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• Published: 27 May 2020

How to use and assess qualitative research methods

• Loraine Busetto   ORCID: orcid.org/0000-0002-9228-7875 1 ,
• Wolfgang Wick 1 , 2 &
• Christoph Gumbinger 1  

Neurological Research and Practice volume  2 , Article number:  14 ( 2020 ) Cite this article

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 , 10 , 11 , 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 , 25 , 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 , 38 , 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

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

Availability of data and materials

Not applicable.

Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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Criteria for Good Qualitative Research: A Comprehensive Review

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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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Good Qualitative Research: Opening up the Debate

Beyond qualitative/quantitative structuralism: the positivist qualitative research and the paradigmatic disclaimer.

What is Qualitative in Research

Avoid common mistakes on your manuscript.

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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• > Qualitative research: its value and applicability

Article contents

What questions are best answered using qualitative research, countering some misconceptions, in conclusion, qualitative research: its value and applicability.

Published online by Cambridge University Press:  02 January 2018

Qualitative research has a rich tradition in the study of human social behaviour and cultures. Its general aim is to develop concepts which help us to understand social phenomena in, wherever possible, natural rather than experimental settings, to gain an understanding of the experiences, perceptions and/or behaviours of individuals, and the meanings attached to them. The effective application of qualitative methods to other disciplines, including clinical, health service and education research, has a rapidly expanding and robust evidence base. Qualitative approaches have particular potential in psychiatry research, singularly and in combination with quantitative methods. This article outlines the nature and potential application of qualitative research as well as attempting to counter a number of misconceptions.

Qualitative research has a rich tradition in the social sciences. Since the late 19th century, researchers interested in studying the social behaviour and cultures of humankind have perceived limitations in trying to explain the phenomena they encounter in purely quantifiable, measurable terms. Anthropology, in its social and cultural forms, was one of the foremost disciplines in developing what would later be termed a qualitative approach, founded as it was on ethnographic studies which sought an understanding of the culture of people from other societies, often hitherto unknown and far removed in geography. Reference Bernard 1 Early researchers would spend extended periods of time living in societies, observing, noting and photographing the minutia of daily life, with the most committed often learning the language of peoples they observed, in the hope of gaining greater acceptance by them and a more detailed understanding of the cultural norms at play. All academic disciplines concerned with human and social behaviour, including anthropology, sociology and psychology, now make extensive use of qualitative research methods whose systematic application was first developed by these colonial-era social scientists.

Their methods, involving observation, participation and discussion of the individuals and groups being studied, as well as reading related textual and visual media and artefacts, form the bedrock of all qualitative social scientific inquiry. The general aim of qualitative research is thus to develop concepts which help us to understand social phenomena in, wherever possible, natural rather than experimental settings, to gain an understanding of the experiences, perceptions and/or behaviours of those studied, and the meanings attached to them. Reference Bryman 2 Researchers interested in finding out why people behave the way they do; how people are affected by events, how attitudes and opinions are formed; how and why cultures and practices have developed in the way they have, might well consider qualitative methods to answer their questions.

It is fair to say that clinical and health-related research is still dominated by quantitative methods, of which the randomised controlled trial, focused on hypothesis-testing through experiment controlled by randomisation, is perhaps the quintessential method. Qualitative approaches may seem obscure to the uninitiated when directly compared with the experimental, quantitative methods used in clinical research. There is increasing recognition among researchers in these fields, however, that qualitative methods such as observation, in-depth interviews, focus groups, consensus methods, case studies and the interpretation of texts can be more effective than quantitative approaches in exploring complex phenomena and as such are valuable additions to the methodological armoury available to them. Reference Denzin and Lincoln 3

In considering what kind of research questions are best answered using a qualitative approach, it is important to remember that, first and foremost, unlike quantitative research, inquiry conducted in the qualitative tradition seeks to answer the question ‘What?’ as opposed to ‘How often?’. Qualitative methods are designed to reveal what is going on by describing and interpreting phenomena; they do not attempt to measure how often an event or association occurs. Research conducted using qualitative methods is normally done with an intent to preserve the inherent complexities of human behaviour as opposed to assuming a reductive view of the subject in order to count and measure the occurrence of phenomena. Qualitative research normally takes an inductive approach, moving from observation to hypothesis rather than hypothesis-testing or deduction, although the latter is perfectly possible.

When conducting research in this tradition, the researcher should, if possible, avoid separating the stages of study design, data collection and analysis, but instead weave backwards and forwards between the raw data and the process of conceptualisation, thereby making sense of the data throughout the period of data collection. Although there are inevitable tensions among methodologists concerned with qualitative practice, there is broad consensus that a priori categories and concepts reflecting a researcher's own preconceptions should not be imposed on the process of data collection and analysis. The emphasis should be on capturing and interpreting research participants' true perceptions and/or behaviours.

Using combined approaches

The polarity between qualitative and quantitative research has been largely assuaged, to the benefit of all disciplines which now recognise the value, and compatibility, of both approaches. Indeed, there can be particular value in using quantitative methods in combination with qualitative methods. Reference Barbour 4 In the exploratory stages of a research project, qualitative methodology can be used to clarify or refine the research question, to aid conceptualisation and to generate a hypothesis. It can also help to identify the correct variables to be measured, as researchers have been known to measure before they fully understand the underlying issues pertaining to a study and, as a consequence, may not always target the most appropriate factors. Qualitative work can be valuable in the interpretation, qualification or illumination of quantitative research findings. This is particularly helpful when focusing on anomalous results, as they test the main hypothesis formulated. Qualitative methods can also be used in combination with quantitative methods to triangulate findings and support the validation process, for example, where three or more methods are used and the results compared for similarity (e.g. a survey, interviews and a period of observation in situ ).

‘There is little value in qualitative research findings because we cannot generalise from them’

Generalisability refers to the extent that the account can be applied to other people, times and settings other than those actually studied. A common criticism of qualitative research is that the results of a study are rarely, if ever, generalisable to a larger population because the sample groups are small and the participants are not chosen randomly. Such criticism fails to recognise the distinctiveness of qualitative research where sampling is concerned. In quantitative research, the intent is to secure a large random sample that is representative of the general population, with the purpose of eliminating individual variations, focusing on generalisations and thereby allowing for statistical inference of results that are applicable across an entire population. In qualitative research, generalisability is based on the assumption that it is valuable to begin to understand similar situations or people, rather than being representative of the target population. Qualitative research is rarely based on the use of random samples, so the kinds of reference to wider populations made on the basis of surveys cannot be used in qualitative analysis.

Qualitative researchers utilise purposive sampling, whereby research participants are selected deliberately to test a particular theoretical premise. The purpose of sampling here is not to identify a random subgroup of the general population from which statistically significant results can be extrapolated, but rather to identify, in a systematic way, individuals that possess relevant characteristics for the question being considered. Reference Strauss and Corbin 5 The researchers must instead ensure that any reference to people and settings beyond those in the study are justified, which is normally achieved by defining, in detail, the type of settings and people to whom the explanation or theory applies based on the identification of similar settings and people in the study. The intent is to permit a detailed examination of the phenomenon, resulting in a text-rich interpretation that can deepen our understanding and produce a plausible explanation of the phenomenon under study. The results are not intended to be statistically generalisable, although any theory they generate might well be.

‘Qualitative research cannot really claim reliability or validity’

In quantitative research, reliability is the extent to which different observers, or the same observers on different occasions, make the same observations or collect the same data about the same object of study. The changing nature of social phenomena scrutinised by qualitative researchers inevitably makes the possibility of the same kind of reliability problematic in their work. A number of alternative concepts to reliability have been developed by qualitative methodologists, however, known collectively as forms of trustworthiness. Reference Guba 6

One way to demonstrate trustworthiness is to present detailed evidence in the form of quotations from interviews and field notes, along with thick textual descriptions of episodes, events and settings. To be trustworthy, qualitative analysis should also be auditable, making it possible to retrace the steps leading to a certain interpretation or theory to check that no alternatives were left unexamined and that no researcher biases had any avoidable influence on the results. Usually, this involves the recording of information about who did what with the data and in what order so that the origin of interpretations can be retraced.

In general, within the research traditions of the natural sciences, findings are validated by their repeated replication, and if a second investigator cannot replicate the findings when they repeat the experiment then the original results are questioned. If no one else can replicate the original results then they are rejected as fatally flawed and therefore invalid. Natural scientists have developed a broad spectrum of procedures and study designs to ensure that experiments are dependable and that replication is possible. In the social sciences, particularly when using qualitative research methods, replication is rarely possible given that, when observed or questioned again, respondents will almost never say or do precisely the same things. Whether results have been successfully replicated is always a matter of interpretation. There are, however, procedures that, if followed, can significantly reduce the possibility of producing analyses that are partial or biased. Reference Altheide, Johnson, Denzin and Lincoln 7

Triangulation is one way of doing this. It essentially means combining multiple views, approaches or methods in an investigation to obtain a more accurate interpretation of the phenomena, thereby creating an analysis of greater depth and richness. As the process of analysing qualitative data normally involves some form of coding, whereby data are broken down into units of analysis, constant comparison can also be used. Constant comparison involves checking the consistency and accuracy of interpretations and especially the application of codes by constantly comparing one interpretation or code with others both of a similar sort and in other cases and settings. This in effect is a form of interrater reliability, involving multiple researchers or teams in the coding process so that it is possible to compare how they have coded the same passages and where there are areas of agreement and disagreement so that consensus can be reached about a code's definition, improving consistency and rigour. It is also good practice in qualitative analysis to look constantly for outliers – results that are out of line with your main findings or any which directly contradict what your explanations might predict, re-examining the data to try to find a way of explaining the atypical finding to produce a modified and more complex theory and explanation.

Qualitative research has been established for many decades in the social sciences and encompasses a valuable set of methodological tools for data collection, analysis and interpretation. Their effective application to other disciplines, including clinical, health service and education research, has a rapidly expanding and robust evidence base. The use of qualitative approaches to research in psychiatry has particular potential, singularly and in combination with quantitative methods. Reference Crabb and Chur-Hansen 8 When devising research questions in the specialty, careful thought should always be given to the most appropriate methodology, and consideration given to the great depth and richness of empirical evidence which a robust qualitative approach is able to provide.

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• Finding Qualitative Studies

Qualitative Research Resources: Finding Qualitative Studies

Created by health science librarians.

• What is Qualitative Research?
• Qualitative Research Basics
• Special Topics
• Training Opportunities: UNC & Beyond
• Help at UNC
• Qualitative Software for Coding/Analysis
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About this Page

Ready-built sets of search terms, database-specific search strategies, general qual search strategies, web resources.

• Assessing Qualitative Research
• Writing Up Your Research
• Integrating Qualitative Research into Systematic Reviews
• Publishing Qualitative Research
• Presenting Qualitative Research
• Qualitative & Libraries: a few gems
• Data Repositories

Why is this information important?

• Electronic databases for health science literature, such as PubMed or CINAHL, often do not index qualitative health studies very clearly.
• Authors also do not always identify their methods using the word "qualitative" in their titles or abstracts; in some cases they may use terminology for a specific qualitative method instead.
• Often, that means that it is hard to find qualitative studies in common health science databases like PubMed

On this page you'll find:

• articles that describe and evaluate search strategies for finding qualitative research
• articles that provide search strategies for specific databases
• web resources on search filters and finding qualitative articles in databases
• links to sets of search terms to use when searching for qualitative research
• Hedges: Evidence Based Health Informatics, McMaster University contains qualitative hedges for Medline, PsycInfo, and Embase
• ISSG Search Filters Resource: Qualitative Research Filters The InterTASC Information Specialists' Sub-Group Search Filter Resource is a collaborative venture to identify, assess and test search filters designed to retrieve research by study design or focus. The Search Filters Resource aims to provide easy access to published and unpublished search filters. It also provides information and guidance on how to critically appraise search filters, study design filters in progress and information on the development and use of search filters. Inclusion of a search filter is not an endorsement of its validity or a recommendation.
• PubMed Health Services Research Queries Using Research Methodology Filters

A Few Articles on Search Strategies for Specific Databases

Wilczynski NL, Marks S, Haynes RB.2007.  Search strategies for identifying qualitative studies in CINAHL.  Qualitative Health Research  17(5):705-10.

Walters LA, Wilczynski NL, Haynes RB; Hedges Team. 2006.  Developing optimal search strategies for retrieving clinically relevant qualitative studies in EMBASE.  Qualitative Health Research  16(1):162-8.

Wong SS, Wilczynski NL, Haynes RB, Hedges Team. 2004.  Developing optimal search strategies for detecting clinically relevant qualitative studies in MEDLINE.   Medinfo   11: 311-316.

McKibbon KA, Wilczynski NL, Haynes RB. 2006.  Developing optimal search strategies for retrieving qualitative studies in PsycINFO.  Evaluation and the Health Professions   29: 440-454.

CINAHL & PsycINFO :

Rosumeck S, Wagner M, Wallraf S, Euler U. A validation study revealed differences in design and performance of search filters for qualitative research in PsycINFO and CINAHL . J Clin Epidemiol. 2020 Dec;128:101-108. doi: 10.1016/j.jclinepi.2020.09.031. Epub 2020 Sep 26. PMID: 32987157.

MEDLINE, CINAHL, Social Science Citation Index (SSCI) :

DeJean D, Giacomini M, Simeonov D, Smith A. Finding Qualitative Research Evidence for Health Technology Assessment . Qual Health Res. 2016 Aug;26(10):1307-17. doi: 10.1177/1049732316644429. Epub 2016 Apr 26. PMID: 27117960.

MEDLINE, EMBASE, CINAHL, PsycINFO :

A Few Articles on General Search Strategies for Qualitative Literature

Booth, A. (2016). Searching for qualitative research for inclusion in systematic reviews: A structured methodological review . Systematic Reviews, 5 doi:http://dx.doi.org.libproxy.lib.unc.edu/10.1186/s13643-016-0249-x

Cook, A., D. Smith, and A. Booth. 2012. Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qualitative Health Research 10: 1435-1443.

Evans, D. 2002.  Database searches for qualitative research .  Journal of the Medical Libraries Association , 90(3): 290-293.

Flemming K, Briggs M. 2007. Electronic searching to locate qualitative research: evaluation of three strategies. J Adv Nurs . 57(1):95-100

Gorecki CA, Brown JM, Briggs M, Nixon J. 2010. Evaluation of five search strategies in retrieving qualitative patient-reported electronic data on the impact of pressure ulcers on quality of life . J Adv Nurs . 66(3):645-52

Grant MJ. 2004 How does your searching grow? A survey of search preferences and the use of optimal search strategies in the identification of qualitative research. Health Info Libr J . 21(1):21-32

Littleton, D, S Marsalis, D Z Bliss. 2004. Searching the literature by design . Western Journal of Nursing Research 26(8): 891-908.

Methley, A.M., S. Campbell, C. Chew-Graham, R. McNally, and S. Cheraghi-Sohi. 2014. PICO, PICOS, and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews . BMC Health Serv Res 14: 579.

Pearson, M., Moxham, T., & Ashton, K. 2011. Effectiveness of Search Strategies for Qualitative Research About Barriers and Facilitators of Program Delivery .  Evaluation & the Health Professions , 34(3), 297–308.  https://doi.org/10.1177/0163278710388029

Petticrew, Mark and Helen Roberts. 2008. Systematic Reviews in the Social Sciences: A Practical Guide. Chapter 4: How to Find the Studies: The Literature Search . Blackwell Publishing: Oxford, UK.

Shaw RL, Booth A, Sutton AJ, Miller T, Smith JA, Young B, et al. 2004. Finding qualitative research: an evaluation of search strategies . BMC Med Res Methodol 4:5

• Campbell Collaboration Information Retrieval Guide Campbell Collaboration is an organization that guides and publishes systematic reviews. This resource is their publication on searching strategies and finding articles; it is not specific to qualitative studies but offers useful hints.
• NYU Libraries: Locating Qualitative Research Includes a good starting list of qualitative keywords for a general keyword based search strategy that can be cut and pasted into any database plus database specific strategies for CINAHL, Medline (including PubMed), and PsycINFO (with APA Index Terms). Note that PsycINFO via OVID strategies would need to be translated for UNC's Ebsco version.
• University of Washington LibGuide: Finding Qualitative Research Articles This guide gives some basic general search strategies when looking for qualitative literature, as well as specific search strategies for specific databases (CINAHL, PubMed, PsycInfo), books, and grey literature.
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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analyzing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, history, etc.

• How does social media shape body image in teenagers?
• How do children and adults interpret healthy eating in the UK?
• What factors influence employee retention in a large organization?
• How is anxiety experienced around the world?
• How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, other interesting articles, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography , action research , phenomenological research, and narrative research. They share some similarities, but emphasize different aims and perspectives.

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

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Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

• Observations: recording what you have seen, heard, or encountered in detailed field notes.
• Interviews:  personally asking people questions in one-on-one conversations.
• Focus groups: asking questions and generating discussion among a group of people.
• Surveys : distributing questionnaires with open-ended questions.
• Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
• You take field notes with observations and reflect on your own experiences of the company culture.
• You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
• You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves “instruments” in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analyzing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

• Prepare and organize your data. This may mean transcribing interviews or typing up fieldnotes.
• Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
• Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorize your data.
• Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
• Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analyzing qualitative data. Although these methods share similar processes, they emphasize different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

• Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

• Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

• Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

• Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

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Researchers must consider practical and theoretical limitations in analyzing and interpreting their data. Qualitative research suffers from:

• Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

• Subjectivity

Due to the researcher’s primary role in analyzing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

• Limited generalizability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalizable conclusions because the data may be biased and unrepresentative of the wider population .

• Labor-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

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

• Chi square goodness of fit test
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

There are five common approaches to qualitative research :

• Grounded theory involves collecting data in order to develop new theories.
• Ethnography involves immersing yourself in a group or organization to understand its culture.
• Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
• Phenomenological research involves investigating phenomena through people’s lived experiences.
• Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organizations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organize your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

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• Open access
• Published: 28 August 2024

A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi

• Trisha Arnold   ORCID: orcid.org/0000-0003-3556-5717 1 , 2 ,
• Laura Whiteley 2 ,
• Kayla K. Giorlando 1 ,
• Andrew P. Barnett 1 , 2 ,
• Ariana M. Albanese 2 ,
• Avery Leigland 1 ,
• Courtney Sims-Gomillia 3 ,
• A. Rani Elwy 2 , 5 ,
• Precious Patrick Edet 3 ,
• Demetra M. Lewis 4 ,
• James B. Brock 4 &
• Larry K. Brown 1 , 2  

Implementation Science Communications volume  5 , Article number:  92 ( 2024 ) Cite this article

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Mississippi (MS) experiences disproportionally high rates of new HIV infections and limited availability of pre-exposure prophylaxis (PrEP). Federally Qualified Health Centers (FQHCs) are poised to increase access to PrEP. However, little is known about the implementation strategies needed to successfully integrate PrEP services into FQHCs in MS.

The study had two objectives: identify barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs.

Semi-structured interviews were conducted with 19 staff and 17 PrEP-eligible patients in MS FQHCs between April 2021 and March 2022. The interview was guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework which covered PrEP facilitators and barriers. Interviews were coded according to the i-PARIHS domains of context, innovation, and recipients, followed by thematic analysis of these codes. Identified implementation strategies were presented to 9 FQHC staff for feedback.

Data suggested that PrEP use at FQHCs is influenced by patient and clinic staff knowledge with higher levels of knowledge reflecting more PrEP use. Perceived side effects are the most significant barrier to PrEP use for patients, but participants also identified several other barriers including low HIV risk perception and untrained providers. Despite these barriers, patients also expressed a strong motivation to protect themselves, their partners, and their communities from HIV. Implementation strategies included education and provider training which were perceived as acceptable and appropriate.

Conclusions

Though patients are motivated to increase protection against HIV, multiple barriers threaten uptake of PrEP within FQHCs in MS. Educating patients and providers, as well as training providers, are promising implementation strategies to overcome these barriers.

Peer Review reports

Contributions to the literature

We propose utilizing Federally Qualified Health Centers (FQHCs) to increase pre-exposure prophylaxis (PrEP) use among people living in Mississippi.

Little is currently known about how to distribute PrEP at FQHCs.

We comprehensively describe the barriers and facilitators to implementing PrEP at FQHCs.

Utilizing effective implementation strategies of PrEP, such as education and provider training at FQHCs, may increase PrEP use and decrease new HIV infections.

Introduction

The HIV outbreak in Mississippi (MS) is among the most critical in the United States (U.S.). It is distinguished by significant inequalities, a considerable prevalence of HIV in remote areas, and low levels of HIV medical care participation and virologic suppression [ 1 ]. MS has consistently ranked among the states with the highest HIV rates in the U.S. This includes being the 6th highest in new HIV diagnoses [ 2 ] and 2nd highest in HIV diagnoses among men who have sex with men (MSM) compared to other states [ 2 , 3 , 4 ]. Throughout MS, the HIV epidemic disproportionately affects racial and ethnic minority groups, particularly among Black individuals. A spatial epidemiology and statistical modeling study completed in MS identified HIV hot spots in the MS Delta region, Southern MS, and in greater Jackson, including surrounding rural counties [ 5 ]. Black race and urban location were positively associated with HIV clusters. This disparity is often driven by the complex interplay of social, economic, and structural factors, including poverty, limited access to healthcare, and stigma [ 5 ].

Pre-exposure prophylaxis (PrEP) has gained significant recognition due to its safety and effectiveness in preventing HIV transmission when taken as prescribed [ 6 , 7 , 8 , 9 ]. However, despite the progression in PrEP and its accessibility, its uptake has been slow among individuals at high risk of contracting HIV, particularly in Southern states such as MS [ 10 , 11 , 12 , 13 , 14 ]. According to the CDC [ 5 ], “4,530 Mississippians at high risk for HIV could potentially benefit from PrEP, but only 927 were prescribed PrEP.” Several barriers hinder PrEP use in MS including limited access to healthcare, cost, stigma, and medical mistrust [ 15 , 16 , 17 ].

Federally qualified health centers (FQHCs) are primary healthcare organizations that are community-based and patient-directed, serve geographically and demographically diverse patients with limited access to medical care, and provide care regardless of a patient’s ability to pay [ 18 ]. FQHCs in these areas exhibit reluctance in prescribing or counseling patients regarding PrEP, primarily because they lack the required training and expertise [ 19 , 20 , 21 ]. Physicians in academic medical centers are more likely to prescribe PrEP compared to those in community settings [ 22 ]. Furthermore, providers at FQHCs may exhibit less familiarity with conducting HIV risk assessments, express concerns regarding potential side effects of PrEP, and have mixed feelings about prescribing it [ 23 , 24 ]. Task shifting might also be needed as some FQHCs may lack sufficient physician support to manage all aspects of PrEP care. Tailored strategies and approaches are necessary for FQHCs to effectively navigate the many challenges that threaten their patients’ access to and utilization of PrEP.

The main objectives of this study were to identify the barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs providing PrEP. To service these objectives, this study had three specific aims. Aim 1 involved conducting a qualitative formative evaluation guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework- with FQHC staff and PrEP-eligible patients across three FQHCs in MS [ 25 ]. Interviews covered each of the three i-PARIHS domains: context, innovation, and recipients. These interviews sought to identify barriers and facilitators to implementing PrEP. Aim 2 involved using interview data to select and tailor implementation strategies from the Expert Recommendations for Implementing Change (ERIC) project [ 26 ] (e.g., provider training) and methods (e.g., telemedicine, PrEP navigators) for the FQHCs. Aim 3 was to member-check the selected implementation strategies and further refine these if necessary. Data from all three aims are presented below. The standards for reporting qualitative research (SRQR) checklist was used to improve the transparency of reporting this qualitative study [ 27 ].

Formative evaluation interviews

Interviews were conducted with 19 staff and 17 PrEP-eligible patients from three FQHCs in Jackson, Canton, and Clarksdale, Mississippi. Staff were eligible to participate if they were English-speaking and employed by their organization for at least a year. Eligibility criteria for patients included: 1) English speaking, 2) aged 18 years or older, 3) a present or prior patient at the FQHC, 4) HIV negative, and 5) currently taking PrEP or reported any one of the following factors that may indicate an increased risk for HIV: in the past year, having unprotected sex with more than one person with unknown (or positive) HIV status, testing positive for a sexually transmitted infection (STI) (syphilis, gonorrhea, or chlamydia), or using injection drugs.

Data collection

The institutional review boards of the affiliated hospitals approved this study prior to data collection. An employee at each FQHC acted as a study contact and assisted with recruitment. The contacts advertised the study through word-of-mouth to coworkers and relayed the contact information of those interested to research staff. Patients were informed about the study from FQHC employees and flyers while visiting the FQHC for HIV testing. Those interested filled out consent-to-contact forms, which were securely and electronically sent to research staff. Potential participants were then contacted by a research assistant, screened for eligibility, electronically consented via DocuSign (a HIPAA-compliant signature capturing program), then scheduled for an interview. Interviews occurred remotely over Zoom, a HIPAA-compliant, video conferencing platform. Interviews were conducted until data saturation was reached. In addition to the interview, all participants were asked to complete a short demographics survey via REDCap, a HIPAA-compliant, online, data collection tool. Each participant received a $100 gift card for their time.

The i-PARIHS framework guided interview content and was used to create a semi-structured interview guide [ 28 ]. Within the i-PARIHS framework’s elements, the interview guide content included facilitators and barriers to PrEP use at the FQHC: 1) the innovation, (PrEP), such as its degree of fit with existing practices and values at FQHCs; 2) the recipients (individuals presenting to FQHCs), such as their PrEP awareness, barriers to receiving PrEP such as motivation, resources, support, and personal PrEP experiences; and 3) the context of the setting (FQHCs), such as clinic staff PrEP awareness, barriers providing PrEP services, and recommendations regarding PrEP care. Interviews specifically asked about the use of telemedicine, various methods for expanding PrEP knowledge for both patients and providers (e.g., social media, advertisements, community events/seminars), and location of services (e.g., mobile clinics, gyms, annual health checkups, health fairs). Staff and patients were asked the same interview questions. Data were reviewed and analyzed iteratively throughout data collection, and interview guides were adapted as needed.

Data analysis

Interviews were all audio-recorded, then transcribed by an outside, HIPAA-certified transcription company. Transcriptions were reviewed for accuracy by the research staff who conducted the interviews.

Seven members of the research team (TA, LW, KKG, AB, CSG, AL, LKB) independently coded the transcripts using an a priori coding schedule that was developed using the i-PARIHS and previous studies [ 15 , 16 , 17 ]. All research team members were trained in qualitative methods prior to beginning the coding process. The coding scheme covered: patient PrEP awareness, clinic staff PrEP awareness, barriers to receiving PrEP services, barriers to providing PrEP services, and motivation to take PrEP. Each coder read each line of text and identified if any of the codes from the a priori coding framework were potentially at play in each piece of text. Double coding was permitted when applicable. New codes were created and defined when a piece of text from transcripts represented a new important idea. Codes were categorized according to alignment with i-PARIHS constructs. To ensure intercoder reliability, the first 50% of the interviews were coded by two researchers. Team meetings were regularly held to discuss coding discrepancies (to reach a consensus). Coded data were organized using NVivo software (Version 12). Data were deductively analyzed using reflexive thematic analysis, a six-step process for analyzing and reporting qualitative data, to determine themes relevant to selecting appropriate implementation strategies to increase PrEP use at FQHCs in MS [ 29 ]. The resulting thematic categories were used to select ERIC implementation strategies [ 26 ]. Elements for each strategy were then operationalized and the mechanism of change for each strategy was hypothesized [ 30 , 31 ]. Mechanisms define how an implementation strategy will have an effect [ 30 , 31 ]. We used the identified determinants to hypothesize the mechanism of change for each strategy.

Member checking focus groups

Member checking is when the data or results are presented back to the participants, who provide feedback [ 32 ] to check for accuracy [ 33 ] and improve the validity of the data [ 34 ]. This process helps reduce the possibility of misrepresentation of the data [ 35 ]. Member checking was completed with clinic staff rather than patients because the focus was on identifying strategies to implement PrEP in the FQHCs.

Two focus groups were conducted with nine staff from the three FQHCs in MS. Eligibility criteria were the same as above. A combination of previously interviewed staff and non-interviewed staff were recruited. Staff members were a mix of medical (e.g., nurses, patient navigators, social workers) and non-medical (e.g., administrative assistant, branding officer) personnel. Focus group one had six participants and focus group two had three participants. The goal was for focus group participants to comprise half of staff members who had previously been interviewed and half of non-interviewed staff.

Participants were recruited and compensated via the same methods as above. All participants electronically consented via DocuSign, and then were scheduled for a focus group. Focus groups occurred remotely over Zoom. Focus groups were conducted until data saturation was reached and no new information surfaced. The goal of the focus groups was to member-check results from the interviews and assess the feasibility and acceptability of selected implementation strategies. PowerPoint slides with the results and implementation strategies written in lay terms were shared with the participants, which is a suggested technique to use in member checking [ 33 ]. Participants were asked to provide feedback on each slide.

Focus groups were all audio-recorded, then transcribed. Transcriptions were reviewed for accuracy by the research staff who completed focus groups. Findings from the focus groups were synthesized using rapid qualitative analyses [ 36 , 37 ]. Facilitators (TA, PPE) both took notes during the focus groups of the primary findings. Notes were then compared during team meetings and results were finalized. Results obtained from previous findings of the interviews and i-PARIHS framework were presented. To ensure the reliability of results, an additional team member (KKG) read the transcripts to verify the primary findings and selected supportive quotes for each theme. Team meetings were regularly held to discuss the results.

Thirty-six semi-structured interviews in HIV hot spots were completed between April 2021 and March 2022. Among the 19 FQHC staff, most staff members had several years of experience working with those at risk for HIV. Staff members were a mix of medical (e.g., doctors, nurses, CNAs, social workers) and non-medical (e.g., receptionists, case managers) personnel. Table 1 provides the demographic characteristics for the 19 FQHC clinic staff and 17 FQHC patients.

Table 2 provides a detailed description of the findings within each category: PrEP knowledge, PrEP barriers, and PrEP motivation. Themes are described in detail, with representative quotes, below. Implementation determinants are specific factors that influence implementation outcomes and can be barriers or facilitators. Table 3 highlights which implementation determinants can increase ( +) or decrease (-) the implementation of PrEP at FQHCs in MS. Each determinant, mapped to its corresponding i-PARIHS construct, is discussed in more detail below. There were no significant differences in responses across the three FQHCs.

PrEP knowledge

Patient prep awareness (i-parihs: recipients).

Most patients had heard of PrEP and were somewhat familiar with the medication. One patient described her knowledge of PrEP as follows, “I know that PrEP is I guess a program that helps people who are high-risk with sexual behaviors and that doesn't have HIV, but they're at high-risk.”- Patient, Age 32, Female, Not on PrEP. However, many lacked knowledge of who may benefit from PrEP, where to receive a prescription, the different medications used for PrEP, and the efficacy of PrEP. Below is a comment made by a patient listing what she would need to know to consider taking PrEP. “I would need to know the price. I would need to know the side effects. I need to know the percentage, like, is it 100 or 90 percent effective.”— Patient, Age Unknown, Female, Not on PrEP. Patients reported learning about PrEP via television and social media commercials, medical providers, and their social networks. One patient reported learning about PrEP from her cousin. “The only person I heard it [PrEP] from was my cousin, and she talks about it all the time, givin’ us advice and lettin’ us know that it’s a good thing.”— Patient, Age Unknown, Female, Not on PrEP.

Clinic Staff PrEP Awareness (i-PARIHS: Context)

Training in who may benefit from PrEP and how to prescribe PrEP varied among clinic staff at different FQHCs. Not all clinics offered formal PrEP education for employees; however, most knew that PrEP is a tool used for HIV prevention. Staff reported learning about PrEP via different speakers and meetings. A clinic staff member reported learning about PrEP during quarterly meetings. “Well, sometimes when we have different staff meetings, we have them quarterly, and we discuss PrEP. Throughout those meetings, they tell us a little bit of information about it, so that's how I know about PrEP.” – Staff, Dental Assistant, Female. Some FQHC staff members reported having very little knowledge of PrEP. One staff member shared that she knew only the “bare minimum” about PrEP, stating,

“I probably know the bare minimum about PrEP. I know a little about it [PrEP] as far as if taken the correct way, it can prevent you from gettin’ HIV. I know it [PrEP] doesn’t prevent against STDs but I know it’s a prevention method for HIV and just a healthier lifestyle.” –Staff, Accountant, Female

A few of the organizations had PrEP navigators to which providers refer patients. These providers were well informed on who to screen for PrEP eligibility and the process for helping the patient obtain a PrEP prescription. One clinic staff member highlighted how providers must be willing to be trained in the process of prescribing PrEP and make time for patients who may benefit. Specifically, she said,

“I have been trained [for PrEP/HIV care]. It just depends on if that’s something that you’re willing to do, they can train on what labs and stuff to order ’cause it’s a whole lot of labs. But usually, I try to do it. At least for everybody that’s high-risk.” – Staff, OB/GYN Nurse Practitioner, Female

Another clinic staff member reported learning about PrEP while observing another staff member being training in PrEP procedures.

“Well, they kinda explained to me what it [PrEP] is, but I was in training with the actual PrEP person, so it was kinda more so for his training. I know what PrEP is. I know the medications and I know he does a patient assistance program. If my patients have partners who are not HIV positive and wanna continue to be HIV negative, I can refer 'em.” – Staff, Administrative Assistant, Female

PrEP barriers

Barriers receiving prep services (i-parihs: recipients, innovation).

Several barriers to receiving PrEP services were identified in both patient and clinic staff interviews. There was a strong concern for the side effects of PrEP. One patient heard that PrEP could cause weight gain and nightmares, “I’m afraid of gaining weight. I’ve heard that actual HIV medication, a lotta people have nightmares or bad dreams.” - Patient, Age 30, Female, Not on PrEP. Another patient was concerned about perceived general side effects that many medications have. “Probably just the [potential] side effects. You know, most of the pills have allergic reactions and side effects, dizziness, seizures, you know.” - Patient, Age 30, Female, Not on PrEP.

The burden of remembering to take a daily pill was also mentioned as a barrier to PrEP use. One female patient explained how PrEP is something she is interested in taking; however, she would be unable to take a daily medication.

“I’m in school now and not used to takin’ a medication every day. I was takin’ a birth control pill, but now take a shot. That was one of the main reasons that I didn’t start PrEP cause they did tell me I could get it that day. So like I wanna be in the mind state to where I’m able to mentally, in my head, take a pill every day. PrEP is somethin’ that I wanna do.” - Patient, Age Unknown, Female, Not on PrEP

Stigma and confidentiality were also barriers to PrEP use at FQHCs. One staff member highlighted how in small communities it is difficult to go to a clinic where employees know you personally. Saying,

“If somebody knows you’re going to talk to this specific person, they know what you’re goin’ back there for, and that could cause you to be a little hesitant in coming. So there’s always gonna be a little hesitancy or mistrust, especially in a small community. Everybody knows everybody. The people that you’re gonna see goes to church with you.” – Staff, Accountant, Female

Some patients had a low perceived risk of HIV and felt PrEP may be an unnecessary addition to their routine. One patient shared that if she perceived she was at risk for HIV, then she would be more interested in taking PrEP, “If it ever came up to the point where I would need it [PrEP], then yes, I would want to know more about it [PrEP].”— Patient, Age Unknown, Female, Not on PrEP.

Some participants expressed difficulty initiating or staying on PrEP because of associated costs, transportation and/or scheduling barriers. A staff member explained how transportation may be available in the city but not available in more rural areas,

“I guess it all depends on the person and where they are. In a city it might take a while, but at least they have the transportation compared to someone that lives in a rural area where transportation might be an issue.” - Staff, Director of Nurses, Female

Childcare during appointments was also mentioned as a barrier, “It looks like here a lot of people don't have transportation or reliable transportation and another thing I don't have anybody to watch my kids right now. —Staff, Patient Navigator, Female.

Barriers Providing PrEP Services (i-PARIHS: Context)

Barriers to providing PrEP services were also identified. Many providers are still not trained in PrEP procedures nor feel comfortable discussing or prescribing PrEP to their patients. One patient shared an experience of going to a provider who was PrEP-uninformed and assumed his medication was to treat HIV,

“Once I told her about it [PrEP], she [clinic provider] literally right in front of me, Googled it [PrEP], and then she was Googlin’ the medication, Descovy. I went to get a lab work, and she came back and was like, “Is this for treatment?” I was like, “Why would you automatically think it’s for treatment?” I literally told her and the nurse, “I would never come here if I lived here.” - Patient, Age 50, Male, Taking PrEP

Also, it was reported that there is not enough variety in the kind of providers who offer PrEP (e.g., OB/GYN, primary care). Many providers such as OB/GYNs could serve as a great way to reach individuals who may benefit from PrEP; however, patients reported a lack of PrEP being discussed in annual visits. “My previous ones (OB/GYN), they’ve talked about birth control and every other method and they asked me if I wanted to get tested for HIV and any STIs, but the conversation never came up about PrEP.” -Patient, Age Unknown, Female, Not on PrEP.

PrEP motivation

Motivation to take prep (i-parihs: recipients).

Participants mentioned several motivators that enhanced patient willingness to use PrEP. Many patients reported being motivated to use PrEP to protect themselves and their partners from HIV. Additionally, participants reported wanting to take PrEP to help their community. One patient reported being motivated by both his sexuality and the rates of HIV in his area, saying, “I mean, I'm bisexual. So, you know, anyway I can protect myself. You know, it's just bein' that the HIV number has risen. You know, that's scary. So just being, in, an area with higher incidents of cases.”— Patient, Age Unknown, Male, Not on PrEP . Some participants reported that experiencing an HIV scare also motivated them to consider using PrEP. One patient acknowledged his behaviors that put him at risk and indicated that this increased his willingness to take PrEP, “I was havin' a problem with, you know, uh, bein' promiscuous. You know? So it [PrEP] was, uh, something that I would think, would help me, if I wasn't gonna change the way I was, uh, actin' sexually.”— Patient, Age Unknown, Male, Taking PrEP .

Table 3 outlines the implementation strategies identified from themes from the interview and focus group data. Below we recognize the barriers and determinants to PrEP uptake for patients attending FQHCs in MS by each i-PARIHS construct (innovation, recipient, context) [ 28 ]. Based on the data, we mapped the determinants to specific strategies from the ERIC project [ 26 ] and hypothesized the mechanism of change for each strategy [ 30 , 31 ].

Two focus groups were conducted with nine staff from threeFQHCs in MS. There were six participants in the 1st focus group and three in the 2nd. Staff members were a mix of medical (e.g., nurses, patient navigators, social workers) and non-medical (e.g., administrative assistant, branding officer) personnel. Table 4 provides the demographic characteristics for the FQHC focus group participants.

Staff participating in the focus groups generally agreed that the strategies identified via the interviews were appropriate and acceptable. Focus group content helped to further clarify some of the selected strategies. Below we highlight findings by each strategy domain.

PrEP information dissemination

Participants specified that awareness of HIV is lower, and stigma related to PrEP is higher in rural areas. One participant specifically said,

“There is some awareness but needs to be more awareness, especially to rural areas here in Mississippi. If you live in the major metropolitan areas there is a lot of information but when we start looking at the rural communities, there is not a lot.” – Staff, Branding Officer, Male

Participants strongly agreed that many patients don’t realize they may benefit from PrEP and that more inclusive advertisements are needed. A nurse specifically stated,

“ When we have new clients that come in that we are trying to inform them about PrEP and I have asked them if they may have seen the commercial, especially the younger population. They will say exactly what you said, that “Oh, I thought that was for homosexuals or whatever,” and I am saying “No, it is for anyone that is at risk.” – Staff, Nurse, Female

Further, staff agreed that younger populations should be included in PrEP efforts to alleviate stigma. Participants added that including PrEP information with other prevention methods (i.e., birth control, vaccines) is a good place to include parents and adolescents:

“Just trying to educate them about Hepatitis and things of that nature, Herpes. I think we should also, as they are approaching 15, the same way we educate them about their cycle coming on and what to expect, it’s almost like we need to start incorporating this (PrEP education), even with different forms of birth control methods with our young ladies.” – Staff, Nurse, Female

Participants agreed that PrEP testimonials would be helpful, specifically from people who started PrEP, stopped, and then were diagnosed with HIV. Participants indicated that this may improve PrEP uptake and persistence. One nurse stated:

“I have seen where a patient has been on PrEP a time or two and at some point, early in the year or later part of the year, and we have seen where they’ve missed those appointments and were not consistent with their medication regimen. And we have seen those who’ve tested positive for HIV. So, if there is a way we could get one of those patients who will be willing to share their testimony, I think they can really be impactful because it’s showing that taking up preventive measures was good and then kind of being inconsistent, this is what the outcome is, unfortunately.” – Staff, Nurse, Female

Increase variety and number of PrEP providers

Participants agreed that a “PrEP champion” (someone to promote PrEP and answer PrEP related questions) would be helpful, especially for providers who need more education about PrEP to feel comfortable prescribing. A patient navigator said,

“I definitely think that a provider PrEP champion is needed in every clinic or organization that is offering PrEP. And it goes back to what we were saying about the providers not being knowledgeable on it [PrEP]. If you have a PrEP champion that already knows this information, it is gonna benefit everybody, patients, patient advocates, the provider, everyone all around. Everyone needs a champion." – Staff, Patient Navigator, Female

Staff noted that they have walk-in appointments for PrEP available; however, they often have too many walk-in appointments to see everyone. They noted that having more resources and providers may alleviate this barrier for some patients:

“We still have challenges with people walking in versus scheduling an appointment, but we do have same day appointments. It is just hard sometimes because the volume that we have at our clinic and the number of patients that we have that walk in on a daily basis.” – Staff, Social Worker, Female

Enhance PrEP provider alliance and trust

Participants agreed that educational meetings would be beneficial and highlighted that meetings should happen regularly and emphasized a preference for in-person meetings. This is emphasized by the statement below,

“They should be in-person with handouts. You have to kind of meet people where they are as far as learning. Giving the knowledge, obtaining the knowledge, and using it, and so you have to find a place. I definitely think that yearly in-person training to update guidelines, medication doses, different things like that." – Staff, Patient Navigator, Female

Staff also suggested hosting one very large collaborative event to bring together all organizations that offer PrEP and HIV testing to meet and discuss additional efforts:

“What I would like to see happen here in the state of Mississippi, because we are so high on the list for new HIV infections, I would like to see a big collaborative event. As far as PrEP goes, those that are not on PrEP, one big collaborative event with different community health centers. You do testing, we do PrEP, and the referral get split. Everyone coming together for one main purpose.” – Staff, Patient Navigator, Female

Increase access to PrEP

Participants highlighted that most of the clinics they worked for already offer a variety of service sites (pharmacy, mobile clinic) but that more clinics should offer these alternative options for patients to receive PrEP. One patient navigator outlined the services they offer,

“We have a mobile unit. We do not have a home health travel nurse. We do telephone visits. We offer primary care, OB/GYN. We have our own pharmacy. We also have samples in our pharmacy available to patients that can’t get their medicine on the same day cos we like to implement same day PrEP. It has worked for us. More people should utilize those services.” – Staff, Patient Navigator, Female

Other staff suggested utilizing minute clinics and pharmacies at grocery stores. Highlighting, that offering PrEP at these locations may increase PrEP uptake.

There has been great scientific expansion of HIV prevention research and priorities must now pivot to addressing how to best implement effective interventions like PrEP [ 38 ]. PrEP remains underutilized among individuals who may benefit, particularly in Southern states such as MS [ 10 , 11 , 12 , 13 , 14 ]. Implementation science could help ameliorate this by identifying barriers and facilitators to PrEP rollout and uptake. We selected and defined several strategies from the ERIC project [ 26 ] to increase PrEP use utilizing FQHCs. Our results, as shown in Table  3 , highlight the four domains of strategies selected: 1) PrEP Information Dissemination, 2) Increase Variety and Number of PrEP Providers, 3) Enhance PrEP Provider Alliance and Trust, and 4) Increase Access to PrEP.

Firstly, individuals cannot utilize PrEP if they are not aware of its presence and utility. In Mississippi, advertising PrEP services is integral to implementation efforts given the existing stigma and lack of health literacy in this region [ 39 ]. Potential avenues for expanding PrEP awareness are integrating it into educational curriculums, adolescents’ routine preventative healthcare, and health fairs. This study compliments prior research that people should be offered sexual health and PrEP education at a younger age to increase awareness of risk, foster change in social norms and enhance willingness to seek out prevention services [ 40 , 41 ]. To meet the resulting growing need for PrEP educators, healthcare professionals should receive up-to-date PrEP information and training, so that they can confidently relay information to their patients. Similar to existing research, increasing provider education could accelerate PrEP expansion [ 42 , 43 , 44 ]. Training programs aimed at increasing provider PrEP knowledge may increase PrEP prescriptions provided [ 43 ] by addressing one of the most frequently listed barriers to PrEP prescription among providers [ 45 , 46 ].

Many patients prefer to receive PrEP at the healthcare locations they already attend and report a barrier to PrEP being limited healthcare settings that offer PrEP [ 39 , 47 , 48 , 49 ]. The aforementioned PrEP training could increase the number of healthcare workers willing to provide PrEP services. It is also imperative that providers in a diverse range of healthcare settings (e.g., primary care, OB/GYN, pediatricians and adolescent medicine providers) join the list of those offering PrEP to reduce stigma and enhance patient comfort.

These results mirrored other studies in the South that have shown that using relatable healthcare providers and trusted members of the community may serve to facilitate PrEP uptake [ 41 , 50 , 51 ]. If patients have a larger number of PrEP providers to choose from, they can select one that best fits their needs (e.g., location, in-network) and preferences (e.g., familiarity, cultural similarities). Enhanced comfort facilitates a strong patient-provider alliance and can lead to more open/honest communication regarding HIV risk behavior.

The lack of conveniently located PrEP providers is consistently reported as a structural barrier in the South [ 44 , 52 ]. This creates an increase in the demand on patients to attend regular follow-up appointments. The three strategies above all play a vital role in increasing access to PrEP. If more individuals are trained to provide PrEP care, there will be more PrEP providers, and patients can choose the best option for them. A sizeable influx of new PrEP providers could help staff new care facilities and service options in the community (e.g., mobile health units, home care, community-based clinics, telemedicine). Offering PrEP via telemedicine and mobile clinics to patients has been largely supported in the literature [ 44 , 53 , 54 ]. Intra- and inter-organizational collaborations could similarly increase PrEP access by sharing information and resources to ensure patients get timely, reliable care.

Our results largely supported previous findings by two systematic reviews on the barriers to PrEP uptake and implementation strategies to overcome it [ 39 , 47 ]. Sullivan et.al.’s review focused on the Southern U.S. [ 38 ], while Bonacci et. al. explored steps to improve PrEP equity for Black and Hispanic/Latino communities [ 47 ]. Both agreed that barriers to PrEP access are complex. Thus, cooperation from policymakers and the expansion of state Medicaid or targeted Medicaid waivers is vital to make PrEP attainable for those living in the coverage gap. Further, many FQHCs receive Ryan White funding for HIV care and treatment, contracting flexibility in the utility of these other sources of support may aid in eliminating the cost of PrEP as a barrier. They also stressed the need for educating community members and healthcare personnel about PrEP, increasing and diversifying PrEP service sites, normalizing PrEP campaigns and screening to alleviate stigma, and streamlining clinical procedures to facilitate the option for same-day PrEP. However, they also noted that these strategies are easier said than done. This further highlights the need for prioritizing research efforts towards implementation studies for effectiveness and practicality of overcoming the complex and systemic needs around HIV prevention/treatment.

The present study was able to build on past findings by providing a more holistic view of the barriers to PrEP use and possible strategies to address them through querying PrEP-eligible patients, medical providers, and non-medical staff. By interviewing a diverse range of stakeholders, it was possible to identify unmet patient needs, current PrEP care procedures and infrastructure, and attitudes and needed resources among those who could potentially be trained to provide PrEP in the future.

Limitations

Our results are limited to participants and clinic staff who were willing to engage in a research interview to discuss PrEP and FQHCs. Results are only generalizable to Mississippi and may be less relevant for other geographic areas. However, this is a strength given these strategies are meant to be tailored specifically to FQHCs in MS. Due to COVID-19 restrictions, interviews were conducted via Zoom. This allowed us to reach participants unable to come in physically for an interview and may have increased their comfort responding to questions [ 55 ]. However, some participants may have been less comfortable discussing via Zoom, which may have limited their willingness to respond.

This study highlighted the need for implementing PrEP strategies to combat HIV in Mississippi. PrEP knowledge, barriers, and motivation were identified as key factors influencing PrEP utilization, and four domains of strategies were identified for improving PrEP accessibility and uptake. Future research should further refine and assess the feasibility and acceptability of selected and defined implementation strategies and test strategies.

Availability of data and materials

De-identified data from this study are not available in a public archive due to sensitive nature of the data. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author.

Abbreviations

Mississippi

Pre-Exposure Prophylaxis

Federally Qualified Health Centers

Integrated-Promoting Action on Research Implementation in Health Services

Expert Recommendations for Implementing Change

Men Who Have Sex With Men

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Acknowledgements

Authors would like to acknowledge and thank Sarah Bailey for reviewing the manuscript and assisting for formatting.

This study was funded by the National Institute of Health (R34MH115744) and was facilitated by the Providence/Boston Center for AIDS Research (P30AI042853). Additionally, work by Dr. Trisha Arnold was supported by the National Institute of Mental Health Grant (K23MH124539-01A1) and work by Dr. Andrew Barnett was supported by the National Institute of Mental Health Grant (T32MH078788). Dr. Elwy is supported by a Department of Veterans Affairs Research Career Scientist Award (RCS 23–018).

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TA and ARE led the conceptualization of this paper. TA, LW, LKB, DML, and JBB completed the literature search and study design. TA, LW, LKB, KKG, PPE, AB, AL, and CSG assisted with analyzing and interpreting the data. TA, ARE, and AMA finalized the results and implementation concepts of the study. All authors read and approved the final manuscript.

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Arnold, T., Whiteley, L., Giorlando, K.K. et al. A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi. Implement Sci Commun 5 , 92 (2024). https://doi.org/10.1186/s43058-024-00632-6

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Parental and healthcare provider attitudes towards the Healthy Child Programme in England: a qualitative analysis

• Tahmid Rahman 1 ,
• Joseph Freer 2 ,
• Isabella Cordani 2 ,
• Michael Papasavva 2 ,
• Leo Dunkel 2 ,
• Robert Walton 2 ,
• Helen L. Storr 2 ,
• Andrew J. Prendergast 2 &
• Joanna Orr 2  

BMC Public Health volume  24 , Article number:  2342 ( 2024 ) Cite this article

Metrics details

The Healthy Child Programme (HCP) in England, delivered by Health Visitors (HV) and Nursery Nurses (NN), aims to assess growth and development in pre-school age children. This qualitative analysis aimed to evaluate the perceptions and experiences of HCP providers and parents located in a London borough.

This qualitative analysis is part of a larger study piloting an automated growth screening algorithm in a London borough. We conducted three focus group discussions; two with parents of pre-school children participating in the pilot study, one in English ( n  = 6) and one in Sylheti ( n  = 5), and one with HVs and NNs ( n  = 11). Sampling was purposeful, and written informed consent was obtained. Groups were facilitated by the same bilingual researcher using semi-structured topic guides. Data were analysed using reflexive thematic analysis and assessed for intercoder reliability.

Three broad themes were identified in the data: (1) lack of clarity around the role of the HV and NN; (2) a lack of resources; and (3) a desire for a preventative service. Underlying these themes was a sense of disempowerment shown by HVs/NNs and parents, as well as systemic issues in terms of the accessibility and practicality of the service. Nevertheless, parents and HVs/NNs all stressed the importance of the service in providing information, reassurance and advice.

Conclusions

Various challenges prevent the HCP from providing equitable and effective care to every child. However, the service was recognised as very valuable by users and providers despite systemic difficulties.

Peer Review reports

The Health Visiting service in England comprises a cadre of nurses and midwives with specialised training, who deliver public health services to mothers, families, and communities. These Health Visitors (HVs) deliver the Healthy Child Programme (HCP) which focuses on child health and development from ages zero to five years. The HCP offers five mandated contacts, from pregnancy to 2 years, to assess the overall child health and development, as well as providing screening, immunisations, advice to parents and signposting to other services. HVs are supported by, and collaborate with, a wide range of other NHS services and teams, including paediatricians, GPs and Nursery Nurses (NNs). HVs and NNs deliver many of the mandated HCP visits, with NNs conducting most 2-year assessments. The HCP offers universal and targeted levels of service depending on the needs of individual families [ 1 ]. Similar well child or child health surveillance programmes exist in the United States, Australia, France, the Netherlands, Sweden and other high-income settings and although there are structural differences the basic elements of the programmes are consistent [ 2 ].

While no formal evaluation of the HCP has been undertaken, each of the programme’s areas of intervention is grounded in strong evidence of positive impacts on maternal and child health [ 3 , 4 , 5 ]. The HCP seeks to address many maternal and child health outcomes, making evaluation of the whole programme challenging. Parental views and attitudes towards the health visiting service have been shown to be positive when they have a good relationship with their HV/NN, when they feel the HV/NN is knowledgeable and listens to their concerns. On the other hand, negative experiences of the service emerge when there is tension in the HV/NN-parent relationship [ 6 , 7 ]. Migrant parents may experience health services for their children differently and their expectations may be shaped by previous experiences in their countries of origin [ 8 ]. There is a lack of evidence focused on the HV/NN perspective, and whether parental and HV/NN perspectives align.

The UK National Health Service (NHS) has experienced funding cuts in recent years, resulting in systemic problems such as staff shortages, difficulty recruiting, long waiting lists for onwards referrals and difficulties arranging appointments [ 9 , 10 , 11 , 12 ]. Cuts to interventions that promote child health have impacts on current and future population health, as well as deepening health and social inequalities [ 13 , 14 ]. Drastic declines in health outcomes such as infant mortality, obesity and tooth decay in pre-school aged children are areas where the health visiting service is well positioned to have a strong positive impact when resources are in place [ 15 ].

Research Aims

To observe and interpret the range of factors involved in shaping HV/NN visits, this sub-study posed the following questions:

How do parents and HV/NNs describe health visits and the role of a HV/NN?

How do parents and HV/NNs envisage service development?

What are the challenges and limitations to service development?

Methodology

Study design.

This qualitative study was conducted as part of a larger pilot project, the Child Development and Growth in East London study (CDGEL). CDGEL was based in a borough of east London with a high level of deprivation. The study sought to generate quantitative and qualitative data on the feasibility and acceptability of a proposed growth screening programme, implemented at age 2 years through HV/NNs. The current analysis utilizes data from a qualitative sub-study among parents and healthcare providers, to evaluate perceptions and experiences of the HCP. We explored how this programme works in east London and identified areas where delivery could be strengthened.

Reflexive positioning

Two researchers, TR and JO, led on data collection and analysis. TR is a male PhD candidate with experience in qualitative methods. His research interests include community wellbeing and the social production of mental health. JO is a female postdoctoral researcher with experience in mixed methods research. Her research interests include child growth and the social determinants of health.

Participants

As part of CDGEL, focus groups were conducted with parents and HV/NNs to evaluate attitudes towards growth screening. Parents were purposively sampled, with every caregiver who attended a study visit within the recruitment timeframe being invited to participate. We aimed to recruit ten participants per focus group, and invitations were halted once a suitable number of participants confirmed attendance. One group was conducted in English and one in Sylheti. HV/NNs were also purposively sampled, with an email invitation circulated to every HV/NN and nursery nurse in the London borough where the study took place and recruitment again halted once a suitable number of participants had agreed to participate. To be eligible, HV/NNs were required to be currently working within the Healthy Child Programme in the area.

Data collection

Two semi-structured topic guides were prepared by JO to facilitate data collection and ensure the research questions were addressed (see appendix 1 and 2). Every group was facilitated by the same English and Sylheti-speaking bilingual researcher, TR, who also translated the parent data collection instrument into Sylheti. The HV/NN focus group was conducted online via Zoom, while the parent focus groups were conducted in person. This reflected the schedules and availability of each group. All sessions were audio recorded, and data transcribed by TR. TR and JO were present at each session and both kept field notes. For in-person focus groups, childcare was provided through a mobile creche. Participants were provided with participant information sheets in advance and were given the opportunity to speak to the study team prior to the sessions. Three of the participants in the HV/NN group were part of the study team who collected data for the wider pilot study. As such they were familiar with the researchers and the background and purpose of the study. There were no other prior relationships between participants and study team. Transcripts were not shared with participants for further feedback. Informed written consent was obtained from each participant.

Data analysis

To recognise the multimodal construction of health visits, poststructural realism (Heller, 2008) provides an apt approach to epistemology and ontology; Heller affirms that meaning is socially constructed but that it is also possible to ascertain a sense of reality through reference to material resources alongside social relations. In turn, both interpretations of interview data and indications towards related material conditions are taken as subjects of study. The analysis was conducted through reflexive thematic analysis (RTA) [ 16 ], to suit the theoretical flexibility required to interpret interview data. We also drew on discourse analytical modes, positioning analysis, and systemic thinking that ties the data to its social and material contexts. Notably, regarding access to services, in positioning theory (Lefebvre, 1991; Moore, 2009), ‘centres’ describe the top of a hierarchy, where power, wealth, information and more are located, while ‘peripheries’ are distanced from these centres. Positioning theory is drawn upon to identify that participants can feel as though they are distanced from the social position of those who would be empowered by the NHS. Where appropriate in the analysis, further analytical modes are used and explained in keeping with the theoretical flexibility of RTA.

We did not seek to achieve data saturation; data saturation is conceptually incompatible with RTA due to the ongoing data interpretation process [ 17 ]. The concept of information power is better suited to evaluate the appropriateness of the sample size [ 18 ]; the sample were broad and diverse enough to capture data on the topic of parental and healthcare professional experiences of the HCP. As the data were initially collected as part of a wider project with a specific aim, sample size calculations were not conducted for the current analysis.

Analyses were conducted by TR and JO. In using RTA, TR and JO familiarised themselves with the dataset by writing reflexive post-session notes and reading through before coding. Initial themes were discussed around the research questions which involved reflections on inductive, data-driven observations alongside theory and research-driven deductions.

Ethical approval for this study was obtained from the Wales Research Ethics Committee 4 (21/WA/0385).

A total of 21 participants took part (11 parents and 10 healthcare professionals) in the focus groups. Further participant characteristics are outlined in Table  1 . Three overarching themes, subthemes and a summary of each are presented in Table  2 . In the text, quotes are attributed to parents (‘P’), or HV/NNs (‘HVNN’).

Theme 1: the role of the HV/NN and the health visiting service

Subtheme 1.1: lack of clarity around the healthcare system.

Parents reported difficulties navigating the healthcare system when they need support for their children, and confusion around the health visiting service compounded that lack of clarity. This was expressed in both parent groups. Many migrant parents felt that their unfamiliarity with the system made it more difficult to navigate, but British parents also validated the difficulties of the system:

Especially if you haven’t grown up in this country […] , it’s really difficult to know [what support children will receive]. P1, Mother, English Language Focus Group. I grew up in this country , and I didn’t know any of this either. I think most of the information I got about services were through either other mums or through children’s centres […] I think that’s where I got most of my information. P2, Mother, English Language Focus Group.

This need to actively seek support was repeated by parents who reported only having reviews “ because I called and I was chasing ” (P3, Mother, English Language Focus Group). Moreover, when other services were involved, the lack of clarity in the system meant that some parents were sent back and forth between services. HV/NNs in turn echoed the same frustrations in working with other parts of the healthcare system:

[HV/NN] said , “oh , he’s delayed. What do I do next? Where do I have to go? What shall I do?” They didn’t say anything. They say , “oh , you need to inform your school”? When I say it in the school , they say “you’re supposed to inform your health visitor”? I don’t know what to do. When I speak to one , they say go to the other. P4, Mother, English Language Focus Group. Nine times out of 10 some of the GPs refer the families back to us. It turns into a game where: “No , go and see a GP. No go and see a health visitor.” And the families are like , “Well who do I see?” So , it does become a bit of a frustration there. HVNN1, Nursery Nurse.

When describing the role of HV/NNs, parents reported being confused about what support the HV/NNs could provide and connected this to the HV/NN’s seemingly limited ability to act upon what they observed despite having expertise:

What happens if there is a problem? […] Because that’s where I’m still trying to understand well , what is the health visitor’s role in this? […] is it to connect you with a specialist? To give you a referral? […] How do we use that resource? P4, Mother, English Language Focus Group.

Despite most of the participants having acknowledged that HV/NNs “ can give advice about what’s concerning , and they can educate us about it ” (P5, Mother, Sylheti Language Focus Group), health visits were compared against specialist interventions and secondary care; parents were unclear as to whether health visits are a form of intervention or assessment. This uncertainty also produced hesitancy towards health visits.

I found this health visitor concept to be a bit weird because I had the impression it’s much more about checking on parents , whether they’re doing their job rather than actually checking the health of the kids. (P6, Mother, English Language Focus Group)

The HV/NNs echoed similar sentiments showing awareness that some parents did not trust the service. The need for parents to be receptive to information was stressed in recognition that a good health visit is collaborative:

The expectations from the families […] is a quick fix and it’s not like that. It’s not like […] you see the health visitor , and everything is okay. It involves parents’ and health professionals’ interaction. (HVNN2, Health Visitor)

Subtheme 1.2: navigating the system

This situation has led some not to seek support from HV/NNs in pursuit of a primary care service that would have been more empowered to help them:

I think I’ve been to the A&E more times than I’ve seen a health visitor […] And maybe that’s also because I just don’t know the system and I don’t even know where to call. P4, Mother, English Language Focus Group.

Despite this lack of clarity, there remained a recognition that health visits can be beneficial, primarily as a source of health education and to provide reassurance for parents:

I feel like , in that profession , they are the experts so I trust them. They studied to be in the profession , so you have to trust them to take care of us. P5, Mother, Sylheti Language Focus Group.

This recognition of professional judgement and the value of human intervention was drawn on as a major strength of the health visits by HV/NNs who emphasised this value within a strained healthcare system:

Because the resources are so limited , it’s more important than ever that health visitors are delivering the Healthy Child Programme to try and impact the behaviour of families. HVNN3, Health Visitor.

Theme 2: strained staffing and resources

Subtheme 2.1: the impact of the pandemic.

The COVID-19 pandemic was reported to have had direct and indirect impacts on health visits.

Parents and HV/NNs agreed in their perception of a health service that has become less personal and seemingly engages more superficially:

I had a very different experience for both children so for the eldest I had a lot more interaction with health visitors and they would have like open sessions where you could go along and talk to somebody while your child plays , but I think because of the pandemic , things were very different with [my youngest child] , and it just wasn’t the same. […] I couldn’t see anyone face to face really. P2, Mother, English Language Focus Group.

HV/NNs recognised that these strains on resources were not solely caused by the pandemic but were multifactorial, and that this impacted on referrals and waiting times:

Right now , with current situations , we make the referrals but due to whatever: our funding , COVID… , parents aren’t being seen in the estimated time. The speech and language time assessment: how long is that? HVNN2, Health Visitor.

Although the impacts of the COVID-19 Pandemic were recognised as important, HV/NNs also felt their service was uniquely positioned to continue to provide care in difficult conditions:

Definitely since COVID – just the workload is just increasing; the needs , times 100. […] You can see that generation of children that have missed out. […] That’s why I feel like our job really comes into effect because we’re able to pick it up and support children and […] give them the best start. HVNN4, Health Visitor.

Subtheme 2.2: inflexibility

When exploring the accessibility of health visits, parents raised concerns about accessing healthcare services more broadly: they reported that it is hard to get appointments; they cannot get in touch easily; and appointments are often inconvenient. How these diverse parental responsibilities shape accessibility was also recognised by the HV/NNs:

This time we had to take them for the two-year review. So obviously it became difficult to take them in with the other children. You have to take them and find childcare for them […] . P5, Mother, Sylheti Language Focus Group. I think it’s a cluster of a number of things. So , it could be parents working , child in nursery , other children to look after , a carer for someone… You know , so it’s a small percentage of everything that makes this huge , big bundle of things. HVNN5, Nursery Nurse.

This difficulty in accessing appointments highlighted the strain on primary care. Beyond an increased case load, unreliable availability of equipment, and the inability to have a set space to work from, these limited resources have taken flexibility away from both HV/NNs and parents.

If you have a place , there is a scale , there’s everything there and you’re in the Children’s Centre , you can signpost to the Children’s Centre staff. And you can see more people. […] It’s like we’re losing the venue. I used to go to [Children’s Centre] during my reviews there. I’ve lost that room. I’ve lost the room in [a different Children’s Centre] so it’s getting really hard for you to see someone properly. HVNN6, Nursery Nurse.

An inflexible system also had the potential to impact parents differently depending on income and employment circumstances. Often the impact was larger on working mothers on lower incomes:

Out of office hours would be good to work with parents because like , I mean , I’m quite lucky at this point that I have afternoons typically available. And I can sort of move stuff around if I need to because I’ve got my partner. But a lot of people are not that lucky. And then they have to take like time off. And I think especially if you’re on a low-income family , that might really prevent it from you going because they just can’t afford it. P1, Mother, English Language Focus Group.

Subtheme 2.3: lack of continuity of care resulted in parents receiving mixed advice

Both parents and HV/NNs expressed dissatisfaction at the lack of continuity of care; parents desired to see the same HV/NN who could be a point of contact throughout their child’s early years and found having to repeat information to different HV/NNs frustrating.

Sometimes , we’ll have a problem and we don’t want to talk to everyone about it and repeat it many times. You just want to have one health visitor and we talk to them. That’s it. That’s easy. I know we had that before - they allocate one to you. But because of COVID we haven’t been able to get in touch with our regular health visitors. P5, Mother, Sylheti Language Focus Group.

Moreover, the benefits of having a single HV/NN included the feeling that they will understand changes more personally and be able to provide personalised support to a greater degree:

The first thing I would like is to have one person; one point of contact , which we can rely on […] if you have someone who knows everything from the date of birth until five years , then you feel more comfortable to talk. P7, Mother, English Language Focus Group.

Parents’ frustration was compounded by instances of receiving mixed advice from different HV/NNs, while similar frustrations with mixed advice are shared by HV/NNs who found that they need to enforce new advice frequently:

Some are more up to date with sort of latest research , latest advice , things that might have changed in sort of the last 10–20 years , and others less so. […] Like it’s very dependent on the individual , which is really dangerous if you don’t know the latest research yourself and you just trust whatever someone tells you. P1, Mother, English Language Focus Group. Because sometimes these parents may have , not just as first-time parents , they could have other children. And over the years , we can all agree that health visits have changed with regards to the information we give parents , because by the time they’ve had their first child , then they’ve had another child , it’s all changed. So obviously , for example , like for weaning , now we say it’s six months , whereas before , it used to be three months. HVNN1, Nursery Nurse.

Subtheme 2.4: power to refer for health and social issues

The disempowerment of HV/NNs was evidenced in the inability to make direct referrals, and the lack of services to refer to, alongside the limited capacity to be flexible with appointment times and locations:

If this is the system that’s supposed to stand in for [greater access to doctors] then kind of like empower this system more. If this is supposed to be what’s checking and kind of doing the more regular check-ups and our medical interface with you know , children’s specific staff , then this maybe needs to be kind of like empowered more to make referrals to you know , do whatever it is that needs to be done. P3, Mother, English Language Focus Group.

The HV/NNs shared in this frustration regarding the inability to refer: “ Even if we wanted to refer to like the obesity clinic as clinicians , we can’t.” (HVNN4, Health Visitor). Wider systemic limitations on the capacity of the NHS and its responsiveness to children’s needs were implicated in preventing health improvement and in reproducing parental anxieties:

We recognise the issue , and then we don’t have any services that we can signpost to , or there’s no sort of clear pathway of what to do when the issue is recognised. And actually , that can raise anxieties further with families , because you’ve sort of left them , haven’t you? You’ve identified a problem. You’ve let them know what the issue is , and then you’re not doing anything about it. HVNN7, Health Visitor.

Parents also showed feelings of disempowerment, for example in the limited ability to advocate for themselves and the reliance upon professionals with strained resources to identify and address needs. Parents suggested that HV/NNs may be well positioned to help in contexts where accessing support is particularly difficult:

They could ask about the house. If the conditions aren’t right , they could guide us towards finding the right support from the council and link us up to them. They look into different issues but there remains a major problem. For whoever’s very needy , they could speak up for them […] Like they need to understand that if it’s overcrowded , for example , obviously that affects the growth of the children. P8, Father, Sylheti Language Focus Group.

Theme 3: desiring a preventative model

Parents and HV/NNs desired a focus on prevention which would be beneficial to children and families, as well as the healthcare system. They pointed out how prevention is already part of the system but could be maximised, and ways in which more prevention, specifically screening, would be desirable.

Measurements can pick up signs , you know , evidence when things are going wrong. We know that development and thriving might be affected by things that are going on at home. […] What’s this child experiencing that might be meaning that they’re not eating , and they’re not growing? HVNN3, Health Visitor

I think in other countries they definitely do like regular tests , or like a blood test at such and such age where you know , things might be picked up that you might not see until much much later , like actual physical outward symptoms […] Like let’s check actually like his tummy or this and that […] Can we just check like that everything is right? P1, Mother, English Language Focus Group.

However, there was the recognition that a more preventative model requires upfront resources, which were seen as lacking in the current health visiting system.

Check-ups aren’t happening. […] it’s what you said: preventative. You’re saying check-ups and it doesn’t feel like there are check-ups. P3, Mother, English Language Focus Group

One of the biggest things , I think , is resources as well. You can’t be inviting children every two to three months , unless you’ve got an identified need , because sometimes clinic spaces become an issue. And those spaces need to be reserved for families where there is an actual need. So you can’t take a blanket approach to all the children that are under your sort of care. HVNN7, Health Visitor.

We sought views on the Healthy Child Programme from health visitors, nursery nurses and parents, and generated three interconnected overarching themes: the role of the HV/NN and the health visiting service; strained staffing and resources; and access to holistic care. There was agreement between parents and HV/NNs that there is a general lack of understanding of what the role of the HV/NNs is, and the importance of the service. Each group felt that this lack of clarity prevented optimal use of the service. Groups also agreed there were limitations on the service posed by the lack of resources available, including low staffing levels and lack of onward resources for families and children with additional needs across social and biological contexts. All participants expressed a desire to empower the health visiting service to deliver preventative and holistic care. While parents wished for more frequent and consistent contact with HV/NNs, they were realistic about the challenges posed by the current lack of resources.

Strengths and limitations

This study has several strengths; by facilitating parental discussions in both English and Sylheti, we were able to include perspectives from under-represented parents. We were also able to simultaneously capture data from parents and health care providers, to obtain a rounded picture of the challenges and opportunities of the health visiting service. The use of focus groups allowed us to collect data on a range of perspectives with limited resources. The wider project from which these data were generated is concerned with quantitative aspects of the 2-year health and development assessment, and these qualitative data add depth to the overall picture of the service.

This study also has limitations; the number of participants was small and self-selected. However, we do not consider the small sample size to be a significant limitation, as we did not seek to reach ‘data saturation’; RTA requires deep engagement with the data and reflexive interpretation [ 17 ], which was prioritized over data saturation. Although all parents participating in CDGEL during a timeframe were invited to the qualitative sub-study, parents needed to agree to participate in this optional extra focus group, making parents who are more motivated likely to be over-represented. Parents with multiple caring responsibilities or with financial or physical difficulties are potentially under-represented in our findings, although we provided travel costs and childcare in an effort to reduce these biases. Paternal perspectives were inadequately captured, as nearly all of our participants were mothers. As ethnicity data was not collected, the study was unable to draw on specific culturally and ethnically rooted factors influencing their experiences. Our findings relate to the health system in England, and therefore do not apply to other healthcare contexts.

Comparison with existing literature

This analysis adds to the existing understanding of how parents feel about the health visiting service by also considering the perspective of the health care providers who deliver this service. Previous work has highlighted how parents appreciate feeling understood and listened to [ 6 , 7 ]; our work generates some ideas as to how this could be achieved, by showing that both parents and HV/NNs acknowledge that the role of the health visiting service is not well understood. Uncertainty around the role of the HV has previously been found to negatively affect some mothers struggling with mental health difficulties in the postpartum period [ 19 ], further aggravated by a reported lack of clarity around referral pathways, in particular when assessing perinatal mental health [ 20 ]. It has been suggested that the role of the health visiting service is hard to define due to the broad scope of the service [ 21 ]. This lack of clarity was observed in all of our groups, and the impacts ranged from inadequate use of the service, to mistrust and misunderstanding between parents and HV/NNs.

The focus on resources in each group echoes previous reports and research on both the health visiting service and the health service more generally. Well-resourced public health interventions have strong evidence of being impactful and cost-effective [ 22 ]. Despite this, recent years have seen declining NHS resources, including in health visiting [ 9 ]. A recent report from the Academy of Medical Sciences recommended urgently improving the family and child health workforce (including health visitors) and reducing fragmentation across sectors, as well as involving the perspective of service users in service development [ 15 ]. We are not aware of other studies that have highlighted parental desire for increased childhood screening and contact with a HV/NN, but we note that the number of mandated visits in the English HCP is lower than those in the other devolved nations (equivalent programmes in Scotland, Wales and Northern Ireland mandate between eight and eleven visits between pregnancy and age 5 years [ 23 ].

Implications for research and practice

This analysis raises various implications for research and practice. Health policy makers should consider the relationship between parents and HV/NNs as a key factor in ensuring the effectiveness of the programme. Managing parental expectations of the service by emphasising the role of the HV/NN and what the service can and cannot provide could promote understanding and adequate use of the service. Parental desire for continuity of care where possible would likely improve collaboration between service and users. Parents also desired more visits, at times which are more convenient. A return to health visiting, where HV/NNs attend families’ homes, could help attenuate inequalities in access to the service, although this would require increased funding. Special consideration of the needs of migrant families and their diverse expectations of the service, shaped by their experiences in their countries of origin, would also help bridge the gap between parental and healthcare professional expectations.

We also identified a need for increased empowerment of the health visiting service; HV/NN are one of few points of contact for vulnerable families, which has the potential ability to link to other healthcare and local authority services. In this way, an empowered health visiting service could act as a gateway to access other services, and to advocate for the needs of these families. However, the needs of parents and HV/NN need to be balanced, and resources also need to be made available to HV/NN if there is to be higher expectations of their role. However, this is difficult in the face of current lack of resources in the healthcare system more widely. A review of models for well child programmes, such as the HCP, suggests that integrative frameworks have strong evidence for achieving better child health outcomes [ 24 ]. Integration of different systems concerned with child wellbeing, such as health, education and social systems, as well as family-centred care which is achieved collaboratively alongside healthcare professionals are recommended.

Collaborative and participatory mixed methods research which encompasses other regions in England is needed to better understand the role of the health visiting service nationally, but also how it could be used optimally in ways that are welcome and acceptable to both families and HV/NNs.

Data availability

The data analysed as part of this qualitative study are available from the corresponding author upon reasonable request.

Abbreviations

Healthy Child Programme

Health Visitor

Nursery Nurse

National Health Service

Child Development and Growth in East London study

Reflexive Thematic Analysis

Parent participant number

Health Visitor or Nursery Nurse participant number

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Acknowledgements

We would like to acknowledge all families and health care providers participating in the Growth and Development in East London Study.

This work was funded by Barts Charity (grant MRC0219 and grant 5757243). AJP is funded by Wellcome (grant 108065/Z/15/Z).

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T.R. conducted data collection, analysed data, interpreted results, and drafted the manuscript. J.F. contributed to the conception, conceptualisation and design of the work, and substantially revised the manuscript. I.C. contributed to the design of the work, assisted in data collection and interpretation of results, and substantially revised the manuscript. M.P. contributed to the design of the work, assisted in data collection and interpretation of results, and substantially revised the manuscript. L.D. contributed to the conception and conceptualisation of the work, and substantially revised the manuscript. R.W. contributed to the conception and conceptualisation of the work, and substantially revised the manuscript. H.L.S contributed to the conception, conceptualisation and design of the work, and substantially revised the manuscript. A.J.P. contributed to the conception, conceptualisation and design of the work, and substantially revised the manuscript. J.O. contributed to the design of the work, assisted in data collection, analysed data, interpreted results, and drafted the manuscript.

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Rahman, T., Freer, J., Cordani, I. et al. Parental and healthcare provider attitudes towards the Healthy Child Programme in England: a qualitative analysis. BMC Public Health 24 , 2342 (2024). https://doi.org/10.1186/s12889-024-19515-5

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Components of safe nursing care in the intensive care units: a qualitative study

• Mozhdeh Tajari 1 ,
• Tahereh Ashktorab 2 &
• Abbas Ebadi 3  

BMC Nursing volume  23 , Article number:  613 ( 2024 ) Cite this article

Metrics details

Patient safety is a global health issue that affects patients worldwide. Providing safe care in the intensive care units (ICUs) is one of the most crucial tasks for nurses. Numerous factors can impact the capacity of nurses to deliver safe care within ICUs. Consequently, this study was undertaken with the aim of identifying the components of safe nursing care in ICUs.

The current research constitutes a qualitative conventional content analysis study conducted from January 2022 to June 2022. The study participants comprised nurses, intensivists, nurse responsible for patient safety, paramedic, patients, and patients’ family member, totaling 21 individuals selected through purposive sampling. Data collection involved individual, in-depth, and semi-structured interviews. Subsequently, data analysis was performed utilizing the approach outlined by Graneheim and Lundman (Nurse Educ Today 24(2):105–12, 2004), leading to the identification of participants’ perspectives.

Three themes were identified as components of safe nursing care in ICUs. These themes include professional behavior (with categories: Implementation of policies, organizing communication, professional ethics), holistic care (with categories: systematic care, comprehensive care of all systems), and safety-oriented organization (with categories: human resource management and safe environment).

Conclusions

The findings of this study underscore the significance of advocating for safe nursing practices in ICUs by emphasizing professional conduct, holistic care, and safety-focused organizational structures. These results align with existing research, suggesting that by introducing tailored interventions and tactics informed by these elements, a safer environment for nursing care can be established for ICUs patients.

Peer Review reports

One of the most crucial indicatorsof quality care is safety (Atashzadeh Shoorideh et al. [ 1 ]). Safety refers to the prevention of all unintentional or intentional harm, such as injury or death due to adverse medication reactions, patient misidentification, or nosocomial infections by healthcare providers (Butler and Hupp [ 2 ]). Recently defined by the World Health Organization in 2021, patient safety is a framework of organized activities that establish cultures, processes, behaviors, technologies, and environments within healthcare organizations. This framework aims to consistently and effectively identify risks, preventable harm, and reduce the likelihood of their occurrence (Organization [ 3 ]).

Unsafe care has significantly contributed to serious medical accidents worldwide (AL-Mugheed et al. [ 4 ]), and the social cost of patient injuries has been reported to be in the trillions of dollars annually (Organization [ 3 ]). Hospital-acquired serious injuries account for 6% of occupied hospital beds and about 7 million hospital admissions per year (Butler and Hupp [ 2 ]). Evidence shows that patient safety is a global health concern that affects patients worldwide, including both developed and developing countries (Austin et al. [ 5 ]).

Patient safety is even more crucial in intensive care units (ICUs) because they are among the most critical hospital units where nurses play a vital role (Mahmoudi [ 6 ]). In these units, the risk of adverse events is heightened due to factors such as the complexity of the patient’s condition and treatment, the presence of numerous electronic devices and equipment, patients’ lack of awareness, and their reliance on nurses and life-support equipment (Marzban et al. [ 7 ]). Apart from patients, nurses also face unique challenges like high job stress, extended working hours, burnout, dissatisfaction, moral dilemmas, conflicts with patients’ families, and decisions regarding end-of-life care (LeClaire et al. [ 8 ]).

According to a study conducted in Brazil, factors affecting patient safety in relation to nursing staff included the workload of staff, training and professional qualification of staff, teamwork, contractual employment, lack of job security, and destructive behaviors (Oliveira et al. [ 9 ]). In the study by Naderi et al. (Naderi [ 10 ])in Iran, the factors affecting patient safety include human resources status, management and organization, interaction and teamwork, medications, equipment, medical environment, patient-related factors, improving patient quality and safety, importance of documentation, evaluation and monitoring, medical errors, and barriers and challenges (Naderi [ 10 ]). In a study by Lima et al. (D’Lima et al. [ 11 ]), concepts obtained in relation to employee risk perception and patient safety included employee individual factors (sub-theme including pragmatism versus perfectionism), team factors (two sub-themes including team dynamics and interdisciplinary tensions), unit factors (sub-theme including achieving dynamic balance), and organizational factors (sub-theme including risk perception) (D’Lima et al. [ 11 ]). Another study identified factors such as nurse error awareness, nurse well-being, teamwork, non-punitive environment, work management, hospital leadership, and ICU leadership as effective factors for safe ICU care (Garrouste-Orgeas et al. [ 12 ]).

Vaismoradi (Vaismoradi [ 13 ])conducted a grounded theory study in Iran, presenting strategies aimed at enhancing safe care. These strategies encompassed altering attitudes and performance, eliminating organizational obstacles, fostering a culture of teamwork, enhancing the influence of nursing leadership, and cultivating a culture centered on safe nursing care. Furthermore, Vaismoradi emphasized the importance of redefining safe care and conducting guiding research in this domain as highly impactful strategies (Vaismoradi [ 13 ]).

Despite the existing researches in the realm of factors and elements associated with patient safety, a noticeable gap in within high-risk and critical units like ICUs is evident. Through the implementation of more targeted studies, it is possible to pinpoint the components of safe nursing care in ICUs that align with the cultural contexts and healthcare systems of different countries. The outcomes of this research at a micro level of management can serve as valuable resources for the education and training of nursing students and professionals, while at a macro level, they can inform the development and implementation of healthcare policies. Hence, this study was initiated with the aim of identifying the components of safe nursing care in ICUs.

Materials and methods

Study design and setting.

The present study is a conventional content analysis approach, carried out from January 2022 to June 2022. The research was conducted in 8 hospitals affiliated with three medical sciences universities in Tehran, the capital of Iran.

Participants

Through purposive sampling, a total of 21 participants were selected for interviews. The participants included 7 nurses, 2 head nurses, 1 clinical supervisor, 1 nurse responsible for patient safety, 5 intensivists, 2 patients, 1 patient family member (patient’s son), 1 patient safety officer from the Ministry of Health, Treatment, and Medical Education, and 1 paramedic. The initial participant selected for the study was a nurse who met the inclusion criteria, possessed extensive experience, and demonstrated effective communication skills. Subsequent participants were chosen based on the data collected from each participant.

Data collection

In this research, data was gathered through individual, in-depth and semi-structured interviews with individuals who met the specified inclusion criteria. interviews were conducted by the first author and recorded using a mobile device with the participants’ consent.

The inclusion criteria for the healthcare personnel involved having a minimum of two years of professional experience in the ICU or in units associated with patient safety. The selection of the two-year threshold was based on the completion of the mandatory manpower plan course and the acquisition of sufficient experience and knowledge. Patients were included if they had a Glasgow Coma Score (GCS) of 15, demonstrated clear speech abilities, and received approval from the ICU intensivist to participate in the interview.

The researcher took into account the diversity of participants in terms of gender, educational background, job position, and work experience, particularly in relation to the nurses. Data collection persisted until data saturation was achieved, and no new codes emerged. A concluding interview was carried out to confirm data saturation. Field notes were utilized for selecting subsequent samples and extracting the codes. During the initial meeting or telephone conversation, the study’s aims were elucidated to the 21 participants. In a subsequent communication, participants conveyed their decision to either agree or decline participation. Upon agreement, interview schedules were arranged. Notably, only one intensivist declined to participate. All interviews were conducted either at the hospital or the workplace. Prior to interviewing patients, consent was obtained from the intensivist, and schedules were coordinated with the head nurse of ICU to ensure minimal disruption to patient care and treatment processes.

The interviews comprised four parts: initial open questions, main questions, follow-up questions, and closed questions. The formulation of the questions was guided by the interview guide and involved consultation with members of the research team. Subsequently, a pilot interview was carried out to identify any weaknesses, leading to a redesign of the questions (Kallio et al. [ 14 ]) (Table 1 ).

Data analysis

Data analysis was conducted by the research team, which comprised a nursing doctoral student (first author) and two nursing professors (second and third authors). The first author performed the data analysis, whereas the remaining authors reviewed and made revisions to the codes, subcategories, and categories. The analysis procedures were conducted utilizing the conventional content analysis approach, following the guidelines proposed by Graniheim and Lundman (Graneheim and Lundman [ 15 ]).

Preparation phase

During this phase, decontextualization was conducted in the following manner. Initially, the interviews, and field notes were transcribed using Word software and thoroughly reviewed to capture the main idea. Subsequently, the semantic units were identified and coded. It is important to highlight that the participants were assigned names based on the sequence of the interviews to uphold anonymity. For instance, the first participant was designated as number 1, while the final participant was denoted as number 21.

Organizing phase

Through ongoing comparisons of codes and categories and iterative recategorization during the study meetings with the research team members, a total of 1997 codes were initially identified. Subsequently, through a process of reviewing the extracted codes multiple times, eliminating duplicates, and consolidating similar items, the number of codes was ultimately reduced to 1770. Initially, the codes were organized into subcategories, followed by the extraction of categories from the integration of these subcategories. Finally, themes were derived from the integration of categories. Ultimately, a comprehensive definition of the concept under investigation along with its associated structures was provided.

Reporting phase

During this phase, the processes of sampling, data collection, data analysis, and the subsequent results were documented and reported.

Data integrity and robustness

In this study, the trustworthiness of the results was enhanced by considering strategies in line with Lincoln and Guba’s four criteria for qualitative studies (Lincoln and Guba [ 16 ]).

Credibility: The credibility of this study is supported by the extensive experience of the first author in the research topic. She conducted her Master’s thesis on medication errors in critical care units and has accumulated numerous years of experience working in ICU as a nurse and head nurse. The data collection period was appropriately extended to ensure the researcher’s continued involvement in the study process. Participant selection aimed for maximum diversity in age, gender, work experience, and educational level. Data collection methods included in-depth interviews and field notes. The research process was overseen by a doctoral student in nursing with expertise in qualitative research. The interviews and initial coding were reviewed and approved by the participants, with any ambiguities promptly addressed. The complete transcripts of the interviews, along with the coding, were initially forwarded to the primary author. Following the incorporation of the feedback, the revised text was then shared with the secondary author for further input. The process of assigning codes to subcategories, identifying categories, and developing themes was carried out consistently throughout.

Transferability: This criterion pertains to the richness of descriptive data. In an effort to maximize transferability, participants were purposefully selected from various positions and across different ICUs, such as internal medicine, neurology, surgery, and trauma.

Dependability: It was ensured through the utilization of various data collection methods such as interviews and field notes, along with continuous analysis and precise documentation of all analysis stages. As the current research formed part of a doctoral thesis, all research phases, data analyses, and findings were documented in 6-month reports and reviewed by four referees.

Confirmability: To ensure confirmability, the researcher documented their preconceptions about the study subject to separate them and prevent bias. Additionally, during data collection, the researcher refrained from reviewing the findings of related or similar studies.

The Ethical Committee of Tehran Islamic Azad University of Medical Sciences, approved the study protocol (IR.IAU.TMU.REC.1399.481). Written informed consent was obtained from all the participant, and data confidentiality was guaranteed in accordance with rules and regulations, and consistent with the requirements of the Ethical Committee that approved the study. The participants were informed about the possible duration of the interviews, the freedom and authority to stop the interview whenever they felt necessary, how to maintain confidentiality of the information, and how the results of the study would be used.

The mean age of the participants in this study was 41.80 years, while the mean work experience of the health care members was 17. 16 years. The demographic characteristics of the participants are delineated in Table  2 .

The average duration of the interviews was 36.42 min, with a maximum duration of 80 min and a minimum duration of 20 min. A total of 1770 codes were extracted and categorized into 43 subcategories. These subcategories were further integrated to form 7 categories, and from these categories, 3 themes were identified (Table  3 ).

• Professional behavior

Participants in this study viewed Implementation of policies, organizing communication with team members, patients, and their families, and adherence to professional ethics as key components of professional behavior.

Implementation of policies

Implementation of policies was identified by all participants as a critical component of ensuring safe care and was frequently emphasized during the interviews. This encompassed various aspects such as appropriate execution of nursing procedure, Safe mechanical ventilation, Safe Medication Administration, Safe blood transfusion, Safe restraint, Proper care of patient connections, pain control, preventing falls, delirium, and deep vein thrombosis, adhering to infection control protocols, ensuring safe patient transfers, and obtaining informed consent. Given the extensive range of subcategories and the constraints on presenting all the details, we will highlight select quotes from a few of these subcategories.

For instance, with regard to the proper execution of protocols, one of the nurses stated:

“Less experienced nurses use the wrong routines of more experienced nurses and this becomes a habit. It is essential to assess the patient, review the doctor’s orders. In certain circumstances, the patient may have specific requirements, such as altering the dressing or removing a drain.” (Participant No. 8).

The nurse responsible for patient safety commented on the importance of safe blood transfusions.

“For blood transfusion, it is ensured that the nurse carefully matches the specifications of the blood bag with the patient’s wristband. Additionally, two nurses verify the blood bag. Patients are monitored regularly during transfusions to detect any side effects. They are also educated about potential side effects of blood transfusions and instructed on appropriate actions to take if such side effects manifest.” (Participant No. 5).

One of the intensivists commented on the inadequate management of the patient’s pain.

“Some nurses administer only muscle relaxants to patients before invasive procedures, which can be distressing. When patients are unable to move but still feel pain, it is crucial for healthcare providers to understand that muscle relaxants should be administered alongside painkillers. Prioritizing pain management for patients should be the primary concern for healthcare professionals.” (Participant No. 4).

One of the patients admitted to the ICU articulated his perception of infection control compliance in the following manner:

“Some nurses frequently disinfected their hands, although we did not observe this practice. It is possible that I overlooked it as well. Even the doctors engage in this behavior. was a doctor who visited the bed adjacent to mine. He touched various surfaces and then proceeded to examine me.” (Participant No 12).

Organizing communication

Participants highlighted various ways in which communication impacts safe nursing care in the ICU. This resulted in the identification of categories stemming from the integration of subcategories such as shift delivery using the ISBAR technique, proper utilization of identification wristbands, accurate documentation, communication with patients, and Inadequate team communication.

For instance, one of the head nurses described her encounter with the ISBAR technique as follows.

“Sometimes in the evening and night shifts, nurses may not follow protocols and not use the ISBAR technique for shift delivery and the next day we find many errors and failures.” (Participant No. 2).

The nurse responsible for patient safety emphasized the importance of proper utilization of identification wristbands.

“The identification wristband plays a crucial role in healthcare settings. Regrettably, there are instances where individuals overlook its significance. One of the key purposes of the wristband is to accurately identify the patient. An incident occurred where a mismatch between the blood bag and the patient’s bracelet led to an incorrect transfusion being administered.” (Participant No. 5).

In relation to inadequate team communication, an intensivist expressed the following viewpoint:

“When the patient had a fever in the middle of the night, the nurse did not report it. Later I found out that she was afraid of waking me up.” (Participant No. 4).

Professional ethics

Participants identified adherence to the principles of professional ethics as a prerequisite and integral part of safe nursing care. This category was formed from the subcategories of respecting patient privacy, human dignity, conscience and professional commitment.

Regarding respecting patient privacy, one of the ICU patients described her experience as follows:

“The first night, the nurses were gentlemen and they were very careful not to make me feel uncomfortable. The blanket was taken off me and I felt that my body was visible. They came to cover my body without me telling them. Or when he wanted to see the operation site, he would just push the blanket aside so that I wouldn’t be tortured. I don’t think anything made me happier at that moment. That’s what security means. It means that I feel.”  (Participant No. 12).

One of the nurses said the following about human dignity:

“When we are safe in the working environment, we are trained and respected by our superiors, we are guided, we do our work correctly and we also provide safe care. But if you are not respected as a person and your health is not protected, you don’t care about that department and that hospital. You just want to finish your shift and leave”. (Participant No. 11).

One of the intensivists commented on Conscience and work commitment as follows:

“A conscientious patient may express his wishes by sighing and moaning and making noise. Or, for example, report to our manager that we are neglecting him, but patients with a low level of consciousness may be neglected. It is up to us and our conscience to provide complete, accurate and correct care. Sometimes doctors and nurses can show inattention and immorality towards these patients”. (Participant No. 18).

• Holistic care

In addition to professional behavior, the participants mentioned other things to ensure the safe nursing care of ICU patients, which led to the formation of this theme with categories of systematic care and comprehensive care of all systems.

Systematic care

The participants were of the opinion that the implementation of the steps of the nursing process is one of the main conditions for the provision of safe care to patients. This category was formed from the subcategories of initial patient assessment, nursing diagnoses, planning, evaluation of care, continuous care and protection from harm and acquired complications.

The patient safety officer in the Ministry of Health, Treatment and Medical Education commented on the importance of the initial assessment of the patient:

“The initial assessment can lead to the safety of the patient. Whether they have an allergy or not. Whether they are at risk of falling or not. If it is assessed correctly, it can prevent future incidents. and determine the conditions of care. We need to see at what level the patient entered hospital and at what level they should be discharged. The side effects of the medication given to the patient should be reviewed. The nurse should deal with these issues”. (Participant No. 6).

One of the nurses pointed out the importance of care evaluation:

“At the beginning of my career, if the patient was in pain, I would give painkillers and I didn’t care whether the pain was controlled or not. Care evaluation brings reassurance to the patient. It means I go back and see if my care was useful or not”. (Participant No. 1).

One of the nurses with years of experience working in the ICU pointed out the importance of continuity of care:

“In my opinion, less attention is paid to the discussion of continuing care for terminal patients. Most ICU patients, because they are unlikely to return to their lives, often do not receive the necessary care, or it is not provided in a very accurate and safe way. For example, infection control is not followed. Medication administration protocols are not followed, or they may not administer many of the patient's medications. They do not do the gavage on time and say that it has no effect on the treatment. Somehow they let the patient die”. (Participant No. 13).

Comprehensive care of all systems

The participants believed that taking care of all body systems and paying attention to the patient’s body and mind is a guarantee of safe nursing care. This category was formed from the subcategories of respiratory care, digestive and nutritional care, nervous system care, genitourinary care, cardiovascular and haemodynamic care, skin and mucous membrane care, and attention to the mental, psychological and emotional state of the patient.

In terms of respiratory care, one of the expert nurses describes his performance as follows :

“I listen to the patient’s breathing at the very beginning of the shift. I look for the presence of distress in the patient. Whether he has rales or not. The chest is bilateral. And it goes up and down symmetrically. I look at the results of the ABG and even the colour and type of secretions. Because the change in the colour of the secretions can be due to pneumonia”. (Participant No. 7).

One of the head nurses also said about genitourinary care:

“Sometimes when a patient has oliguria, the nurse does not analyse to understand the cause of the oliguria. She quickly gives the patient furosemide. I have seen a lot of inexperienced staff. I tell them about the catheter route first and check the condition of the bladder. Then I check the amount of fluids given and the patient’s CVP. Then check the status of medications and tests. Finally, I report it to the intensivist doctor for a tell order or a I request to visit the patient. Don’t go to the last treatment first”. (Participant No. 2).

One of the patients also mentioned that paying attention to the mental, psychological and emotional state of the patient and their family is an important part of safe care:

“In those first moments I was scared and anxious because the nurse’s words and explanations were very good and calmed me down. After two days of feeling better, I really wanted to see my partner. Seeing my wife was more important to me than anything else. My heart was broken. Everything made me cry. But seeing my wife gave me peace. Even though it was short. I don’t know. Why did some allow it and others didn’t? I don’t know if it’s legal or not, but it seems to be a matter of taste”. (Participant No. 12).

Safety oriented organization

Participants believe that nurses’ efforts to provide safe care to patients depend on a safety focused organization. This content consists of human resource management and safe environment categories.

Human resource management

Employing qualified human resources, monitoring the performance of human resources, error reporting and control, arrangement of human resources, sufficient human resources supply, Providing general and specific training to human resources.

This category was formed from the subcategories of employing qualified human resources, monitoring the performance of human resources, error reporting and control, arrangement of human resources, sufficient human resources supply, Providing general and specific training to human resources..

Regarding the employing qualified human resources, the nurse responsible for patient safety said:

“We have a selection committee that asks questions of the nurses. Once they are accepted, the training starts. Ten hours of important safety and infection control instructions and report writing. We train them and then they go through 70 h of training under the supervision of the ICU supervisor. The supervisor fills in three checklists for each nurse, covering behavioral, general and specialist skills, and sends them to us. If he gets the required number of points, he starts work, otherwise the training has to be repeated”. (Participant No. 5).

The statement of one of the nurses regarding the arrangement of human resources was as follows:

“If I am in charge of the shift, I will divide the work carefully and I will try to arrange it in such a way that it is fair and each nurse has both patient with lots of work and with little work. Not that a nurse should have "two busy patients or two patients with little work”. I try not to give complicated patients to new and inexperienced nurses who cannot manage the patient”. (Participant No. 10).

One of the nurses, related to the sufficient human resources supply, said:

“Nurses’ salaries are paid late, their salaries are not commensurate with their work. There is no justice in the workplace, there is discrimination. There is job dissatisfaction. There is little encouragement and a lot of punishment. All of this prevents safe patient care. Besides, the nurse loses her motivation. That’s why I want to leave.”  (Participant No. 13).

Safe environment

This category was formed from the subcategories of safe equipment and safe structure.

With regard to safe equipment, the patient safety officer in the Ministry of Health, Treatment and Medical Education said:

“To provide safe care, the equipment must be safe. And then we expect safe care from the nurse. If our bed is not safe, how can we expect the nurse to prevent falls? If we have a lack of wavy mattress , how can we expect nurses to prevent pressure sores?”  (Participant No. 6).

Also, the statement of the nurse responsible for patient safety regarding the safe structure was as follows:

“The patient’s safety must be ensured from the moment they arrive at the hospital. From the elevators and the stairs to the door and the wall, etc . In the ICU, the conditions are more specific. In our hospital’s intensive care unit, one of the beds is placed in a corner where the nurse cannot see it. They always put an extra bed in front of this unit. Every time a patient has a CPR code in that unit, it takes a few minutes to remove the extra bed and bring the crash cart into the unit. Exactly, the golden time of CPR is lost”. (Participant No. 5).

The participants in this study have delineated the components of safe nursing care in the ICUs through the aforementioned scenarios. Consequently, drawing from the outcomes of this investigation, safe nursing care can be delineated as follows: Safe nursing care in the ICU is characterized by a holistic care that encompasses systematic and comprehensive care. In delivering such care, nurses exhibit professional behavior by implementation of policies, organizing communication with patients and peers, and upholding professional ethics. In a safety-oriented organization, safe nursing care is evidenced by the establishment of a safe environment and the effective management of human resources.

The present study was conducted with the aim of identifying the components of safe nursing care in the ICUs. Three themes were identified: professional behavior, systematic care, and safety-oriented organization. In this section, the results are compared and discussed with other studies.

The theme of professional behavior emerged by combining the categories implementation of policies, organizing communication, and professional ethics. The participants believe that safe care depends not only on following policies but also on adhering to the principles of professional ethics and organizing communication with all team members and patients.

In term of implementation of policies, Williams et al. concluded that adherence to guidelines can lead to faster diagnosis of sepsis (Williams [ 17 ]), and improves patient safety in medication prescribing (Nouhi et al. [ 18 ]). The results of the study by Santos et al. (Santos [ 19 ]) in Brazil showed that adherence to clinical guidelines leads to better outcomes in patient restraint, positive effect on pain and delirium (Carrothers et al. [ 20 ]; , Thomas et al. [ 21 ]), prevention of falls (Tuma et al. [ 22 ]), and prevention of deep vein thrombosis (Malhotra et al. [ 23 ]). However, it has been argued that adherence to guidelines may jeopardize the autonomy of the nurse, and the nurse may not be able to manage the situation effectively at times not foreseen in the guidelines (Barnard [ 24 ]). For this reason, it seems that, in addition to following the established guidelines, the nurse should have creativity and decision-making power, and be able to identify and prepare for possible out-of-procedure cases for the implementation of each procedure. In the present study, pain control was identified as one of the factors of safe care in the ICU, and most of the participants repeatedly mentioned the pain experience of patients hospitalized in the ICU; in the study conducted in the United States, more than 50% of patients on mechanical ventilation had experienced pain (Fink et al. [ 25 ]). However, in a Norwegian study, only 10% of ICU patients reported pain at rest and 27% reported pain during repositioning (Olsen et al. [ 26 ]). This discrepancy may be due to differences in facilities, equipment, quality of drugs, pain control protocols and nursing methods. It appears that many of the subcategories identified in the professional behavior theme as components of safe care have been introduced and confirmed in other studies. And the results of this study support the previous findings. However, it should be noted that the identification of these components does not necessarily guarantee their implementation, and their implementation requires multilateral planning. For example, despite the importance of safe drug therapy, Ateshzadeh et al. (Atashzadeh Shoorideh et al. [ 1 ])) showed that the level of compliance with drug administration standards was only 2.6% in hospitals under the University of Medical Sciences A in Tehran and 9.4% in hospitals under the University of Medical Sciences B (Atashzadeh Shoorideh et al. [ 1 ]). Regarding infection control, Randa et al. showed that nurses’ performance in hand washing, wearing gowns, gloves and masks was far from the standards (Randa et al. [ 27 ]). Another study found that only 10.83% of nurses avoided incorrect connections (Bayatmanesh et al. [ 28 ]).

The results of this study showed that organizing communication between nurses and other members of the care team is as effective as implementing policies. Haddeland et al. (Haddeland et al. [ 29 ])in Norway demonstrated the importance and need to improve the use of the ISBAR tool to improve patient safety. They concluded that it is essential that healthcare professionals work together to ensure that everyone has the same situational awareness and that good clinical practice is developed and maintained. Correct use of identification wristbands (Barbosa et al. [ 30 ]), accurate recording of all information related to investigations, interventions and their evaluation (Aldawood et al. [ 31 ]), and communication with the patient (Danis [ 32 ])are effective in improving patient safety. The results of the present study are supported by previous studies. In Iran, Abdi et al. (Abdi et al. [ 33 ])concluded that poor communication and lack of team spirit had a negative impact on patient safety (Abdi et al. [ 33 ]). In Saudi Arabia, Al-Dawood et al. (Aldawood et al. [ 31 ])showed that poor team communication was one of the barriers to reducing patient safety in the ICU. Ensuring effective communication is critical to maintaining patient safety and can be achieved by implementing standard communication protocols, providing regular training and education on effective communication, and promoting a culture of collaboration and teamwork (Muller et al. [ 34 ]). Despite the importance of communication to patient safety, the results of evaluations in Iran are disappointing. A review study by Moghadam et al. (Moghadam et al. [ 35 ]), which surveyed Iranian hospitals on the implementation of mandatory patient safety standards, found that the implementation of mandatory standards in the area of ‘interaction with patients and society’ received the lowest score.

According to the results of this research, the principles of professional ethics are necessary to ensure patient safety. The results of studies have shown that things such as respect for privacy (Timmins et al. [ 36 ]), respect for human dignity and worth (Sugarman [ 37 ]; , Smith and Cole [ 38 ]), conscience (Herzer and Pronovost [ 39 ])and professional commitment (Teng et al. [ 40 ]; , Al-Hamdan et al. [ 41 ])are the principles of safe care. The results of the study by Mohammadi et al. (Mohammadi [ 42 ]) in Iran on safe care in ICUs and its relationship with moral courage showed that there is a significant relationship between moral courage and the principles of safe care. In line with previous studies, the present study showed that professional ethics is an important component of safe care in ICUs.

The present study identified holistic care as another effective factor in providing safe care. Holistic care is the systematic and comprehensive care of all systems of the patient’s body. These findings support previous research highlighting the importance of systems thinking and safe care in improving patient safety and overall quality of care (Moazez et al. [ 43 ]). Based on the findings of the study by Wick et al. (Wick et al. [ 44 ]), comprehensive care that addresses the physical, emotional, social and spiritual needs of patients was introduced as a solution to improve outcomes and patient satisfaction. In the study on the design of safe nursing care tools by Rashvand et al. (Rashvand et al. [ 45 ]), attention to the physical needs and attention to the psychological needs of patients were introduced as the main factors of safe nursing care. In addition to the aforementioned studies, the findings of this study are consistent with the holistic and widely used theories in nursing. These include Martha Rogers’ theory, Margaret Newman’s theory and Watson’s theory. A comprehensive review of holistic theories shows that holistic nursing is a two-way human relationship process in which the nurse is attentive, purposeful and alert in the process of caring for the patient as a whole. The result is an improvement in the nurse’s and patient’s sense of wellbeing, quality of care and ultimately patient safety (Yazdi and Talebi [ 46 ]).

In addition to the cases mentioned, the results of this study show the importance of promoting safe care in ICUs through a safety-oriented organizational approach. The creation of a safe environment is also directly related to the safety of the structure and the provision of safe equipment. In line with the present study, Naderi et al. (Naderi [ 10 ])also introduced in their study the state of human resources, management and organization, interaction and teamwork, equipment, environment, and evaluation and monitoring as the main factors affecting patient safety in the hospital (Naderi [ 10 ]). In the study by Lima et al. (D’Lima et al. [ 11 ]), organizational factors were identified as a threat to patient safety. This means that when employees perceive a risk from the organization, they stop providing safe care to patients. In Oliveira et al.’s study (Oliveira et al. [ 9 ]), employee workload, training and professional qualifications, teamwork, contractual employment, lack of job security and disruptive behavior were introduced as factors that interfere with patient safety. In the theoretical model of safe care presented by Vaismoradi (Vaismoradi [ 13 ]) the removal of organizational barriers was identified as one of the strategies to improve patient safety . Thus, based on the results of the present study and other studies, it can be said that healthcare organizations play an important role in patient safety.

Research limitations

One of the limitations of the current study was the absence of theories related to patient safety, which compelled the researchers to resort to the conventional content analysis method.

Another limitation was the lack of specific studies in ICU departments, which made it difficult to compare the present study with similar studies.

In the present study, despite the use of observations and field notes, the primary method of data collection was interviewing the participants. In future studies, incorporating other data collection methods can enhance the depth of the study.

The researcher’s extensive background in working in the intensive care unit as a nurse and head nurse, along with their familiarity with non-safe care practices, posed a risk of introducing bias. To mitigate this bias during the interviews, the researcher endeavored to adopt a listening role and formulate questions in accordance with the interview guide.

A significant portion of the patients admitted to the ICU did not qualify for inclusion in the study as a result of their diminished level of consciousness, reliance on mechanical ventilation, and administration of sedative and hypnotic medications. Identifying suitable participants proved challenging, necessitating extensive consultations and diligent follow-up by the researcher.

Patients exhibited caution in sharing their negative experiences due to concerns about potential repercussions from staff. Building trust to encourage open communication without self-censorship proved to be a lengthy endeavor. In addition, in one particular case, the patient expressed concern about the proximity of her bed to the nursing station, fearing that her conversations would be overheard by the nursing staff. Consequently, in adherence to the patient’s comfort and in consultation with the anesthesiologist, the interview was relocated to a different room to ensure confidentiality and optimal clinical conditions.

Due to the COVID-19 pandemic and the associated restrictions on patient visits, access to the patient’s family was difficult. The researcher had to make several attempts to make appointments for interviews.

The provision of safe care in the ICU is influenced by various components. According to the findings of this study, nurses exhibit professional behavior, such as implementation of policies, organizing communication with team members, patients, and their families, and adherence to professional ethics. They also demonstrate holistic care by following the nursing process and considering the entire system. Conversely, healthcare organizations play a crucial role in ensuring safe care by providing appropriate equipment and maintaining environmental safety. A safety-focused organization can enhance the delivery of safe care to patients in the ICU by offering a secure environment and reliable equipment. This not only ensures patient safety but also boosts staff efficiency, reduces error risks, and ultimately enhances patient outcomes and overall care quality. Healthcare organizations can establish conditions for safe patient care by recruiting suitable staff, monitoring their performance, and addressing their training requirements. Competent nurses, through the provision of comprehensive and systematic care, can deliver safe and high-quality services to patients. It is imperative to emphasize that achieving the desired outcomes necessitates collaborative efforts among healthcare organizations, nurses, and other healthcare professionals.

Availability of data and materials

Due to university policies, the datasets generated and utilized for the present study are not publically accessible but are available from the corresponding author upon justifiable request.

Abbreviations

Intensive Care Unit

Glasgow Coma Score

Identify, Situation, Background, Assessment, Recommendation

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The present study is part of the findings of the doctoral thesis, which was completed after obtaining the necessary permissions from Tehran Islamic Azad University of Medical Sciences. The research team would like to thank the staff of this university and all the participants in this research.

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Tajari, M., Ashktorab, T. & Ebadi, A. Components of safe nursing care in the intensive care units: a qualitative study. BMC Nurs 23 , 613 (2024). https://doi.org/10.1186/s12912-024-02281-5

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Qualitative vs Quantitative Research Methods & Data Analysis

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The main difference between quantitative and qualitative research is the type of data they collect and analyze.

Quantitative data is information about quantities, and therefore numbers, and qualitative data is descriptive, and regards phenomenon which can be observed but not measured, such as language.

• Quantitative research collects numerical data and analyzes it using statistical methods. The aim is to produce objective, empirical data that can be measured and expressed numerically. Quantitative research is often used to test hypotheses, identify patterns, and make predictions.
• Qualitative research gathers non-numerical data (words, images, sounds) to explore subjective experiences and attitudes, often via observation and interviews. It aims to produce detailed descriptions and uncover new insights about the studied phenomenon.

On This Page:

What Is Qualitative Research?

Qualitative research is the process of collecting, analyzing, and interpreting non-numerical data, such as language. Qualitative research can be used to understand how an individual subjectively perceives and gives meaning to their social reality.

Qualitative data is non-numerical data, such as text, video, photographs, or audio recordings. This type of data can be collected using diary accounts or in-depth interviews and analyzed using grounded theory or thematic analysis.

Qualitative research is multimethod in focus, involving an interpretive, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Denzin and Lincoln (1994, p. 2)

Interest in qualitative data came about as the result of the dissatisfaction of some psychologists (e.g., Carl Rogers) with the scientific study of psychologists such as behaviorists (e.g., Skinner ).

Since psychologists study people, the traditional approach to science is not seen as an appropriate way of carrying out research since it fails to capture the totality of human experience and the essence of being human.  Exploring participants’ experiences is known as a phenomenological approach (re: Humanism ).

Qualitative research is primarily concerned with meaning, subjectivity, and lived experience. The goal is to understand the quality and texture of people’s experiences, how they make sense of them, and the implications for their lives.

Qualitative research aims to understand the social reality of individuals, groups, and cultures as nearly as possible as participants feel or live it. Thus, people and groups are studied in their natural setting.

Some examples of qualitative research questions are provided, such as what an experience feels like, how people talk about something, how they make sense of an experience, and how events unfold for people.

Research following a qualitative approach is exploratory and seeks to explain ‘how’ and ‘why’ a particular phenomenon, or behavior, operates as it does in a particular context. It can be used to generate hypotheses and theories from the data.

Qualitative Methods

There are different types of qualitative research methods, including diary accounts, in-depth interviews , documents, focus groups , case study research , and ethnography .

The results of qualitative methods provide a deep understanding of how people perceive their social realities and in consequence, how they act within the social world.

The researcher has several methods for collecting empirical materials, ranging from the interview to direct observation, to the analysis of artifacts, documents, and cultural records, to the use of visual materials or personal experience. Denzin and Lincoln (1994, p. 14)

Here are some examples of qualitative data:

Interview transcripts : Verbatim records of what participants said during an interview or focus group. They allow researchers to identify common themes and patterns, and draw conclusions based on the data. Interview transcripts can also be useful in providing direct quotes and examples to support research findings.

Observations : The researcher typically takes detailed notes on what they observe, including any contextual information, nonverbal cues, or other relevant details. The resulting observational data can be analyzed to gain insights into social phenomena, such as human behavior, social interactions, and cultural practices.

Unstructured interviews : generate qualitative data through the use of open questions.  This allows the respondent to talk in some depth, choosing their own words.  This helps the researcher develop a real sense of a person’s understanding of a situation.

Diaries or journals : Written accounts of personal experiences or reflections.

Notice that qualitative data could be much more than just words or text. Photographs, videos, sound recordings, and so on, can be considered qualitative data. Visual data can be used to understand behaviors, environments, and social interactions.

Qualitative Data Analysis

Qualitative research is endlessly creative and interpretive. The researcher does not just leave the field with mountains of empirical data and then easily write up his or her findings.

Qualitative interpretations are constructed, and various techniques can be used to make sense of the data, such as content analysis, grounded theory (Glaser & Strauss, 1967), thematic analysis (Braun & Clarke, 2006), or discourse analysis .

For example, thematic analysis is a qualitative approach that involves identifying implicit or explicit ideas within the data. Themes will often emerge once the data has been coded .

Key Features

• Events can be understood adequately only if they are seen in context. Therefore, a qualitative researcher immerses her/himself in the field, in natural surroundings. The contexts of inquiry are not contrived; they are natural. Nothing is predefined or taken for granted.
• Qualitative researchers want those who are studied to speak for themselves, to provide their perspectives in words and other actions. Therefore, qualitative research is an interactive process in which the persons studied teach the researcher about their lives.
• The qualitative researcher is an integral part of the data; without the active participation of the researcher, no data exists.
• The study’s design evolves during the research and can be adjusted or changed as it progresses. For the qualitative researcher, there is no single reality. It is subjective and exists only in reference to the observer.
• The theory is data-driven and emerges as part of the research process, evolving from the data as they are collected.

Limitations of Qualitative Research

• Because of the time and costs involved, qualitative designs do not generally draw samples from large-scale data sets.
• The problem of adequate validity or reliability is a major criticism. Because of the subjective nature of qualitative data and its origin in single contexts, it is difficult to apply conventional standards of reliability and validity. For example, because of the central role played by the researcher in the generation of data, it is not possible to replicate qualitative studies.
• Also, contexts, situations, events, conditions, and interactions cannot be replicated to any extent, nor can generalizations be made to a wider context than the one studied with confidence.
• The time required for data collection, analysis, and interpretation is lengthy. Analysis of qualitative data is difficult, and expert knowledge of an area is necessary to interpret qualitative data. Great care must be taken when doing so, for example, looking for mental illness symptoms.

Advantages of Qualitative Research

• Because of close researcher involvement, the researcher gains an insider’s view of the field. This allows the researcher to find issues that are often missed (such as subtleties and complexities) by the scientific, more positivistic inquiries.
• Qualitative descriptions can be important in suggesting possible relationships, causes, effects, and dynamic processes.
• Qualitative analysis allows for ambiguities/contradictions in the data, which reflect social reality (Denscombe, 2010).
• Qualitative research uses a descriptive, narrative style; this research might be of particular benefit to the practitioner as she or he could turn to qualitative reports to examine forms of knowledge that might otherwise be unavailable, thereby gaining new insight.

What Is Quantitative Research?

Quantitative research involves the process of objectively collecting and analyzing numerical data to describe, predict, or control variables of interest.

The goals of quantitative research are to test causal relationships between variables , make predictions, and generalize results to wider populations.

Quantitative researchers aim to establish general laws of behavior and phenomenon across different settings/contexts. Research is used to test a theory and ultimately support or reject it.

Quantitative Methods

Experiments typically yield quantitative data, as they are concerned with measuring things.  However, other research methods, such as controlled observations and questionnaires , can produce both quantitative information.

For example, a rating scale or closed questions on a questionnaire would generate quantitative data as these produce either numerical data or data that can be put into categories (e.g., “yes,” “no” answers).

Experimental methods limit how research participants react to and express appropriate social behavior.

Findings are, therefore, likely to be context-bound and simply a reflection of the assumptions that the researcher brings to the investigation.

There are numerous examples of quantitative data in psychological research, including mental health. Here are a few examples:

Another example is the Experience in Close Relationships Scale (ECR), a self-report questionnaire widely used to assess adult attachment styles .

The ECR provides quantitative data that can be used to assess attachment styles and predict relationship outcomes.

Neuroimaging data : Neuroimaging techniques, such as MRI and fMRI, provide quantitative data on brain structure and function.

This data can be analyzed to identify brain regions involved in specific mental processes or disorders.

For example, the Beck Depression Inventory (BDI) is a clinician-administered questionnaire widely used to assess the severity of depressive symptoms in individuals.

The BDI consists of 21 questions, each scored on a scale of 0 to 3, with higher scores indicating more severe depressive symptoms. 

Quantitative Data Analysis

Statistics help us turn quantitative data into useful information to help with decision-making. We can use statistics to summarize our data, describing patterns, relationships, and connections. Statistics can be descriptive or inferential.

Descriptive statistics help us to summarize our data. In contrast, inferential statistics are used to identify statistically significant differences between groups of data (such as intervention and control groups in a randomized control study).

• Quantitative researchers try to control extraneous variables by conducting their studies in the lab.
• The research aims for objectivity (i.e., without bias) and is separated from the data.
• The design of the study is determined before it begins.
• For the quantitative researcher, the reality is objective, exists separately from the researcher, and can be seen by anyone.
• Research is used to test a theory and ultimately support or reject it.

Limitations of Quantitative Research

• Context: Quantitative experiments do not take place in natural settings. In addition, they do not allow participants to explain their choices or the meaning of the questions they may have for those participants (Carr, 1994).
• Researcher expertise: Poor knowledge of the application of statistical analysis may negatively affect analysis and subsequent interpretation (Black, 1999).
• Variability of data quantity: Large sample sizes are needed for more accurate analysis. Small-scale quantitative studies may be less reliable because of the low quantity of data (Denscombe, 2010). This also affects the ability to generalize study findings to wider populations.
• Confirmation bias: The researcher might miss observing phenomena because of focus on theory or hypothesis testing rather than on the theory of hypothesis generation.

Advantages of Quantitative Research

• Scientific objectivity: Quantitative data can be interpreted with statistical analysis, and since statistics are based on the principles of mathematics, the quantitative approach is viewed as scientifically objective and rational (Carr, 1994; Denscombe, 2010).
• Useful for testing and validating already constructed theories.
• Rapid analysis: Sophisticated software removes much of the need for prolonged data analysis, especially with large volumes of data involved (Antonius, 2003).
• Replication: Quantitative data is based on measured values and can be checked by others because numerical data is less open to ambiguities of interpretation.
• Hypotheses can also be tested because of statistical analysis (Antonius, 2003).

Antonius, R. (2003). Interpreting quantitative data with SPSS . Sage.

Black, T. R. (1999). Doing quantitative research in the social sciences: An integrated approach to research design, measurement and statistics . Sage.

Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology . Qualitative Research in Psychology , 3, 77–101.

Carr, L. T. (1994). The strengths and weaknesses of quantitative and qualitative research : what method for nursing? Journal of advanced nursing, 20(4) , 716-721.

Denscombe, M. (2010). The Good Research Guide: for small-scale social research. McGraw Hill.

Denzin, N., & Lincoln. Y. (1994). Handbook of Qualitative Research. Thousand Oaks, CA, US: Sage Publications Inc.

Glaser, B. G., Strauss, A. L., & Strutzel, E. (1968). The discovery of grounded theory; strategies for qualitative research. Nursing research, 17(4) , 364.

Minichiello, V. (1990). In-Depth Interviewing: Researching People. Longman Cheshire.

Punch, K. (1998). Introduction to Social Research: Quantitative and Qualitative Approaches. London: Sage

Further Information

• Mixed methods research
• Designing qualitative research
• Methods of data collection and analysis
• Introduction to quantitative and qualitative research
• Checklists for improving rigour in qualitative research: a case of the tail wagging the dog?
• Qualitative research in health care: Analysing qualitative data
• Qualitative data analysis: the framework approach
• Using the framework method for the analysis of
• Qualitative data in multi-disciplinary health research
• Content Analysis
• Grounded Theory
• Thematic Analysis

• Open access
• Published: 27 August 2024

Facilitators and barriers to interprofessional collaboration among health professionals in primary healthcare centers in Qatar: a qualitative exploration using the “Gears” model

• Alla El-Awaisi 1 ,
• Ola Hasan Yakti 2 ,
• Abier Mohamed Elboshra 1 ,
• Kawthar Hasan Jasim 1 ,
• Alzahraa Fathi AboAlward 1 ,
• Raghad Walid Shalfawi 3 ,
• Ahmed Awaisu 1 ,
• Daniel Rainkie 4 ,
• Noora Al Mutawa 3 , 5 &
• Stella Major 6  

BMC Primary Care volume  25 , Article number:  316 ( 2024 ) Cite this article

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The number of patients seeking medical care is increasing, necessitating more access to primary healthcare services. As several of these patients usually present with complex medical conditions, the need for interprofessional collaboration (IPC) among health professionals in primary care is necessary. IPC is essential for facing the increasing and challenging healthcare demands. Therefore, the facilitators of and the barriers to IPC should be studied in the hope that the results will be used to promote such endeavors.

This study aimed to explore the perspectives of different health professionals regarding the facilitators of and the barriers to IPC in the primary healthcare settings in Qatar.

A qualitative study using focus groups was conducted within the Primary Health Care Corporation (PHCC) in Qatar. Several health professionals were invited to participate in the focus groups. The focus groups were uniprofessional for general practitioners (GPs), nurses, and dentists, while they were interprofessional for the other health professionals. Focus groups were audio-recorded and transcribed verbatim and validated by the research team. The data were analyzed by deductive thematic analysis using the “Gears” Conceptual Model as a coding framework.

Fourteen focus groups were conducted involving 58 participants (including 17 GPs, 12 nurses, 15 pharmacists, 3 dentists, and 11 allied health professionals) working in PHCC in Qatar. The findings revealed a spectrum of factors influencing IPC, categorized into four main domains: Macro, Meso, Micro, and individual levels, with each accompanied by relevant barriers and facilitators. Key challenges identified included a lack of communication skills, insufficient professional competencies, and power imbalances, among others. To address these challenges, recommendations were made to implement dedicated training sessions on IPC, reduce hierarchical barriers among different health professionals, and enhance the effectiveness of existing systems. Conversely, it was emphasized that projects and campaigns focused on IPC, alongside the development of enhanced communication skills and the presence of supportive leadership, as essential for facilitating effective IPC in PHCCs.

The interplay between the meso, macro, micro, and individual levels highlight the significance of a multifaceted approach to interventions, aiming to enhance the successes of IPC. While initiatives like interprofessional education training are underway, numerous challenges persist before achieving improved collaboration and more efficient integration of IPC in the PHCC setting.

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Introduction

The World Health Organization (WHO) projects a global deficit of health professionals in comparison to the needs, expected to exceed 18 million by 2030, which will impede the provision of optimal healthcare services. In their “Global strategy on human resources for health: Workforce 2030”, they highlighted the need to equip health professionals with the skills needed to practice collaboratively in interprofessional teams [ 1 ]. One of the best solutions to face this strain on the healthcare system and to provide better management of the complex health challenges is to implement and promote the concept of interprofessional collaboration (IPC) as these demands often are beyond the expertise of any single profession [ 2 , 3 , 4 ]. According to the WHO, IPC occurs when “multiple healthcare workers from different professional backgrounds provide comprehensive services by working with patients, their families, caregivers, and communities to deliver the highest quality of care across settings” [ 2 ]. IPC recently has become one of the core demands of accreditors, funding institutions, policymakers, and practicing health professionals, recognizing its potential to improve the quality of care and address the increasing demand for healthcare services [ 5 , 6 , 7 , 8 ].

Research has consistently highlighted the positive impact of IPC on healthcare work processes, patient safety, and patient outcomes across various disease states such as diabetes, heart failure and asthma, which were treated in hospital, primary care, and community settings [ 9 , 10 , 11 ]. Research has concluded that a high degree of IPC has led to better subjective outcomes, including overall satisfaction, treatment success, and willingness to recommend the healthcare institution to others. Additionally, objective outcomes such as reduced mortality rate, readmissions, and hospital length of stay have been noted. Furthermore, collaboration has been associated with improved decision-making and increased innovation [ 12 , 13 ]. It has also been demonstrated that as the relationship and level of connectedness between physicians and other health professionals increase; hospitalization costs and readmission rates decrease [ 14 ].

Primary healthcare is the foundation of any country’s healthcare system. It is not only considered the primary point of contact with the healthcare system, but it also serves as the vehicle for ensuring continuity of care across settings. The increase in the number of people with multiple chronic diseases that are associated with considerable social, functional, and emotional impairment and an increase in the healthcare demand, leading to an increase in the needed services [ 15 , 16 , 17 , 18 ]. Consequently, policymakers on an international scale have persistently advocated for the greater integration of interprofessional team-based care in primary healthcare settings and the development of influencing factors that explicitly acknowledge the value of this collaborative approach [ 19 , 20 ]. Several studies in the literature have highlighted the positive outcomes associated with effective collaboration within primary healthcare settings [ 21 , 22 , 23 ]. This has led to an internationally movement towards team-based primary healthcare, to enhance the integration of services and to emphasize health promotion and chronic disease management [ 19 ]. Ineffective collaboration leads to an increased risk of preventable errors, lack of efficiency, and loss of motivation, resulting in suboptimal patient care based on nurses’ opinions [ 24 ].

While IPC efforts are usually initiated by policymakers, research have demonstrated that health professionals’ play a vital role in providing high-quality IPC. Therefore, it is of crucial importance to consider the perspectives of health professionals working in primary healthcare settings regarding IPC when designing and implementing IPC projects [ 25 ]. Numerous studies have examined IPC across various countries. For example, a systematic review was conducted to explore facilitators and barriers to IPC implementation in primary healthcare settings. This review included studies conducted in Great Britain, the United States, the Netherlands, Australia, Spain, Brazil, Canada, and New Zealand. The findings of this review indicated that allied health professionals generally hold positive perceptions of IPC within primary healthcare contexts [ 26 , 27 ]. However, limited research has been conducted to investigate healthcare IPC practice in Qatar, particularly in primary healthcare settings. Given the recent expansion of scope of practice in primary care in Qatar [ 28 ], it is essential to explore the current practices in primary healthcare in Qatar in terms of IPC facilitators and barriers, and determining the necessary steps to achieve optimal collaboration within the Qatari healthcare system.

This study is a continuation of a previous study that explored the perspective of 1415 health professionals in primary healthcare settings through a self-administered questionnaire [ 28 ]. Results of the study showed that health professionals generally have a positive attitude and readiness toward IPC. Interprofessional differences were noted regarding their readiness to be involved in IPC, where physicians had slightly more positive readiness towards understanding their professional identity compared to other health professionals. Health professionals with previous IPC or interprofessional education (IPE) experiences revealed greater, but non-significant positive attitudes toward IPC compared to those without previous experiences. Participants suggested that facilitators and barriers for IPC in primary healthcare settings are conceptual rather than physical. Facilitators included personal belief in IPC benefit, higher professional satisfaction, interprofessional respect, appreciation of other health professionals’ role, institutional support, and leadership. Barriers identified included lack of time, leadership, support, and limited resources.

In an effort to understand the health professionals’ perception of the facilitators and barriers for IPC in primary healthcare in Qatar, the current study will explore the factors affecting the IPC in primary healthcare in Qatar using the “Gears” conceptual model [ 7 ]. The Gears model offers a taxonomy of factors influencing IPC within Interprofessional Primary Care Teams (IPCTs). These factors are categorized into levels: policymakers (macro gear), organizational managers (meso gear), healthcare teams (micro gear), and health professionals (individual gear). Most of the factors identified by the “Gears model” are within the micro gear, or those affecting the individual. These involve formal processes such as quality audits and group problem-solving; social processes pertained to open communication and supportive colleagues; team attitudes such as feeling part of the team; and team structure such as team size and having a collaboration champion or facilitator. Macro gears/policy factors are those that change less frequently and are pertained to regulations regarding the general scope of practice, funding, etc. Meso gears/ organizational factors are those that change more often and affect more than one team in the organization, those are concerned with the information systems, organizational culture, etc. Individual factors include the individual health professional characteristics such as belief in IPC care and personal flexibility.

The aim of this study is to identify factors facilitating or impeding IPC in primary healthcare in Qatar by exploring the perspectives of health professionals working in primary healthcare qualitatively. These include GPs, nurses, pharmacists, dentists, and allied health professionals (lab technicians, physiotherapists, dieticians, and radiographers). Findings from this study will be used to find ways to enhance and promote collaborative practice in primary healthcare in Qatar.

Study design

In this qualitative study design, data were collected through semi-structured focus groups. A qualitative approach was used to explore comprehensively the lived experiences of health professional’s perspective as it allows for investigating a phenomenon from the people who have experienced it. It gives a deeper insight and answers to what, how, and why questions [ 12 ].

Study setting

The study was conducted among health professionals working in the Primary Health Care Corporation (PHCC) in Qatar. PHCC was established in 1978 to provide comprehensive primary healthcare services and became an independent body in 2012 with full administrative and financial autonomy. At the present time, the PHCC provides PHC through 27 PHC centers distributed across the country. Each center is staffed with health professionals who provide a broad range of services, focusing on health promotion and disease prevention. PHCC has adopted and implemented family medicine model of care and offers a wide range of services, including general medicine, dentistry, ophthalmology, optometry, ENT, dermatology, mental health, preventive and lifestyle services such as wellness, premarital care, cancer screening, gym and geriatric, physiotherapy and radiology services [ 29 ]. In February 2018, a local continuous professional development (CPD) program was initiated by PHCC Workforce Training Department (WFTD) for implementing learning activities across the 27 PHCC health centers using interprofessional and collaborative approaches.

Study participants and sampling

The study comprised 58 participants, including 17 general practitioners, 12 nurses, 3 dentists, 15 pharmacists, and 11 allied health professionals (e.g., laboratory technologists, radiologists, optometrists, and audiologists) working in PHCC in Qatar. A purposive sampling strategy was employed to select health professionals with experience or understanding of IPC, aiming to maximize participant recruitment and ensure representation of the study population’s views [ 16 ]. Sampling continued until thematic saturation was reached, indicating no further emergent ideas from discussions [ 17 ].

Participants’ recruitment

Emails were sent to the health professionals working at PHCC in Qatar inviting them to participate in the study focus groups that were planned to be conducted at Qatar University or PHCC headquarters. Recruitment of participants was facilitated through WFTD which took the responsibility of recruiting and arranging appropriate focus group schedule that can suit study participants. An invitation email was sent with consent form and participant information sheet to participants prior to the focus groups.

Data collection

The topic guide was developed through discussions with the research team, a review of previous literature, and based on phase 1 quantitative results [ 28 ] (please see supplementary file). A pilot interview was conducted with minor adjustments and included a few health professionals working in PHCC. Because no significant changes were made it was included in the final analysis. The focus group were uniprofessional (i.e. homogenous groups) for GPs, nurses and dentist and interprofessional (i.e. heterogeneous groups) for the remaining health professionals and varied in duration between 90 and 120 min. The discussions were audio-recorded and transcribed verbatim.

Data analysis

A deductive thematic analysis was conducted of data, which is an analytical method in which authors use existing themes, categories, or domains to categorize new data under such categories [ 30 ]. Participants’ ideas were categorized under four main domains adapted from the “Gears model” [ 7 ]. The gears model outlines the factors affecting IPC within IPCTs under four main factor domains: macro, meso, micro, and individual factors. AME, AA, KJ, RS reviewed and validated the transcripts. They then independently reviewed couple of transcripts to generate codes in discussion with the lead author (AE). Coding for the rest of the transcripts was validated by one faculty member from the research team. A final discussion took place with all authors to agree on themes and subthemes.

Reflexivity

During the data collection and analysis process, the research team engaged in reflexive practices to mitigate potential biases. The team consisted of various individuals with diverse backgrounds, including faculty members with pharmacy, nursing and medical backgrounds, three of whom were practicing health professionals, along with four pharmacy students and one alumna. The team offered a broad spectrum of perspectives and insights for data generation and analysis. These faculty members had an understanding of IPE and had previously conducted workshops on interprofessional collaboration for health professionals at PHCC. With a background in IPC, participants’ ideas were more easily understood, facilitating deeper engagement, and enabling the comprehension of their perspectives more readily, thus ensuring a comprehensive interpretation of the data. Throughout the research process, attention was paid to the potential influence of professional backgrounds, with reflexive practices employed to mitigate biases and ensure the integrity of the findings.

Data collection were mostly led by the principal investigator, with support from students adhering to a pre-defined topic guide to minimize personal biases. To further enhance trustworthiness of the study, students independently coded the data, which was validated by a faculty member of the research team. The team met several times to review and compare codes and themes, refining the analysis iteratively until consensus was reached. Each stage of the research process was overseen by the principal investigator, ensuring the rigor and robustness of the study.

Fourteen focus groups were conducted between September 2019 and February 2020, involving 58 health professionals working in primary healthcare centers in Qatar (17 general practitioners, 12 nurses 15 pharmacists, 3 dentists, and 11 allied health professionals). The baseline characteristics of the participants are summarized in Table  1 . Four domains, 10 themes, and 14 sub-themes were identified from the focus groups. The domains, themes, and sub-themes are summarized in Table  2 .

Gears domain 1: macro factors

Facilitators, theme 1: the influence of organizational policies on ipc.

Several factors were identified by health professionals pertaining to the policies that can affect IPC. These factors were mainly related to the rules and regulations set by the organization’s managers or government bodies, which typically influence the general scopes of practice, funding mechanisms, and remuneration of providers. Consensus was reached that these regulations play a significant role in fostering IPC among health professionals.

“Actually , we have very well prepared and organized policies. Policies related to teamwork , which align with best-practices and international guidelines. The policies at our PHCC facilitate collaboration… but how to use it? Is everybody aware of its use?” [Laboratory technologist 1].

No major barriers were identified under the macro factors.

Gear’s domain 2: meso factors

Theme 2.1: leveraging technology for enhanced communication.

Participants unanimously agreed that the current health information system, specifically CERNER, serve as a strong facilitator for enhancing communication among health professionals. It enables seamless sharing of patients’ details documented by other health professionals.

“I find the CERNER system software amazing , because you can get to see the history of the patients and previous appointments records. Everything is well documented” [Dentist 3].

Theme 2.2: communication hindered by limitations in healthcare information system utilization

Several participants noted that current system (CERNER) is not fully utilized for documenting and reporting of medical or medication errors which can serve as a barrier. As an example, one participant expressed reluctance to utilize the system and filing an OVA (incidental report) for fear of retaliation in case the reporter is identified.

“If I were to write OVA (incidental report) for him/her , he/she will get angry at me. So , there’s no use. Actually , the purpose is to report in order for others to learn from them , but there is no clear pathway that there will be no consequences for us reporters” [Nurse 2].

Furthermore, another HCP mentioned that the current information system might be a barrier, as not all health professionals have equal access to the system.

“The pharmacist is not allowed to enter a recommendation into the system; they have their own system” [GP 5].

Theme 2.3: barriers in organizational dynamics hindering IPC

Sub-theme 2.3.1: hierarchy hinders collaborative spirit.

One of the primary obstacles to collaboration within the institution is perceived to be the presence of a hierarchical structure. This perception is based not only in the observable existence of a grading system that categorizes health professionals according to their profession and seniority, but also in the benefits associated with higher hierarchical positions.

“The hierarchy is influenced by salary differences” [GP 4].

Participants in the study observed that this hierarchical system leads to disparities, which undermine their willingness to collaborate. As an example, pharmacists expressed feeling of being treated differently compared to GPs, who are routinely offered opportunities to attend international conferences. The lack of such opportunities for pharmacists and other health professionals further reinforces the perception of hierarchy within the institution.

“I have tried to attend a conference; I have a right to enhance my education. Why does this apply to the GP and not to the pharmacist?” [Pharmacist 8]. “He -the GP- thinks that the pharmacist as being of lower status , and he is the only one to have the authority to write and make decisions” [Pharmacist 9].

Sub-theme 2.3.2: blame culture instils apprehension among health professionals

Another significant factor that had a considerable impact on collaborative efforts was the existence of a culture of blame within the PHCC organization. This culture of blame surfaced frequently during discussions among health professionals and was found to hinder effective collaboration among team members. Some perceived the level of blame not to be equitable.

“What if I did a mistake? And what if the mistake was done by the GP? The blame wouldn’t be equal. We would receive more blame” [Nurse 3]. “I still believe that some of us should refrain from perpetuating a blame culture or name-calling. After all , all of us are human beings. We are prone to making errors” [GP 10]. “We need to promote a culture of no blame. When things go wrong or mistakes occur , we should view them as collective challenges rather than assigning fault to individuals and subjecting them to humiliation. This approach will significantly transform the overall attitude within the environment” [GP 2].

Sub-theme 2.3.3: Lack of feedback contributes to the perception that health professionals’ efforts are undervalued

Some health professionals have expressed concerns regarding the lack of feedback on their performance, interventions, and error reports, particularly within Datix, a patient safety software utilized for healthcare risk reporting. This absence of feedback is perceived as a significant impediment to IPC, as it fosters the perception that the efforts of health professionals are not adequately acknowledged or valued.

“The risk management team should gather data and determine the significance of incidents reported through Datix , which is serious or recurring. If a mistake is repeated , they will ask or make an investigation about this issue. However , aside from these instances , no action is taken. No feedback is provided” [Pharmacist 1].

Gears domain 3: micro factor

Theme 3.1: expanding the scope of practice of team members enhances collaboration.

Given that IPC heavily relies on teamwork, the topic of collaborative efforts and teamwork surfaced frequently during focus groups.

“ The most important thing in primary healthcare practice is the teamwork. We underscore its importance , as it permeates our daily operations” [GP 6].

Expanding the scope of practice of healthcare team members has the potential to foster enhanced collaboration between team members. For example, pharmacists who participated in the discussions expressed that the inclusion of a clinical pharmacist within PHCC would enhance collaboration. This is attributed to the direct involvement of the clinical pharmacist with the interprofessional team, which obviates the need for external prompting to initiate collaborative efforts.

Theme 3.2: effective communication channels foster collaboration

Effective collaboration among participants was found to significantly hinge on the establishment of robust communication channels. This encompasses both formal features and tools, ranging from cordial and conversational telephonic exchanges to more structured modes of communication, such as the sharing of electronic patient records. Several participants cited instances of proficient communication that had led to successful collaboration outcomes.

“Every colleague should be encouraged to express their concerns , whether in written form or verbally , as it facilitates communication” [Dentist 3]. “Many doctors respect our opinion and express gratitude , acknowledging that we draw their attention to certain points“ [Pharmacist 9].

The majority of participants highlighted the importance of communication tools provided by the institution, including telephones, the CERNER system, and email platforms. Participants expressed their appreciation for these communication channels, noting that they effectively save time and enable seamless collaboration, even when they are attending to patients in different locations.

“It’s not difficult because we have our colleagues , whom we can contact directly by phone” [Dentist 1].

Theme 3.3: formal team processes have a significant role in facilitating collaboration

Sub-theme 3.3.1: supportive leaders empower team members to collaborate.

Leaders who demonstrate appreciation and dedication play a crucial role in fostering positive experiences of IPC. Regular interprofessional meetings organized by these leaders ensure that the environment is conducive to collaboration, and support empowering health professionals to initiate and engage in collaborative endeavor.

“So , if we have any issues , we talk to our supervisor , who then reports it to the health center manager. She is really supportive” [Pharmacist 3].

Sub-theme 3.3.2: engagement in interprofessional initiatives enhances collaboration among team members

Participants emphasized that their involvement in workplace initiatives, such as projects, campaigns, seminars, and workshops, played a crucial role in promoting IPC. According to health professionals, these initiatives were beneficial as they provided them with diverse professional perspectives, opinions, and ideas, which in turn enhanced their chances of success in their collaborative efforts.

“In our health center , we initiated a project to improve the practice of antibiotic prescribing. We were collaborating with GPs to know from them how to write and put a protocol to lessen the misuse of antibiotic” [Pharmacist 2].

Participants also recognized that engaging in collaborative research activities involving multiple team members was an effective facilitator for enhancing patient safety.

“I conducted research on medication use reviews , actively engaging with general practitioners’ clinics. I would regularly visit these clinics to share information about the study. During these interactions , I explained my criteria , encouraging them to refer eligible patients to the pharmacy” [Pharmacist 6].

Furthermore, vaccination campaigns were considered essential by several pharmacists as they provided opportunities for collaboration with other disciplines including educational outreach events. Several pharmacists reported on their involvement in these campaigns and the subsequent positive impact on collaboration dynamics. Specifically, one pharmacist highlighted a reduction in the uptake of pneumococcal vaccine among eligible patients and assumed a proactive role by gathering information from various GPs regarding the decreased prescription of such vaccines.

“We did a project in collaboration with GPs , regarding vaccinating high risk patients with pneumococcal vaccine” [Pharmacist 4]. “During the immunization week , I held a seminar about immunization. I taught them -nurses- individually how to use each vaccine properly and why we are using it” [Pharmacist 2].

Moreover, participants found case-based discussions and interprofessional training sessions with other health professionals valuable for collaboration. These sessions allowed discussion of each profession’s role and facilitated idea exchange.

“ As part of our interprofessional education efforts , we conduct weekly lectures and brief discussions for an hour… sometimes , new nurses and physiotherapists attend these lectures…… We discuss how we can help promote the collaboration between all of us for better care for the patients” [GP 9].

Sub-theme 3.3.3: optimizing accessible healthcare environments

Experiences related to the impact of the environment on collaboration were generally positively perceived. For instance, the close proximity of a nurse diabetic educator to the pharmacy facilitated direct communication between pharmacists and educators, enabling them to address any concerns more efficiently. Moreover, having practitioners co-located in a single setting, rather than dispersed in various locations within the center, was deemed more advantageous.

“We have it , diabetic educator , clinical pharmacist , and GP all in one place , so they all work together for assessment of patient and education , particularly high-risk patient” [Pharmacist 4].

Theme 3.4: time constraints impede collaboration and affect patient outcomes

Participants identified time constraints as a significant challenge to collaboration, with health professionals struggling to allocate sufficient time for documentation, communication, and knowledge-sharing, potentially impacting patient outcomes.

“We can’t afford the luxury of opening CERNER each time since we are already occupied with other tasks” [Pharmacist 5]. “Even when there is an issue …. we should learn from it. We are not learning. We just want to finish this issue and just move on because there is no time. There is too much work” [Laboratory technologist 1].

Theme: 3.5: lack of clarity in scope of practice leads to misunderstandings and hinders collaboration

A number of health professionals expressed concerns regarding the potential misunderstanding of their scope of practice, leading to requests to perform tasks beyond their designated role which impact the collaborative culture leading to frustration.

“Nurses are responsible for taking vital signs , following the patient’s care plan , and managing medications , but cleaning is not part of their role although some doctors mistakenly believe it to be so” [Nurse 3]. “At times , we notice that some GPs are unaware of the difference between a technician and a radiologist” [Laboratory technologist 1].

Gears domain 4: individual factors

Theme 4.1: prior exposure to ipe enhances appreciation for ipc.

The study observed that health professionals who had prior experience with IPE exhibited a greater appreciation towards collaborative work.

“We learned and practiced IPE during our education. However , in practical settings , there is still a need for a comprehensive understanding of IPE and its implementation. While there are individual efforts to apply it , full implementation has not been achieved yet” [Pharmacist 3].

Theme 4.2: health professionals’ factors

Subtheme 4.2.1: effective communication skills drive enhanced collaboration among health professionals.

Effective communication was deemed crucial by participants in healthcare settings. Nurses felt valued and integral to the team when equipped with proper communication skills, while GPs found direct communication with other health professionals to be advantageous, enhancing their practice.

“Quite a few times , I’ve reached out to the on-site ophthalmologist by phone. When there’s a concern about a patient , whether its suspected cornea issues or the need to rule out certain conditions , a simple phone call often results in them accommodating the patient. The ophthalmologist has consistently been responsive and helpful in these interactions” [GP 6].

Subtheme 4.2.2: positive interpersonal qualities among health professionals enhance collaboration

The collaboration within the team is influenced by health professionals’ interpersonal qualities which was identified as a significant factor, with approachability and friendliness being crucial in facilitating collaboration.

“The difference here is that I find everybody to be approachable and friendly [GP 6]. Very friendly environment. You can approach the nurses , the doctors—everyone is accessible” [GP 10].

Furthermore, respect and trust were highly valued facilitators of IPC and were discussed in conjunction with other facilitators.

“Mutual respect among all health professionals will facilitate smoother and more effective collaboration” [Nurse 3]. “We must respect each other. Just because I am a GP , it doesn’t mean my opinion is the only opinion or the correct one” [GP 3].

Theme 4.3: patient perceptions impact IPC

Patient perceptions were found to exert a considerable impact on the dynamics of collaboration between nurses, GPs, and other health professionals. Participants reported that patients tended to perceive nurses as occupying a subordinate position relative to GPs, and consequently, were less forthcoming in discussing healthcare concerns with them.

“ You are the nurse; you know less than the doctor” [Nurse 4]. “ Patients typically highly value recommendations from physicians. However , when they seek advice or education from nurses or pharmacists , they sometimes may not value it as much as they would if it came from a physician ” [Pharmacist 7].

Additionally, participants believe patients regard GPs as the key health professionals, and preferred to communicate exclusively with them. This perception placed an additional workload on GPs, leading to potential consequences on their capacity to collaborate effectively with other health professionals.

“We need to educate patients more about the roles each team member plays and how we all work together as a team. When a patient comes in , they often see the doctor as the leader but it’s important for them to understand the contributions of all team members” [GP 5].

Theme 4.4: impact of of perceived approachability and ego on IPC

On the other hand, encountered challenges in communicating with GPs, including when they perceived a sense of ego, or if they were less approachable. Nurses expressed reluctancy to approach pharmacists or GPs whom they felt would not respect them.

“ Being approachable is one of the most important things especially when it comes to the team. For example , some of the nurses would know a lot of information about the patient but if you’re not an approachable GP , they will not come and voluntarily divulge the information” [GP 6]. “Ego. When you are dealing with people these things are barriers and the best solution is always communication” [Nurse 6].

Similarly, GPs encountered similar challenges in communicating with other health professionals if they perceived them as unfriendly or unapproachable. However, they differed from the nurses in that they seemed to encounter these challenges within their own field of practice rather than in interactions with other health professionals.

Theme 5: enhancing IPC through equity, training, and support

The study participants put forth several proposals to enhance IPC in their workplace. A key recommendation was to ensure equity among health professionals, such that all members had full and equal access to patient files. This would enable effective IPC by keeping all team members abreast of the patient’s evolving health status and treatment plan. Participants recognized that institutional and leadership support would be necessary to achieve this equity. Additionally, due to the acknowledged limitations posed by workload and time constraints, many participants suggested that the recruitment of additional staff could facilitate IPC processes. Further, the participants proposed the need for more frequent training sessions to improve communication skills, enhance system and documentation writing, and provide IPC disease management, role clarification, and professional competencies education.

“When they send you for training you will be empowered” [Nurse 2].

Finally, health professionals emphasized the importance of a supportive system that offers constructive feedback to identify weaknesses and facilitate continuous improvement of practice. In addition, health professionals remarked on the impact of managerial support on collaboration and performance.

“When we receive support from the health center manager during our practice , we find that collaboration improves , leading to better outcomes” [Pharmacist 2].

This qualitative focus group study explored facilitators of and barriers to IPC as perceived by health professionals (including GPs, nurses, pharmacists, dentists, and allied health professionals) from various backgrounds in primary healthcare in Qatar using the “Gears” conceptual model. Overall, the majority of health professionals who participated in this study have acknowledged and appreciated the importance of IPC work within their institutions, which is consistent with other published studies [ 27 , 31 , 32 ].

Facilitators under the micro-gear domain focused on healthcare teams. Participants agreed that the diversity of health professionals within the same PHCC is a major facilitator for better collaboration. They also agreed that the presence of different communication channels (e.g. telephones, CERNER, etc.) is another facilitator. Supportive leaders in the team were acknowledged to have a positive influence on attitudes toward IPC. IPE activities were identified as positively influencing attitudes towards toward IPE and IPC. These findings are consistent with those of other studies. There was an agreement among several studies regarding the importance of open communication and various communication strategies and tools in facilitating IPC [ 33 , 34 ]. For example, Müller et al. [ 33 ], in their study where authors interviewed several clinical executive managers, found that participants agreed that multilateral communication is one of the enablers for effective IPC. Facilitators within the individual-gear, includes Individual contextual factors contributing to IPC such as previous exposure to IPC, patient related factors, and characteristics of health professionals. Previous exposure to IPC emerged as a significant facilitator for both health professionals and patients. Communication skills were identified as crucial in supporting exposure to IPC. Participants highlighted the importance of accessible communication methods, such as availability by phone or in person conversations, eliminating roadblocks to IPC. Furthermore, the approachability of health professionals, characterized by their openness to information sharing and their trust and respect for the competency, knowledge, and skills of other health professionals was a key facilitator to IPC.

Regarding the meso-gear facilitators, participants valued the importance of receiving ongoing, and timely feedback based on practice experiences to consolidate learning and minimize recurrence of errors. They advocated for utilizing data from platforms such as Datix; an Incident Reporting System (IRS), which is a valuable resource among all team members involved in patient care. Participants recommend a wider use of such data for learning, in interprofessional team meetings. This aligns with evidence from the literature which suggests that critical to the success of any IRS is the quality of the feedback given to reporters to enable learning, encourage reporting, and give reporters evidence that the information they are providing is being used appropriately [ 35 , 36 ]. Space and proximity are reported as excellent opportunity for teams to work together and share perspectives in the care for the patient [ 37 ]. As new PHCC centers are created to serve the growing needs of Qatar’s population, leaders can benefit from including members of the care teams, in the final design discussions, so that space and proximity can continue to remain optimal and facilitate interprofessional practice and team centered patient care.

The least number of factors were identified under the macro-gears. These relate to governance and regulations, which were considered as a major facilitator for better IPC in the primary healthcare setting in Qatar. The participants in this study had reflected on the existing policy and regulatory facilitators that foster collaborative practice in PHC setting in Qatar, but did not discuss barriers to policies and regulations. The study findings reaffirm the potential role and influence of government policies and regulations in facilitating IPC in primary care settings from the perspective of the health professionals. Additionally, organizational-level policies were also perceived as key facilitators. This aligns with the macro-level factors of the Gears conceptual model, which allows the conceptualization of the intricate relationships between this and the other domains of the model from the perspective of the health professionals. Previous studies have documented the influence of policy and regulation in promoting collaborative practice and IPE. One international review has summarized the global policies and legal factors influencing the behaviors of health professionals towards successful implementation of collaborative practice [ 38 ]. These factors largely influence the scope of practice of various health professions and how the different professions work collaboratively, funding mechanisms, and reimbursement systems for health services.

In Qatar, health professions and practices are regulated by the Department of Healthcare Professions under the Ministry of Public Health (MoPH) [ 39 ], which is considered a key aspect of professional practice [ 38 ]. Although there are no umbrella laws to regulate multiple health professions under a single statute, which is a major drawback to an effective and conducive implementation of collaborative practice in various settings, having a unified regulatory and legal structure has been shown to foster a culture of equity among different health professionals [ 40 ]. An important aspect of policy and professional regulation is the scope of practice, which should typically clarify roles and represent specific areas of competence for each particular health profession. Participants indicated the presence of scope of practice for various professions in the State of Qatar. Previous studies and reports have highlighted the importance of restructuring the scope of practice of health professions towards effective IPC and to remove barriers to healthcare provision. This will allow health professionals to practice within the scope of their practices and to the full extent of their professional competence without encroaching other professions’ scope of practice, which will ultimately lead to effective collaborative practice [ 41 , 42 ]. In addition, funding and reimbursement are macro-level aspects that can significantly impact IPC [ 40 , 43 ]. In the present study, there was a consensus that these regulatory factors play a key role in facilitating the IPC among the health professionals in primary care settings in Qatar.

Barriers pertaining to the healthcare teams, or the micro-gear, are the lack of understanding of other professionals’ scope of practice, and the lack of time. This is not different from what is reported in the literature, where lack of time and poor understanding of other health professionals ' roles were considered, besides other barriers, major hinderers for IPC in one review paper that collected multiple articles that studied the enablers and hinderers of IPC [ 34 ]. For the individual-gear barriers, health professionals identified that the hierarchy entrenched within the healthcare system contributed a major barrier to collaboration. Within the studied context, GPs are seen as the pinnacle health professional by patients. Therefore, patients are reluctant to provide information to health professionals other than the GP. This ultimately reduces the effectiveness of the healthcare system as the scope of practice of the remainder of the interprofessional team are constrained to meet patient needs. This might limit other health professionals’ roles, and hence they might be less able to exchange care. This idea might go with the concept of the “patient-doctor dyad” that has been reported in the literature, where authors described that one of the hinderers of IPC is the patient’s desire to be mainly seen and examined by GPs, which is often prioritized over collaborative care [ 44 , 45 , 46 ]. Pharmacists, in this study, described that patients also might ignore pharmacists’ recommendations if it was not aligned with the GPs’ recommendations. While IPC may beget IPC, participants remarked that there was difficulty bringing IPC to life in their PHCC context. Knowledge of IPC must be accompanied by a shift in organizational culture, supported by policies and performance review, led by champions, and guided by exemplars of IPC.

Two subthemes were considered under the meso-factors, which are mainly regarding the information system and the organizational culture. Our results indicate that although a health information system (HIS) is operating within the primary healthcare center (PHCC) system, however, not all members of the team use nor rely on it, to complete their duties in patient care. This fragmentation of data systems poses a threat to team unity and excludes some team members (in this context the pharmacists) from being on the same page as the rest. Efforts to merge all data subunits and enable all team members to access the HIS, can enhance work time efficiency (a micro challenge) that participants reported for pharmacists to require in order to be on the same page as the other care providers in the team and is supported by research which stresses the benefits of a health information system which enables the participation of all staff who are directly concerned with patient care in that setting [ 47 , 48 ].

In the interest of optimizing patient safety, whilst participants in this study valued the opportunity for a shared HIS to serve as a platform where errors could be recorded, our data indicates that health care team members did not feel safe enough to do so. According to Smiley and colleagues [ 49 ] the fear of being fired and subjected to judicial inquiry and prosecution make many nurses conceal errors. This aligns with our participants’ reported concerns about the prevalence of “blame culture” and how this results in individuals feeling personally and professionally vulnerable. Blame culture in health care organizations is mainly associated with the approach used by management when dealing with medical errors and accidents [ 50 , 51 ]. Efforts to embrace a culture that promotes transparency and accountability, and management approach which as described by Catino [ 52 ] relates the causal factors of a given event to the whole organization rather than the individual, are priorities for the PHCC organizational leadership to consider.

Furthermore, hierarchy in privileges, such as varied levels of access to professional development opportunities, threatens team unity, and in turn generates a sense where some professions feel less valued for working in their roles. Educators postulate that if individuals from different professions learn together, they will be able to more effectively work together in teams to achieve desired outcomes [ 53 ]. Integrating CPD in interprofessional decision support with quality improvement and patient safety initiatives will likely enhance the uptake and ability to sustain these educational initiatives [ 54 ]. For instance, the “Schwartz Center Rounds” in the US and UK provide a forum in which professional and nonprofessional staff across healthcare disciplines can discuss challenging psychosocial and emotional aspects of a patient’s care and the impact of these challenges on the care team. These rounds do not focus solely on decision-making, but attendees report significantly enhanced appreciation of colleagues’ roles and contributions, communication, and teamwork [ 55 ]. In this way, the professional learning needs can meet not only the individual profession, but also translate into opportunities for teams to problem solve together and in turn improve safer patient care.

In general, the current study results on facilitators and barriers to IPC align well with those identified by a review study by [ 34 ] that summarized the facilitators and barriers for interprofessional care in primary healthcare. Common facilitators in both studies are the lack of time and training for the health professionals, lack of understanding of others’ roles, and poor communication. It is interesting to note that fears relating to professional identity were identified as a hinderer in the review; however, it was not mentioned by any HCP in the current study. This could be due to the proper understanding of the self-role of the HCP in this study. IPC enablers identified by the review were all reported in this study (i.e. communication tools, co-location of HCP, and recognition of other professionals’ roles and contributions).

Strengths and limitations

One strength of this study is the use of the “Gears model” to understand facilitators and barriers at each level within the IPCTs. Identifying the facilitators and barriers at each level of the work environment makes it easier for decision-makers to identify the gaps and the points that need improvement specific for each level, and hence will help implement appropriate, and probably more efficient, interventions suitable for each level to improve IPC within the PHCC settings. The current study included a high diversity of health professionals and did not focus on certain professions, which aligns with what interprofessional work is all about. This study, as mentioned before, is a continuation of a previous quantitative study done on more than 1400 health professionals to assess their attitude toward IPC. Although the previous study showed that health professionals have a positive attitude toward IPC, which was evident by the survey, the current study examined these quantitative findings from a qualitative lens. This provided a clearer insight to ensure a comprehensive understanding of what shapes these perspectives.

Limitations of the study might include the lack of anonymity in focus groups, which might increase the social desirability. Second, although the study included multiple professions, most participants were GPs, pharmacists, or nurses. Moreover, some HCP were not present (e.g. pharmacy technicians, and physiotherapists), which could limit the generalizability of the current study to these professions.

The interplay between the meso, macro, micro, and individual gears showcases the importance of a multifaceted approach to interventions to amplify the successes of IPC. Policies such as data sharing and collaborative key performance indicators support the interaction between the meso and individual gears. The individual assists the macro and meso gears through communication and trust in the scope of practice of the other team members. Simultaneously, health professionals must advocate for their colleagues to patients. Patients have a direct connection to the micro and individual gears which ultimately affect the care being provided to them.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

Thanks to Dr. Jessie Johnson from the University of Calgary-Qatar for her initial support with this project. Also, we would like to thank all health professionals from primary health care who volunteered to participate in this study.

This publication was supported by Qatar University Student Grant [QUST-1-CPH-2020-25]/ [QUST-2-CPH-2019-3]. The findings achieved herein are solely the responsibility of the author[s].

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AE contributed to the conception of this research idea, study design, data collection, data analysis, and including supporting all stages of this paper. AME, KJ, AAZ, RS accompanied AE in the focus groups. AME, KJ, AAZ, RS, AA, DR, NA, SM supported with the study design, study conceptualization, analysis, and interpretation of findings. OY supported with the data validation, analysis, and interpretation of findings. All authors contributed to drafting the manuscript and reviewed and approved the final version of the manuscript.

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El-Awaisi, A., Yakti, O.H., Elboshra, A.M. et al. Facilitators and barriers to interprofessional collaboration among health professionals in primary healthcare centers in Qatar: a qualitative exploration using the “Gears” model. BMC Prim. Care 25 , 316 (2024). https://doi.org/10.1186/s12875-024-02537-8

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Synthesising quantitative and qualitative evidence to inform guidelines on complex interventions: clarifying the purposes, designs and outlining some methods

1 School of Social Sciences, Bangor University, Wales, UK

Andrew Booth

2 School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK

Graham Moore

3 School of Social Sciences, Cardiff University, Wales, UK

Kate Flemming

4 Department of Health Sciences, The University of York, York, UK

Özge Tunçalp

5 Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland

Elham Shakibazadeh

6 Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

Associated Data

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Guideline developers are increasingly dealing with more difficult decisions concerning whether to recommend complex interventions in complex and highly variable health systems. There is greater recognition that both quantitative and qualitative evidence can be combined in a mixed-method synthesis and that this can be helpful in understanding how complexity impacts on interventions in specific contexts. This paper aims to clarify the different purposes, review designs, questions, synthesis methods and opportunities to combine quantitative and qualitative evidence to explore the complexity of complex interventions and health systems. Three case studies of guidelines developed by WHO, which incorporated quantitative and qualitative evidence, are used to illustrate possible uses of mixed-method reviews and evidence. Additional examples of methods that can be used or may have potential for use in a guideline process are outlined. Consideration is given to the opportunities for potential integration of quantitative and qualitative evidence at different stages of the review and guideline process. Encouragement is given to guideline commissioners and developers and review authors to consider including quantitative and qualitative evidence. Recommendations are made concerning the future development of methods to better address questions in systematic reviews and guidelines that adopt a complexity perspective.

Summary box

• When combined in a mixed-method synthesis, quantitative and qualitative evidence can potentially contribute to understanding how complex interventions work and for whom, and how the complex health systems into which they are implemented respond and adapt.
• The different purposes and designs for combining quantitative and qualitative evidence in a mixed-method synthesis for a guideline process are described.
• Questions relevant to gaining an understanding of the complexity of complex interventions and the wider health systems within which they are implemented that can be addressed by mixed-method syntheses are presented.
• The practical methodological guidance in this paper is intended to help guideline producers and review authors commission and conduct mixed-method syntheses where appropriate.
• If more mixed-method syntheses are conducted, guideline developers will have greater opportunities to access this evidence to inform decision-making.

Introduction

Recognition has grown that while quantitative methods remain vital, they are usually insufficient to address complex health systems related research questions. 1 Quantitative methods rely on an ability to anticipate what must be measured in advance. Introducing change into a complex health system gives rise to emergent reactions, which cannot be fully predicted in advance. Emergent reactions can often only be understood through combining quantitative methods with a more flexible qualitative lens. 2 Adopting a more pluralist position enables a diverse range of research options to the researcher depending on the research question being investigated. 3–5 As a consequence, where a research study sits within the multitude of methods available is driven by the question being asked, rather than any particular methodological or philosophical stance. 6

Publication of guidance on designing complex intervention process evaluations and other works advocating mixed-methods approaches to intervention research have stimulated better quality evidence for synthesis. 1 7–13 Methods for synthesising qualitative 14 and mixed-method evidence have been developed or are in development. Mixed-method research and review definitions are outlined in box 1 .

Defining mixed-method research and reviews

Pluye and Hong 52 define mixed-methods research as “a research approach in which a researcher integrates (a) qualitative and quantitative research questions, (b) qualitative research methods* and quantitative research designs, (c) techniques for collecting and analyzing qualitative and quantitative evidence, and (d) qualitative findings and quantitative results”.A mixed-method synthesis can integrate quantitative, qualitative and mixed-method evidence or data from primary studies.† Mixed-method primary studies are usually disaggregated into quantitative and qualitative evidence and data for the purposes of synthesis. Thomas and Harden further define three ways in which reviews are mixed. 53

• The types of studies included and hence the type of findings to be synthesised (ie, qualitative/textual and quantitative/numerical).
• The types of synthesis method used (eg, statistical meta-analysis and qualitative synthesis).
• The mode of analysis: theory testing AND theory building.

*A qualitative study is one that uses qualitative methods of data collection and analysis to produce a narrative understanding of the phenomena of interest. Qualitative methods of data collection may include, for example, interviews, focus groups, observations and analysis of documents.

†The Cochrane Qualitative and Implementation Methods group coined the term ‘qualitative evidence synthesis’ to mean that the synthesis could also include qualitative data. For example, qualitative data from case studies, grey literature reports and open-ended questions from surveys. ‘Evidence’ and ‘data’ are used interchangeably in this paper.

This paper is one of a series that aims to explore the implications of complexity for systematic reviews and guideline development, commissioned by WHO. This paper is concerned with the methodological implications of including quantitative and qualitative evidence in mixed-method systematic reviews and guideline development for complex interventions. The guidance was developed through a process of bringing together experts in the field, literature searching and consensus building with end users (guideline developers, clinicians and reviewers). We clarify the different purposes, review designs, questions and synthesis methods that may be applicable to combine quantitative and qualitative evidence to explore the complexity of complex interventions and health systems. Three case studies of WHO guidelines that incorporated quantitative and qualitative evidence are used to illustrate possible uses of mixed-method reviews and mechanisms of integration ( table 1 , online supplementary files 1–3 ). Additional examples of methods that can be used or may have potential for use in a guideline process are outlined. Opportunities for potential integration of quantitative and qualitative evidence at different stages of the review and guideline process are presented. Specific considerations when using an evidence to decision framework such as the Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence (DECIDE) framework 15 or the new WHO-INTEGRATE evidence to decision framework 16 at the review design and evidence to decision stage are outlined. See online supplementary file 4 for an example of a health systems DECIDE framework and Rehfuess et al 16 for the new WHO-INTEGRATE framework. Encouragement is given to guideline commissioners and developers and review authors to consider including quantitative and qualitative evidence in guidelines of complex interventions that take a complexity perspective and health systems focus.

Designs and methods and their use or applicability in guidelines and systematic reviews taking a complexity perspective

Supplementary data

Taking a complexity perspective.

The first paper in this series 17 outlines aspects of complexity associated with complex interventions and health systems that can potentially be explored by different types of evidence, including synthesis of quantitative and qualitative evidence. Petticrew et al 17 distinguish between a complex interventions perspective and a complex systems perspective. A complex interventions perspective defines interventions as having “implicit conceptual boundaries, representing a flexible, but common set of practices, often linked by an explicit or implicit theory about how they work”. A complex systems perspective differs in that “ complexity arises from the relationships and interactions between a system’s agents (eg, people, or groups that interact with each other and their environment), and its context. A system perspective conceives the intervention as being part of the system, and emphasises changes and interconnections within the system itself”. Aspects of complexity associated with implementation of complex interventions in health systems that could potentially be addressed with a synthesis of quantitative and qualitative evidence are summarised in table 2 . Another paper in the series outlines criteria used in a new evidence to decision framework for making decisions about complex interventions implemented in complex systems, against which the need for quantitative and qualitative evidence can be mapped. 16 A further paper 18 that explores how context is dealt with in guidelines and reviews taking a complexity perspective also recommends using both quantitative and qualitative evidence to better understand context as a source of complexity. Mixed-method syntheses of quantitative and qualitative evidence can also help with understanding of whether there has been theory failure and or implementation failure. The Cochrane Qualitative and Implementation Methods Group provide additional guidance on exploring implementation and theory failure that can be adapted to address aspects of complexity of complex interventions when implemented in health systems. 19

Health-system complexity-related questions that a synthesis of quantitative and qualitative evidence could address (derived from Petticrew et al 17 )

It may not be apparent which aspects of complexity or which elements of the complex intervention or health system can be explored in a guideline process, or whether combining qualitative and quantitative evidence in a mixed-method synthesis will be useful, until the available evidence is scoped and mapped. 17 20 A more extensive lead in phase is typically required to scope the available evidence, engage with stakeholders and to refine the review parameters and questions that can then be mapped against potential review designs and methods of synthesis. 20 At the scoping stage, it is also common to decide on a theoretical perspective 21 or undertake further work to refine a theoretical perspective. 22 This is also the stage to begin articulating the programme theory of the complex intervention that may be further developed to refine an understanding of complexity and show how the intervention is implemented in and impacts on the wider health system. 17 23 24 In practice, this process can be lengthy, iterative and fluid with multiple revisions to the review scope, often developing and adapting a logic model 17 as the available evidence becomes known and the potential to incorporate different types of review designs and syntheses of quantitative and qualitative evidence becomes better understood. 25 Further questions, propositions or hypotheses may emerge as the reviews progress and therefore the protocols generally need to be developed iteratively over time rather than a priori.

Following a scoping exercise and definition of key questions, the next step in the guideline development process is to identify existing or commission new systematic reviews to locate and summarise the best available evidence in relation to each question. For example, case study 2, ‘Optimising health worker roles for maternal and newborn health through task shifting’, included quantitative reviews that did and did not take an additional complexity perspective, and qualitative evidence syntheses that were able to explain how specific elements of complexity impacted on intervention outcomes within the wider health system. Further understanding of health system complexity was facilitated through the conduct of additional country-level case studies that contributed to an overall understanding of what worked and what happened when lay health worker interventions were implemented. See table 1 online supplementary file 2 .

There are a few existing examples, which we draw on in this paper, but integrating quantitative and qualitative evidence in a mixed-method synthesis is relatively uncommon in a guideline process. Box 2 includes a set of key questions that guideline developers and review authors contemplating combining quantitative and qualitative evidence in mixed-methods design might ask. Subsequent sections provide more information and signposting to further reading to help address these key questions.

Key questions that guideline developers and review authors contemplating combining quantitative and qualitative evidence in a mixed-methods design might ask

Compound questions requiring both quantitative and qualitative evidence?

Questions requiring mixed-methods studies?

Separate quantitative and qualitative questions?

Separate quantitative and qualitative research studies?

Related quantitative and qualitative research studies?

Mixed-methods studies?

Quantitative unpublished data and/or qualitative unpublished data, eg, narrative survey data?

Throughout the review?

Following separate reviews?

At the question point?

At the synthesis point?

At the evidence to recommendations stage?

Or a combination?

Narrative synthesis or summary?

Quantitising approach, eg, frequency analysis?

Qualitising approach, eg, thematic synthesis?

Tabulation?

Logic model?

Conceptual model/framework?

Graphical approach?

• WHICH: Which mixed-method designs, methodologies and methods best fit into a guideline process to inform recommendations?

Complexity-related questions that a synthesis of quantitative and qualitative evidence can potentially address

Petticrew et al 17 define the different aspects of complexity and examples of complexity-related questions that can potentially be explored in guidelines and systematic reviews taking a complexity perspective. Relevant aspects of complexity outlined by Petticrew et al 17 are summarised in table 2 below, together with the corresponding questions that could be addressed in a synthesis combining qualitative and quantitative evidence. Importantly, the aspects of complexity and their associated concepts of interest have however yet to be translated fully in primary health research or systematic reviews. There are few known examples where selected complexity concepts have been used to analyse or reanalyse a primary intervention study. Most notable is Chandler et al 26 who specifically set out to identify and translate a set of relevant complexity theory concepts for application in health systems research. Chandler then reanalysed a trial process evaluation using selected complexity theory concepts to better understand the complex causal pathway in the health system that explains some aspects of complexity in table 2 .

Rehfeuss et al 16 also recommends upfront consideration of the WHO-INTEGRATE evidence to decision criteria when planning a guideline and formulating questions. The criteria reflect WHO norms and values and take account of a complexity perspective. The framework can be used by guideline development groups as a menu to decide which criteria to prioritise, and which study types and synthesis methods can be used to collect evidence for each criterion. Many of the criteria and their related questions can be addressed using a synthesis of quantitative and qualitative evidence: the balance of benefits and harms, human rights and sociocultural acceptability, health equity, societal implications and feasibility (see table 3 ). Similar aspects in the DECIDE framework 15 could also be addressed using synthesis of qualitative and quantitative evidence.

Integrate evidence to decision framework criteria, example questions and types of studies to potentially address these questions (derived from Rehfeuss et al 16 )

GIS, Geographical Information System; RCT, randomised controlled trial.

Questions as anchors or compasses

Questions can serve as an ‘anchor’ by articulating the specific aspects of complexity to be explored (eg, Is successful implementation of the intervention context dependent?). 27 Anchor questions such as “How does intervention x impact on socioeconomic inequalities in health behaviour/outcome x” are the kind of health system question that requires a synthesis of both quantitative and qualitative evidence and hence a mixed-method synthesis. Quantitative evidence can quantify the difference in effect, but does not answer the question of how . The ‘how’ question can be partly answered with quantitative and qualitative evidence. For example, quantitative evidence may reveal where socioeconomic status and inequality emerges in the health system (an emergent property) by exploring questions such as “ Does patterning emerge during uptake because fewer people from certain groups come into contact with an intervention in the first place? ” or “ are people from certain backgrounds more likely to drop out, or to maintain effects beyond an intervention differently? ” Qualitative evidence may help understand the reasons behind all of these mechanisms. Alternatively, questions can act as ‘compasses’ where a question sets out a starting point from which to explore further and to potentially ask further questions or develop propositions or hypotheses to explore through a complexity perspective (eg, What factors enhance or hinder implementation?). 27 Other papers in this series provide further guidance on developing questions for qualitative evidence syntheses and guidance on question formulation. 14 28

For anchor and compass questions, additional application of a theory (eg, complexity theory) can help focus evidence synthesis and presentation to explore and explain complexity issues. 17 21 Development of a review specific logic model(s) can help to further refine an initial understanding of any complexity-related issues of interest associated with a specific intervention, and if appropriate the health system or section of the health system within which to contextualise the review question and analyse data. 17 23–25 Specific tools are available to help clarify context and complex interventions. 17 18

If a complexity perspective, and certain criteria within evidence to decision frameworks, is deemed relevant and desirable by guideline developers, it is only possible to pursue a complexity perspective if the evidence is available. Careful scoping using knowledge maps or scoping reviews will help inform development of questions that are answerable with available evidence. 20 If evidence of effect is not available, then a different approach to develop questions leading to a more general narrative understanding of what happened when complex interventions were implemented in a health system will be required (such as in case study 3—risk communication guideline). This should not mean that the original questions developed for which no evidence was found when scoping the literature were not important. An important function of creating a knowledge map is also to identify gaps to inform a future research agenda.

Table 2 and online supplementary files 1–3 outline examples of questions in the three case studies, which were all ‘COMPASS’ questions for the qualitative evidence syntheses.

Types of integration and synthesis designs in mixed-method reviews

The shift towards integration of qualitative and quantitative evidence in primary research has, in recent years, begun to be mirrored within research synthesis. 29–31 The natural extension to undertaking quantitative or qualitative reviews has been the development of methods for integrating qualitative and quantitative evidence within reviews, and within the guideline process using evidence to decision-frameworks. Advocating the integration of quantitative and qualitative evidence assumes a complementarity between research methodologies, and a need for both types of evidence to inform policy and practice. Below, we briefly outline the current designs for integrating qualitative and quantitative evidence within a mixed-method review or synthesis.

One of the early approaches to integrating qualitative and quantitative evidence detailed by Sandelowski et al 32 advocated three basic review designs: segregated, integrated and contingent designs, which have been further developed by Heyvaert et al 33 ( box 3 ).

Segregated, integrated and contingent designs 32 33

Segregated design.

Conventional separate distinction between quantitative and qualitative approaches based on the assumption they are different entities and should be treated separately; can be distinguished from each other; their findings warrant separate analyses and syntheses. Ultimately, the separate synthesis results can themselves be synthesised.

Integrated design

The methodological differences between qualitative and quantitative studies are minimised as both are viewed as producing findings that can be readily synthesised into one another because they address the same research purposed and questions. Transformation involves either turning qualitative data into quantitative (quantitising) or quantitative findings are turned into qualitative (qualitising) to facilitate their integration.

Contingent design

Takes a cyclical approach to synthesis, with the findings from one synthesis informing the focus of the next synthesis, until all the research objectives have been addressed. Studies are not necessarily grouped and categorised as qualitative or quantitative.

A recent review of more than 400 systematic reviews 34 combining quantitative and qualitative evidence identified two main synthesis designs—convergent and sequential. In a convergent design, qualitative and quantitative evidence is collated and analysed in a parallel or complementary manner, whereas in a sequential synthesis, the collation and analysis of quantitative and qualitative evidence takes place in a sequence with one synthesis informing the other ( box 4 ). 6 These designs can be seen to build on the work of Sandelowski et al , 32 35 particularly in relation to the transformation of data from qualitative to quantitative (and vice versa) and the sequential synthesis design, with a cyclical approach to reviewing that evokes Sandelowski’s contingent design.

Convergent and sequential synthesis designs 34

Convergent synthesis design.

Qualitative and quantitative research is collected and analysed at the same time in a parallel or complementary manner. Integration can occur at three points:

a. Data-based convergent synthesis design

All included studies are analysed using the same methods and results presented together. As only one synthesis method is used, data transformation occurs (qualitised or quantised). Usually addressed one review question.

b. Results-based convergent synthesis design

Qualitative and quantitative data are analysed and presented separately but integrated using a further synthesis method; eg, narratively, tables, matrices or reanalysing evidence. The results of both syntheses are combined in a third synthesis. Usually addresses an overall review question with subquestions.

c. Parallel-results convergent synthesis design

Qualitative and quantitative data are analysed and presented separately with integration occurring in the interpretation of results in the discussion section. Usually addresses two or more complimentary review questions.

Sequential synthesis design

A two-phase approach, data collection and analysis of one type of evidence (eg, qualitative), occurs after and is informed by the collection and analysis of the other type (eg, quantitative). Usually addresses an overall question with subquestions with both syntheses complementing each other.

The three case studies ( table 1 , online supplementary files 1–3 ) illustrate the diverse combination of review designs and synthesis methods that were considered the most appropriate for specific guidelines.

Methods for conducting mixed-method reviews in the context of guidelines for complex interventions

In this section, we draw on examples where specific review designs and methods have been or can be used to explore selected aspects of complexity in guidelines or systematic reviews. We also identify other review methods that could potentially be used to explore aspects of complexity. Of particular note, we could not find any specific examples of systematic methods to synthesise highly diverse research designs as advocated by Petticrew et al 17 and summarised in tables 2 and 3 . For example, we could not find examples of methods to synthesise qualitative studies, case studies, quantitative longitudinal data, possibly historical data, effectiveness studies providing evidence of differential effects across different contexts, and system modelling studies (eg, agent-based modelling) to explore system adaptivity.

There are different ways that quantitative and qualitative evidence can be integrated into a review and then into a guideline development process. In practice, some methods enable integration of different types of evidence in a single synthesis, while in other methods, the single systematic review may include a series of stand-alone reviews or syntheses that are then combined in a cross-study synthesis. Table 1 provides an overview of the characteristics of different review designs and methods and guidance on their applicability for a guideline process. Designs and methods that have already been used in WHO guideline development are described in part A of the table. Part B outlines a design and method that can be used in a guideline process, and part C covers those that have the potential to integrate quantitative, qualitative and mixed-method evidence in a single review design (such as meta-narrative reviews and Bayesian syntheses), but their application in a guideline context has yet to be demonstrated.

Points of integration when integrating quantitative and qualitative evidence in guideline development

Depending on the review design (see boxes 3 and 4 ), integration can potentially take place at a review team and design level, and more commonly at several key points of the review or guideline process. The following sections outline potential points of integration and associated practical considerations when integrating quantitative and qualitative evidence in guideline development.

Review team level

In a guideline process, it is common for syntheses of quantitative and qualitative evidence to be done separately by different teams and then to integrate the evidence. A practical consideration relates to the organisation, composition and expertise of the review teams and ways of working. If the quantitative and qualitative reviews are being conducted separately and then brought together by the same team members, who are equally comfortable operating within both paradigms, then a consistent approach across both paradigms becomes possible. If, however, a team is being split between the quantitative and qualitative reviews, then the strengths of specialisation can be harnessed, for example, in quality assessment or synthesis. Optimally, at least one, if not more, of the team members should be involved in both quantitative and qualitative reviews to offer the possibility of making connexions throughout the review and not simply at re-agreed junctures. This mirrors O’Cathain’s conclusion that mixed-methods primary research tends to work only when there is a principal investigator who values and is able to oversee integration. 9 10 While the above decisions have been articulated in the context of two types of evidence, variously quantitative and qualitative, they equally apply when considering how to handle studies reporting a mixed-method study design, where data are usually disaggregated into quantitative and qualitative for the purposes of synthesis (see case study 3—risk communication in humanitarian disasters).

Question formulation

Clearly specified key question(s), derived from a scoping or consultation exercise, will make it clear if quantitative and qualitative evidence is required in a guideline development process and which aspects will be addressed by which types of evidence. For the remaining stages of the process, as documented below, a review team faces challenges as to whether to handle each type of evidence separately, regardless of whether sequentially or in parallel, with a view to joining the two products on completion or to attempt integration throughout the review process. In each case, the underlying choice is of efficiencies and potential comparability vs sensitivity to the underlying paradigm.

Once key questions are clearly defined, the guideline development group typically needs to consider whether to conduct a single sensitive search to address all potential subtopics (lumping) or whether to conduct specific searches for each subtopic (splitting). 36 A related consideration is whether to search separately for qualitative, quantitative and mixed-method evidence ‘streams’ or whether to conduct a single search and then identify specific study types at the subsequent sifting stage. These two considerations often mean a trade-off between a single search process involving very large numbers of records or a more protracted search process retrieving smaller numbers of records. Both approaches have advantages and choice may depend on the respective availability of resources for searching and sifting.

Screening and selecting studies

Closely related to decisions around searching are considerations relating to screening and selecting studies for inclusion in a systematic review. An important consideration here is whether the review team will screen records for all review types, regardless of their subsequent involvement (‘altruistic sifting’), or specialise in screening for the study type with which they are most familiar. The risk of missing relevant reports might be minimised by whole team screening for empirical reports in the first instance and then coding them for a specific quantitative, qualitative or mixed-methods report at a subsequent stage.

Assessment of methodological limitations in primary studies

Within a guideline process, review teams may be more limited in their choice of instruments to assess methodological limitations of primary studies as there are mandatory requirements to use the Cochrane risk of bias tool 37 to feed into Grading of Recommendations Assessment, Development and Evaluation (GRADE) 38 or to select from a small pool of qualitative appraisal instruments in order to apply GRADE; Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) 39 to assess the overall certainty or confidence in findings. The Cochrane Qualitative and Implementation Methods Group has recently issued guidance on the selection of appraisal instruments and core assessment criteria. 40 The Mixed-Methods Appraisal Tool, which is currently undergoing further development, offers a single quality assessment instrument for quantitative, qualitative and mixed-methods studies. 41 Other options include using corresponding instruments from within the same ‘stable’, for example, using different Critical Appraisal Skills Programme instruments. 42 While using instruments developed by the same team or organisation may achieve a degree of epistemological consonance, benefits may come more from consistency of approach and reporting rather than from a shared view of quality. Alternatively, a more paradigm-sensitive approach would involve selecting the best instrument for each respective review while deferring challenges from later heterogeneity of reporting.

Data extraction

The way in which data and evidence are extracted from primary research studies for review will be influenced by the type of integrated synthesis being undertaken and the review purpose. Initially, decisions need to be made regarding the nature and type of data and evidence that are to be extracted from the included studies. Method-specific reporting guidelines 43 44 provide a good template as to what quantitative and qualitative data it is potentially possible to extract from different types of method-specific study reports, although in practice reporting quality varies. Online supplementary file 5 provides a hypothetical example of the different types of studies from which quantitative and qualitative evidence could potentially be extracted for synthesis.

The decisions around what data or evidence to extract will be guided by how ‘integrated’ the mixed-method review will be. For those reviews where the quantitative and qualitative findings of studies are synthesised separately and integrated at the point of findings (eg, segregated or contingent approaches or sequential synthesis design), separate data extraction approaches will likely be used.

Where integration occurs during the process of the review (eg, integrated approach or convergent synthesis design), an integrated approach to data extraction may be considered, depending on the purpose of the review. This may involve the use of a data extraction framework, the choice of which needs to be congruent with the approach to synthesis chosen for the review. 40 45 The integrative or theoretical framework may be decided on a priori if a pre-developed theoretical or conceptual framework is available in the literature. 27 The development of a framework may alternatively arise from the reading of the included studies, in relation to the purpose of the review, early in the process. The Cochrane Qualitative and Implementation Methods Group provide further guidance on extraction of qualitative data, including use of software. 40

Synthesis and integration

Relatively few synthesis methods start off being integrated from the beginning, and these methods have generally been subject to less testing and evaluation particularly in a guideline context (see table 1 ). A review design that started off being integrated from the beginning may be suitable for some guideline contexts (such as in case study 3—risk communication in humanitarian disasters—where there was little evidence of effect), but in general if there are sufficient trials then a separate systematic review and meta-analysis will be required for a guideline. Other papers in this series offer guidance on methods for synthesising quantitative 46 and qualitative evidence 14 in reviews that take a complexity perspective. Further guidance on integrating quantitative and qualitative evidence in a systematic review is provided by the Cochrane Qualitative and Implementation Methods Group. 19 27 29 40 47

Types of findings produced by specific methods

It is highly likely (unless there are well-designed process evaluations) that the primary studies may not themselves seek to address the complexity-related questions required for a guideline process. In which case, review authors will need to configure the available evidence and transform the evidence through the synthesis process to produce explanations, propositions and hypotheses (ie, findings) that were not obvious at primary study level. It is important that guideline commissioners, developers and review authors are aware that specific methods are intended to produce a type of finding with a specific purpose (such as developing new theory in the case of meta-ethnography). 48 Case study 1 (antenatal care guideline) provides an example of how a meta-ethnography was used to develop a new theory as an end product, 48 49 as well as framework synthesis which produced descriptive and explanatory findings that were more easily incorporated into the guideline process. 27 The definitions ( box 5 ) may be helpful when defining the different types of findings.

Different levels of findings

Descriptive findings —qualitative evidence-driven translated descriptive themes that do not move beyond the primary studies.

Explanatory findings —may either be at a descriptive or theoretical level. At the descriptive level, qualitative evidence is used to explain phenomena observed in quantitative results, such as why implementation failed in specific circumstances. At the theoretical level, the transformed and interpreted findings that go beyond the primary studies can be used to explain the descriptive findings. The latter description is generally the accepted definition in the wider qualitative community.

Hypothetical or theoretical finding —qualitative evidence-driven transformed themes (or lines of argument) that go beyond the primary studies. Although similar, Thomas and Harden 56 make a distinction in the purposes between two types of theoretical findings: analytical themes and the product of meta-ethnographies, third-order interpretations. 48

Analytical themes are a product of interrogating descriptive themes by placing the synthesis within an external theoretical framework (such as the review question and subquestions) and are considered more appropriate when a specific review question is being addressed (eg, in a guideline or to inform policy). 56

Third-order interpretations come from translating studies into one another while preserving the original context and are more appropriate when a body of literature is being explored in and of itself with broader or emergent review questions. 48

Bringing mixed-method evidence together in evidence to decision (EtD) frameworks

A critical element of guideline development is the formulation of recommendations by the Guideline Development Group, and EtD frameworks help to facilitate this process. 16 The EtD framework can also be used as a mechanism to integrate and display quantitative and qualitative evidence and findings mapped against the EtD framework domains with hyperlinks to more detailed evidence summaries from contributing reviews (see table 1 ). It is commonly the EtD framework that enables the findings of the separate quantitative and qualitative reviews to be brought together in a guideline process. Specific challenges when populating the DECIDE evidence to decision framework 15 were noted in case study 3 (risk communication in humanitarian disasters) as there was an absence of intervention effect data and the interventions to communicate public health risks were context specific and varied. These problems would not, however, have been addressed by substitution of the DECIDE framework with the new INTEGRATE 16 evidence to decision framework. A d ifferent type of EtD framework needs to be developed for reviews that do not include sufficient evidence of intervention effect.

Mixed-method review and synthesis methods are generally the least developed of all systematic review methods. It is acknowledged that methods for combining quantitative and qualitative evidence are generally poorly articulated. 29 50 There are however some fairly well-established methods for using qualitative evidence to explore aspects of complexity (such as contextual, implementation and outcome complexity), which can be combined with evidence of effect (see sections A and B of table 1 ). 14 There are good examples of systematic reviews that use these methods to combine quantitative and qualitative evidence, and examples of guideline recommendations that were informed by evidence from both quantitative and qualitative reviews (eg, case studies 1–3). With the exception of case study 3 (risk communication), the quantitative and qualitative reviews for these specific guidelines have been conducted separately, and the findings subsequently brought together in an EtD framework to inform recommendations.

Other mixed-method review designs have potential to contribute to understanding of complex interventions and to explore aspects of wider health systems complexity but have not been sufficiently developed and tested for this specific purpose, or used in a guideline process (section C of table 1 ). Some methods such as meta-narrative reviews also explore different questions to those usually asked in a guideline process. Methods for processing (eg, quality appraisal) and synthesising the highly diverse evidence suggested in tables 2 and 3 that are required to explore specific aspects of health systems complexity (such as system adaptivity) and to populate some sections of the INTEGRATE EtD framework remain underdeveloped or in need of development.

In addition to the required methodological development mentioned above, there is no GRADE approach 38 for assessing confidence in findings developed from combined quantitative and qualitative evidence. Another paper in this series outlines how to deal with complexity and grading different types of quantitative evidence, 51 and the GRADE CERQual approach for qualitative findings is described elsewhere, 39 but both these approaches are applied to method-specific and not mixed-method findings. An unofficial adaptation of GRADE was used in the risk communication guideline that reported mixed-method findings. Nor is there a reporting guideline for mixed-method reviews, 47 and for now reports will need to conform to the relevant reporting requirements of the respective method-specific guideline. There is a need to further adapt and test DECIDE, 15 WHO-INTEGRATE 16 and other types of evidence to decision frameworks to accommodate evidence from mixed-method syntheses which do not set out to determine the statistical effects of interventions and in circumstances where there are no trials.

When conducting quantitative and qualitative reviews that will subsequently be combined, there are specific considerations for managing and integrating the different types of evidence throughout the review process. We have summarised different options for combining qualitative and quantitative evidence in mixed-method syntheses that guideline developers and systematic reviewers can choose from, as well as outlining the opportunities to integrate evidence at different stages of the review and guideline development process.

Review commissioners, authors and guideline developers generally have less experience of combining qualitative and evidence in mixed-methods reviews. In particular, there is a relatively small group of reviewers who are skilled at undertaking fully integrated mixed-method reviews. Commissioning additional qualitative and mixed-method reviews creates an additional cost. Large complex mixed-method reviews generally take more time to complete. Careful consideration needs to be given as to which guidelines would benefit most from additional qualitative and mixed-method syntheses. More training is required to develop capacity and there is a need to develop processes for preparing the guideline panel to consider and use mixed-method evidence in their decision-making.

This paper has presented how qualitative and quantitative evidence, combined in mixed-method reviews, can help understand aspects of complex interventions and the systems within which they are implemented. There are further opportunities to use these methods, and to further develop the methods, to look more widely at additional aspects of complexity. There is a range of review designs and synthesis methods to choose from depending on the question being asked or the questions that may emerge during the conduct of the synthesis. Additional methods need to be developed (or existing methods further adapted) in order to synthesise the full range of diverse evidence that is desirable to explore the complexity-related questions when complex interventions are implemented into health systems. We encourage review commissioners and authors, and guideline developers to consider using mixed-methods reviews and synthesis in guidelines and to report on their usefulness in the guideline development process.

Handling editor: Soumyadeep Bhaumik

Contributors: JN, AB, GM, KF, ÖT and ES drafted the manuscript. All authors contributed to paper development and writing and agreed the final manuscript. Anayda Portela and Susan Norris from WHO managed the series. Helen Smith was series Editor. We thank all those who provided feedback on various iterations.

Funding: Funding provided by the World Health Organization Department of Maternal, Newborn, Child and Adolescent Health through grants received from the United States Agency for International Development and the Norwegian Agency for Development Cooperation.

Disclaimer: ÖT is a staff member of WHO. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of WHO.

Competing interests: No financial interests declared. JN, AB and ÖT have an intellectual interest in GRADE CERQual; and JN has an intellectual interest in the iCAT_SR tool.

Patient consent: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data sharing statement: No additional data are available.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Published: 31 August 2024

Knowledge mapping and evolution of research on older adults’ technology acceptance: a bibliometric study from 2013 to 2023

• Xianru Shang   ORCID: orcid.org/0009-0000-8906-3216 1 ,
• Zijian Liu 1 ,
• Chen Gong 1 ,
• Zhigang Hu 1 ,
• Yuexuan Wu 1 &
• Chengliang Wang   ORCID: orcid.org/0000-0003-2208-3508 2  

Humanities and Social Sciences Communications volume  11 , Article number:  1115 ( 2024 ) Cite this article

Metrics details

• Science, technology and society

The rapid expansion of information technology and the intensification of population aging are two prominent features of contemporary societal development. Investigating older adults’ acceptance and use of technology is key to facilitating their integration into an information-driven society. Given this context, the technology acceptance of older adults has emerged as a prioritized research topic, attracting widespread attention in the academic community. However, existing research remains fragmented and lacks a systematic framework. To address this gap, we employed bibliometric methods, utilizing the Web of Science Core Collection to conduct a comprehensive review of literature on older adults’ technology acceptance from 2013 to 2023. Utilizing VOSviewer and CiteSpace for data assessment and visualization, we created knowledge mappings of research on older adults’ technology acceptance. Our study employed multidimensional methods such as co-occurrence analysis, clustering, and burst analysis to: (1) reveal research dynamics, key journals, and domains in this field; (2) identify leading countries, their collaborative networks, and core research institutions and authors; (3) recognize the foundational knowledge system centered on theoretical model deepening, emerging technology applications, and research methods and evaluation, uncovering seminal literature and observing a shift from early theoretical and influential factor analyses to empirical studies focusing on individual factors and emerging technologies; (4) moreover, current research hotspots are primarily in the areas of factors influencing technology adoption, human-robot interaction experiences, mobile health management, and aging-in-place technology, highlighting the evolutionary context and quality distribution of research themes. Finally, we recommend that future research should deeply explore improvements in theoretical models, long-term usage, and user experience evaluation. Overall, this study presents a clear framework of existing research in the field of older adults’ technology acceptance, providing an important reference for future theoretical exploration and innovative applications.

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Introduction.

In contemporary society, the rapid development of information technology has been intricately intertwined with the intensifying trend of population aging. According to the latest United Nations forecast, by 2050, the global population aged 65 and above is expected to reach 1.6 billion, representing about 16% of the total global population (UN 2023 ). Given the significant challenges of global aging, there is increasing evidence that emerging technologies have significant potential to maintain health and independence for older adults in their home and healthcare environments (Barnard et al. 2013 ; Soar 2010 ; Vancea and Solé-Casals 2016 ). This includes, but is not limited to, enhancing residential safety with smart home technologies (Touqeer et al. 2021 ; Wang et al. 2022 ), improving living independence through wearable technologies (Perez et al. 2023 ), and increasing medical accessibility via telehealth services (Kruse et al. 2020 ). Technological innovations are redefining the lifestyles of older adults, encouraging a shift from passive to active participation (González et al. 2012 ; Mostaghel 2016 ). Nevertheless, the effective application and dissemination of technology still depends on user acceptance and usage intentions (Naseri et al. 2023 ; Wang et al. 2023a ; Xia et al. 2024 ; Yu et al. 2023 ). Particularly, older adults face numerous challenges in accepting and using new technologies. These challenges include not only physical and cognitive limitations but also a lack of technological experience, along with the influences of social and economic factors (Valk et al. 2018 ; Wilson et al. 2021 ).

User acceptance of technology is a significant focus within information systems (IS) research (Dai et al. 2024 ), with several models developed to explain and predict user behavior towards technology usage, including the Technology Acceptance Model (TAM) (Davis 1989 ), TAM2, TAM3, and the Unified Theory of Acceptance and Use of Technology (UTAUT) (Venkatesh et al. 2003 ). Older adults, as a group with unique needs, exhibit different behavioral patterns during technology acceptance than other user groups, and these uniquenesses include changes in cognitive abilities, as well as motivations, attitudes, and perceptions of the use of new technologies (Chen and Chan 2011 ). The continual expansion of technology introduces considerable challenges for older adults, rendering the understanding of their technology acceptance a research priority. Thus, conducting in-depth research into older adults’ acceptance of technology is critically important for enhancing their integration into the information society and improving their quality of life through technological advancements.

Reviewing relevant literature to identify research gaps helps further solidify the theoretical foundation of the research topic. However, many existing literature reviews primarily focus on the factors influencing older adults’ acceptance or intentions to use technology. For instance, Ma et al. ( 2021 ) conducted a comprehensive analysis of the determinants of older adults’ behavioral intentions to use technology; Liu et al. ( 2022 ) categorized key variables in studies of older adults’ technology acceptance, noting a shift in focus towards social and emotional factors; Yap et al. ( 2022 ) identified seven categories of antecedents affecting older adults’ use of technology from an analysis of 26 articles, including technological, psychological, social, personal, cost, behavioral, and environmental factors; Schroeder et al. ( 2023 ) extracted 119 influencing factors from 59 articles and further categorized these into six themes covering demographics, health status, and emotional awareness. Additionally, some studies focus on the application of specific technologies, such as Ferguson et al. ( 2021 ), who explored barriers and facilitators to older adults using wearable devices for heart monitoring, and He et al. ( 2022 ) and Baer et al. ( 2022 ), who each conducted in-depth investigations into the acceptance of social assistive robots and mobile nutrition and fitness apps, respectively. In summary, current literature reviews on older adults’ technology acceptance exhibit certain limitations. Due to the interdisciplinary nature and complex knowledge structure of this field, traditional literature reviews often rely on qualitative analysis, based on literature analysis and periodic summaries, which lack sufficient objectivity and comprehensiveness. Additionally, systematic research is relatively limited, lacking a macroscopic description of the research trajectory from a holistic perspective. Over the past decade, research on older adults’ technology acceptance has experienced rapid growth, with a significant increase in literature, necessitating the adoption of new methods to review and examine the developmental trends in this field (Chen 2006 ; Van Eck and Waltman 2010 ). Bibliometric analysis, as an effective quantitative research method, analyzes published literature through visualization, offering a viable approach to extracting patterns and insights from a large volume of papers, and has been widely applied in numerous scientific research fields (Achuthan et al. 2023 ; Liu and Duffy 2023 ). Therefore, this study will employ bibliometric methods to systematically analyze research articles related to older adults’ technology acceptance published in the Web of Science Core Collection from 2013 to 2023, aiming to understand the core issues and evolutionary trends in the field, and to provide valuable references for future related research. Specifically, this study aims to explore and answer the following questions:

RQ1: What are the research dynamics in the field of older adults’ technology acceptance over the past decade? What are the main academic journals and fields that publish studies related to older adults’ technology acceptance?

RQ2: How is the productivity in older adults’ technology acceptance research distributed among countries, institutions, and authors?

RQ3: What are the knowledge base and seminal literature in older adults’ technology acceptance research? How has the research theme progressed?

RQ4: What are the current hot topics and their evolutionary trajectories in older adults’ technology acceptance research? How is the quality of research distributed?

Methodology and materials

Research method.

In recent years, bibliometrics has become one of the crucial methods for analyzing literature reviews and is widely used in disciplinary and industrial intelligence analysis (Jing et al. 2023 ; Lin and Yu 2024a ; Wang et al. 2024a ; Xu et al. 2021 ). Bibliometric software facilitates the visualization analysis of extensive literature data, intuitively displaying the network relationships and evolutionary processes between knowledge units, and revealing the underlying knowledge structure and potential information (Chen et al. 2024 ; López-Robles et al. 2018 ; Wang et al. 2024c ). This method provides new insights into the current status and trends of specific research areas, along with quantitative evidence, thereby enhancing the objectivity and scientific validity of the research conclusions (Chen et al. 2023 ; Geng et al. 2024 ). VOSviewer and CiteSpace are two widely used bibliometric software tools in academia (Pan et al. 2018 ), recognized for their robust functionalities based on the JAVA platform. Although each has its unique features, combining these two software tools effectively constructs mapping relationships between literature knowledge units and clearly displays the macrostructure of the knowledge domains. Particularly, VOSviewer, with its excellent graphical representation capabilities, serves as an ideal tool for handling large datasets and precisely identifying the focal points and hotspots of research topics. Therefore, this study utilizes VOSviewer (version 1.6.19) and CiteSpace (version 6.1.R6), combined with in-depth literature analysis, to comprehensively examine and interpret the research theme of older adults’ technology acceptance through an integrated application of quantitative and qualitative methods.

Data source

Web of Science is a comprehensively recognized database in academia, featuring literature that has undergone rigorous peer review and editorial scrutiny (Lin and Yu 2024b ; Mongeon and Paul-Hus 2016 ; Pranckutė 2021 ). This study utilizes the Web of Science Core Collection as its data source, specifically including three major citation indices: Science Citation Index Expanded (SCIE), Social Sciences Citation Index (SSCI), and Arts & Humanities Citation Index (A&HCI). These indices encompass high-quality research literature in the fields of science, social sciences, and arts and humanities, ensuring the comprehensiveness and reliability of the data. We combined “older adults” with “technology acceptance” through thematic search, with the specific search strategy being: TS = (elder OR elderly OR aging OR ageing OR senile OR senior OR old people OR “older adult*”) AND TS = (“technology acceptance” OR “user acceptance” OR “consumer acceptance”). The time span of literature search is from 2013 to 2023, with the types limited to “Article” and “Review” and the language to “English”. Additionally, the search was completed by October 27, 2023, to avoid data discrepancies caused by database updates. The initial search yielded 764 journal articles. Given that searches often retrieve articles that are superficially relevant but actually non-compliant, manual screening post-search was essential to ensure the relevance of the literature (Chen et al. 2024 ). Through manual screening, articles significantly deviating from the research theme were eliminated and rigorously reviewed. Ultimately, this study obtained 500 valid sample articles from the Web of Science Core Collection. The complete PRISMA screening process is illustrated in Fig. 1 .

Presentation of the data culling process in detail.

Data standardization

Raw data exported from databases often contain multiple expressions of the same terminology (Nguyen and Hallinger 2020 ). To ensure the accuracy and consistency of data, it is necessary to standardize the raw data (Strotmann and Zhao 2012 ). This study follows the data standardization process proposed by Taskin and Al ( 2019 ), mainly executing the following operations:

(1) Standardization of author and institution names is conducted to address different name expressions for the same author. For instance, “Chan, Alan Hoi Shou” and “Chan, Alan H. S.” are considered the same author, and distinct authors with the same name are differentiated by adding identifiers. Diverse forms of institutional names are unified to address variations caused by name changes or abbreviations, such as standardizing “FRANKFURT UNIV APPL SCI” and “Frankfurt University of Applied Sciences,” as well as “Chinese University of Hong Kong” and “University of Hong Kong” to consistent names.

(2) Different expressions of journal names are unified. For example, “International Journal of Human-Computer Interaction” and “Int J Hum Comput Interact” are standardized to a single name. This ensures consistency in journal names and prevents misclassification of literature due to differing journal names. Additionally, it involves checking if the journals have undergone name changes in the past decade to prevent any impact on the analysis due to such changes.

(3) Keywords data are cleansed by removing words that do not directly pertain to specific research content (e.g., people, review), merging synonyms (e.g., “UX” and “User Experience,” “aging-in-place” and “aging in place”), and standardizing plural forms of keywords (e.g., “assistive technologies” and “assistive technology,” “social robots” and “social robot”). This reduces redundant information in knowledge mapping.

Bibliometric results and analysis

Distribution power (rq1), literature descriptive statistical analysis.

Table 1 presents a detailed descriptive statistical overview of the literature in the field of older adults’ technology acceptance. After deduplication using the CiteSpace software, this study confirmed a valid sample size of 500 articles. Authored by 1839 researchers, the documents encompass 792 research institutions across 54 countries and are published in 217 different academic journals. As of the search cutoff date, these articles have accumulated 13,829 citations, with an annual average of 1156 citations, and an average of 27.66 citations per article. The h-index, a composite metric of quantity and quality of scientific output (Kamrani et al. 2021 ), reached 60 in this study.

Trends in publications and disciplinary distribution

The number of publications and citations are significant indicators of the research field’s development, reflecting its continuity, attention, and impact (Ale Ebrahim et al. 2014 ). The ranking of annual publications and citations in the field of older adults’ technology acceptance studies is presented chronologically in Fig. 2A . The figure shows a clear upward trend in the amount of literature in this field. Between 2013 and 2017, the number of publications increased slowly and decreased in 2018. However, in 2019, the number of publications increased rapidly to 52 and reached a peak of 108 in 2022, which is 6.75 times higher than in 2013. In 2022, the frequency of document citations reached its highest point with 3466 citations, reflecting the widespread recognition and citation of research in this field. Moreover, the curve of the annual number of publications fits a quadratic function, with a goodness-of-fit R 2 of 0.9661, indicating that the number of future publications is expected to increase even more rapidly.

A Trends in trends in annual publications and citations (2013–2023). B Overlay analysis of the distribution of discipline fields.

Figure 2B shows that research on older adults’ technology acceptance involves the integration of multidisciplinary knowledge. According to Web of Science Categories, these 500 articles are distributed across 85 different disciplines. We have tabulated the top ten disciplines by publication volume (Table 2 ), which include Medical Informatics (75 articles, 15.00%), Health Care Sciences & Services (71 articles, 14.20%), Gerontology (61 articles, 12.20%), Public Environmental & Occupational Health (57 articles, 11.40%), and Geriatrics & Gerontology (52 articles, 10.40%), among others. The high output in these disciplines reflects the concentrated global academic interest in this comprehensive research topic. Additionally, interdisciplinary research approaches provide diverse perspectives and a solid theoretical foundation for studies on older adults’ technology acceptance, also paving the way for new research directions.

Knowledge flow analysis

A dual-map overlay is a CiteSpace map superimposed on top of a base map, which shows the interrelationships between journals in different domains, representing the publication and citation activities in each domain (Chen and Leydesdorff 2014 ). The overlay map reveals the link between the citing domain (on the left side) and the cited domain (on the right side), reflecting the knowledge flow of the discipline at the journal level (Leydesdorff and Rafols 2012 ). We utilize the in-built Z-score algorithm of the software to cluster the graph, as shown in Fig. 3 .

The left side shows the citing journal, and the right side shows the cited journal.

Figure 3 shows the distribution of citing journals clusters for older adults’ technology acceptance on the left side, while the right side refers to the main cited journals clusters. Two knowledge flow citation trajectories were obtained; they are presented by the color of the cited regions, and the thickness of these trajectories is proportional to the Z-score scaled frequency of citations (Chen et al. 2014 ). Within the cited regions, the most popular fields with the most records covered are “HEALTH, NURSING, MEDICINE” and “PSYCHOLOGY, EDUCATION, SOCIAL”, and the elliptical aspect ratio of these two fields stands out. Fields have prominent elliptical aspect ratios, highlighting their significant influence on older adults’ technology acceptance research. Additionally, the major citation trajectories originate in these two areas and progress to the frontier research area of “PSYCHOLOGY, EDUCATION, HEALTH”. It is worth noting that the citation trajectory from “PSYCHOLOGY, EDUCATION, SOCIAL” has a significant Z-value (z = 6.81), emphasizing the significance and impact of this development path. In the future, “MATHEMATICS, SYSTEMS, MATHEMATICAL”, “MOLECULAR, BIOLOGY, IMMUNOLOGY”, and “NEUROLOGY, SPORTS, OPHTHALMOLOGY” may become emerging fields. The fields of “MEDICINE, MEDICAL, CLINICAL” may be emerging areas of cutting-edge research.

Main research journals analysis

Table 3 provides statistics for the top ten journals by publication volume in the field of older adults’ technology acceptance. Together, these journals have published 137 articles, accounting for 27.40% of the total publications, indicating that there is no highly concentrated core group of journals in this field, with publications being relatively dispersed. Notably, Computers in Human Behavior , Journal of Medical Internet Research , and International Journal of Human-Computer Interaction each lead with 15 publications. In terms of citation metrics, International Journal of Medical Informatics and Computers in Human Behavior stand out significantly, with the former accumulating a total of 1,904 citations, averaging 211.56 citations per article, and the latter totaling 1,449 citations, with an average of 96.60 citations per article. These figures emphasize the academic authority and widespread impact of these journals within the research field.

Research power (RQ2)

Countries and collaborations analysis.

The analysis revealed the global research pattern for country distribution and collaboration (Chen et al. 2019 ). Figure 4A shows the network of national collaborations on older adults’ technology acceptance research. The size of the bubbles represents the amount of publications in each country, while the thickness of the connecting lines expresses the closeness of the collaboration among countries. Generally, this research subject has received extensive international attention, with China and the USA publishing far more than any other countries. China has established notable research collaborations with the USA, UK and Malaysia in this field, while other countries have collaborations, but the closeness is relatively low and scattered. Figure 4B shows the annual publication volume dynamics of the top ten countries in terms of total publications. Since 2017, China has consistently increased its annual publications, while the USA has remained relatively stable. In 2019, the volume of publications in each country increased significantly, this was largely due to the global outbreak of the COVID-19 pandemic, which has led to increased reliance on information technology among the elderly for medical consultations, online socialization, and health management (Sinha et al. 2021 ). This phenomenon has led to research advances in technology acceptance among older adults in various countries. Table 4 shows that the top ten countries account for 93.20% of the total cumulative number of publications, with each country having published more than 20 papers. Among these ten countries, all of them except China are developed countries, indicating that the research field of older adults’ technology acceptance has received general attention from developed countries. Currently, China and the USA were the leading countries in terms of publications with 111 and 104 respectively, accounting for 22.20% and 20.80%. The UK, Germany, Italy, and the Netherlands also made significant contributions. The USA and China ranked first and second in terms of the number of citations, while the Netherlands had the highest average citations, indicating the high impact and quality of its research. The UK has shown outstanding performance in international cooperation, while the USA highlights its significant academic influence in this field with the highest h-index value.

A National collaboration network. B Annual volume of publications in the top 10 countries.

Institutions and authors analysis

Analyzing the number of publications and citations can reveal an institution’s or author’s research strength and influence in a particular research area (Kwiek 2021 ). Tables 5 and 6 show the statistics of the institutions and authors whose publication counts are in the top ten, respectively. As shown in Table 5 , higher education institutions hold the main position in this research field. Among the top ten institutions, City University of Hong Kong and The University of Hong Kong from China lead with 14 and 9 publications, respectively. City University of Hong Kong has the highest h-index, highlighting its significant influence in the field. It is worth noting that Tilburg University in the Netherlands is not among the top five in terms of publications, but the high average citation count (130.14) of its literature demonstrates the high quality of its research.

After analyzing the authors’ output using Price’s Law (Redner 1998 ), the highest number of publications among the authors counted ( n  = 10) defines a publication threshold of 3 for core authors in this research area. As a result of quantitative screening, a total of 63 core authors were identified. Table 6 shows that Chen from Zhejiang University, China, Ziefle from RWTH Aachen University, Germany, and Rogers from Macquarie University, Australia, were the top three authors in terms of the number of publications, with 10, 9, and 8 articles, respectively. In terms of average citation rate, Peek and Wouters, both scholars from the Netherlands, have significantly higher rates than other scholars, with 183.2 and 152.67 respectively. This suggests that their research is of high quality and widely recognized. Additionally, Chen and Rogers have high h-indices in this field.

Knowledge base and theme progress (RQ3)

Research knowledge base.

Co-citation relationships occur when two documents are cited together (Zhang and Zhu 2022 ). Co-citation mapping uses references as nodes to represent the knowledge base of a subject area (Min et al. 2021). Figure 5A illustrates co-occurrence mapping in older adults’ technology acceptance research, where larger nodes signify higher co-citation frequencies. Co-citation cluster analysis can be used to explore knowledge structure and research boundaries (Hota et al. 2020 ; Shiau et al. 2023 ). The co-citation clustering mapping of older adults’ technology acceptance research literature (Fig. 5B ) shows that the Q value of the clustering result is 0.8129 (>0.3), and the average value of the weight S is 0.9391 (>0.7), indicating that the clusters are uniformly distributed with a significant and credible structure. This further proves that the boundaries of the research field are clear and there is significant differentiation in the field. The figure features 18 cluster labels, each associated with thematic color blocks corresponding to different time slices. Highlighted emerging research themes include #2 Smart Home Technology, #7 Social Live, and #10 Customer Service. Furthermore, the clustering labels extracted are primarily classified into three categories: theoretical model deepening, emerging technology applications, research methods and evaluation, as detailed in Table 7 .

A Co-citation analysis of references. B Clustering network analysis of references.

Seminal literature analysis

The top ten nodes in terms of co-citation frequency were selected for further analysis. Table 8 displays the corresponding node information. Studies were categorized into four main groups based on content analysis. (1) Research focusing on specific technology usage by older adults includes studies by Peek et al. ( 2014 ), Ma et al. ( 2016 ), Hoque and Sorwar ( 2017 ), and Li et al. ( 2019 ), who investigated the factors influencing the use of e-technology, smartphones, mHealth, and smart wearables, respectively. (2) Concerning the development of theoretical models of technology acceptance, Chen and Chan ( 2014 ) introduced the Senior Technology Acceptance Model (STAM), and Macedo ( 2017 ) analyzed the predictive power of UTAUT2 in explaining older adults’ intentional behaviors and information technology usage. (3) In exploring older adults’ information technology adoption and behavior, Lee and Coughlin ( 2015 ) emphasized that the adoption of technology by older adults is a multifactorial process that includes performance, price, value, usability, affordability, accessibility, technical support, social support, emotion, independence, experience, and confidence. Yusif et al. ( 2016 ) conducted a literature review examining the key barriers affecting older adults’ adoption of assistive technology, including factors such as privacy, trust, functionality/added value, cost, and stigma. (4) From the perspective of research into older adults’ technology acceptance, Mitzner et al. ( 2019 ) assessed the long-term usage of computer systems designed for the elderly, whereas Guner and Acarturk ( 2020 ) compared information technology usage and acceptance between older and younger adults. The breadth and prevalence of this literature make it a vital reference for researchers in the field, also providing new perspectives and inspiration for future research directions.

Research thematic progress

Burst citation is a node of literature that guides the sudden change in dosage, which usually represents a prominent development or major change in a particular field, with innovative and forward-looking qualities. By analyzing the emergent literature, it is often easy to understand the dynamics of the subject area, mapping the emerging thematic change (Chen et al. 2022 ). Figure 6 shows the burst citation mapping in the field of older adults’ technology acceptance research, with burst citations represented by red nodes (Fig. 6A ). For the ten papers with the highest burst intensity (Fig. 6B ), this study will conduct further analysis in conjunction with literature review.

A Burst detection of co-citation. B The top 10 references with the strongest citation bursts.

As shown in Fig. 6 , Mitzner et al. ( 2010 ) broke the stereotype that older adults are fearful of technology, found that they actually have positive attitudes toward technology, and emphasized the centrality of ease of use and usefulness in the process of technology acceptance. This finding provides an important foundation for subsequent research. During the same period, Wagner et al. ( 2010 ) conducted theory-deepening and applied research on technology acceptance among older adults. The research focused on older adults’ interactions with computers from the perspective of Social Cognitive Theory (SCT). This expanded the understanding of technology acceptance, particularly regarding the relationship between behavior, environment, and other SCT elements. In addition, Pan and Jordan-Marsh ( 2010 ) extended the TAM to examine the interactions among predictors of perceived usefulness, perceived ease of use, subjective norm, and convenience conditions when older adults use the Internet, taking into account the moderating roles of gender and age. Heerink et al. ( 2010 ) adapted and extended the UTAUT, constructed a technology acceptance model specifically designed for older users’ acceptance of assistive social agents, and validated it using controlled experiments and longitudinal data, explaining intention to use by combining functional assessment and social interaction variables.

Then the research theme shifted to an in-depth analysis of the factors influencing technology acceptance among older adults. Two papers with high burst strengths emerged during this period: Peek et al. ( 2014 ) (Strength = 12.04), Chen and Chan ( 2014 ) (Strength = 9.81). Through a systematic literature review and empirical study, Peek STM and Chen K, among others, identified multidimensional factors that influence older adults’ technology acceptance. Peek et al. ( 2014 ) analyzed literature on the acceptance of in-home care technology among older adults and identified six factors that influence their acceptance: concerns about technology, expected benefits, technology needs, technology alternatives, social influences, and older adult characteristics, with a focus on differences between pre- and post-implementation factors. Chen and Chan ( 2014 ) constructed the STAM by administering a questionnaire to 1012 older adults and adding eight important factors, including technology anxiety, self-efficacy, cognitive ability, and physical function, based on the TAM. This enriches the theoretical foundation of the field. In addition, Braun ( 2013 ) highlighted the role of perceived usefulness, trust in social networks, and frequency of Internet use in older adults’ use of social networks, while ease of use and social pressure were not significant influences. These findings contribute to the study of older adults’ technology acceptance within specific technology application domains.

Recent research has focused on empirical studies of personal factors and emerging technologies. Ma et al. ( 2016 ) identified key personal factors affecting smartphone acceptance among older adults through structured questionnaires and face-to-face interviews with 120 participants. The study found that cost, self-satisfaction, and convenience were important factors influencing perceived usefulness and ease of use. This study offers empirical evidence to comprehend the main factors that drive smartphone acceptance among Chinese older adults. Additionally, Yusif et al. ( 2016 ) presented an overview of the obstacles that hinder older adults’ acceptance of assistive technologies, focusing on privacy, trust, and functionality.

In summary, research on older adults’ technology acceptance has shifted from early theoretical deepening and analysis of influencing factors to empirical studies in the areas of personal factors and emerging technologies, which have greatly enriched the theoretical basis of older adults’ technology acceptance and provided practical guidance for the design of emerging technology products.

Research hotspots, evolutionary trends, and quality distribution (RQ4)

Core keywords analysis.

Keywords concise the main idea and core of the literature, and are a refined summary of the research content (Huang et al. 2021 ). In CiteSpace, nodes with a centrality value greater than 0.1 are considered to be critical nodes. Analyzing keywords with high frequency and centrality helps to visualize the hot topics in the research field (Park et al. 2018 ). The merged keywords were imported into CiteSpace, and the top 10 keywords were counted and sorted by frequency and centrality respectively, as shown in Table 9 . The results show that the keyword “TAM” has the highest frequency (92), followed by “UTAUT” (24), which reflects that the in-depth study of the existing technology acceptance model and its theoretical expansion occupy a central position in research related to older adults’ technology acceptance. Furthermore, the terms ‘assistive technology’ and ‘virtual reality’ are both high-frequency and high-centrality terms (frequency = 17, centrality = 0.10), indicating that the research on assistive technology and virtual reality for older adults is the focus of current academic attention.

Research hotspots analysis

Using VOSviewer for keyword co-occurrence analysis organizes keywords into groups or clusters based on their intrinsic connections and frequencies, clearly highlighting the research field’s hot topics. The connectivity among keywords reveals correlations between different topics. To ensure accuracy, the analysis only considered the authors’ keywords. Subsequently, the keywords were filtered by setting the keyword frequency to 5 to obtain the keyword clustering map of the research on older adults’ technology acceptance research keyword clustering mapping (Fig. 7 ), combined with the keyword co-occurrence clustering network (Fig. 7A ) and the corresponding density situation (Fig. 7B ) to make a detailed analysis of the following four groups of clustered themes.

A Co-occurrence clustering network. B Keyword density.

Cluster #1—Research on the factors influencing technology adoption among older adults is a prominent topic, covering age, gender, self-efficacy, attitude, and and intention to use (Berkowsky et al. 2017 ; Wang et al. 2017 ). It also examined older adults’ attitudes towards and acceptance of digital health technologies (Ahmad and Mozelius, 2022 ). Moreover, the COVID-19 pandemic, significantly impacting older adults’ technology attitudes and usage, has underscored the study’s importance and urgency. Therefore, it is crucial to conduct in-depth studies on how older adults accept, adopt, and effectively use new technologies, to address their needs and help them overcome the digital divide within digital inclusion. This will improve their quality of life and healthcare experiences.

Cluster #2—Research focuses on how older adults interact with assistive technologies, especially assistive robots and health monitoring devices, emphasizing trust, usability, and user experience as crucial factors (Halim et al. 2022 ). Moreover, health monitoring technologies effectively track and manage health issues common in older adults, like dementia and mild cognitive impairment (Lussier et al. 2018 ; Piau et al. 2019 ). Interactive exercise games and virtual reality have been deployed to encourage more physical and cognitive engagement among older adults (Campo-Prieto et al. 2021 ). Personalized and innovative technology significantly enhances older adults’ participation, improving their health and well-being.

Cluster #3—Optimizing health management for older adults using mobile technology. With the development of mobile health (mHealth) and health information technology, mobile applications, smartphones, and smart wearable devices have become effective tools to help older users better manage chronic conditions, conduct real-time health monitoring, and even receive telehealth services (Dupuis and Tsotsos 2018 ; Olmedo-Aguirre et al. 2022 ; Kim et al. 2014 ). Additionally, these technologies can mitigate the problem of healthcare resource inequality, especially in developing countries. Older adults’ acceptance and use of these technologies are significantly influenced by their behavioral intentions, motivational factors, and self-management skills. These internal motivational factors, along with external factors, jointly affect older adults’ performance in health management and quality of life.

Cluster #4—Research on technology-assisted home care for older adults is gaining popularity. Environmentally assisted living enhances older adults’ independence and comfort at home, offering essential support and security. This has a crucial impact on promoting healthy aging (Friesen et al. 2016 ; Wahlroos et al. 2023 ). The smart home is a core application in this field, providing a range of solutions that facilitate independent living for the elderly in a highly integrated and user-friendly manner. This fulfills different dimensions of living and health needs (Majumder et al. 2017 ). Moreover, eHealth offers accurate and personalized health management and healthcare services for older adults (Delmastro et al. 2018 ), ensuring their needs are met at home. Research in this field often employs qualitative methods and structural equation modeling to fully understand older adults’ needs and experiences at home and analyze factors influencing technology adoption.

Evolutionary trends analysis

To gain a deeper understanding of the evolutionary trends in research hotspots within the field of older adults’ technology acceptance, we conducted a statistical analysis of the average appearance times of keywords, using CiteSpace to generate the time-zone evolution mapping (Fig. 8 ) and burst keywords. The time-zone mapping visually displays the evolution of keywords over time, intuitively reflecting the frequency and initial appearance of keywords in research, commonly used to identify trends in research topics (Jing et al. 2024a ; Kumar et al. 2021 ). Table 10 lists the top 15 keywords by burst strength, with the red sections indicating high-frequency citations and their burst strength in specific years. These burst keywords reveal the focus and trends of research themes over different periods (Kleinberg 2002 ). Combining insights from the time-zone mapping and burst keywords provides more objective and accurate research insights (Wang et al. 2023b ).

Reflecting the frequency and time of first appearance of keywords in the study.

An integrated analysis of Fig. 8 and Table 10 shows that early research on older adults’ technology acceptance primarily focused on factors such as perceived usefulness, ease of use, and attitudes towards information technology, including their use of computers and the internet (Pan and Jordan-Marsh 2010 ), as well as differences in technology use between older adults and other age groups (Guner and Acarturk 2020 ). Subsequently, the research focus expanded to improving the quality of life for older adults, exploring how technology can optimize health management and enhance the possibility of independent living, emphasizing the significant role of technology in improving the quality of life for the elderly. With ongoing technological advancements, recent research has shifted towards areas such as “virtual reality,” “telehealth,” and “human-robot interaction,” with a focus on the user experience of older adults (Halim et al. 2022 ). The appearance of keywords such as “physical activity” and “exercise” highlights the value of technology in promoting physical activity and health among older adults. This phase of research tends to make cutting-edge technology genuinely serve the practical needs of older adults, achieving its widespread application in daily life. Additionally, research has focused on expanding and quantifying theoretical models of older adults’ technology acceptance, involving keywords such as “perceived risk”, “validation” and “UTAUT”.

In summary, from 2013 to 2023, the field of older adults’ technology acceptance has evolved from initial explorations of influencing factors, to comprehensive enhancements in quality of life and health management, and further to the application and deepening of theoretical models and cutting-edge technologies. This research not only reflects the diversity and complexity of the field but also demonstrates a comprehensive and in-depth understanding of older adults’ interactions with technology across various life scenarios and needs.

Research quality distribution

To reveal the distribution of research quality in the field of older adults’ technology acceptance, a strategic diagram analysis is employed to calculate and illustrate the internal development and interrelationships among various research themes (Xie et al. 2020 ). The strategic diagram uses Centrality as the X-axis and Density as the Y-axis to divide into four quadrants, where the X-axis represents the strength of the connection between thematic clusters and other themes, with higher values indicating a central position in the research field; the Y-axis indicates the level of development within the thematic clusters, with higher values denoting a more mature and widely recognized field (Li and Zhou 2020 ).

Through cluster analysis and manual verification, this study categorized 61 core keywords (Frequency ≥5) into 11 thematic clusters. Subsequently, based on the keywords covered by each thematic cluster, the research themes and their directions for each cluster were summarized (Table 11 ), and the centrality and density coordinates for each cluster were precisely calculated (Table 12 ). Finally, a strategic diagram of the older adults’ technology acceptance research field was constructed (Fig. 9 ). Based on the distribution of thematic clusters across the quadrants in the strategic diagram, the structure and developmental trends of the field were interpreted.

Classification and visualization of theme clusters based on density and centrality.

As illustrated in Fig. 9 , (1) the theme clusters of #3 Usage Experience and #4 Assisted Living Technology are in the first quadrant, characterized by high centrality and density. Their internal cohesion and close links with other themes indicate their mature development, systematic research content or directions have been formed, and they have a significant influence on other themes. These themes play a central role in the field of older adults’ technology acceptance and have promising prospects. (2) The theme clusters of #6 Smart Devices, #9 Theoretical Models, and #10 Mobile Health Applications are in the second quadrant, with higher density but lower centrality. These themes have strong internal connections but weaker external links, indicating that these three themes have received widespread attention from researchers and have been the subject of related research, but more as self-contained systems and exhibit independence. Therefore, future research should further explore in-depth cooperation and cross-application with other themes. (3) The theme clusters of #7 Human-Robot Interaction, #8 Characteristics of the Elderly, and #11 Research Methods are in the third quadrant, with lower centrality and density. These themes are loosely connected internally and have weak links with others, indicating their developmental immaturity. Compared to other topics, they belong to the lower attention edge and niche themes, and there is a need for further investigation. (4) The theme clusters of #1 Digital Healthcare Technology, #2 Psychological Factors, and #5 Socio-Cultural Factors are located in the fourth quadrant, with high centrality but low density. Although closely associated with other research themes, the internal cohesion within these clusters is relatively weak. This suggests that while these themes are closely linked to other research areas, their own development remains underdeveloped, indicating a core immaturity. Nevertheless, these themes are crucial within the research domain of elderly technology acceptance and possess significant potential for future exploration.

Discussion on distribution power (RQ1)

Over the past decade, academic interest and influence in the area of older adults’ technology acceptance have significantly increased. This trend is evidenced by a quantitative analysis of publication and citation volumes, particularly noticeable in 2019 and 2022, where there was a substantial rise in both metrics. The rise is closely linked to the widespread adoption of emerging technologies such as smart homes, wearable devices, and telemedicine among older adults. While these technologies have enhanced their quality of life, they also pose numerous challenges, sparking extensive research into their acceptance, usage behaviors, and influencing factors among the older adults (Pirzada et al. 2022 ; Garcia Reyes et al. 2023 ). Furthermore, the COVID-19 pandemic led to a surge in technology demand among older adults, especially in areas like medical consultation, online socialization, and health management, further highlighting the importance and challenges of technology. Health risks and social isolation have compelled older adults to rely on technology for daily activities, accelerating its adoption and application within this demographic. This phenomenon has made technology acceptance a critical issue, driving societal and academic focus on the study of technology acceptance among older adults.

The flow of knowledge at the level of high-output disciplines and journals, along with the primary publishing outlets, indicates the highly interdisciplinary nature of research into older adults’ technology acceptance. This reflects the complexity and breadth of issues related to older adults’ technology acceptance, necessitating the integration of multidisciplinary knowledge and approaches. Currently, research is primarily focused on medical health and human-computer interaction, demonstrating academic interest in improving health and quality of life for older adults and addressing the urgent needs related to their interactions with technology. In the field of medical health, research aims to provide advanced and innovative healthcare technologies and services to meet the challenges of an aging population while improving the quality of life for older adults (Abdi et al. 2020 ; Wilson et al. 2021 ). In the field of human-computer interaction, research is focused on developing smarter and more user-friendly interaction models to meet the needs of older adults in the digital age, enabling them to actively participate in social activities and enjoy a higher quality of life (Sayago, 2019 ). These studies are crucial for addressing the challenges faced by aging societies, providing increased support and opportunities for the health, welfare, and social participation of older adults.

Discussion on research power (RQ2)

This study analyzes leading countries and collaboration networks, core institutions and authors, revealing the global research landscape and distribution of research strength in the field of older adults’ technology acceptance, and presents quantitative data on global research trends. From the analysis of country distribution and collaborations, China and the USA hold dominant positions in this field, with developed countries like the UK, Germany, Italy, and the Netherlands also excelling in international cooperation and research influence. The significant investment in technological research and the focus on the technological needs of older adults by many developed countries reflect their rapidly aging societies, policy support, and resource allocation.

China is the only developing country that has become a major contributor in this field, indicating its growing research capabilities and high priority given to aging societies and technological innovation. Additionally, China has close collaborations with countries such as USA, the UK, and Malaysia, driven not only by technological research needs but also by shared challenges and complementarities in aging issues among these nations. For instance, the UK has extensive experience in social welfare and aging research, providing valuable theoretical guidance and practical experience. International collaborations, aimed at addressing the challenges of aging, integrate the strengths of various countries, advancing in-depth and widespread development in the research of technology acceptance among older adults.

At the institutional and author level, City University of Hong Kong leads in publication volume, with research teams led by Chan and Chen demonstrating significant academic activity and contributions. Their research primarily focuses on older adults’ acceptance and usage behaviors of various technologies, including smartphones, smart wearables, and social robots (Chen et al. 2015 ; Li et al. 2019 ; Ma et al. 2016 ). These studies, targeting specific needs and product characteristics of older adults, have developed new models of technology acceptance based on existing frameworks, enhancing the integration of these technologies into their daily lives and laying a foundation for further advancements in the field. Although Tilburg University has a smaller publication output, it holds significant influence in the field of older adults’ technology acceptance. Particularly, the high citation rate of Peek’s studies highlights their excellence in research. Peek extensively explored older adults’ acceptance and usage of home care technologies, revealing the complexity and dynamics of their technology use behaviors. His research spans from identifying systemic influencing factors (Peek et al. 2014 ; Peek et al. 2016 ), emphasizing familial impacts (Luijkx et al. 2015 ), to constructing comprehensive models (Peek et al. 2017 ), and examining the dynamics of long-term usage (Peek et al. 2019 ), fully reflecting the evolving technology landscape and the changing needs of older adults. Additionally, the ongoing contributions of researchers like Ziefle, Rogers, and Wouters in the field of older adults’ technology acceptance demonstrate their research influence and leadership. These researchers have significantly enriched the knowledge base in this area with their diverse perspectives. For instance, Ziefle has uncovered the complex attitudes of older adults towards technology usage, especially the trade-offs between privacy and security, and how different types of activities affect their privacy needs (Maidhof et al. 2023 ; Mujirishvili et al. 2023 ; Schomakers and Ziefle 2023 ; Wilkowska et al. 2022 ), reflecting a deep exploration and ongoing innovation in the field of older adults’ technology acceptance.

Discussion on knowledge base and thematic progress (RQ3)

Through co-citation analysis and systematic review of seminal literature, this study reveals the knowledge foundation and thematic progress in the field of older adults’ technology acceptance. Co-citation networks and cluster analyses illustrate the structural themes of the research, delineating the differentiation and boundaries within this field. Additionally, burst detection analysis offers a valuable perspective for understanding the thematic evolution in the field of technology acceptance among older adults. The development and innovation of theoretical models are foundational to this research. Researchers enhance the explanatory power of constructed models by deepening and expanding existing technology acceptance theories to address theoretical limitations. For instance, Heerink et al. ( 2010 ) modified and expanded the UTAUT model by integrating functional assessment and social interaction variables to create the almere model. This model significantly enhances the ability to explain the intentions of older users in utilizing assistive social agents and improves the explanation of actual usage behaviors. Additionally, Chen and Chan ( 2014 ) extended the TAM to include age-related health and capability features of older adults, creating the STAM, which substantially improves predictions of older adults’ technology usage behaviors. Personal attributes, health and capability features, and facilitating conditions have a direct impact on technology acceptance. These factors more effectively predict older adults’ technology usage behaviors than traditional attitudinal factors.

With the advancement of technology and the application of emerging technologies, new research topics have emerged, increasingly focusing on older adults’ acceptance and use of these technologies. Prior to this, the study by Mitzner et al. ( 2010 ) challenged the stereotype of older adults’ conservative attitudes towards technology, highlighting the central roles of usability and usefulness in the technology acceptance process. This discovery laid an important foundation for subsequent research. Research fields such as “smart home technology,” “social life,” and “customer service” are emerging, indicating a shift in focus towards the practical and social applications of technology in older adults’ lives. Research not only focuses on the technology itself but also on how these technologies integrate into older adults’ daily lives and how they can improve the quality of life through technology. For instance, studies such as those by Ma et al. ( 2016 ), Hoque and Sorwar ( 2017 ), and Li et al. ( 2019 ) have explored factors influencing older adults’ use of smartphones, mHealth, and smart wearable devices.

Furthermore, the diversification of research methodologies and innovation in evaluation techniques, such as the use of mixed methods, structural equation modeling (SEM), and neural network (NN) approaches, have enhanced the rigor and reliability of the findings, enabling more precise identification of the factors and mechanisms influencing technology acceptance. Talukder et al. ( 2020 ) employed an effective multimethodological strategy by integrating SEM and NN to leverage the complementary strengths of both approaches, thus overcoming their individual limitations and more accurately analyzing and predicting older adults’ acceptance of wearable health technologies (WHT). SEM is utilized to assess the determinants’ impact on the adoption of WHT, while neural network models validate SEM outcomes and predict the significance of key determinants. This combined approach not only boosts the models’ reliability and explanatory power but also provides a nuanced understanding of the motivations and barriers behind older adults’ acceptance of WHT, offering deep research insights.

Overall, co-citation analysis of the literature in the field of older adults’ technology acceptance has uncovered deeper theoretical modeling and empirical studies on emerging technologies, while emphasizing the importance of research methodological and evaluation innovations in understanding complex social science issues. These findings are crucial for guiding the design and marketing strategies of future technology products, especially in the rapidly growing market of older adults.

Discussion on research hotspots and evolutionary trends (RQ4)

By analyzing core keywords, we can gain deep insights into the hot topics, evolutionary trends, and quality distribution of research in the field of older adults’ technology acceptance. The frequent occurrence of the keywords “TAM” and “UTAUT” indicates that the applicability and theoretical extension of existing technology acceptance models among older adults remain a focal point in academia. This phenomenon underscores the enduring influence of the studies by Davis ( 1989 ) and Venkatesh et al. ( 2003 ), whose models provide a robust theoretical framework for explaining and predicting older adults’ acceptance and usage of emerging technologies. With the widespread application of artificial intelligence (AI) and big data technologies, these theoretical models have incorporated new variables such as perceived risk, trust, and privacy issues (Amin et al. 2024 ; Chen et al. 2024 ; Jing et al. 2024b ; Seibert et al. 2021 ; Wang et al. 2024b ), advancing the theoretical depth and empirical research in this field.

Keyword co-occurrence cluster analysis has revealed multiple research hotspots in the field, including factors influencing technology adoption, interactive experiences between older adults and assistive technologies, the application of mobile health technology in health management, and technology-assisted home care. These studies primarily focus on enhancing the quality of life and health management of older adults through emerging technologies, particularly in the areas of ambient assisted living, smart health monitoring, and intelligent medical care. In these domains, the role of AI technology is increasingly significant (Qian et al. 2021 ; Ho 2020 ). With the evolution of next-generation information technologies, AI is increasingly integrated into elder care systems, offering intelligent, efficient, and personalized service solutions by analyzing the lifestyles and health conditions of older adults. This integration aims to enhance older adults’ quality of life in aspects such as health monitoring and alerts, rehabilitation assistance, daily health management, and emotional support (Lee et al. 2023 ). A survey indicates that 83% of older adults prefer AI-driven solutions when selecting smart products, demonstrating the increasing acceptance of AI in elder care (Zhao and Li 2024 ). Integrating AI into elder care presents both opportunities and challenges, particularly in terms of user acceptance, trust, and long-term usage effects, which warrant further exploration (Mhlanga 2023 ). These studies will help better understand the profound impact of AI technology on the lifestyles of older adults and provide critical references for optimizing AI-driven elder care services.

The Time-zone evolution mapping and burst keyword analysis further reveal the evolutionary trends of research hotspots. Early studies focused on basic technology acceptance models and user perceptions, later expanding to include quality of life and health management. In recent years, research has increasingly focused on cutting-edge technologies such as virtual reality, telehealth, and human-robot interaction, with a concurrent emphasis on the user experience of older adults. This evolutionary process demonstrates a deepening shift from theoretical models to practical applications, underscoring the significant role of technology in enhancing the quality of life for older adults. Furthermore, the strategic coordinate mapping analysis clearly demonstrates the development and mutual influence of different research themes. High centrality and density in the themes of Usage Experience and Assisted Living Technology indicate their mature research status and significant impact on other themes. The themes of Smart Devices, Theoretical Models, and Mobile Health Applications demonstrate self-contained research trends. The themes of Human-Robot Interaction, Characteristics of the Elderly, and Research Methods are not yet mature, but they hold potential for development. Themes of Digital Healthcare Technology, Psychological Factors, and Socio-Cultural Factors are closely related to other themes, displaying core immaturity but significant potential.

In summary, the research hotspots in the field of older adults’ technology acceptance are diverse and dynamic, demonstrating the academic community’s profound understanding of how older adults interact with technology across various life contexts and needs. Under the influence of AI and big data, research should continue to focus on the application of emerging technologies among older adults, exploring in depth how they adapt to and effectively use these technologies. This not only enhances the quality of life and healthcare experiences for older adults but also drives ongoing innovation and development in this field.

Research agenda

Based on the above research findings, to further understand and promote technology acceptance and usage among older adults, we recommend future studies focus on refining theoretical models, exploring long-term usage, and assessing user experience in the following detailed aspects:

Refinement and validation of specific technology acceptance models for older adults: Future research should focus on developing and validating technology acceptance models based on individual characteristics, particularly considering variations in technology acceptance among older adults across different educational levels and cultural backgrounds. This includes factors such as age, gender, educational background, and cultural differences. Additionally, research should examine how well specific technologies, such as wearable devices and mobile health applications, meet the needs of older adults. Building on existing theoretical models, this research should integrate insights from multiple disciplines such as psychology, sociology, design, and engineering through interdisciplinary collaboration to create more accurate and comprehensive models, which should then be validated in relevant contexts.

Deepening the exploration of the relationship between long-term technology use and quality of life among older adults: The acceptance and use of technology by users is a complex and dynamic process (Seuwou et al. 2016 ). Existing research predominantly focuses on older adults’ initial acceptance or short-term use of new technologies; however, the impact of long-term use on their quality of life and health is more significant. Future research should focus on the evolution of older adults’ experiences and needs during long-term technology usage, and the enduring effects of technology on their social interactions, mental health, and life satisfaction. Through longitudinal studies and qualitative analysis, this research reveals the specific needs and challenges of older adults in long-term technology use, providing a basis for developing technologies and strategies that better meet their requirements. This understanding aids in comprehensively assessing the impact of technology on older adults’ quality of life and guiding the optimization and improvement of technological products.

Evaluating the Importance of User Experience in Research on Older Adults’ Technology Acceptance: Understanding the mechanisms of information technology acceptance and use is central to human-computer interaction research. Although technology acceptance models and user experience models differ in objectives, they share many potential intersections. Technology acceptance research focuses on structured prediction and assessment, while user experience research concentrates on interpreting design impacts and new frameworks. Integrating user experience to assess older adults’ acceptance of technology products and systems is crucial (Codfrey et al. 2022 ; Wang et al. 2019 ), particularly for older users, where specific product designs should emphasize practicality and usability (Fisk et al. 2020 ). Researchers need to explore innovative age-appropriate design methods to enhance older adults’ usage experience. This includes studying older users’ actual usage preferences and behaviors, optimizing user interfaces, and interaction designs. Integrating feedback from older adults to tailor products to their needs can further promote their acceptance and continued use of technology products.

Conclusions

This study conducted a systematic review of the literature on older adults’ technology acceptance over the past decade through bibliometric analysis, focusing on the distribution power, research power, knowledge base and theme progress, research hotspots, evolutionary trends, and quality distribution. Using a combination of quantitative and qualitative methods, this study has reached the following conclusions:

Technology acceptance among older adults has become a hot topic in the international academic community, involving the integration of knowledge across multiple disciplines, including Medical Informatics, Health Care Sciences Services, and Ergonomics. In terms of journals, “PSYCHOLOGY, EDUCATION, HEALTH” represents a leading field, with key publications including Computers in Human Behavior , Journal of Medical Internet Research , and International Journal of Human-Computer Interaction . These journals possess significant academic authority and extensive influence in the field.

Research on technology acceptance among older adults is particularly active in developed countries, with China and USA publishing significantly more than other nations. The Netherlands leads in high average citation rates, indicating the depth and impact of its research. Meanwhile, the UK stands out in terms of international collaboration. At the institutional level, City University of Hong Kong and The University of Hong Kong in China are in leading positions. Tilburg University in the Netherlands demonstrates exceptional research quality through its high average citation count. At the author level, Chen from China has the highest number of publications, while Peek from the Netherlands has the highest average citation count.

Co-citation analysis of references indicates that the knowledge base in this field is divided into three main categories: theoretical model deepening, emerging technology applications, and research methods and evaluation. Seminal literature focuses on four areas: specific technology use by older adults, expansion of theoretical models of technology acceptance, information technology adoption behavior, and research perspectives. Research themes have evolved from initial theoretical deepening and analysis of influencing factors to empirical studies on individual factors and emerging technologies.

Keyword analysis indicates that TAM and UTAUT are the most frequently occurring terms, while “assistive technology” and “virtual reality” are focal points with high frequency and centrality. Keyword clustering analysis reveals that research hotspots are concentrated on the influencing factors of technology adoption, human-robot interaction experiences, mobile health management, and technology for aging in place. Time-zone evolution mapping and burst keyword analysis have revealed the research evolution from preliminary exploration of influencing factors, to enhancements in quality of life and health management, and onto advanced technology applications and deepening of theoretical models. Furthermore, analysis of research quality distribution indicates that Usage Experience and Assisted Living Technology have become core topics, while Smart Devices, Theoretical Models, and Mobile Health Applications point towards future research directions.

Through this study, we have systematically reviewed the dynamics, core issues, and evolutionary trends in the field of older adults’ technology acceptance, constructing a comprehensive Knowledge Mapping of the domain and presenting a clear framework of existing research. This not only lays the foundation for subsequent theoretical discussions and innovative applications in the field but also provides an important reference for relevant scholars.

Limitations

To our knowledge, this is the first bibliometric analysis concerning technology acceptance among older adults, and we adhered strictly to bibliometric standards throughout our research. However, this study relies on the Web of Science Core Collection, and while its authority and breadth are widely recognized, this choice may have missed relevant literature published in other significant databases such as PubMed, Scopus, and Google Scholar, potentially overlooking some critical academic contributions. Moreover, given that our analysis was confined to literature in English, it may not reflect studies published in other languages, somewhat limiting the global representativeness of our data sample.

It is noteworthy that with the rapid development of AI technology, its increasingly widespread application in elderly care services is significantly transforming traditional care models. AI is profoundly altering the lifestyles of the elderly, from health monitoring and smart diagnostics to intelligent home systems and personalized care, significantly enhancing their quality of life and health care standards. The potential for AI technology within the elderly population is immense, and research in this area is rapidly expanding. However, due to the restrictive nature of the search terms used in this study, it did not fully cover research in this critical area, particularly in addressing key issues such as trust, privacy, and ethics.

Consequently, future research should not only expand data sources, incorporating multilingual and multidatabase literature, but also particularly focus on exploring older adults’ acceptance of AI technology and its applications, in order to construct a more comprehensive academic landscape of older adults’ technology acceptance, thereby enriching and extending the knowledge system and academic trends in this field.

Data availability

The datasets analyzed during the current study are available in the Dataverse repository: https://doi.org/10.7910/DVN/6K0GJH .

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Acknowledgements

This research was supported by the Social Science Foundation of Shaanxi Province in China (Grant No. 2023J014).

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Xianru Shang, Zijian Liu, Chen Gong, Zhigang Hu & Yuexuan Wu

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Conceptualization, XS, YW, CW; methodology, XS, ZL, CG, CW; software, XS, CG, YW; writing-original draft preparation, XS, CW; writing-review and editing, XS, CG, ZH, CW; supervision, ZL, ZH, CW; project administration, ZL, ZH, CW; funding acquisition, XS, CG. All authors read and approved the final manuscript. All authors have read and approved the re-submission of the manuscript.

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Shang, X., Liu, Z., Gong, C. et al. Knowledge mapping and evolution of research on older adults’ technology acceptance: a bibliometric study from 2013 to 2023. Humanit Soc Sci Commun 11 , 1115 (2024). https://doi.org/10.1057/s41599-024-03658-2

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DOI : https://doi.org/10.1057/s41599-024-03658-2

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