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What is Qualitative in Qualitative Research

Patrik aspers.

1 Department of Sociology, Uppsala University, Uppsala, Sweden

2 Seminar for Sociology, Universität St. Gallen, St. Gallen, Switzerland

3 Department of Media and Social Sciences, University of Stavanger, Stavanger, Norway

What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being “qualitative,” the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term “qualitative.” Then, drawing on ideas we find scattered across existing work, and based on Becker’s classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research.

If we assume that there is something called qualitative research, what exactly is this qualitative feature? And how could we evaluate qualitative research as good or not? Is it fundamentally different from quantitative research? In practice, most active qualitative researchers working with empirical material intuitively know what is involved in doing qualitative research, yet perhaps surprisingly, a clear definition addressing its key feature is still missing.

To address the question of what is qualitative we turn to the accounts of “qualitative research” in textbooks and also in empirical work. In his classic, explorative, interview study of deviance Howard Becker ( 1963 ) asks ‘How does one become a marijuana user?’ In contrast to pre-dispositional and psychological-individualistic theories of deviant behavior, Becker’s inherently social explanation contends that becoming a user of this substance is the result of a three-phase sequential learning process. First, potential users need to learn how to smoke it properly to produce the “correct” effects. If not, they are likely to stop experimenting with it. Second, they need to discover the effects associated with it; in other words, to get “high,” individuals not only have to experience what the drug does, but also to become aware that those sensations are related to using it. Third, they require learning to savor the feelings related to its consumption – to develop an acquired taste. Becker, who played music himself, gets close to the phenomenon by observing, taking part, and by talking to people consuming the drug: “half of the fifty interviews were conducted with musicians, the other half covered a wide range of people, including laborers, machinists, and people in the professions” (Becker 1963 :56).

Another central aspect derived through the common-to-all-research interplay between induction and deduction (Becker 2017 ), is that during the course of his research Becker adds scientifically meaningful new distinctions in the form of three phases—distinctions, or findings if you will, that strongly affect the course of his research: its focus, the material that he collects, and which eventually impact his findings. Each phase typically unfolds through social interaction, and often with input from experienced users in “a sequence of social experiences during which the person acquires a conception of the meaning of the behavior, and perceptions and judgments of objects and situations, all of which make the activity possible and desirable” (Becker 1963 :235). In this study the increased understanding of smoking dope is a result of a combination of the meaning of the actors, and the conceptual distinctions that Becker introduces based on the views expressed by his respondents. Understanding is the result of research and is due to an iterative process in which data, concepts and evidence are connected with one another (Becker 2017 ).

Indeed, there are many definitions of qualitative research, but if we look for a definition that addresses its distinctive feature of being “qualitative,” the literature across the broad field of social science is meager. The main reason behind this article lies in the paradox, which, to put it bluntly, is that researchers act as if they know what it is, but they cannot formulate a coherent definition. Sociologists and others will of course continue to conduct good studies that show the relevance and value of qualitative research addressing scientific and practical problems in society. However, our paper is grounded in the idea that providing a clear definition will help us improve the work that we do. Among researchers who practice qualitative research there is clearly much knowledge. We suggest that a definition makes this knowledge more explicit. If the first rationale for writing this paper refers to the “internal” aim of improving qualitative research, the second refers to the increased “external” pressure that especially many qualitative researchers feel; pressure that comes both from society as well as from other scientific approaches. There is a strong core in qualitative research, and leading researchers tend to agree on what it is and how it is done. Our critique is not directed at the practice of qualitative research, but we do claim that the type of systematic work we do has not yet been done, and that it is useful to improve the field and its status in relation to quantitative research.

The literature on the “internal” aim of improving, or at least clarifying qualitative research is large, and we do not claim to be the first to notice the vagueness of the term “qualitative” (Strauss and Corbin 1998 ). Also, others have noted that there is no single definition of it (Long and Godfrey 2004 :182), that there are many different views on qualitative research (Denzin and Lincoln 2003 :11; Jovanović 2011 :3), and that more generally, we need to define its meaning (Best 2004 :54). Strauss and Corbin ( 1998 ), for example, as well as Nelson et al. (1992:2 cited in Denzin and Lincoln 2003 :11), and Flick ( 2007 :ix–x), have recognized that the term is problematic: “Actually, the term ‘qualitative research’ is confusing because it can mean different things to different people” (Strauss and Corbin 1998 :10–11). Hammersley has discussed the possibility of addressing the problem, but states that “the task of providing an account of the distinctive features of qualitative research is far from straightforward” ( 2013 :2). This confusion, as he has recently further argued (Hammersley 2018 ), is also salient in relation to ethnography where different philosophical and methodological approaches lead to a lack of agreement about what it means.

Others (e.g. Hammersley 2018 ; Fine and Hancock 2017 ) have also identified the treat to qualitative research that comes from external forces, seen from the point of view of “qualitative research.” This threat can be further divided into that which comes from inside academia, such as the critique voiced by “quantitative research” and outside of academia, including, for example, New Public Management. Hammersley ( 2018 ), zooming in on one type of qualitative research, ethnography, has argued that it is under treat. Similarly to Fine ( 2003 ), and before him Gans ( 1999 ), he writes that ethnography’ has acquired a range of meanings, and comes in many different versions, these often reflecting sharply divergent epistemological orientations. And already more than twenty years ago while reviewing Denzin and Lincoln’ s Handbook of Qualitative Methods Fine argued:

While this increasing centrality [of qualitative research] might lead one to believe that consensual standards have developed, this belief would be misleading. As the methodology becomes more widely accepted, querulous challengers have raised fundamental questions that collectively have undercut the traditional models of how qualitative research is to be fashioned and presented (1995:417).

According to Hammersley, there are today “serious treats to the practice of ethnographic work, on almost any definition” ( 2018 :1). He lists five external treats: (1) that social research must be accountable and able to show its impact on society; (2) the current emphasis on “big data” and the emphasis on quantitative data and evidence; (3) the labor market pressure in academia that leaves less time for fieldwork (see also Fine and Hancock 2017 ); (4) problems of access to fields; and (5) the increased ethical scrutiny of projects, to which ethnography is particularly exposed. Hammersley discusses some more or less insufficient existing definitions of ethnography.

The current situation, as Hammersley and others note—and in relation not only to ethnography but also qualitative research in general, and as our empirical study shows—is not just unsatisfactory, it may even be harmful for the entire field of qualitative research, and does not help social science at large. We suggest that the lack of clarity of qualitative research is a real problem that must be addressed.

Towards a Definition of Qualitative Research

Seen in an historical light, what is today called qualitative, or sometimes ethnographic, interpretative research – or a number of other terms – has more or less always existed. At the time the founders of sociology – Simmel, Weber, Durkheim and, before them, Marx – were writing, and during the era of the Methodenstreit (“dispute about methods”) in which the German historical school emphasized scientific methods (cf. Swedberg 1990 ), we can at least speak of qualitative forerunners.

Perhaps the most extended discussion of what later became known as qualitative methods in a classic work is Bronisław Malinowski’s ( 1922 ) Argonauts in the Western Pacific , although even this study does not explicitly address the meaning of “qualitative.” In Weber’s ([1921–-22] 1978) work we find a tension between scientific explanations that are based on observation and quantification and interpretative research (see also Lazarsfeld and Barton 1982 ).

If we look through major sociology journals like the American Sociological Review , American Journal of Sociology , or Social Forces we will not find the term qualitative sociology before the 1970s. And certainly before then much of what we consider qualitative classics in sociology, like Becker’ study ( 1963 ), had already been produced. Indeed, the Chicago School often combined qualitative and quantitative data within the same study (Fine 1995 ). Our point being that before a disciplinary self-awareness the term quantitative preceded qualitative, and the articulation of the former was a political move to claim scientific status (Denzin and Lincoln 2005 ). In the US the World War II seem to have sparked a critique of sociological work, including “qualitative work,” that did not follow the scientific canon (Rawls 2018 ), which was underpinned by a scientifically oriented and value free philosophy of science. As a result the attempts and practice of integrating qualitative and quantitative sociology at Chicago lost ground to sociology that was more oriented to surveys and quantitative work at Columbia under Merton-Lazarsfeld. The quantitative tradition was also able to present textbooks (Lundberg 1951 ) that facilitated the use this approach and its “methods.” The practices of the qualitative tradition, by and large, remained tacit or was part of the mentoring transferred from the renowned masters to their students.

This glimpse into history leads us back to the lack of a coherent account condensed in a definition of qualitative research. Many of the attempts to define the term do not meet the requirements of a proper definition: A definition should be clear, avoid tautology, demarcate its domain in relation to the environment, and ideally only use words in its definiens that themselves are not in need of definition (Hempel 1966 ). A definition can enhance precision and thus clarity by identifying the core of the phenomenon. Preferably, a definition should be short. The typical definition we have found, however, is an ostensive definition, which indicates what qualitative research is about without informing us about what it actually is :

Qualitative research is multimethod in focus, involving an interpretative, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives. (Denzin and Lincoln 2005 :2)

Flick claims that the label “qualitative research” is indeed used as an umbrella for a number of approaches ( 2007 :2–4; 2002 :6), and it is not difficult to identify research fitting this designation. Moreover, whatever it is, it has grown dramatically over the past five decades. In addition, courses have been developed, methods have flourished, arguments about its future have been advanced (for example, Denzin and Lincoln 1994) and criticized (for example, Snow and Morrill 1995 ), and dedicated journals and books have mushroomed. Most social scientists have a clear idea of research and how it differs from journalism, politics and other activities. But the question of what is qualitative in qualitative research is either eluded or eschewed.

We maintain that this lacuna hinders systematic knowledge production based on qualitative research. Paul Lazarsfeld noted the lack of “codification” as early as 1955 when he reviewed 100 qualitative studies in order to offer a codification of the practices (Lazarsfeld and Barton 1982 :239). Since then many texts on “qualitative research” and its methods have been published, including recent attempts (Goertz and Mahoney 2012 ) similar to Lazarsfeld’s. These studies have tried to extract what is qualitative by looking at the large number of empirical “qualitative” studies. Our novel strategy complements these endeavors by taking another approach and looking at the attempts to codify these practices in the form of a definition, as well as to a minor extent take Becker’s study as an exemplar of what qualitative researchers actually do, and what the characteristic of being ‘qualitative’ denotes and implies. We claim that qualitative researchers, if there is such a thing as “qualitative research,” should be able to codify their practices in a condensed, yet general way expressed in language.

Lingering problems of “generalizability” and “how many cases do I need” (Small 2009 ) are blocking advancement – in this line of work qualitative approaches are said to differ considerably from quantitative ones, while some of the former unsuccessfully mimic principles related to the latter (Small 2009 ). Additionally, quantitative researchers sometimes unfairly criticize the first based on their own quality criteria. Scholars like Goertz and Mahoney ( 2012 ) have successfully focused on the different norms and practices beyond what they argue are essentially two different cultures: those working with either qualitative or quantitative methods. Instead, similarly to Becker ( 2017 ) who has recently questioned the usefulness of the distinction between qualitative and quantitative research, we focus on similarities.

The current situation also impedes both students and researchers in focusing their studies and understanding each other’s work (Lazarsfeld and Barton 1982 :239). A third consequence is providing an opening for critiques by scholars operating within different traditions (Valsiner 2000 :101). A fourth issue is that the “implicit use of methods in qualitative research makes the field far less standardized than the quantitative paradigm” (Goertz and Mahoney 2012 :9). Relatedly, the National Science Foundation in the US organized two workshops in 2004 and 2005 to address the scientific foundations of qualitative research involving strategies to improve it and to develop standards of evaluation in qualitative research. However, a specific focus on its distinguishing feature of being “qualitative” while being implicitly acknowledged, was discussed only briefly (for example, Best 2004 ).

In 2014 a theme issue was published in this journal on “Methods, Materials, and Meanings: Designing Cultural Analysis,” discussing central issues in (cultural) qualitative research (Berezin 2014 ; Biernacki 2014 ; Glaeser 2014 ; Lamont and Swidler 2014 ; Spillman 2014). We agree with many of the arguments put forward, such as the risk of methodological tribalism, and that we should not waste energy on debating methods separated from research questions. Nonetheless, a clarification of the relation to what is called “quantitative research” is of outmost importance to avoid misunderstandings and misguided debates between “qualitative” and “quantitative” researchers. Our strategy means that researchers, “qualitative” or “quantitative” they may be, in their actual practice may combine qualitative work and quantitative work.

In this article we accomplish three tasks. First, we systematically survey the literature for meanings of qualitative research by looking at how researchers have defined it. Drawing upon existing knowledge we find that the different meanings and ideas of qualitative research are not yet coherently integrated into one satisfactory definition. Next, we advance our contribution by offering a definition of qualitative research and illustrate its meaning and use partially by expanding on the brief example introduced earlier related to Becker’s work ( 1963 ). We offer a systematic analysis of central themes of what researchers consider to be the core of “qualitative,” regardless of style of work. These themes – which we summarize in terms of four keywords: distinction, process, closeness, improved understanding – constitute part of our literature review, in which each one appears, sometimes with others, but never all in the same definition. They serve as the foundation of our contribution. Our categories are overlapping. Their use is primarily to organize the large amount of definitions we have identified and analyzed, and not necessarily to draw a clear distinction between them. Finally, we continue the elaboration discussed above on the advantages of a clear definition of qualitative research.

In a hermeneutic fashion we propose that there is something meaningful that deserves to be labelled “qualitative research” (Gadamer 1990 ). To approach the question “What is qualitative in qualitative research?” we have surveyed the literature. In conducting our survey we first traced the word’s etymology in dictionaries, encyclopedias, handbooks of the social sciences and of methods and textbooks, mainly in English, which is common to methodology courses. It should be noted that we have zoomed in on sociology and its literature. This discipline has been the site of the largest debate and development of methods that can be called “qualitative,” which suggests that this field should be examined in great detail.

In an ideal situation we should expect that one good definition, or at least some common ideas, would have emerged over the years. This common core of qualitative research should be so accepted that it would appear in at least some textbooks. Since this is not what we found, we decided to pursue an inductive approach to capture maximal variation in the field of qualitative research; we searched in a selection of handbooks, textbooks, book chapters, and books, to which we added the analysis of journal articles. Our sample comprises a total of 89 references.

In practice we focused on the discipline that has had a clear discussion of methods, namely sociology. We also conducted a broad search in the JSTOR database to identify scholarly sociology articles published between 1998 and 2017 in English with a focus on defining or explaining qualitative research. We specifically zoom in on this time frame because we would have expect that this more mature period would have produced clear discussions on the meaning of qualitative research. To find these articles we combined a number of keywords to search the content and/or the title: qualitative (which was always included), definition, empirical, research, methodology, studies, fieldwork, interview and observation .

As a second phase of our research we searched within nine major sociological journals ( American Journal of Sociology , Sociological Theory , American Sociological Review , Contemporary Sociology , Sociological Forum , Sociological Theory , Qualitative Research , Qualitative Sociology and Qualitative Sociology Review ) for articles also published during the past 19 years (1998–2017) that had the term “qualitative” in the title and attempted to define qualitative research.

Lastly we picked two additional journals, Qualitative Research and Qualitative Sociology , in which we could expect to find texts addressing the notion of “qualitative.” From Qualitative Research we chose Volume 14, Issue 6, December 2014, and from Qualitative Sociology we chose Volume 36, Issue 2, June 2017. Within each of these we selected the first article; then we picked the second article of three prior issues. Again we went back another three issues and investigated article number three. Finally we went back another three issues and perused article number four. This selection criteria was used to get a manageable sample for the analysis.

The coding process of the 89 references we gathered in our selected review began soon after the first round of material was gathered, and we reduced the complexity created by our maximum variation sampling (Snow and Anderson 1993 :22) to four different categories within which questions on the nature and properties of qualitative research were discussed. We call them: Qualitative and Quantitative Research, Qualitative Research, Fieldwork, and Grounded Theory. This – which may appear as an illogical grouping – merely reflects the “context” in which the matter of “qualitative” is discussed. If the selection process of the material – books and articles – was informed by pre-knowledge, we used an inductive strategy to code the material. When studying our material, we identified four central notions related to “qualitative” that appear in various combinations in the literature which indicate what is the core of qualitative research. We have labeled them: “distinctions”, “process,” “closeness,” and “improved understanding.” During the research process the categories and notions were improved, refined, changed, and reordered. The coding ended when a sense of saturation in the material arose. In the presentation below all quotations and references come from our empirical material of texts on qualitative research.

Analysis – What is Qualitative Research?

In this section we describe the four categories we identified in the coding, how they differently discuss qualitative research, as well as their overall content. Some salient quotations are selected to represent the type of text sorted under each of the four categories. What we present are examples from the literature.

Qualitative and Quantitative

This analytic category comprises quotations comparing qualitative and quantitative research, a distinction that is frequently used (Brown 2010 :231); in effect this is a conceptual pair that structures the discussion and that may be associated with opposing interests. While the general goal of quantitative and qualitative research is the same – to understand the world better – their methodologies and focus in certain respects differ substantially (Becker 1966 :55). Quantity refers to that property of something that can be determined by measurement. In a dictionary of Statistics and Methodology we find that “(a) When referring to *variables, ‘qualitative’ is another term for *categorical or *nominal. (b) When speaking of kinds of research, ‘qualitative’ refers to studies of subjects that are hard to quantify, such as art history. Qualitative research tends to be a residual category for almost any kind of non-quantitative research” (Stiles 1998:183). But it should be obvious that one could employ a quantitative approach when studying, for example, art history.

The same dictionary states that quantitative is “said of variables or research that can be handled numerically, usually (too sharply) contrasted with *qualitative variables and research” (Stiles 1998:184). From a qualitative perspective “quantitative research” is about numbers and counting, and from a quantitative perspective qualitative research is everything that is not about numbers. But this does not say much about what is “qualitative.” If we turn to encyclopedias we find that in the 1932 edition of the Encyclopedia of the Social Sciences there is no mention of “qualitative.” In the Encyclopedia from 1968 we can read:

Qualitative Analysis. For methods of obtaining, analyzing, and describing data, see [the various entries:] CONTENT ANALYSIS; COUNTED DATA; EVALUATION RESEARCH, FIELD WORK; GRAPHIC PRESENTATION; HISTORIOGRAPHY, especially the article on THE RHETORIC OF HISTORY; INTERVIEWING; OBSERVATION; PERSONALITY MEASUREMENT; PROJECTIVE METHODS; PSYCHOANALYSIS, article on EXPERIMENTAL METHODS; SURVEY ANALYSIS, TABULAR PRESENTATION; TYPOLOGIES. (Vol. 13:225)

Some, like Alford, divide researchers into methodologists or, in his words, “quantitative and qualitative specialists” (Alford 1998 :12). Qualitative research uses a variety of methods, such as intensive interviews or in-depth analysis of historical materials, and it is concerned with a comprehensive account of some event or unit (King et al. 1994 :4). Like quantitative research it can be utilized to study a variety of issues, but it tends to focus on meanings and motivations that underlie cultural symbols, personal experiences, phenomena and detailed understanding of processes in the social world. In short, qualitative research centers on understanding processes, experiences, and the meanings people assign to things (Kalof et al. 2008 :79).

Others simply say that qualitative methods are inherently unscientific (Jovanović 2011 :19). Hood, for instance, argues that words are intrinsically less precise than numbers, and that they are therefore more prone to subjective analysis, leading to biased results (Hood 2006 :219). Qualitative methodologies have raised concerns over the limitations of quantitative templates (Brady et al. 2004 :4). Scholars such as King et al. ( 1994 ), for instance, argue that non-statistical research can produce more reliable results if researchers pay attention to the rules of scientific inference commonly stated in quantitative research. Also, researchers such as Becker ( 1966 :59; 1970 :42–43) have asserted that, if conducted properly, qualitative research and in particular ethnographic field methods, can lead to more accurate results than quantitative studies, in particular, survey research and laboratory experiments.

Some researchers, such as Kalof, Dan, and Dietz ( 2008 :79) claim that the boundaries between the two approaches are becoming blurred, and Small ( 2009 ) argues that currently much qualitative research (especially in North America) tries unsuccessfully and unnecessarily to emulate quantitative standards. For others, qualitative research tends to be more humanistic and discursive (King et al. 1994 :4). Ragin ( 1994 ), and similarly also Becker, ( 1996 :53), Marchel and Owens ( 2007 :303) think that the main distinction between the two styles is overstated and does not rest on the simple dichotomy of “numbers versus words” (Ragin 1994 :xii). Some claim that quantitative data can be utilized to discover associations, but in order to unveil cause and effect a complex research design involving the use of qualitative approaches needs to be devised (Gilbert 2009 :35). Consequently, qualitative data are useful for understanding the nuances lying beyond those processes as they unfold (Gilbert 2009 :35). Others contend that qualitative research is particularly well suited both to identify causality and to uncover fine descriptive distinctions (Fine and Hallett 2014 ; Lichterman and Isaac Reed 2014 ; Katz 2015 ).

There are other ways to separate these two traditions, including normative statements about what qualitative research should be (that is, better or worse than quantitative approaches, concerned with scientific approaches to societal change or vice versa; Snow and Morrill 1995 ; Denzin and Lincoln 2005 ), or whether it should develop falsifiable statements; Best 2004 ).

We propose that quantitative research is largely concerned with pre-determined variables (Small 2008 ); the analysis concerns the relations between variables. These categories are primarily not questioned in the study, only their frequency or degree, or the correlations between them (cf. Franzosi 2016 ). If a researcher studies wage differences between women and men, he or she works with given categories: x number of men are compared with y number of women, with a certain wage attributed to each person. The idea is not to move beyond the given categories of wage, men and women; they are the starting point as well as the end point, and undergo no “qualitative change.” Qualitative research, in contrast, investigates relations between categories that are themselves subject to change in the research process. Returning to Becker’s study ( 1963 ), we see that he questioned pre-dispositional theories of deviant behavior working with pre-determined variables such as an individual’s combination of personal qualities or emotional problems. His take, in contrast, was to understand marijuana consumption by developing “variables” as part of the investigation. Thereby he presented new variables, or as we would say today, theoretical concepts, but which are grounded in the empirical material.

Qualitative Research

This category contains quotations that refer to descriptions of qualitative research without making comparisons with quantitative research. Researchers such as Denzin and Lincoln, who have written a series of influential handbooks on qualitative methods (1994; Denzin and Lincoln 2003 ; 2005 ), citing Nelson et al. (1992:4), argue that because qualitative research is “interdisciplinary, transdisciplinary, and sometimes counterdisciplinary” it is difficult to derive one single definition of it (Jovanović 2011 :3). According to them, in fact, “the field” is “many things at the same time,” involving contradictions, tensions over its focus, methods, and how to derive interpretations and findings ( 2003 : 11). Similarly, others, such as Flick ( 2007 :ix–x) contend that agreeing on an accepted definition has increasingly become problematic, and that qualitative research has possibly matured different identities. However, Best holds that “the proliferation of many sorts of activities under the label of qualitative sociology threatens to confuse our discussions” ( 2004 :54). Atkinson’s position is more definite: “the current state of qualitative research and research methods is confused” ( 2005 :3–4).

Qualitative research is about interpretation (Blumer 1969 ; Strauss and Corbin 1998 ; Denzin and Lincoln 2003 ), or Verstehen [understanding] (Frankfort-Nachmias and Nachmias 1996 ). It is “multi-method,” involving the collection and use of a variety of empirical materials (Denzin and Lincoln 1998; Silverman 2013 ) and approaches (Silverman 2005 ; Flick 2007 ). It focuses not only on the objective nature of behavior but also on its subjective meanings: individuals’ own accounts of their attitudes, motivations, behavior (McIntyre 2005 :127; Creswell 2009 ), events and situations (Bryman 1989) – what people say and do in specific places and institutions (Goodwin and Horowitz 2002 :35–36) in social and temporal contexts (Morrill and Fine 1997). For this reason, following Weber ([1921-22] 1978), it can be described as an interpretative science (McIntyre 2005 :127). But could quantitative research also be concerned with these questions? Also, as pointed out below, does all qualitative research focus on subjective meaning, as some scholars suggest?

Others also distinguish qualitative research by claiming that it collects data using a naturalistic approach (Denzin and Lincoln 2005 :2; Creswell 2009 ), focusing on the meaning actors ascribe to their actions. But again, does all qualitative research need to be collected in situ? And does qualitative research have to be inherently concerned with meaning? Flick ( 2007 ), referring to Denzin and Lincoln ( 2005 ), mentions conversation analysis as an example of qualitative research that is not concerned with the meanings people bring to a situation, but rather with the formal organization of talk. Still others, such as Ragin ( 1994 :85), note that qualitative research is often (especially early on in the project, we would add) less structured than other kinds of social research – a characteristic connected to its flexibility and that can lead both to potentially better, but also worse results. But is this not a feature of this type of research, rather than a defining description of its essence? Wouldn’t this comment also apply, albeit to varying degrees, to quantitative research?

In addition, Strauss ( 2003 ), along with others, such as Alvesson and Kärreman ( 2011 :10–76), argue that qualitative researchers struggle to capture and represent complex phenomena partially because they tend to collect a large amount of data. While his analysis is correct at some points – “It is necessary to do detailed, intensive, microscopic examination of the data in order to bring out the amazing complexity of what lies in, behind, and beyond those data” (Strauss 2003 :10) – much of his analysis concerns the supposed focus of qualitative research and its challenges, rather than exactly what it is about. But even in this instance we would make a weak case arguing that these are strictly the defining features of qualitative research. Some researchers seem to focus on the approach or the methods used, or even on the way material is analyzed. Several researchers stress the naturalistic assumption of investigating the world, suggesting that meaning and interpretation appear to be a core matter of qualitative research.

We can also see that in this category there is no consensus about specific qualitative methods nor about qualitative data. Many emphasize interpretation, but quantitative research, too, involves interpretation; the results of a regression analysis, for example, certainly have to be interpreted, and the form of meta-analysis that factor analysis provides indeed requires interpretation However, there is no interpretation of quantitative raw data, i.e., numbers in tables. One common thread is that qualitative researchers have to get to grips with their data in order to understand what is being studied in great detail, irrespective of the type of empirical material that is being analyzed. This observation is connected to the fact that qualitative researchers routinely make several adjustments of focus and research design as their studies progress, in many cases until the very end of the project (Kalof et al. 2008 ). If you, like Becker, do not start out with a detailed theory, adjustments such as the emergence and refinement of research questions will occur during the research process. We have thus found a number of useful reflections about qualitative research scattered across different sources, but none of them effectively describe the defining characteristics of this approach.

Although qualitative research does not appear to be defined in terms of a specific method, it is certainly common that fieldwork, i.e., research that entails that the researcher spends considerable time in the field that is studied and use the knowledge gained as data, is seen as emblematic of or even identical to qualitative research. But because we understand that fieldwork tends to focus primarily on the collection and analysis of qualitative data, we expected to find within it discussions on the meaning of “qualitative.” But, again, this was not the case.

Instead, we found material on the history of this approach (for example, Frankfort-Nachmias and Nachmias 1996 ; Atkinson et al. 2001), including how it has changed; for example, by adopting a more self-reflexive practice (Heyl 2001), as well as the different nomenclature that has been adopted, such as fieldwork, ethnography, qualitative research, naturalistic research, participant observation and so on (for example, Lofland et al. 2006 ; Gans 1999 ).

We retrieved definitions of ethnography, such as “the study of people acting in the natural courses of their daily lives,” involving a “resocialization of the researcher” (Emerson 1988 :1) through intense immersion in others’ social worlds (see also examples in Hammersley 2018 ). This may be accomplished by direct observation and also participation (Neuman 2007 :276), although others, such as Denzin ( 1970 :185), have long recognized other types of observation, including non-participant (“fly on the wall”). In this category we have also isolated claims and opposing views, arguing that this type of research is distinguished primarily by where it is conducted (natural settings) (Hughes 1971:496), and how it is carried out (a variety of methods are applied) or, for some most importantly, by involving an active, empathetic immersion in those being studied (Emerson 1988 :2). We also retrieved descriptions of the goals it attends in relation to how it is taught (understanding subjective meanings of the people studied, primarily develop theory, or contribute to social change) (see for example, Corte and Irwin 2017 ; Frankfort-Nachmias and Nachmias 1996 :281; Trier-Bieniek 2012 :639) by collecting the richest possible data (Lofland et al. 2006 ) to derive “thick descriptions” (Geertz 1973 ), and/or to aim at theoretical statements of general scope and applicability (for example, Emerson 1988 ; Fine 2003 ). We have identified guidelines on how to evaluate it (for example Becker 1996 ; Lamont 2004 ) and have retrieved instructions on how it should be conducted (for example, Lofland et al. 2006 ). For instance, analysis should take place while the data gathering unfolds (Emerson 1988 ; Hammersley and Atkinson 2007 ; Lofland et al. 2006 ), observations should be of long duration (Becker 1970 :54; Goffman 1989 ), and data should be of high quantity (Becker 1970 :52–53), as well as other questionable distinctions between fieldwork and other methods:

Field studies differ from other methods of research in that the researcher performs the task of selecting topics, decides what questions to ask, and forges interest in the course of the research itself . This is in sharp contrast to many ‘theory-driven’ and ‘hypothesis-testing’ methods. (Lofland and Lofland 1995 :5)

But could not, for example, a strictly interview-based study be carried out with the same amount of flexibility, such as sequential interviewing (for example, Small 2009 )? Once again, are quantitative approaches really as inflexible as some qualitative researchers think? Moreover, this category stresses the role of the actors’ meaning, which requires knowledge and close interaction with people, their practices and their lifeworld.

It is clear that field studies – which are seen by some as the “gold standard” of qualitative research – are nonetheless only one way of doing qualitative research. There are other methods, but it is not clear why some are more qualitative than others, or why they are better or worse. Fieldwork is characterized by interaction with the field (the material) and understanding of the phenomenon that is being studied. In Becker’s case, he had general experience from fields in which marihuana was used, based on which he did interviews with actual users in several fields.

Grounded Theory

Another major category we identified in our sample is Grounded Theory. We found descriptions of it most clearly in Glaser and Strauss’ ([1967] 2010 ) original articulation, Strauss and Corbin ( 1998 ) and Charmaz ( 2006 ), as well as many other accounts of what it is for: generating and testing theory (Strauss 2003 :xi). We identified explanations of how this task can be accomplished – such as through two main procedures: constant comparison and theoretical sampling (Emerson 1998:96), and how using it has helped researchers to “think differently” (for example, Strauss and Corbin 1998 :1). We also read descriptions of its main traits, what it entails and fosters – for instance, an exceptional flexibility, an inductive approach (Strauss and Corbin 1998 :31–33; 1990; Esterberg 2002 :7), an ability to step back and critically analyze situations, recognize tendencies towards bias, think abstractly and be open to criticism, enhance sensitivity towards the words and actions of respondents, and develop a sense of absorption and devotion to the research process (Strauss and Corbin 1998 :5–6). Accordingly, we identified discussions of the value of triangulating different methods (both using and not using grounded theory), including quantitative ones, and theories to achieve theoretical development (most comprehensively in Denzin 1970 ; Strauss and Corbin 1998 ; Timmermans and Tavory 2012 ). We have also located arguments about how its practice helps to systematize data collection, analysis and presentation of results (Glaser and Strauss [1967] 2010 :16).

Grounded theory offers a systematic approach which requires researchers to get close to the field; closeness is a requirement of identifying questions and developing new concepts or making further distinctions with regard to old concepts. In contrast to other qualitative approaches, grounded theory emphasizes the detailed coding process, and the numerous fine-tuned distinctions that the researcher makes during the process. Within this category, too, we could not find a satisfying discussion of the meaning of qualitative research.

Defining Qualitative Research

In sum, our analysis shows that some notions reappear in the discussion of qualitative research, such as understanding, interpretation, “getting close” and making distinctions. These notions capture aspects of what we think is “qualitative.” However, a comprehensive definition that is useful and that can further develop the field is lacking, and not even a clear picture of its essential elements appears. In other words no definition emerges from our data, and in our research process we have moved back and forth between our empirical data and the attempt to present a definition. Our concrete strategy, as stated above, is to relate qualitative and quantitative research, or more specifically, qualitative and quantitative work. We use an ideal-typical notion of quantitative research which relies on taken for granted and numbered variables. This means that the data consists of variables on different scales, such as ordinal, but frequently ratio and absolute scales, and the representation of the numbers to the variables, i.e. the justification of the assignment of numbers to object or phenomenon, are not questioned, though the validity may be questioned. In this section we return to the notion of quality and try to clarify it while presenting our contribution.

Broadly, research refers to the activity performed by people trained to obtain knowledge through systematic procedures. Notions such as “objectivity” and “reflexivity,” “systematic,” “theory,” “evidence” and “openness” are here taken for granted in any type of research. Next, building on our empirical analysis we explain the four notions that we have identified as central to qualitative work: distinctions, process, closeness, and improved understanding. In discussing them, ultimately in relation to one another, we make their meaning even more precise. Our idea, in short, is that only when these ideas that we present separately for analytic purposes are brought together can we speak of qualitative research.

Distinctions

We believe that the possibility of making new distinctions is one the defining characteristics of qualitative research. It clearly sets it apart from quantitative analysis which works with taken-for-granted variables, albeit as mentioned, meta-analyses, for example, factor analysis may result in new variables. “Quality” refers essentially to distinctions, as already pointed out by Aristotle. He discusses the term “qualitative” commenting: “By a quality I mean that in virtue of which things are said to be qualified somehow” (Aristotle 1984:14). Quality is about what something is or has, which means that the distinction from its environment is crucial. We see qualitative research as a process in which significant new distinctions are made to the scholarly community; to make distinctions is a key aspect of obtaining new knowledge; a point, as we will see, that also has implications for “quantitative research.” The notion of being “significant” is paramount. New distinctions by themselves are not enough; just adding concepts only increases complexity without furthering our knowledge. The significance of new distinctions is judged against the communal knowledge of the research community. To enable this discussion and judgements central elements of rational discussion are required (cf. Habermas [1981] 1987 ; Davidsson [ 1988 ] 2001) to identify what is new and relevant scientific knowledge. Relatedly, Ragin alludes to the idea of new and useful knowledge at a more concrete level: “Qualitative methods are appropriate for in-depth examination of cases because they aid the identification of key features of cases. Most qualitative methods enhance data” (1994:79). When Becker ( 1963 ) studied deviant behavior and investigated how people became marihuana smokers, he made distinctions between the ways in which people learned how to smoke. This is a classic example of how the strategy of “getting close” to the material, for example the text, people or pictures that are subject to analysis, may enable researchers to obtain deeper insight and new knowledge by making distinctions – in this instance on the initial notion of learning how to smoke. Others have stressed the making of distinctions in relation to coding or theorizing. Emerson et al. ( 1995 ), for example, hold that “qualitative coding is a way of opening up avenues of inquiry,” meaning that the researcher identifies and develops concepts and analytic insights through close examination of and reflection on data (Emerson et al. 1995 :151). Goodwin and Horowitz highlight making distinctions in relation to theory-building writing: “Close engagement with their cases typically requires qualitative researchers to adapt existing theories or to make new conceptual distinctions or theoretical arguments to accommodate new data” ( 2002 : 37). In the ideal-typical quantitative research only existing and so to speak, given, variables would be used. If this is the case no new distinction are made. But, would not also many “quantitative” researchers make new distinctions?

Process does not merely suggest that research takes time. It mainly implies that qualitative new knowledge results from a process that involves several phases, and above all iteration. Qualitative research is about oscillation between theory and evidence, analysis and generating material, between first- and second -order constructs (Schütz 1962 :59), between getting in contact with something, finding sources, becoming deeply familiar with a topic, and then distilling and communicating some of its essential features. The main point is that the categories that the researcher uses, and perhaps takes for granted at the beginning of the research process, usually undergo qualitative changes resulting from what is found. Becker describes how he tested hypotheses and let the jargon of the users develop into theoretical concepts. This happens over time while the study is being conducted, exemplifying what we mean by process.

In the research process, a pilot-study may be used to get a first glance of, for example, the field, how to approach it, and what methods can be used, after which the method and theory are chosen or refined before the main study begins. Thus, the empirical material is often central from the start of the project and frequently leads to adjustments by the researcher. Likewise, during the main study categories are not fixed; the empirical material is seen in light of the theory used, but it is also given the opportunity to kick back, thereby resisting attempts to apply theoretical straightjackets (Becker 1970 :43). In this process, coding and analysis are interwoven, and thus are often important steps for getting closer to the phenomenon and deciding what to focus on next. Becker began his research by interviewing musicians close to him, then asking them to refer him to other musicians, and later on doubling his original sample of about 25 to include individuals in other professions (Becker 1973:46). Additionally, he made use of some participant observation, documents, and interviews with opiate users made available to him by colleagues. As his inductive theory of deviance evolved, Becker expanded his sample in order to fine tune it, and test the accuracy and generality of his hypotheses. In addition, he introduced a negative case and discussed the null hypothesis ( 1963 :44). His phasic career model is thus based on a research design that embraces processual work. Typically, process means to move between “theory” and “material” but also to deal with negative cases, and Becker ( 1998 ) describes how discovering these negative cases impacted his research design and ultimately its findings.

Obviously, all research is process-oriented to some degree. The point is that the ideal-typical quantitative process does not imply change of the data, and iteration between data, evidence, hypotheses, empirical work, and theory. The data, quantified variables, are, in most cases fixed. Merging of data, which of course can be done in a quantitative research process, does not mean new data. New hypotheses are frequently tested, but the “raw data is often the “the same.” Obviously, over time new datasets are made available and put into use.

Another characteristic that is emphasized in our sample is that qualitative researchers – and in particular ethnographers – can, or as Goffman put it, ought to ( 1989 ), get closer to the phenomenon being studied and their data than quantitative researchers (for example, Silverman 2009 :85). Put differently, essentially because of their methods qualitative researchers get into direct close contact with those being investigated and/or the material, such as texts, being analyzed. Becker started out his interview study, as we noted, by talking to those he knew in the field of music to get closer to the phenomenon he was studying. By conducting interviews he got even closer. Had he done more observations, he would undoubtedly have got even closer to the field.

Additionally, ethnographers’ design enables researchers to follow the field over time, and the research they do is almost by definition longitudinal, though the time in the field is studied obviously differs between studies. The general characteristic of closeness over time maximizes the chances of unexpected events, new data (related, for example, to archival research as additional sources, and for ethnography for situations not necessarily previously thought of as instrumental – what Mannay and Morgan ( 2015 ) term the “waiting field”), serendipity (Merton and Barber 2004 ; Åkerström 2013 ), and possibly reactivity, as well as the opportunity to observe disrupted patterns that translate into exemplars of negative cases. Two classic examples of this are Becker’s finding of what medical students call “crocks” (Becker et al. 1961 :317), and Geertz’s ( 1973 ) study of “deep play” in Balinese society.

By getting and staying so close to their data – be it pictures, text or humans interacting (Becker was himself a musician) – for a long time, as the research progressively focuses, qualitative researchers are prompted to continually test their hunches, presuppositions and hypotheses. They test them against a reality that often (but certainly not always), and practically, as well as metaphorically, talks back, whether by validating them, or disqualifying their premises – correctly, as well as incorrectly (Fine 2003 ; Becker 1970 ). This testing nonetheless often leads to new directions for the research. Becker, for example, says that he was initially reading psychological theories, but when facing the data he develops a theory that looks at, you may say, everything but psychological dispositions to explain the use of marihuana. Especially researchers involved with ethnographic methods have a fairly unique opportunity to dig up and then test (in a circular, continuous and temporal way) new research questions and findings as the research progresses, and thereby to derive previously unimagined and uncharted distinctions by getting closer to the phenomenon under study.

Let us stress that getting close is by no means restricted to ethnography. The notion of hermeneutic circle and hermeneutics as a general way of understanding implies that we must get close to the details in order to get the big picture. This also means that qualitative researchers can literally also make use of details of pictures as evidence (cf. Harper 2002). Thus, researchers may get closer both when generating the material or when analyzing it.

Quantitative research, we maintain, in the ideal-typical representation cannot get closer to the data. The data is essentially numbers in tables making up the variables (Franzosi 2016 :138). The data may originally have been “qualitative,” but once reduced to numbers there can only be a type of “hermeneutics” about what the number may stand for. The numbers themselves, however, are non-ambiguous. Thus, in quantitative research, interpretation, if done, is not about the data itself—the numbers—but what the numbers stand for. It follows that the interpretation is essentially done in a more “speculative” mode without direct empirical evidence (cf. Becker 2017 ).

Improved Understanding

While distinction, process and getting closer refer to the qualitative work of the researcher, improved understanding refers to its conditions and outcome of this work. Understanding cuts deeper than explanation, which to some may mean a causally verified correlation between variables. The notion of explanation presupposes the notion of understanding since explanation does not include an idea of how knowledge is gained (Manicas 2006 : 15). Understanding, we argue, is the core concept of what we call the outcome of the process when research has made use of all the other elements that were integrated in the research. Understanding, then, has a special status in qualitative research since it refers both to the conditions of knowledge and the outcome of the process. Understanding can to some extent be seen as the condition of explanation and occurs in a process of interpretation, which naturally refers to meaning (Gadamer 1990 ). It is fundamentally connected to knowing, and to the knowing of how to do things (Heidegger [1927] 2001 ). Conceptually the term hermeneutics is used to account for this process. Heidegger ties hermeneutics to human being and not possible to separate from the understanding of being ( 1988 ). Here we use it in a broader sense, and more connected to method in general (cf. Seiffert 1992 ). The abovementioned aspects – for example, “objectivity” and “reflexivity” – of the approach are conditions of scientific understanding. Understanding is the result of a circular process and means that the parts are understood in light of the whole, and vice versa. Understanding presupposes pre-understanding, or in other words, some knowledge of the phenomenon studied. The pre-understanding, even in the form of prejudices, are in qualitative research process, which we see as iterative, questioned, which gradually or suddenly change due to the iteration of data, evidence and concepts. However, qualitative research generates understanding in the iterative process when the researcher gets closer to the data, e.g., by going back and forth between field and analysis in a process that generates new data that changes the evidence, and, ultimately, the findings. Questioning, to ask questions, and put what one assumes—prejudices and presumption—in question, is central to understand something (Heidegger [1927] 2001 ; Gadamer 1990 :368–384). We propose that this iterative process in which the process of understanding occurs is characteristic of qualitative research.

Improved understanding means that we obtain scientific knowledge of something that we as a scholarly community did not know before, or that we get to know something better. It means that we understand more about how parts are related to one another, and to other things we already understand (see also Fine and Hallett 2014 ). Understanding is an important condition for qualitative research. It is not enough to identify correlations, make distinctions, and work in a process in which one gets close to the field or phenomena. Understanding is accomplished when the elements are integrated in an iterative process.

It is, moreover, possible to understand many things, and researchers, just like children, may come to understand new things every day as they engage with the world. This subjective condition of understanding – namely, that a person gains a better understanding of something –is easily met. To be qualified as “scientific,” the understanding must be general and useful to many; it must be public. But even this generally accessible understanding is not enough in order to speak of “scientific understanding.” Though we as a collective can increase understanding of everything in virtually all potential directions as a result also of qualitative work, we refrain from this “objective” way of understanding, which has no means of discriminating between what we gain in understanding. Scientific understanding means that it is deemed relevant from the scientific horizon (compare Schütz 1962 : 35–38, 46, 63), and that it rests on the pre-understanding that the scientists have and must have in order to understand. In other words, the understanding gained must be deemed useful by other researchers, so that they can build on it. We thus see understanding from a pragmatic, rather than a subjective or objective perspective. Improved understanding is related to the question(s) at hand. Understanding, in order to represent an improvement, must be an improvement in relation to the existing body of knowledge of the scientific community (James [ 1907 ] 1955). Scientific understanding is, by definition, collective, as expressed in Weber’s famous note on objectivity, namely that scientific work aims at truths “which … can claim, even for a Chinese, the validity appropriate to an empirical analysis” ([1904] 1949 :59). By qualifying “improved understanding” we argue that it is a general defining characteristic of qualitative research. Becker‘s ( 1966 ) study and other research of deviant behavior increased our understanding of the social learning processes of how individuals start a behavior. And it also added new knowledge about the labeling of deviant behavior as a social process. Few studies, of course, make the same large contribution as Becker’s, but are nonetheless qualitative research.

Understanding in the phenomenological sense, which is a hallmark of qualitative research, we argue, requires meaning and this meaning is derived from the context, and above all the data being analyzed. The ideal-typical quantitative research operates with given variables with different numbers. This type of material is not enough to establish meaning at the level that truly justifies understanding. In other words, many social science explanations offer ideas about correlations or even causal relations, but this does not mean that the meaning at the level of the data analyzed, is understood. This leads us to say that there are indeed many explanations that meet the criteria of understanding, for example the explanation of how one becomes a marihuana smoker presented by Becker. However, we may also understand a phenomenon without explaining it, and we may have potential explanations, or better correlations, that are not really understood.

We may speak more generally of quantitative research and its data to clarify what we see as an important distinction. The “raw data” that quantitative research—as an idealtypical activity, refers to is not available for further analysis; the numbers, once created, are not to be questioned (Franzosi 2016 : 138). If the researcher is to do “more” or “change” something, this will be done by conjectures based on theoretical knowledge or based on the researcher’s lifeworld. Both qualitative and quantitative research is based on the lifeworld, and all researchers use prejudices and pre-understanding in the research process. This idea is present in the works of Heidegger ( 2001 ) and Heisenberg (cited in Franzosi 2010 :619). Qualitative research, as we argued, involves the interaction and questioning of concepts (theory), data, and evidence.

Ragin ( 2004 :22) points out that “a good definition of qualitative research should be inclusive and should emphasize its key strengths and features, not what it lacks (for example, the use of sophisticated quantitative techniques).” We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. Qualitative research, as defined here, is consequently a combination of two criteria: (i) how to do things –namely, generating and analyzing empirical material, in an iterative process in which one gets closer by making distinctions, and (ii) the outcome –improved understanding novel to the scholarly community. Is our definition applicable to our own study? In this study we have closely read the empirical material that we generated, and the novel distinction of the notion “qualitative research” is the outcome of an iterative process in which both deduction and induction were involved, in which we identified the categories that we analyzed. We thus claim to meet the first criteria, “how to do things.” The second criteria cannot be judged but in a partial way by us, namely that the “outcome” —in concrete form the definition-improves our understanding to others in the scientific community.

We have defined qualitative research, or qualitative scientific work, in relation to quantitative scientific work. Given this definition, qualitative research is about questioning the pre-given (taken for granted) variables, but it is thus also about making new distinctions of any type of phenomenon, for example, by coining new concepts, including the identification of new variables. This process, as we have discussed, is carried out in relation to empirical material, previous research, and thus in relation to theory. Theory and previous research cannot be escaped or bracketed. According to hermeneutic principles all scientific work is grounded in the lifeworld, and as social scientists we can thus never fully bracket our pre-understanding.

We have proposed that quantitative research, as an idealtype, is concerned with pre-determined variables (Small 2008 ). Variables are epistemically fixed, but can vary in terms of dimensions, such as frequency or number. Age is an example; as a variable it can take on different numbers. In relation to quantitative research, qualitative research does not reduce its material to number and variables. If this is done the process of comes to a halt, the researcher gets more distanced from her data, and it makes it no longer possible to make new distinctions that increase our understanding. We have above discussed the components of our definition in relation to quantitative research. Our conclusion is that in the research that is called quantitative there are frequent and necessary qualitative elements.

Further, comparative empirical research on researchers primarily working with ”quantitative” approaches and those working with ”qualitative” approaches, we propose, would perhaps show that there are many similarities in practices of these two approaches. This is not to deny dissimilarities, or the different epistemic and ontic presuppositions that may be more or less strongly associated with the two different strands (see Goertz and Mahoney 2012 ). Our point is nonetheless that prejudices and preconceptions about researchers are unproductive, and that as other researchers have argued, differences may be exaggerated (e.g., Becker 1996 : 53, 2017 ; Marchel and Owens 2007 :303; Ragin 1994 ), and that a qualitative dimension is present in both kinds of work.

Several things follow from our findings. The most important result is the relation to quantitative research. In our analysis we have separated qualitative research from quantitative research. The point is not to label individual researchers, methods, projects, or works as either “quantitative” or “qualitative.” By analyzing, i.e., taking apart, the notions of quantitative and qualitative, we hope to have shown the elements of qualitative research. Our definition captures the elements, and how they, when combined in practice, generate understanding. As many of the quotations we have used suggest, one conclusion of our study holds that qualitative approaches are not inherently connected with a specific method. Put differently, none of the methods that are frequently labelled “qualitative,” such as interviews or participant observation, are inherently “qualitative.” What matters, given our definition, is whether one works qualitatively or quantitatively in the research process, until the results are produced. Consequently, our analysis also suggests that those researchers working with what in the literature and in jargon is often called “quantitative research” are almost bound to make use of what we have identified as qualitative elements in any research project. Our findings also suggest that many” quantitative” researchers, at least to some extent, are engaged with qualitative work, such as when research questions are developed, variables are constructed and combined, and hypotheses are formulated. Furthermore, a research project may hover between “qualitative” and “quantitative” or start out as “qualitative” and later move into a “quantitative” (a distinct strategy that is not similar to “mixed methods” or just simply combining induction and deduction). More generally speaking, the categories of “qualitative” and “quantitative,” unfortunately, often cover up practices, and it may lead to “camps” of researchers opposing one another. For example, regardless of the researcher is primarily oriented to “quantitative” or “qualitative” research, the role of theory is neglected (cf. Swedberg 2017 ). Our results open up for an interaction not characterized by differences, but by different emphasis, and similarities.

Let us take two examples to briefly indicate how qualitative elements can fruitfully be combined with quantitative. Franzosi ( 2010 ) has discussed the relations between quantitative and qualitative approaches, and more specifically the relation between words and numbers. He analyzes texts and argues that scientific meaning cannot be reduced to numbers. Put differently, the meaning of the numbers is to be understood by what is taken for granted, and what is part of the lifeworld (Schütz 1962 ). Franzosi shows how one can go about using qualitative and quantitative methods and data to address scientific questions analyzing violence in Italy at the time when fascism was rising (1919–1922). Aspers ( 2006 ) studied the meaning of fashion photographers. He uses an empirical phenomenological approach, and establishes meaning at the level of actors. In a second step this meaning, and the different ideal-typical photographers constructed as a result of participant observation and interviews, are tested using quantitative data from a database; in the first phase to verify the different ideal-types, in the second phase to use these types to establish new knowledge about the types. In both of these cases—and more examples can be found—authors move from qualitative data and try to keep the meaning established when using the quantitative data.

A second main result of our study is that a definition, and we provided one, offers a way for research to clarify, and even evaluate, what is done. Hence, our definition can guide researchers and students, informing them on how to think about concrete research problems they face, and to show what it means to get closer in a process in which new distinctions are made. The definition can also be used to evaluate the results, given that it is a standard of evaluation (cf. Hammersley 2007 ), to see whether new distinctions are made and whether this improves our understanding of what is researched, in addition to the evaluation of how the research was conducted. By making what is qualitative research explicit it becomes easier to communicate findings, and it is thereby much harder to fly under the radar with substandard research since there are standards of evaluation which make it easier to separate “good” from “not so good” qualitative research.

To conclude, our analysis, which ends with a definition of qualitative research can thus both address the “internal” issues of what is qualitative research, and the “external” critiques that make it harder to do qualitative research, to which both pressure from quantitative methods and general changes in society contribute.

Acknowledgements

Financial Support for this research is given by the European Research Council, CEV (263699). The authors are grateful to Susann Krieglsteiner for assistance in collecting the data. The paper has benefitted from the many useful comments by the three reviewers and the editor, comments by members of the Uppsala Laboratory of Economic Sociology, as well as Jukka Gronow, Sebastian Kohl, Marcin Serafin, Richard Swedberg, Anders Vassenden and Turid Rødne.

Biographies

is professor of sociology at the Department of Sociology, Uppsala University and Universität St. Gallen. His main focus is economic sociology, and in particular, markets. He has published numerous articles and books, including Orderly Fashion (Princeton University Press 2010), Markets (Polity Press 2011) and Re-Imagining Economic Sociology (edited with N. Dodd, Oxford University Press 2015). His book Ethnographic Methods (in Swedish) has already gone through several editions.

is associate professor of sociology at the Department of Media and Social Sciences, University of Stavanger. His research has been published in journals such as Social Psychology Quarterly, Sociological Theory, Teaching Sociology, and Music and Arts in Action. As an ethnographer he is working on a book on he social world of big-wave surfing.

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Contributor Information

Patrik Aspers, Email: [email protected] .

Ugo Corte, Email: [email protected] .

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What is Qualitative in Qualitative Research

Affiliations.

• 1 1Department of Sociology, Uppsala University, Uppsala, Sweden.
• 2 2Seminar for Sociology, Universität St. Gallen, St. Gallen, Switzerland.
• 3 3Department of Media and Social Sciences, University of Stavanger, Stavanger, Norway.
• PMID: 31105362
• PMCID: PMC6494783
• DOI: 10.1007/s11133-019-9413-7

What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being "qualitative," the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term "qualitative." Then, drawing on ideas we find scattered across existing work, and based on Becker's classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research.

Keywords: Epistemology; Methods; Phenomenology; Philosophy of science; Qualitative research.

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How to use and assess qualitative research methods

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

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

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

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

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

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

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

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

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

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

Availability of data and materials

Not applicable.

Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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Loraine Busetto, Wolfgang Wick & Christoph Gumbinger

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Busetto, L., Wick, W. & Gumbinger, C. How to use and assess qualitative research methods. Neurol. Res. Pract. 2 , 14 (2020). https://doi.org/10.1186/s42466-020-00059-z

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The Oxford Handbook of Qualitative Research (2nd edn)

Patricia Leavy Independent Scholar Kennebunk, ME, USA

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The Oxford Handbook of Qualitative Research, second edition, presents a comprehensive retrospective and prospective review of the field of qualitative research. Original, accessible chapters written by interdisciplinary leaders in the field make this a critical reference work. Filled with robust examples from real-world research; ample discussion of the historical, theoretical, and methodological foundations of the field; and coverage of key issues including data collection, interpretation, representation, assessment, and teaching, this handbook aims to be a valuable text for students, professors, and researchers. This newly revised and expanded edition features up-to-date examples and topics, including seven new chapters on duoethnography, team research, writing ethnographically, creative approaches to writing, writing for performance, writing for the public, and teaching qualitative research.

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Qualitative Research : Definition

Qualitative research is the naturalistic study of social meanings and processes, using interviews, observations, and the analysis of texts and images.  In contrast to quantitative researchers, whose statistical methods enable broad generalizations about populations (for example, comparisons of the percentages of U.S. demographic groups who vote in particular ways), qualitative researchers use in-depth studies of the social world to analyze how and why groups think and act in particular ways (for instance, case studies of the experiences that shape political views).   

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• > Journals
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• > The Psychiatrist
• > Volume 37 Issue 6
• > Qualitative research: its value and applicability

Article contents

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

Published online by Cambridge University Press:  02 January 2018

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

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

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

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

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

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

Using combined approaches

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

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

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

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

‘Qualitative research cannot really claim reliability or validity’

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

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

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

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

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

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• Volume 37, Issue 6
• Steven J. Agius (a1)
• DOI: https://doi.org/10.1192/pb.bp.113.042770

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Qualitative vs Quantitative Research

Types of empirical research, list of journals friendly to qualitative work.

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Quantitative Research is used to quantify the problem by way of generating numerical data or data that can be transformed into useable statistics. It is used to quantify attitudes, opinions, behaviors, and other defined variables – and generalize results from a larger sample population.

Qualitative Research is primarily exploratory research.  It is used to gain an understanding of underlying reasons, opinions, and motivations. This data is usually gathered using conversational methods such as interviews or focus groups.

Some journals and even some disciplines may have a preference as to what type of empirical research they wish to publish.  Some authors who have written an article that is primarily qualitative in nature, may seek out journals that are "qualitative research friendly." We have listed a few such journals below. 

• International Journal of Qualitative Methods
• Journal of Mixed Methods Research
• Quality & Quantity
• List of qualitative research journals compiled by Saint Louis University

You can also look through the last few issues of a journal to see if the articles they publish tend to be more qualitative or quantitative in nature.

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• Last Updated: Mar 12, 2024 2:40 PM
• URL: https://libguides.lib.rochester.edu/newscholar

• Open access
• Published: 06 June 2024

“The genie is out of the bottle”: a qualitative study on the impact of COVID-19 on continuing professional development

• Sophie Soklaridis 1 , 2 , 3 , 4 , 11 ,
• Rowen Shier 1 ,
• Rabia Zaheer 1 ,
• Michelle Scully 1 ,
• Betsy Williams 5 , 6 , 7 ,
• Sam J. Daniel 8 , 10 ,
• Sanjeev Sockalingam 1 , 2 , 4 ,
• Linda Dang 9 &
• Martin Tremblay 10  

BMC Medical Education volume  24 , Article number:  631 ( 2024 ) Cite this article

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The onset of the COVID-19 pandemic catalysed a monumental shift in the field of continuing professional development (CPD). Prior to this, the majority of CPD group-learning activities were offered in-person. However, the pandemic forced the field to quickly pivot towards more novel methods of learning and teaching in view of social distancing regulations. The purpose of this study was to obtain the perspectives of CPD leaders on the impact of the pandemic to elucidate trends, innovations, and potential future directions in the field.

Semi-structured interviews were conducted between April-September 2022 with 23 CPD leaders from Canada and the USA. Interviews were audio-recorded, transcribed, and de-identified. A thematic analysis approach was used to analyse the data and generate themes.

Participants characterised COVID-19 as compelling widespread change in the field of CPD. From the interviews, researchers generated six themes pertaining to the impact of the pandemic on CPD: (1) necessity is the mother of innovation, (2) the paradox of flexibility and accessibility, (3) we’re not going to unring the bell, (4) reimagining design and delivery, (5) creating an evaluative culture, and (6) a lifeline in times of turmoil.

This qualitative study discusses the impact of the pandemic on the field of CPD and leaders’ vision for the future. Despite innumerable challenges, the pandemic created opportunities to reform design and delivery. Our findings indicate a necessity to maintain an innovative culture to best support learners, to improve the healthcare system, and to prepare for future emergencies.

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Continuing professional development (CPD) in the health professions comprises education activities which serve to maintain, develop, and/or increase health professionals’ competence and performance [ 1 , 2 ]. Research suggests that CPD is integral to safe and effective practice, and that a lack of engagement in CPD activities results in risks to patients, staff, and organisations [ 3 ].

With the global onset of the Coronavirus disease 2019 (COVID-19) pandemic in March 2020, the field of CPD was met with unprecedented disruption, echoing the turmoil felt across society. Prior to this, formal CPD opportunities were predominantly provided in person, through conferences, courses, seminars, workshops, and grand rounds [ 4 ]. Similarly, informal CPD activities traditionally took place through person-to-person mentoring, coaching [ 5 ], or membership in a community of practice [ 6 ]. Despite an abundance of promising digital technology pre-pandemic, CPD organisations largely exhibited resistance towards embracing novel delivery methods [ 7 ]. However, with the advent of COVID-19, ushering in an era of self-isolation and physical-distancing measures [ 8 ], CPD providers were compelled to adapt their approach to delivery and accreditation [ 9 ]. The urgency of this transformation was further elevated by the centrality of CPD in equipping clinicians with credible information and the necessary skills to navigate the evolving health crisis [ 10 ]. In this qualitative study, we conducted semi-structured interviews with leaders in the field of CPD across Canada and the USA to understand the trends and innovations in teaching and learning that emerged from the pandemic and to explore how leaders imagine the future of CPD education. We discuss shifting attitudes and the emergence of new priority areas. This work contributes significantly to the literature by illuminating the field’s own standpoint on its successes and shortcomings during the pandemic and ambitions for the future. We note that at the time of writing of this article the World Health Organization has declared an end to COVID-19 as a Public Health Emergency of International Concern [ 11 ], likewise there appears to be a prevailing trend to downplay the pandemic as a past tense phenomenon in an effort to return to a semblance of normalcy [ 12 ]. However, the implications of the pandemic for CPD continue to reshape the landscape, necessitating ongoing adaptations and an enduring commitment to address the evolving needs of clinician learners.

Given the exploratory nature of our study, a qualitative research design was chosen as the most appropriate method for eliciting the perspectives of CPD leaders.

Participants and recruitment

To meet the inclusion criteria, participants had to be: (1) CPD leaders, (2) work in Canada or the USA, and (3) be fluent in written and verbal English. Our criteria for a “CPD leader” included involvement in CPD scholarship (discovery, integration, application, and/or teaching) [ 13 ], while holding a formal leadership position or having 10 + years of experience in the field.

A total of 23 participants were recruited using purposive and convenience sampling [ 14 ]. This combined approach allowed us to specifically recruit individuals with expertise in CPD leadership and the knowledge needed to answer our research question. It also provided an opportunity to ask individuals within our professional network to suggest colleagues who might be interested in participating in our study. To capture variability and diversity in perspectives, participants were selected from a range of institutions (universities, colleges, and academic health centres) and geographical regions from Canada (British Columbia, Manitoba, Nova Scotia, Ontario, Quebec) and the USA (California, Illinois, Kentucky, Maryland, Ohio, Tennessee, Wisconsin). Participants’ experience in the field ranged from 2 to 35 years, and multiple participants ( n  = 12) held dual roles as CPD professionals and medical doctors.

Prospective participants were contacted by the principal investigator (SSok) through email to inform them about the study. Interested participants were thereupon forwarded to a member of the research team (RS, RZ), who was not known to them and had no affiliation with any of the CPD offices, to recruit and initiate the consent and interview process.

Data collection

Interviews, approximately 60 min in length, were conducted between April and September 2022 by two members of the research team (RS, RZ) via WebEx video conferencing [ 15 ]. Research Electronic Data Capture (REDCap), a secure web-based software platform, was used to obtain e-consent from participants [ 16 , 17 ]. Interviews were audio-recorded, transcribed, and de-identified. Quotes included in this article convey key messages from the wider data set and have been lightly edited for clarity. Open-ended interview questions covered topics including: (1) How has COVID-19 disrupted CPD? (2) How are CPD organisations adapting to the new reality? and (3) Potential future directions in CPD? (See Additional file 1 for the complete set of interview questions).

Data analysis

We conducted a thematic analysis using the six-step process detailed by Braun and Clarke [ 18 ]. After a familiarisation period, authors (RS, RZ, SSok) independently reviewed a subset of transcripts before collaboratively generating an initial codebook. Subsequently, all 23 transcripts were uploaded into Dedoose 9.0.54 qualitative-analysis software [ 19 ] and coded by authors LD, MS, and RS. Authors (LD, MS, RS, RZ, SSok) met routinely to discuss coding, reflexive memos, and to identify recurring patterns in the data. Next, authors (BW, LD, MS, MT, RS, RZ, SSok) organised codes into preliminary themes, ensuring that all codes captured under one theme were interrelated. Iterative re-coding and analysis were performed to refine themes until they were reflective of the complete data set. This article presents a subset of the data gathered during the study. A portion of the data was separately published in consideration of its distinctive thematic elements warranting detailed examination [ 20 ].

Trustworthiness

In this study we employed intercoder reliability [ 21 ], negative case analysis [ 22 ], and reflexivity [ 23 ] to enhance the trustworthiness of our analysis. Double-coding was implemented for the first three transcripts until coder consensus was established. Throughout coding and analysis, authors (LD, MS, RS, RZ) engaged in reflexive memoing to extract meaning from the data, promote critical thinking, and enhance team dialogue [ 24 ]. Furthermore, given our diverse personal and professional identities, we frequently engaged in discussion to determine appropriate research paradigms for our research objectives and to investigate our collective subjectivity [ 25 ].

Research Ethics Board approval was obtained from the Centre for Addiction and Mental Health (REB 023/2021).

From the data, we generated six themes related to the impact of the pandemic on CPD organisations: (1) necessity is the mother of innovation, (2) the paradox of flexibility and accessibility, (3) we’re not going to unring the bell, (4) reimagining design and delivery, (5) creating an evaluative culture, and (6) a lifeline in times of turmoil (See Table  1 ).

Theme 1: necessity is the mother of innovation

According to our participants, prior to the pandemic, there was widespread reluctance within CPD to deviate from ‘traditional’ ways of delivery, namely in-person education. The field showed little inclination towards the integration of emerging technologies or alternative educational approaches, holding firm in a ‘don’t fix what isn’t broken’ mentality.

“Healthcare providers are initially very resistant to new technology; we don’t want to play with new technology. We only want ‘safe’ stuff.” – P015.

The disruptions of the pandemic engendered a need for adaptation within CPD organisations. Many participants commented that change was long overdue, specifying that the required tools and technologies already existed, however, implementation had been limited. Against this setting, the pandemic brought forth an opportunity to leverage these preexisting innovations.

“Technology was already disrupting but people had a choice […] COVID took those choices away. It accelerated the use of technologies that already existed which people were struggling to get deployed.” – P008. “I guess if you say, necessity is the mother of invention, we innovated. But it’s not so much innovation as it was in some cases, we were just forced to use the tools that were there in order to connect and interact.” – P013.

Participants noted that the pandemic fundamentally shifted decision-making mechanisms within their organisations. For CPD course developers this comprised the implementation of rapid knowledge dissemination strategies and swift determinations regarding modalities and formats. Similarly, CPD accreditors created rapid response teams to expedite their procedures. Thus, previously arduous hierarchical processes were replaced with rapid and targeted decision-making approaches.

“We didn’t have the luxury of saying, okay, we can work three months with a planning committee. Everything we did in terms of identifying subject matter experts, how we engage them, the frequency we engage them, all of our processes that were tried and true for so many years, we just had to stop and re-design given this environment. I think that’s innovation.” – P002.

However, as illustrated by one participant, as the health crisis has waned, some of the conventional hierarchical practices in CPD have begun to resurface:

“In the beginning I think there was more space for innovation because a lot of the hierarchy that goes along with decision making within any institution was taken away because people realised that you had to do things, and you had to do things quickly. Some of that hierarchy has come back now.” – P007.

Nevertheless, participants determined that the pandemic imposed a much-needed shift in prevailing attitudes towards innovation:

“In the past when you brought those [technologies] up, people’s eyes glazed over […] Now they’re like, oh really, I could do that? I can operate an anaesthesia machine remotely? Tell me more! Before it was, you’ve got to be kidding me, that’s dangerous.” – P008.

Theme 2: the paradox of flexibility and accessibility

The response to virtual learning was mixed. CPD providers faced many challenges as they navigated unfamiliar technology, striving to make the content both meaningful and engaging. Additionally, concerns emerged about the potential loss of ‘hands-on’ experience, prompting questions about pedagogical quality and transferability:

“Some of it we have noticed from the residents that have been coming through, and certainly from the course that I developed, I think people are missing out on some of the hands-on training that virtual CPD cannot provide.” – P023.

Despite pedagogical uncertainties, there appeared to be a marked rise in CPD programming attendance, with many attributing this to increased accessibility and flexibility. The pivot towards virtual CPD offerings enabled participation from a broader community of clinicians in ways that were not possible pre-pandemic. Notably, some participants described how virtual platforms enhanced accessibility.

“The good thing has been the reach. Many of the providers are saying that they’ve been able to reach individual learners and audiences, including those internationally and in more rural areas that we were not able to reach before.” – P002. “For example, in India, women emergency physicians are never resourced to go to international conferences. The guys go, and the women stay behind and man the fort. Having something remote can provide access to education.” – P016. “For our young membership it’s good because they can attend even if they have a baby at home.” – P012.

Furthermore, one participant highlighted the utility of virtual CPD for learners with diverse learning needs:

“There are people that have hearing disabilities that really appreciate being online, as it’s a controlled environment […] They can really focus and concentrate on what is being said, and with the addition of subtitles, it’s really reducing some accessibility challenges.” – P019.

In contrast, some participants were less optimistic about virtual education. Although women were cited as potential benefactors of virtual CPD, they were also asymmetrically burdened by household and parental obligations during the pandemic, thus limiting their capacity to meaningfully engage in CPD.

“Women’s work was impacted significantly for clinicians and non-clinicians, because even though we talk about equality and we’re working outside our homes, we still do far more at home. I could give you examples of two or three PhD researchers in CPD who I had meetings with, and their partner got the good computer, the office, the quiet space in the basement, and they were in the TV room with SpongeBob playing […] I suspect when we look at the literature we’ll discover that a lot of guys wrote papers during COVID, and a lot of women just didn’t have the bandwidth.” – P016.

Moreover, participants signalled the challenges that older clinicians experienced with the rapid introduction of new technologies:

“A lot of our senior members closed their practices, and retired either because of the lack of patients, or the lack of their ability to acquire the technology that they needed to see their patients virtually and confidently. It really put such a burden on them.” – P023.

Similarly, several participants cautioned against adding superfluous virtual education to a busy clinician’s life. Given the inordinate rate of burnout associated with the pandemic, participants felt that an overabundance of programming compromised both clinicians’ task attention and their work/life boundaries.

“I think added flexibility for people is something that’s really important. A “7 a.m. Grand Rounds” where half of your female faculty couldn’t attend because they were dropping children off at school, but now they’re online and can actually participate. But I also think it really needs to be tempered because just because you can put something online and ask that a clinician do it in their spare time, it just erodes into the time that they’re not supposed to be doing work.” – P003. “Normally [clinicians] would book off their practice and would go to a conference for two days. That was no longer possible. So, moving online, even though there was greater flexibility, there was still that sense that I might have to stop at any moment and take a call.” – P009.

Theme 3: we’re not going to unring the bell

As pandemic restrictions eased, many organisations moved towards a “hybrid,” “blended,” or “hyflex” model of delivery. Footnote 1 Despite the lack of clarity around these terms, there was widespread expectation that this model will remain prominent.

“I foresee us living in a hybrid environment for a long time and having that extra flexibility for people to determine how they want to participate.” – P020. “The definitions are constantly changing because we haven’t really defined what it’s going to look like after the pandemic. There are all of these words that we’re using like hyflex, hybrid, but there’s no concrete definition. And there are ways of collaborative learning with technology that haven’t even been defined yet.” – P017.

Conversely, several participants acknowledged that virtual delivery may not always be preferred. While some learners appreciated this new mode of delivery, many lamented the loss of networking and social connection, as well as the Zoom fatigue associated with videoconferencing. Participants substantiated this through examples such as clinicians’ eagerness to resume in-person events despite the presence of tangible barriers, including travel time:

“We offered [a conference] virtually and in-person. The virtual numbers were so low that we cancelled the virtual. We have about 260 mostly rural doctors coming down to a location in the province because networking and getting out of the communities was so important.” – P010. “The number one complaint is we can’t break bread. We can’t talk with one another. We can’t meet our future employers. Maybe they want to speak with somebody on the east coast or the west coast. How are the programs different? We can have these conversations, but it’s limited.” – P017.

Additional considerations pertaining to hybrid events can act as deterrents. For instance, these events can be more cost prohibitive, requiring additional staffing and information technology infrastructure. This can make hybrid delivery especially challenging to implement in smaller scale contexts.

“Many [organisations] were doing hybrid [events]. We tried to do that, but we had such low numbers that it wasn’t worth the cost. It costs so much more to do both.” – P010. “The biggest problem we have right now is the smaller teams cannot do hybrid CPD. We tried to help them, but it was not a success […] They are now starting to do face-to-face CPD, and they did virtual CPD during the pandemic, but the hybrid one is really, really difficult to implement.” – P004.

Hybrid events were also described as more challenging to host than exclusively virtual or in-person events. During the initial transition to virtual delivery, both learners and educators had to navigate unfamiliar technology. Educators had to adapt their content and find ways to meaningfully engage the audience in the absence of body language and the inclination of learners to multitask. These challenges are compounded in a hybrid environment where educators must decipher how to effectively engage both audiences simultaneously.

“But if we do the two together, that’s where I think the challenge is going to be. How do you integrate both an in-person and a virtual component, and be able to satisfy both audiences, and have everyone feel included in a meaningful way?” – P010.

Despite these concerns, most participants concurred that the field has changed forever:

“What it’s going to look like after the pandemic is really hard to say because everything is changing so quickly right now, but we’re not going to unring the bell. You’re not going to get to a point where we’re going to go back to the way things were before the pandemic as far as teaching and CPD goes. We’re on a very steep learning curve right now.” – P017.

Theme 4: reimagining design and delivery

In addition to the longevity of hybrid education, participants shared how CPD could further refine delivery methods to maximise learning and drive practice change. They commented on anticipated learning model trends which included: micro and practice-based learning; learner-centric and personalised learning; workplace-based and in situ learning; collaborative learning (team-based and interprofessional education); longitudinal learning; and mentoring/coaching. Further research is needed to determine optimal learning environments, approaches, and design.

“I think CPD going forward is no longer the kind of didactic, bums in seats […] I think CPD needs to be workplace-based, practice-based, able to do where you are at, when you have time to do it, with the space and tools that you have.” – P009. “The future of CPD really has to be flexible, individualised, point in time, work integrated, leveraging people’s experiences. That sounds almost impossible today. How do you do that? Other than having a one-to-one educator learner structure. That’s my immediate thought. But that’s because we haven’t figured it out yet.” – P005.

Participants similarly contemplated the use of technology to enhance CPD education, including social media, electronic medical records, virtual reality, and artificial intelligence (AI).

“I have a feeling long-term-wise there are a lot of activities that AI could replace. For example, instead of speaking to a coach about a problem, you could get that basic interaction with AI, and you could go back to it as often as you needed as opposed to using those human resources, which is often where we run out of steam. I see [AI] as a potential significant addition that would make the delivery of CPD easier, but still effective and impactful.” – P018.

In tandem with reimagined tools and methods for education, a few participants underscored the importance of involving key stakeholders in education design, emphasising the importance of these voices in the conception, implementation, and delivery of CPD.

“Scholarship in innovation without ensuring that the end user is at the table with the implementation in the design of what you’re trying to create, I think it is potentially an oversight. Because the best designed, best intended education, with the most robust outcomes, if it cannot be adopted and integrated into the workflow of your target audience, it’s not going to matter.” – P003. “I think one way to improve things would be to have a patient, somebody who is using the health services, to have them in our meetings, and to have them take a look at the evaluation that we do of our program.” – P004.

Theme 5: creating an evaluative culture

Participants called for improved evaluation strategies to assess the quality of CPD education as well as learner and, ultimately, patient outcomes. Historically, evaluation has been insufficient and under-resourced, however, post-COVID, there appears to be increasing momentum towards a data-driven approach to improving service delivery.

“As leaders in CPD, we need to create a culture of finding new ways. We need to test what we’re actually doing and gather data and show whether or not it’s working.” – P013. “Is the quality of what is produced virtually of higher quality, lesser quality, or the same quality as in-person CPD? – P023. “We need to have some evaluations that really do reflect likelihood to change. It no longer cuts the mustard to say we served ‘x’ number of people, and they liked it.” – P011.

Furthermore, evaluations should be multipronged, longitudinal, and demonstrate tangible outcomes:

“All education should be designed around outcomes; improved patient outcomes, improved environment for people to practise in, increased value, decreased cost; there are a million.” – P003.

However, some participants noted that barriers such as limited resources, including time and money, continue to hinder meaningful evaluation initiatives.

“I think that resources don’t exist to measure outcomes and design activities in a meaningful way. Pushing on [CPD] offices to create education that leads to meaningful outcomes, again without providing the resources to measure the patient outcomes or collect and analyse the data is unfair.” – P003.

Evaluation is integral to demonstrating the value of CPD. Despite the increasing recognition of its importance, much work remains to ensure it is ingrained within the field.

“If we can’t show our value to decreasing costs and improving patient outcomes in the long-term, I do believe there is a significant threat to CPD education.” – P002. “Evaluation culture is starting, but we still have so much teaching to do to make sure that it’s something that is well accepted.” – P004.

Theme 6: a lifeline in times of turmoil

Finally, participants remarked that the value of CPD became heightened during the pandemic among medical professionals and the public. Amid chaos and confusion, it became a trusted source of information providing life-saving education about the virus, ultimately, becoming a lifeline for those working in medicine.

“It has impressed me how much CPD can do to be of value and a change in what is happening to the population. CPD plays a critical role in not only just delivering education […] We are a trusted source.” – P010. “I think the value of CPD has been significantly elevated. It became a very important, valued, sought after solution to a complex problem. And so, it has elevated its position in health professions.” – P005.

Moreover, CPD attained an indispensable status in the reorganisation of the healthcare system, expanding their mandate and facilitating interprofessional and cross-organisational collaboration to manage the crisis.

“CPD became a forum to manage this health crisis. This has shown the power of education and bringing the leaders together in helping to manage a health crisis or anything healthcare related.” – P010. “We helped our colleagues organise themselves. We reorganised the healthcare system. The nurses were gone, so what do you do in the clinics now? How can we help them? So CPD now includes management. That is something that we didn’t do before. We needed to do CPD for team leaders. They needed that. They needed the help to manage their team. All the organisation of the clinic, of the hospital, how can we be there for them, and teach them how to do it? The subjects of CPD exploded with the pandemic.” – P004.

To best prepare for the next emergency, participants extracted key lessons from COVID-19, which included adaptability, rapid decision-making, and collaboration.

“Today it’s COVID. Tomorrow it may be something else. So, educators need to find that adaptability.” – P005.

“I think we need to think about how CPD can help institutions prepare for the next pandemic. We’re going to have another pandemic at some point, how do we learn from this so that we’re better prepared to help our institutions, and how can we be strategic players in that so we can ramp up much more efficiently and less chaotically the next time we have to deal with an emergency like this.” – P014.

However, some participants expressed concern that the lessons from this pandemic may lose traction. Notably, one participant positioned this apprehension in the context of the 2002–2004 severe acute respiratory syndrome (SARS) outbreak, highlighting that much of the knowledge gained from that crisis was overlooked. This led to inadequate emergency preparedness resulting in the reactionary approach to innovation during COVID-19.

“[An author] wrote an article about SARS1 in which he outlined all of the things that CPD should become because of SARS1. It included using technology more, more longitudinal, more networking. SARS1 was quite short lived, although it was still very impactful. But there we were ten years later reading the article and it told us exactly what we should have been doing, and we would have been very prepared […] Most people will probably say that CPD has changed forever. I think it’s changed given that we’ve been in this pandemic for quite a long time. I’m still not convinced CPD has changed forever. I don’t know if we’ve changed our mindset enough as a group of professionals. I think we’re still thinking about knowledge transfer in a very traditional way. I probably sit on the side of, we will go back to as it was, more than we will hold on to the changes.” – P013.

Irrespective of participants’ viewpoints on the lasting impact of COVID-19 on CPD, there was widespread agreement that a comprehensive examination of both the failures and successes of the field’s response to the crisis is essential.

“Let’s say we get another pandemic, how can CPD be more effective in rolling out information? It’s hard to teach when information is not reliable and is ever-changing. How can CPD offices in the future, using COVID as an example, find out what went wrong, what went right?” – P011. “By the time something like a crisis happens it’s too late. It’s too late to innovate. You just respond.” – P013.

To our knowledge, this is the first study exploring the perspectives of CPD leaders regarding the impact of COVID-19 on CPD and potential directions post-pandemic. We found that the pandemic incited a long-awaited transformation in teaching and delivery, although some CPD leaders expressed reservations about the endurance of these changes. Historical evidence attests that periods of turmoil act as powerful catalysts for innovation. Our participants substantiated that the pandemic acted as an inflection point for CPD. McMahon [ 10 ] highlights that the urgent demand for new solutions prompted CPD organisations to adopt a more decentralised approach to decision-making, thus fostering an environment ripe for innovation. In alignment with the broader literature, our findings indicate that the most prominent change experienced within CPD was the transition to virtual education which was associated with a significant surge in CPD attendance at the beginning of the pandemic [ 10 , 29 , 30 , 31 ].

Increased flexibility and accessibility have been touted as the primary advantages of online learning [ 29 , 32 ]; however, there exists a duality of sentiments regarding the implications for historically excluded groups. Some scholars contend that the flexibility offered by virtual delivery has the potential to eliminate systemic barriers for equity-denied groups [ 29 , 32 ]. In particular, COVID-19 may have increased access to medical education content for women [ 29 ], parents of young children [ 33 ], individuals from remote communities [ 29 , 34 ], and international audiences [ 35 ] who may face barriers to in-person attendance. Conversely, we found that in certain instances, virtual delivery impeded clinicians’ ability to meaningfully engage in CPD, particularly for women and senior clinicians. This duality is recognized in the literature which cautions that virtual CPD may inadvertently reinforce gender disparities. There is evidence that women were disproportionately burdened by household and childcare duties during the pandemic, thereby potentially reducing their capacity to engage in virtual CPD [ 33 , 36 ]. While additional research on this topic is warranted, in light of these nascent findings, CPD program developers should consider the divergent experiences that exist among different populations when assessing content delivery modalities.

Despite the challenges listed above, our findings suggest a prevailing interest in retaining the virtual component of medical education which may significantly alter the nature of CPD delivery moving forward. In fact, some scholars argue that learning preferences have been permanently altered by the pandemic [ 31 ]. Given undergraduate and graduate medical education students also pivoted to virtual learning, with research indicating a high degree of acceptance [ 37 ], this may further reinforce the enduring nature of the virtual component. While the wider literature indicates a preference towards “hybrid” education [ 31 , 32 ], there remains gaps in knowledge regarding this modality. Our research indicates a foremost need to obtain definitional clarity regarding what constitutes “hybrid,” “hyflex,” and/or “blended” education. In addition, there remains a paucity of literature on the unique considerations associated with meaningful engagement during hybrid events. Preliminary research has begun to contribute to this gap, for example, Gottlieb et al. [ 35 ] found that using multiple mediums can introduce challenges with synchrony that dilute the quality of experience for both in-person and virtual audiences. The authors suggest that enlisting technology specialists, creating opportunities for interactivity and engagement, and ensuring that content is appropriate for digital format are crucial to enhancing hybrid events. In proceeding forward, the creation of best practices in hybrid CPD is imperative.

In conjunction with this pivot towards virtual formats, our participants asserted that greater change is needed in CPD to sustain relevance in the face of evolving societal circumstances. These calls to reform CPD predate the pandemic [ 38 ]. Our participants exhorted the investigation and adoption of innovative learning models such as team-based, workplace, and practice-based learning, which gained momentum during the pandemic. These approaches are crucial for thinking and moving beyond professional silos [ 39 ], enhancing knowledge translation through practice [ 40 ], and ensuring learned skills and knowledge are relevant to patient care [ 41 ], respectively. Moreover, several of our participants expressed a keen interest in expanding the use of innovative technology which they experimented with during COVID-19, albeit with varying degrees of success. This included the use of trending digital tools such as social media [ 42 ], podcasting [ 43 ], and AI [ 44 ], which have been explored by other scholars.

Our participants further voiced the need for CPD to be informed by systematic evaluation to measure learning and clinical outcomes. Scholars have long advocated for robust evaluation and assessment practices in CPD, contending that the development of effective learning interventions requires evidence-based content with well-defined, attainable, and measurable learning outcomes [ 45 ]. This can help bolster the value of CPD by providing objective indicators that demonstrate how CPD activities improve clinician performance, augment healthcare quality, and improve cost effectiveness [ 46 ]. While outcome evaluation is crucial, a recent scoping review [ 47 ] examining CPD evaluation techniques revealed major gaps; the authors argue for comprehensive approaches that integrate process evaluation and that are guided by theoretical frameworks. We contend that this endeavour is not possible without meaningful support from CPD offices, through both increased financial and human resources.

As a final consideration, our participants underscored the need for CPD to adopt a proactive stance in preparation for future crises. However, in light of CPD’s failure to implement lessons from previous emergencies, participants expressed concerns that takeaways from COVID-19 may not be internalised and applied moving forward. For example, in their article on CPD delivery after the 2003 Toronto SARS outbreak, Davis et al. [ 48 ] urged providers to develop a “flexible” emergency preparedness plan outlining the role of technology in achieving those aims. Moreover, the authors stressed the importance of transitioning CPD from “a passive, reactive model toward a multimodal, proactive, and systemic vehicle” to facilitate the dissemination of up-to-date information. These recommendations resonated with our participants, who felt that had these been effectuated, the field would have been better prepared for COVID-19. Drawing on lessons from the past with an eye to the future, three paramount COVID-19 takeaways were proposed: (1) the importance of fostering a culture of innovation, (2) promoting interprofessional and patient collaborations, and (3) demonstrating the value proposition of CPD as a lifeline for clinicians.

Limitations

We note that because the study sample was restricted to participants from Canada and the USA, the findings should be interpreted within this specific contextual milieu and may not necessarily be transferable to other settings. While we made efforts to recruit a diverse sample (including professional backgrounds and years of experience), we did not formally collect demographic data. Finally, given this research captured perspectives during a determinate timeframe, we acknowledge that attitudes, perspectives, and experiences may have evolved as the COVID-19 situation has progressed.

The pandemic presented profound implications for CPD, compelling a culture of adaptability and innovation. The challenges generated opportunities for the field to reimagine CPD design and delivery to reflect evolving societal conditions and preferences. Moreover, this allowed the field to build resilience and demonstrate its value to healthcare and greater society. We caution that while the public health emergency appears to have subsided, our research underscores the need to sustain progress made during the crisis to ensure a better “new normal.” As we move forward, we call for the CPD community to leverage this momentum and internalise lessons learned to avoid perpetuating past mistakes during inevitable future crises.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

It is important to note that terms such as “hybrid,” “blended,” and “hyflex” remain ambiguous with limited understanding of their precise definitions [ 26 ]. Our participants further noted there is a prevailing trend to use the above terms interchangeably in the field of CPD. As such, for the purposes of this article, we can only offer a loose definition of “hybrid,” “blended,” and “hyflex” learning as incorporating both in-person and online components [ 26 , 27 , 28 ]. Further research is needed to establish comprehensive definitions in the CPD context.

Abbreviations

• Continuing professional development

Coronavirus disease 2019

Artificial intelligence

Severe acute respiratory syndrome

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Acknowledgements

The authors thank the Fédération des médecins spécialistes du Québec for providing financial support for this work.

This study was funded by the Fédération des médecins spécialistes du Québec Collaborative Research Grant (grant number N/A).

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SSok was involved in the conception of the project, the design, data acquisition, data analysis, data interpretation, and the writing of the manuscript. RS contributed to the data acquisition, data analysis, data interpretation, and writing of the manuscript. RZ contributed to the data acquisition, data analysis, data interpretation, and writing of the manuscript. MS contributed to the data analysis, data interpretation, and writing of the manuscript. BW contributed to the data analysis, data interpretation, and writing of the manuscript. SJD was involved in the conception of the project, the design, and writing of the manuscript. SS contributed to the data acquisition and writing of the manuscript. LD contributed to the data analysis, data interpretation, and writing of the manuscript. MT was involved in the conception of the project, the design, data analysis, data interpretation, and writing of the manuscript.

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The first (SSok), second (RS), third (RZ), fourth (MS), sixth (SJD), seventh (SS), eighth (LD), and ninth (MT) are Canadian, while the fifth (BW) is American. SSok, RS, RZ, and MS are qualitative critical social science researchers. BW, SJD, SS, and MT conduct clinical outcomes research using both quantitative and qualitative methodologies. At the time of the study, LD was a student. Five authors (SSok, BW, SJD, SS, and MT) are actively engaged in North American continuing professional development initiatives, whereas four authors (RS, RZ, MS, and LD) maintain a peripheral role in the field through research contributions. Three of the authors (BW, SJD, and SS) provide clinical care.

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Soklaridis, S., Shier, R., Zaheer, R. et al. “The genie is out of the bottle”: a qualitative study on the impact of COVID-19 on continuing professional development. BMC Med Educ 24 , 631 (2024). https://doi.org/10.1186/s12909-024-05498-9

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Core Dimensions of Social Inclusion for Residents with Mental Health and/or Substance Use Challenges: A Qualitative Meta-synthesis

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Promoting social inclusion of persons with mental health and/or substance use challenges is a political priority. Despite this, this group continues to face multiple obstacles to feeling socially included. Considering the importance of experiencing social inclusion for a person’s recovery process and quality of life, an in-depth understanding of what characterizes social inclusion for this group is warranted. This meta-synthesis aimed to synthesize the qualitative findings from original research papers addressing social inclusion in a supported housing context from the perspectives of residents with mental health and/or substance use challenges.. This meta-synthesis was designed according to the recommendations of Sandelowski and Barroso ( 2007 ). Systematic searches in databases were conducted in Ovid Medline, Embase, CINAHL Complete, PsycINFO, Web of Science, and Scopus. Fourteen papers met the inclusion criteria and were included. The extracted data were analyzed in line with Graneheim and Lundman’s ( 2004 ) descriptions of qualitative content analysis. The analysis resulted in three overarching categories describing core dimensions of residents’ experiences with social inclusion: having access to core resources, participating actively oneself, and being existentially anchored . All categories contained sub-categories. Based on the findings, a new multidimensional conceptualization of social inclusion in a supported housing context was developed.

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Introduction

Domestically and globally, promoting social inclusion of persons with mental health and/or substance use challenges remains an important political goal (Norwegian Directorate of Health, 2012 , 2014 , 2016 ; United Nations, 2006 ). Persons with mental health and/or substance use challenges face multiple obstacles to experiencing a sense of belonging (Ogundipe et al., 2020 ; Semb et al., 2019 , 2021 ) and participating in the community (Ness et al., 2014 ; Skogens et al., 2018 ). This is therefore a core matter of concern, as social inclusion plays a crucial role in a person’s recovery process (De Ruysscher et al., 2017 ; Ness et al., 2014 ; Skogens et al., 2018 ) and is increasingly recognized as a key component of quality of life for this group (Filia et al., 2018 ).

Social inclusion is a multidimensional concept that includes subjective and objective dimensions such as a sense of belonging and community participation (Blank et al., 2016 ; Leonhardt et al., 2022 ; Lloyd et al., 2006 ; Ogundipe et al., 2020 , 2022 ), where both dimensions have been identified as core facilitators of recovery (Brekke et al., 2017 ; Davidson et al., 2008 ; De Ruysscher et al., 2017 ; Skogens et al., 2018 ). Thus, it is vital to gain a deeper understanding of what characterizes social inclusion for this group. This meta-synthesis addresses this issue.

Articles 19 and 30 of the United Nations Convention on the Rights of Persons with Disabilities stress the importance of fully experiencing community inclusion, which includes social inclusion (United Nations, 2006 ). To achieve social inclusion, article 19 highlights everyone’s right to have a home and receive support in the community and to have the freedom to make choices related to their living conditions. Furthermore, article 30 emphasizes the right to participate in cultural life, recreation, leisure, and sports (United Nations, 2006 ). Despite these rights, residents with mental health and/or substance use challenges, many of whom live in supported housing, continue to experience obstacles to exercising these rights (Blank et al., 2016 ; Brekke, 2019; Fields, 2011 ; Ogundipe et al., 2020 ; Ogundipe et al., 2022 ; Pilla & Park-Taylor, 2021 ; Todd et al., 2004 ).

Historically and politically, the mental health deinstitutionalization process aimed to promote the social inclusion of persons with mental health and/or substance challenges in the community (Fakhoury & Priebe, 2007 ). Following deinstitutionalization, an array of community-based housing programs (Fakhoury et al., 2002 ), hereafter referred to as supported housing programs, were introduced to support persons with mental health and/or substance use challenges to live in regular neighborhoods. The ambition was that decentralized care and support would facilitate housing stability, recovery, and life goals, enabling service users and residents to participate and integrate into their local communities and society at large (Ware et al., 2007 ; Wong & Solomon, 2002 ). Supported housing programs vary from congregate residential sites with high levels of on-site staff supervision to scattered-site apartments with off-site support (Gonzalez & Andvig, 2015a ). Although the level of support in supported housing programs may vary, social inclusion is considered a core aim in such programs (Fakhoury et al., 2002 ; Fakhoury & Priebe, 2007 ).

Social inclusion is a complex, multi-dimensional concept, which still lacks a consensual definition (Quilgars and Pleace, 2016 ). In the context of supported housing, social inclusion has been defined as “involving persons’ social interactions with community members and the structure of their social network” (Wong & Solomon, 2002 , pp. 18–19). Although Wong and Solomon’s ( 2002 ) definition were coined more than two decades ago and is widely quoted, it has also been criticized for being too narrow (Gulcur et al., 2007 ; Quilgars & Pleace, 2016 ). In this meta-synthesis, a broad focus on social inclusion is adopted, in which a sense of belonging and various forms of community participation (e.g., social participation) are recognized as dimensions of social inclusion (Blank et al., 2016 ; Leonhardt et al., 2022 ; Lloyd et al., 2006 ; Ogundipe et al., 2020 , 2022 ).

Previous research on social inclusion in the context of supported housing has shown that receiving housing is only one step towards perceived inclusion among persons with mental health and/or substance use challenges. However, there is still a distinct difference between receiving housing in the community and feeling socially included and part of the community where one lives. This recognition has led some researchers to state that persons with mental health and/or substance use challenges are “in the community, but not part of it” (Ware et al., 2007 , p. 469). This argument underscores the need to promote experiences of social inclusion that go beyond assigning housing (Ogundipe et al., 2020 ; Ware et al., 2007 ; Wong & Solomon, 2002 ). A key issue regarding supported housing and social inclusion is the question of what social inclusion means for residents (Quilgars & Pleace, 2016 ). This calls for an in-depth understanding of what characterizes the core dimensions of social inclusion for persons with mental health and/or substance use challenges living in supported housing. This study therefore aimed to synthesize findings from qualitative studies addressing social inclusion for this group from the perspectives of residents, and we asked the following research question:

What characterizes the core dimensions of social inclusion for persons with mental health and/or substance use challenges living in supported housing?

For this meta-synthesis, we applied a flexible descriptive design, leaning on the recommendations of Sandelowski and Barroso ( 2007 ). The methodological approach applied in this meta-synthesis followed six phases: (1) formulating the research question, (2) conducting a systematic literature search, (3) screening and selecting appropriate research papers, (4) analyzing and synthesizing qualitative findings, (5) maintaining quality control, and (6) presenting findings.

Databases and Search Strategy

Six databases were considered relevant for systematic searches to identify relevant papers addressing core dimensions of social inclusion in a supported housing context: Ovid Medline, Embase, CINAHL Complete, PsycINFO, Web of Science, and Scopus. The chosen databases cover general health issues, psychological issues, and interdisciplinary issues, all relevant to the aim of this meta-synthesis. Keywords and terms from the controlled vocabularies of the selected databases, where these were available, covering the three main categories/themes, housing AND social inclusion AND mental health/substance use/co-occurring disorders, were identified. Further possible search words were identified by the authors based on their knowledge of keywords used in the research literature.

In the housing literature, the terms “supported housing” and “supportive housing” are frequently defined in similar ways (Rog, 2004 ), and are often used interchangeably (Tabol et al., 2010 ). Thus, research papers addressing persons living in housing program contexts identified as supported housing and supportive housing were included. Likewise, papers addressing other housing programs with similar principles, such as resident empowerment, choice, community inclusion, and flexible support, were also included. Core information about the housing programs in the included papers is presented in Table  1 .

We applied a search filter for identify qualitative papers developed by Biomedical Information of the Dutch Library Association and further adapted to several other databases by librarians at the University of Stavanger. The search was limited to papers published in English or Scandinavian languages. The search was performed in February 2022 by a specialist health librarian at the University of South-Eastern Norway. An outline of the search strategy is presented in Fig.  1 . A detailed search strategy is available from the authors upon request.

The search strategy

Inclusion Criteria

The inclusion criteria for qualitative research papers were: (1) papers published in peer-reviewed journals, (2) papers addressing social inclusion, and (3) papers with a qualitative design or mixed studies reporting findings from qualitative results.

Retrieval of Papers

The search strategy identified a total of 1549 papers. Of these, 772 were removed as they were duplicates. The abstracts from the remaining 777 papers were thoroughly reviewed, resulting in 638 papers being excluded for reasons related to the inclusion criteria. The remaining 139 papers were obtained, and a full-text screening of these led to the elimination of 114 papers. At this stage, papers addressing homelessness and transitioning from streets or institutions to housing were removed. The remaining 25 papers were thoroughly assessed with the study aim and research question of the meta-synthesis in mind, resulting in the exclusion of an additional 11 papers. Finally, 14 papers were left for further analysis. The paper retrieval process is presented in the flow chart in Fig.  2 .

PRISMA flow chart presenting the process of paper retrieval

The 14 papers included in this meta-synthesis came from Canada ( n  = 7), the USA ( n  = 5), Norway ( n  = 1), and Sweden ( n  = 1) and were published between 1999 and 2021. One paper was published in 1999 (Boydell et al., 1999 ), two papers between 2000 and 2010 (Walker & Seasons, 2002 ; Wong et al., 2006 ), while 11 papers were published in 2011–2021 (Chan, 2020 ; Estrella et al., 2021 ; Fields, 2011 ; Golembiewski et al., 2017 ; Henwood et al., 2018 ; Kirst et al., 2020 ; Macnaughton et al., 2016 ; Ogundipe et al., 2020 ; Piat et al., 2017a , 2017b ; Tjörnstrand et al., 2020 ). The total number of residents as informants across the papers was 758. The sample size ranged from 5 to 195 across the papers. Eleven papers had a qualitative design only (Boydell et al., 1999 ; Chan, 2020 ; Estrella et al., 2021 ; Fields, 2011 ; Henwood et al., 2018 ; Macnaughton et al., 2016 ; Ogundipe et al., 2020 ; Piat et al., 2017a , 2017b ; Walker & Seasons, 2002 ; Wong, 2006), while three papers used a mixed methods design with qualitative and quantitative methods (Golembiewski et al., 2017 ; Kirst et al., 2020 ; Tjörnstrand et al., 2020 ). Notably, in the three mixed methods papers the authors used the qualitative data only. Data analysis was based on reported qualitative findings from a total of 758 participants. Table 2 provides an overview of the characteristics of the 14 papers included.

Quality Appraisal

The 14 included papers were assessed and scored based on the Critical Appraisal Skills Programme (CASP) for qualitative studies: (1) a clear statement of aim, (2) a qualitative methodology is appropriate, (3) congruence between research design and research aims, (4) recruitment strategy appropriate to meet the research aim, (5) the data collection method addresses the research issue, (6) relationship between the researcher and the participants described, (7) ethical issues have been considered, (8) a rigorous data analysis, and (9) a clear statement of the findings (CASP, 2013 ). Papers received one point for each CASP criterion met, giving a possible maximum score of nine for each paper. As suggested by Eriksen et al. ( 2020 , 2022 ), a score of nine indicated a high methodological quality, a score of 7–8 implied moderate quality, and papers with a score of 6 or less were of low quality. As recommended by Sandelowski and Barroso ( 2007 ), no papers were excluded based on quality criteria only. The quality assessment was performed independently by two authors. After scoring separately, the two authors met to compare and discuss their assessments and revised the scores until a consensus was reached. The final CASP scores are presented in Table  3 . The paper where the first author was one of the authors was appraised by the last author only.

Data Extraction

The research question with “ core dimensions of social inclusion ” as the units of analysis guided the extraction of relevant information constituting data from the included papers. This involved detailed data providing any relevant information on residents’ experiences of social inclusion, sense of belonging, and social participation. These data were extracted into a data extraction sheet consisting of three columns. The first column listed the main themes, subthemes, categories, and subcategories from the extracted findings as reported in each paper. The second column comprised the original authors’ descriptions of the findings. The final column consisted of the quotes the original authors presented in their papers.

Data Analysis

Data were analyzed using the five phases of content analysis proposed by Graneheim and Lundman ( 2004 ). The first phase requires selecting the relevant text in line with the research question and thus the units of analysis. Texts that in any way described experiences of social inclusion, belonging, and social participation of persons with mental health and/or substance use challenges were extracted into an extraction sheet prepared for further analysis of the data. The second phase involves identifying meaning units. The third phase centers on the process of condensation. In the fourth phase, the condensed meaning units are coded and gathered into subcategories. In the fifth phase, subcategories are further developed into categories.

In the first phase, the first and last author independently performed a close reading of the data extraction sheet to obtain an overall impression of the data, while also noting potentially relevant topics and patterns. Thereafter, the two authors met to compare and discuss their extracted data, and then modified the extraction sheet as necessary. In the second phase, the authors individually and repeatedly read the data extraction sheet to identify meaning units (i.e., sentences or paragraphs that contained aspects related to the units of analysis) (Graneheim & Lundman, 2004 ). While reading the data extraction sheet line by line, meaning units were highlighted in color. When the reading was completed, the meaning units identified were copied into a new column labeled “meaning units” in the extraction sheet. The third phase of analysis involved the process of condensing the meaning units. The authors aimed to keep the condensation close to the original text by using the original language from the meaning units to ensure that valuable information was not lost. In the fourth phase of analysis, the condensed meaning units were abstracted. The process of abstraction occurred in two steps. First, each condensed meaning unit was coded to organize the material. Afterward, the authors proceeded to group these codes. Grouping was achieved by identifying similarities and differences and then gathering the codes into subcategories, describing the manifest meaning of the data in the extraction sheet. Moreover, grouping required reading and re-reading the data extraction sheet to ensure that valuable information was not lost. In the fifth and final phase, subcategories were further sorted into categories.

Ethical Considerations

Ethical approval was not required for this paper, as the data originated from published papers.

The qualitative content analysis aimed to answer the following research question: What characterizes the core dimensions of social inclusion for persons with mental health and/or substance abuse challenges living in supported housing? The data analysis resulted in three categories, each divided into three subcategories, describing in-depth core dimensions of the experience of social inclusion of persons with mental health and/or substance use challenges living in supported housing. The dimensions (categories) were (1) having access to core resources, (2) actively participating oneself, and (3) being existentially anchored. The categories with subcategories are presented in Table  4 .

Having Access to Core Resources

Having access to core resources was an essential dimension of social inclusion. This category consisted of three subcategories: (1) having a safe place to live , (2) having support from family members and professionals, and (3) having support from a broader community.

Having a Safe Place to Live

Having a safe home appeared to be crucial for establishing and re-establishing a social network, and thus feeling socially integrated. This allowed residents to pursue new social relationships (Golembiewski et al., 2017 ), usually with other residents (Golembiewski et al., 2017 ; Piat et al., 2017b ; Tjörnstrand et al., 2020 ) and with people outside the housing facility (Macnaughton et al., 2016 ; Piat et al., 2017a , 2017b ). Having a safe place to live motivated residents to re-establish important and meaningful relationships, often with family members (e.g., children, siblings, parents) or earlier friends and romantic partners (Golembiewski et al., 2017 ; Kirst et al., 2020 ; Macnaughton et al., 2016 ).

Having a safe home entailed having a place where one could enjoy oneself (Piat et al., 2017b ), sharing good moments, and thereby achieving closer relationships (Chan, 2020 ; Tjörnstrand et al., 2020 ). Furthermore, having core resources such as storage possibilities, a television, computer, and furniture helped residents to be engaged and informed, thus facilitating social participation and ultimately an experience of being socially integrated. Likewise, having a home also made it easier to have a pet to help combat loneliness, and facilitated forming new relationships (Macnaughton et al., 2016 ; Piat et al., 2017b ), which could lead to social networking and greater integration.

Having Support from Family Members and Professionals

Having support from family members and professionals was described as vital for managing social connections and integration outside the housing setting (Fields, 2011 ; Kirst et al., 2020 ; Macnaughton et al., 2016 ; Piat et al., 2017a , 2017b ). The support referred to how family members for shorter or longer periods often had to make up for residents’ few friends and limited social life (Golembiewski et al., 2017 ; Piat et al., 2017b ). Moreover, families’ financial and material support and driving the residents to activities were vital to enable them to participate socially in their local communities (10, 11). Likewise, support from staff involved providing necessary information on important social venues and social events (Kirst et al., 2020 ; Macnaughton et al., 2016 ), as well as assistance with everyday challenges. Support from staff in the pursuit of personal goals (Estrella et al., 2021 ; Golembiewski et al., 2017 ; Ogundipe et al., 2020 ; Piat et al., 2017a ) was experienced as an encouragement to participate in the local community. Furthermore, staff-led activities in the housing facility (Piat et al., 2017b ; Tjörnstrand et al., 2020 ) and staff as “friend-like” conversation partners (Tjörnstrand et al., 2020 ) were vital for residents’ feeling of social inclusion in the housing setting.

Having Support from a Broader Community

Support from the broader local community represented a vital resource for a sense of social inclusion. Having support to remain in their preferred neighborhood (Fields, 2011 ) or to pursue educational and vocational goals (Macnaughton et al., 2016 ), and to return to work, or to stay in a job (Kirst et al., 2020 ) depended on support and flexibility from neighbors (Wong et al., 2006 ), landlords (Fields, 2011 ), employers, and other community members (Kirst et al., 2020 ; Wong et al., 2006 ). The qualities most valued for an experience of social inclusion were unity, solidarity, respect, and kindness (Fields, 2011 ; Kirst et al., 2020 ; Ogundipe et al., 2020 ; Wong et al., 2006 ).

Participating Actively Oneself

To be the one actively taking the initiative to participate was a crucial dimension for experiencing social inclusion. This category included three subcategories illustrating how residents’ efforts at participation played a crucial role in a feeling of social inclusion. The subcategories were: (1) participating in available social settings , (2) participating by adapting to fit in , and (3) participating in reciprocal relationships.

Participating in Available Social Settings

Participating actively in social settings was underlined as necessary to become socially included in the local community (Estrella et al., 2021 ; Fields, 2011 ; Macnaughton et al., 2016 ). Active participation entailed taking the initiative to interact with others at local places and events, such as bus stops, local stores, town watch meetings, or neighborhood clean-ups (Wong et al., 2006 ). The residents further underlined the importance of participating in leisure activities (Estrella et al., 2021 ; Fields, 2011 ; Kirst et al., 2020 ; Macnaughton et al., 2016 ), as these activities provided stronger experiences of social connections and interaction with people in their communities (Estrella et al., 2021 ; Walker & Seasons, 2002 ), and thus a sense of belonging and social inclusion. Leisure activities involving active participation in the community were gardening, excursions, celebrating special occasions, visits, sports, exercise, and cooking (Kirst et al., 2020 ; Piat et al., 2017a , 2017b ; Tjörnstrand et al., 2020 ).

Participating by Adapting to Fit in

The residents intentionally adapted to and applied strategies and behaviors they deemed necessary for being socially included. Such strategies were described as remembering to mind their own business, trying to be invisible, or trying to blend and thereby fit in (Boydell et al., 1999 ; Fields, 2011 ; Wong et al., 2006 ). Participating by adapting one’s strategy was also due to limited finances (Piat et al., 2017a ; Walker & Seasons, 2002 ) and could be exemplified by taking part in leisure activities, such as billiards, during hours when prices were lower or visiting places were buying something to eat or drink was not required to participate (Piat et al., 2017a ).

Participating in Reciprocal Relationships

The residents clearly described how participating in reciprocal relationships involving mutual exchanges of support was important for feeling socially included. They underlined working actively towards becoming a source of support for others and having the possibility to be involved in reciprocal relationships.

Establishing reciprocal relationships involved taking practical steps towards becoming an active contributing member of one’s community. This entailed supporting others with daily chores, providing financial support if necessary to their family (Piat et al., 2017a ), signing up to be a volunteer (Kirst et al., 2020 ; Macnaughton et al., 2016 ), or calling each other when the smoke detector alarm went off (Wong et al., 2006 ). Being supportive and thereby a resource for others seemed to help residents persist in participating in their communities (Kirst et al., 2020 ; Macnaughton et al., 2016 ). Likewise, experiencing kindness from others and being a source of kindness to others were vital elements. Moreover, engaging or reengaging in social roles such as being a parent, grandparent, student, or employee was also underlined (Chan, 2020 ; Kirst et al., 2020 ; Macnaughton et al., 2016 ).

Being Existentially Anchored

Experiencing oneself socially included also involved the dimension of being existentially anchored. The category being existentially anchored comprised three subcategories: (1) being in the process of belonging , (2) being autonomous and free to make choices, and (3) being able to be oneself .

Being in the Process of Belonging

Becoming socially included was seen as a process over time, requiring patience. Understanding and experiencing social inclusion as an ongoing process of belonging helped residents to internalize and keep alive hope for a better future (Kirst et al., 2020 ; Macnaughton et al., 2016 ; Wong et al., 2006 ). Belonging was described as a long-term process related to the fact that residents often only felt a temporary sense of belonging. Despite a sense of belonging, or temporary belonging, to their current community, the desire to belong elsewhere in the future was voiced (Ogundipe et al., 2020 ).

Being Autonomous and Free to make Choices

Being autonomous and having the freedom to choose and decide how to participate and how to belong was a core existential dimension of experiencing oneself as socially included (Chan, 2020 ; Ogundipe et al., 2020 ; Tjörnstrand et al., 2020 ). The feeling of being autonomous included the freedom to decide on one’s social closeness or distance with others, particularly those whose company the residents believed would jeopardize their efforts to become autonomous people capable of living in their community (Fields, 2011 ; Piat et al., 2017b ). Moreover, having greater control and choices over when and how to interact with others was vital for autonomy and thus a sense of inclusion (Kirst et al., 2020 ; Macnaughton et al., 2016 ).

Being Able to Be Oneself

Being able to be oneself, and thus in tune with one’s authentic self, was important for a sense of belonging. Places in which this authentic and existential dimension was experienced were their own home (Chan, 2020 ) and some community settings (Fields, 2011 ). Being in tune with one’s true authentic self, appeared to be easier in community settings regarded as “less normative” and free from stigma and discrimination.

This meta-synthesis aimed to answer the research question What characterizes the core dimensions of social inclusion for persons with mental health and/or substance use challenges living in supported housing ? The synthesized findings from the 14 included papers add greater depth to knowledge of the characteristics of perceived social inclusion for this group. This in-depth knowledge holds the potential to further promote the rights of persons with mental health and/or substance use challenges to be included in their local communities and society at large.

The findings are particularly interesting when mirrored against articles 19 and 30 of the United Nations Convention on the Rights of Persons with Disabilities (United Nations, 2006 ). As elaborated on in the introduction, the findings correspond to article 19 in that having a home, and thus a safe place to live, is the core resource for experiencing social inclusion. These findings are also supported by findings reported in a meta-synthesis by Gonzalez and Andvig ( 2015b ) showing that having a safe home is undoubtedly the most important resource for this group as for anybody else. Furthermore, article 30 underlines the right to participate. Despite this, residents with mental health and/or substance use challenges clearly encounter obstacles to exercising these rights (Fields, 2011 ; Ogundipe et al., 2020 , 2022 ; Pilla & Park-Taylor, 2021 ).

On the issue of participation, our findings provide an in-depth understanding of what residents consider vital to participation beyond merely having the right. For the residents, participating entailed being actively involved, and having equal roles in reciprocal relationships and a diversity of social settings. Moreover, they found that participating actively also involved adapting to what they considered necessary to succeed and fit in. This in-depth understanding therefore adds the knowledge that just having the right to participate does not guarantee social inclusion; it is also necessary to take active steps to participate and to have the necessary support to enable participation.

Considering the findings in terms of history and mental health deinstitutionalization involving housing strategies with the overall aim of social inclusion of this group (Fakhoury & Priebe, 2007 ), our findings broaden and expand the understanding of what that means for the residents themselves. In this respect, our findings are in line with strategies highlighting the importance of housing stability, community participation, and the importance of each resident having life goals and hopes for the future. Moreover, our findings also revealed that social inclusion requires support on all levels, such as the residents’ families, professionals, and the broader local community. To what degree this support is adequate, comprehensive, and in line with the residents’ needs may be questioned. On this issue, a meta-synthesis by Gonzalez and Andvig ( 2015a ) has reported the complexity and variety of service users’ support needs. Furthermore, staff working in supported housing facilities have stated that a lack of financial resources was a barrier to promoting and supporting residents’ experiences of being socially included in their local community (McCauley et al., 2015 ; Miler et al., 2022 ; Ogundipe et al., 2022 ), emphasizing that social inclusion remains an important goal in these settings.

Some attempts have been made to define social inclusion. The quite narrow, but often quoted, definition of social inclusion by Wong and Solomon ( 2002 ) is considered not to fully cover the dimensions of what the residents themselves find characteristic of being socially included. In the definition by Wong and Salomon (2002), a sense of belonging is seen as a psychological rather than a social process and is therefore referred to as psychological inclusion. Thus, our findings are more in line with the broader concept of social inclusion in which a sense of belonging and various forms of community participation (e.g., social participation) are key dimensions (Mahar et al., 2013 ; Lloyd et al., 2006 ). In the definition by Mahar et al. ( 2013 ), a sense of belonging is seen as a core issue that refers to a subjective sense of worth and respect derived from reciprocal relationships built on shared experiences, beliefs, or personal characteristics. The sense of belonging is further characterized as a dynamic process; hence social environments can enhance or detract from a person’s sense of belonging. These influences from social environments may be transitory or persistent in their impact on the sense of belonging. Social participation is seen as a dimension of social inclusion that involves participating actively in social activities that can potentially lead to experiences of friendship and happiness (Lloyd et al., 2006 ).

The findings of this meta-synthesis resonate well with the conceptualization of recovery as “a deeply social, unique, and shared process in which our living conditions, material surroundings, social relations, and sense of self evolve. Recovery is about striving to live satisfying, hopeful, and reciprocal lives …” (Topor et al., 2022 , p. 11). The findings of this meta-synthesis also emphasize the significance of adequate living conditions, support at various levels, reciprocal relationships, and the ability to actively play a role oneself and to be oneself as core dimensions of residents’ experiences of social inclusion.

To our knowledge, no other reviews or meta-syntheses have been published aiming to summarize or synthesize qualitative findings describing what characterizes social inclusion from a person-centred perspective of persons with mental health and/or substance use challenges living in supported housing. However, Watson et al. ( 2019 ) conducted a qualitative meta-synthesis seeking to learn from the lived experiences of residents with persistent mental health challenges about how supported housing facilitates social connection and participation.

Yet another meta-synthesis by Gonzalez and Andvig ( 2015b ), two dimensions of social inclusion were identified, namely a sense of belonging and social participation . These findings resonate well with our synthesized findings, and thus the findings of these two meta-syntheses mutually support each other’s findings, as well as our findings. Thus, the existential dimension of belonging and social participation should be integrated into the definition of social inclusion.

Holding the above elaborated findings together, it is pertinent to use the relevant and mutually supportive findings to propose a new definition of what characterizes social inclusion for residents living in supported housing. Hence, we suggested the following definition as the meta-level of this meta-synthesis: In the context of supported housing, social inclusion for persons with mental health and/or substance use challenges is characterized by having access to core resources like a safe place to live and support on different levels (families, professionals, and a broader community). It also involves participating actively oneself in social settings, being involved in reciprocal relationships, and being existentially anchored through experiences of belonging, autonomy, and authenticity .

Methodological Considerations

This meta-synthesis has both strengths and weaknesses. In our literature search, we meticulously selected the most relevant databases and used a comprehensive search strategy, which enhanced the strength of this study. In addition, this meta-synthesis was improved by using a competent academic librarian to perform the systematic searches. In including and excluding relevant papers and extracting data, the two researchers worked independently and engaged in discussions until they reached agreement. Moreover, we used a transparent definition of supported housing and provided a detailed description of the housing programs referenced in the included papers. Additionally, we presented the results of the quality appraisal of each study clearly and openly. These strategies are considered a study strength. Regarding the data analysis and synthesis, a strength of this study is that it provided a profound understanding of what characterizes the core dimensions of social inclusion for residents with mental health and/or substance use challenges. Furthermore, the reflexive process employed by several researchers engaged in data analysis serves to enhance the trustworthiness of this study.

Despite our efforts to ensure transparency in all our choices on all levels of this meta-synthesis, it is important to acknowledge that the inconsistent terminology and variation in housing programs in this field challenged the development of a precise search strategy and thus might have weakened the retrieval of papers. Furthermore, this inconsistency might also have influenced the extraction of information from each paper and the analysis and synthesis of the data (MacPherson et al., 2018 ).

The core findings in this meta-synthesis were having access to core resources, participating actively oneself , and being existentially anchored , along with the subcategories (please see Table  4 ). Based on these findings, we suggest a new definition of social inclusion in the context of supported housing: Social inclusion for persons with mental health and/or substance use challenges is characterized by having access to core resources like a safe place to live and support on different levels (families, professionals, and a broader community). It also involves participating actively oneself in social settings, being involved in reciprocal relationships, and being existentially anchored through experiences of belonging, autonomy, and authenticity.

Recommendations for Mental Health and Substance Use Services

Based on the findings, we recommend improvements in promoting social inclusion at the policy level, at the service and support level, and the resident level. At the policy level, any intervention that can strengthen access to core resources, facilitate active participation, and promote existential issues must be taken into consideration. At the service and support level, we recommend systematic training and support programs for staff to enhance staff knowledge, skills, and attitudes in these areas. At the resident level, we recommend assessing residents’ needs and challenges concerning social inclusion to provide individualized support to each resident.

Recommendations for Further Research

Based on the findings, we suggest that researchers in this field explore and/or try out various systematic training and support programs aiming to enhance social inclusion for the group in question. These could be individual or group-based social training programs or other educational, psychosocial, or therapeutic interventions at the group or individual level.

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Ogundipe, E., Sælør, K.T., Biong, S. et al. Core Dimensions of Social Inclusion for Residents with Mental Health and/or Substance Use Challenges: A Qualitative Meta-synthesis. J. Psychosoc. Rehabil. Ment. Health (2024). https://doi.org/10.1007/s40737-024-00415-1

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Expanding the non-technical skills vocabulary of operating room nurses: a qualitative study

• Irene Sirevåg 1 ,
• Ingrid Tjoflåt 2 &
• Britt Sætre Hansen 2  

BMC Nursing volume  22 , Article number:  323 ( 2023 ) Cite this article

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Operating room nurses have specialised technical and non-technical skills and are essential members of the surgical team. The profession’s dependency of tacit knowledge has made their non-technical skills difficult to access for researchers, thus, creating limitations in the identification of the non-technical skills of operating room nurses. Non-technical skills are categorised in the crew resource management framework, and previously, non-technical skills of operating room nurses have been identified within the scope of the framework. The purpose of this study is to explore operating room nurses’ descriptions of their practices in search for non-technical skills not included in the crew resource management framework.

This study has a qualitative design. An expert panel of experienced operating room nurses (N = 96) in Norway provided qualitative descriptions of their practice in a Delphi survey. The data were analysed in an inductive thematic analysis. This study was conducted and reported in line with Standards for Reporting Qualitative Research (SRQR).

The inductive thematic analysis developed two themes, ‘Ethical competence’ and ‘Professional accountability’, that encompass operating room nurses’ novel descriptions of their non-technical skills. The participants take pride in having the patients’ best interest as their main objective even if this may threaten their position in the team.

Conclusions

This study has identified novel non-technical skills that are not described in the crew resource management framework. These findings will contribute to the development of a new behavioural marker system for the non-technical skills of operating room nurses. This system will facilitate verbalisation of tacit knowledge and contribute to an increased knowledge about the operating room nursing profession.

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Operating room (OR) nursing as a profession originates from the early days of surgery on anaesthetised patients [ 1 ]. Since then, it has developed from attending the surgeon and providing ‘household’ of the OR, to a profession with advanced specialised skills. Traditionally, OR nursing relied on historical legacy, with tacit and unspoken knowledge developed within the OR, rather than theoretical principles and evidence-based knowledge [ 1 ]. The main issue with tacit and unspoken knowledge lies in the name; it is difficult to verbalise. Tacit knowledge has been described as knowledge nurses are aware of but struggle to explain [ 2 ]. With the requirements of modern healthcare and formalised OR nursing education, all relevant skills-sets must be verbalizable. Sirevåg et al. [ 3 ] found that the use of non-technical skills (NTS) vocabulary helped the OR nurses verbalise their tacit knowledge. By using the term NTS, defined as ‘the cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance’ p.1 [ 4 ], we gain a common vocabulary for the former ‘tacit skills’ [ 3 ].

When relying on NTS developing over time, as have traditionally been the case, we accept a higher risk of adverse events until novice and student OR nurses have developed their NTS. Therefore, to ensure safe surgery independent of staff experience, systematic training and, subsequently, assessment of NTS are necessary [ 5 ]. The Crew Resource Management (CRM) coursework was initially developed for training NTS in aviation [ 6 ]. Requirements from the aviation authorities led to the development of a behavioural marker system for the assessment of pilot’s NTS [ 6 ]. Subsequently, Flin et al. have constructed a CRM framework of the main NTS categories and elements based on CRM courses and NTS lists from various organisations (Table  1 , Columns 1 and 2) [ 4 ]. Several behavioural marker systems for individual skills training and assessment have been developed based on the CRM system. According to Flin et al. [ 4 ], these tools must be customised with user specific behavioural markers, and the developers of such tools must define the context and identify all relevant NTS of the target users.

OR nursing is practiced by scrub and circulating nurses behind closed doors. The lack of verbalisation of their competence results in hospital administration, and even other members of the surgical team, being unaware of their full competencies and responsibilities [ 1 , 7 ]. These issues may have contributed to ‘outsiders’ defining OR nursing in relation to the surgeons [ 7 ]. When examining the development of an existing NTS assessment tool, the Scrub Practitioners’ List of Intraoperative Non-Technical Skills (SPLINTS) [ 8 ], we detect that some limitations were made which may decrease the usability of the instrument. Firstly, in SPLINTS, the intraoperative timespan is defined as ‘knife-to-skin to close’ (p. 826) [ 9 ], which corresponds with the period the surgeon is present. However, the OR nursing profession defines the intraoperative timespan as the time from when the patient arrives at the OR until they are transferred to the recovery unit after surgery [ 10 ]. Furthermore, the development of the SPLINTS instrument was based exclusively on the scrub nurse’s skills, thus dismissing the NTS of the circulating nursing role [ 11 ].

The first step in developing a customised taxonomy of skills for OR nursing is to identify the nurses’ skills and behaviours that are considered to influence their safe performance [ 4 ]. Literature searches in the CINAHL and Medline databases (operating room nurs*/perioperative nurs* and non-technical skills/nontechnical skills) identified two reviews and seven empirical studies, where the NTS of OR nurses were identified to some degree with OR nurses as informants/participants. The most frequently identified NTS for scrub and circulating nurses were in the ‘communication’, ‘situation awareness’, and ‘teamwork’ categories [ 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Two studies identified the ‘task management’ category for scrub and circulating nurses [ 13 , 15 ]. However, the ‘decision making’ and ‘leadership’ categories were only identified for circulating nurses [ 13 , 15 , 16 ]. Two studies found that ethical aspects influence OR nurses’ NTS [ 18 , 19 ]. The research shows that the NTS of scrub nurses are more widely explored than those of circulating nurses [ 13 , 14 , 15 , 16 , 17 ]. However, the circulating nurses’ NTS are more advanced and autonomous than those of scrub nurses [ 13 , 15 , 16 ]. While most studies on NTS are based on the CRM framework; Hanssen et al. [ 19 ] shows that there may be other aspects of NTS not yet captured by the literature.

To improve the education, and promote life-long learning, regarding NTS for OR nurses we want to construct a new behavioural marker tool for NTS observation and assessment that includes the NTS of both the circulating and the scrub OR nursing role during the entire intra-operative timespan. To generate an item pool of NTS descriptions for our tool development we must include the identified NTS of scrub and circulating nurses and further explore whether there are NTS outside the CRM framework which should be included to create a customised tool.

This study aims to explore OR nurses’ descriptions of their practices in search for NTS not covered by the CRM framework.

We have used an exploratory design with an inductive thematic analysis to explores the dimensions of NTS [ 20 ]. The Delphi technique is considered suitable for capturing collective knowledge within a group, and for researching areas that lack empirical data [ 21 , 22 ] Thus, the Delphi technique was chosen to open the ‘closed doors’ of OR nursing and exploring its NTS. Although a three-round Delphi technique was conducted, the data for this study is limited to the qualitative elaborations of the second round. This study was conducted and reported in line with Standards for Reporting Qualitative Research (SRQR).

Population and sample

The success of the Delphi technique depends upon an ‘expert’ panel [ 23 ]; thus, we defined eligible experts as being OR nurses with a minimum of 2 years post-training experience. In Norway, the qualifications required for OR nurses include being registered nurses and to have completed additional post graduate education (18 months) or Masters’ degree (24 months) specialising in OR nursing where the main difference between the educations are the writing of a master’s thesis. Furthermore, the OR nurses alternate between the scrub and circulating role throughout the day. The Norwegian Association of Operating Room Nurses distributed our invitations containing survey links to 1640 members, and we performed the convenience sampling through self-recruitment.

The inclusion criteria were:

OR nurse in active duty.

Minimum 2-years post-training experience.

Completion of previous Delphi round.

Scholars have discussed the proper sample size for Delphi studies in the methodological literature. For example, Keeney et al. [ 23 ] suggests balancing the ability to generate conclusions with practical management of the panel size. Therefore, we considered a panel size of approximately 100 participants to be sufficient yet feasible, and 106 participants were recruited. We expected some attrition to occur between rounds; hence, 96 OR nurses participated in the second round.

Data collection

The Delphi survey was conducted between May and August 2020. We created and implemented the surveys in Norwegian using online survey software (SurveyXact 12.9; Ramboll Management Consulting, Copenhagen, Denmark) based on the categories and elements presented in the CRM framework [ 4 ] (Table  1 ). The Delphi survey was pre-tested by three fellow academics before it was piloted by 10 OR nurses meeting our inclusion criteria. A full description of the surveys for all three rounds is presented in a separate article [ 16 ]. Based on the first-round analysis we realised there were some misinterpretations of the elements; thus, we constructed the qualitative questions to operationalise and adapt the contents to the perioperative context (Table  1 ). In order to maintain a reasonable completion time in the second-round survey, the participants were asked to select the three most important categories of NTS. Subsequently they received follow-up questions about the selected categories and their respective elements. The panel were encouraged to write freely without limitations regarding word-count or content. We collected approximately 32,500 words of rich content from 490 text field answers. Table  1 presents the distribution of the answers.

Data analysis

Following the initial deductive (theory-driven, CRM framework) analysis, the selective coding resulted in a large amount of uncoded, content rich data. For this study, these residual qualitative data were analysed (all authors) using inductive thematic analysis to explore the NTS in OR nursing not covered by the CRM framework [ 24 ]. The open questions led to lengthy answers and rich data, which allowed an inductive (data-driven) approach in the analyses. As the data was written, the initial transcription step recommended by Braun and Clarke was redundant [ 24 ]. The contents of all text fields were exported from SurveyXact into Microsoft Word (Microsoft, Redmond, WA, USA), and were thoroughly read and controlled for their relevance and sensitive contents. The edited Norwegian text was imported to Nvivo 12 Pro (Alfasoft, Göteborg, Sweden) where we re-read the text and annotated areas of particular interest. We searched for descriptions of OR nursing practice which were in line with the previously mentioned definition of NTS and performed a complete coding. We then revised the codes, merging similar codes. We searched for patterns across the codes and developed candidate sub-themes containing NTS descriptions. The candidate sub-themes were then reviewed, and some were merged. Sub-themes with similar contents were grouped into themes. We reviewed the codes belonging to each theme and ensured that all theme names represent their contents. Illustrative citations were translated into English by the first author. We developed a thematic map (Fig. 1) and finalised our analysis in writing up the results and discussing the findings [ 24 ]. The inductive thematic analysis developed two themes answering our aim. Thus, the OR nurses’ NTS outside CRM are organised into the themes ‘Ethical competence’ and ‘Professional accountability’.

Ethical considerations

We conducted this research study according to the ethical principles of the Declaration of Helsinki and the Norwegian National Research Legislation [ 25 , 26 ]. The study was approved by the Norwegian Centre for Research Data (ref.#: 155,726). All participants were asked to read the provided information prior to confirming their informed consent and activating the survey. The participants could withdraw at any time without ramifications. Anonymity was ensured between the panel members. However, the iteration process of the Delphi technique hinders the anonymity between researchers and participants. We treated e-mail addresses as personal information and stored them accordingly. We removed any identifying characteristics from the submitted text before analysis to provide confidentiality in the absence of anonymity [ 20 ]. All data storage protocols adhered to the requirements of the Norwegian Centre for Research Data.

Researcher characteristics and reflexivity

Two of the authors (IS and IT) are experienced OR nurses, which provided some preconceptions during the planning of the research and the construction of the Delphi survey. Our prior understanding of the OR nursing profession, and its areas of responsibility, provided insights and facilitated a deeper understanding of the situations described by our participants. By collecting data through a survey, we did not influence the participants’ contributions. We took great care not to insert our own experiences into the data.

We develop the trustworthiness of the qualitative aspects of the Delphi study by demonstrating the credibility, dependability, confirmability, transferability, and authenticity of our findings according to Lincoln and Guba’s framework [ 27 , 28 ]. We enhanced the credibility of the sub-study’s results by providing transparency in our expert panel selection and provided the reader with the survey questions in relation to the CRM framework. Two of the authors (IS and IT) are OR nurses and are familiar with the ‘tribal’ language in the OR. This familiarity should establish confidence in the truth of the data and their interpretations [ 20 ]. The dependability of our data refers to its stability over time and different conditions [ 20 ]. The demographic data confirm the representativeness of the expert sample in our panel [ 29 ]. The anonymity between panel members in a Delphi approach removes group bias. In addition, the panel size should ensure that a single opinion did not overpower the group. Therefore, the study findings could be repeated if our study is to be replicated with comparable participants and context. The confirmability of our results refers to their objectivity or that the data is a good representation of the participants’ information [ 20 ]. All authors actively participated in the interpretations and analysis. We ensured that no data were invented by the authors by repeatedly revisiting the original statements. The presentation of the findings includes quotes from the participants to illustrate that the interpretations are not invented by the authors. The transferability of our results refers to the extent our findings can have applicability in other settings [ 20 ]. To aid the reader in determining the level of transferability to their context, we aimed for transparency in all study steps. The inclusion criteria are presented, and the researchers did not control the self-inclusion of the participants. The authenticity of the text is enhanced by the citations which convey the mood of the participants’ experiences [ 20 ].

Following our exploration of the OR nurses’ narratives of their practices we developed two themes, ‘Ethical competence’ and ‘Professional accountability’, which illustrates their NTS outside the CRM framework. The findings will be presented according to themes and subthemes developed in our thematic analysis guided by Braun and Clarke (Fig. 1) [ 24 ]. Due to the nature of the data collection, we are unable to pair participant numbers with citations.

Thematic map: Themes and sub-themes

Participants

96 OR nurses completed the second Delphi round, which provided the qualitative data for this study. The expert panel members had a mean post-training experience of 24.4 years. Norwegian hospitals conduct three shifts in 24 h, and the work schedules for more than half of the panel members included evening or night shifts. Most of our participants were employed full time (35,5 h/week for shift-workers); however, half of these participants worked more than full time. Table  2 provides the participants’ demographics in detail.

Ethical competence

The OR nurses take pride in having the patients’ best interest as their main objective throughout their work, thus displaying their ‘Ethical competence’. This theme includes two sub-themes: ‘Engaging in respectful care and practice’ and ‘Being the patients guardian and advocate in the OR’.

Engaging in respectful care and practice

A core function of the OR nurse is to maintain a sterile field to prevent infections, even when it may be perceived as disrespectful by the surgeon: ‘I have asked the surgeon to take a break to allow me to reinforce the draping, or for the surgeon to change gloves. Often, they are not interested in taking this break, but I refuse to give them instruments until we have re-established sterility’. The panel members consider all their actions as aspects of care, even when their patient is asleep or otherwise incapacitated. During surgery, the scrub nurses inspect every instrument for damage or residue, and they segregate all instruments contaminated by bowel, abscesses, or cysts from other instruments. All these aspects of managing asepticism illustrates how the OR nurse cares for patients by preventing surgical site infections.

Another aspect of respectful care is thoughtful positioning of patients on the operating table. Nurses mainly perform this when the patient has no, or reduced, awareness of their body or surroundings. However, the OR nurses are conscious of positioning the patient with care to prevent nerve damage, decubitus, and malignant hypothermia: ‘ As the circulating nurse, I monitor the positioning of the patient throughout the surgery. Is everything OK? Maybe their leg has slipped off the table? ’

As experienced team workers, the OR nurses recognise that each profession has their own responsibilities and that respectful cooperation is needed to reach the goal of successful surgery for their patients: ‘ This cooperation is amazing, and the joy of the work rubs off onto the patient’. The expert panel agreed that cooperation strengthens the surgical team. However, this requires effort from all team members. Some panel members experienced a lack of understanding and respect of their work, and that they were not allowed enough time to perform their job according to their professional standards: ‘I have experienced that a patient tried to free herself from the leg supports and almost fell off the operating table […] and it was difficult to keep her safe. This happened because the anaesthesia was terminated before I had secured the patient’. A well-functioning team depends on respect between team members. Some of the OR nurses showed their respect by ‘lifting others up’ through providing support and positive feedback.

Being the patients’ guardian and advocate in the OR

When engaging with the patients prior to anaesthesia, the OR nurse safeguards that all the information is correct and that the patient understands what will happen to them. This creates an opportunity for discovering and rectifying issues like wrong surgical site or procedure: ’The patient was scheduled with amputation … Luckily, I knew them from their actual amputation earlier that week and knew that the correct plan for today was wound revision and change of vacuum bandages. The surgeon had copied the previous requisition.’ Panel members also described advocating for their patients during surgery: ‘ I have urged the surgeon to administer more local anaesthetics during surgery on an awake patient with unsatisfactory pain relief. The surgeon was reluctant because they were focusing on the procedure. Sometimes, when I advocate for my patient, no one listens… ’. Hence, OR nurses serve as guardians and advocates for the patient before and during their surgical procedure.

Professional accountability

The panel members note that they have the competence to organise and manage individual procedures as well as surgical schedules. Furthermore, they must maintain their awareness of the patient, technical equipment, procedures, and the coordination needed to ensure that the patient receives safe and efficient treatment. With this professional accountability, the OR nurse contributes to minimising the risk of adverse events. Two sub-themes, ‘Displaying tailored professional competence’ and ‘Displaying autonomy, confidence, and courage’, comprise this theme.

Displaying tailored professional competence

The panel members value their competence as highly educated health-care practitioners. They use their advanced knowledge to decide which OR is appropriate, which operating table and equipment meets the requirement for the patient’s safe positioning, and what medical or technical equipment is compatible with the surgeon’s needs and the patient’s conditions. Through extensive experience, they develop the competence to consider the consequences of their choices for the patient and the health-care personnel. Although our panel comprised experienced OR nurses, they are aware of their responsibility in training new colleagues. The novice OR nurses build competence by being supported by their experienced colleagues: ‘To see them, listen to them, and give them advice when needed. Learning is promoted when they feel safe and have a sense of coping, instead of feeling anxious’.

The panel members’ tailored competence is also visible in their interactions with other team members. The Safe Surgery checklist is implemented in Norway [ 30 ]. However, some panel members have experienced that team members do not pay attention during ‘time-outs’ because of their simultaneous work or parallel conversations. They may miss essential information, which results in the lack of shared understanding, repetition of information, and prolonged anaesthesia time. A panel member shared an extreme consequence of not having a proper ‘time-out’: ‘ I have taken part in doing the wrong surgery on a patient after a poorly executed ‘time out’ ’. Several panel members have experienced that some surgeons rush out when surgery is completed, leaving the rest of the team responsible for completing the ‘after surgery’ part of the checklist. The absence of the surgeon’s point of view may compromise the accuracy of the information passed on during the patient’s transfer into postoperative care.

Displaying autonomy, confidence, and courage

The OR nurses position themselves as autonomous members of the surgical team who act independently rather than just following task lists and answering their colleagues’ demands: ‘ We decide when to move the patient into the OR. We decide when to call the surgeon. We decide which infection control routines to implement. We decide how to arrange the equipment. […] The OR nurses have a wide range of responsibilities’. The panel members describe that they regularly take responsibility on behalf of others: ‘I once refused to give the cardiac surgeon his sutures because a gauze was missing. The surgeon was grumpy, but eventually he found a gauze that was used for cooling behind the heart. He thanked me later’. One OR nurse described the frustration of having to police their colleagues and the consequences it had on a personal level: ‘ I am fed up with surgeons not adhering to the standards of preoperative hand hygiene and masks, but I am even more fed up with fellow OR nurses who don’t make sure the team follows the rules. They become more popular than me because I want to keep up my professional standards and follow the rules’. This illustrates how the OR nurses use their professional confidence and personal courage to do the right thing for their patient, despite the hierarchical authority within the OR and the potential risk of being disfavoured by the surgeon.

Our findings show that the International Council of Nurses’ code of ethics are embedded in the participants’ performance. Their respect for the first code: ‘Nurses’ primary professional responsibility is to people requiring nursing care…’ [ 31 ] is illustrated by participants repeatedly stating that ‘the patient always comes first’ even when it damages their own position in the surgical team. Norms such as ethical competence and professional accountability has not previously been discussed in relation to CRM based behavioural marker tools, and it might be timely to raise the question why such rich norms for core skills are not captured by existing frameworks and tools.

Ethical competence as non-technical skills

From an outsider’s perspective, the technical expertise of OR nurses is often perceived as the antithesis of caring with nursing and technology representing two opposing paradigms [ 32 ]. However, from within the closed doors of the OR, it is apparent that being technologically competent is perceived as being caring. Our findings illustrate that nursing in a technological environment requires the interweaving of caring and technology [ 33 ], and the tension between nursing and technology described by Barnard and Sandelowski [ 34 ] is not recognised in our data. Furthermore, while Locsin [ 35 ] theorise over the relationship between technological competency and caring, our participants considers correct handling of technical equipment and smooth instrumentation when serving the surgeon as acts of caring, which is similar to the findings of Bull and FitzGerald [ 33 ]. Intraoperative nursing care is characterised by constantly being present throughout the surgery and personalising nursing care procedures for each patient [ 10 ]. The participating OR nurses emphasised the importance of establishing a connection with their patients. However, the level of connection varies according to time allowances, with ample time given during preparation for elective surgery but only time for eye contact and maybe a reassuring touch during acute situations. In some instances, the patient may already be anaesthetised upon arrival in the OR; however, the OR nurses still care for these patients through their prevention of positioning-related injuries, surgical site infections, malignant hypothermia, or other undesired outcomes. The OR nurse’s care is mostly invisible to the patient. However, similarly to Bull and FitzGerald [ 33 ], our findings show that the OR nurses took pride in providing excellent patient care even when the patient is unaware. Thus, while Nordström & Wihlborg [ 36 ] highlight the OR nurses’ advocacy for awake patients, our study, along with Levesque et al. [ 37 ], found that the advocacy continues when the patients are unable to advocate for themselves.

Our findings illustrate that value conflicts are created between requirements for efficiency and the desire to do the best for the patients. According to Blomberg et al. [ 38 ], these value conflicts are particularly common when the surgical team do not consider the OR nurse to be competent. In these situations, our participants portrayed moral courage in their efforts to protect their patients, even if they end up being perceived as bossy or difficult by the surgical team. Blomberg et al. [ 38 ] described this moral courage as acting according to one’s conviction despite criticism from others. When the OR nurse discovers threats to their patient’s safety, such as wrongly marked surgical sites or missing surgical objects, they consult with the surgeon to rectify the issue. Therefore, they contribute to a shared risk awareness among the surgical team [ 39 ]. Such incidents may seem minor, but if not ameliorated, they may lead to major harm for the patients. Few researchers have explored the OR nurses’ error-preventing ability; however, Yang et al. [ 40 ] found that the circulating nurse play a significant role in identifying and addressing potential harmful incidents. When our panel members make decisions, they have the patients’ best interests as their guidance. Therefore, ethical considerations regarding the patients influence the OR nurses’ NTS. Few previous studies have identified the ethical aspects of NTS [ 18 , 19 ]. However, Kelvered et al. [ 10 ] also found that OR nurses portrayed their ethical views and moral approach through their desire to promote their patients’ well-being. According to their descriptions of their work, the panel members position themselves as safeguards and advocates in the OR, or as Voight [ 41 ] commented, they are ‘the last line of defence for patient safety’ (p. 822).

Professional accountability as non-technical skills

All surgical team members are experts with specialised skills that are inaccessible to someone without their training and experience. They are members of established professions that declare their responsibility for certain tasks [ 42 ]. There is some degree of division of labour within the team, which requires the knowledge of other team members’ competence and trust in their abilities [ 42 ]. Traditionally, OR nurses were trained in situ while working in the OR [ 1 ]. Following an increase in educational level, OR nurses now have more autonomous functions. However, they still have an underdeveloped language for verbalising their competence to the surgical team. Thus, OR nursing can be described similarly to an iceberg, where only the ‘above-water’ work is visible to the other professions in the perioperative team while their ‘under-water’ work is unverbalised. The lack of verbalisation results in OR nursing competence being invisible to the surgical team and also hospital administration, which is comparable to ‘the invisible work of nurses’ described by Allen [ 43 ]. This may explain why several study participants experience that their competence is underestimated, and the importance of their work underrated. Furthermore, they are not allowed sufficient time to perform their responsibilities according to the required standards. Both experienced and new OR nurses in other contexts have described this feeling of invisibility, being underrated, and not given enough time to provide quality care [ 36 , 37 , 44 ]. Therefore, the pursuit of efficiency to complete surgical task may cause a spiral effect, where the efficiency may hinder the surgical team’s recognition of the OR nurses’ contribution to the team [ 7 ].

The safety of the OR environment relies on procedures and standards; however, the team members adherence to these standards varies. The participating OR nurses display a sense of responsibility on behalf of other professions when they must argue with other team members to convince them to meet the given standards. Similarly, Nordström et al. [ 36 ] found that OR nurses and nurse anaesthetists took responsibility to remind other team members to do their tasks, while Flin et al. [ 11 ] underestimates the autonomy of the OR nurses and reduces their ability to ‘adhering to codes of good practice and guidelines’ (p.11). The OR nurses’ sense of responsibility on behalf of others originates from a professional obligation to keep the patient safe. However, if the corrected team members perceive this as a disturbance, the correction comes at a professional cost for OR nurses.

Successful treatments depend on the establishment of a shared understanding among the surgical team. However, the communication among team members before the patient arrives and the suspension of activities during surgical time-outs are the two most frequently missed nursing care areas in the OR [ 45 ]. Our results show that gathering the teams’ attention during time-outs is challenging. Neuhaus et al. [ 39 ] noted that the time-outs are considered burdensome by surgeons and anaesthetists. In addition, time-outs are often combined with tasks like scrubbing and draping. However, Freundlich et al. [ 46 ] found fewer disruptions and mainly full-team attendance during time-out when they were initiated by the circulating OR nurse. Levesque et al. [ 37 ] found that although the circulating nurse is in a good position to lead the surgical team in some situations, they did not receive the organisational support to lead.

A core responsibility for OR nurses is to establish and maintain an aseptic field; therefore, when they notify a team member of a breach of sterility, it is usually respected. However, some of our participants portrayed great courage and professional confidence when contesting their surgeons about missing gauzes or retained items during counting procedures. The extensive experience of our participants (mean, 23 years), and their high level of education, may influence this courage. Furthermore, the OR nurses become trusted members of the surgical team through building their experience, and thus become more comfortable speaking up [ 37 ].

Our results show that ethical competence and professional accountability are cognitive and personal resource NTS essential to patients’ safety. Similarly, Hanssen et al. (2020) identified respecting and caring for the patient in a rushed environment, and respect within the perioperative nursing team as ethical NTS. Previously, Agha et al. [ 47 ] have identified that such personal and professional values are required, along with technical and non-technical skills, for creating good surgical practices.

Strengths and limitations of the work

The Delphi technique for data collection in this study provides both strengths and limitations. The Delphi survey was conducted during the initial months of the COVID-19 pandemic, which highly influenced data collection from healthcare workers. Face-to-face interviews were not an option during this period; however, the survey’s free text fields proved to be a robust substitute. We collected rich data from a larger and more representative group of OR nurses. However, we had limited opportunities for clarification and further elaboration. The online survey software enabled the inclusion of participants representing all Norwegian health regions and allowed the participants to use their preferred device for the survey and take breaks at their own convenience.

Recommendations for further research

Considering the variety of qualifications required for OR nursing in different countries, our findings might not be representative in contexts where OR nurses have less education and experience than our panel members. We recommend further qualitative research studies to explore the NTS of OR nurses over different contexts. We will also recommend an exploration of NTS outside the CRM framework for other professions within the surgical team.

The participants of this study have opened the closed doors to the OR. By exploring their narratives, we have identified that ‘Ethical competence’ and ‘Professional accountability’ are descriptors of OR nurses’ NTS that are essential for safe and efficient OR nursing without being included in the CRM framework. After more than a decade of constructing NTS behavioural marker systems for healthcare within the borders of the CRM framework, it may be timely to acknowledge that not all NTS in OR nursing, and the surgical team, can be drawn from those of the pilots. Our findings illustrate that not only behavioural marker systems, but also the CRM framework itself may need adaptation to allow for successful implementation into healthcare.

In a time with a global outcry over the lack of qualified OR nurses, and the threat of less qualified personnel taking over OR nursing responsibilities, verbalisation of the competence of the profession is paramount to inform hospital management and funding bodies of OR nurses’ contribution to safe and efficient surgical treatment. The authors are developing a new behavioural marker system for the NTS of OR nurses. By including these novel NTS, or (formerly) tacit skills, in a new behavioural marker system, the verbalisation of OR nursing skills will be facilitated.

Data Availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Operating Room

• Non-technical skills

Crew Resource Management

The Scrub Practitioners List of Interoperative Non-Technical Skills

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Irene Sirevåg: Project administrator. Conceptualisation and methodology of the study. Investigation and data collection. Analysis of the data. Design of tables and figures and drafting of the original manuscript. Editing of the manuscript. Approval of the final version of the manuscript. Ingrid Tjoflåt: Conceptualisation and methodology of the study. Analysis of the data. Review and editing of the manuscript. Approval of the final version of the manuscript. Britt Sætre Hansen: Conceptualisation and methodology of the study. Analysis of the data. Review and editing of the manuscript. Approval of the final version of the manuscript.

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We conducted this research study according to the ethical principles of the Declaration of Helsinki and the Norwegian National Research Legislation. In Norway, the ethical approval is divided between the Norwegian centre for research data (data protection) and the Regional Ethical Committees (Medical and Health related research). The Norwegian Centre for Research Data (ref.#: 155726) has approved that the data protection plan of the study complies with Norwegian legislation ( https://lovdata.no/dokument/NL/lov/2018-06-15-38 ) and the European General Data Protection Regulation (GDPR). Our study does not qualify for consideration by the Regional Ethical Committee since it does not involve human intervention or invasive studies, human biological material or health information, and thus does not fall under the jurisdiction of the Law of medical and health related research ( https://lovdata.no/dokument/NL/lov/2008-06-20-44 ). Written informed concent was obtained from all participants, and they were informed about the rigth to withdraw from the study at any point.

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Sirevåg, I., Tjoflåt, I. & Hansen, B.S. Expanding the non-technical skills vocabulary of operating room nurses: a qualitative study. BMC Nurs 22 , 323 (2023). https://doi.org/10.1186/s12912-023-01500-9

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Received : 22 May 2023

Accepted : 12 September 2023

Published : 19 September 2023

DOI : https://doi.org/10.1186/s12912-023-01500-9

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