help you get a grasp of what a good literature review looks like and how it can advance your study, let’s take a look at a few examples.

Reader-Friendly Example: The Power of Peers

The first is by Janice McCabe ( 2016 ) and is from an article on peer networks in the journal Contexts . Contexts presents articles in a relatively reader-friendly format, with the goal of reaching a large audience for interesting sociological research. Read this example carefully and note how easily McCabe is able to convey the relevance of her own work by situating it in the context of previous studies:

Scholars who study education have long acknowledged the importance of peers for students’ well-being and academic achievement. For example, in 1961, James Coleman argued that peer culture within high schools shapes students’ social and academic aspirations and successes. More recently, Judith Rich Harris has drawn on research in a range of areas—from sociological studies of preschool children to primatologists’ studies of chimpanzees and criminologists’ studies of neighborhoods—to argue that peers matter much more than parents in how children “turn out.” Researchers have explored students’ social lives in rich detail, as in Murray Milner’s book about high school students, Freaks, Geeks, and Cool Kids , and Elizabeth Armstrong and Laura Hamilton’s look at college students, Paying for the Party . These works consistently show that peers play a very important role in most students’ lives. They tend, however, to prioritize social over academic influence and to use a fuzzy conception of peers rather than focusing directly on friends—the relationships that should matter most for student success. Social scientists have also studied the power of peers through network analysis, which is based on uncovering the web of connections between people. Network analysis involves visually mapping networks and mathematically comparing their structures (such as the density of ties) and the positions of individuals within them (such as how central a given person is within the network). As Nicholas Christakis and James Fowler point out in their book Connected , network structure influences a range of outcomes, including health, happiness, wealth, weight, and emotions. Given that sociologists have long considered network explanations for social phenomena, it’s surprising that we know little about how college students’ friends impact their experiences. In line with this network tradition, I focus on the structure of friendship networks, constructing network maps so that the differences we see across participants are due to the underlying structure, including each participant’s centrality in their friendship group and the density of ties among their friends. ( 23 )

What did you notice? In her very second sentence, McCabe uses “for example” to introduce a study by Coleman, thereby indicating that she is not going to tell you every single study in this area but is going to tell you that (1) there is a lot of research in this area, (2) it has been going on since at least 1961, and (3) it is still relevant (i.e., recent studies are still being done now). She ends her first paragraph by summarizing the body of literature in this area (after giving you a few examples) and then telling you what may have been (so far) left out of this research. In the second paragraph, she shifts to a separate interesting focus that is related to the first but is also quite distinct. Lit reviews very often include two (or three) distinct strands of literature, the combination of which nicely backgrounds this particular study . In the case of our female gymnast study (above), those two strands might be (1) cultures of silence around sports injuries and (2) the importance of coaches. McCabe concludes her short and sweet literature review with one sentence explaining how she is drawing from both strands of the literature she has succinctly presented for her particular study. This example should show you that literature reviews can be readable, helpful, and powerful additions to your final presentation.

Authoritative Academic Journal Example: Working Class Students’ College Expectations

The second example is more typical of academic journal writing. It is an article published in the British Journal of Sociology of Education by Wolfgang Lehmann ( 2009 ):

Although this increase in post-secondary enrolment and the push for university is evident across gender, race, ethnicity, and social class categories, access to university in Canada continues to be significantly constrained for those from lower socio-economic backgrounds (Finnie, Lascelles, and Sweetman 2005). Rising tuition fees coupled with an overestimation of the cost and an underestimation of the benefits of higher education has put university out of reach for many young people from low-income families (Usher 2005). Financial constraints aside, empirical studies in Canada have shown that the most important predictor of university access is parental educational attainment. Having at least one parent with a university degree significantly increases the likelihood of a young person to attend academic-track courses in high school, have high educational and career aspirations, and ultimately attend university (Andres et al. 1999, 2000; Lehmann 2007a). Drawing on Bourdieu’s various writing on habitus and class-based dispositions (see, for example, Bourdieu 1977, 1990), Hodkinson and Sparkes (1997) explain career decisions as neither determined nor completely rational. Instead, they are based on personal experiences (e.g., through employment or other exposure to occupations) and advice from others. Furthermore, they argue that we have to understand these decisions as pragmatic, rather than rational. They are pragmatic in that they are based on incomplete and filtered information, because of the social context in which the information is obtained and processed. New experiences and information can, however, also be allowed into one’s world, where they gradually or radically transform habitus, which in turn creates the possibility for the formation of new and different dispositions. Encountering a supportive teacher in elementary or secondary school, having ambitious friends, or chance encounters can spark such transformations. Transformations can be confirming or contradictory, they can be evolutionary or dislocating. Working-class students who enter university most certainly encounter such potentially transformative situations. Granfield (1991) has shown how initially dislocating feelings of inadequacy and inferiority of working-class students at an elite US law school were eventually replaced by an evolutionary transformation, in which the students came to dress, speak and act more like their middle-class and upper-class peers. In contrast, Lehmann (2007b) showed how persistent habitus dislocation led working-class university students to drop out of university. Foskett and Hemsley-Brown (1999) argue that young people’s perceptions of careers are a complex mix of their own experiences, images conveyed through adults, and derived images conveyed by the media. Media images of careers, perhaps, are even more important for working-class youth with high ambitions as they offer (generally distorted) windows into a world of professional employment to which they have few other sources of access. It has also been argued that working-class youth who do continue to university still face unique, class-specific challenges, evident in higher levels of uncertainty (Baxter and Britton 2001; Lehmann 2004, 2007a; Quinn 2004), their higher education choices (Ball et al. 2002; Brooks 2003; Reay et al. 2001) and fears of inadequacy because of their cultural outsider status (Aries and Seider 2005; Granfield 1991). Although the number of working-class university students in Canada has slowly increased, that of middle-class students at university has risen far more steeply (Knighton and Mizra 2002). These different enrolment trajectories have actually widened the participation gap, which in tum explains our continued concerns with the potential outsider status Indeed, in a study comparing first-generation working-class and traditional students who left university without graduating, Lehmann (2007b) found that first-generation working-class students were more likely to leave university very early in some cases within the first two months of enrollment. They were also more likely to leave university despite solid academic performance. Not “fitting in,” not “feeling university,” and not being able to “relate to these people” were key reasons for eventually withdrawing from university. From the preceding review of the literature, a number of key research questions arise: How do working-class university students frame their decision to attend university? How do they defy the considerable odds documented in the literature to attend university? What are the sources of information and various images that create dispositions to study at university? What role does their social-class background- or habitus play in their transition dispositions and how does this translate into expectations for university? ( 139 )

What did you notice here? How is this different from (and similar to) the first example? Note that rather than provide you with one or two illustrative examples of similar types of research, Lehmann provides abundant source citations throughout. He includes theory and concepts too. Like McCabe, Lehmann is weaving through multiple literature strands: the class gap in higher education participation in Canada, class-based dispositions, and obstacles facing working-class college students. Note how he concludes the literature review by placing his research questions in context.

Find other articles of interest and read their literature reviews carefully. I’ve included two more for you at the end of this chapter . As you learned how to diagram a sentence in elementary school (hopefully!), try diagramming the literature reviews. What are the “different strands” of research being discussed? How does the author connect these strands to their own research questions? Where is theory in the lit review, and how is it incorporated (e.g., Is it a separate strand of its own or is it inextricably linked with previous research in this area)?

One model of how to structure your literature review can be found in table 9.1. More tips, hints, and practices will be discussed later in the chapter.

Table 9.1. Model of Literature Review, Adopted from Calarco (2020:166)

Embracing Theory

A good research study will, in some form or another, use theory. Depending on your particular study (and possibly the preferences of the members of your committee), theory may be built into your literature review. Or it may form its own section in your research proposal/design (e.g., “literature review” followed by “theoretical framework”). In my own experience, I see a lot of graduate students grappling with the requirement to “include theory” in their research proposals. Things get a little squiggly here because there are different ways of incorporating theory into a study (Are you testing a theory? Are you generating a theory?), and based on these differences, your literature review proper may include works that describe, explain, and otherwise set forth theories, concepts, or frameworks you are interested in, or it may not do this at all. Sometimes a literature review sets forth what we know about a particular group or culture totally independent of what kinds of theoretical framework or particular concepts you want to explore. Indeed, the big point of your study might be to bring together a body of work with a theory that has never been applied to it previously. All this is to say that there is no one correct way to approach the use of theory and the writing about theory in your research proposal.

Students are often scared of embracing theory because they do not exactly understand what it is. Sometimes, it seems like an arbitrary requirement. You’re interested in a topic; maybe you’ve even done some research in the area and you have findings you want to report. And then a committee member reads over what you have and asks, “So what?” This question is a good clue that you are missing theory, the part that connects what you have done to what other researchers have done and are doing. You might stumble upon this rather accidentally and not know you are embracing theory, as in a case where you seek to replicate a prior study under new circumstances and end up finding that a particular correlation between behaviors only happens when mediated by something else. There’s theory in there, if you can pull it out and articulate it. Or it might be that you are motivated to do more research on racial microaggressions because you want to document their frequency in a particular setting, taking for granted the kind of critical race theoretical framework that has done the hard work of defining and conceptualizing “microaggressions” in the first place. In that case, your literature review could be a review of Critical Race Theory, specifically related to this one important concept. That’s the way to bring your study into a broader conversation while also acknowledging (and honoring) the hard work that has preceded you.

Rubin ( 2021 ) classifies ways of incorporating theory into case study research into four categories, each of which might be discussed somewhat differently in a literature review or theoretical framework section. The first, the least theoretical, is where you set out to study a “configurative idiographic case” ( 70 ) This is where you set out to describe a particular case, leaving yourself pretty much open to whatever you find. You are not expecting anything based on previous literature. This is actually pretty weak as far as research design goes, but it is probably the default for novice researchers. Your committee members should probably help you situate this in previous literature in some way or another. If they cannot, and it really does appear you are looking at something fairly new that no one else has bothered to research before, and you really are completely open to discovery, you might try using a Grounded Theory approach, which is a methodological approach that foregrounds the generation of theory. In that case, your “theory” section can be a discussion of “Grounded Theory” methodology (confusing, yes, but if you take some time to ponder, you will see how this works). You will still need a literature review, though. Ideally one that describes other studies that have ever looked at anything remotely like what you are looking at—parallel cases that have been researched.

The second approach is the “disciplined configurative case,” in which theory is applied to explain a particular case or topic. You are not trying to test the theory but rather assuming the theory is correct, as in the case of exploring microaggressions in a particular setting. In this case, you really do need to have a separate theory section in addition to the literature review, one in which you clearly define the theoretical framework, including any of its important concepts. You can use this section to discuss how other researchers have used the concepts and note any discrepancies in definitions or operationalization of those concepts. This way you will be sure to design your study so that it speaks to and with other researchers. If everyone who is writing about microaggressions has a different definition of them, it is hard for others to compare findings or make any judgments about their prevalence (or any number of other important characteristics). Your literature review section may then stand alone and describe previous research in the particular area or setting, irrespective of the kinds of theory underlying those studies.

The third approach is “heuristic,” one in which you seek to identify new variables, hypotheses, mechanisms, or paths not yet explained by a theory or theoretical framework. In a way, you are generating new theory, but it is probably more accurate to say that you are extending or deepening preexisting theory. In this case, having a single literature review that is focused on the theory and the ways the theory has been applied and understood (with all its various mechanisms and pathways) is probably your best option. The focus of the literature reviewed is less on the case and more on the theory you are seeking to extend.

The final approach is “theory testing,” which is much rarer in qualitative studies than in quantitative, where this is the default approach. Theory-testing cases are those where a particular case is used to see if an existing theory is accurate or accurate under particular circumstances. As with the heuristic approach, your literature review will probably draw heavily on previous uses of the theory, but you may end up having a special section specifically about cases very close to your own . In other words, the more your study approaches theory testing, the more likely there is to be a set of similar studies to draw on or even one important key study that you are setting your own study up in parallel to in order to find out if the theory generated there operates here.

If we wanted to get very technical, it might be useful to distinguish theoretical frameworks properly from conceptual frameworks. The latter are a bit looser and, given the nature of qualitative research, often fit exploratory studies. Theoretical frameworks rely on specific theories and are essential for theory-testing studies. Conceptual frameworks can pull in specific concepts or ideas that may or may not be linked to particular theories. Think about it this way: A theory is a story of how the world works. Concepts don’t presume to explain the whole world but instead are ways to approach phenomena to help make sense of them. Microaggressions are concepts that are linked to Critical Race Theory. One could contextualize one’s study within Critical Race Theory and then draw various concepts, such as that of microaggressions from the overall theoretical framework. Or one could bracket out the master theory or framework and employ the concept of microaggression more opportunistically as a phenomenon of interest. If you are unsure of what theory you are using, you might want to frame a more practical conceptual framework in your review of the literature.

Helpful Tips

How to maintain good notes for what your read.

Over the years, I have developed various ways of organizing notes on what I read. At first, I used a single sheet of full-size paper with a preprinted list of questions and points clearly addressed on the front side, leaving the second side for more reflective comments and free-form musings about what I read, why it mattered, and how it might be useful for my research. Later, I developed a system in which I use a single 4″ × 6″ note card for each book I read. I try only to use the front side (and write very small), leaving the back for comments that are about not just this reading but things to do or examine or consider based on the reading. These notes often mean nothing to anyone else picking up the card, but they make sense to me. I encourage you to find an organizing system that works for you. Then when you set out to compose a literature review, instead of staring at five to ten books or a dozen articles, you will have ten neatly printed pages or notecards or files that have distilled what is important to know about your reading.

It is also a good idea to store this data digitally, perhaps through a reference manager. I use RefWorks, but I also recommend EndNote or any other system that allows you to search institutional databases. Your campus library will probably provide access to one of these or another system. Most systems will allow you to export references from another manager if and when you decide to move to another system. Reference managers allow you to sort through all your literature by descriptor, author, year, and so on. Even so, I personally like to have the ability to manually sort through my index cards, recategorizing things I have read as I go. I use RefWorks to keep a record of what I have read, with proper citations, so I can create bibliographies more easily, and I do add in a few “notes” there, but the bulk of my notes are kept in longhand.

What kinds of information should you include from your reading? Here are some bulleted suggestions from Calarco ( 2020:113–114 ), with my own emendations:

• Citation . If you are using a reference manager, you can import the citation and then, when you are ready to create a bibliography, you can use a provided menu of citation styles, which saves a lot of time. If you’ve originally formatted in Chicago Style but the journal you are writing for wants APA style, you can change your entire bibliography in less than a minute. When using a notecard for a book, I include author, title, date as well as the library call number (since most of what I read I pull from the library). This is something RefWorks is not able to do, and it helps when I categorize.

I begin each notecard with an “intro” section, where I record the aims, goals, and general point of the book/article as explained in the introductory sections (which might be the preface, the acknowledgments, or the first two chapters). I then draw a bold line underneath this part of the notecard. Everything after that should be chapter specific. Included in this intro section are things such as the following, recommended by Calarco ( 2020 ):

• Key background . “Two to three short bullet points identifying the theory/prior research on which the authors are building and defining key terms.”
• Data/methods . “One or two short bullet points with information about the source of the data and the method of analysis, with a note if this is a novel or particularly effective example of that method.” I use [M] to signal methodology on my notecard, which might read, “[M] Int[erview]s (n-35), B[lack]/W[hite] voters” (I need shorthand to fit on my notecard!).
• Research question . “Stated as briefly as possible.” I always provide page numbers so I can go back and see exactly how this was stated (sometimes, in qualitative research, there are multiple research questions, and they cannot be stated simply).
• Argument/contributions . “Two to three short bullet points briefly describing the authors’ answer to the central research question and its implication for research, theory, and practice.” I use [ARG] for argument to signify the argument, and I make sure this is prominently visible on my notecard. I also provide page numbers here.

For me, all of this fits in the “intro” section, which, if this is a theoretically rich, methodologically sound book, might take up a third or even half of the front page of my notecard. Beneath the bold underline, I report specific findings or particulars of the book as they emerge chapter by chapter. Calarco’s ( 2020 ) next step is the following:

• Key findings . “Three to four short bullet points identifying key patterns in the data that support the authors’ argument.”

All that remains is writing down thoughts that occur upon finishing the article/book. I use the back of the notecard for these kinds of notes. Often, they reach out to other things I have read (e.g., “Robinson reminds me of Crusoe here in that both are looking at the effects of social isolation, but I think Robinson makes a stronger argument”). Calarco ( 2020 ) concludes similarly with the following:

• Unanswered questions . “Two to three short bullet points that identify key limitations of the research and/or questions the research did not answer that could be answered in future research.”

As I mentioned, when I first began taking notes like this, I preprinted pages with prompts for “research question,” “argument,” and so on. This was a great way to remind myself to look for these things in particular. You can do the same, adding whatever preprinted sections make sense to you, given what you are studying and the important aspects of your discipline. The other nice thing about the preprinted forms is that it keeps your writing to a minimum—you cannot write more than the allotted space, even if you might want to, preventing your notes from spiraling out of control. This can be helpful when we are new to a subject and everything seems worth recording!

After years of discipline, I have finally settled on my notecard approach. I have thousands of notecards, organized in several index card filing boxes stacked in my office. On the top right of each card is a note of the month/day I finished reading the item. I can remind myself what I read in the summer of 2010 if the need or desire ever arose to do so…those invaluable notecards are like a memento of what my brain has been up to!

Where to Start Looking for Literature

Your university library should provide access to one of several searchable databases for academic books and articles. My own preference is JSTOR, a service of ITHAKA, a not-for-profit organization that works to advance and preserve knowledge and to improve teaching and learning through the use of digital technologies. JSTOR allows you to search by several keywords and to narrow your search by type of material (articles or books). For many disciplines, the “literature” of the literature review is expected to be peer-reviewed “articles,” but some disciplines will also value books and book chapters. JSTOR is particularly useful for article searching. You can submit several keywords and see what is returned, and you can also narrow your search by a particular journal or discipline. If your discipline has one or two key journals (e.g., the American Journal of Sociology and the American Sociological Review are key for sociology), you might want to go directly to those journals’ websites and search for your topic area. There is an art to when to cast your net widely and when to refine your search, and you may have to tack back and forth to ensure that you are getting all that is relevant but not getting bogged down in all studies that might have some marginal relevance.

Some articles will carry more weight than others, and you can use applications like Google Scholar to see which articles have made and are continuing to make larger impacts on your discipline. Find these articles and read them carefully; use their literature review and the sources cited in those articles to make sure you are capturing what is relevant. This is actually a really good way of finding relevant books—only the most impactful will make it into the citations of journals. Over time, you will notice that a handful of articles (or books) are cited so often that when you see, say, Armstrong and Hamilton ( 2015 ), you know exactly what book this is without looking at the full cite. This is when you know you are in the conversation.

You might also approach a professor whose work is broadly in the area of your interest and ask them to recommend one or two “important” foundational articles or books. You can then use the references cited in those recommendations to build up your literature. Just be careful: some older professors’ knowledge of the literature (and I reluctantly add myself here) may be a bit outdated! It is best that the article or book whose references and sources you use to build your body of literature be relatively current.

Keep a List of Your Keywords

When using searchable databases, it is a good idea to keep a list of all the keywords you use as you go along so that (1) you do not needlessly duplicate your efforts and (2) you can more easily adjust your search as you get a better sense of what you are looking for. I suggest you keep a separate file or even a small notebook for this and you date your search efforts.

Here’s an example:

Table 9.2. Keep a List of Your Keywords

Think Laterally

How to find the various strands of literature to combine? Don’t get stuck on finding the exact same research topic you think you are interested in. In the female gymnast example, I recommended that my student consider looking for studies of ballerinas, who also suffer sports injuries and around whom there is a similar culture of silence. It turned out that there was in fact research about my student’s particular questions, just not about the subjects she was interested in. You might do something similar. Don’t get stuck looking for too direct literature but think about the broader phenomenon of interest or analogous cases.

Read Outside the Canon

Some scholars’ work gets cited by everyone all the time. To some extent, this is a very good thing, as it helps establish the discipline. For example, there are a lot of “Bourdieu scholars” out there (myself included) who draw ideas, concepts, and quoted passages from Bourdieu. This makes us recognizable to one another and is a way of sharing a common language (e.g., where “cultural capital” has a particular meaning to those versed in Bourdieusian theory). There are empirical studies that get cited over and over again because they are excellent studies but also because there is an “echo chamber effect” going on, where knowing to cite this study marks you as part of the club, in the know, and so on. But here’s the problem with this: there are hundreds if not thousands of excellent studies out there that fail to get appreciated because they are crowded out by the canon. Sometimes this happens because they are published in “lower-ranked” journals and are never read by a lot of scholars who don’t have time to read anything other than the “big three” in their field. Other times this happens because the author falls outside of the dominant social networks in the field and thus is unmentored and fails to get noticed by those who publish a lot in those highly ranked and visible spaces. Scholars who fall outside the dominant social networks and who publish outside of the top-ranked journals are in no way less insightful than their peers, and their studies may be just as rigorous and relevant to your work, so it is important for you to take some time to read outside the canon. Due to how a person’s race, gender, and class operate in the academy, there is also a matter of social justice and ethical responsibility involved here: “When you focus on the most-cited research, you’re more likely to miss relevant research by women and especially women of color, whose research tends to be under-cited in most fields. You’re also more likely to miss new research, research by junior scholars, and research in other disciplines that could inform your work. Essentially, it is important to read and cite responsibly, which means checking that you’re not just reading and citing the same white men and the same old studies that everyone has cited before you” ( Calarco 2020:112 ).

Consider Multiple Uses for Literature

Throughout this chapter, I’ve referred to the literature of interest in a rather abstract way, as what is relevant to your study. But there are many different ways previous research can be relevant to your study. The most basic use of the literature is the “findings”—for example, “So-and-so found that Canadian working-class students were concerned about ‘fitting in’ to the culture of college, and I am going to look at a similar question here in the US.” But the literature may be of interest not for its findings but theoretically—for example, employing concepts that you want to employ in your own study. Bourdieu’s definition of social capital may have emerged in a study of French professors, but it can still be relevant in a study of, say, how parents make choices about what preschools to send their kids to (also a good example of lateral thinking!).

If you are engaged in some novel methodological form of data collection or analysis, you might look for previous literature that has attempted that. I would not recommend this for undergraduate research projects, but for graduate students who are considering “breaking the mold,” find out if anyone has been there before you. Even if their study has absolutely nothing else in common with yours, it is important to acknowledge that previous work.

Describing Gaps in the Literature

First, be careful! Although it is common to explain how your research adds to, builds upon, and fills in gaps in the previous research (see all four literature review examples in this chapter for this), there is a fine line between describing the gaps and misrepresenting previous literature by failing to conduct a thorough review of the literature. A little humility can make a big difference in your presentation. Instead of “This is the first study that has looked at how firefighters juggle childcare during forest fire season,” say, “I use the previous literature on how working parents juggling childcare and the previous ethnographic studies of firefighters to explore how firefighters juggle childcare during forest fire season.” You can even add, “To my knowledge, no one has conducted an ethnographic study in this specific area, although what we have learned from X about childcare and from Y about firefighters would lead us to expect Z here.” Read more literature review sections to see how others have described the “gaps” they are filling.

Use Concept Mapping

Concept mapping is a helpful tool for getting your thoughts in order and is particularly helpful when thinking about the “literature” foundational to your particular study. Concept maps are also known as mind maps, which is a delightful way to think about them. Your brain is probably abuzz with competing ideas in the early stages of your research design. Write/draw them on paper, and then try to categorize and move the pieces around into “clusters” that make sense to you. Going back to the gymnasts example, my student might have begun by jotting down random words of interest: gymnasts * sports * coaches * female gymnasts * stress * injury * don’t complain * women in sports * bad coaching * anxiety/stress * careers in sports * pain. She could then have begun clustering these into relational categories (bad coaching, don’t complain culture) and simple “event” categories (injury, stress). This might have led her to think about reviewing literature in these two separate aspects and then literature that put them together. There is no correct way to draw a concept map, as they are wonderfully specific to your mind. There are many examples you can find online.

Ask Yourself, “How Is This Sociology (or Political Science or Public Policy, Etc.)?”

Rubin ( 2021:82 ) offers this suggestion instead of asking yourself the “So what?” question to get you thinking about what bridges there are between your study and the body of research in your particular discipline. This is particularly helpful for thinking about theory. Rubin further suggests that if you are really stumped, ask yourself, “What is the really big question that all [fill in your discipline here] care about?” For sociology, it might be “inequality,” which would then help you think about theories of inequality that might be helpful in framing your study on whatever it is you are studying—OnlyFans? Childcare during COVID? Aging in America? I can think of some interesting ways to frame questions about inequality for any of those topics. You can further narrow it by focusing on particular aspects of inequality (Gender oppression? Racial exclusion? Heteronormativity?). If your discipline is public policy, the big questions there might be, How does policy get enacted, and what makes a policy effective? You can then take whatever your particular policy interest is—tax reform, student debt relief, cap-and-trade regulations—and apply those big questions. Doing so would give you a handle on what is otherwise an intolerably vague subject (e.g., What about student debt relief?).

Sometimes finding you are in new territory means you’ve hit the jackpot, and sometimes it means you’ve traveled out of bounds for your discipline. The jackpot scenario is wonderful. You are doing truly innovative research that is combining multiple literatures or is addressing a new or under-examined phenomenon of interest, and your research has the potential to be groundbreaking. Congrats! But that’s really hard to do, and it might be more likely that you’ve traveled out of bounds, by which I mean, you are no longer in your discipline . It might be that no one has written about this thing—at least within your field— because no one in your field actually cares about this topic . ( Rubin 2021:83 ; emphases added)

Don’t Treat This as a Chore

Don’t treat the literature review as a chore that has to be completed, but see it for what it really is—you are building connections to other researchers out there. You want to represent your discipline or area of study fairly and adequately. Demonstrate humility and your knowledge of previous research. Be part of the conversation.

Supplement: Two More Literature Review Examples

Elites by harvey ( 2011 ).

In the last two decades, there has been a small but growing literature on elites. In part, this has been a result of the resurgence of ethnographic research such as interviews, focus groups, case studies, and participant observation but also because scholars have become increasingly interested in understanding the perspectives and behaviors of leaders in business, politics, and society as a whole. Yet until recently, our understanding of some of the methodological challenges of researching elites has lagged behind our rush to interview them.

There is no clear-cut definition of the term elite, and given its broad understanding across the social sciences, scholars have tended to adopt different approaches. Zuckerman (1972) uses the term ultraelites to describe individuals who hold a significant amount of power within a group that is already considered elite. She argues, for example, that US senators constitute part of the country’s political elite but that among them are the ultraelites: a “subset of particularly powerful or prestigious influentials” (160). She suggests that there is a hierarchy of status within elite groups. McDowell (1998) analyses a broader group of “professional elites” who are employees working at different levels for merchant and investment banks in London. She classifies this group as elite because they are “highly skilled, professionally competent, and class-specific” (2135). Parry (1998:2148) uses the term hybrid elites in the context of the international trade of genetic material because she argues that critical knowledge exists not in traditional institutions “but rather as increasingly informal, hybridised, spatially fragmented, and hence largely ‘invisible,’ networks of elite actors.” Given the undertheorization of the term elite, Smith (2006) recognizes why scholars have shaped their definitions to match their respondents . However, she is rightly critical of the underlying assumption that those who hold professional positions necessarily exert as much influence as initially perceived. Indeed, job titles can entirely misrepresent the role of workers and therefore are by no means an indicator of elite status (Harvey 2010).

Many scholars have used the term elite in a relational sense, defining them either in terms of their social position compared to the researcher or compared to the average person in society (Stephens 2007). The problem with this definition is there is no guarantee that an elite subject will necessarily translate this power and authority in an interview setting. Indeed, Smith (2006) found that on the few occasions she experienced respondents wanting to exert their authority over her, it was not from elites but from relatively less senior workers. Furthermore, although business and political elites often receive extensive media training, they are often scrutinized by television and radio journalists and therefore can also feel threatened in an interview, particularly in contexts that are less straightforward to prepare for such as academic interviews. On several occasions, for instance, I have been asked by elite respondents or their personal assistants what they need to prepare for before the interview, which suggests that they consider the interview as some form of challenge or justification for what they do.

In many cases, it is not necessarily the figureheads or leaders of organizations and institutions who have the greatest claim to elite status but those who hold important social networks, social capital, and strategic positions within social structures because they are better able to exert influence (Burt 1992; Parry 1998; Smith 2005; Woods 1998). An elite status can also change, with people both gaining and losing theirs over time. In addition, it is geographically specific, with people holding elite status in some but not all locations. In short, it is clear that the term elite can mean many things in different contexts, which explains the range of definitions. The purpose here is not to critique these other definitions but rather to highlight the variety of perspectives.

When referring to my research, I define elites as those who occupy senior-management- and board-level positions within organizations. This is a similar scope of definition to Zuckerman’s (1972) but focuses on a level immediately below her ultraelite subjects. My definition is narrower than McDowell’s (1998) because it is clear in the context of my research that these people have significant decision-making influence within and outside of the firm and therefore present a unique challenge to interview. I deliberately use the term elite more broadly when drawing on examples from the theoretical literature in order to compare my experiences with those who have researched similar groups.

”Changing Dispositions among the Upwardly Mobile” by Curl, Lareau, and Wu ( 2018 )

There is growing interest in the role of cultural practices in undergirding the social stratification system. For example, Lamont et al. (2014) critically assess the preoccupation with economic dimensions of social stratification and call for more developed cultural models of the transmission of inequality. The importance of cultural factors in the maintenance of social inequality has also received empirical attention from some younger scholars, including Calarco (2011, 2014) and Streib (2015). Yet questions remain regarding the degree to which economic position is tied to cultural sensibilities and the ways in which these cultural sensibilities are imprinted on the self or are subject to change. Although habitus is a core concept in Bourdieu’s theory of social reproduction, there is limited empirical attention to the precise areas of the habitus that can be subject to change during upward mobility as well as the ramifications of these changes for family life.

In Bourdieu’s (1984) highly influential work on the importance of class-based cultural dispositions, habitus is defined as a “durable system of dispositions” created in childhood. The habitus provides a “matrix of perceptions” that seems natural while also structuring future actions and pathways. In many of his writings, Bourdieu emphasized the durability of cultural tastes and dispositions and did not consider empirically whether these dispositions might be changed or altered throughout one’s life (Swartz 1997). His theoretical work does permit the possibility of upward mobility and transformation, however, through the ability of the habitus to “improvise” or “change” due to “new experiences” (Friedman 2016:131). Researchers have differed in opinion on the durability of the habitus and its ability to change (King 2000). Based on marital conflict in cross-class marriages, for instance, Streib (2015) argues that cultural dispositions of individuals raised in working-class families are deeply embedded and largely unchanging. In a somewhat different vein, Horvat and Davis (2011:152) argue that young adults enrolled in an alternative educational program undergo important shifts in their self-perception, such as “self-esteem” and their “ability to accomplish something of value.” Others argue there is variability in the degree to which habitus changes dependent on life experience and personality (Christodoulou and Spyridakis 2016). Recently, additional studies have investigated the habitus as it intersects with lifestyle through the lens of meaning making (Ambrasat et al. 2016). There is, therefore, ample discussion of class-based cultural practices in self-perception (Horvat and Davis 2011), lifestyle (Ambrasat et al. 2016), and other forms of taste (Andrews 2012; Bourdieu 1984), yet researchers have not sufficiently delineated which aspects of the habitus might change through upward mobility or which specific dimensions of life prompt moments of class-based conflict.

Bourdieu (1999:511; 2004) acknowledged simmering tensions between the durable aspects of habitus and those aspects that have been transformed—that is, a “fractured” or “cleft” habitus. Others have explored these tensions as a “divided” or “fragmented” habitus (Baxter and Britton 2001; Lee and Kramer 2013). Each of these conceptions of the habitus implies that changes in cultural dispositions are possible but come with costs. Exploration of the specific aspects of one’s habitus that can change and generate conflict contributes to this literature.

Scholars have also studied the costs associated with academic success for working-class undergraduates (Hurst 2010; Lee and Kramer 2013; London 1989; Reay 2017; Rondini 2016; Stuber 2011), but we know little about the lasting effects on adults. For instance, Lee and Kramer (2013) point to cross-class tensions as family and friends criticize upwardly mobile individuals for their newly acquired cultural dispositions. Documenting the tension many working-class students experience with their friends and families of origin, they find that the source of their pain or struggle is “shaped not only by their interactions with non-mobile family and friends but also within their own minds, by their own assessments of their social positions, and by how those positions are interpreted by others” (Lee and Kramer 2013:29). Hurst (2010) also explores the experiences of undergraduates who have been academically successful and the costs associated with that success. She finds that decisions about “class allegiance and identity” are required aspects of what it means to “becom[e] educated” (4) and that working-class students deal with these cultural changes differently. Jack (2014, 2016) also argues that there is diversity among lower-income students, which yields varied college experiences. Naming two groups, the “doubly disadvantaged” and the “privileged poor,” he argues that previous experience with “elite environments” (2014:456) prior to college informs students’ ability to take on dominant cultural practices, particularly around engagement, such as help seeking or meeting with professors (2016). These studies shed light on the role college might play as a “lever for mobility” (2016:15) and discuss the pain and difficulty associated with upward mobility among undergraduates, but the studies do not illuminate how these tensions unfold in adulthood. Neither have they sufficiently addressed potential enduring tensions with extended family members as well as the specific nature of the difficulties.

Some scholars point to the positive outcomes upwardly mobile youth (Lehmann 2009) and adults (Stuber 2005) experience when they maintain a different habitus than their newly acquired class position, although, as Jack (2014, 2016) shows, those experiences may vary depending on one’s experience with elite environments in their youth. Researchers have not sufficiently explored the specific aspects of the habitus that upwardly mobile adults change or the conflicts that emerge with family and childhood friends as they reach adulthood and experience colliding social worlds. We contribute to this scholarship with clear examples of self-reported changes to one’s cultural dispositions in three specific areas: “horizons,” food and health, and communication. We link these changes to enduring tension with family members, friends, and colleagues and explore varied responses to this tension based on race.

Further Readings

Bloomberg, Linda Dale, and Marie F. Volpe. 2012. Completing Your Qualitative Dissertation: A Road Map from Beginning to End . 2nd ed. Thousand Oaks, CA: SAGE. In keeping with its general approach to qualitative research, includes a “road map” for conducting a literature review.

Hart, Chris. 1998. Doing a Literature Review: Releasing the Social Science Research Imagination . London: SAGE. A how-to book dedicated entirely to conducting a literature review from a British perspective. Useful for both undergraduate and graduate students.

Machi, Lawrence A., and Brenda T. McEvoy. 2022. The Literature Review: Six Steps to Success . 4th ed. Newbury Park, CA: Corwin. A well-organized guidebook complete with reflection sections to prompt successful thinking about your literature review.

Ridley, Diana. 2008. The Literature Review: A Step-by-Step Guide for Students . London: SAGE. A highly recommended companion to conducting a literature review for doctoral-level students.

The process of systematically searching through pre-existing studies (“literature”) on the subject of research; also, the section of a presentation in which the pre-existing literature is discussed.

Follow-up questions used in a semi-structured interview  to elicit further elaboration.  Suggested prompts can be included in the interview guide  to be used/deployed depending on how the initial question was answered or if the topic of the prompt does not emerge spontaneously.

A tool for identifying relationships among ideas by visually representing them on paper.  Most concept maps depict ideas as boxes or circles (also called nodes), which are structured hierarchically and connected with lines or arrows (also called arcs). These lines are labeled with linking words and phrases to help explain the connections between concepts.  Also known as mind mapping.

The people who are the subjects of an interview-based qualitative study. In general, they are also known as the participants, and for purposes of IRBs they are often referred to as the human subjects of the research.

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

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A Guide to Writing a Qualitative Systematic Review Protocol to Enhance Evidence-Based Practice in Nursing and Health Care

Affiliations.

• 1 PhD candidate, School of Nursing and Midwifey, Monash University, and Clinical Nurse Specialist, Adult and Pediatric Intensive Care Unit, Monash Health, Melbourne, Victoria, Australia.
• 2 Lecturer, School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia.
• 3 Senior Lecturer, School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia.
• PMID: 26790142
• DOI: 10.1111/wvn.12134

Background: The qualitative systematic review is a rapidly developing area of nursing research. In order to present trustworthy, high-quality recommendations, such reviews should be based on a review protocol to minimize bias and enhance transparency and reproducibility. Although there are a number of resources available to guide researchers in developing a quantitative review protocol, very few resources exist for qualitative reviews.

Aims: To guide researchers through the process of developing a qualitative systematic review protocol, using an example review question.

Methodology: The key elements required in a systematic review protocol are discussed, with a focus on application to qualitative reviews: Development of a research question; formulation of key search terms and strategies; designing a multistage review process; critical appraisal of qualitative literature; development of data extraction techniques; and data synthesis. The paper highlights important considerations during the protocol development process, and uses a previously developed review question as a working example.

Implications for research: This paper will assist novice researchers in developing a qualitative systematic review protocol. By providing a worked example of a protocol, the paper encourages the development of review protocols, enhancing the trustworthiness and value of the completed qualitative systematic review findings.

Linking evidence to action: Qualitative systematic reviews should be based on well planned, peer reviewed protocols to enhance the trustworthiness of results and thus their usefulness in clinical practice. Protocols should outline, in detail, the processes which will be used to undertake the review, including key search terms, inclusion and exclusion criteria, and the methods used for critical appraisal, data extraction and data analysis to facilitate transparency of the review process. Additionally, journals should encourage and support the publication of review protocols, and should require reference to a protocol prior to publication of the review results.

Keywords: guidelines; meta synthesis; qualitative; systematic review protocol.

© 2016 Sigma Theta Tau International.

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Qualitative systematic reviews: their importance for our understanding of research relevant to pain

This article outlines what a qualitative systematic review is and explores what it can contribute to our understanding of pain. Many of us use evidence of effectiveness for various interventions when working with people in pain. A good systematic review can be invaluable in bringing together research evidence to help inform our practice and help us understand what works. In addition to evidence of effectiveness, understanding how people with pain experience both their pain and their care can help us when we are working with them to provide care that meets their needs. A rigorous qualitative systematic review can also uncover new understandings, often helping illuminate ‘why’ and can help build theory. Such a review can answer the question ‘What is it like to have chronic pain?’ This article presents the different stages of meta-ethnography, which is the most common methodology used for qualitative systematic reviews. It presents evidence from four meta-ethnographies relevant to pain to illustrate the types of findings that can emerge from this approach. It shows how new understandings may emerge and gives an example of chronic musculoskeletal pain being experienced as ‘an adversarial struggle’ across many aspects of the person’s life. This article concludes that evidence from qualitative systematic reviews has its place alongside or integrated with evidence from more quantitative approaches.

Many of us use evidence of effectiveness for various interventions when working with people in pain. A good systematic review can be invaluable in bringing together research evidence to help inform our practice and help us understand what works. In addition to evidence of effectiveness, understanding how people with pain experience both their pain and their care can help us when we are working with them to provide care that meets their needs. A high-quality qualitative systematic review can also uncover new understandings, often helping illuminate ‘why’ and can help build theory. A qualitative systematic review could answer the question ‘What is it like to have chronic non-malignant pain?’

The purpose of this article is to outline what a qualitative systematic review is and explore what it can contribute to our understanding of pain. A qualitative systematic review brings together research on a topic, systematically searching for research evidence from primary qualitative studies and drawing the findings together. There is a debate over whether the search needs to be exhaustive. 1 , 2 Methods for systematic reviews of quantitative research are well established and explicit and have been pioneered through the Cochrane Collaboration. Methods for qualitative systematic reviews have been developed more recently and are still evolving. The Cochrane Collaboration now has a Qualitative and Implementation Methods Group, including a register of protocols, illustrating the recognition of the importance of qualitative research within the Cochrane Collaboration. In November 2013, an editorial described the Cochrane Collaboration’s first publication of a qualitative systematic review as ‘a new milestone’ for Cochrane. 3 Other editorials have raised awareness of qualitative systematic reviews in health. 4

Noblit and Hare 5 were pioneers in the area of synthesising qualitative data. They describe such reviews as aggregated or as interpretative. The aggregated review summarises the data, and Hannes and Pearson 6 provide a worked example of an aggregation approach. Interpretative approaches, as the name suggests, interpret the data, and from that interpretation, new understandings can develop that may lead to development of a theory that helps us to understand or predict behaviour. Types of interpretative qualitative systematic reviews include meta-ethnography, critical interpretative synthesis, realist synthesis and narrative synthesis. More details about these and other approaches can be found in other papers and books. 1 , 5 , 7 – 11 This article will describe one approach, meta-ethnography, as it was identified as the most frequently used approach, 1 and there are some examples using meta-ethnography that focus on pain. A meta-ethnographic approach can be used with a variety of qualitative methodologies, not only ethnography. The data for a meta-ethnography are the concepts or themes described by the authors of the primary studies.

Noblit and Hare 5 outlined the seven steps of a meta-ethnography: (1) getting started, (2) deciding what is relevant, (3) reading the studies, (4) determining how studies are related to each other, (5) translating studies into each other, (6) synthesising translations and (7) expressing the synthesis.

The first three might seem relatively straightforward, although Lee et al. 12 emphasised both the importance and nuances of the reading stage, and Toye et al. 13 discuss the complexities of making quality assessments of qualitative papers and searching for this type of study. You need to understand what data to extract from the papers and how you are going to do this.

You have to first identify what is a concept and what is purely descriptive. Toye et al. 2 describe a process for collaboratively identifying concepts. In determining how studies are related to each other and translating them into each other, the meta-ethnographer compares the concepts found in each study with each other and then groups similar concepts into conceptual themes. Translating studies into each other involves looking at where concepts between studies agree (reciprocal synthesis) and where they do not agree (refutational synthesis). Developing conceptual categories can be challenging as you need to judge the extent to which a concept from one study adequately reflects concepts from other studies and choose one that seems to fit best. This is discussed in more detail in Toye et al. 2 , 13

To synthesise the translation, a line of argument is then developed from the conceptual categories. How the concepts group and relate to each other are developed. This provides an overall interpretation of the findings, ensuring this is grounded in the data from the primary studies. You are aiming to explain, and new concepts and understandings may emerge, which can then go on to underpin development of theory. For example, a qualitative systematic review that explored medicine taking found that ‘resistance’ was a new concept, revealed through meta-ethnography, and this helped understanding of lay responses to medicine taking. 1 Hannes and Macaitis, 14 in a review of published papers, reported that over time, authors have become more transparent about searching and critical appraisal, but that the synthesis element of reviews is often not well described. Being transparent about decisions that are interpretative has its own challenges. Working collaboratively to challenge interpretations and assumptions can be helpful. 2 , 12 The next section will use examples of qualitative systematic reviews from the pain field to illuminate what this type of review can contribute to our understanding of pain.

What can a qualitative systematic review contribute to the field of pain – some examples

Toye et al. 2 , 15 undertook a meta-ethnography to look at patients’ experiences of chronic non-malignant musculoskeletal pain. At the time of this research, no other qualitative systematic reviews had been published in this area. Their review included 77 papers reporting 60 individual studies, resulting from searches of six electronic bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, AMED and HMIC) from inception until February 2012 and hand-searching key journals from 2001 to 2012.

They developed a new concept which they identified as an ‘adversarial struggle’. This struggle took place across five main dimensions: (1) there was a struggle to affirm themselves, where there was a tension between the ‘real me’ (without pain) and ‘not real me’ (me with pain). (2) The present and future were often unpredictable, and construction of time was altered and they struggled to reconstruct themselves in time. (3) People struggled to find an acceptable explanation for their pain and suffering. (4) There was a struggle to negotiate the healthcare system and (5) a struggle for pain to be seen as legitimate, including the need to be believed, and a struggle to know whether to show or hide their pain. Some people were able to move forward with pain. They saw their body as more integrated, they re-defined what was normal, they told people about their pain, they were part of a community of people with pain and they felt more expert on how their pain affected them and what they could do about it.

So, this meta-ethnography highlighted the adversarial nature of having chronic musculoskeletal pain and how this struggle pervaded many different areas of their life. It also illustrated how by showing patients their pain is understood and being alongside the person in pain, they can start to move forward. A short film based on the 77 papers in this meta-ethnography has been made and is available on YouTube. 16 This film was made as an attempt to disseminate the findings of a meta-ethnography in a way that is accessible to a range of people.

Snelgrove and Liossi 17 undertook a meta-ethnography of qualitative research in chronic low back pain (CLBP) using meta-ethnography. They included 33 papers of 28 studies published between 2000 and 2012. They identified three overarching themes of (1) the impact of CLBP on self, (2) relationships with others (health professionals and family and friends) and (3) coping with CLBP. They found that very few successful coping strategies were reported. Like Toye et al., 2 , 15 they also reported disruption to self, distancing their valued self from their painful self, legitimising pain, the struggle to manage daily living and the importance of social relationships alongside negotiation of their care in the health system.

MacNeela et al. 18 also undertook a meta-ethnography of experiences of CLBP. They included 38 articles published between 1994 and 2012 representing 28 studies. They identified four themes: (1) the undermining influence of pain, (2) the disempowering impact on all levels, (3) unsatisfying relationships with healthcare professionals and (4) learning to live with the pain. They reported the findings being dominated by ‘wide-ranging distress and loss’. They discussed the disempowering consequences of pain and a search for help. However, they also highlighted self-determination and resilience and suggested these could offer ‘pathways to endurance’. They emphasised self-management and adaptation, which resonates with the moving forward category reported by Toye et al. 2 , 15

Froud et al. 19 looked at the impact of low back pain on people’s lives. They describe their approach as meta-ethnographic and meta-narrative. They included 49 papers of about 42 studies from inception of databases searched until July 2011. They described five themes: activities, relationships, work, stigma and changing outlook, which they derived from ‘participant-level data’. They described their findings as showing patients wanted to be believed. They highlighted the importance of social factors when developing relevant outcome measures. There are other examples of qualitative systematic reviews relevant to pain. 20 – 23

Different qualitative systematic reviews on a similar subject may come up with overlapping but also some different findings. This could be, for example, because different search periods or different inclusion criteria are used, so different primary studies may be included in different reviews. In addition, undertaking a qualitative systematic review requires researchers to interpret concepts. This interpretation does not need to be a limitation. For example, to ensure rigour and transparency, Toye et al. 24 report a process of collaborative interpretation of concepts among a team of experienced qualitative researchers to ensure individual interpretations were challenged and remained grounded in the original studies. They also published a detailed audit trail of the processes and decisions made. 2 Campbell et al. 1 argue ‘Meta-ethnography is a highly interpretative method requiring considerable immersion in the individual studies to achieve a synthesis. It places substantial demands upon the synthesiser and requires a high degree of qualitative research skill’. It is important to be able to think conceptually when undertaking a meta-ethnography, and it can be a time-consuming process. However, the ability of a meta-ethnography to synthesise a large number of primary research studies, generate new conceptual understandings and thus increase our understanding of patients’ experiences of pain makes it a very useful resource for our evidence-based practice.

The way forward

A register of qualitative systematic reviews would be useful for researchers and clinicians, so there was a clear way of identifying existing qualitative reviews or reviews that are planned or underway. The Cochrane Collaboration does now have a register for protocols of qualitative systematic reviews being undertaken under the aegis of the Cochrane Qualitative and Implementation Methods Group. It would help those wanting to undertake qualitative systematic reviews if reviews that were underway were registered and described more clearly to prevent duplication of effort, for example, using ‘qualitative systematic review’ and the methodological approach used (such as meta-ethnography) in the title and/or abstract. The Toye et al. 2 protocol 25 was accessible on the National Institutes for Health website from 2010. The Snelgrove and Liossi 17 study was done without external funding, so it would be difficult to pick up that it was underway. The MacNeela et al. 18 study was listed on the Irish Research Council for the Humanities and Social Sciences under their Research Development Initiative 2008–2009, but was described as ‘Motivation and Beliefs among People Experiencing Chronic Low Back Pain’, so it was not clearly identified at that stage as a qualitative systematic review. Finally, the Froud et al. 19 award details 26 do not mention qualitative systematic reviews or meta-ethnography. This highlights the difficulty of finding some of these reviews and the importance of a register of both completed and ongoing reviews.

This article has argued that qualitative systematic reviews have their place alongside or integrated with more quantitative approaches. There is an increasing body of evidence from qualitative systematic reviews. They can synthesise primary research, and this can be helpful for the busy practitioner. The methods for these approaches are still developing, and attention to rigour at each stage is crucial. It is important that each stage of the synthesis is reported transparently and that the researchers’ stance is clearly reported. 27 Meta-ethnographies published over the last year 2 , 15 , 17 – 19 have drawn together a wide range of primary studies and shown that people’s lives can be markedly changed by their pain across multiple dimensions of their life.

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

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Qualitative researchers TEND to:

Researchers using qualitative methods tend to:

• t hink that social sciences cannot be well-studied with the same methods as natural or physical sciences
• feel that human behavior is context-specific; therefore, behavior must be studied holistically, in situ, rather than being manipulated
• employ an 'insider's' perspective; research tends to be personal and thereby more subjective.
• do interviews, focus groups, field research, case studies, and conversational or content analysis.

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Qualitative Research (an operational definition)

Qualitative Research: an operational description

Purpose : explain; gain insight and understanding of phenomena through intensive collection and study of narrative data

Approach: inductive; value-laden/subjective; holistic, process-oriented

Hypotheses: tentative, evolving; based on the particular study

Lit. Review: limited; may not be exhaustive

Setting: naturalistic, when and as much as possible

Sampling : for the purpose; not necessarily representative; for in-depth understanding

Measurement: narrative; ongoing

Design and Method: flexible, specified only generally; based on non-intervention, minimal disturbance, such as historical, ethnographic, or case studies

Data Collection: document collection, participant observation, informal interviews, field notes

Data Analysis: raw data is words/ ongoing; involves synthesis

Data Interpretation: tentative, reviewed on ongoing basis, speculative

• Qualitative research with more structure and less subjectivity
• Increased application of both strategies to the same study ("mixed methods")
• Evidence-based practice emphasized in more fields (nursing, social work, education, and others).

Some Other Guidelines

• Guide for formatting Graphs and Tables
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Quantitative researchers TEND to:

Researchers using quantitative methods tend to:

• think that both natural and social sciences strive to explain phenomena with confirmable theories derived from testable assumptions
• attempt to reduce social reality to variables, in the same way as with physical reality
• try to tightly control the variable(s) in question to see how the others are influenced.
• Do experiments, have control groups, use blind or double-blind studies; use measures or instruments.

Quantitative Research (an operational definition)

Quantitative research: an operational description

Purpose: explain, predict or control phenomena through focused collection and analysis of numberical data

Approach: deductive; tries to be value-free/has objectives/ is outcome-oriented

Hypotheses : Specific, testable, and stated prior to study

Lit. Review: extensive; may significantly influence a particular study

Setting: controlled to the degree possible

Sampling: uses largest manageable random/randomized sample, to allow generalization of results to larger populations

Measurement: standardized, numberical; "at the end"

Design and Method: Strongly structured, specified in detail in advance; involves intervention, manipulation and control groups; descriptive, correlational, experimental

Data Collection: via instruments, surveys, experiments, semi-structured formal interviews, tests or questionnaires

Data Analysis: raw data is numbers; at end of study, usually statistical

Data Interpretation: formulated at end of study; stated as a degree of certainty

This page on qualitative and quantitative research has been adapted and expanded from a handout by Suzy Westenkirchner. Used with permission.

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Article Contents

Introduction, when to use qualitative research, how to judge qualitative research, conclusions, authors' roles, conflict of interest.

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Qualitative research methods: when to use them and how to judge them

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K. Hammarberg, M. Kirkman, S. de Lacey, Qualitative research methods: when to use them and how to judge them, Human Reproduction , Volume 31, Issue 3, March 2016, Pages 498–501, https://doi.org/10.1093/humrep/dev334

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In March 2015, an impressive set of guidelines for best practice on how to incorporate psychosocial care in routine infertility care was published by the ESHRE Psychology and Counselling Guideline Development Group ( ESHRE Psychology and Counselling Guideline Development Group, 2015 ). The authors report that the guidelines are based on a comprehensive review of the literature and we congratulate them on their meticulous compilation of evidence into a clinically useful document. However, when we read the methodology section, we were baffled and disappointed to find that evidence from research using qualitative methods was not included in the formulation of the guidelines. Despite stating that ‘qualitative research has significant value to assess the lived experience of infertility and fertility treatment’, the group excluded this body of evidence because qualitative research is ‘not generally hypothesis-driven and not objective/neutral, as the researcher puts him/herself in the position of the participant to understand how the world is from the person's perspective’.

Qualitative and quantitative research methods are often juxtaposed as representing two different world views. In quantitative circles, qualitative research is commonly viewed with suspicion and considered lightweight because it involves small samples which may not be representative of the broader population, it is seen as not objective, and the results are assessed as biased by the researchers' own experiences or opinions. In qualitative circles, quantitative research can be dismissed as over-simplifying individual experience in the cause of generalisation, failing to acknowledge researcher biases and expectations in research design, and requiring guesswork to understand the human meaning of aggregate data.

As social scientists who investigate psychosocial aspects of human reproduction, we use qualitative and quantitative methods, separately or together, depending on the research question. The crucial part is to know when to use what method.

The peer-review process is a pillar of scientific publishing. One of the important roles of reviewers is to assess the scientific rigour of the studies from which authors draw their conclusions. If rigour is lacking, the paper should not be published. As with research using quantitative methods, research using qualitative methods is home to the good, the bad and the ugly. It is essential that reviewers know the difference. Rejection letters are hard to take but more often than not they are based on legitimate critique. However, from time to time it is obvious that the reviewer has little grasp of what constitutes rigour or quality in qualitative research. The first author (K.H.) recently submitted a paper that reported findings from a qualitative study about fertility-related knowledge and information-seeking behaviour among people of reproductive age. In the rejection letter one of the reviewers (not from Human Reproduction ) lamented, ‘Even for a qualitative study, I would expect that some form of confidence interval and paired t-tables analysis, etc. be used to analyse the significance of results'. This comment reveals the reviewer's inappropriate application to qualitative research of criteria relevant only to quantitative research.

In this commentary, we give illustrative examples of questions most appropriately answered using qualitative methods and provide general advice about how to appraise the scientific rigour of qualitative studies. We hope this will help the journal's reviewers and readers appreciate the legitimate place of qualitative research and ensure we do not throw the baby out with the bath water by excluding or rejecting papers simply because they report the results of qualitative studies.

In psychosocial research, ‘quantitative’ research methods are appropriate when ‘factual’ data are required to answer the research question; when general or probability information is sought on opinions, attitudes, views, beliefs or preferences; when variables can be isolated and defined; when variables can be linked to form hypotheses before data collection; and when the question or problem is known, clear and unambiguous. Quantitative methods can reveal, for example, what percentage of the population supports assisted conception, their distribution by age, marital status, residential area and so on, as well as changes from one survey to the next ( Kovacs et al. , 2012 ); the number of donors and donor siblings located by parents of donor-conceived children ( Freeman et al. , 2009 ); and the relationship between the attitude of donor-conceived people to learning of their donor insemination conception and their family ‘type’ (one or two parents, lesbian or heterosexual parents; Beeson et al. , 2011 ).

In contrast, ‘qualitative’ methods are used to answer questions about experience, meaning and perspective, most often from the standpoint of the participant. These data are usually not amenable to counting or measuring. Qualitative research techniques include ‘small-group discussions’ for investigating beliefs, attitudes and concepts of normative behaviour; ‘semi-structured interviews’, to seek views on a focused topic or, with key informants, for background information or an institutional perspective; ‘in-depth interviews’ to understand a condition, experience, or event from a personal perspective; and ‘analysis of texts and documents’, such as government reports, media articles, websites or diaries, to learn about distributed or private knowledge.

Qualitative methods have been used to reveal, for example, potential problems in implementing a proposed trial of elective single embryo transfer, where small-group discussions enabled staff to explain their own resistance, leading to an amended approach ( Porter and Bhattacharya, 2005 ). Small-group discussions among assisted reproductive technology (ART) counsellors were used to investigate how the welfare principle is interpreted and practised by health professionals who must apply it in ART ( de Lacey et al. , 2015 ). When legislative change meant that gamete donors could seek identifying details of people conceived from their gametes, parents needed advice on how best to tell their children. Small-group discussions were convened to ask adolescents (not known to be donor-conceived) to reflect on how they would prefer to be told ( Kirkman et al. , 2007 ).

When a population cannot be identified, such as anonymous sperm donors from the 1980s, a qualitative approach with wide publicity can reach people who do not usually volunteer for research and reveal (for example) their attitudes to proposed legislation to remove anonymity with retrospective effect ( Hammarberg et al. , 2014 ). When researchers invite people to talk about their reflections on experience, they can sometimes learn more than they set out to discover. In describing their responses to proposed legislative change, participants also talked about people conceived as a result of their donations, demonstrating various constructions and expectations of relationships ( Kirkman et al. , 2014 ).

Interviews with parents in lesbian-parented families generated insight into the diverse meanings of the sperm donor in the creation and life of the family ( Wyverkens et al. , 2014 ). Oral and written interviews also revealed the embarrassment and ambivalence surrounding sperm donors evident in participants in donor-assisted conception ( Kirkman, 2004 ). The way in which parents conceptualise unused embryos and why they discard rather than donate was explored and understood via in-depth interviews, showing how and why the meaning of those embryos changed with parenthood ( de Lacey, 2005 ). In-depth interviews were also used to establish the intricate understanding by embryo donors and recipients of the meaning of embryo donation and the families built as a result ( Goedeke et al. , 2015 ).

It is possible to combine quantitative and qualitative methods, although great care should be taken to ensure that the theory behind each method is compatible and that the methods are being used for appropriate reasons. The two methods can be used sequentially (first a quantitative then a qualitative study or vice versa), where the first approach is used to facilitate the design of the second; they can be used in parallel as different approaches to the same question; or a dominant method may be enriched with a small component of an alternative method (such as qualitative interviews ‘nested’ in a large survey). It is important to note that free text in surveys represents qualitative data but does not constitute qualitative research. Qualitative and quantitative methods may be used together for corroboration (hoping for similar outcomes from both methods), elaboration (using qualitative data to explain or interpret quantitative data, or to demonstrate how the quantitative findings apply in particular cases), complementarity (where the qualitative and quantitative results differ but generate complementary insights) or contradiction (where qualitative and quantitative data lead to different conclusions). Each has its advantages and challenges ( Brannen, 2005 ).

Qualitative research is gaining increased momentum in the clinical setting and carries different criteria for evaluating its rigour or quality. Quantitative studies generally involve the systematic collection of data about a phenomenon, using standardized measures and statistical analysis. In contrast, qualitative studies involve the systematic collection, organization, description and interpretation of textual, verbal or visual data. The particular approach taken determines to a certain extent the criteria used for judging the quality of the report. However, research using qualitative methods can be evaluated ( Dixon-Woods et al. , 2006 ; Young et al. , 2014 ) and there are some generic guidelines for assessing qualitative research ( Kitto et al. , 2008 ).

Although the terms ‘reliability’ and ‘validity’ are contentious among qualitative researchers ( Lincoln and Guba, 1985 ) with some preferring ‘verification’, research integrity and robustness are as important in qualitative studies as they are in other forms of research. It is widely accepted that qualitative research should be ethical, important, intelligibly described, and use appropriate and rigorous methods ( Cohen and Crabtree, 2008 ). In research investigating data that can be counted or measured, replicability is essential. When other kinds of data are gathered in order to answer questions of personal or social meaning, we need to be able to capture real-life experiences, which cannot be identical from one person to the next. Furthermore, meaning is culturally determined and subject to evolutionary change. The way of explaining a phenomenon—such as what it means to use donated gametes—will vary, for example, according to the cultural significance of ‘blood’ or genes, interpretations of marital infidelity and religious constructs of sexual relationships and families. Culture may apply to a country, a community, or other actual or virtual group, and a person may be engaged at various levels of culture. In identifying meaning for members of a particular group, consistency may indeed be found from one research project to another. However, individuals within a cultural group may present different experiences and perceptions or transgress cultural expectations. That does not make them ‘wrong’ or invalidate the research. Rather, it offers insight into diversity and adds a piece to the puzzle to which other researchers also contribute.

In qualitative research the objective stance is obsolete, the researcher is the instrument, and ‘subjects’ become ‘participants’ who may contribute to data interpretation and analysis ( Denzin and Lincoln, 1998 ). Qualitative researchers defend the integrity of their work by different means: trustworthiness, credibility, applicability and consistency are the evaluative criteria ( Leininger, 1994 ).

Trustworthiness

A report of a qualitative study should contain the same robust procedural description as any other study. The purpose of the research, how it was conducted, procedural decisions, and details of data generation and management should be transparent and explicit. A reviewer should be able to follow the progression of events and decisions and understand their logic because there is adequate description, explanation and justification of the methodology and methods ( Kitto et al. , 2008 )

Credibility

Credibility is the criterion for evaluating the truth value or internal validity of qualitative research. A qualitative study is credible when its results, presented with adequate descriptions of context, are recognizable to people who share the experience and those who care for or treat them. As the instrument in qualitative research, the researcher defends its credibility through practices such as reflexivity (reflection on the influence of the researcher on the research), triangulation (where appropriate, answering the research question in several ways, such as through interviews, observation and documentary analysis) and substantial description of the interpretation process; verbatim quotations from the data are supplied to illustrate and support their interpretations ( Sandelowski, 1986 ). Where excerpts of data and interpretations are incongruent, the credibility of the study is in doubt.

Applicability

Applicability, or transferability of the research findings, is the criterion for evaluating external validity. A study is considered to meet the criterion of applicability when its findings can fit into contexts outside the study situation and when clinicians and researchers view the findings as meaningful and applicable in their own experiences.

Larger sample sizes do not produce greater applicability. Depth may be sacrificed to breadth or there may be too much data for adequate analysis. Sample sizes in qualitative research are typically small. The term ‘saturation’ is often used in reference to decisions about sample size in research using qualitative methods. Emerging from grounded theory, where filling theoretical categories is considered essential to the robustness of the developing theory, data saturation has been expanded to describe a situation where data tend towards repetition or where data cease to offer new directions and raise new questions ( Charmaz, 2005 ). However, the legitimacy of saturation as a generic marker of sampling adequacy has been questioned ( O'Reilly and Parker, 2013 ). Caution must be exercised to ensure that a commitment to saturation does not assume an ‘essence’ of an experience in which limited diversity is anticipated; each account is likely to be subtly different and each ‘sample’ will contribute to knowledge without telling the whole story. Increasingly, it is expected that researchers will report the kind of saturation they have applied and their criteria for recognising its achievement; an assessor will need to judge whether the choice is appropriate and consistent with the theoretical context within which the research has been conducted.

Sampling strategies are usually purposive, convenient, theoretical or snowballed. Maximum variation sampling may be used to seek representation of diverse perspectives on the topic. Homogeneous sampling may be used to recruit a group of participants with specified criteria. The threat of bias is irrelevant; participants are recruited and selected specifically because they can illuminate the phenomenon being studied. Rather than being predetermined by statistical power analysis, qualitative study samples are dependent on the nature of the data, the availability of participants and where those data take the investigator. Multiple data collections may also take place to obtain maximum insight into sensitive topics. For instance, the question of how decisions are made for embryo disposition may involve sampling within the patient group as well as from scientists, clinicians, counsellors and clinic administrators.

Consistency

Consistency, or dependability of the results, is the criterion for assessing reliability. This does not mean that the same result would necessarily be found in other contexts but that, given the same data, other researchers would find similar patterns. Researchers often seek maximum variation in the experience of a phenomenon, not only to illuminate it but also to discourage fulfilment of limited researcher expectations (for example, negative cases or instances that do not fit the emerging interpretation or theory should be actively sought and explored). Qualitative researchers sometimes describe the processes by which verification of the theoretical findings by another team member takes place ( Morse and Richards, 2002 ).

Research that uses qualitative methods is not, as it seems sometimes to be represented, the easy option, nor is it a collation of anecdotes. It usually involves a complex theoretical or philosophical framework. Rigorous analysis is conducted without the aid of straightforward mathematical rules. Researchers must demonstrate the validity of their analysis and conclusions, resulting in longer papers and occasional frustration with the word limits of appropriate journals. Nevertheless, we need the different kinds of evidence that is generated by qualitative methods. The experience of health, illness and medical intervention cannot always be counted and measured; researchers need to understand what they mean to individuals and groups. Knowledge gained from qualitative research methods can inform clinical practice, indicate how to support people living with chronic conditions and contribute to community education and awareness about people who are (for example) experiencing infertility or using assisted conception.

Each author drafted a section of the manuscript and the manuscript as a whole was reviewed and revised by all authors in consultation.

No external funding was either sought or obtained for this study.

The authors have no conflicts of interest to declare.

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Research Methods

• Getting Started
• Literature Review Research
• Research Design
• Research Design By Discipline
• SAGE Research Methods
• Teaching with SAGE Research Methods

Literature Review

• What is a Literature Review?
• What is NOT a Literature Review?
• Purposes of a Literature Review
• Types of Literature Reviews
• Literature Reviews vs. Systematic Reviews
• Systematic vs. Meta-Analysis

Literature Review  is a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works.

Also, we can define a literature review as the collected body of scholarly works related to a topic:

• Summarizes and analyzes previous research relevant to a topic
• Includes scholarly books and articles published in academic journals
• Can be an specific scholarly paper or a section in a research paper

The objective of a Literature Review is to find previous published scholarly works relevant to an specific topic

• Help gather ideas or information
• Keep up to date in current trends and findings
• Help develop new questions

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Helps focus your own research questions or problems
• Discovers relationships between research studies/ideas.
• Suggests unexplored ideas or populations
• Identifies major themes, concepts, and researchers on a topic.
• Tests assumptions; may help counter preconceived ideas and remove unconscious bias.
• Identifies critical gaps, points of disagreement, or potentially flawed methodology or theoretical approaches.
• Indicates potential directions for future research.

All content in this section is from Literature Review Research from Old Dominion University 

Keep in mind the following, a literature review is NOT:

Not an essay 

Not an annotated bibliography  in which you summarize each article that you have reviewed.  A literature review goes beyond basic summarizing to focus on the critical analysis of the reviewed works and their relationship to your research question.

Not a research paper   where you select resources to support one side of an issue versus another.  A lit review should explain and consider all sides of an argument in order to avoid bias, and areas of agreement and disagreement should be highlighted.

A literature review serves several purposes. For example, it

• provides thorough knowledge of previous studies; introduces seminal works.
• helps focus one’s own research topic.
• identifies a conceptual framework for one’s own research questions or problems; indicates potential directions for future research.
• suggests previously unused or underused methodologies, designs, quantitative and qualitative strategies.
• identifies gaps in previous studies; identifies flawed methodologies and/or theoretical approaches; avoids replication of mistakes.
• helps the researcher avoid repetition of earlier research.
• suggests unexplored populations.
• determines whether past studies agree or disagree; identifies controversy in the literature.
• tests assumptions; may help counter preconceived ideas and remove unconscious bias.

As Kennedy (2007) notes*, it is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the original studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally that become part of the lore of field. In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews.

Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are several approaches to how they can be done, depending upon the type of analysis underpinning your study. Listed below are definitions of types of literature reviews:

Argumentative Review      This form examines literature selectively in order to support or refute an argument, deeply imbedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to to make summary claims of the sort found in systematic reviews.

Integrative Review      Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication.

Historical Review      Few things rest in isolation from historical precedent. Historical reviews are focused on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review      A review does not always focus on what someone said [content], but how they said it [method of analysis]. This approach provides a framework of understanding at different levels (i.e. those of theory, substantive fields, research approaches and data collection and analysis techniques), enables researchers to draw on a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection and data analysis, and helps highlight many ethical issues which we should be aware of and consider as we go through our study.

Systematic Review      This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyse data from the studies that are included in the review. Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?"

Theoretical Review      The purpose of this form is to concretely examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review help establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

* Kennedy, Mary M. "Defining a Literature."  Educational Researcher  36 (April 2007): 139-147.

All content in this section is from The Literature Review created by Dr. Robert Larabee USC

Robinson, P. and Lowe, J. (2015),  Literature reviews vs systematic reviews.  Australian and New Zealand Journal of Public Health, 39: 103-103. doi: 10.1111/1753-6405.12393

What's in the name? The difference between a Systematic Review and a Literature Review, and why it matters . By Lynn Kysh from University of Southern California

Systematic review or meta-analysis?

A  systematic review  answers a defined research question by collecting and summarizing all empirical evidence that fits pre-specified eligibility criteria.

A  meta-analysis  is the use of statistical methods to summarize the results of these studies.

Systematic reviews, just like other research articles, can be of varying quality. They are a significant piece of work (the Centre for Reviews and Dissemination at York estimates that a team will take 9-24 months), and to be useful to other researchers and practitioners they should have:

• clearly stated objectives with pre-defined eligibility criteria for studies
• explicit, reproducible methodology
• a systematic search that attempts to identify all studies
• assessment of the validity of the findings of the included studies (e.g. risk of bias)
• systematic presentation, and synthesis, of the characteristics and findings of the included studies

Not all systematic reviews contain meta-analysis. 

Meta-analysis is the use of statistical methods to summarize the results of independent studies. By combining information from all relevant studies, meta-analysis can provide more precise estimates of the effects of health care than those derived from the individual studies included within a review.  More information on meta-analyses can be found in  Cochrane Handbook, Chapter 9 .

A meta-analysis goes beyond critique and integration and conducts secondary statistical analysis on the outcomes of similar studies.  It is a systematic review that uses quantitative methods to synthesize and summarize the results.

An advantage of a meta-analysis is the ability to be completely objective in evaluating research findings.  Not all topics, however, have sufficient research evidence to allow a meta-analysis to be conducted.  In that case, an integrative review is an appropriate strategy. 

Some of the content in this section is from Systematic reviews and meta-analyses: step by step guide created by Kate McAllister.

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Criteria for Good Qualitative Research: A Comprehensive Review

• Regular Article
• Open access
• Published: 18 September 2021
• Volume 31 , pages 679–689, ( 2022 )

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• Drishti Yadav   ORCID: orcid.org/0000-0002-2974-0323 1  

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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Yadav, D. Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Edu Res 31 , 679–689 (2022). https://doi.org/10.1007/s40299-021-00619-0

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Progress in remote sensing and gis-based fdi research based on quantitative and qualitative analysis.

1. Introduction

2. research methods and data, 2.1. research methods, 2.2. data sources and screening, 2.3. data processing, 3. subject categories and publication trends, 3.1. subject evolution, 3.2. trends in the number and cited times of published papers, 4. the intellectual structure, 4.1. quantitative analysis, 4.2. qualitative analysis, 4.2.1. macro-environmental research at national, regional, and city scales, 4.2.2. global industrial development and layout, 4.2.3. research on global value chains, 4.2.4. micro-information geography of tncs, 4.2.5. internationalization and commercialization of geo-information industry, 4.2.6. multiple data and interdisciplinary approaches, 5. discussions and conclusions, data availability statement, acknowledgments, conflicts of interest.

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Li, Z. Progress in Remote Sensing and GIS-Based FDI Research Based on Quantitative and Qualitative Analysis. Land 2024 , 13 , 1313. https://doi.org/10.3390/land13081313

Li Z. Progress in Remote Sensing and GIS-Based FDI Research Based on Quantitative and Qualitative Analysis. Land . 2024; 13(8):1313. https://doi.org/10.3390/land13081313

Li, Zifeng. 2024. "Progress in Remote Sensing and GIS-Based FDI Research Based on Quantitative and Qualitative Analysis" Land 13, no. 8: 1313. https://doi.org/10.3390/land13081313

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• Open access
• Published: 21 August 2024

Facilitators and barriers to evidence adoption for central venous catheters post-insertion maintenance in oncology nurses: a multi-center mixed methods study

• Funa Yang 1 ,
• Ka Yan Ho 2 ,
• Katherine Ka Wai Lam 2 ,
• Ting Mao 2 ,
• Yan Wen 3 ,
• Liqing Li 4 ,
• Xiuxiu Yang 5 ,
• Na Xiao 6 ,
• Yanling Gao 7 ,
• Xiaoxia Xu 1 ,
• Frances-Kam-Yuet Wong 2 ,
• Hongying Shi 8 &
• Lanwei Guo 9  

BMC Nursing volume  23 , Article number:  581 ( 2024 ) Cite this article

Metrics details

The post-insertion maintenance of central venous catheters(CVCs)is a common, vital procedure undertaken by nurses. Existing literature lacks a comprehensive review of evidence adoption for CVCs post-insertion maintenance specifically within the oncology context. This investigation assessed evidence-based practice by oncology nurses in the care of CVCs, elucidating facilitators and obstacles to this adoption process.

This was a sequential explanatory mixed methods study, executed from May 2022 to April 2023, adhering to the GRAMMS checklist. The study commenced with a cross-sectional study through clinical observation that scrutinized the adoption of scientific evidence for CVC maintenance, analyzing 1314 records from five hospitals in China. Subsequently, a semi-structured, in-depth interview with nurses based on the i-PARIHS framework was conducted to ascertain facilitators and barriers to evidence adoption for CVCs post-insertion maintenance. Fifteen nurses were recruited through purposive sampling. Descriptive statistics were used to summarize quantitative data, while content analysis was used to analyze qualitative data.

An overall compliance rate of 90.0% was observed; however, two domains exhibited a lower adoption rate of less than 80%, namely disinfection of infusion connector and disinfection of skin and catheter. Three barriers and two facilitators were discerned from the interviews. Barriers encompassed (1) difficulty in accessing the evidence, (2) lack of involvement from nurse specialists, and (3) challenges from internal and external environments. Facilitators comprised (1) the positive attitudes of specialist nurses toward evidence application, and (2) the formation of a team specializing in intravenous therapy within hospitals.

There exists a significant opportunity to improve the adoption of evidence-based practices for CVC maintenance. Considering the identified barriers and facilitators, targeted interventions should be conceived and implemented at the organizational level to augment oncology evidence-based practice, especially the clinical evidence pertinent to infection control protocols.

Trial registration

This investigation was sanctioned by the Medical Ethics Committee of Henan Cancer Hospital (Number 2023-KY-0014).

Peer Review reports

Catheter technology has evolved to accommodate the multifaceted medical necessities of disparate patient populations [ 1 ]. Central venous catheters (CVCs) instruments essential for chemotherapy, parenteral nutrition, hemodynamic monitoring, and other interventions, are often inserted into oncology patients [ 2 , 3 ]. This insertion disrupts skin integrity, thereby heightening the susceptibility of patients to infections. Concurrently, the immunosuppression engendered by chemotherapy and radiotherapy [ 4 , 5 ], amplifies the risk for CVC-associated complications, such as bloodstream infection, thrombosis, and catheter malfunction [ 3 ]. The estimated incidence of CVC-related infections in oncology patients ranges from 0.5 to10 per 1000 CVC-days [ 6 , 7 ], with variations in the incidence of CVC-associated thrombi ranging from 27 to 66%, when assessed by routine screening venography [ 3 , 8 ]. Unforeseen catheter removal necessitated by these complications, can induce anxiety, pain, helplessness, and apprehension regarding subsequent catheter injection [ 9 ].

Post-insertion management is pivotal in circumventing catheter-related complications, including infections, thromboses, and mechanical injuries. Numerous institutions and regulatory bodies have promulgated recommendations and guidelines to mitigate these complications [ 10 , 11 , 12 ]. Despite the critical nature of adherence to these protocols in clinical environments, compliance among healthcare professionals is frequently suboptimal, as evidenced by studies indicating merely 60% adherence to guidelines pertaining to CVC post-insertion management [ 13 ]. Remarkably, no extant research has reviewed nursing compliance for post-insertion management of CVCs within the context of Chinese oncology patients.

Evidence-based practice, a cornerstone of clinical care across various countries, including China, demands a progressive and time-consuming adoption process by healthcare professionals. Existing literature underscores a temporal span of 17 years for research findings to be integrated into clinical routines [ 14 ], with only half eventually achieving widespread acceptance [ 15 ]. Evidence-based nursing emphasizes that nurses should not only identify and implement best practices for patients, but also integrate these practices with their clinical experience [ 16 ]. This paradigm emphasizes that nurses should synergize best-evidence practice with clinical experience, ensuring that implementation is a confluence of optimal evidence and consideration of patient’s unique situation, medical requirements, resource accessibility, environmental conditions, collaborative dynamics, and potential hindrances [ 17 , 18 ].

Examined through the lens of implementation science, the adoption of clinical practice guidelines for CVCs encounters various challenges and obstructions. These include the inherent complexity of the evidence, the multifaceted nature of the healthcare environment, financial constraints, personnel receptivity, and organizational policies [ 19 , 20 , 21 ]. Ascertaining facilitators and barriers to evidence adoption for CVCs post-insertion maintenance represents an essential and foundational step in transmuting optimal evidence into tangible clinical practice. In this context, the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) framework serves as a prominent model in implementation science, illustrating pathways for successful guideline promotion and assimilation within clinical settings, by focusing on innovation, recipients of change and context, as well as facilitation impacts [ 22 , 23 ].

The i-PARIHS framework was employed to navigate our qualitative interview, delineating the facilitators and barriers to compliance with the evidence-based practice in post-insertion maintenance for CVCs within oncological contexts. This framework, multi-dimensional in its construct, elucidates the modalities through which successful promotion and implementation of guidelines may transpire in clinical environments [ 24 ]. Within the i-PARIHS framework, four core components are instrumental for translating evidence into practice. These components are encapsulated in the framework’s core conceptual equation: SI = Facn(I + R + C) (SI: Successful Implementation of evidence; Facn: Facilitation; I: Innovation; R: Recipients; C: Context) [ 25 ]. Within this equation, ‘innovation’ encompasses not only the intervention itself, but also the underlying evidence informing it. ‘Recipients’ denote those individuals or collectives affected by or exerting influence over the implementation process, while ‘context’ integrates both the internal and external environmental variables. Additionally, ‘facilitation’ alludes to specific elements that may expedite the translation of evidence-based practice [ 25 , 26 , 27 ]. The successful implementation of evidence into clinical practice is conceptualized as a resultant synthesis of innovation, recipients, context, and facilitation [ 27 ]. In oncology nursing, the i-PARIHS framework can assist cancer nurses in exploring the determinants of evidence-based nursing and integrating the best evidence or innovations into clinical settings, enabling cancer nurses to deliver high-quality supportive cancer care through facilitating factors such as multidisciplinary cooperation and resource integration. For example, Roberts et al [ 28 ] conducted a descriptive mixed method in supportive cancer care and evaluated the utility of the i-PARIHS framework for introducing patient-reported outcome measures into oncology patients. In the qualitative segment of this investigation, we sought to harness the i-PARIHS framework to dissect the nuanced interplay of these components, thereby enriching our comprehension of the implementation dynamics governing post-insertion management for CVCs within oncological settings.

Presently, literature is deficient in studies investigating the adoption of scientific evidence in post-insertion management for CVCs within the Chinese oncology nursing community. Moreover, few have applied the i-PARIHS framework for evaluation purposes [ 25 , 29 , 30 ]. To redress this scholarly deficiency, the present study endeavored to appraise the adoption of scientific evidence in post-insertion management for CVCs by oncology nurses in China. Crucially, we harnessed the i-PARIHS framework to delineate facilitators and barriers to evidence adoption for CVCs post-insertion maintenance, employing qualitative interviews, as an exemplary method to garner profound insights into these influential factors.

This investigation comprised a sequential explanatory mixed-methods study spanning multiple centers, conducted between May 2022 to April 2023. It commenced with a cross-sectional study from May 2022 to January 2023, followed by a qualitative study from February 2023 to April 2023. In the qualitative phase, a deductive method based on the i-PARIHS framework was used to explore barriers and facilitators to evidence adoption for CVCs post-insertion maintenance. Compliance with the GRAMMS checklist was maintained throughout the process.

Sample and sampling

The parallel mixed methods sampling [ 31 ] and purposive sampling strategy were used to select suitable participants, the informants of the interview were a subset of the quantitative study. For the quantitative part, nurses who fulfilled this inclusion criteria were included: caring patients having an established cancer diagnosis with a CVC, defined as a catheter introduced into the internal jugular vein, subclavian vein, or femoral vein. Regarding the qualitative study, the inclusion criteria for informants were: (1) involvement in the observation study; (2) completion of national or provincial specialized intravenous nurse training courses (exceeding 3 months) and attainment of corresponding qualifications; (3) registration as nurses delivering intravenous therapy for a period surpassing 5 years post-qualification; (4) direct care provision to cancer patients; and (5) voluntary participation in the interviews with informed consent. Exclusion criteria were applied to nurses who had resigned from hospital settings. Data saturation was realized upon conducting interviews with 15 informants.

Setting and data collection

The investigation encompassed oncology wards across five hospitals in China, namely Henan Cancer Hospital, Zhengzhou Central Hospital, Luohe Central Hospital, Sanmenxia Central Hospital, and Pingdingshan Hospital. Each of these tertiary-level hospitals housed approximately 1000–3000 beds. All CVCs within these institutions were positioned by designated venous catheterization centers following a uniform protocol. Additionally, oncology ward nurses underwent specific training on the post-insertion management of CVCs.

In the quantitative phase, to assess the evidence adoption for CVCs post-insertion maintenance within oncology wards, an audit team was formed, which comprised five nursing managers and ten intravenous therapy nurse specialists from five research centers. The audit members were from different parts of different organizations and had no working relationship with the nurses being evaluated. The research team also devised an audit checklist to scrutinize the adoption of scientific evidence in the post-insertion management of CVCs and conducted clinical observation. The audit checklist encompassed 30 items, stratified into 10 distinct domains: (1) hand hygiene, (2) assessment, (3) infusion connector disinfection, (4) infusion connector replacement, (5) infusion device replacement, (6) confirmation of in-situ catheter, (7) catheter and skin disinfection, (8) catheter dressing and fixation, (9) flushing, and (10) catheter covering. Supplementary file 1 delineates the checklist in detail. All participating oncology nurses were subsequently assessed through clinical observation utilizing this checklist to ascertain their adherence to scientific evidence in post-insertion management. Audit criteria were dichotomized, with “yes” signifying compliance with recommended practice, and “no” indicating deviation therefrom. The evaluation commenced with the audit team screening the medical records of all patients within the oncology wards. Upon identification of patients diagnosed with cancer and inserted with CVC, a designated audit member came to the ward to appraise the adherence to scientific evidence in post-insertion management of CVCs by the patient’s primary nurse, utilizing the checklist via clinical observation.

In the qualitative phase, a series of in-depth semi-structured interviews were administered by the first author, who was a nursing manager and hailed from different departments with the informants. All informants will be informed of the quantitative findings before the interview to ensure the continuity of the two research phases. The interviews were conducted either face-to-face in a meeting room of the informants’ ward or online (e.g. WeChat video calls or Tencent conferences), contingent upon the informants’ preference. A semi-structured interview guide was meticulously crafted by researchers predicated upon the i-PARIHS framework and the findings in the quantitative phase. This guide was subsequently pilot-tested on two intravenous therapy nurse specialists. Supplementary file 2 elucidates the guiding inquiries of the finalized semi-structured interview guide. Before acquiring written consent, the informants were thoroughly apprised of the study’s purpose and content. All interviews were diligently audio-recorded, with individual durations averaging 45 min, and ranging from 32 to 56 min.

Data analysis

Quantitative data analysis.

Quantitative data procured from the cross-sectional study were analyzed using IBM SPSS v26.0. Descriptive statistics were deployed, where continuous variables were elucidated by means and standard deviations, and categorical variables by frequencies and percentages. The sample size calculation adhered to the audit checklist’s item count, guided by the formula [ 32 ]: n=[Max(number of items)×(10 ∼ 15)]×[1+(10% ∼ 15%)]. With the checklist comprising 30 items and an anticipated attrition rate of 15%, the minimal requisite sample size amounted to 518.

Qualitative data analysis

The qualitative data stemming from the interviews were scrutinized through content analysis, supported by Nvivo 10. Preliminary to the analysis, audio recordings were verbatim transcribed. A six-phase coding process was diligently followed [ 33 ]: (a) data familiarization; (b) initial code generation; (c) thematic code search; (d) theme review; (e) theme definition and naming; and (f) final analysis production. To obviate subjective bias, interview transcripts were separately coded by two researchers, well-versed in qualitative research. The data analysis employed a deductive reasoning process based on the four components of the i-PARIHS framework, including innovation, recipients, context, and facilitation. Similar codes were categorized, and interrelated categories were amalgamated to discern major themes. Subsequent dialogue and revision by the two coding researchers and the first author led to a consensus, culminating in the translation of the codebook into English by the first author.

Ethical considerations

This investigation was sanctioned by the Medical Ethics Committee of Henan Cancer Hospital (Number 2023-KY-0014). All participants were apprised that their involvement was voluntary, with strict confidentiality maintained concerning personal information, accessible solely by the research team. Moreover, adherence to the principles of the Helsinki Declaration was stringently upheld. In this study, our targeted participants were nurses who have provided care for patients with a confirmed cancer diagnosis with CVCs. Therefore, patients were not involved in the study. Screening of the patient’s medical records was solely to facilitate the identification of eligible nurses, which would not involve any personal information about patients. Informed consent to participate was obtained from all the participants.

Rigorous in the quantitative part was upheld by multiple strategies. Firstly, the developmental process of checklists allowed wide input from diverse sources regarding the checklist content [ 34 , 35 ]. To ensure board sources of input to the checklist content, our team exhaustively examined pertinent evidence-based practice guidelines, expert opinions, and national and local health policies endorsed by various professional entities, including the Infusion Nursing Society [ 11 ], National Health Commission [ 36 , 37 ], National Institute of Hospital Administration [ 38 ], Chinese Nursing Association [ 12 ]. The checklist further embodied salient recommendations for CVC management as stipulated by the NICE guideline [ 39 ]. The research team extracted, collated, and integrated the evidence on CVC maintenance therein into a preliminary checklist. In addition, expert testing was employed to ensure the feasibility. Two CVC specialists from the Intravenous Infusion Therapy of the Chinese Nursing Association appraised and refined the items to validate the checklist’s feasibility, and the final checklist was formed. Secondly, the audit members were thoroughly briefed regarding the study’s objectives, content, and procedures to ensure comprehension. Besides, comprehensive training was provided to all audit members on the checklist to evaluate the assimilation of scientific evidence in post-insertion management of CVCs, thereby enhancing inter-rater reliability.

To uphold the rigor in the qualitative part, we adhered to the criteria outlined by Guba and Lincoln [ 40 ]. Credibility was promoted by having a researcher with extensive experience in conducting qualitative research to conduct the interviews. A concerted effort to mitigate recall bias and errors through field notes and recording equipment to capture the interview process. Subsequent verbatim transcription in Mandarin was conducted within 24 h of the interviews to ensure the accuracy of the findings. Interview transcripts were separately coded by two researchers, well-versed in qualitative research. Similar codes were categorized, and interrelated categories were amalgamated to discern major themes. Dialogue and revision by the two coding researchers and the first author led to a consensus. Additionally, throughout the interview process, the interviewer adopted empathetic techniques, including a non-judgmental stance, honoring all responses, fostering a supportive environment for the informants to divulge their emotions, and keen observation of salient non-verbal cues such as facial expressions, gestures, postures, and eye contact. To ensure transferability, purposive sampling was used to maximize the diversity of the informants in characteristics such as age, education level, and years of experience. To procure rich data and invaluable insights into informants’ experiences, informants were reassured that they could articulate their perspectives without fear of judgment or reprisal. Regular consultations were held to assess the data, allowing the researchers to understand the data and avoid potential misinterpretations. To enhance both dependability and confirmability, triangulation was employed to ensure that the results aligned with informants’ perceptions and experiences. Three supplementary intravenous therapy nurse specialists were enlisted to validate the findings. Their eligibility was aligned with those in the qualitative interviews. Initial engagements involved inviting the three specialists to review a thematic representation of our preliminary findings, with clarifications furnished by the interviewer. Subsequently, these specialists were encouraged to query and feedback on the tentative results and to reflect and notate comments. Transcripts were then examined employing qualitative methodologies congruent with phenomenological design. Following this process, concurrence was reached within our research team that the nurse specialists’ evaluations substantiated our delineated themes, subthemes, and interpretations.

Cross-sectional study

Background characteristics of nurses evaluated for the adoption of scientific evidence for post-insertion management of cvcs.

During the designated study period, 1314 nurses were included in the evaluation. Table  1 delineates the demographic and professional characteristics of the participants. A significant majority of the participants, 96.3% were female, the mean tenure of working experience stood at 8.3 years, 51.3% of participants possessed a college degree, 40.6% were classified as primary nurses, and a substantial 92.4% originated from departments specializing in medical oncology, surgical oncology, or radiotherapy oncology.

Adoption of scientific evidence in post-insertion management for CVCs

Table  2 encapsulates the adoption of scientific evidence for post-insertion management of CVCs by oncology nurses. A total of 1,314 field observations were conducted by the evaluation team throughout the study. The cumulative adoption rate was calculated at 90.0%. Within the evaluation checklist’s 10 categories, half were found to have adoption rates less than 90%, including hand hygiene, preoperative assessment, infusion connector disinfection, confirmation of in-situ catheter, and skin and catheter disinfection. Specifically, two categories exhibited a lower adoption rate of less than 80%, namely disinfection of infusion connector and disinfection of skin and catheter. Furthermore, of the 30 checklist items, 14 recommendations were identified with an adoption rate falling below 90%, including specific practices related to disinfection, blood flow management, and post-transfusion procedures. Four items that achieved less than an 80% adoption rate were the disinfection of the infusion connector, skin, and catheter.

Qualitative study

Background characteristics of the informants.

Table  3 delineates the demographic attributes of the informants who partook in the interviews. Among them, the mean age was 34.0 years, with 14 females and 9 holding a bachelor’s degree. Additionally, 12 had served in the specialized role of a CVC nurse for more than 11 years.

Barriers to compliance

Through an analysis of the semi-structured interviews, three barriers were discerned that may hinder the adoption of scientific evidence in post-insertion management for CVCs within oncology settings, mapping to three components of i-PARIHS framework of innovation, recipient, and context, shown in Table  4 .

Theme 1: Difficulty in accessing the evidence (Innovation)

Subtheme 1: insufficiency of training on research skills for appraisal and synthesis of evidence.

Concurrent with the evolution of evidence-based practice, the proliferation of high-quality evidence continues to unfold. A significant proportion of informants recognized the critical role of evidence-based practice in patient outcomes, they concurred that accessing high-quality evidence constitutes the preliminary stage of evidence-based practice. The informants expressed a keen motivation to acquire knowledge on optimal post-insertion management strategies for CVCs. Nonetheless, they were confronted with a paucity of training on research, resulting in uncertainty regarding where to locate evidence and how to evaluate its quality amidst an expanding volume of available evidence. The evidence at hand was occasionally disjointed or even contradictory, thereby posing challenges to the informants in synthesizing it to guide their clinical practice. As articulated by one informant:

“The landscape of evidence concerning post-insertion management for CVCs is in a constant state of flux. Regrettably , my knowledge remains anchored to guidelines published several years prior. Although I aspire to familiarize myself with the most current guidelines , I am at a loss as to where to obtain them.” (N.5).

Another informant stressed the need for institutional support, stating:

“ It would be beneficial if the hospital could facilitate research training or directly identify and disseminate the pertinent guidelines. We could then integrate these guidelines into our practice. ” (N.7).

Yet another shared a similar sentiment, remarking:

“With the myriad of evidence available for post-insertion management , I often encounter fragmented evidence across various channels , such as WeChat accounts. Lacking training in research , I find myself uncertain of the reliability of these pieces of evidence and , consequently , refrain from applying them.” (N.9).

Subtheme 2. Clinical applicability of evidence

The informants predominantly emphasized that the clinical applicability of evidence was a decisive factor influencing the feasibility of implementation. Specifically, they stressed that the evidence must be aligned with patient needs and seamlessly integrated into clinical environments. Certain occurrences, such as blood oozing at the puncture site after coughing, rendered some recommendations impracticable. Without careful adaptation, the direct application of recommended practices could present frontline nurses with considerable obstacles, leading to a loss of motivation. An informant in the semi-structured interview highlighted this, stating:

“According to the latest guidelines for CVC care , immediate replacement is mandated in cases of exudation. Yet , it is common for patients to cough after surgery , thus , blood oozing is inevitable. The consequent necessity to repeatedly change dressings not only escalates the nursing workload but also meets with disapproval from patients. Therefore , this recommendation is virtually infeasible to implement.” (N.8).

Another informant expressed similar concerns, saying:

“Changes to workflows , such as methods of catheter disinfection , changed after implementing the new practice. The initial adaptation was challenging. Regular training and reinforcement are imperative to secure compliance. Additionally , a flowchart could serve to elucidate the procedures involved in executing the new practice.” (N.10).

One more informant also noted:

“The guideline prescribes a specific area for disinfection , yet the suitability of this may vary depending on the anatomical location of CVC insertion. Thus , the stipulated size of the disinfection area is often impractical in a clinical context. Adhering to it rigidly would augment the complexity of our operations.” (N.6).

Subtheme 3: sustainability in applying the evidence

The interviews revealed that although training on post-insertion maintenance for CVCs had been conducted within hospitals and oncology departments, the sustenance and enhancement of its application were predominantly contingent on nursing managers. A glaring absence of corresponding policies and oversight mechanisms to encourage compliance with post-insertion management in oncology settings was evident. Furthermore, there was a notable deficiency in understanding the potential adverse health ramifications for patients should the post-insertion management for CVCs not be adhered to. The absence of prompt feedback on post-insertion management consequently attenuated the nurses’ impetus to integrate evidence into practice. As elucidated by an informant:

“Our superiors mandated the implementation of post-insertion management for CVCs. However , compliance was fleeting , as the emphasis was not sustained. Consequently , we reverted to our original practices.” (N.7).

Another informant expressed a similar sentiment, stating:

“It (post-insertion management for CVCs) only lasted for a period of time and then we stopped. Indeed , we have relied on our established practices for an extensive duration without encountering complications.” (N.3).

Yet another informant suggested an enhancement in oversight, remarking:

“The monitoring framework for post-insertion management necessitates reform. Specifically , integration with our extant monitoring system is advisable to preclude redundancy in workflow and diminish workload. Additionally , reciprocal monitoring between nurses on day and night shifts could more adeptly pinpoint issues with CVCs.” (N.11).

Theme 2: lack of involvement from nurse specialists (recipients)

Subtheme 1. absence of participation in the evidence-translation process.

Some informants disclosed their exclusion from the process of crafting hospital regulations and workflows. Consequently, these specialists were impeded from conveying their insights and strategies to nursing managers, who occupied roles pivotal to policy development. This rendered them incapable of refining post-insertion maintenance for CVCs in alignment with the most judicious evidence. As articulated by an informant as an intravenous treatment nurse specialist:

“The hospital mandated adherence to their newest guideline for post-insertion management for CVCs. However , discerning a distinction between this purported latest iteration and the current version is elusive , given our non-involvement in the guideline’s development.” (N.1).

This perspective was reiterated by another nurse specialist, who lamented:

“While the utilization of the best evidence is commendable , I find myself perplexed. We are marginalized during the policymaking process for CVC management. Those responsible for the guideline’s formulation lack the pertinent expertise.” (N.13).

Subtheme 2. Insufficiency of nurse specialists to oversee the quality of care

A prevalent sentiment among the informants was the inadequate presence of intravenous treatment nurse specialists within their institutions. This scarcity hindered the provision of sufficient oversight for less-experienced nurses, thereby posing challenges to the maintenance of care quality in post-insertion management. During a semi-structured interview, an informant expressed the dilemma succinctly:

“My responsibilities preclude devoting sufficient time to ensuring the proper execution of post-insertion management for CVCs within my ward , given the sheer magnitude of routine tasks. My ability to focus on this particular issue (post-insertion management) is consequently constrained.” (N.7).

Another informant lamented the challenges inherent in the singular role of intravenous therapy nurse specialist within the ward:

“I stand as the sole intravenous therapy nurse specialist in our ward , and the daily completion of routine tasks forces me into overtime to supervise juniors and instruct them on post-insertion management. My capacity to focus on this task (post-insertion management) is thus compromised.” (N.15).

Additionally, another informant articulated the distractions that impede the care process:

“While engaged in post-insertion management , my focus is incessantly diverted by other routine tasks. Consequently , I find myself unable to concentrate fully on the care process , resulting in certain steps being inadvertently overlooked.” (N.14).

Subtheme 3. Difficulty in achieving consensus with medical staff

Several informants elucidated that the domain of intravenous therapy was heavily influenced by medical staff, a fact that emerged as a major barrier to changing the current practice of post-insertion management. The tendency of doctors to concentrate exclusively on insertion procedures, neglecting post-insertion maintenance, exacerbates this issue. Correspondingly, the specialized expertise of nurses in providing post-insertion management often goes unrecognized in the formulation of hospital policies. Therefore, achieving consensus on necessary alterations to post-insertion maintenance based on the evidence proves arduous. For instance, an informant conveyed:

“My involvement in the management team is dictated by my professional role , yet I have remained excluded from the development of hospital-wide policies , focusing solely on managing my department. This is because doctors dominated the hospital management team.” (N.3).

Another informant resonated with this sentiment, emphasizing:

“To effect meaningful changes to post-insertion management for CVCs , the endorsement of doctors , particularly department heads , is indispensable. Their support would considerably facilitate the integration of novel practices.” (N.2).

Furthermore, an informant pointed out the doctors’ lack of concern:

“While numerous physicians elect to insert CVCs into cancer patients for the administration of chemotherapy , their attentiveness to post-insertion management is minimal , sometimes even diminishing its significance.” (N.9).

Theme 3: challenges from internal and external environments (context)

Subtheme 1 inadequate atmosphere for internal change.

The majority of informants, having participated in assorted programs aimed at amending current practices, observed a discernible lack of vigor in the climate for change within hospitals. This tepidity failed to galvanize frontline nurses to embrace new methodologies, especially as their primary focus was anchored on patient safety. As long as existing practices yielded improvements in patient outcomes without adverse events, nurses exhibited little motivation to explore innovations. At the managerial echelon, the informants noted an absence of multidisciplinary collaboration in enhancing post-insertion management for CVCs, coupled with a deficient incentive structure for change. Even among intravenous therapy nurse specialists, consensus on the mission to promote the adoption of best practices remained elusive. An informant elaborated:

“Nurses are more concerned about patients’ safety. They are more conservative about innovations. The implementation of a broad-scale program to alter current practices is inherently intricate , encompassing various facets and necessitating extensive communication and coordination with diverse stakeholders.” (N.4).

Another informant articulated a nuanced observation, stating:

“We have discerned that the standards of post-insertion management leave much to be desired. This deficiency is not amenable to superficial remedies; it mandates that nursing leaders devise systematic strategies to sustain change and galvanize universal participation.” (N.10).

Further elaboration was provided by another informant, who commented on the cultural constraints within the hospital:

“Our hospital gets our own culture. The senior staff do not advocate for changing our practices according to scientific evidence as long as the current practices bring benefits to patients.” (N.12).

Subtheme 2 paucity of external support

A consensus among informants underscored the significance of support from nursing managers and leaders in enhancing post-insertion maintenance for CVCs. Their guiding policies shape the procedural approach; however, several informants expressed concerns that this managerial support, though overtly positive, lacked substantial backing in terms of regular training and resource allocation. Moreover, the incorporation of the best available evidence in post-insertion management for CVCs necessitates specific materials such as connectors and disinfectants. This requirement might burden the department’s budget, thereby hindering effective adoption. In the interview, one informant mentioned:

“Things are not so simple. The hospital (department) does not provide necessary equipment for post-insertion management , such as special kit sets. This complicated the whole process. It is very difficult for us to work.” (N.7).

Another informant, specializing in intravenous therapy, expressed the desire for more conducive working conditions:

“As an intravenous therapy nurse specialist , I yearn for the hospital to allocate space for work focused on service enhancement. At present , I am still tasked with routine duties. Specialists ought to be entrusted with more complex responsibilities. Allotting more time to these intricate tasks , rather than routine work , would undoubtedly elevate the quality of post-insertion management for CVCs.” (N.6).

Further insights were provided by another informant, who suggested:

“Should the hospital initiate a dedicated nursing clinic for intravenous infusion , or foster opportunities for intellectual discourse , it would facilitate the acquisition of skills in post-insertion management , thereby augmenting the overall quality of nursing care.” (N.8).

Facilitators of compliance

Two facilitative elements were identified in the quest for compliance with post-insertion maintenance for CVCs, shown in Table  4 .

Theme 1: positive attitudes of specialist nurses toward evidence application

Most informants asserted that their professional identity can be enhanced through the adoption of evidence-based practice. Specifically, by altering the existing protocols on CVC management, the informants perceived a greater recognition and appreciation of their contributions by nursing leaders, colleagues, patients, and patients’ families. This affirmation of their professional identity consequently augmented their sense of self-worth. The informants also posited that the promotion of evidence-based practice could demonstrate to other nurses that their professional growth was not confined to administrative roles but extended to specialized patient care. An informant elucidated:

“After completing my specialist training , I returned to my hospital to contribute to the development of CVC management guidelines. Now , everyone who encounters problems in CVC management , they will seek for my advice.” (N.10).

Additional insights were provided by other informants:

“Everyone acknowledges my work and my passion. It is a kind of achievement.” (N.11). “Nurse specialists in intravenous therapy serve not merely as practitioners performing injections and infusions but also as educators and facilitators , imparting advanced knowledge to peers and patients , and assuming leadership within the department.” (N.2).

Theme 2: formation of a team specializing in intravenous therapy within hospitals

The informants indicated that their hospitals had instituted professional teams to oversee post-insertion maintenance for CVCs. Particularly after receiving specialization, these nurses are empowered to scrutinize care quality and impart relevant training to their colleagues. When frontline nurses are tasked with post-insertion maintenance for CVCs, these trained specialists can offer guidance and feedback, thereby enhancing the quality of care. An informant shared during a semi-structured interview:

“Having worked only a few years , I began to acquire knowledge about CVC management through a training course at my hospital. This instruction has greatly expanded my understanding and skills.” (N.4).

Another informant reflected on the specialized care required for cancer patients:

“Cancer patients represent a unique cohort , exhibiting a wide variation in medical conditions. When I encounter complexities in providing CVC care , I often consult the professional group on intravenous therapy. The guidance from nurse specialists is invariably insightful and greatly facilitates my practice.” (N.6).

The deployment of CVCs is linked with catheter-associated complications in oncology patients, which may culminate in extended hospital stays and augmented morbidity and mortality rates, thereby constituting a substantial menace to patient safety and escalating healthcare expenditures. In China, nurses are exempted from inserting CVCs but are mandated to administer post-insertion maintenance. Evidence implementation in post-insertion maintenance for CVCs is imperative for nurses engaged in oncological settings to mitigate the aforementioned perils and ramifications [ 41 ].

The quantitative findings in the present research revealed an overall adoption rate of 90.0% concerning evidence adoption in post-insertion maintenance for CVCs in oncology environments. The high rate of evidence adoption was potentially influenced by the inclusion of oncology patients rendered immunocompromised through radiotherapy and chemotherapy. This, in turn, necessitates heightened attention by oncology nurses to infection control protocols during all aspects of CVC management. Although this figure was promising, this study also revealed that there was still room for improvement in the current practice to achieve the expected targets of evidence-based practice. We found that 14 out of 30 practices enumerated in the evaluation checklist did not achieve 90% adoption rate among oncology nurses. These findings were consistent with studies in the West demonstrating unsatisfactory compliance rates in post-insertion management for CVCs [ 42 , 43 ]. Notably, the poorest adoption (< 80%) of evidence-based practices were primarily related to infection control, particularly the disinfection of infusion connector, skin, and catheter, which are associated with complications of catheter-related bloodstream infections and deserve to be heeded. The quantitative data provided more precise information on identifying the weak and critical segment of post-insertion maintenance for CVCs. As in any evidence implementation project, evaluating the pivotal clinical questions and identifying the key segments is crucial for promoting evidence-based clinical translation and implementation [ 44 ]. Consequently, the results highlighted a clear and effective avenue for improvement, which is developing targeted and addressed implementation strategies for disinfection control in the future to enhance the quality of post-insertion maintenance for CVCs in China.

One feature of this study is the continuity and consistency of the quantitative and qualitative research. All informants were a subset of the quantitative phase and involved in the quantitative study before providing their specifically targeted insights and opinions. The outcomes of the clinical observation serve to delineate the specific challenges, laying the groundwork for an in-depth analysis of hindrances and further devising targeted strategies for amelioration [ 45 ]. Additionally, successful evidence implementation is regarded as an outcome resulting from the quality and type of innovation, the characteristics of context, recipients who are influenced or implement the innovation, and how the innovation is facilitated [ 46 ]. Guided by the i-PARIHS framework, the qualitative dialogues were deductively reasoned into four key elements of the clinical implementation of evidence, including innovation, recipients, context, and facilitation [ 47 ]. Facilitators and barriers to adopting scientific evidence in post-insertion maintenance for CVCs among oncology nurses were further clarified using this framework.

The qualitative data identified the difficulty in accessing the evidence was a main barrier to evidence practice in CVCs post-insertion maintenance, mapping to the innovation in the i-PARHIS framework. Knowledge deficit in the evidence may result in low compliance with CVCs maintenance [ 48 ]. In the field of CVCs post-insertion maintenance, the large amount of evidence published does not represent an increase in nurses’ knowledge. Continuous training is necessary to promote best practices in CVC maintenance, not just in knowledge and key points in each procedure, but in the ability to appraise and synthesize evidence. Of the identified barriers to innovation, the clinical applicability of evidence was persistently mentioned by informants, which emphasized that the evidence should be modified, tailored, or refined to fit local context or needs [ 49 ]. Especially some evidence practices related to infection control, e.g. suggested size of the disinfected area, naturally dried waiting after disinfection, seemed hard to apply in clinical operations with workload. Continuous monitoring and periodic revisions to post-insertion management protocols for CVCs are essential to ensure clinical applicability [ 50 ]. Additionally, nurses were concerned with the increased budget resulting from the evidence-based practices related to the inflection control measures. For instance, the cost of a recommended disinfectant, i.e. chlorhexidine gluconate alcohol is 3 to 4 times more expensive than general disinfectants. Therefore, facilitators should be preoccupied with evidence that may increase clinical costs and develop strategies in advance to ensure the sustainability of CVC maintenance evidence application. At the same time, these phenomena were the possible reasons for the quantitative results that most infection control measures in post-insertion management failed to achieve at least 80% adoption rates.

Nurses are the major recipients, responsible for evidence adoption for CVCs post-insertion maintenance. Fortunately, all informants in our qualitative study manifested a positive attitude toward adopting scientific evidence in post-insertion management for CVCs. This is significant, as delineated by Ferrara et al [ 42 , 51 ], attitudes of healthcare workers were crucial to promote adherence to guidelines. Notwithstanding the positive attitudes of our informants, they did mention the difficulties in participating in the evidence-translation process and hospital policymaking, thus hindering the adoption of evidence in post-insertion management for CVCs. This phenomenon is particularly pronounced in China, attributing to medical dominance. Relative to the medical profession, nursing is a comparatively nascent discipline [ 52 ]. Furthermore, a conventional societal perception prevails that nurses are subordinate to physicians, possessing diminished autonomy within healthcare environments [ 53 ]. This perception, combined with an inherently hierarchical structure, diminishes nurses’ participation in policymaking, resulting in their perspectives on post-insertion management for CVCs being marginalized within hospital policy. Encouraging multidisciplinary involvement will provide more opportunities and facilities for specialist nurses to be better involved in addressing such situations. It would be beneficial to expand the scope of involvement by working more closely with the medical team, organizational managers, and patients, who are all key stakeholders in promoting evidence-based practice for CVC maintenance [ 54 ]. One potential approach is the establishment of nurse-led multidisciplinary teams for CVC or the creation of specialist clinics, which can facilitate communication and collaboration with the medical teams and utilize the professional value of specialist nurses.

Aligning with the i-PARIHS framework, the context includes the external and internal environment or organizational culture [ 25 ]. Workload as a barrier should be mentioned, especially since the research settings in this study are tertiary public hospitals with more than 1000 beds. Previous systematic reviews [ 55 ] explicitly indicated that a lower nurse-to-patient ratio was associated with an increased risk of healthcare-associated infections, which was the single significant predictor for bloodstream infections related to CVCs [ 48 ]. The correlation between workload and catheter infection control is also indirectly illustrated considering the low infection control implementation rate in this study’s quantitative results. Moreover, a lack of CVC-maintained required materials, such as CVC maintenance kits and chlorhexidine gluconate alcohol, can also decrease compliance with evidence-based practice. This perspective is consistent with another study from China [ 56 ], which focused on implementation strategies for CVC maintenance in pediatric intensive care units. External support and negotiation from the medical insurance finance, healthcare organization, materials supply department, and nursing department, cannot be ignored. Financial allocations should be strategically increased to avail the necessary human resources and materials for implementing evidence-based practices in CVC management, e.g. purchasing recommended disinfectants or materials. Furthermore, a positive culture can promote the application of innovation, thereby facilitating change [ 56 ]. Within the internal culture, another finding in the study was that managers or frontline specialist nurses were more conservative towards the change and emphasized priority on patient safety. These are misconceptions about change and safety, need to be reversed by the implementation facilitator by creating an adequate atmosphere for change through best-evidence training, demonstration of excellent practice, and performance or moral incentives.

The significance of identifying facilitators is to enhance the facilitators in implementation strategies to increase the uptake of evidence-based clinical innovations [ 57 ]. Two main facilitators of evidence practice for CVC maintenance emerged in this present study. Informants indicated the positive attitudes of specialist nurses toward evidence application, as well as constituting a specialized team focused on CVCs within all research sites, had the potential efficacy in promoting evidence practice for CVC maintenance. Previous literature also supported the effectiveness of such professional teams in enhancing evidence adoption in various clinical practices and settings [ 58 , 59 ]. Nevertheless, a consideration warranting scrutiny is that forming such professional teams necessitates professional training, iteration of knowledge and concept, and communication with and support from management to better leverage the influence of the academic team in the hospital. Consequently, further investigations and well-developed operational mechanisms are warranted to leverage the role of professional teams comprehensively in evidence-based practice.

Strengths and limitations

To our best understanding, this was the first study that adopted a sequential explanatory mixed method based on the i-PARIHS, an implementation science framework, to scrutinize the integration of scientific evidence in post-insertion maintenance for CVCs and identify facilitators and barriers to the evidence adoption within oncological settings in China. An additional virtue pertains to the expansive scale of the research, executed across five medical centers and encompassing 1,314 clinical observations. Such a voluminous dataset conferred robustness and precision in the estimation. Notwithstanding these strengths, certain limitations must also be acknowledged. Firstly, the trustworthiness of the quantitative data from the cross-sectional study might be compromised as the audit checklist did not undergo a psychometric properties test notwithstanding some evidence suggesting that it might not be necessary for the audit checklist [ 34 , 35 ]. Secondly, we did not apply advanced statistical methods to analyze the data as the current analysis could achieve the study objectives. However, advanced statistical methods may be useful to verify some identified facilitators and barriers in evidence adoption, and hence future studies are recommended to do so. Thirdly, this study was conducted in hospitals in China. Due to the difference in organizational structures and cultural beliefs between China and Western countries, which might affect the generalizability of findings in overseas. Fourthly, the semi-structured interviews were conducted by a nurse manager, which might affect the willingness and perceptions of informants to share their opinions due to power imbalance. Lastly, this study adopted different methods, i.e., face-to-face and online platforms to conduct interviews. There might be differences in the study results due to the interview techniques.

Conclusions

This research has bridged an existing gap in the literature, unearthing that the aggregate adoption rate of evidence in post-insertion management for CVCs by nurses within the oncology setting stood at 90.0%. Among all the advocated practices, infection control protocols were the least adopted. Employing the i-PARIHS framework, we identified two facilitators, including the positive attitudes of specialist nurses to evidence application and formation of a team specializing in intravenous therapy within all sites; as well as three barriers mapping to three elements in the i-PARIHS framework, including difficulty in accessing the evidence, lack of involvement from nurse specialists and challenges from internal and external environments. Stemming from these recognized facilitators and obstructions, tailored interventions must be strategized and instituted at an organizational stratum to enhance the execution of the guideline, with particular emphasis on the clinical evidence pertinent to infection control.

Data availability

The datasets used or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Central Venous Catheters

Integrated Promoting Action on Research Implementation in Health Services

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Acknowledgements

We would like to sincerely thank the participants and those who facilitated the research in the study.

The research was supported by the Soft Science Key Project of the Science and Technology Tackling Program of Henan Provincial Health Commission (RKX202301003).

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FNY, KYHo, LWG designed the study. FNY, QL conducted the literature search and wrote the initial proposal. FNY, KYHo, TM analyzed the data and interpretation of data. FNY and KYH drafted the manuscript. YW, LQ L, XXY, NX, YLG contributed to the data collection process. XXX, HYS, LWG, FKYW, KKWL reviewed and provided expert opinions. All authors read and approved the final manuscript.

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Yang, F., Ho, K.Y., Lam, K.K.W. et al. Facilitators and barriers to evidence adoption for central venous catheters post-insertion maintenance in oncology nurses: a multi-center mixed methods study. BMC Nurs 23 , 581 (2024). https://doi.org/10.1186/s12912-024-02242-y

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Study Protocol

Adolescent HIV prevent and care framework: A global scoping review protocol- BSGH 006

Contributed equally to this work with: Gamji Rabiu Abu-Ba’are, Osman Wumpini Shamrock

Roles Conceptualization, Supervision, Writing – original draft, Writing – review & editing

Affiliations School of Nursing, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual, and Global Health Lab, Accra, Ghana, School of Nursing, Yale University, New Haven, Connecticut, United States of America, Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, Connecticut, United States of America, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, United States of America

* E-mail: [email protected]

Affiliations School of Nursing, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual, and Global Health Lab, Accra, Ghana

Roles Methodology, Writing – original draft, Writing – review & editing

Affiliation Edward G. Miner Library, University of Rochester Medical Center, Rochester, New York, United States of America

Roles Conceptualization, Writing – original draft, Writing – review & editing

Affiliation Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, United States of America

Affiliations Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual, and Global Health Lab, Accra, Ghana, School of Nursing, Yale University, New Haven, Connecticut, United States of America, Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, Connecticut, United States of America

• Gamji Rabiu Abu-Ba’are, 
• Osman Wumpini Shamrock, 
• Darcey Rodriguez, 
• George Rudolph Kofi Agbemedu, 
• LaRon E. Nelson

• Published: August 19, 2024
• https://doi.org/10.1371/journal.pone.0289994
• Peer Review
• Reader Comments

Among adolescents, HIV/AIDs remains a significant cause of death globally [ 1 – 4 ]. Given the unique stages in human development, adolescents have been shown to fall within a sexually active phase. Combined with other social and structural factors in their immediate environments, HIV prevention and care among adolescents can be filled with challenges for intervention. This paper outlines this protocol to systematically review peer-reviewed literature in prevention and care among adolescents 10–19 years. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) will be used to report this scoping review. The review will involve screening and extracting data using covidence as the primary tool. The review will encompass quantitative, qualitative, and mixed methods studies, utilizing a search strategy from electronic databases such as PubMed (NCBI), Web of Science Core Collection (Clarivate), Embase (Elsevier), and Scopus (Elsevier). Additionally, a search will be conducted for grey literature using Global Index Medicus (WHO), MedNar (Deep Web Technologies), and Central Register of Controlled Trials (Cochrane). Duplicate removal and selection of articles that meet the inclusion criteria for the study will be performed using Covidence. Once the screening process is complete, data will be extracted from the full-text screened articles in Covidence. We will pilot the extracted data in Covidence to ensure that all relevant information has been captured, making necessary changes if required. Data extraction will be carried out by at least two authors, with any conflicts resolved by the same authors. If a conflict cannot be resolved between the two, a third author will make a final determination. We aim to analyze data thematically by employing a grounded theory approach to generate codes pertinent to the research question. The team will review and discuss codes to create a cohesive set of codes that will be instrumental in identifying knowledge gaps and constructing themes that summarize the data. The proposed systematic review will be among the pioneering efforts to rigorously assess global data on HIV prevention and care, with a specific focus on adolescents 10–19 years. It will consider the diverse socio-economic factors and experiences shaping these adolescents’ lives in HIV prevention and care. We expect this review to yield critical insights into the present landscape of HIV prevention and care for individuals aged 10–19. These findings will also play a pivotal role in shaping the development of a global framework that researchers and stakeholders can readily adopt and implement across socio-economic contexts. This framework will aim to address the unique needs of all adolescents concerning HIV prevention and care.

Citation: Abu-Ba’are GR, Shamrock OW, Rodriguez D, Agbemedu GRK, Nelson LE (2024) Adolescent HIV prevent and care framework: A global scoping review protocol- BSGH 006. PLoS ONE 19(8): e0289994. https://doi.org/10.1371/journal.pone.0289994

Editor: Graeme Hoddinott, Stellenbosch University, SOUTH AFRICA

Received: August 17, 2023; Accepted: June 28, 2024; Published: August 19, 2024

Copyright: © 2024 Abu-Ba’are et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Deidentified research data will be made publicly available when the study is completed and published.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Globally, HIV remains one of the leading causes of death worldwide [ 5 ]. Controlling the spread of the virus has been a major challenge, posing significant problems in advancing preventative measures and providing continuous care to affected individuals [ 6 – 10 ]. The global prevalence of HIV has reduced in this decade, but significant regional variations in trends and modes of transmission exist [ 11 , 12 ]. The epidemiology of HIV among various key population groups, such as adolescents and socially marginalized groups, based on varying community perceptions about sex, has challenged the global efforts to control the spread of the virus [ 13 – 17 ]. Adolescents aged 10–19 years account for approximately 16% of the world’s population. In 2021, 1.7 million adolescents were living with HIV, comprising 5% of all people living with HIV globally, and accounted for 11% of all new infections among emerging adults [ 18 , 19 ].

Adolescent HIV/AIDS is a distinct epidemic that needs to be handled and managed differently from adult HIV [ 20 , 21 ]. Adolescent sexual and reproductive health remains a significant public health concern globally, especially in communities where child marriage and adolescent childbearing are high, with low exposure to modern contraceptives [ 22 ]. Several factors contribute to the high prevalence of HIV among adolescents, including vulnerability during their transitional stage in life and biological changes that can affect their social relationships, potentially leading to risky behaviors that increase the risk of HIV infections [ 19 , 23 – 25 ]. The severity of addressing HIV prevention and care in adolescence is crucial, as many adolescents with HIV are unaware of their status and fail to consistently use condoms in sexual encounters or face challenges when accessing preventive options due to alcohol-drug abuse, sex-HIV-age stigma and discrimination [ 26 – 27 ].

Adherence to HIV medication is a concern among adolescents diagnosed with HIV [ 28 – 32 ]. Accepting a positive HIV test result is challenging for adolescents due to the need for lifelong treatment and worries about their future goals regarding health, education, career and marriage, among other personal goals, producing a micro-level barrier to adolescents’ readiness for HIV care [ 21 , 33 ]. HIV stigma and sex stigma in some communities deter adolescents from accessing HIV care [ 33 , 34 ]. Additionally, the side effects of HIV medications can affect adherence as they can affect adolescents’ ability and willingness to consistently take their prescribed Antiretrovirals [ 35 – 37 ]. Determining appropriate antiretroviral (ART) dosages for sustained suppression in adolescents is challenging adolescent may experience growth spurt, particularly in under resourced health facilities [ 38 ]. Failure to take the correct dosage of antiretroviral can intensify side effects and result in poor adherence [ 39 – 41 ].

Although several preventative measures have been proposed to curb the incidence of HIV among adolescents, it has been recognized that no singular technique is enough to address the epidemic adequately, hence, an integrated approach that combines biomedical preventive techniques with behavioral and structural interventions is recommended as the ideal means of preventing HIV among adolescents [ 6 , 42 ]. The World Health Organization has also proposed using psychosocial techniques to support preventive measures for HIV among adolescents [ 43 ]. Considering that contextual factors significantly influence the effectiveness of interventions in HIV prevention and care among adolescents, it is important to pay attention to regional dynamics when proposing interventions for adolescents. Adolescent girls in 2021 accounted for 75% of all new HIV infections among adolescents. This percentage was even higher with adolescent girls in the 35 HIV-priority countries in UNICEF’s Strategic Plan, accounting for 80% of all new HIV infections among adolescents. In sub-Saharan Africa in the same year, about six times as many adolescent girls were newly infected with HIV than adolescent boys. Beyond the sub-Saharan Africa region, the highest numbers of HIV-positive adolescents are in Asia and Latin America. In East Asia and the Pacific, more boys are newly infected with HIV each year than girls in adolescence. This finding mirrors the various distinct risk behaviors in the respective regions, which suggests that interventions must be personalized to the specific nature and dynamic of the epidemic.

Moreover, there’s a lack of a universal framework that adequately encompasses the multifaceted dynamics of HIV among adolescents, particularly those between the ages of 10–19 years. It’s important to address the gaps in adolescent HIV prevention and care research. Failing to consider social differences, intersectionality, and political climates in different geographical areas could hinder the development of practical and universally applicable policy recommendations that cater to the needs of this population. Our review proposes to:

• Develop a comprehensive assessment of data by conducting a thorough evaluation of existing research on HIV prevention and care among adolescents aged 10–19, considering diverse social factors such as geography, race, sex, age, gender, education, religion, sexual orientation, occupation, nationality, marital status, socio-economic status, disability, and immigration status.
• Use data to develop a global framework based on theory, research and practice to capture the diverse dynamics inherent in adolescent HIV prevention and care. This framework will be adaptable to various economic contexts and provide a standardized measure to support intervention in adolescent HIV prevention and care.

Method and analysis

We will utilize the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) by Tricco et al. (2018) for reporting this scoping review. As outlined by Tricco et al. (2018), the first step in conducting a scoping review is to develop a protocol to clarify the purpose and methodology of the review. By documenting and sharing this protocol, we aim to ensure transparency in our process and prevent duplication of efforts in the field of adolescent HIV prevention and care [ 45 , 46 ].

Ethics and dissemination

Our scoping review findings will be published in a peer-reviewed journal, making them accessible to researchers, practitioners, and the public. We will also share these findings at relevant conferences and events on adolescent HIV prevention and care. Additionally, we aim to use the insights gained from this review to inform future research studies, addressing gaps in the scholarly literature on HIV among adolescents, particularly in prevention and care.

Patient and public involvement

This study does not involve human participants or data collection, so it does not require ethical approval. The research findings will be disseminated through various channels, including conferences, webinars, and peer-reviewed manuscripts. The insights gained from this study have the potential to inform and influence the policies and practices of government health agencies and healthcare facilities, fostering improvements in the field.

Criteria for study inclusion

Only articles addressing HIV prevention or care among adolescents aged 10–19 will be considered. Such articles must present empirical data on the topic and be published in English. We will limit the search inclusion to English for two reasons. The first is due to the unavailability of a multilingual reviewer in the research team and the cost of translation services. The second is connected to our researchers’ expertise and proficiencies in English to ensure an accurate and thorough review of selected studies, enhancing the reliability of data extraction and minimizing the possibility of misinterpretation. Only studies published after 2013 will be included to provide up-to-date information.

Criteria for study exclusion

The review will exclude all individuals aged below 10 and above 19 years. Studies that do not capture empirical data on the topic and are not published in English will be excluded. Studies published before 2013 will be excluded. This review will not include certain types of publications such as review papers (including scoping and systematic reviews), book chapters, reports, opinions, commentaries, conference abstracts, and articles published in languages other than English.

Types of studies

Our review will include quantitative, qualitative, and mixed methods studies. We will encompass both experimental and observational studies without excluding any based on methodological approaches. However, we will exclude articles that synthesize existing literature, such as reviews, in our analysis.

Search strategy

Identifying sources..

A medical librarian (DR) from the University of Rochester Medical Center will create the search strategy with input from other authors to help find any extra sources, such as grey literature, similar to what was done in other protocols [ 45 , 46 ].

Electronic database searching.

DR will conduct a literature search using PubMed (NCBI), Web of Science Core Collection (Clarivate), Embase (Elsevier), and Scopus (Elsevier). The search strategy will use a combination of index terms when available in each database and keywords including HIV, adolescent, care continuum, and anti-retroviral agents. See attached file for an example. The search will limit results to those published in the English language between 2013 to present.

Grey literature searching.

Grey literature will also be searched for using Global Index Medicus (WHO), MedNar (Deep Web Technologies), and Central Registry of Controlled Trials (Cochrane) to capture other relevant data that may not be included in other databases.

Data screening.

After the search process is complete, all articles will be exported to Covidence, and duplicate articles will be removed. Using the inclusion criteria set forth by the team, a two-step screening process will occur in Covidence. After de-duplication, the first process will include two reviewers screening the title and abstract of all remaining articles. After the title and abstract screening process, a team of two will independently review the full text of articles that have met the inclusion criteria. When the two reviewers complete the screening process, they will meet to resolve any conflicts. If the two reviewers cannot resolve, a third reviewer will make a final determination.

Data extraction

Data extraction will begin after all articles have undergone title, abstract, and full-text screening. Using Covidence, the data extraction form will identify publication details, including title, author, and year of publication. The form will also extract data on the methods, including study design, aim, and date. Participate data will include a description of the population, methods of recruitment, and number of participants.

To ensure that all the relevant data is captured as intended, the data extraction form in Covidence will be pilot-tested on a few studies. After pilot testing, modifications will be made, and the form will be used to collect data from eligible studies. The data extraction process will involve two authors working together to ensure accuracy. In the event of any conflicts, they will discuss and resolve the issues. If they are unable to reach an agreement, a third reviewer will be consulted to make a final determination. The review will adhere to the JBI guidelines when conducting the review.

Analysis and reporting.

The findings in the study will adhere to the guidelines outlined in PRISMA-ScR [ 44 ]. We will present a narrative summary of the results while utilizing tables to organize the data. The outcomes will be categorized, taking into account the number of studies, their designs, and methodology. Additionally, key findings from each study will be condensed and presented in tables. Although we will focus on screening experimental studies, we will not conduct quantitative data analysis. Instead, we will employ descriptive statistics such as frequency and range to elucidate the results. Our data will be thematically analyzed [ 45 , 46 ]. We will utilize grounded theory and establish a comprehensive list of codes relevant to the research question and outcomes. This code list will undergo a duplicate review by the research team involved in the data extraction process. A consensus will be reached on a unified set of codes through group discussion. These codes serve as the foundation for creating themes that capture the narrative synthesis of the extracted data and identify any existing knowledge gaps. The proposed framework will be guided by data derived from the systematic review and recommendations from researchers in the diverse research fields in HIV prevention and care among adolescents aged 10–19 years. We will use data derived to serve as a checklist and measure the extent to which the framework considers the social differences, intersectionality, and political climates of adolescents globally.

Outcome. The primary objective of this study is to gain a comprehensive understanding of the current state of HIV prevention and care research among adolescents aged 10–19 years. We will use this knowledge to create a global framework that can be easily used in various economic contexts and serve as a standardized intervention measure in adolescent HIV prevention and care. This framework proposes to enhance research, theory, practice, and policy efforts that consider the diverse experiences of adolescents in HIV prevention and care.

The prevention and care of HIV among adolescents pose significant global challenges due to various factors, including their transitional stage in life, vulnerability associated with their age groups, and the complex interplay of biological, structural, and social factors [ 23 , 24 , 47 ]. These factors individually and collectively may hinder efforts to reduce adolescent HIV-related deaths and transmission. The prevalence of HIV among adolescents is particularly concerning, with areas such as the sub-Saharan region experiencing higher burden of HIV-related deaths among this population group, exacerbated by risky behaviors associated with their transitional stage and a lack of awareness of HIV status [ 4 ]. Our review will aim to analyze global data on HIV prevention and care, focusing on adolescents aged 10–19 years. We will take into account various socio-economic factors and life experiences that affect how these adolescents engage with HIV prevention and care. The insights gained from this analysis will be invaluable in tailoring HIV prevention and care specifically for this age group. Additionally, we plan to use these findings to create a framework that researchers and stakeholders can easily adopt in different socio-economic contexts. This framework will cater to the unique needs of all adolescents in HIV prevention and care, ensuring inclusivity and effectiveness in diverse settings.

Strengths and limitations of this study

1. A notable strength of this study will be its rigorous approach to literature search conducted by a skilled librarian. The search strategy will be comprehensive, augmented by including grey literature sources. This meticulous process will thoroughly cover the existing literature, bolstering the study’s credibility and reliability.

2. Furthermore, this study will offer significant advantage by providing cutting-edge insights and valuable guidance for future research and interventions focused on enhancing awareness among adolescents in HIV prevention and care globally. By keeping abreast of the latest developments, this research will actively advance effective strategies and interventions in this critical area of HIV research.

3. The restriction to articles published exclusively in the English language may be one of the notable limitations of this study. While this ensures consistency and enables a comprehensive analysis within that language, it may inadvertently exclude valuable contributions from non-English sources.

4. Another anticipated limitation of this study will be its specific focus on adolescents (10–19) as the target population. While this emphasis allows for in-depth exploration and tailored insights, it may overlook valuable perspectives and findings relevant to other age groups or people affected by HIV prevention and care.

Supporting information

S1 checklist. prisma-p 2015 checklist..

https://doi.org/10.1371/journal.pone.0289994.s001

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• PubMed/NCBI
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• 5. WHO. The top 10 causes of death—Factsheet. WHO reports. 2020;(December 2020).

• Open access
• Published: 18 August 2024

Entrustable professional activities for bedside clinical teachers

• Ayesha Rafiq 1 &
• Ahsan Sethi 2  

BMC Medical Education volume  24 , Article number:  887 ( 2024 ) Cite this article

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Metrics details

Bedside teaching is an important modality for training medical students and postgraduate trainees in clinical settings. Despite its significance, the effective practice of Bedside teaching has been declining over the past few decades. The literature highlighted the need for structured training, assessment, and certification or in other words entrustment of bedside teachers. The current study aims to develop and validate the Entrustable Professional Activities (EPAs) for bedside clinical teachers.

A multi-method study with clinical teachers, medical educationists, and postgraduate medical students was conducted from July 2021-22. First, a nominal group using the jigsaw puzzle technique was conducted with 16 participants to identify EPAs. Then these EPAs were mapped and validated by the skills/competencies identified in the literature. Next, the EPAs were evaluated using the EQual rubric by 3 medical educationists. This was followed by two-rounds of modified Delphi to develop consensus among 90 participants in round-one and 69 in round-two. For qualitative data, a thematic analysis was conducted. For quantitative data, means and standard deviations were calculated.

The study identified five EPAs for bedside clinical teachers: developing bedside teaching program, planning bedside teaching session, conducting bedside teaching, conducting bedside assessments and evaluating bedside teaching.

Conclusions

This study comprehensively developed and validated a full description of EPAs for bedside clinical teachers. The EPAs identified in the study can serve as a guiding framework for bedside clinical teachers’ training, assessment, and entrustment.

Peer Review reports

Bedside teaching (BST) is one of the most important aspects of undergraduate and postgraduate medical education [ 1 ] It allows learners to develop effective history-taking, physical examinations, clinical reasoning, communication and problem-solving skills in real life clinical settings [ 2 ] BST also helps in learning professionalism and medical ethics. Despite its significance, the effective practice of BST has been declining over the past few decades [ 1 ]. Several reasons have been cited for its decline such as a lack of resources and incentives by hospitals, patients’ discomfort and their unavailability during rounds, increased advancements in technology, increased workload of clinicians, and most importantly their lack of training for BST [ 3 ]. Many clinical teachers learn to teach BST through observation and experimentation and remain ignorant of the educational theories, andragogical principles, and teaching methods [ 1 , 3 , 4 ].

Over the last few decades, there have been expectations from clinical teachers to develop certain educational competencies for effective clinical teaching. In this regard, various educational competency frameworks, guidelines, and training programs have been introduced globally. Literature described several competency frameworks for faculty members such as those proposed by Hesketh et al., [ 5 ] Tigelaar et al., [ 6 ] Molenaar et al., [ 7 ] Milner et al., [ 8 ] Hatem et al., [ 9 ] Srinivasan et al., [ 10 ] Ross et al., [ 11 ] Daouk-Oyry et al., [ 12 ] and Walsh et al. [ 13 ]. However, these frameworks do not guide the teachers on implementing them in their context. Several guidelines for providing effective clinical supervision such as Recognizing and approving trainers by General Medical Council (UK) [ 14 ]; the American Psychological Association’s Guidelines for Clinical Supervision of Health Service Psychologists [ 15 ]; the New Zealand Psychologists Board Guidelines on Supervision [ 16 ]; and the Psychology Board of Australia Guidelines for Supervisors and Supervision Training Providers [ 17 ] are also available. There is also a clinician educator milestone project for the assessment of the educational skills of teaching faculty, which is a joint effort of the Accreditation Council for Graduate Medical Education, the Accreditation Council for Continuing Medical Education, the Association of American Medical Colleges, and the American Association of Colleges of Osteopathic Medicine [ 18 ]. In Pakistan, the College of Physicians and Surgeons [ 19 ] conducts four training workshops which are mandatory to become a clinical supervisor. Unfortunately, these frameworks or trainings for clinical supervisors neither guarantee the transfer of training to the workplace nor ensure the maintenance of competence. Except for some developed countries such as USA, UK, and Canada [ 20 ], the educational competencies of clinical supervisors are not formally assessed in many countries.

Medical students and trainees have reported dissatisfaction with clinical teachers’ competence to understand the level of learners, observe patient-trainee encounters, provide a safe learning environment, demonstrate clinical tasks consistently, deliver constructive feedback, and encourage reflections [ 21 , 22 , 23 ] They reported experiencing opportunistic learning, which varies from one preceptor to another [ 24 ] This necessitates attention towards the selection, training, and preparation of clinical teachers for effective supervision of students [ 25 , 26 ]. To develop, maintain, and bring continuous improvements in teaching competence, there is a need for structured training, assessments, and periodic certification of Bedside Clinical Teachers [ 25 ] or in other words Entrustment of Bedside Clinical Teachers.

Entrustable Professional Activities (EPAs) are defined as a set of professional tasks that can be fully entrusted to a learner to perform independently once they have attained the required specific competencies [ 27 ]. EPAs were first introduced in 2005 for graduate medical students [ 27 ]. Later, the use of EPAs has been increasingly taken up by various health professions with the intent to improve patient safety in the workplace [ 28 ]. EPAs embrace the concept of Competency-Based Medical Education (CBME) which in turn emphasizes the attainment and demonstration of required competencies that are crucial for job performance [ 29 ]. EPAs ground competencies in daily clinical practice & make them assessable. EPAs lay more emphasis on outcome-based, learner-centered, and skills-oriented flexible education, while less on time-barred training, which distinguishes it from the traditional training approaches [ 30 ]. Development of EPAs for BST can help inform faculty training in this important modality for training medical students. These can also be used for training of residents to reduce the burden of clinical teachers [ 31 ] The use of EPAs will also enhance the confidence, insight, and motivation of clinical teachers, while reducing the discomfort of patients and medical students in the process [ 25 , 26 ]. Dewey et al., [ 25 ] proposed the use of EPAs for teaching faculty as well. Iqbal et al., [ 32 ] also emphasized on expanding EPAs for faculty training on specific teaching domains such as bedside teaching, mentoring, small group discussions, etc. In the literature, we could only find one study that developed an EPA for BST [ 33 ]. They used a focus group discussion and open-ended questionnaires via e-mail to collect participants’ perspectives on BST definitions and its essential features to develop an EPA for BST. However, their participants did not involve medical educationists who are the stakeholders in designing, implementing, and evaluating BST. Also, they did not use an EPA evaluation tool such as EQual rubric [ 34 ] for quality or ensured a national consensus or validation [ 35 ] of the final set of EPAs. The current study aims to develop and validate Entrustable Professional Activities (EPAs) for bedside clinical teachers through a rigorous multimethod approach.

Multimethod study design. Abbreviations: JPT, Jigsaw puzzle technique; NGT, Nominal group technique

A multi-method study was conducted in Pakistan from July 2021 - July 2022 (Fig.  1 ). Ethical approval was obtained from the Ethical Review Board of Medical Teaching Institution Abbottabad (Approval Code/Ref.No.RC-2022/EA-01/143 dated 24.05.2021). As an EPA expert has not been precisely defined in the literature, therefore we invited clinical teachers, medical educationists, and postgraduate medical students involved with BST for the study. Participants were selected through purposive maximum variation sampling. The inclusion criteria were set as clinical teachers with a relevant qualification of Member of College of Physicians and Surgeons (MCPS)/ Fellow of College of Physicians and Surgeons (FCPS), a minimum of three years’ field experience, and a designation of Assistant Professor or above. For medical educationists, a relevant qualification of Master in Health Professions Education (MHPE)/ PhD in Health Professions Education, a minimum of three years of experience, and a designation of Assistant Professor or above. Postgraduate students of any age, gender, specialty, and having willingness to participate in the study, were included. The participants were invited through a seminar and email including an information sheet and consent form.

In phase 1, we identified EPAs for BST. We invited 16 participants at Ayub Medical and Teaching Institution Abbottabad, which is a 1460-bedded tertiary care teaching hospital in Pakistan, and currently caters to around 1482 medical students and 546 postgraduate residents in different disciplines of Medicine, Surgery, and Dentistry. Participants were given orientation on study objectives. As the EPA concept was relatively novel to most of them, a detailed presentation encompassing substantial information on EPAs was given by the authors to ensure a common understanding among the participants. The first set of EPAs was developed using the Nominal Group Technique (NGT). In NGT, the experts are involved in independent activities and group interactions for quality ideas (in this research EPAs) generation and consensus development [ 36 ]. As part of NGT, a jigsaw puzzle technique [ 37 ] was used to generate EPAs’ description i.e., title; specifications and limitations; potential risks in case of failure; required competencies; required knowledge, skills, attitudes, and experience; resources for assessment; level of supervision and expiry period [ 38 ]. Jigsaw puzzle technique helped to develop a comprehensive description of all the EPAs through collaborative ideas of all participants in one session. Participants were grouped into four jigsaw groups, where each member of the group was tasked to develop the assigned aspect of EPAs description for all the EPAs. Members (from each jigsaw group) with the same assigned task were then regrouped as expert groups to discuss and compare their ideas with others. Next participants were returned to their original jigsaw groups, where they revised their descriptions to develop a full set of descriptions for all EPAs. Lastly, each group presented their sets of descriptions to other groups for discussion and clarification resulting in the final set of EPAs with descriptions.

The EPAs developed in phase 1 were then validated with the literature review [ 39 ]. A search was made with keywords (EPAs, bedside teaching, and clinical teachers) and by using their synonyms and various combinations in Medline, Embase, Cochrane, ERIC, ScienceDirect, and Google Scholar (Additional file 1 ). Inclusion criteria were set as full text, original articles, and systematic and scoping reviews in the English language with a focus on Medicine specialty. Search also involved controlled vocabulary and free text terms combined using Boolean operators ‘AND’ and ‘OR’.

In this phase, the EQual rubric was used to evaluate the structure and content of EPAs because it reliably measures the alignment of the key domains of EPAs with literature defined standards. It consists of 14 questions which are classified under three sub-scales: EPAs as discrete units of work; EPAs as entrustable, essential, and important tasks of the profession; and EPAs’ curricular role [ 34 ]. An online survey was created using QuestionPro ® (Survey Analytics LLC, Beaverton, Oregon, USA) based on 14 items of the EQual rubric along with three additional questions regarding EPAs improvement (Additional file 2 ). An orientation video on the EQual rubric was also inserted into the first page of the survey for participants’ guidance [ 40 ]. A modified Angoff approach was used for the determination of a cut-off score of 3.95 for EPAs adequacy. Three expert medical educationists with qualifications and experience in clinical teaching and medical education reviewed each EPA using the rubric.

Data was analyzed using means, standard deviations, and level of agreement for each EPA. Free text comments were summarized as standalone qualitative data [ 41 ]. Changes were made when suggested by at least two experts for items with mean scores below 3.95.

This phase used a modified Delphi technique to seek national consensus on EPAs identified in the earlier phases [ 42 ]. Participants of this phase included clinical teachers and postgraduate students from multiple specialties as well as medical educationists. By using purposive maximum variation sampling, participants across Pakistan with known contacts were sent invitations through emails for participation. To increase the sample size, we also employed snowball sampling which is a non-probability sampling method and involves asking initially willing participants to suggest other diverse and information-rich participants with similar characteristics from among their acquaintances. Participants’ number reached 90, which is considered appropriate in Delphi studies involving diverse groups [ 41 ].

A piloted and electronically developed questionnaire via QuestionPro was distributed to participants in two rounds. Participants were provided with AMEE Guide No.140 on recommended description of an EPA, to use as a reference guide [ 38 ]. Participants’ agreement was asked on a 5-point Likert scale from strongly agree to strongly disagree. Round-one survey’s first part was about participants’ demographics and the second part had two sections, A and B. Section A consisted of seven questions repeated for each EPA. The first six questions were about participants’ agreement on the provided title; specifications; limitations; potential risks in case of failure; competencies; and knowledge, skills, and attitude, while the seventh question asked for suggestions for improvements. Section B had four questions. The first two questions asked for participants’ agreement on the provided EPA level and required resources of entrustment. The last two questions asked for participants’ comments on the expiry period and suggestions on the overall EPAs’ description (Additional file 3 ). Round-two survey had ten questions for EPAs’ descriptions, which received below 80% agreement or had major revisions based on round-one (Additional file 4 ).

Data were analyzed using means, standard deviations, and level of agreements. The consensus was set as ≥ 80% agreement for a minimum score of 4 out of 5 on a 5-point Likert scale. Suggestions were incorporated when recommended by at least two participants and after thorough review and discussions amongst the authors.

Initial 16 EPAs were refined through different phases into 5 EPAs. Demographic details of participants who were clinical teachers, medical educationists, and postgraduate medical students are given in Table  1 . Participants belonged to a diverse range of specialties and from different cities grouped into four provinces of Pakistan.

The participants included 10 (62.5%) males and 6 (37.5%) females (Table  1 ). This phase resulted in a set of 16 EPAs and their descriptions (Table  2 ). However, a definitive consensus could not be obtained for the expiry period of EPAs, so it was included for comments in the round-one Delphi survey.

Five new EPAs i.e., EPAs 7, 12, 17, 20, and 21 were added via literature review through selected databases resulting in 21 EPAs (Table  2 ).

Of 21 EPAs, 11 made below the 3.95 cut-off score and were nested with other EPAs as suggested by the participants resulting in 10 EPAs (Table  2 ).

Phase 4 - Delphi

Of 144 invitees, 90 agreed to participate in the study. The response rate to round-one was 85.5%(77/90 responses). Four EPAs scored ≥ 80% agreements, while titles of six EPAs scored < 80% agreements. Modifications were also made to those EPAs’ descriptions that had already scored ≥ 80% agreement if suggested by at least two participants or with consensus among researchers reviewing the comments. Guided by participants’ feedback, EPAs 2, 6, and 10 were nested under the recommended title as “developing BST program”; EPAs 1 and 5 as “planning BST”, EPAs 3, 4, and 9 as “conducting BST”; EPA 8 was retained as “conducting BST assessments” and EPA 7 as “evaluating BST” resulting into five EPAs (Table  2 ). Levels of entrustment for all EPAs had scored > 80% agreement, so, it was not repeated in round-two. Regarding required resources for entrustment, “minutes of meeting” failed to achieve ≥ 80% agreement and was eliminated from the list (Summary of results of round-one of a modified delphi study is available as Additional file 5 ).

Round-two was completed by 69 participants. Eight participants could not fill in the survey because of other commitments. The response rate for round-two was 89.6% (69/77 responses). In this round, all five EPAs, and their descriptions scored ≥ 80% agreement (Summary of the results of round-two of a modified Delphi study is available as Additional file 5 and 6 ) (Insert Table  2 here provided as a separate file of Tables  1 and 2 ).

Five EPAs were developed through four phases of a multimethod approach for bedside teachers of both undergraduate and postgraduate students (Additional file 6 ). The primary set of 16 EPAs was gradually refined through these phases under the guidance of the participants’ feedback to a final set of five EPAs. Some EPAs were nested with others as sub-activities which is consistent with the literature, advocating EPAs to be broader in design that provide less detailed guidance to the trainee on their expected work [ 43 ].

Resulting EPAs are developing BST program, planning BST session, conducting BST, conducting bedside assessments, and evaluating BST. Each of these EPAs encompasses a full set of descriptions and requires standalone entrustment because a bedside teacher can attain certification for developing BST sessions, but is not yet able to plan or conduct BST.

First EPA ensured an organized and well-defined set of tasks for bedside teachers. It was related to planning and developing a complete BST program that encompassed the development of BST curriculum, study guides, assessment policies, written ethical guidelines, feedback, and evaluation forms in collaboration with all stakeholders. It also included a suggestion from a participant of round-two Delphi to use an evidence-based approach while designing the BST curriculum as supported by literature studies [ 44 , 45 , 46 , 47 , 48 ] Second EPA was planning individual BST sessions for ensuring timely and smooth information delivery to students. It included lesson planning, pre-briefing the patients, and orienting the students before BST [ 33 , 49 , 50 ] Participants endorsed this EPA in avoiding untoward situations between doctors and patients or their attendants. Third EPA incorporated steps for BST conduction based on principles of evidence-based teaching and this was in line with previous studies [ 51 , 52 , 53 ] Fourth EPA is the ability of bedside teachers to design and conduct standardized assessments using multiple workplace-based assessment tools [ 54 , 55 ]. This is important because carefully designed assessments lead to professional competence in medical students. The last EPA encompassed tasks related to the evaluation of BST sessions and program, vital for any ongoing dynamic process. This EPA will serve to bring improvements in the overall EPAs structure by identifying BST tasks not yet recognizable in this study. Nearly all study participants deemed these EPAs important, but they also pointed out that these tasks might not be practical in terms of bigger workload of clinical faculty.

Only one study in the literature developed EPA for BST [ 33 ]. However that study did not involve diverse stakeholders including medical educationaists and only used focus group discussion and survey for developing BST definitions and features. On the other hand, the current study involved medical educationists involved in professional development, clinical teachers and postgraduate students and used a four-phased multimethod approach for EPAs development and validation [ 56 ]. Moreover, this study also focused on the development of a full set of descriptions of individual EPAs [ 38 ] to provide explicit details for bedside teachers training programs. Also, Participants chose competency domains required for each EPA from the teaching competency framework for the medical educators proposed by Srinivasan et al., [ 10 ] We have used this framework because it included six core competencies, based on the ACGME competencies framework: medical knowledge; learner-centeredness; interpersonal and communication skills; professionalism and role modeling; practice-based reflection; and systems-based practice and four specialized competencies: program design/implementation, evaluation/scholarship, leadership, and mentorship. These competencies were also cross-referenced with educator roles, from CanMEDS, to ascertain role-specific skills [ 10 ].

For summative entrustment, bedside teachers need to be evaluated by experts using multiple assessment methods at various stages of their training and professional development. Assessment methods which are also supported by other studies include direct observation [ 57 ] 360◦ feedback [ 58 ] reflective portfolio [ 59 ] Objective Structured Teaching Examinations [ 60 ] etc. This study used three instead of the original five entrustment levels as proposed for small group facilitators [ 61 ]. Levels of indirect supervision and entrusted to supervise others had not been used as indirect supervision may not be instantly available to teachers during an ongoing session, and without additional courses, a teacher is not competent enough to train other teachers [ 61 ]. It is our opinion that an EPA may expire if bedside teachers do not undergo appraisals for three consecutive years. This is because, unlike clinical skills, teaching skills may not immediately decay over time but would need re-entrustment after the expiry.

Implications

These EPAs can empower bedside teachers for capacity building by recognizing gaps in their BST practice and accordingly improving them. This would also benefit students, patients, program developers, and medical institutions. As recommended for EPA-based programs [ 38 ] this study also entailed that experienced teachers should train, and assess beginner levels and give appraisals to them for their performance. Teachers can then be awarded certification for independent BST after attaining the required entrustment level. As suggested, a ‘statement of awarded responsibility’ (STAR) can be given to a teacher achieving adequate expertise in an EPA [ 25 ] to signify that a certain task has now been entrusted to the awarded teacher to be performed proficiently. Entrusted teachers can be given reasonable points for the attained STARs to be used for recruitment and promotion [ 62 ] These EPAs can also be adopted as structured faculty development or continuing professional development programs to operationalize BST training at the workplace [ 63 ].

The strength of this study was that to our knowledge, it is the first study that used a multimethod approach to develop and validate a full set of descriptions of EPAs for bedside teachers in collaboration with clinical teachers, medical educationists, and postgraduate students to maximally accommodate their requirements and perspectives. This study design can serve as a guide for other researchers to develop EPAs in other fields.

This study also had some limitations. The study was confined to the context of Pakistan where EPAs’ concept is relatively novel and the majority of the participants had minimal prior experience of EPAs development. However, we tried to cope with this limitation, by providing substantial information on EPAs to the participants before each phase and throughout the study whenever required. Participants were mainly selected for their experience with BST. However, there is still a possibility of lacking one or more items in EPAs description relevant to work of bedside teachers, necessitating these EPAs to be field tested, revisited, and modified if required. Regarding the limitation section in EPAs description, the majority of participants of round-one Delphi misunderstood it as barriers of BST, therefore, their comments were not included. Although this was clarified to them again in round-two, however, some participants commented that limitations can be better identified once EPAs are executed. This study only focused on BST, therefore, its findings would be difficult to generalize to other teaching settings.

This study comprehensively developed and validated a full description of EPAs for bedside clinical teachers. The EPAs identified in the study can serve as a guiding framework for the training, assessment, and entrustment of bedside clinical teachers. Future research should explore the long-term impact of implementing EPAs on bedside clinical teachers’ performance, student outcomes, and overall patient safety.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Abbreviations

The International Association for Medical Education

Bedside Teaching

Competency Based Medical Education

• Entrustable Professional Activities

Education Resources Information Center

Fellow Of College of Physicians and Surgeons

Jigsaw Puzzle Technique

Member Of College of Physicians and Surgeons

Masters In Health Professions Education

Nominal Group Technique

Doctor Of Philosophy

Statement of Awarded Responsibility

United Kingdom

United States of America

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Acknowledgements

The authors would like to thank all the participants for their active contribution to this research project. We would also like to thank Dr. Najia Sajjad Khan and Dr. Anam Rafiq for their valuable feedback and support throughout the project. The study was conducted as part of First author’s MHPE dissertation under the supervision of Dr Ahsan Sethi.

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AS conceptualized and designed the study. Both authors have made substantial contributions to the acquisition, analysis, and interpretation of data; as well as in writing, proofreading, and approving the final manuscript.

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Correspondence to Ahsan Sethi .

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Ethical approval was obtained from Ethical Review Board of Medical Teaching Institution Abbottabad (Approval Code/Ref.No.RC-2022/EA-01/143 dated 24.05.2021) and informed written consent was taken from the participants.

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Rafiq, A., Sethi, A. Entrustable professional activities for bedside clinical teachers. BMC Med Educ 24 , 887 (2024). https://doi.org/10.1186/s12909-024-05876-3

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Received : 06 May 2024

Accepted : 08 August 2024

Published : 18 August 2024

DOI : https://doi.org/10.1186/s12909-024-05876-3

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