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Qualitative Research

The “what,” “why,” “who,” and “how”.

Cypress, Brigitte S. EdD, RN, CCRN

Brigitte S. Cypress, EdD, RN, CCRN, is assistant professor at Lehman College and The Graduate Center, City University of New York.

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Address correspondence and reprint requests to: Brigitte S. Cypress, EdD, RN, CCRN, PO Box 2205, Pocono Summit, PA 18346 ( [email protected] ).

There has been a general view of qualitative research as a lower level form of inquiry and the diverse conceptualizations of what it is, its use or utility, its users, the process of how it is conducted, and its scientific merit. This fragmented understanding and varied ways in which qualitative research is conceived, synthesized, and presented have a myriad of implications in demonstrating and enhancing the utilization of its findings and the ways and skills required in transforming knowledge gained from it. The purpose of this article is to define qualitative research and discuss its significance in research, the questions it addresses, its characteristics, methods and criteria for rigor, and the type of results it can offer. A framework for understanding the “what,” “why,” “who,” and “how” of qualitative research; the different approaches; and the strategies to achieve trustworthiness are presented. Qualitative research provides insights into health-related phenomena and seeks to understand and interpret subjective experience and thus humanizes health care and can enrich further research inquiries and be made clearer and more rigorous as it is relevant to the perspective and goals of nursing.

Qualitative research methods began to appear in nursing in 1960s and 1970s amid cautious and reluctant acceptance. In the 1980s, qualitative health research emerged as a distinctive domain and mode of inquiry. 1 Qualitative research refers to any kind of research that produces findings not arrived at by means of statistical analysis or other means of quantification. 2,3 It uses a naturalistic approach that seeks to understand phenomena about persons’ lives, stories, and behavior including those related to health, organizational functioning, social movements, or interactional relationships. Qualitative research is underpinned by several theoretical perspectives, namely, constructivist-interpretive, critical, postpositivist, poststructural/postmodern, and feminism. 4 One conducts a qualitative study to uncover the nature of the person’s experiences with a phenomenon in context-specific conditions such as illness (acute and chronic), addiction, loss, disability, and end of life. Qualitative research is used to explore, uncover, describe, and understand what lies behind any phenomenon about which maybe little is known. This deeper understanding of the phenomenon in its specific context can be attained only through a qualitative inquiry than mere numbers and statistical models could provide using a quantitative approach. Qualitative inquiry represents a legitimate mode of social and human science exploration, without apology or comparisons to quantitative research. 5

This article describes what is qualitative research methodology, the “what,” “why,” “who,” and “how,” including its components. The aim is to simplify the terminology and process of qualitative inquiry to enable novice readers of research to better understand the concepts involved.

WHY DO QUALITATIVE RESEARCH?

The tradition of using qualitative methods to study human phenomena is grounded in the social sciences. 6 This methodological revolution has made way for a more interpretative approach because aspects of human values, culture, and relationships are not described fully using quantitative research methods. Unlike quantitative researchers who seek causal determination, prediction, and generalization of findings, qualitative researchers allow for the phenomenon of interest to unfold naturally, 7 strive to explore, describe and understand it, and delve into a colorful, deep, contextual world of interpretations. 8 Thus, the practice of qualitative research has expanded to clinical settings because empirical approaches have proven to be inadequate in answering questions related to human subjectivity where interpretation is involved. 9 Consequently, qualitative health research is a research approach to exploring health and illness as they are perceived by the people themselves rather than from the researcher’s perspective. 10 Morse 10 further stated that “Researchers use qualitative research methods to illicit emotions and perspectives, beliefs and values, actions, and behaviors and to understand the participant’s responses to health and illness and the meanings they construct about the experience.” 10 (p21) It provides a rich inductive description that necessitates interpretations. Researchers in the health care arena, practitioners, and policy makers are increasingly pressed to translate these findings for practice, put them to use, and evaluate how useful they actually are in effecting desired change with goal of improving public health and reducing disparities in health care delivery. 1 Even though qualitative research has been used for many decades, and it is in fact flourishing, it is not free of criticisms from experts with impoverished view of the methodology.

Despite the current urgency of the utilization of qualitative methodologies in research studies, questions are raised for its lack of objectivity, generalizability, utility, and its tendency to be anecdotal. 1 Critics continue to make these charges related to their limited understanding of qualitative designs, approaches, and methods. Sandelowski 1 asserted that the current urgency about the utility of qualitative research findings is the result of several converging trends in health care research that include the elevation of practical over basic knowledge as the highest form of knowledge, the proliferation of qualitative health research studies, and the rise of evidence-based practice as a paradigm and methodology for health care. 1 Consequently, these events have, in turn, contributed to the growing interest of incorporating qualitative health research findings into evidence-based practice.

Morse 10 asserted that there are other reasons for conducting a qualitative inquiry. Others believe that the role of qualitative inquiry is to provide hypothesis and research questions that can be posed from the findings of qualitative research studies. Qualitative research can also serve as a foundation from which surveys and questionnaires could be developed, thus increasing its validity that would produce models for quantitative testing. But, what is really the most important function of qualitative inquiry? According to Morse, 10 this key function is the moral imperative of qualitative inquiry to humanize health care. She stated, “The social justice agenda of qualitative health research is one that humanizes health care.” 10 (p52) So, what is humanizing health care? Morse 10 stated, “Humanizing encompasses a perspective on attitudes, beliefs, expectations, practices, and behaviors that influence the quality of care, administration of that care, conditions judged to warrant (or not warrant) empathetic care, responses to care and therapeutics, and anticipated and actual outcomes of patient or community care.” 10 (pp54,55)

Conducting research should be sort of a social justice project. 10 Denzin 11 recognizes making social justice a public agenda within qualitative inquiry. He emphasized that qualitative inquiry can contribute to social justice through ( a ) identifying different definitions of a problem and/or situation that is being evaluated with some agreement that change is required; ( b ) the assumptions that are held by policy makers, clients, welfare workers, online professionals, and other interested parties can be located and shown to be correct or incorrect; ( c ) strategic points of interventions can be identified and thus evaluated and improved; ( d ) suggest alternative moral points of view from which the problem, the policy, and the program can be interpreted and assessed; and ( e ) the limits of statistics and statistical evaluations can be exposed with the more qualitative materials furnished by this approach. 11

WHO DOES QUALITATIVE RESEARCH?

Qualitative research is done by researchers in the social sciences as well as by practitioners in fields that concern themselves with issues related to human behavior and functioning. 3 They are also health professionals who are able to identify a research question and able to recognize the particular context and situation that would achieve the best answers. 10 According to Morse, 10 the qualitative health researcher should be an expert methodologist who should have the understanding of illness, the patient’s condition, and the staff roles and relationships and able to balance the clinical situation from different perspectives. 10 (p23) A qualitative researcher also requires theoretical and social sensibility, interactional skills, and the ability to maintain analytical distance while drawing upon past experience and theoretical knowledge to interpret what is seen or observed. 3

WHAT ARE THE CHARACTERISTICS OF QUALITATIVE RESEARCH?

Creswell 12 discussed that qualitative research studies today involve closer attention to the interpretive nature of inquiry and situating the study within the political, social, and cultural context of the researchers, participants, and readers of the study. He presented several characteristics of qualitative research, which are ( a ) natural setting: data are collected face-to-face in the field at the site where participants experience the phenomenon under study; the inquiry should be conducted in a way that does not disturb the natural context of the phenomenon; ( b ) researcher as key instrument: the researchers collect the data themselves rather than relying on instruments developed by others; ( c ) multiple sources of data: researchers gather multiple forms of data including interviews, observations, and examining documents rather than rely on a single source; ( d ) inductive data analysis: data are organized into abstract units of information (“bottom-up” or moving from specific to general), working back and forth between the themes and the database until a comprehensive set of themes is established and ending up with general conclusions or theories; ( e ) participant’s meanings: the researchers keep a focus on learning the meaning that the participants hold about the phenomenon, not the meaning that the researchers bring to the study; ( f ) emergent design: the initial plan for the study cannot be tightly prescribed; rather, it is emergent, and all phases of the process may change or shift after the researchers enter the field and begin to collect the data; ( g ) theoretical lens: use of a “lens” to view the study such as the concept of culture, gender, race or class differences, and social, political, or historical context of the problem under study; ( h ) interpretive inquiry: a form of inquiry in which researchers make interpretation of what they see, hear, and understand that cannot be separated from their own background, history, context, and prior understanding; ( i ) holistic account: reporting multiple perspectives, identifying the many factors involved in a situation, and sketching the larger picture that emerges. 12

WHAT ARE THE METHODS FREQUENTLY USED IN QUALITATIVE RESEARCH?

The research question dictates the method to be used for a qualitative study. Qualitative and quantitative questions are distinct and serve different purposes. 10 Some of the different types of qualitative research that will be discussed in this article are phenomenology, grounded theory, ethnography, case study, and narrative research. Researchers from different disciplines use these approaches depending on what the purpose of the study is.

Narrative research begins with the experiences as expressed in lived and told stories of individuals. Narrative is a spoken word or written text giving an account of an event/action chronologically connected. Some examples of this approach are biographical studies, autobiographies, and life stories. Kvangarsnes et al 13 explored the patient perceptions of chronic obstructive pulmonary disease exacerbation and their experiences of their relations with health personnel during care and treatment using narrative research design. Ten in-depth qualitative interviews were conducted with patients who had been admitted to 2 intensive care units (ICUs) in Western Norway during the autumn of 2009 and the spring of 2010. Narrative analysis and theories on trust and power were used to analyze the interviews. The patients perceived that they were completely dependent on others during the acute phase. Some stated that they had experienced an altered perception of reality and had not understood how serious their situation was. Although the patients trusted the health personnel in helping them breathe, they also told stories about care deficiencies and situations in which they felt neglected. This study shows that patients with an acute exacerbation of chronic obstructive pulmonary disease often feel wholly dependent on health personnel during the exacerbation and, as a result, experience extreme vulnerability.

Whereas a narrative approach explores the life of a single person, a phenomenological study describes the meaning for several individuals of their lived experiences of a phenomenon. 12 Phenomenology is the most inductive of all qualitative methods. 10 The philosophical assumptions of phenomenology rest on some common grounds: the study of the lived experiences of persons, the view that these experiences are conscious ones and the development of descriptions of the essences of these experiences, not explanations or analysis. 12 There are different types of phenomenological approaches, namely, descriptive-transcendental (Husserl, Giorgi), interpretive/hermeneutic (Heidegger, Gadamer, Jen-Luc Nancy), descriptive-hermeneutic (van Manen), empirical-transcendental (Moustakas), and existential (Sarte, Heidegger, Merleau-Ponty). A phenomenological study conducted by Cypress 14 explored the lived experiences of nurses, patients, and family members during critical illness in the emergency department (ED). Data were collected over a 6-month period by means of in-depth interviews, and thematic analysis was done using van Manen’s 15 hermeneutic-phenomenological approach. The findings of this qualitative phenomenological study indicate that the patient’s and family member’s perception of the nurses in the ED relates to their critical thinking skills, communication, sensitivity, and caring abilities. Nurses of this study identified that response to the patient’s physiological deficit is paramount in the ED, and involving the patients and families in the human care processes will help attain this goal.

While phenomenology aims to illuminate themes and describe the meaning of lived experiences of a number of individuals, grounded theory has the intent to move beyond description and to generate or discover a theory, an abstract analytical schema of a process, or interaction shaped by the views of a large number of participants. 12 This qualitative method was developed by Glaser and Strauss 16 in 1967. Other grounded theorists followed, including Clarke, 17 who relies on postmodern perspectives, and Charmaz, 18 on constructivist approach. Gallagher et al 19 collected and analyzed qualitative data using grounded theory to understand nurses’ end-of-life (EOL) decision-making practices in 5 ICUs in different cultural contexts. Interviews were conducted with 51 experienced ICU nurses in university or hospital premises in 5 countries. The comparative analysis of the data within and across data generated by the different research teams enabled researchers to develop a deeper understanding of EOL decision-making practices in the ICU. The core category that emerged was “negotiated reorienting.” Gallagher et al 19 stated, “Whilst nurses do not make the ‘ultimate’ EOL decisions, they engage in 2 core practices: consensus seeking (involving coaxing, information cuing and voice enabling) and emotional holding (creating time-space and comfort giving).” 19 (p794)

Although a grounded theory approach examines a number of individuals to develop a theory, participants are not studied as 1 unit. Ethnography uses a larger number of individuals and focuses on an entire cultural group as 1 unit of analysis. This qualitative approach describes and interprets the shared and learned patters of values, behaviors, beliefs, and language of a cultural-sharing group. 12 There are many forms of ethnography, namely, confessional, life history, autoethnography, feminist, ethnographic novels, visual ethnography found in photography and video, and electronic media. Price 20 explored what aspects affect registered health care professionals’ ability to care for patients within the technological environment of a critical care unit. Ethnography was utilized to focus on the cultural elements within a situation. Data collection involved participant observation, document review, and semistructured interviews. Nineteen participants took part in the study. An overarching theme of the “crafting process” was developed with subthemes of “vigilance,” “focus of attention,” “being present,” and “expectations,” with the ultimate goal of achieving the best interests for the individual patient.

A culture-sharing group in ethnography can be considered a case, but its aim is to ascertain how the culture works rather than understanding 1 or more specific cases within a bounded system. Creswell 12 defines case study research as an approach in which the researcher explores a bounded system (a case) or multiple bounded systems (cases) over time through detailed in-depth data collection involving multiple sources of information and reports a case description and case-based themes. 12 (p73) In terms of intent, there are 3 types of case study: single instrumental, collective or multiple, and the intrinsic case study. Hyde-Wyatt 21 studied spinally injured patients on sedation in the ICU. A reflection-on-action exercise was carried out when a spinally injured patient became physically active during a sedation hold. This was attributed to hyperactive delirium. Reflection on this incident led to a literature search for guidance on the likelihood of delirium causing secondary spinal injury in patients with unstable fractures. Through a case study approach, the research was reviewed in relation to a particular patient. This case study illustrated that there was a knowledge deficit when it came to managing the combination of the patient’s spinal injury and delirium. Sedation cessation episodes are an essential part of patient care on intensive care. For spinally injured patients, these may need to be modified to sedation reductions to prevent sudden wakening and uncontrolled movement should the patient be experiencing hyperactive delirium.

WHAT IS THE PROCESS OF CONCEPTUALIZING AND DESIGNING A QUALITATIVE RESEARCH?

Designing a qualitative is not a fully structured, rigid process. Even books and experts vary in their understanding and guides in the “how to” perspective of a qualitative inquiry. Conducting a qualitative study is also extremely difficult. 10 Sometimes there is concern about access and the qualitative procedures involved in data collection including disclosure of participant’s identity and confidentiality of data. Nevertheless, qualitative research involves a rigorous and scientific process that serves as guide for researchers who are planning to embark on a journey and complete a naturalistic inquiry.

Unlike quantitative research that involves a fairly linear process, qualitative studies have a flexible approach and flow of activities, and the researchers do not know in advance exactly how the study will unfold. 22 The process of designing a qualitative study does not begin with the methods—which in fact is the easiest part of naturalistic research. 12 Qualitative researchers usually begin with a broad topic focusing on 1 aspect or a phenomenon of which little is known. The phenomenon may be one in the “real world,” a gap in the literature, or past findings of investigations, for example, in the area of social and human sciences. 12 A fairly broad question is then posed to be able to allow the focus to be delineated and sharpened once the study is underway.

Once the research question is posed, the researchers should conduct a brief literature review to inform the question asked and to help establish the significance of the problem. There is a continuous debate about the value of doing a literature review prior to collecting of data and how much of it should be done. Some believe that knowledge about findings of previous studies might influence the conceptualization of the phenomenon of interest, which ideally should be illuminated from the participants rather than on prior findings. 22 A grounded theory investigator, for example, may make a point of not conducting a review of literature before beginning the study to avoid “contamination” of the data with preconceived concepts and notions about what might be relevant. 2 After the review of literature, the researchers must identify an appropriate site for the study to be conducted.

Selecting and gaining entry to the site require knowledge of settings in which participants in their lifeworld are experiencing the phenomenon under study. For example, research in the area of health is a very broad topic. A researcher should determine definitions, concepts, scope, and theories about health that will be used for the proposed qualitative inquiry. Health can be perceived as absence or presence of illness, physical, psychosocial, psychological, and spiritual health of individuals, families, or groups. 10 Morse 10 further stated that “Research into the intimate, experiential and interpersonal aspects of illness, into caring for the ill, and into seeking and maintaining wellness introduces extraordinary methodological challenges.” 10 (p89) Thus, knowledge about the characteristics of participants who will be recruited for the study and the specific context of the settings (ie, hospital/institution, community/outpatient) where they are at the time when research will be conducted is important. To be able to gain entry to the site, the ethical aspect of the study should also be addressed. Approval from the institution’s institutional review board and informed consent from the participants must be obtained. Qualitative studies have special ethical concerns involved because of the more intimate nature of the relationship that typically develop between researchers and participants. 22 The researchers must develop specific plans addressing these issues. After addressing the ethical concerns and gaining entry to the site, an overall approach should be planned and developed.

It has been previously addressed that even though the researchers plan for a specific approach to be used, the design can be emergent during the course of data collection. Modifications are made as the need arises. It is rare that a qualitative study has rigidly structured design that will prohibit changes while in the field, 22 but being aware that the purposes, questions, and methods of research are all interconnected and interrelated so that the study appears as a cohesive whole rather than fragmented isolated parts. 5 For example, patients in hospitals have limited abilities related to their medical condition and the contextual features of a hospital. A patient’s condition may demand a different method be used because of patient fatigue, the interruptions of data collection for treatments, or physician’s rounds and visitors. In this context, the study requires modifications of methods, and participation in a research study has the lowest priority at this specific moment and time. 10

In qualitative studies, sampling, data collection, and analysis including interpretation take place repetitively. The sampling method usually used is purposive. Qualitative researchers use rigorous data collection procedures by talking to participants face-to-face, interviewing, and observing them (individual, focus groups, or an entire culture) to be able to explore the phenomenon under study. The discussions and observations are loosely structured, allowing participants full range of beliefs, feelings, and behaviors. 22 Other types of information that can be collected are documents, photographs, audiovisual materials, sounds, e-mail massages, digital text messages, and computer software. The backbone of qualitative research is extensive collection of data from multiple sources of information. 12 After organizing and storing the data, the researcher will try to make sense of the data, working inductively from particulars to more general perspectives until categories, codes, and themes emerge and are illuminated, which are used to build a rich description of the phenomenon. 12,22 The researcher analyzes data using multiple levels of abstraction. Analysis and interpretation are ongoing concurrent activities that guide the researchers about the kinds of questions to ask or observations to make. The kinds of data gathered become increasingly meaningful as the theory emerges. When themes and categories become repetitive and redundant and no new information can be gleaned, the researcher has reached data saturation and thus stops collecting data and recruitment of participants. 22 Trustworthiness of the data and rigor have to be then established. Steps have to be taken to confirm that the findings accurately reflect the experiences and perceptions of participants rather than the researcher’s viewpoints. Some of the strategies that can be used are validation techniques that include confirming and triangulating data from several sources, going back to participants, sharing preliminary interpretations with them, asking them whether the researcher’s thematic analysis is consistent with their experiences, 22 (p55) and having other expert researchers review the procedures undertaken and interpretations made. 12

FINAL THOUGHTS

Qualitative research uses a naturalistic approach that seeks to understand phenomena in context-specific settings, attempting to make sense of it and interpreting in terms of meaning people bring to them. It contributes to the humanizing of health care as it addresses content about health and illness. Qualitative research does not have firm or rigid guidelines and takes time to conduct. Some of the methods for a qualitative inquiry are narrative research, phenomenology, grounded theory, case study, and ethnography. Although the study design emerges during the inquiry, it follows the pattern of scientific research. Researchers collect data rigorously in natural settings over a period and analyze them inductively to establish patterns or themes. Ethical decisions and considerations for rigor and trustworthiness are also continuously threaded throughout the study. The final report presents the active voices of participants and the description and interpretation of the meaning of the phenomenon including the reflexivity of the researcher.

Goals of nursing; Health care; Qualitative research

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• Volume 21, Issue 3
• Data collection in qualitative research
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• David Barrett 1 ,
• http://orcid.org/0000-0003-1130-5603 Alison Twycross 2
• 1 Faculty of Health Sciences , University of Hull , Hull , UK
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr David Barrett, Faculty of Health Sciences, University of Hull, Hull HU6 7RX, UK; D.I.Barrett{at}hull.ac.uk

https://doi.org/10.1136/eb-2018-102939

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Qualitative research methods allow us to better understand the experiences of patients and carers; they allow us to explore how decisions are made and provide us with a detailed insight into how interventions may alter care. To develop such insights, qualitative research requires data which are holistic, rich and nuanced, allowing themes and findings to emerge through careful analysis. This article provides an overview of the core approaches to data collection in qualitative research, exploring their strengths, weaknesses and challenges.

Collecting data through interviews with participants is a characteristic of many qualitative studies. Interviews give the most direct and straightforward approach to gathering detailed and rich data regarding a particular phenomenon. The type of interview used to collect data can be tailored to the research question, the characteristics of participants and the preferred approach of the researcher. Interviews are most often carried out face-to-face, though the use of telephone interviews to overcome geographical barriers to participant recruitment is becoming more prevalent. 1

A common approach in qualitative research is the semistructured interview, where core elements of the phenomenon being studied are explicitly asked about by the interviewer. A well-designed semistructured interview should ensure data are captured in key areas while still allowing flexibility for participants to bring their own personality and perspective to the discussion. Finally, interviews can be much more rigidly structured to provide greater control for the researcher, essentially becoming questionnaires where responses are verbal rather than written.

Deciding where to place an interview design on this ‘structural spectrum’ will depend on the question to be answered and the skills of the researcher. A very structured approach is easy to administer and analyse but may not allow the participant to express themselves fully. At the other end of the spectrum, an open approach allows for freedom and flexibility, but requires the researcher to walk an investigative tightrope that maintains the focus of an interview without forcing participants into particular areas of discussion.

Example of an interview schedule 3

What do you think is the most effective way of assessing a child’s pain?

Have you come across any issues that make it difficult to assess a child’s pain?

What pain-relieving interventions do you find most useful and why?

When managing pain in children what is your overall aim?

Whose responsibility is pain management?

What involvement do you think parents should have in their child’s pain management?

What involvement do children have in their pain management?

Is there anything that currently stops you managing pain as well as you would like?

What would help you manage pain better?

Interviews present several challenges to researchers. Most interviews are recorded and will need transcribing before analysing. This can be extremely time-consuming, with 1 hour of interview requiring 5–6 hours to transcribe. 4 The analysis itself is also time-consuming, requiring transcriptions to be pored over word-for-word and line-by-line. Interviews also present the problem of bias the researcher needs to take care to avoid leading questions or providing non-verbal signals that might influence the responses of participants.

Focus groups

The focus group is a method of data collection in which a moderator/facilitator (usually a coresearcher) speaks with a group of 6–12 participants about issues related to the research question. As an approach, the focus group offers qualitative researchers an efficient method of gathering the views of many participants at one time. Also, the fact that many people are discussing the same issue together can result in an enhanced level of debate, with the moderator often able to step back and let the focus group enter into a free-flowing discussion. 5 This provides an opportunity to gather rich data from a specific population about a particular area of interest, such as barriers perceived by student nurses when trying to communicate with patients with cancer. 6

From a participant perspective, the focus group may provide a more relaxing environment than a one-to-one interview; they will not need to be involved with every part of the discussion and may feel more comfortable expressing views when they are shared by others in the group. Focus groups also allow participants to ‘bounce’ ideas off each other which sometimes results in different perspectives emerging from the discussion. However, focus groups are not without their difficulties. As with interviews, focus groups provide a vast amount of data to be transcribed and analysed, with discussions often lasting 1–2 hours. Moderators also need to be highly skilled to ensure that the discussion can flow while remaining focused and that all participants are encouraged to speak, while ensuring that no individuals dominate the discussion. 7

Observation

Participant and non-participant observation are powerful tools for collecting qualitative data, as they give nurse researchers an opportunity to capture a wide array of information—such as verbal and non-verbal communication, actions (eg, techniques of providing care) and environmental factors—within a care setting. Another advantage of observation is that the researcher gains a first-hand picture of what actually happens in clinical practice. 8 If the researcher is adopting a qualitative approach to observation they will normally record field notes . Field notes can take many forms, such as a chronological log of what is happening in the setting, a description of what has been observed, a record of conversations with participants or an expanded account of impressions from the fieldwork. 9 10

As with other qualitative data collection techniques, observation provides an enormous amount of data to be captured and analysed—one approach to helping with collection and analysis is to digitally record observations to allow for repeated viewing. 11 Observation also provides the researcher with some unique methodological and ethical challenges. Methodologically, the act of being observed may change the behaviour of the participant (often referred to as the ‘Hawthorne effect’), impacting on the value of findings. However, most researchers report a process of habitation taking place where, after a relatively short period of time, those being observed revert to their normal behaviour. Ethically, the researcher will need to consider when and how they should intervene if they view poor practice that could put patients at risk.

The three core approaches to data collection in qualitative research—interviews, focus groups and observation—provide researchers with rich and deep insights. All methods require skill on the part of the researcher, and all produce a large amount of raw data. However, with careful and systematic analysis 12 the data yielded with these methods will allow researchers to develop a detailed understanding of patient experiences and the work of nurses.

• Twycross AM ,
• Williams AM ,
• Huang MC , et al
• Onwuegbuzie AJ ,
• Dickinson WB ,
• Leech NL , et al
• Twycross A ,
• Emerson RM ,
• Meriläinen M ,
• Ala-Kokko T

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Commissioned; internally peer reviewed.

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Research Article

A qualitative exploration of barriers to efficient and effective structured medication reviews in primary care: Findings from the DynAIRx study

Roles Data curation, Formal analysis, Methodology, Validation, Writing – original draft, Writing – review & editing

Affiliations Academic Unit for Ageing & Stroke Research, Bradford Teaching Hospitals NHS Foundation Trust, University of Leeds, Bradford, United Kingdom, Faculty of Medicine and Health, School of Medicine, University of Leeds, Leeds, United Kingdom

Roles Data curation, Formal analysis, Validation, Writing – original draft, Writing – review & editing

Affiliation Institute of Population Health, University of Liverpool, Liverpool, United Kingdom

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliations Institute of Population Health, University of Liverpool, Liverpool, United Kingdom, Directorate of Mental Health and Learning Disabilities, Powys Teaching Health Board, Bronllys, United Kingdom

Roles Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Validation, Writing – review & editing

Affiliation General Practice and Primary Care, School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom

Roles Conceptualization, Investigation, Methodology, Supervision, Writing – review & editing

Roles Conceptualization, Supervision, Writing – review & editing

Roles Conceptualization, Formal analysis, Investigation, Methodology, Validation, Writing – review & editing

Roles Writing – review & editing

Affiliations Faculty of Medicine and Health, School of Medicine, University of Leeds, Leeds, United Kingdom, Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom

Roles Conceptualization, Writing – review & editing

Affiliation Department of Computer Science, University of Liverpool, Liverpool, United Kingdom

Affiliation Division of Informatics, Imaging & Data Science, University of Manchester, Manchester, United Kingdom

Affiliation NIHR Applied Research Collaboration North West Coast, United Kingdom

Affiliations Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom, School of Computing, University of Leeds, Leeds, United Kingdom

Roles Project administration, Resources

Affiliation Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool, United Kingdom

Affiliation Merseycare NHS Foundation Trust, Liverpool, United Kingdom

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Resources, Supervision, Writing – review & editing

•  [ ... ],

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Centre for Experimental Therapeutics, University of Liverpool, Liverpool, United Kingdom, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom

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• Aseel S. Abuzour, 
• Samantha A. Wilson, 
• Alan A. Woodall, 
• Frances S. Mair, 
• Andrew Clegg, 
• Eduard Shantsila, 
• Mark Gabbay, 
• Michael Abaho, 
• Asra Aslam, 

• Published: August 30, 2024
• https://doi.org/10.1371/journal.pone.0299770
• Reader Comments

Introduction

Structured medication reviews (SMRs), introduced in the United Kingdom (UK) in 2020, aim to enhance shared decision-making in medication optimisation, particularly for patients with multimorbidity and polypharmacy. Despite its potential, there is limited empirical evidence on the implementation of SMRs, and the challenges faced in the process. This study is part of a larger DynAIRx (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) project which aims to introduce Artificial Intelligence (AI) to SMRs and develop machine learning models and visualisation tools for patients with multimorbidity. Here, we explore how SMRs are currently undertaken and what barriers are experienced by those involved in them.

Qualitative focus groups and semi-structured interviews took place between 2022–2023. Six focus groups were conducted with doctors, pharmacists and clinical pharmacologists (n = 21), and three patient focus groups with patients with multimorbidity (n = 13). Five semi-structured interviews were held with 2 pharmacists, 1 trainee doctor, 1 policy-maker and 1 psychiatrist. Transcripts were analysed using thematic analysis.

Two key themes limiting the effectiveness of SMRs in clinical practice were identified: ‘Medication Reviews in Practice’ and ‘Medication-related Challenges’. Participants noted limitations to the efficient and effectiveness of SMRs in practice including the scarcity of digital tools for identifying and prioritising patients for SMRs; organisational and patient-related challenges in inviting patients for SMRs and ensuring they attend; the time-intensive nature of SMRs, the need for multiple appointments and shared decision-making; the impact of the healthcare context on SMR delivery; poor communication and data sharing issues between primary and secondary care; difficulties in managing mental health medications and specific challenges associated with anticholinergic medication.

SMRs are complex, time consuming and medication optimisation may require multiple follow-up appointments to enable a comprehensive review. There is a need for a prescribing support system to identify, prioritise and reduce the time needed to understand the patient journey when dealing with large volumes of disparate clinical information in electronic health records. However, monitoring the effects of medication optimisation changes with a feedback loop can be challenging to establish and maintain using current electronic health record systems.

Citation: Abuzour AS, Wilson SA, Woodall AA, Mair FS, Clegg A, Shantsila E, et al. (2024) A qualitative exploration of barriers to efficient and effective structured medication reviews in primary care: Findings from the DynAIRx study. PLoS ONE 19(8): e0299770. https://doi.org/10.1371/journal.pone.0299770

Editor: Kathleen Bennett, Royal College of Surgeons in Ireland, IRELAND

Received: February 16, 2024; Accepted: June 24, 2024; Published: August 30, 2024

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

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: DynAIRx has been funded by the National Institute for Health and Care Research (NIHR) Artificial Intelligence for Multiple Long-Term Conditions (AIM) call (NIHR 203986). MG is partly funded by the NIHR Applied Research Collaboration North West Coast (ARC NWC). AW is partly funded by a Health and Care Research Wales Research Time Award (NHS-RTA-21-02). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This research is supported by the NIHR ARC NWC. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Competing interests: No competing interests

Structured medication reviews (SMRs) were introduced in the United Kingdom (UK) in October 2020 and incorporated into the NHS England Directed Enhanced Service (DES) contract for 2021 [ 1 ]. SMRs represent a National Institute for Health and Care Excellence (NICE)-approved clinical intervention facilitating shared-decision making between clinicians and patients, to inform treatment decisions. The objective is to reduce medication-related harm in patients with complex or problematic polypharmacy [ 1 , 2 ]. While General Practitioners (GPs), pharmacists and advanced nurse practitioners (ANPs) who meet training criteria can conduct SMRs, the prevailing expectation is for clinical pharmacists within Primary Care Networks (PCNs) to assume primary responsibility as a commissioned service [ 3 ]. The varied methods employed by PCNs to proactively identify patients suitable for SMRs, and conduct these reviews, is contingent on available resources and capacity. Anecdotal evidence suggests that PCNs currently use limited digital tools, such as searching electronic health records (EHR) based on the total number of drugs prescribed or disease codes, to identify patients at risk of medication-related harm.

There is sparse empirical evidence reporting on the implementation of SMRs, their impact on patient outcomes, and the challenges faced by healthcare professionals (HCPs) and patients during SMRs [ 4 , 5 ]. This scarcity of evidence is unsurprising given that SMRs were introduced in 2020 amidst the COVID-19 pandemic [ 1 ]. Nonetheless, estimates suggest a percentage reduction in per-patient medicines following an SMR ranging from 2.7% to 9.9%, with up to 19.5% reduction in use for the highest-risk group in care homes [ 6 ].

Patients with complex multimorbidity and polypharmacy, whose medicines have not been optimised are at risk of adverse outcomes and medication-related harm [ 7 ]. The definition of complex multimorbidity is contentious [ 8 ] but here we are referring to patients living with four or more conditions, which is strongly associated with polypharmacy [ 8 , 9 ]. The use of data from EHRs to develop evidence-based digital health tools can be a promising resource to assist HCPs in conducting targeted, efficient and effective SMRs.

The NIHR-funded DynAIRx study (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) aims to develop AI-driven tools that integrate information from electronic health and social care records, clinical guidelines and risk-prediction models in order to support the delivery of SMRs [ 10 ]. The DynAIRx project will produce machine learning models, dashboards, and different tools including Causal Inferencing to provide clinicians and patients with evidence-based information to prioritise patients at most risk of harm and/or patients most likely to benefit from SMRs. Aligned with the NICE multimorbidity guidelines, [ 7 , 11 ] DynAIRx will focus on three patient groups at high-risk of rapidly worsening health from multimorbidity: (a) individuals with mental and physical health co-morbidity, [ 12 – 14 ] in whom the prescribing for mental health improvement can lead to adverse physical health consequences; (b) those with complex multimorbidity (four or more long-term health conditions taking ten or more drugs); [ 9 , 15 ] and (c) older people with frailty who are at high risk of adverse outcomes [ 16 ].

The initial step towards introducing AI-driven prescribing support tools into clinical practice involves understanding the current scope of work, how SMRs are presently undertaken and by whom, the time required in real-world clinical practice to undertake them, and crucially, investigate what determinants act as potential barriers to efficient and effective SMR implementation. The aim of this study was to explore how SMRs are undertaken and what barriers those undertaking them (and receiving them) experience.

Participants and recruitment

This study sought to recruit health care or management professionals working in health care settings (primary care in the community or secondary care in hospital services) across the UK where review of prescription medications is a regular part of the clinical workload. This included those working in General Practice, secondary care hospital services (geriatric medicine, clinical pharmacology, falls clinics, mental health practitioners), clinical commissioning of services or management of clinical services (practice managers), and pharmacists, including PCN pharmacists (those involved in conducting SMRs across several neighbouring GP practices). Patient participants included those with (a) multiple and physical co-morbidities; (b) complex multimorbidity; (c) older people with frailty. Patient and carer representatives of the three key multimorbidity groups outlined above were also invited. This included recruiting adult individuals (over the age of 18) with/or caring for someone with multiple (4 or more) long-term health conditions, co-existing mental and physical health problems, prescribed ≥10 regular medications, frailty.

Purposive sampling identified potential HCP participants that were known to be involved in medicines optimisation services through the researchers own clinical and professional networks. Snowballing (wherein research participants were asked to assist the recruitment by attempting to identify other potential participants) was employed to identify contacts through existing service providers along with advertisement in GP forums and at national events for individuals participating in clinical polypharmacy research [ 17 ]. Purposive sampling of potential patient representatives were identified through advertisement across the NIHR Applied Research Collaboration public advisor networks and through research databases at the researchers host institutions. Potential participants were provided with study information and an invitation to participate. Participants received comprehensive briefings from researchers about the study, and written consent was obtained prior to the focus group or interview participation. Withdrawal of consent was permitted at any stage, even after the focus group or interview.

Ethical approval

The Newcastle North Tyneside Research Ethics Committee (REC reference:22/NE/0088) granted ethical approval for the DynAIRx study.

Data collection

Data collection occurred from November 2022 to November 2023. Focus groups and semi-structured interviews were conducted to gather participant views. Focus groups were utilised for patient participants in order to stimulate discussion of common and shared experiences. Individual interviews supplemented the HCP focus groups in order to ensure as many HCPs could be involved as possible owing to time constraints for some HCPs. Focus group topic guides and interview schedules were developed and refined by the clinical members of the research team (LW, AA, AW, FM, AG) and tailored to HCP and patient groups. The topic guides (see S1 Appendix ) included questions exploring the experience of conducting or receiving SMRs, barriers to undertaking them and opinions on key medication challenges in multimorbidity groups from both the clinician and patient perspective. Sessions occurred in person and online (via Microsoft Teams), lasting from 49 to 109 minutes. Audio recordings underwent verbatim transcription and anonymisation to remove any potentially identifiable information. Each participant was assigned a code, and recordings were subsequently deleted. Data collection and analysis occurred concurrently. The Consolidated Criteria for Reporting Qualitative Research checklist was used to ensure comprehensive reporting of our qualitative study (see S1 Appendix ). No participant withdrew consent for their data to be used in the study.

Data analysis

Transcripts were imported into QSR NVivo 12® and analysed using thematic analysis [ 18 ]. Transcripts were read to familiarise researchers with the data. Inductive reasoning guided the initial coding by AA and SW, who collated and examined codes to identify themes. The multidisciplinary coding team (AA, SW, LW, AW, FM) consisted of clinicians and researchers, and engaged in regular reflexive practices to ensure a rigorous and transparent qualitative study. Recognising the diverse expertise and perspectives within the team, we held regular coding clinics where codes and initial themes were reviewed and discussed. By openly sharing our perspectives and challenging each other’s viewpoints, we aimed to balance our interpretations and avoid overemphasis on any single disciplinary lens. This allowed us to critically examine how our professional backgrounds and assumptions might shape the interpretation of findings. These reflexive sessions were instrumental in identifying and mitigating biases, ensuring that our analysis remained grounded in the participants’ narratives rather than our preconceptions. Themes were defined and supported by quotes. Detailed notes of discussions and developments were kept to ensure analytical rigour and plausibility [ 19 ]. The remaining dataset underwent hybrid inductive and deductive thematic analysis using the inductively defined themes, with codes and themes iteratively revised. Once all team members agreed no new codes or meaning to influence thematic analysis were emerging, we assumed saturation was achieved [ 20 ]. At this point, further recruitment was stopped.

Six focus groups with HCPs (n = 21) and 3 patient focus groups (n = 13) were conducted. A further five semi-structured interviews with HCPs took place (see Table 1 for details).

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https://doi.org/10.1371/journal.pone.0299770.t001

Two overarching themes developed from analysis of the HCP and patient interviews and focus groups, within which a number of sub-themes emerged:

• Limited availability of digital tools to assist in identifying and prioritising patients for a SMR
• Organisational challenges and patient factors affecting patient engagement for a SMR
• Time consuming “detective work”
• SMRs require multiple appointments
• Influence of healthcare context on delivering SMR
• Factors influencing deprescribing discussions
• Poor communication and data sharing between primary and secondary care
• Difficulties managing mental health medication for prescriber and patient
• Challenges around anticholinergic medication optimisation for prescriber

Fig 1 displays each key theme from this study and a detailed list of the barriers to each stage of the SMR process. Supplementary quotes for each theme can be found in S2 Appendix .

https://doi.org/10.1371/journal.pone.0299770.g001

• a. Limited availability of digital tools to assist in identifying and prioritising patients for a SMR

PCN pharmacists reported proactively identifying and prioritising patients to conduct SMRs. Patient identification was based on the criteria outlined by the DESGP contract, which includes patients in care homes (both nursing and residential facilities), individuals with complex multimorbidity and polypharmacy, urgently referred patients, older individuals encountering medication-related harms, and patients recently discharged from hospital. HCPs also referenced using available healthcare management automated search tools within the EHR, including ‘Ardens search’ [ 21 ] and ‘ProActive Register Management (PARM) diabetes’ [ 22 ], to identify pre-determined conditions, prescribing alerts and other variables that form part of the practice workload. They also used targets from the Investment and Impact Fund (IIF) for patient identification (IIF is an incentive scheme where PCNs can improve health and the quality of care for patients with multimorbidity), which participants described as beneficial but a waste of resources in the context of SMRs which should focus on patients with complex multimorbidity and polypharmacy [ 23 ]. Despite this, HCPs noted a limited number of digital tools to assist in identifying and prioritising patients for a SMR.

“I’ll be honest that we’ve not really had any tools that have been developed specific for supporting SMR.” (Pharmacist 2, Interview)

Since the introduction of EHRs in the NHS, HCPs are expected to assign ‘SNOMED codes’ to document patients with specific diagnostic, symptom or treatment codes in a logical hierarchical manner to specify clinical information [ 24 ]. These codes facilitate searches for specific medical conditions, symptoms and treatments within the GP EHR, facilitating the identification of individuals requiring an SMR. Pharmacists noted that EHR searches do not adequately consider the complexity of patients, making it challenging to stratify those that would benefit most from an SMR. Additionally, participants highlighted a lack of sensitivity and specificity in the current search mechanisms (meaning the searches either do not identify all the intended patients or identify too many).

“ The actual indicator that my team has been focusing on is supposed to be the ones where patients are prone to medication errors … but when I actually look at the patients, I haven’t got a clue why the actual computer system has decided that most of the time.” (Participant 1, Pharmacist FG1)

HCPs were concerned that the identification of patients who would benefit from an SMR could exceed the clinical capacity of the staff available to meet the need. They felt that any digital tool used to prioritise patients’ needs should match the clinical capacity of the practice.

“ The tools have to be a bit cleverer … We can generate a list of patients today … PCNs at the moment essentially do that, but what you have to do is almost the list that’s generated to the capacity … People would not switch it on if they felt that it could generate lots of patients you would not then see.” (Policy-maker, Interview)

• b. Organisational challenges and patient factors affecting patient engagement for a SMR

GPs or secondary care clinicians (excluding clinical pharmacologists) often conducted opportunistic medication reviews, compared to the proactive SMRs conducted by PCN pharmacists. In alignment with the DES requirements, HCPs described how the task of conducting an SMR was contingent upon organisational contracts, practice size, and staff availability. The presence of a PCN pharmacist for SMRs facilitated streamlined tasks, enabling GPs to focus on patients with more complex medical profiles. GPs voiced concerns about burnout in areas where demand for SMR exceeded the clinical capacity to undertake them. This challenge was particularly pronounced in regions of lower socioeconomic status where patients often presented with complex multimorbidity and polypharmacy at a younger age, especially those with co-morbid mental and physical health problems. Moreover, respondents felt that patients residing in deprived areas were less likely to attend scheduled SMRs, compelling GPs to resort to opportunistic reviews. This highlights potential inequity in access to SMRs and overall health surveillance.

“In the poorer area of the practice there’s no clinical pharmacist, that’s all done opportunistically, if done at all, by the GP partners there. I think that there’s a couple that are approaching burn out, if not complete burn out and the practice is almost run by locums. So, when I’m going in there, it’s quite tough and I will often see medications that are inappropriately prescribed, polypharmacy, several of the same drugs, and I will opportunistically undertake a structured medical review.” (Participant 3, GP FG1)

• c. Time consuming “detective work”

Whether HCPs identified patients proactively or opportunistically, the preparation time for a medication review ranged from 10 minutes to 1 hour. Several factors influenced this preparation time, including the availability of information, case complexity, barriers to accessing information, information density, and time constraints. The challenge in finding and collating information within the patient’s clinical records constituted a significant portion of the preparation time. For instance, discharge letters from hospitals are often located as attachments within the patient record, requiring HCPs to locate and read the letter. These necessary preparatory activities take away from the face-to-face time available with the patient.

“ Probably double the amount of prep time than it was actually with the patient. I mean, granted we did spend a while with the patient because we both like to talk, and the patient certainly did, but I think, and that’s the problem, isn’t it? You get the best information out of your patient when you let them talk and you let them tell you lots of things that you wouldn’t normally ask, but you haven’t got the time to do that so it’s tricky isn’t it to find the balance. But the biggest thing with the prep time was getting the information.” (Participant 3, Pharmacist FG1)

HCPs also conveyed frustration regarding the substantial time required to determine the original indication for a particular prescription and the ongoing necessity for it, even during major transition periods such as a patient’s admission to a care home.

“ We don’t get enough actual structured reviews, so they’ll be getting put on medication, people in care homes, and then left on those medicines. There’s no recognition of the changes. As you move in a care home, you’re generally more frailer, your renal function, haematic function might not be as great and, you know, you’re not moving as much, so your need for some medicines might not be as great as it was when the medicine was first started. ” (Policy-maker, Interview) “So along with what you said about deprescribing Selective Serotonin Reuptake Inhibitors (SSRIs) , especially , you know they’ve been on them for 4–5 years and they are adamant they don’t want to reduce them or stop them or have any sort of conversation about it , yeah , they’re quite challenging I think . Also , I think sometimes you can’t quite work out what medications people have been on . I mean if we talk about SSRIs they may have tried multiple different ones in the past and sometimes it’s difficult to work out what they’ve been on without having to go through the long , long list searching all the different medications that are SSRIs that they’ve tried . It would be so helpful if you know it could just bring up yeah been used before , and then know which one you could try…knowing that you want to try a different one . ” (Participant 6, GP FG1)

Although it is possible within the EHR system to link the prescription of an individual drug to its clinical indication, anecdotal evidence suggests this is time consuming and therefore may not be done in clinical practice.. As such, indications for prescribed medicines are recorded in the free text for the consultation which can easily become obscured over time within the extensive information contained in the clinical record. Examining the clinical free text for this information was emphasised as a challenge in efficiently conducting SMRs.

“ Although in my letters I would clearly state to the GP why I am prescribing the second line antipsychotic just so that people know, but over time that tends to get lost, the rationale for that prescribing tends to get lost and before you know you leave post, somebody else comes and begins to increase that second antipsychotic you know, so that becomes a problem. ” (Participant 1, Psychiatrist FG)

Moreover, existing EHRs are not adept at presenting patient histories in a manner conducive to HCPs pinpointing areas for potential deprescribing. This deficiency in the system leads to a cumulative high pill burden for patients, as illustrated in the quote below.

“ At the age of [ 18 – 20 ], I was diagnosed with bipolar. I am now [71–74] and I have lived for that period of time on medication, a lot of medication actually … I counted the number of tablets and my boxes on my bedside the other day and there was 13 different tablets, so that is what I am being prescribed by my GP. ” (Patient 1, Mental and physical co-morbidities FG)

Patients also expressed uncertainty about the initial reasons for starting medications. Patients reported receiving medications for many years and being unsure whether the medication was still necessary.

“ She is also on a daily injection of adult growth hormone which another consultant put her on at the time and she has been having them for probably 10 to 15 years, and no-one seems to know now who initially prescribed it and who is in charge of that. I am concerned, does she really need them? She is having them every day … Initially it was an asset to go with the immunodeficiency but now I don’t really know. ” (Patient 5, Mental and physical co-morbidities FG)

• d. SMRs require multiple appointments

SMRs typically lasted a minimum of 30 minutes, often extending beyond this duration. The variability in duration was contingent upon the patient’s complexity and the focused nature of the review. Allowing adequate time to address broader health concerns was deemed crucial, enabling the identification of potential issues requiring deeper exploration by the clinician.

HCPs acknowledged that SMRs were not a singular event, and patients might necessitate multiple appointments for a comprehensive review. Consequently, EHR systems were recognised as needing functionality to alert HCPs to schedule additional appointments after the initial SMR, emphasising the iterative and ongoing nature of medication reviews.

“ The first time I see patients, you want almost a bit of a holistic conversation, but actually when you start making interventions you go with what matters most to the patient or where the biggest risk is and you then table the others … You can imagine that being 2 or 3 hours in 4 different appointments before you get to the bottom of where you want to be … I think we had to contact on average about 2 to 3 times per patient, but there were more complex patients as well … I don’t think you can stop medicines or optimise medicines without seeing that patient again as least once. ” (Policy-maker interview)

Patients expressed a desire to be involved in the decision-making during reviews and valued the opportunity to discuss issues such as how medications fit into their routines and other resources that may be available to them.

"I’ve got a series of chronic things, take a load of pills and they’re each for separate things, and I have been concerned for years whether there’s any interaction with them, between them. And also they make me feel tired all the time and perhaps there are some of them where I could actually get rid of them." (Patient 1, Older people with frailty FG)

• e. Influence of healthcare context on delivering SMR

The duration of conducting a SMR was also contingent on the specific healthcare setting in which it took place. One pharmacist highlighted that SMRs conducted in care homes lacked a strict time limit and were oriented towards achieving specific outcomes, such as the number of medicines deprescribed in particular patient groups. This reflected the contextual variability in the conduct and objectives of SMRs, emphasising the need for flexibility in the approach based on the healthcare environment and patient population.

“ We were just told take whatever time you need but because we were not measured on the quantity, we were measured on the quality, and we were recorded the number of medicines basically stopped and in particular groups actually so, and then that would have gone on the report because that was the way of showing what we were doing and the basic value for money I guess .” (Participant 1, Pharmacist FG1)

The emphasis placed on a medication list varied depending on the reviewer and the healthcare setting. A pharmacist working in secondary care articulated a tendency to allocate less attention to certain medicines in a hospital setting, prioritising focus on medications more likely to cause harm. This perspective highlights the nuanced approach that different HCPs may adopt based on their expertise and the specific context in which they operate.

“ At the moment, the bisphosphonate would be something that I’m less concerned about it a very high acuity environment, that’s the thing that I’m probably going to, maybe if I get a chance, write in the discharge summary for the GP to check up on whether or not that’s still appropriate. Whereas I’m chasing those big harms .” (Participant 2, Pharmacist FG1)

• f. Factors influencing deprescribing discussions

Discussions around deprescribing between HCPs and patients were reported to be influenced by several factors. These included the specific type of medicine to be deprescribed, the patient’s willingness to discontinue the medication, sociodemographic location, availability of additional health services in the area, whether the medication was initially prescribed in primary or secondary care and the existence of pre-established stopping criteria for certain medications (e.g., bisphosphonates for more than 5 years). Additionally, HCPs and patients acknowledged a degree of reluctance to engage in deprescribing due to perceived potential risks associated with the cessation of certain medications. These multifaceted factors contribute to the complexity and individualised nature of deprescribing discussions within the healthcare context.

“I find it really, really difficult because all of the guidelines will say, oh, you should have this patient on statins, etc., and you think I really probably shouldn’t they’re 95, but having stopped them in the past then a patient unfortunately ends up with a stroke, they go to hospital, the hospital tells them it’s because their GP stopped their statin and puts them back on .” (Participant 2, GP FG2) “ The antidepressant one is interesting . So , I did work for 9 years in a really deprived area . . . SSRIs for a long time and they were pretty reluctant to come off it but usually willing to accept if it didn’t work out just put them back on it . It just meant in a much more middle-class area there’s the opposite where they’re all desperate to come off it and probably coming off it far too soon . So , I don’t think it needs to be doctor-led , it seems to be more about their external pressures and there’s been a lot of areas done in deprived communities with link workers and social prescribers and I think if you’re going to look at polypharmacy in these sort of groups then that’s probably the way to do it stopping all their meds .” (Participant 4, GP FG1)

In one case, a pharmacist highlighted the challenges associated with decision-making when optimising medicines for complex, younger patients, emphasising the impact of side-effects on their quality of life. Equally, the importance of considering quality of life in frail older adults with polypharmacy was acknowledged, although perceived as less complicated than in younger adults.

"I know well that’s it isn’t it, it’s not necessarily that they’re a complex medicine it’s that there is evidence to say that this can prolong your life but it’s causing them that much upset, so it’s, for me it’s not necessarily the, I can’t think of any particular group of drug its more the younger you get, you know 50 is very young and that you have got a lot of life left to live so that’s when it becomes more of a clinical decision for me that as a pharmacist I don’t feel like I would be able to make" (Participant 1, Pharmacist FG1)

• 2. Medication-related Challenges

Potential for medication-related harm identified by our key stakeholder groups included issues with specific medicines, conditions, and risky medication combinations; mental health medications; prescriptions from specialists; anticholinergic medicines; difficulties in determining prescription timelines to assist in decision-making; challenges with younger complex patients; and siloed care.

• a. Poor communication & data sharing between primary and secondary care

HCPs identified the challenge of extracting information from hospital discharge letters as a key source of frustration. Patients, in particular, assumed that EHRs seamlessly connected primary and secondary care, and in some cases, their community pharmacy. This assumption left patients bewildered and, in certain cases, reliant on the HCPs knowing the complete narrative behind their health records. The disjointed communication and misconceptions surrounding record integration emphasised the need for improved interoperability to enhance the continuum of care.

“ We will be waiting a week for an outpatient letter to come through and it’s really confusing, stop this, change that, increase the dose here, and you’re kind of stuck in the middle. So sometimes the patient will have left that meeting there and it will be ‘like go and see your GP and they will do this bit’, well [that’s] not happening until I’ve got that letter. There is that real mismatch of communication. ” (Participant 1, GP FG2) “ When the repeat prescription came through , despite the fact that the surgery had received the discharge letter , everything was all wrong , and this is just one of those things that happens . So , you get a review and it is whether that data from that review and the story behind it and who it goes back to and whether it is acted on , I think that is important .” (Patient 3, Complex multimorbidity FG)

Communication gaps between GPs, specialist clinicians, and patients were evident due to varying expectations. GPs expressed challenges in managing specialist medications with patients, including concerns about patients’ ability to self-manage their medicines. These challenges highlighted aspects of fragmented care between primary care and specialist clinicians. HCPs also cited difficulties and reluctance in communicating and potentially engaging in conflict with specialist doctors. Participants described specialist doctors as lacking a holistic view when prescribing for patients, favouring certain medicines, and having limited knowledge in drug interactions.

“I think multidisciplinary is key, however when I notice that I liaise with specialists, depending on who I speak to, their drug is the most important and trying to get a consensus about what is best for the patient is obviously one of the challenges like that’s how we got in this situation to begin with you know, so I do find that’s one of the challenges. so, I think you need someone who is you know, who is a specialist but has also got a sort of holistic view of patient care as well which doesn’t always happen in secondary care, but sometimes does.” (Participant 3, Polypharmacy FG)

Participants noted that central nervous system medicines had complicated medication regimens and hence required more coordinated care and responsibility between the specialist prescriber and GP. Addressing these challenges calls for enhanced collaboration, knowledge exchange, and a holistic approach to patient care between primary care and specialist clinicians.

“ I find it, with the pain management clinic, they stop medication, give you a list of all these other tablets you need to start to see how things go and then sort of leave you to it, discharge the patient in your hands and expect you to sort of manage it all. And the same thing is with migraine and headaches from neurology. That’s just a minefield … I think when you’re in specialty, you feel that you can give any sort of long protracted complicated regime and the patient is just going to manage it because that’s the only medication that you think that they’re on. So yeah, they can be quite difficult .” (Participant 5, GP FG1) “ He [GP] says that we can’t actually change any medication to do with your bipolar , that has got to be done by your psychiatrists … I don’t think they would change anything to do with psychiatry .” (Patient 1, Mental and physical co-morbidities FG)

• b. Difficulties managing mental health medication

Mental health medication and management emerged as a consistent sub-theme across key HCP stakeholder groups, irrespective of their professional background. Both doctors and pharmacists described difficulties in monitoring and adjusting psychiatric medicines, including uncertainties about how to address specific issues related to psychiatric medicines. Participants expressed a sense of being ‘out of their depth’, particularly concerning antipsychotic medicines. They conveyed a lack of confidence in assessing the risks and benefits of antipsychotic prescribing, feeling deskilled in this specific area of medication management, and finding it challenging to safely challenge prescribers. This sense of unease prompted participants to seek ways of contacting the mental health team, only to encounter additional hurdles, such as difficulties in locating relevant information within patient records to facilitate multidisciplinary coordinated patient care.

“ But the other one is someone with very complex psychiatric problems, still maybe under the mental health team, and I haven’t got really access to the details apart from maybe I’ve got, you know, some of the other diagnoses. But if I think maybe one of those drugs is potentially causing more harm than could then I’m not clear how then to action that and who to speak to and who were they actually seeing ” (Participant 1, Polypharmacy FG)

For example, a clinical pharmacologist explained that evaluating the success of managing antipsychotics is not as straightforward as assessing physical health conditions. This complexity may contribute to the observed lack of confidence among HCPs when it comes to deprescribing psychiatric medicines. The nuanced nature of mental health outcomes, compared to more tangible markers of success in physical health, adds an additional layer of intricacy to the decision-making process in psychiatry. This includes the complexity of managing mental health medication.

“ The biggest challenge group that I think we face in a deprived area is the patients who are on long term opioid medication, long term neuropathic meds, they’ve probably got a diagnosis of fibromyalgia, they’ve probably got personality disorder plus / minus mental health problems. And the issues that we have is that they’ve almost been sequentially added medication on because GPs don’t really often know what to do with them unless you have a special interest in that field like I do. And when they go and see pharmacists, they are very challenging to pharmacists and pharmacists don’t have the clinical knowledge to be able to sift through what can often be quite dramatic presentations. ” (Participant 1, GP FG1)

• c. Challenges around anticholinergic medicines

Anticholinergic medicines, which inhibit the neurotransmitter acetylcholine involved in numerous physiological functions, has been associated with adverse outcomes such as cognitive decline and falls, particularly when multiple anticholinergic medicines are used concurrently (termed anticholinergic burden) [ 25 , 26 ]. GPs, clinical pharmacologists, and pharmacists described the importance of reviewing and deprescribing anticholinergic medicines where possible. However, the process of calculating anticholinergic burden (ACB) in frail, older adults is time consuming, primarily due to the absence of automated calculators embedded within the EHR system.

Doctors and pharmacists expressed frustrations around the re-prescribing of anticholinergics after deprescribing them. They attributed the persistence of high ACB to limitations in prescribing guidelines and a scarcity of alternative options to replace anticholinergic drugs. These challenges highlighted the need for tools within EHR systems to facilitate efficient assessment of ACB, alongside a broader exploration of prescribing guidelines and alternatives to enhance deprescribing practices.

“ One of the things that I often see in general practice is that there’s lots of anticholinergics, usually amitriptyline because it’s kind of given out for other reasons for what it’s licensed for. So, sleep is probably the most common thing that I see it used for, or avoiding long term opioids in chronic arthritic pain, and often that’s because we have other options for them but we’re not allowed to prescribe them. So, melatonin is probably the most common thing that we could put them on which has a lot better safety profile, but we are just completely discouraged from prescribing it. And likewise access to other interventions that would help arthritic pain rather than putting them on NSAIDS which obviously carry risk or opioids which aren’t overly effective outside the acute pain window. It’s often the lack of other stuff that raises all of the anticholinergic burden. ” (Participant 1, GP FG1)

Participants welcomed any digital tool that could streamline routine work processes, including information retrieval, automated dose calculations, and assessing the risk of developing diseases to optimise medicines during a SMR in a patient-centred manner, with the goal of enhancing efficiency in the medication optimisation process.

Medication reviews by HCPs can take significant preparation, and are time consuming, primarily due to the need to gather and understand patient information and to develop an understanding of a patient’s medical history and social circumstances. In addition, currently, there is no easy way to identify from the EHR which patients are at greatest risk of medication-related harm and those most likely to benefit from an SMR. The EHR systems used in primary care contain enormous volumes of information which becomes particularly challenging and time-consuming to navigate for complex individuals living with multiple long-term conditions and taking many medications. The way that information is organised in the system leads to a large proportion of time spent linking medications to their original indication and examining the patient journey. This time could be better spent discussing shared decisions with the patient. The EHR has not evolved in line with increasing patient complexity. The findings of this report emphasise the need for enhanced functionalities in EHRs to support effective medication management in the context of deprescribing discussions where a nuanced understanding of a patient’s medication history is crucial.

Our study has highlighted the challenges facing those undertaking SMRs in more socioeconomically disadvantaged areas, where people experience multimorbidity (and co-existent polypharmacy) 10–15 years earlier than their affluent peers [ 27 , 28 ]. These populations have complex healthcare needs at a younger age, the care of which falls to the already over-stretched GPs. Areas with greater socioeconomic disadvantage often have lower health literacy, resulting from a combination of lower educational attainment, economic barriers like the need to prioritise food and heating over health seeking, and psychosocial stressors affecting decision-making relating to health [ 29 , 30 ]. Health literacy applies not only to the patient but to the clinician who may also be unaware of the psychosocioeconomic situation of the patient, leading to a communication gap when discussing the risk and benefit of medicines to reach a shared-decision [ 31 – 33 ]. Accordingly, complex conversations involving numeracy calculations of risk may take longer and require repetition, but may also be of less priority for the patient and/or carer than other more immediate life concerns.

As preparation time is repeatedly cited as a barrier to effective SMR, a potential solution that would support SMRs in those with lower health literacy should include any digital intervention that saves on preparation time. This would enable more time for the clinician to engage with the patient and discuss complexities around risk and benefit, which would go some way to addressing the existing health disparity that affects those experiencing socioeconomic disadvantage. For HCPs working in areas of socioeconomic deprivation, lack of HCP capacity alongside patients declining SMR invitations were cited as barriers to undertaking SMRs. Moreover, HCPs described the usefulness of a system to identify availability of different health services in surrounding areas (e.g. weight management service) [ 27 , 28 ]. A recent study co-produced SMR resources to empower patients in their healthcare and support them in making the most out of their SMR. This included producing resources in a number of different languages including audio recorded resources for patients with visual impairment [ 34 , 35 ]. Embedded links to resources for HCPs to provide to patients before and/or after an SMR can be one potential way to utilise digital health and empower patients to reduce inequity in access to healthcare.

Our study also highlighted medication-related challenges such as difficulties managing mental health, specialist and anticholinergic medications. HCPs reported that a lack of alternatives to medication for symptom management hampered their ability to optimise some of the more potentially harmful medication classes such as opioids, anti-depressants, anticholinergics and gabapentinoids. Non-pharmacological alternatives, where appropriate, such as counselling need to be readily and equitably accessible for this approach to be considered a reliable option [ 36 ]. Mental health medication management stood out as a consistent challenge. HCPs in our study, regardless of their professional background, expressed difficulty in monitoring and adjusting psychiatric drugs. There was also a general lack of confidence and skill when it came to monitoring and adjusting antipsychotic medications, with the measurement of success in managing these medications being ambiguous. This is consistent with previous studies that note GPs lack of confidence in managing patients with serious mental health illness [ 12 , 37 ]. One recent study reported that less than half of GP trainees in England and Wales have trained in a mental health setting between 2013 and 2015 [ 38 ]. In addition to the need for HCPs in primary care to become trained to address issues related to psychiatric medicines, EHRs must include basic information about the indication for the prescribed psychiatric medicine and the appropriate mental health team contact details for GPs to be able to address these issues. This would have the potential to enable multidisciplinary coordination of care with mental health patients.

Another challenging group of medicines was those with anticholinergic effects. This drug class was also a recurring issue among GPs, clinical pharmacologists, and pharmacists. HCPs found it time consuming to calculate the ACB in frail, older adults. Although there are several ACB scales available that have been developed and validated, participants stated that automated calculators to calculate ACB are not easily accessible or embedded into EHRs. In addition, there is considerable variability between anticholinergic scales making it difficult to ascertain which scale to use to calculate ACB [ 39 ]. As such, taking the time out to include every medicine a patient is taking to calculate their ACB is time consuming, reducing opportunities for potential deprescribing discussions with patients.

Limitations

This study was conducted in the UK, which provides universal access to healthcare. However, findings from our study may also be applicable internationally to other health systems which operate a universal social insurance model where there is a primary care and secondary care gatekeeping model, including the need for HCP coordination [ 40 , 41 ] or deprescribing challenges [ 42 , 43 ]. This study is part of a larger qualitative study examining both barriers to SMRs and potential digital solutions, including AI-assisted approaches. As such, the HCP participants likely included a number of clinicians with a particular interest in digital-driven solutions in healthcare. We sought to include a wide variety of HCPs from different practice backgrounds in order to mitigate this. In addition, some of the focus groups contained unexpected small numbers of clinicians at one time, owing to the competing demands on clinician time. However, the data collected were rich and contributed significantly to achieving thematic saturation. The insights gained from these discussions were consistent with those from larger groups, reinforcing the validity of our findings.

Conclusions

There are few useful digital tools that can identify patients that would benefit most from an SMR or monitor the effects of medication optimisation when medicines are altered. Our findings showed that significant time is needed to prepare and conduct a SMR, with complex patients sometimes needing multiple appointments to enable a comprehensive review. The DynAIRx project will use findings from this study to address the barriers of conducting an SMR by producing dashboards and visualisations to summarise the patient’s medical journey; develop digital tools to prioritise patients that would benefit most from an SMR; and identify optimal interventions for specific multimorbidity and polypharmacy patient groups.

Supporting information

S1 appendix. topic guides for interviews and focus groups and coreq checklist..

https://doi.org/10.1371/journal.pone.0299770.s001

S2 Appendix. Table containing additional explanatory quotes relating to subthemes.

https://doi.org/10.1371/journal.pone.0299770.s002

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Qualitative research, leslie gelling reader in nursing, faculty of health, social care and education, anglia ruskin university, cambridge, england.

Qualitative research has an important role in helping nurses and other healthcare professionals understand patient experiences of health and illness. Qualitative researchers have a large number of methodological options and therefore should take care in planning and conducting their research. This article offers a brief overview of some of the key issues qualitative researchers should consider.

Nursing Standard . 29, 30, 43-47. doi: 10.7748/ns.29.30.43.e9749

This article has been subject to double blind peer review

Received: 06 November 2014

Accepted: 17 November 2014

Ethnography - focus groups - grounded theory - interviews - phenomenology - qualitative research

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25 March 2015 / Vol 29 issue 30

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Differences between Qualitative & Quantitative Research

" Quantitative research ," also called " empirical research ," refers to any research based on something that can be accurately and precisely measured.  For example, it is possible to discover exactly how many times per second a hummingbird's wings beat and measure the corresponding effects on its physiology (heart rate, temperature, etc.).

" Qualitative research " refers to any research based on something that is impossible to accurately and precisely measure.  For example, although you certainly can conduct a survey on job satisfaction and afterwards say that such-and-such percent of your respondents were very satisfied with their jobs, it is not possible to come up with an accurate, standard numerical scale to measure the level of job satisfaction precisely.

It is so easy to confuse the words "quantitative" and "qualitative," it's best to use "empirical" and "qualitative" instead.

Hint: An excellent clue that a scholarly journal article contains empirical research is the presence of some sort of statistical analysis

See "Examples of Qualitative and Quantitative" page under "Nursing Research" for more information.

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[Importance of qualitative research for nursing and nursing science]

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• 1 Universität Utrecht.
• PMID: 9370721

Qualitative research has an important place in nursing science and is becoming increasingly recognized. Qualitative research in nursing mainly deals with the lived experiences of patients and nurses. In the field of chronic illness, qualitative research has brought to the open some of the processes chronically ill patients undergo and what it means living with chronic illness. In addition, new insights were gained about the processes involved in receiving and in giving care. Qualitative research about chronic illness provided nurses with understanding of the lived experience of patients. This understanding is essential for good nursing care. However, qualitative research is not the only method and for some aspects of nursing not the adequate one. Qualitative and quantitative research are complementary.

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• Two decades of insider research: what we know and don't know about chronic illness experience. Thorne SE, Paterson BL. Thorne SE, et al. Annu Rev Nurs Res. 2000;18:3-25. Annu Rev Nurs Res. 2000. PMID: 10918930 Review.
• Capturing day-to-day aspects of living with chronic illness: the need for longitudinal designs. Russell CK, Gregory DM. Russell CK, et al. Can J Nurs Res. 2000 Dec;32(3):99-102. Can J Nurs Res. 2000. PMID: 11928137 Review. No abstract available.
• Ricoeur's hermeneutic phenomenology: an implication for nursing research. Charalambous A, Papadopoulos IR, Beadsmoore A. Charalambous A, et al. Scand J Caring Sci. 2008 Dec;22(4):637-42. doi: 10.1111/j.1471-6712.2007.00566.x. Epub 2008 Oct 16. Scand J Caring Sci. 2008. PMID: 19000085
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Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study

• Salah Alshagrawi   ORCID: orcid.org/0000-0003-2800-4794 1 &
• Norah Alhodaithy 2  

BMC Public Health volume  24 , Article number:  2333 ( 2024 ) Cite this article

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Practicing hand hygiene is a cost-effective method to decrease the occurrence of Healthcare-Associated Infections (HAIs). However, despite their simplicity, adhering to hand hygiene methods among healthcare workers (HCWs) can be highly challenging. We aim to examine the factors influencing hand hygiene compliance as perceived by HCWs working in the intensive care units (ICUs) at several major hospitals in Riyadh, Saudi Arabia.

This qualitative study was conducted by adopting a content analysis to examine the interviews of HCWs who are currently working in the ICUs of various major hospitals located in the capital city of Riyadh, Saudi Arabia.

We interviewed 49 HCWs working in ICUs, with an average age of 38 and 8 years of experience. The HCWs comprised doctors ( n  = 12), anesthesiologists ( n  = 6), and nurses ( n  = 31). There were 34 females and 15 males among the participants. Our analysis revealed several factors that impact hand hygiene compliance, including individual, work/environment, team, task, patient, organizational, and management concerns. Several obstacles and possibilities for enhancement have been identified.

The results of this study would enhance our comprehension of hand hygiene practices and serve as a foundation for creating future strategies and assessment methods to enhance compliance with hand hygiene protocols in ICUs.

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Introduction

Practicing hand hygiene is a cost-effective method to decrease the occurrence of Healthcare-Associated Infections (HAIs), impeding the advancement of antibiotic resistance, and enhancing patient safety [ 1 ]. Consequently, hand hygiene has become a vital element of infection control protocols [ 2 ]. Proper hand hygiene alone can reduce hospital infections by 50% [ 3 ]. Several studies have shown that following hand hygiene guidelines can improve patient safety and health while reducing complications, length of hospital stay, and mortality [ 4 , 5 ]. However, despite their simplicity, adhering to hand hygiene methods can be highly challenging, and several studies have demonstrated that healthcare workers (HCWs) struggle to consistently comply with proper hand hygiene protocols [ 6 , 7 ]. There is evidence indicating a significant difference between how individuals perceive their performance in the setting of health care and how they perform [ 8 ].

Maintaining hand hygiene compliance poses a significant challenge, and numerous studies have demonstrated that HCWs exhibit inadequate performance and express limited acceptance of the practice [ 6 , 7 ]. According to the World Health Organization (WHO), less than 50% of HCWs and less than 10% of institutions with heavy workloads adhere to hand hygiene regulations [ 9 ]. Globally, some estimates suggest that hand hygiene adherence is approximately 40% [ 10 , 11 ]. The rate of compliance with hand washing was significantly lower among doctors (32%) compared to nurses (48%), and lower before (21%) compared to after (47%) patient interaction [ 12 , 13 ]. Although the level of hand hygiene adherence by HCWs has historically been poor, using effective measures and interventions can greatly improve compliance with hand hygiene. A study found that when an institution makes a concerted effort to improve appropriate procedures, adherence rates increase to 65% [ 14 ].

Hand hygiene practices might be compromised by several factors such as individuals’ attitudes, beliefs, perceptions, and knowledge [ 15 , 16 , 17 ]. Studies have demonstrated that factors such as motivation, sufficient working staff, effective leadership, and proper training are effective in promoting adherence to hand hygiene protocols [ 18 , 19 ]. Additional research revealed barriers like irritation and damage to nails and hands; difficult-to-access faucets and hand wash basins; being overwhelmed or lacking enough time; being understaffed or overcrowded; interfering with patient and medical staff interactions; believing that patients’ need for hand hygiene comes first; and not having enough time for hand hygiene [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ].

The ICU is one of the departments that has the greatest susceptibility to HAIs. Although the ICU admits a lower number of patients in comparison to other departments within the hospital, it has a prevalence of HAIs that is two to five times higher [ 27 ]. ICU-admitted patients are at a heightened risk due to their potential to sustain severe injuries, the presence of invasive lines, diminished awareness, or inadequate immunity against infection [ 28 ]. ICU had lower rates of compliance with hand hygiene compared to other hospital wards. The compliance with hand hygiene protocols was much lower in ICUs (30–40%) compared to regular wards (50–60%) [ 28 ].

To the best of our knowledge, no qualitative study regarding the determinants of hand hygiene HCWs in the ICU has been conducted in Saudi Arabia. Therefore, this study aims to conduct a qualitative examination of the factors influencing hand hygiene compliance as perceived by HCWs working in the ICUs at several major hospitals in Riyadh, Saudi Arabia.

Study design

This study employed standard content analysis, a methodical process for categorizing and classifying data to evaluate, examine, and develop the fundamental concepts derived from the acquired data [ 29 ]. Qualitative research is an essential approach for examining emotions, and perspectives, and comprehending the complexities of human behavior that cannot be captured by quantitative investigations [ 30 ].

Sample and settings

We extended invitations to a total of forty-nine HCWs who are currently working in the ICU of various major hospitals located in the capital city of Riyadh, Saudi Arabia. Purposive sampling was employed to identify participants with the most diversity in age, sex, employment history, and educational attainment. The eligibility requirements for HCWs include having at least three months of prior experience working in critical care units and providing direct care to patients. The size of the sample is determined by the saturation of the data, which dictates whether there are enough findings to give comprehensive insight [ 29 ]. Data saturation was achieved in the current study after conducting interviews with 45 persons. However, an additional three interviews were conducted to confirm data saturation.

Data collection procedure

From January 4 to January 28, 2024, we conducted semi-structured individual online interviews utilizing open-ended questions to acquire an in-depth understanding of the factors that influence adherence to hand hygiene. The author performed the interviews in each of the cases. To develop the question guides and achieve the study’s purpose, relevant research was reviewed [ 31 ]. The questions underwent modest adjustments to ensure their comprehensiveness and clarity following a pilot test involving four participants.

Each interview started with the typical introduction, including acquainting oneself with the researchers and gaining an understanding of the objectives and methodologies of the study (Table  1 ). In addition, the researcher employed a series of scripted dialogues to familiarize themselves with the participants and cultivate a friendly atmosphere. The duration of the interviews varied between 40 and 50 min, during which the researcher encouraged healthcare professionals to participate in a discussion while articulating their viewpoints. Online interviewing proved beneficial in preventing dropouts as it allowed for flexible scheduling and the ability to record the interview. However, there were some minor drawbacks related to technical difficulties that occurred during the interview.

Data analysis

The data obtained was examined utilizing Graneheim and Lundman’s five-step content analysis methodology [ 32 , 33 ]. Through this methodology, codes, and themes are discovered via a methodical categorization procedure. Every interview was verbatim transcribed during the initial phase. To ensure the researchers’ full immersion in the data and to get a thorough understanding of the topic, the interview texts were thoroughly examined on several occasions. Subsequently, a comprehensive analysis was conducted on the interview transcripts to pinpoint crucial areas that were relevant to the purpose of the study. The last step entailed compressing crucial segments and categorizing them with relevant codes. The initial codes were categorized into groups based on their similarities and differences. The latent content of the data was detected and retrieved using this approach. An assistant researcher and the primary author carried out all analytic methods. The trustworthiness was assessed using Guba and Lincoln’s standards, which include confirmability, transferability, credibility, and dependability [ 34 , 35 ]. Background information, data collecting techniques, procedure, handling of data, transcripts, data evaluation, strategy, and study results were evaluated as part of the peer review process.

Ethical considerations

The study was approved by the King Fahad Medical City Institutional Review Board under number 1R800010471 and Federal Wide Assurance number FWA00018774. Following participant recruitment, the study’s aims were described to the participants, and at the start of the interview, informed written consent was acquired before any audio recording started. Data confidentiality and the freedom to join and leave the research were disclosed to the participants.

This study included 49 HCWs working in ICUs, with an average age of 38 and 8 years of experience. The HCWs comprised doctors ( n  = 12), anesthesiologists ( n  = 6), and nurses ( n  = 31). There were 34 females and 15 males among the participants.

By employing the content analysis approach, we have identified 5 overarching categories and 15 subcategories that contribute to the factors influencing hand hygiene compliance among HCWs in ICUs. Table  2 provides a concise overview of the primary categories and their corresponding subcategories.

Category 1: Individual factors

Subcategory a. knowledge of healthcare workers.

The perception that people were knowledgeable about hand hygiene guidelines was widely discussed. The majority of participants reported having the appropriate degree of knowledge regarding hand hygiene recommendations such as the WHO’s Five Moments for hand cleanliness. Furthermore, most participants demonstrated comprehension of the repercussions of inadequate hand hygiene practices, such as the development of antibiotic resistance, prolonged hospital stays, nosocomial infections, and even death.

“ I think that most of us know how to be clean and know how important it is to follow the rules. We know what will happen if some of us don’t follow the rules , and it will have an effect on the care of the patients , the hospital , and the staff .” (P8-A Doctor).

On the other hand, a few of the participants failed to recognize the significance of washing their hands and demonstrated a lack of understanding regarding the possibility of using gloves as an alternative to washing their hands.

“ We don’t all know the same things. Some of us don’t understand how important it is to wash our hands and say we don’t have time to do it. Also , I see that many of my coworkers wear gloves instead of washing their hands to save time and get the same level of protection .” (P13-A nurse). “ Some people , especially those who are new or haven’t done it before , don’t have the information and skills to practice good cleanliness .” (P28-A Anesthesiologist).

Subcategory B. Healthcare workers’ attitude

The experiences of most participants indicated that the views and attitudes of HCWs towards hand hygiene practice were crucial factors contributing to their failure to comply with hand hygiene protocols. Most subjects had a favorable attitude towards hand hygiene.

“ I think that washing my hands is easy , will save lives , and will benefit both the patient and me .” (P15-A nurse).

Subcategory C. Healthcare workers’ cognitive ability

The majority of respondents stated the cognitive competence and capability of the HCWs. Specifically, the impact of bias and memory on hand hygiene compliance was attributed to continuing stress and weariness.

“ While I think I know how to properly wash my hands and am well aware of the benefits , I do forget to do it sometimes when I have too much on my mind. I think my mind is on more important things , though. ” (P37-A nurse). “ Unfortunately , your mind just can’t work the same way it did at the start of the shift after a long day of work. I get sidetracked easily , forget some of the steps needed for good hand cleanliness , and can’t concentrate.” (P5-A Anesthesiologist).

Category 2: Team factors

Subcategory a. behavioral norms and patterns.

The majority of participants identified the behavioral norms and patterns advocated by the healthcare team as a crucial component in influencing the behavior of HCWs and determining the appropriate steps to be made regarding hand cleanliness. The establishment of these standards fostered a sense of collective accountability and specific anticipations among team members.

“ People around me , like my fellow nurses , help me a lot to be steady and aware of how to wash my hands. There are things we need to do , and we all know that these things are necessary to give the patient the best care and keep us all safe. Everyone on the team keeps an eye on each other in case anyone forgets something or needs help. This makes us more confident in our ability to give our patients the right care .” (P7-A nurse).

Subcategory B. Participative leadership

Most participants reported that effective leadership fosters an environment of shared accountability with a supportive atmosphere.

“ The team leader might make a difference in following the right steps , like washing your hands. Our leader is our example , our teacher , and the person who wakes us up and tells us of our main goal: to take care of our patients .” (P41-A nurse). “ I worked with different groups. If you have the right people on your team , they will give you the right advice and feedback and won’t blame you for your mistakes. These kinds of acts show the rules that the group and the ward follow , which may be different and better than those in other wards .” (P35-A nurse).

Subcategory C. Effective communication

The method of sharing knowledge among team members was identified as a significant factor in enhancing their adherence to hand hygiene measures. Facilitating transparent and candid communication of information and guidance enabled HCWs to overcome instances of forgetfulness and non-compliance with hand hygiene protocols.

“ It was important for everyone on the team to talk to each other. It was easy to remember to wash our hands when someone said they were going to or asked if everyone was done. This helped us all form good habits. ” (P27-A Anesthesiologist).

Moreover, when leaders demonstrate transparency and openness in disclosing past instances of infection, they provide the foundation for a cooperative learning environment.

“ Our view on the problem has changed since we learned about the number of infections in our department and how they compare to other departments and hospitals. We began talking about it with our coworkers and other experts.” (P29-A nurse).

Category 3: Work environment factors

Subcategory a. heavy workload.

Most participants indicated that the number of monitored patients and the demanding workload were crucial factors influencing hand hygiene compliance.

“ There are a lot of pressing and serious cases in the ICU , and we need to focus on a number of important tasks. Also , I have to deal with more than three people at once , and each one has different needs. This makes it hard to concentrate. ” (P11-A nurse).

Several participants stated that the excessive workload in the ICU can be attributable to the insufficient number of workers.

“ Not only do we have a lot of patients , but we also don’t have enough servers , which makes it hard to keep up with effective hand cleanliness. Too much needs to be done in too little time to make sure care is given .” (P19-A nurse).

Subcategory B. Shift pattern

The majority of participants have expressed concerns over the extended duration of their work shifts, which may exceed 12 h. Exhaustion and tension were additional significant obstacles to maintaining proper hand hygiene.

“ It seems like days last longer than they do. At the end of the shift , I’m so worn out and tired that I can’t even think straight. This makes me worry that I might not give my patients the care they need. ” (P23-A nurse). “ It feels like days are longer than they really are. When the shift is over , I’m so tired and worn out that I can’t even think straight. This makes me worry that I might not give my patients the care they need .” (P36-A nurse).

Subcategory C. Wards layout and physical design

Several participants have indicated that decreased adherence has been partly attributed to the physical configuration and arrangement of the space, as well as the fast-paced medical setting, notably in the critical care unit.

“ Sometimes , going to the sink or hand cleaner takes too much time and effort. I have to walk a long way to get to a sink , and sometimes I have to wait because it’s being used or look for another one. This is very important when there are too many people. ” (P32-A Doctor).

Category 4: Task factors

Subcategory a. hand hygiene frequency.

Some participants reported that some aspects of performing hand hygiene were a factor in ensuring compliance. For instance, the frequency and time of the process were also mentioned as another task-specific factor.

“ The constant washing of my hands has damaged the skin on my hands. Many dollars have been spent on medicated creams to protect my skin from too much cleaning and chemicals that make it sensitive .” (P2-A nurse). “ I have to make sure I have done the five moments of hand washing with every patient encounter. This would take too much time given the number of patients we are in contact with every day .” (P17-A Anesthesiologist).

Subcategory B. Physical damage and consequence

The nature of the task of performing hand hygiene involved using certain disinfectant and chemical ingredients which can pose skin irritation and nail damage over time.

“ Keeping up with rules about hand hygiene requires me to wash my hands a lot , which has done a lot of damage to my nails. It hurts most of the time now , and washing it makes it worse. ” (P24-A nurse).

Several participants have reported experiencing allergic reactions to certain disinfectants, soaps, or gloves utilized during the hand hygiene procedure.

“ Unfortunately , certain products used in the hospital make me and some of my coworkers very uncomfortable. To follow hand cleanliness rules , we have to avoid using those items , so I have to find other ones or use them less often .” (P40-A nurse).

Category 5: Organizational and management factors

Subcategory a. equipment availability.

One of the factors that contributed to compliance with hand hygiene was the availability of appropriate equipment, which was mentioned as a limitation.

“ There isn’t enough hand sanitizer when there are a lot of patients and not enough workers , especially during the day shift. We have to move to other rooms or look for it in other places. ” (P28-A nurse). “ Gloves and alcohol rubs are not always available when we need them , and we can’t always count on having enough. We sometimes have to make quick trade-offs and find other ways to get the tools we need to follow the needed hand hygiene routine. ” (P1-A nurse).

Subcategory B. Equipment quality

The majority of participants cited the quality of the equipment as a significant factor that contributed to their compliance with hand hygiene recommendations.

“ While we want to always follow the rules and wash our hands properly , the products and tools we have access to aren’t up to par. For example , some gloves aren’t very durable , and some chemicals in soap can irritate the skin. ” (P38-A nurse).

Some participants have stated that skin allergy responses have occurred as a result of items and equipment that have poor standards.

“ Itchy skin and an allergy to the chemicals in the gloves and sensitizers make me sick. These toxins hurt me a lot when I come in touch with them. My opinion is that the company should look out for its workers and keep them safe. I wish we had something that wouldn’t make allergies worse .” (P17-A nurse).

Subcategory C. Supervision and monitoring

Supervisor monitoring, together with proper planning, administration, and training opportunities, were crucial factors in achieving the desired level of hand hygiene.

“ The supervisor of our hospital is dedicated to creating a mindset of patient safety. Too many training , motivator , tracking , and billboard warnings made it easy to forget .” (P16-A nurse). “ When you have responsive and helpful management , you can talk about a problem and know that they will do something about it and make things better. ” (P5-A nurse).

Subcategory D. Safety and Just Culture

Most participants expressed that establishing a psychologically secure workplace and a fair culture, where the act of admitting errors is highly regarded, is a vital factor in ensuring compliance with hand hygiene.

“ When violations happen , management has a system where no one is to blame. I see it as a way to report any mistakes I make or gaps in my skills without worrying about being blamed for bad behavior .” (P34-A Anesthesiologist). “ We care about having an atmosphere that helps each other. Some areas have a strict and organized way of handling and making sure that people wash their hands. I don’t think this will help. I want to know that my opinion is heard , and it should be used to make things better instead of to stop people from doing something .” (P15-A nurse).

The present study sought to assess the perspective of HCWs in the ICU about the determinants of complying with hand hygiene protocols. This was accomplished using a qualitative research approach involving online interviews. The analysis of respondents’ narratives identified five major themes: individual, team, work environment, task, and organizational factors.

The participants in our study generally expressed a belief that they have sufficient knowledge of the standards and optimal methods for hand hygiene. Other studies supported and confirmed these findings [ 17 ]. A recent study indicated that the amount of knowledge expressed was moderate [ 36 ]. Additionally, it was found that a prevalent misunderstanding among HCWs was the tendency to prioritize wearing gloves above washing their hands [ 13 ]. This finding aligns with previous research conducted in ICUs, which indicated that despite the frequent use of gloves by nurses, they often neglected to properly wash or sanitize their hands after removing them [ 37 ]. Notably, substantial levels of knowledge do not invariably correspond to substantial compliance. This was demonstrated in one study in which, despite possessing a high level of knowledge, HCWs exhibited below-average adherence to hand hygiene protocols [ 15 , 24 ].

A significant proportion of our research participants had a positive attitude and perspective about hand hygiene. Other studies have shown similar findings [ 23 ]. Several studies have found that HCWs who have positive attitudes are more likely to consistently follow hand hygiene procedures [ 38 , 39 , 40 ]. However, some researchers have suggested that the attitudes of HCWs have a negligible effect on their compliance with hand hygiene protocols [ 41 , 42 , 43 ]. One plausible rationale is that these studies assessed numerous facets of attitudes toward different dimensions of hand hygiene [ 38 , 44 ]. For instance, measuring HCWs’ attitudes toward the benefits of hand hygiene could result in an agreement between the participants. The study we conducted was limited to exploring general perceptions concerning the importance and purpose of hand hygiene. As a result, it will be essential to develop educational initiatives to assess and improve HCWs’ knowledge and attitudes regarding hand-washing techniques and the standardization of health practices to enhance hand hygiene among HCWs [ 45 , 46 ].

The current study found that adherence to hand hygiene practice was significantly influenced by behavioral norms, patterns, and role modeling. Other studies have established that adherence to hand hygiene protocols is significantly influenced by the presence of role models [ 47 ]. Physicians, particularly those in high positions, have significant influence over the adherence of HCWs to hand hygiene standards [ 48 ]. This highlights the crucial role of staff and management in promoting and supporting hand hygiene measures to ensure patient safety [ 49 ]. Multiple studies have shown that a significant factor in determining hand-washing habits among young and inexperienced employees is the perception of social pressure from their superiors [ 50 , 51 ]. Furthermore, further studies have discovered that the absence of favorable social norms and role models among physicians and managers acts as a hindrance to the adoption of effective hand hygiene practices [ 52 ]. Hence, it is imperative to utilize the assistance and involvement of senior personnel, particularly physicians, to encourage strict compliance with hand hygiene practices. Simultaneously, the combination of direct monitoring and immediate feedback offers an unbiased evaluation and facilitates the provision of continuous education in real-time, resulting in improved patient care that is both more effective and safe [ 53 , 54 ]. Furthermore, it is important to establish a safety culture when implementing the feedback process. Hence, organizational culture plays a crucial role in facilitating the exchange of hand hygiene feedback without instilling fear of criticism or retaliation [ 55 , 56 , 57 , 58 ]. Several research has demonstrated that a lack of affiliation with the ICU team and limited social cohesion mostly hindered these participants from properly addressing the problem [ 59 , 60 ].

Work and environmental circumstances have the potential to impact HCWs adherence to appropriate hand hygiene protocols. Our research revealed that fatigue and burnout resulting from an excessive workload pose a significant obstacle. Staff fatigue has an impact on the effectiveness of hand hygiene [ 61 ]. HCWs were less attentive to hand hygiene practice toward the end of their shift work owing to exhaustion, and the longer the break interval between shift work, the more hand hygiene was performed [ 62 ]. In addition, HCWs are unable to allocate sufficient time for hand hygiene practices due to their heavy workload. This, along with environmental and social challenges, might contribute to job burnout [ 63 ]. Additional research has also documented a correlation between a high volume of work and situations of emergency and less adherence to hand hygiene protocols [ 64 ]. critical units have been associated with low compliance [ 25 ]. This assumption aligns with earlier research that has discovered a greater percentage of adherence in Neonatal Intensive Care Units (NICUs) compared to adult wards [ 65 ]. Multiple studies have highlighted overload as a significant obstacle to HCWs’ adherence to hand hygiene protocols [ 64 , 66 ]. The participants in the current study identified workload and a high patient volume as the primary factors contributing to failing to comply with hand hygiene. Participants expressed a belief that they lacked sufficient time to engage in hand hygiene under emergency situations, a finding consistent with the results of several research [ 64 ]. Thus, it may be inferred that HCWs may not be able to adhere to proper hand hygiene practices despite their familiarity with the recommended hand-washing procedure, as a result of their heavy workload [ 63 ]. Our research identified another obstacle, which is the inadequate physical space design. One of the barriers to practicing hand hygiene that was identified was the inadequate arrangement of the physical space in the ward, specifically with the accessibility to hand washing stations and alcohol containers. Substituting gloves for hand hygiene, limited hospital space, and unavailability of hand wash basins have been considered as barriers to hand hygiene practice, which were consistent with our study [ 23 , 64 , 66 ].

Most participants indicated obstacles associated with the nature and characteristics of hand hygiene duties and processes. One contributing factor was the frequent repetition of the activity, which led to excessive use of chemical disinfectants. This overuse can result in skin damage, pain in the hands, and even loss of nails. Similar results have been reported in other studies [ 23 , 67 ]. Insufficient availability of suitable hand hygiene products, inadequate supply of tissue paper, absence of hand dryers, and skin damage caused by repeated washing are significant obstacles to maintaining proficient hand hygiene [ 68 ]. The respondents also identified the time necessary to perform hand hygiene adequately, taking into account the five-second hand cleansing guidelines, as an additional task-specific barrier. Due to their heavy workload of patients and services, HCWs have limited time to adhere to hand sanitation protocols [ 12 ].

HCWs were unable to effectively adhere to hand hygiene protocols due to insufficient facilities and equipment, an issue that has also been noted in previous research [ 38 ]. Therefore, providing sufficient facilities and equipment is essential for effectively following hand hygiene requirements in practice [ 66 ]. Moreover, the use of proper supplies such as the correct detergent, disposable towels, and tissues, together with the implementation of automated faucets, were recognized as major reasons that led to hand hygiene protocols [ 63 ]. Therefore, the presence of adequate and high-quality equipment can promote compliance with hand hygiene regimens, thereby helping to prevent the transmission of infections.

Participants recognized the crucial role of healthcare institutions in providing the necessary assistance to enhance compliance with hand hygiene. Previous research has shown that attempts to improve hand hygiene have been insufficient due to a lack of attention given to the organizational culture [ 38 , 69 ]. Compliance with hand hygiene is generally accepted to be significantly impacted by the participation of organization leaders in infection prevention [ 70 ]. Recommended methods to promote appropriate hand hygiene practices include constructive criticism, direction from management, and well-organized work environments [ 66 ]. Hospital authorities are responsible for ensuring that correct hand hygiene protocols are followed, and they would benefit from increased supervision to address any obstacles that may hinder the implementation of these measures [ 71 ]. Thus, Hospital management can employ a hand hygiene audit system to receive prompt feedback and provide ongoing interactive teaching until satisfactory compliance is attained.

While the participants acknowledged the need to maintain adequate hand hygiene, they expressed that a major obstacle was the absence of a secure setting to report any instances of non-compliance with hand hygiene procedures [ 72 ]. The majority of participants felt that a safety culture was beneficial in ensuring the maintenance of appropriate hand hygiene practices. When HCWs perceive hand hygiene as a shared and collaborative responsibility, they can achieve the highest degree of hand hygiene [ 73 ]. It has been demonstrated that programs that concentrate on altering the culture of the firm provide positive outcomes [ 74 ]. Hence, it is imperative that we develop innovative strategies to transform the blame culture prevalent in the healthcare sector into a culture of collaboration and collective responsibility.

The majority of participants have emphasized that training and education play a crucial role in affecting adherence to hand cleanliness. Similar results were corroborated by additional investigations [ 75 ]. Efficiently constructed training programs have the potential to accelerate the learning process, ensure that staff members are well-informed about guidelines, and enhance the relationships among HCWs. Furthermore, individualized on-site training conducted by the infection control team was found to have a more significant effect compared to training delivered in a group setting [ 58 ]. Hence, implementing frequent training sessions to enhance employee knowledge and comprehension, together with providing support and constructive criticism, might be an essential component in embracing hand hygiene regulations [ 66 ].

There are a few limitations in our study. Firstly, because of its qualitative nature, we should exercise caution when generalizing ours. In addition, the limited number of participants from some categories, such as physicians, may have hindered our ability to discern variations among the professional groups. Despite these constraints, we obtained valuable understanding regarding the fact that certain settings encouraged staff to wash their hands more often. The conceivable method to address this issue is to remove individual, managerial, and organizational obstacles. This solution can be beneficial for future research, education, and practice.

The main aim of this study was to examine the key factors that influence the behavior of HCWs in the ICU when it comes to hand hygiene. Our research revealed several factors that impact hand hygiene compliance, including individual, work/environment, team, task, patient, organizational, and management concerns. Several obstacles and possibilities for enhancement have been recognized. The results of this study would enhance our comprehension of hand hygiene practices and serve as a foundation for creating future strategies and assessment methods to enhance compliance with hand hygiene protocols in ICUs. These treatments should incorporate these elements, considering the specific individual, cultural, and institutional aspects. We also recommend transitioning from a culture of blame to a culture of collaboration to enhance compliance with hand hygiene practices. Further research is necessary in the future to investigate the link between the discovered factors, uncover other drivers, and extend the findings to a broader context, given the nature of the qualitative study.

Data availability

Date are available on reasonable request.

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Alshagrawi, S., Alhodaithy, N. Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study. BMC Public Health 24 , 2333 (2024). https://doi.org/10.1186/s12889-024-19461-2

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Methodologic and Data-Analysis Triangulation in Case Studies: A Scoping Review

Margarithe charlotte schlunegger.

1 Department of Health Professions, Applied Research & Development in Nursing, Bern University of Applied Sciences, Bern, Switzerland

2 Faculty of Health, School of Nursing Science, Witten/Herdecke University, Witten, Germany

Maya Zumstein-Shaha

Rebecca palm.

3 Department of Health Care Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany

Associated Data

Supplemental material, sj-docx-1-wjn-10.1177_01939459241263011 for Methodologic and Data-Analysis Triangulation in Case Studies: A Scoping Review by Margarithe Charlotte Schlunegger, Maya Zumstein-Shaha and Rebecca Palm in Western Journal of Nursing Research

We sought to explore the processes of methodologic and data-analysis triangulation in case studies using the example of research on nurse practitioners in primary health care.

Design and methods:

We conducted a scoping review within Arksey and O’Malley’s methodological framework, considering studies that defined a case study design and used 2 or more data sources, published in English or German before August 2023.

Data sources:

The databases searched were MEDLINE and CINAHL, supplemented with hand searching of relevant nursing journals. We also examined the reference list of all the included studies.

In total, 63 reports were assessed for eligibility. Ultimately, we included 8 articles. Five studies described within-method triangulation, whereas 3 provided information on between/across-method triangulation. No study reported within-method triangulation of 2 or more quantitative data-collection procedures. The data-collection procedures were interviews, observation, documentation/documents, service records, and questionnaires/assessments. The data-analysis triangulation involved various qualitative and quantitative methods of analysis. Details about comparing or contrasting results from different qualitative and mixed-methods data were lacking.

Conclusions:

Various processes for methodologic and data-analysis triangulation are described in this scoping review but lack detail, thus hampering standardization in case study research, potentially affecting research traceability. Triangulation is complicated by terminological confusion. To advance case study research in nursing, authors should reflect critically on the processes of triangulation and employ existing tools, like a protocol or mixed-methods matrix, for transparent reporting. The only existing reporting guideline should be complemented with directions on methodologic and data-analysis triangulation.

Case study research is defined as “an empirical method that investigates a contemporary phenomenon (the ‘case’) in depth and within its real-world context, especially when the boundaries between phenomenon and context may not be clearly evident. A case study relies on multiple sources of evidence, with data needing to converge in a triangulating fashion.” 1 (p15) This design is described as a stand-alone research approach equivalent to grounded theory and can entail single and multiple cases. 1 , 2 However, case study research should not be confused with single clinical case reports. “Case reports are familiar ways of sharing events of intervening with single patients with previously unreported features.” 3 (p107) As a methodology, case study research encompasses substantially more complexity than a typical clinical case report. 1 , 3

A particular characteristic of case study research is the use of various data sources, such as quantitative data originating from questionnaires as well as qualitative data emerging from interviews, observations, or documents. Therefore, a case study always draws on multiple sources of evidence, and the data must converge in a triangulating manner. 1 When using multiple data sources, a case or cases can be examined more convincingly and accurately, compensating for the weaknesses of the respective data sources. 1 Another characteristic is the interaction of various perspectives. This involves comparing or contrasting perspectives of people with different points of view, eg, patients, staff, or leaders. 4 Through triangulation, case studies contribute to the completeness of the research on complex topics, such as role implementation in clinical practice. 1 , 5 Triangulation involves a combination of researchers from various disciplines, of theories, of methods, and/or of data sources. By creating connections between these sources (ie, investigator, theories, methods, data sources, and/or data analysis), a new understanding of the phenomenon under study can be obtained. 6 , 7

This scoping review focuses on methodologic and data-analysis triangulation because concrete procedures are missing, eg, in reporting guidelines. Methodologic triangulation has been called methods, mixed methods, or multimethods. 6 It can encompass within-method triangulation and between/across-method triangulation. 7 “Researchers using within-method triangulation use at least 2 data-collection procedures from the same design approach.” 6 (p254) Within-method triangulation is either qualitative or quantitative but not both. Therefore, within-method triangulation can also be considered data source triangulation. 8 In contrast, “researchers using between/across-method triangulation employ both qualitative and quantitative data-collection methods in the same study.” 6 (p254) Hence, methodologic approaches are combined as well as various data sources. For this scoping review, the term “methodologic triangulation” is maintained to denote between/across-method triangulation. “Data-analysis triangulation is the combination of 2 or more methods of analyzing data.” 6 (p254)

Although much has been published on case studies, there is little consensus on the quality of the various data sources, the most appropriate methods, or the procedures for conducting methodologic and data-analysis triangulation. 5 According to the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) clearinghouse for reporting guidelines, one standard exists for organizational case studies. 9 Organizational case studies provide insights into organizational change in health care services. 9 Rodgers et al 9 pointed out that, although high-quality studies are being funded and published, they are sometimes poorly articulated and methodologically inadequate. In the reporting checklist by Rodgers et al, 9 a description of the data collection is included, but reporting directions on methodologic and data-analysis triangulation are missing. Therefore, the purpose of this study was to examine the process of methodologic and data-analysis triangulation in case studies. Accordingly, we conducted a scoping review to elicit descriptions of and directions for triangulation methods and analysis, drawing on case studies of nurse practitioners (NPs) in primary health care as an example. Case studies are recommended to evaluate the implementation of new roles in (primary) health care, such as that of NPs. 1 , 5 Case studies on new role implementation can generate a unique and in-depth understanding of specific roles (individual), teams (smaller groups), family practices or similar institutions (organization), and social and political processes in health care systems. 1 , 10 The integration of NPs into health care systems is at different stages of progress around the world. 11 Therefore, studies are needed to evaluate this process.

The methodological framework by Arksey and O’Malley 12 guided this scoping review. We examined the current scientific literature on the use of methodologic and data-analysis triangulation in case studies on NPs in primary health care. The review process included the following stages: (1) establishing the research question; (2) identifying relevant studies; (3) selecting the studies for inclusion; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) consulting experts in the field. 12 Stage 6 was not performed due to a lack of financial resources. The reporting of the review followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review) guideline by Tricco et al 13 (guidelines for reporting systematic reviews and meta-analyses [ Supplementary Table A ]). Scoping reviews are not eligible for registration in PROSPERO.

Stage 1: Establishing the Research Question

The aim of this scoping review was to examine the process of triangulating methods and analysis in case studies on NPs in primary health care to improve the reporting. We sought to answer the following question: How have methodologic and data-analysis triangulation been conducted in case studies on NPs in primary health care? To answer the research question, we examined the following elements of the selected studies: the research question, the study design, the case definition, the selected data sources, and the methodologic and data-analysis triangulation.

Stage 2: Identifying Relevant Studies

A systematic database search was performed in the MEDLINE (via PubMed) and CINAHL (via EBSCO) databases between July and September 2020 to identify relevant articles. The following terms were used as keyword search strategies: (“Advanced Practice Nursing” OR “nurse practitioners”) AND (“primary health care” OR “Primary Care Nursing”) AND (“case study” OR “case studies”). Searches were limited to English- and German-language articles. Hand searches were conducted in the journals Nursing Inquiry , BMJ Open , and BioMed Central ( BMC ). We also screened the reference lists of the studies included. The database search was updated in August 2023. The complete search strategy for all the databases is presented in Supplementary Table B .

Stage 3: Selecting the Studies

Inclusion and exclusion criteria.

We used the inclusion and exclusion criteria reported in Table 1 . We included studies of NPs who had at least a master’s degree in nursing according to the definition of the International Council of Nurses. 14 This scoping review considered studies that were conducted in primary health care practices in rural, urban, and suburban regions. We excluded reviews and study protocols in which no data collection had occurred. Articles were included without limitations on the time period or country of origin.

Inclusion and Exclusion Criteria.

Screening process

After the search, we collated and uploaded all the identified records into EndNote v.X8 (Clarivate Analytics, Philadelphia, Pennsylvania) and removed any duplicates. Two independent reviewers (MCS and SA) screened the titles and abstracts for assessment in line with the inclusion criteria. They retrieved and assessed the full texts of the selected studies while applying the inclusion criteria. Any disagreements about the eligibility of studies were resolved by discussion or, if no consensus could be reached, by involving experienced researchers (MZ-S and RP).

Stages 4 and 5: Charting the Data and Collating, Summarizing, and Reporting the Results

The first reviewer (MCS) extracted data from the selected publications. For this purpose, an extraction tool developed by the authors was used. This tool comprised the following criteria: author(s), year of publication, country, research question, design, case definition, data sources, and methodologic and data-analysis triangulation. First, we extracted and summarized information about the case study design. Second, we narratively summarized the way in which the data and methodological triangulation were described. Finally, we summarized the information on within-case or cross-case analysis. This process was performed using Microsoft Excel. One reviewer (MCS) extracted data, whereas another reviewer (SA) cross-checked the data extraction, making suggestions for additions or edits. Any disagreements between the reviewers were resolved through discussion.

A total of 149 records were identified in 2 databases. We removed 20 duplicates and screened 129 reports by title and abstract. A total of 46 reports were assessed for eligibility. Through hand searches, we identified 117 additional records. Of these, we excluded 98 reports after title and abstract screening. A total of 17 reports were assessed for eligibility. From the 2 databases and the hand search, 63 reports were assessed for eligibility. Ultimately, we included 8 articles for data extraction. No further articles were included after the reference list screening of the included studies. A PRISMA flow diagram of the study selection and inclusion process is presented in Figure 1 . As shown in Tables 2 and ​ and3, 3 , the articles included in this scoping review were published between 2010 and 2022 in Canada (n = 3), the United States (n = 2), Australia (n = 2), and Scotland (n = 1).

PRISMA flow diagram.

Characteristics of Articles Included.

Overview of Within-Method, Between/Across-Method, and Data-Analysis Triangulation.

Research Question, Case Definition, and Case Study Design

The following sections describe the research question, case definition, and case study design. Case studies are most appropriate when asking “how” or “why” questions. 1 According to Yin, 1 how and why questions are explanatory and lead to the use of case studies, histories, and experiments as the preferred research methods. In 1 study from Canada, eg, the following research question was presented: “How and why did stakeholders participate in the system change process that led to the introduction of the first nurse practitioner-led Clinic in Ontario?” (p7) 19 Once the research question has been formulated, the case should be defined and, subsequently, the case study design chosen. 1 In typical case studies with mixed methods, the 2 types of data are gathered concurrently in a convergent design and the results merged to examine a case and/or compare multiple cases. 10

Research question

“How” or “why” questions were found in 4 studies. 16 , 17 , 19 , 22 Two studies additionally asked “what” questions. Three studies described an exploratory approach, and 1 study presented an explanatory approach. Of these 4 studies, 3 studies chose a qualitative approach 17 , 19 , 22 and 1 opted for mixed methods with a convergent design. 16

In the remaining studies, either the research questions were not clearly stated or no “how” or “why” questions were formulated. For example, “what” questions were found in 1 study. 21 No information was provided on exploratory, descriptive, and explanatory approaches. Schadewaldt et al 21 chose mixed methods with a convergent design.

Case definition and case study design

A total of 5 studies defined the case as an organizational unit. 17 , 18 - 20 , 22 Of the 8 articles, 4 reported multiple-case studies. 16 , 17 , 22 , 23 Another 2 publications involved single-case studies. 19 , 20 Moreover, 2 publications did not state the case study design explicitly.

Within-Method Triangulation

This section describes within-method triangulation, which involves employing at least 2 data-collection procedures within the same design approach. 6 , 7 This can also be called data source triangulation. 8 Next, we present the single data-collection procedures in detail. In 5 studies, information on within-method triangulation was found. 15 , 17 - 19 , 22 Studies describing a quantitative approach and the triangulation of 2 or more quantitative data-collection procedures could not be included in this scoping review.

Qualitative approach

Five studies used qualitative data-collection procedures. Two studies combined face-to-face interviews and documents. 15 , 19 One study mixed in-depth interviews with observations, 18 and 1 study combined face-to-face interviews and documentation. 22 One study contained face-to-face interviews, observations, and documentation. 17 The combination of different qualitative data-collection procedures was used to present the case context in an authentic and complex way, to elicit the perspectives of the participants, and to obtain a holistic description and explanation of the cases under study.

All 5 studies used qualitative interviews as the primary data-collection procedure. 15 , 17 - 19 , 22 Face-to-face, in-depth, and semi-structured interviews were conducted. The topics covered in the interviews included processes in the introduction of new care services and experiences of barriers and facilitators to collaborative work in general practices. Two studies did not specify the type of interviews conducted and did not report sample questions. 15 , 18

Observations

In 2 studies, qualitative observations were carried out. 17 , 18 During the observations, the physical design of the clinical patients’ rooms and office spaces was examined. 17 Hungerford et al 18 did not explain what information was collected during the observations. In both studies, the type of observation was not specified. Observations were generally recorded as field notes.

Public documents

In 3 studies, various qualitative public documents were studied. 15 , 19 , 22 These documents included role description, education curriculum, governance frameworks, websites, and newspapers with information about the implementation of the role and general practice. Only 1 study failed to specify the type of document and the collected data. 15

Electronic health records

In 1 study, qualitative documentation was investigated. 17 This included a review of dashboards (eg, provider productivity reports or provider quality dashboards in the electronic health record) and quality performance reports (eg, practice-wide or co-management team-wide performance reports).

Between/Across-Method Triangulation

This section describes the between/across methods, which involve employing both qualitative and quantitative data-collection procedures in the same study. 6 , 7 This procedure can also be denoted “methodologic triangulation.” 8 Subsequently, we present the individual data-collection procedures. In 3 studies, information on between/across triangulation was found. 16 , 20 , 21

Mixed methods

Three studies used qualitative and quantitative data-collection procedures. One study combined face-to-face interviews, documentation, and self-assessments. 16 One study employed semi-structured interviews, direct observation, documents, and service records, 20 and another study combined face-to-face interviews, non-participant observation, documents, and questionnaires. 23

All 3 studies used qualitative interviews as the primary data-collection procedure. 16 , 20 , 23 Face-to-face and semi-structured interviews were conducted. In the interviews, data were collected on the introduction of new care services and experiences of barriers to and facilitators of collaborative work in general practices.

Observation

In 2 studies, direct and non-participant qualitative observations were conducted. 20 , 23 During the observations, the interaction between health professionals or the organization and the clinical context was observed. Observations were generally recorded as field notes.

In 2 studies, various qualitative public documents were examined. 20 , 23 These documents included role description, newspapers, websites, and practice documents (eg, flyers). In the documents, information on the role implementation and role description of NPs was collected.

Individual journals

In 1 study, qualitative individual journals were studied. 16 These included reflective journals from NPs, who performed the role in primary health care.

Service records

Only 1 study involved quantitative service records. 20 These service records were obtained from the primary care practices and the respective health authorities. They were collected before and after the implementation of an NP role to identify changes in patients’ access to health care, the volume of patients served, and patients’ use of acute care services.

Questionnaires/Assessment

In 2 studies, quantitative questionnaires were used to gather information about the teams’ satisfaction with collaboration. 16 , 21 In 1 study, 3 validated scales were used. The scales measured experience, satisfaction, and belief in the benefits of collaboration. 21 Psychometric performance indicators of these scales were provided. However, the time points of data collection were not specified; similarly, whether the questionnaires were completed online or by hand was not mentioned. A competency self-assessment tool was used in another study. 16 The assessment comprised 70 items and included topics such as health promotion, protection, disease prevention and treatment, the NP-patient relationship, the teaching-coaching function, the professional role, managing and negotiating health care delivery systems, monitoring and ensuring the quality of health care practice, and cultural competence. Psychometric performance indicators were provided. The assessment was completed online with 2 measurement time points (pre self-assessment and post self-assessment).

Data-Analysis Triangulation

This section describes data-analysis triangulation, which involves the combination of 2 or more methods of analyzing data. 6 Subsequently, we present within-case analysis and cross-case analysis.

Mixed-methods analysis

Three studies combined qualitative and quantitative methods of analysis. 16 , 20 , 21 Two studies involved deductive and inductive qualitative analysis, and qualitative data were analyzed thematically. 20 , 21 One used deductive qualitative analysis. 16 The method of analysis was not specified in the studies. Quantitative data were analyzed using descriptive statistics in 3 studies. 16 , 20 , 23 The descriptive statistics comprised the calculation of the mean, median, and frequencies.

Qualitative methods of analysis

Two studies combined deductive and inductive qualitative analysis, 19 , 22 and 2 studies only used deductive qualitative analysis. 15 , 18 Qualitative data were analyzed thematically in 1 study, 22 and data were treated with content analysis in the other. 19 The method of analysis was not specified in the 2 studies.

Within-case analysis

In 7 studies, a within-case analysis was performed. 15 - 20 , 22 Six studies used qualitative data for the within-case analysis, and 1 study employed qualitative and quantitative data. Data were analyzed separately, consecutively, or in parallel. The themes generated from qualitative data were compared and then summarized. The individual cases were presented mostly as a narrative description. Quantitative data were integrated into the qualitative description with tables and graphs. Qualitative and quantitative data were also presented as a narrative description.

Cross-case analyses

Of the multiple-case studies, 5 carried out cross-case analyses. 15 - 17 , 20 , 22 Three studies described the cross-case analysis using qualitative data. Two studies reported a combination of qualitative and quantitative data for the cross-case analysis. In each multiple-case study, the individual cases were contrasted to identify the differences and similarities between the cases. One study did not specify whether a within-case or a cross-case analysis was conducted. 23

Confirmation or contradiction of data

This section describes confirmation or contradiction through qualitative and quantitative data. 1 , 4 Qualitative and quantitative data were reported separately, with little connection between them. As a result, the conclusions on neither the comparisons nor the contradictions could be clearly determined.

Confirmation or contradiction among qualitative data

In 3 studies, the consistency of the results of different types of qualitative data was highlighted. 16 , 19 , 21 In particular, documentation and interviews or interviews and observations were contrasted:

• Confirmation between interviews and documentation: The data from these sources corroborated the existence of a common vision for an NP-led clinic. 19
• Confirmation among interviews and observation: NPs experienced pressure to find and maintain their position within the existing system. Nurse practitioners and general practitioners performed complete episodes of care, each without collaborative interaction. 21
• Contradiction among interviews and documentation: For example, interviewees mentioned that differentiating the scope of practice between NPs and physicians is difficult as there are too many areas of overlap. However, a clear description of the scope of practice for the 2 roles was provided. 21

Confirmation through a combination of qualitative and quantitative data

Both types of data showed that NPs and general practitioners wanted to have more time in common to discuss patient cases and engage in personal exchanges. 21 In addition, the qualitative and quantitative data confirmed the individual progression of NPs from less competent to more competent. 16 One study pointed out that qualitative and quantitative data obtained similar results for the cases. 20 For example, integrating NPs improved patient access by increasing appointment availability.

Contradiction through a combination of qualitative and quantitative data

Although questionnaire results indicated that NPs and general practitioners experienced high levels of collaboration and satisfaction with the collaborative relationship, the qualitative results drew a more ambivalent picture of NPs’ and general practitioners’ experiences with collaboration. 21

Research Question and Design

The studies included in this scoping review evidenced various research questions. The recommended formats (ie, how or why questions) were not applied consistently. Therefore, no case study design should be applied because the research question is the major guide for determining the research design. 2 Furthermore, case definitions and designs were applied variably. The lack of standardization is reflected in differences in the reporting of these case studies. Generally, case study research is viewed as allowing much more freedom and flexibility. 5 , 24 However, this flexibility and the lack of uniform specifications lead to confusion.

Methodologic Triangulation

Methodologic triangulation, as described in the literature, can be somewhat confusing as it can refer to either data-collection methods or research designs. 6 , 8 For example, methodologic triangulation can allude to qualitative and quantitative methods, indicating a paradigmatic connection. Methodologic triangulation can also point to qualitative and quantitative data-collection methods, analysis, and interpretation without specific philosophical stances. 6 , 8 Regarding “data-collection methods with no philosophical stances,” we would recommend using the wording “data source triangulation” instead. Thus, the demarcation between the method and the data-collection procedures will be clearer.

Within-Method and Between/Across-Method Triangulation

Yin 1 advocated the use of multiple sources of evidence so that a case or cases can be investigated more comprehensively and accurately. Most studies included multiple data-collection procedures. Five studies employed a variety of qualitative data-collection procedures, and 3 studies used qualitative and quantitative data-collection procedures (mixed methods). In contrast, no study contained 2 or more quantitative data-collection procedures. In particular, quantitative data-collection procedures—such as validated, reliable questionnaires, scales, or assessments—were not used exhaustively. The prerequisites for using multiple data-collection procedures are availability, the knowledge and skill of the researcher, and sufficient financial funds. 1 To meet these prerequisites, research teams consisting of members with different levels of training and experience are necessary. Multidisciplinary research teams need to be aware of the strengths and weaknesses of different data sources and collection procedures. 1

Qualitative methods of analysis and results

When using multiple data sources and analysis methods, it is necessary to present the results in a coherent manner. Although the importance of multiple data sources and analysis has been emphasized, 1 , 5 the description of triangulation has tended to be brief. Thus, traceability of the research process is not always ensured. The sparse description of the data-analysis triangulation procedure may be due to the limited number of words in publications or the complexity involved in merging the different data sources.

Only a few concrete recommendations regarding the operationalization of the data-analysis triangulation with the qualitative data process were found. 25 A total of 3 approaches have been proposed 25 : (1) the intuitive approach, in which researchers intuitively connect information from different data sources; (2) the procedural approach, in which each comparative or contrasting step in triangulation is documented to ensure transparency and replicability; and (3) the intersubjective approach, which necessitates a group of researchers agreeing on the steps in the triangulation process. For each case study, one of these 3 approaches needs to be selected, carefully carried out, and documented. Thus, in-depth examination of the data can take place. Farmer et al 25 concluded that most researchers take the intuitive approach; therefore, triangulation is not clearly articulated. This trend is also evident in our scoping review.

Mixed-methods analysis and results

Few studies in this scoping review used a combination of qualitative and quantitative analysis. However, creating a comprehensive stand-alone picture of a case from both qualitative and quantitative methods is challenging. Findings derived from different data types may not automatically coalesce into a coherent whole. 4 O’Cathain et al 26 described 3 techniques for combining the results of qualitative and quantitative methods: (1) developing a triangulation protocol; (2) following a thread by selecting a theme from 1 component and following it across the other components; and (3) developing a mixed-methods matrix.

The most detailed description of the conducting of triangulation is the triangulation protocol. The triangulation protocol takes place at the interpretation stage of the research process. 26 This protocol was developed for multiple qualitative data but can also be applied to a combination of qualitative and quantitative data. 25 , 26 It is possible to determine agreement, partial agreement, “silence,” or dissonance between the results of qualitative and quantitative data. The protocol is intended to bring together the various themes from the qualitative and quantitative results and identify overarching meta-themes. 25 , 26

The “following a thread” technique is used in the analysis stage of the research process. To begin, each data source is analyzed to identify the most important themes that need further investigation. Subsequently, the research team selects 1 theme from 1 data source and follows it up in the other data source, thereby creating a thread. The individual steps of this technique are not specified. 26 , 27

A mixed-methods matrix is used at the end of the analysis. 26 All the data collected on a defined case are examined together in 1 large matrix, paying attention to cases rather than variables or themes. In a mixed-methods matrix (eg, a table), the rows represent the cases for which both qualitative and quantitative data exist. The columns show the findings for each case. This technique allows the research team to look for congruency, surprises, and paradoxes among the findings as well as patterns across multiple cases. In our review, we identified only one of these 3 approaches in the study by Roots and MacDonald. 20 These authors mentioned that a causal network analysis was performed using a matrix. However, no further details were given, and reference was made to a later publication. We could not find this publication.

Case Studies in Nursing Research and Recommendations

Because it focused on the implementation of NPs in primary health care, the setting of this scoping review was narrow. However, triangulation is essential for research in this area. This type of research was found to provide a good basis for understanding methodologic and data-analysis triangulation. Despite the lack of traceability in the description of the data and methodological triangulation, we believe that case studies are an appropriate design for exploring new nursing roles in existing health care systems. This is evidenced by the fact that case study research is widely used in many social science disciplines as well as in professional practice. 1 To strengthen this research method and increase the traceability in the research process, we recommend using the reporting guideline and reporting checklist by Rodgers et al. 9 This reporting checklist needs to be complemented with methodologic and data-analysis triangulation. A procedural approach needs to be followed in which each comparative step of the triangulation is documented. 25 A triangulation protocol or a mixed-methods matrix can be used for this purpose. 26 If there is a word limit in a publication, the triangulation protocol or mixed-methods matrix needs to be identified. A schematic representation of methodologic and data-analysis triangulation in case studies can be found in Figure 2 .

Schematic representation of methodologic and data-analysis triangulation in case studies (own work).

Limitations

This study suffered from several limitations that must be acknowledged. Given the nature of scoping reviews, we did not analyze the evidence reported in the studies. However, 2 reviewers independently reviewed all the full-text reports with respect to the inclusion criteria. The focus on the primary care setting with NPs (master’s degree) was very narrow, and only a few studies qualified. Thus, possible important methodological aspects that would have contributed to answering the questions were omitted. Studies describing the triangulation of 2 or more quantitative data-collection procedures could not be included in this scoping review due to the inclusion and exclusion criteria.

Conclusions

Given the various processes described for methodologic and data-analysis triangulation, we can conclude that triangulation in case studies is poorly standardized. Consequently, the traceability of the research process is not always given. Triangulation is complicated by the confusion of terminology. To advance case study research in nursing, we encourage authors to reflect critically on methodologic and data-analysis triangulation and use existing tools, such as the triangulation protocol or mixed-methods matrix and the reporting guideline checklist by Rodgers et al, 9 to ensure more transparent reporting.

Supplemental Material

Acknowledgments.

The authors thank Simona Aeschlimann for her support during the screening process.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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

Supplemental Material: Supplemental material for this article is available online.