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500+ Qualitative Research Titles and Topics

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Qualitative research is a methodological approach that involves gathering and analyzing non-numerical data to understand and interpret social phenomena. Unlike quantitative research , which emphasizes the collection of numerical data through surveys and experiments, qualitative research is concerned with exploring the subjective experiences, perspectives, and meanings of individuals and groups. As such, qualitative research topics can be diverse and encompass a wide range of social issues and phenomena. From exploring the impact of culture on identity formation to examining the experiences of marginalized communities, qualitative research offers a rich and nuanced perspective on complex social issues. In this post, we will explore some of the most compelling qualitative research topics and provide some tips on how to conduct effective qualitative research.

Qualitative Research Titles

Qualitative research titles often reflect the study’s focus on understanding the depth and complexity of human behavior, experiences, or social phenomena. Here are some examples across various fields:

• “Understanding the Impact of Project-Based Learning on Student Engagement in High School Classrooms: A Qualitative Study”
• “Navigating the Transition: Experiences of International Students in American Universities”
• “The Role of Parental Involvement in Early Childhood Education: Perspectives from Teachers and Parents”
• “Exploring the Effects of Teacher Feedback on Student Motivation and Self-Efficacy in Middle Schools”
• “Digital Literacy in the Classroom: Teacher Strategies for Integrating Technology in Elementary Education”
• “Culturally Responsive Teaching Practices: A Case Study in Diverse Urban Schools”
• “The Influence of Extracurricular Activities on Academic Achievement: Student Perspectives”
• “Barriers to Implementing Inclusive Education in Public Schools: A Qualitative Inquiry”
• “Teacher Professional Development and Its Impact on Classroom Practice: A Qualitative Exploration”
• “Student-Centered Learning Environments: A Qualitative Study of Classroom Dynamics and Outcomes”
• “The Experience of First-Year Teachers: Challenges, Support Systems, and Professional Growth”
• “Exploring the Role of School Leadership in Fostering a Positive School Culture”
• “Peer Relationships and Learning Outcomes in Cooperative Learning Settings: A Qualitative Analysis”
• “The Impact of Social Media on Student Learning and Engagement: Teacher and Student Perspectives”
• “Understanding Special Education Needs: Parent and Teacher Perceptions of Support Services in Schools

Health Science

• “Living with Chronic Pain: Patient Narratives and Coping Strategies in Managing Daily Life”
• “Healthcare Professionals’ Perspectives on the Challenges of Rural Healthcare Delivery”
• “Exploring the Mental Health Impacts of COVID-19 on Frontline Healthcare Workers: A Qualitative Study”
• “Patient and Family Experiences of Palliative Care: Understanding Needs and Preferences”
• “The Role of Community Health Workers in Improving Access to Maternal Healthcare in Rural Areas”
• “Barriers to Mental Health Services Among Ethnic Minorities: A Qualitative Exploration”
• “Understanding Patient Satisfaction in Telemedicine Services: A Qualitative Study of User Experiences”
• “The Impact of Cultural Competence Training on Healthcare Provider-Patient Communication”
• “Navigating the Transition to Adult Healthcare Services: Experiences of Adolescents with Chronic Conditions”
• “Exploring the Use of Alternative Medicine Among Patients with Chronic Diseases: A Qualitative Inquiry”
• “The Role of Social Support in the Rehabilitation Process of Stroke Survivors”
• “Healthcare Decision-Making Among Elderly Patients: A Qualitative Study of Preferences and Influences”
• “Nurse Perceptions of Patient Safety Culture in Hospital Settings: A Qualitative Analysis”
• “Experiences of Women with Postpartum Depression: Barriers to Seeking Help”
• “The Impact of Nutrition Education on Eating Behaviors Among College Students: A Qualitative Approach”
• “Understanding Resilience in Survivors of Childhood Trauma: A Narrative Inquiry”
• “The Role of Mindfulness in Managing Work-Related Stress Among Corporate Employees: A Qualitative Study”
• “Coping Mechanisms Among Parents of Children with Autism Spectrum Disorder”
• “Exploring the Psychological Impact of Social Isolation in the Elderly: A Phenomenological Study”
• “Identity Formation in Adolescence: The Influence of Social Media and Peer Groups”
• “The Experience of Forgiveness in Interpersonal Relationships: A Qualitative Exploration”
• “Perceptions of Happiness and Well-Being Among University Students: A Cultural Perspective”
• “The Impact of Art Therapy on Anxiety and Depression in Adult Cancer Patients”
• “Narratives of Recovery: A Qualitative Study on the Journey Through Addiction Rehabilitation”
• “Exploring the Psychological Effects of Long-Term Unemployment: A Grounded Theory Approach”
• “Attachment Styles and Their Influence on Adult Romantic Relationships: A Qualitative Analysis”
• “The Role of Personal Values in Career Decision-Making Among Young Adults”
• “Understanding the Stigma of Mental Illness in Rural Communities: A Qualitative Inquiry”
• “Exploring the Use of Digital Mental Health Interventions Among Adolescents: A Qualitative Study”
• “The Psychological Impact of Climate Change on Young Adults: An Exploration of Anxiety and Action”
• “Navigating Identity: The Role of Social Media in Shaping Youth Culture and Self-Perception”
• “Community Resilience in the Face of Urban Gentrification: A Case Study of Neighborhood Change”
• “The Dynamics of Intergenerational Relationships in Immigrant Families: A Qualitative Analysis”
• “Social Capital and Economic Mobility in Low-Income Neighborhoods: An Ethnographic Approach”
• “Gender Roles and Career Aspirations Among Young Adults in Conservative Societies”
• “The Stigma of Mental Health in the Workplace: Employee Narratives and Organizational Culture”
• “Exploring the Intersection of Race, Class, and Education in Urban School Systems”
• “The Impact of Digital Divide on Access to Healthcare Information in Rural Communities”
• “Social Movements and Political Engagement Among Millennials: A Qualitative Study”
• “Cultural Adaptation and Identity Among Second-Generation Immigrants: A Phenomenological Inquiry”
• “The Role of Religious Institutions in Providing Community Support and Social Services”
• “Negotiating Public Space: Experiences of LGBTQ+ Individuals in Urban Environments”
• “The Sociology of Food: Exploring Eating Habits and Food Practices Across Cultures”
• “Work-Life Balance Challenges Among Dual-Career Couples: A Qualitative Exploration”
• “The Influence of Peer Networks on Substance Use Among Adolescents: A Community Study”

Business and Management

• “Navigating Organizational Change: Employee Perceptions and Adaptation Strategies in Mergers and Acquisitions”
• “Corporate Social Responsibility: Consumer Perceptions and Brand Loyalty in the Retail Sector”
• “Leadership Styles and Organizational Culture: A Comparative Study of Tech Startups”
• “Workplace Diversity and Inclusion: Best Practices and Challenges in Multinational Corporations”
• “Consumer Trust in E-commerce: A Qualitative Study of Online Shopping Behaviors”
• “The Gig Economy and Worker Satisfaction: Exploring the Experiences of Freelance Professionals”
• “Entrepreneurial Resilience: Success Stories and Lessons Learned from Failed Startups”
• “Employee Engagement and Productivity in Remote Work Settings: A Post-Pandemic Analysis”
• “Brand Storytelling: How Narrative Strategies Influence Consumer Engagement”
• “Sustainable Business Practices: Stakeholder Perspectives in the Fashion Industry”
• “Cross-Cultural Communication Challenges in Global Teams: Strategies for Effective Collaboration”
• “Innovative Workspaces: The Impact of Office Design on Creativity and Collaboration”
• “Consumer Perceptions of Artificial Intelligence in Customer Service: A Qualitative Exploration”
• “The Role of Mentoring in Career Development: Insights from Women in Leadership Positions”
• “Agile Management Practices: Adoption and Impact in Traditional Industries”

Environmental Studies

• “Community-Based Conservation Efforts in Tropical Rainforests: A Qualitative Study of Local Perspectives and Practices”
• “Urban Sustainability Initiatives: Exploring Resident Participation and Impact in Green City Projects”
• “Perceptions of Climate Change Among Indigenous Populations: Insights from Traditional Ecological Knowledge”
• “Environmental Justice and Industrial Pollution: A Case Study of Community Advocacy and Response”
• “The Role of Eco-Tourism in Promoting Conservation Awareness: Perspectives from Tour Operators and Visitors”
• “Sustainable Agriculture Practices Among Smallholder Farmers: Challenges and Opportunities”
• “Youth Engagement in Climate Action Movements: Motivations, Perceptions, and Outcomes”
• “Corporate Environmental Responsibility: A Qualitative Analysis of Stakeholder Expectations and Company Practices”
• “The Impact of Plastic Pollution on Marine Ecosystems: Community Awareness and Behavioral Change”
• “Renewable Energy Adoption in Rural Communities: Barriers, Facilitators, and Social Implications”
• “Water Scarcity and Community Adaptation Strategies in Arid Regions: A Grounded Theory Approach”
• “Urban Green Spaces: Public Perceptions and Use Patterns in Megacities”
• “Environmental Education in Schools: Teachers’ Perspectives on Integrating Sustainability into Curricula”
• “The Influence of Environmental Activism on Policy Change: Case Studies of Grassroots Campaigns”
• “Cultural Practices and Natural Resource Management: A Qualitative Study of Indigenous Stewardship Models”

Anthropology

• “Kinship and Social Organization in Matrilineal Societies: An Ethnographic Study”
• “Rituals and Beliefs Surrounding Death and Mourning in Diverse Cultures: A Comparative Analysis”
• “The Impact of Globalization on Indigenous Languages and Cultural Identity”
• “Food Sovereignty and Traditional Agricultural Practices Among Indigenous Communities”
• “Navigating Modernity: The Integration of Traditional Healing Practices in Contemporary Healthcare Systems”
• “Gender Roles and Equality in Hunter-Gatherer Societies: An Anthropological Perspective”
• “Sacred Spaces and Religious Practices: An Ethnographic Study of Pilgrimage Sites”
• “Youth Subcultures and Resistance: An Exploration of Identity and Expression in Urban Environments”
• “Cultural Constructions of Disability and Inclusion: A Cross-Cultural Analysis”
• “Interethnic Marriages and Cultural Syncretism: Case Studies from Multicultural Societies”
• “The Role of Folklore and Storytelling in Preserving Cultural Heritage”
• “Economic Anthropology of Gift-Giving and Reciprocity in Tribal Communities”
• “Digital Anthropology: The Role of Social Media in Shaping Political Movements”
• “Migration and Diaspora: Maintaining Cultural Identity in Transnational Communities”
• “Cultural Adaptations to Climate Change Among Coastal Fishing Communities”

Communication Studies

• “The Dynamics of Family Communication in the Digital Age: A Qualitative Inquiry”
• “Narratives of Identity and Belonging in Diaspora Communities Through Social Media”
• “Organizational Communication and Employee Engagement: A Case Study in the Non-Profit Sector”
• “Cultural Influences on Communication Styles in Multinational Teams: An Ethnographic Approach”
• “Media Representation of Women in Politics: A Content Analysis and Audience Perception Study”
• “The Role of Communication in Building Sustainable Community Development Projects”
• “Interpersonal Communication in Online Dating: Strategies, Challenges, and Outcomes”
• “Public Health Messaging During Pandemics: A Qualitative Study of Community Responses”
• “The Impact of Mobile Technology on Parent-Child Communication in the Digital Era”
• “Crisis Communication Strategies in the Hospitality Industry: A Case Study of Reputation Management”
• “Narrative Analysis of Personal Stories Shared on Mental Health Blogs”
• “The Influence of Podcasts on Political Engagement Among Young Adults”
• “Visual Communication and Brand Identity: A Qualitative Study of Consumer Interpretations”
• “Communication Barriers in Cross-Cultural Healthcare Settings: Patient and Provider Perspectives”
• “The Role of Internal Communication in Managing Organizational Change: Employee Experiences”

Information Technology

• “User Experience Design in Augmented Reality Applications: A Qualitative Study of Best Practices”
• “The Human Factor in Cybersecurity: Understanding Employee Behaviors and Attitudes Towards Phishing”
• “Adoption of Cloud Computing in Small and Medium Enterprises: Challenges and Success Factors”
• “Blockchain Technology in Supply Chain Management: A Qualitative Exploration of Potential Impacts”
• “The Role of Artificial Intelligence in Personalizing User Experiences on E-commerce Platforms”
• “Digital Transformation in Traditional Industries: A Case Study of Technology Adoption Challenges”
• “Ethical Considerations in the Development of Smart Home Technologies: A Stakeholder Analysis”
• “The Impact of Social Media Algorithms on News Consumption and Public Opinion”
• “Collaborative Software Development: Practices and Challenges in Open Source Projects”
• “Understanding the Digital Divide: Access to Information Technology in Rural Communities”
• “Data Privacy Concerns and User Trust in Internet of Things (IoT) Devices”
• “The Effectiveness of Gamification in Educational Software: A Qualitative Study of Engagement and Motivation”
• “Virtual Teams and Remote Work: Communication Strategies and Tools for Effectiveness”
• “User-Centered Design in Mobile Health Applications: Evaluating Usability and Accessibility”
• “The Influence of Technology on Work-Life Balance: Perspectives from IT Professionals”

Tourism and Hospitality

• “Exploring the Authenticity of Cultural Heritage Tourism in Indigenous Communities”
• “Sustainable Tourism Practices: Perceptions and Implementations in Small Island Destinations”
• “The Impact of Social Media Influencers on Destination Choice Among Millennials”
• “Gastronomy Tourism: Exploring the Culinary Experiences of International Visitors in Rural Regions”
• “Eco-Tourism and Conservation: Stakeholder Perspectives on Balancing Tourism and Environmental Protection”
• “The Role of Hospitality in Enhancing the Cultural Exchange Experience of Exchange Students”
• “Dark Tourism: Visitor Motivations and Experiences at Historical Conflict Sites”
• “Customer Satisfaction in Luxury Hotels: A Qualitative Study of Service Excellence and Personalization”
• “Adventure Tourism: Understanding the Risk Perception and Safety Measures Among Thrill-Seekers”
• “The Influence of Local Communities on Tourist Experiences in Ecotourism Sites”
• “Event Tourism: Economic Impacts and Community Perspectives on Large-Scale Music Festivals”
• “Heritage Tourism and Identity: Exploring the Connections Between Historic Sites and National Identity”
• “Tourist Perceptions of Sustainable Accommodation Practices: A Study of Green Hotels”
• “The Role of Language in Shaping the Tourist Experience in Multilingual Destinations”
• “Health and Wellness Tourism: Motivations and Experiences of Visitors to Spa and Retreat Centers”

Qualitative Research Topics

Qualitative Research Topics are as follows:

• Understanding the lived experiences of first-generation college students
• Exploring the impact of social media on self-esteem among adolescents
• Investigating the effects of mindfulness meditation on stress reduction
• Analyzing the perceptions of employees regarding organizational culture
• Examining the impact of parental involvement on academic achievement of elementary school students
• Investigating the role of music therapy in managing symptoms of depression
• Understanding the experience of women in male-dominated industries
• Exploring the factors that contribute to successful leadership in non-profit organizations
• Analyzing the effects of peer pressure on substance abuse among adolescents
• Investigating the experiences of individuals with disabilities in the workplace
• Understanding the factors that contribute to burnout among healthcare professionals
• Examining the impact of social support on mental health outcomes
• Analyzing the perceptions of parents regarding sex education in schools
• Investigating the experiences of immigrant families in the education system
• Understanding the impact of trauma on mental health outcomes
• Exploring the effectiveness of animal-assisted therapy for individuals with anxiety
• Analyzing the factors that contribute to successful intergenerational relationships
• Investigating the experiences of LGBTQ+ individuals in the workplace
• Understanding the impact of online gaming on social skills development among adolescents
• Examining the perceptions of teachers regarding technology integration in the classroom
• Analyzing the experiences of women in leadership positions
• Investigating the factors that contribute to successful marriage and long-term relationships
• Understanding the impact of social media on political participation
• Exploring the experiences of individuals with mental health disorders in the criminal justice system
• Analyzing the factors that contribute to successful community-based programs for youth development
• Investigating the experiences of veterans in accessing mental health services
• Understanding the impact of the COVID-19 pandemic on mental health outcomes
• Examining the perceptions of parents regarding childhood obesity prevention
• Analyzing the factors that contribute to successful multicultural education programs
• Investigating the experiences of individuals with chronic illnesses in the workplace
• Understanding the impact of poverty on academic achievement
• Exploring the experiences of individuals with autism spectrum disorder in the workplace
• Analyzing the factors that contribute to successful employee retention strategies
• Investigating the experiences of caregivers of individuals with Alzheimer’s disease
• Understanding the impact of parent-child communication on adolescent sexual behavior
• Examining the perceptions of college students regarding mental health services on campus
• Analyzing the factors that contribute to successful team building in the workplace
• Investigating the experiences of individuals with eating disorders in treatment programs
• Understanding the impact of mentorship on career success
• Exploring the experiences of individuals with physical disabilities in the workplace
• Analyzing the factors that contribute to successful community-based programs for mental health
• Investigating the experiences of individuals with substance use disorders in treatment programs
• Understanding the impact of social media on romantic relationships
• Examining the perceptions of parents regarding child discipline strategies
• Analyzing the factors that contribute to successful cross-cultural communication in the workplace
• Investigating the experiences of individuals with anxiety disorders in treatment programs
• Understanding the impact of cultural differences on healthcare delivery
• Exploring the experiences of individuals with hearing loss in the workplace
• Analyzing the factors that contribute to successful parent-teacher communication
• Investigating the experiences of individuals with depression in treatment programs
• Understanding the impact of childhood trauma on adult mental health outcomes
• Examining the perceptions of college students regarding alcohol and drug use on campus
• Analyzing the factors that contribute to successful mentor-mentee relationships
• Investigating the experiences of individuals with intellectual disabilities in the workplace
• Understanding the impact of work-family balance on employee satisfaction and well-being
• Exploring the experiences of individuals with autism spectrum disorder in vocational rehabilitation programs
• Analyzing the factors that contribute to successful project management in the construction industry
• Investigating the experiences of individuals with substance use disorders in peer support groups
• Understanding the impact of mindfulness meditation on stress reduction and mental health
• Examining the perceptions of parents regarding childhood nutrition
• Analyzing the factors that contribute to successful environmental sustainability initiatives in organizations
• Investigating the experiences of individuals with bipolar disorder in treatment programs
• Understanding the impact of job stress on employee burnout and turnover
• Exploring the experiences of individuals with physical disabilities in recreational activities
• Analyzing the factors that contribute to successful strategic planning in nonprofit organizations
• Investigating the experiences of individuals with hoarding disorder in treatment programs
• Understanding the impact of culture on leadership styles and effectiveness
• Examining the perceptions of college students regarding sexual health education on campus
• Analyzing the factors that contribute to successful supply chain management in the retail industry
• Investigating the experiences of individuals with personality disorders in treatment programs
• Understanding the impact of multiculturalism on group dynamics in the workplace
• Exploring the experiences of individuals with chronic pain in mindfulness-based pain management programs
• Analyzing the factors that contribute to successful employee engagement strategies in organizations
• Investigating the experiences of individuals with internet addiction disorder in treatment programs
• Understanding the impact of social comparison on body dissatisfaction and self-esteem
• Examining the perceptions of parents regarding childhood sleep habits
• Analyzing the factors that contribute to successful diversity and inclusion initiatives in organizations
• Investigating the experiences of individuals with schizophrenia in treatment programs
• Understanding the impact of job crafting on employee motivation and job satisfaction
• Exploring the experiences of individuals with vision impairments in navigating public spaces
• Analyzing the factors that contribute to successful customer relationship management strategies in the service industry
• Investigating the experiences of individuals with dissociative amnesia in treatment programs
• Understanding the impact of cultural intelligence on intercultural communication and collaboration
• Examining the perceptions of college students regarding campus diversity and inclusion efforts
• Analyzing the factors that contribute to successful supply chain sustainability initiatives in organizations
• Investigating the experiences of individuals with obsessive-compulsive disorder in treatment programs
• Understanding the impact of transformational leadership on organizational performance and employee well-being
• Exploring the experiences of individuals with mobility impairments in public transportation
• Analyzing the factors that contribute to successful talent management strategies in organizations
• Investigating the experiences of individuals with substance use disorders in harm reduction programs
• Understanding the impact of gratitude practices on well-being and resilience
• Examining the perceptions of parents regarding childhood mental health and well-being
• Analyzing the factors that contribute to successful corporate social responsibility initiatives in organizations
• Investigating the experiences of individuals with borderline personality disorder in treatment programs
• Understanding the impact of emotional labor on job stress and burnout
• Exploring the experiences of individuals with hearing impairments in healthcare settings
• Analyzing the factors that contribute to successful customer experience strategies in the hospitality industry
• Investigating the experiences of individuals with gender dysphoria in gender-affirming healthcare
• Understanding the impact of cultural differences on cross-cultural negotiation in the global marketplace
• Examining the perceptions of college students regarding academic stress and mental health
• Analyzing the factors that contribute to successful supply chain agility in organizations
• Understanding the impact of music therapy on mental health and well-being
• Exploring the experiences of individuals with dyslexia in educational settings
• Analyzing the factors that contribute to successful leadership in nonprofit organizations
• Investigating the experiences of individuals with chronic illnesses in online support groups
• Understanding the impact of exercise on mental health and well-being
• Examining the perceptions of parents regarding childhood screen time
• Analyzing the factors that contribute to successful change management strategies in organizations
• Understanding the impact of cultural differences on international business negotiations
• Exploring the experiences of individuals with hearing impairments in the workplace
• Analyzing the factors that contribute to successful team building in corporate settings
• Understanding the impact of technology on communication in romantic relationships
• Analyzing the factors that contribute to successful community engagement strategies for local governments
• Investigating the experiences of individuals with attention deficit hyperactivity disorder (ADHD) in treatment programs
• Understanding the impact of financial stress on mental health and well-being
• Analyzing the factors that contribute to successful mentorship programs in organizations
• Investigating the experiences of individuals with gambling addictions in treatment programs
• Understanding the impact of social media on body image and self-esteem
• Examining the perceptions of parents regarding childhood education
• Analyzing the factors that contribute to successful virtual team management strategies
• Investigating the experiences of individuals with dissociative identity disorder in treatment programs
• Understanding the impact of cultural differences on cross-cultural communication in healthcare settings
• Exploring the experiences of individuals with chronic pain in cognitive-behavioral therapy programs
• Analyzing the factors that contribute to successful community-building strategies in urban neighborhoods
• Investigating the experiences of individuals with alcohol use disorders in treatment programs
• Understanding the impact of personality traits on romantic relationships
• Examining the perceptions of college students regarding mental health stigma on campus
• Analyzing the factors that contribute to successful fundraising strategies for political campaigns
• Investigating the experiences of individuals with traumatic brain injuries in rehabilitation programs
• Understanding the impact of social support on mental health and well-being among the elderly
• Exploring the experiences of individuals with chronic illnesses in medical treatment decision-making processes
• Analyzing the factors that contribute to successful innovation strategies in organizations
• Investigating the experiences of individuals with dissociative disorders in treatment programs
• Understanding the impact of cultural differences on cross-cultural communication in education settings
• Examining the perceptions of parents regarding childhood physical activity
• Analyzing the factors that contribute to successful conflict resolution in family relationships
• Investigating the experiences of individuals with opioid use disorders in treatment programs
• Understanding the impact of emotional intelligence on leadership effectiveness
• Exploring the experiences of individuals with learning disabilities in the workplace
• Analyzing the factors that contribute to successful change management in educational institutions
• Investigating the experiences of individuals with eating disorders in recovery support groups
• Understanding the impact of self-compassion on mental health and well-being
• Examining the perceptions of college students regarding campus safety and security measures
• Analyzing the factors that contribute to successful marketing strategies for nonprofit organizations
• Investigating the experiences of individuals with postpartum depression in treatment programs
• Understanding the impact of ageism in the workplace
• Exploring the experiences of individuals with dyslexia in the education system
• Investigating the experiences of individuals with anxiety disorders in cognitive-behavioral therapy programs
• Understanding the impact of socioeconomic status on access to healthcare
• Examining the perceptions of parents regarding childhood screen time usage
• Analyzing the factors that contribute to successful supply chain management strategies
• Understanding the impact of parenting styles on child development
• Exploring the experiences of individuals with addiction in harm reduction programs
• Analyzing the factors that contribute to successful crisis management strategies in organizations
• Investigating the experiences of individuals with trauma in trauma-focused therapy programs
• Examining the perceptions of healthcare providers regarding patient-centered care
• Analyzing the factors that contribute to successful product development strategies
• Investigating the experiences of individuals with autism spectrum disorder in employment programs
• Understanding the impact of cultural competence on healthcare outcomes
• Exploring the experiences of individuals with chronic illnesses in healthcare navigation
• Analyzing the factors that contribute to successful community engagement strategies for non-profit organizations
• Investigating the experiences of individuals with physical disabilities in the workplace
• Understanding the impact of childhood trauma on adult mental health
• Analyzing the factors that contribute to successful supply chain sustainability strategies
• Investigating the experiences of individuals with personality disorders in dialectical behavior therapy programs
• Understanding the impact of gender identity on mental health treatment seeking behaviors
• Exploring the experiences of individuals with schizophrenia in community-based treatment programs
• Analyzing the factors that contribute to successful project team management strategies
• Investigating the experiences of individuals with obsessive-compulsive disorder in exposure and response prevention therapy programs
• Understanding the impact of cultural competence on academic achievement and success
• Examining the perceptions of college students regarding academic integrity
• Analyzing the factors that contribute to successful social media marketing strategies
• Investigating the experiences of individuals with bipolar disorder in community-based treatment programs
• Understanding the impact of mindfulness on academic achievement and success
• Exploring the experiences of individuals with substance use disorders in medication-assisted treatment programs
• Investigating the experiences of individuals with anxiety disorders in exposure therapy programs
• Understanding the impact of healthcare disparities on health outcomes
• Analyzing the factors that contribute to successful supply chain optimization strategies
• Investigating the experiences of individuals with borderline personality disorder in schema therapy programs
• Understanding the impact of culture on perceptions of mental health stigma
• Exploring the experiences of individuals with trauma in art therapy programs
• Analyzing the factors that contribute to successful digital marketing strategies
• Investigating the experiences of individuals with eating disorders in online support groups
• Understanding the impact of workplace bullying on job satisfaction and performance
• Examining the perceptions of college students regarding mental health resources on campus
• Analyzing the factors that contribute to successful supply chain risk management strategies
• Investigating the experiences of individuals with chronic pain in mindfulness-based pain management programs
• Understanding the impact of cognitive-behavioral therapy on social anxiety disorder
• Understanding the impact of COVID-19 on mental health and well-being
• Exploring the experiences of individuals with eating disorders in treatment programs
• Analyzing the factors that contribute to successful leadership in business organizations
• Investigating the experiences of individuals with chronic pain in cognitive-behavioral therapy programs
• Understanding the impact of cultural differences on intercultural communication
• Examining the perceptions of teachers regarding inclusive education for students with disabilities
• Investigating the experiences of individuals with depression in therapy programs
• Understanding the impact of workplace culture on employee retention and turnover
• Exploring the experiences of individuals with traumatic brain injuries in rehabilitation programs
• Analyzing the factors that contribute to successful crisis communication strategies in organizations
• Investigating the experiences of individuals with anxiety disorders in mindfulness-based interventions
• Investigating the experiences of individuals with chronic illnesses in healthcare settings
• Understanding the impact of technology on work-life balance
• Exploring the experiences of individuals with learning disabilities in academic settings
• Analyzing the factors that contribute to successful entrepreneurship in small businesses
• Understanding the impact of gender identity on mental health and well-being
• Examining the perceptions of individuals with disabilities regarding accessibility in public spaces
• Understanding the impact of religion on coping strategies for stress and anxiety
• Exploring the experiences of individuals with chronic illnesses in complementary and alternative medicine treatments
• Analyzing the factors that contribute to successful customer retention strategies in business organizations
• Investigating the experiences of individuals with postpartum depression in therapy programs
• Understanding the impact of ageism on older adults in healthcare settings
• Examining the perceptions of students regarding online learning during the COVID-19 pandemic
• Analyzing the factors that contribute to successful team building in virtual work environments
• Investigating the experiences of individuals with gambling disorders in treatment programs
• Exploring the experiences of individuals with chronic illnesses in peer support groups
• Analyzing the factors that contribute to successful social media marketing strategies for businesses
• Investigating the experiences of individuals with ADHD in treatment programs
• Understanding the impact of sleep on cognitive and emotional functioning
• Examining the perceptions of individuals with chronic illnesses regarding healthcare access and affordability
• Investigating the experiences of individuals with borderline personality disorder in dialectical behavior therapy programs
• Understanding the impact of social support on caregiver well-being
• Exploring the experiences of individuals with chronic illnesses in disability activism
• Analyzing the factors that contribute to successful cultural competency training programs in healthcare settings
• Understanding the impact of personality disorders on interpersonal relationships
• Examining the perceptions of healthcare providers regarding the use of telehealth services
• Investigating the experiences of individuals with dissociative disorders in therapy programs
• Understanding the impact of gender bias in hiring practices
• Exploring the experiences of individuals with visual impairments in the workplace
• Analyzing the factors that contribute to successful diversity and inclusion programs in the workplace
• Understanding the impact of online dating on romantic relationships
• Examining the perceptions of parents regarding childhood vaccination
• Analyzing the factors that contribute to successful communication in healthcare settings
• Understanding the impact of cultural stereotypes on academic achievement
• Exploring the experiences of individuals with substance use disorders in sober living programs
• Analyzing the factors that contribute to successful classroom management strategies
• Understanding the impact of social support on addiction recovery
• Examining the perceptions of college students regarding mental health stigma
• Analyzing the factors that contribute to successful conflict resolution in the workplace
• Understanding the impact of race and ethnicity on healthcare access and outcomes
• Exploring the experiences of individuals with post-traumatic stress disorder in treatment programs
• Analyzing the factors that contribute to successful project management strategies
• Understanding the impact of teacher-student relationships on academic achievement
• Analyzing the factors that contribute to successful customer service strategies
• Investigating the experiences of individuals with social anxiety disorder in treatment programs
• Understanding the impact of workplace stress on job satisfaction and performance
• Exploring the experiences of individuals with disabilities in sports and recreation
• Analyzing the factors that contribute to successful marketing strategies for small businesses
• Investigating the experiences of individuals with phobias in treatment programs
• Understanding the impact of culture on attitudes towards mental health and illness
• Examining the perceptions of college students regarding sexual assault prevention
• Analyzing the factors that contribute to successful time management strategies
• Investigating the experiences of individuals with addiction in recovery support groups
• Understanding the impact of mindfulness on emotional regulation and well-being
• Exploring the experiences of individuals with chronic pain in treatment programs
• Analyzing the factors that contribute to successful conflict resolution in romantic relationships
• Investigating the experiences of individuals with autism spectrum disorder in social skills training programs
• Understanding the impact of parent-child communication on adolescent substance use
• Examining the perceptions of parents regarding childhood mental health services
• Analyzing the factors that contribute to successful fundraising strategies for non-profit organizations
• Investigating the experiences of individuals with chronic illnesses in support groups
• Understanding the impact of personality traits on career success and satisfaction
• Exploring the experiences of individuals with disabilities in accessing public transportation
• Analyzing the factors that contribute to successful team building in sports teams
• Investigating the experiences of individuals with chronic pain in alternative medicine treatments
• Understanding the impact of stigma on mental health treatment seeking behaviors
• Examining the perceptions of college students regarding diversity and inclusion on campus.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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About Journal

American Journal of Qualitative Research (AJQR)  is a quarterly peer-reviewed academic journal that publishes qualitative research articles from a number of social science disciplines such as psychology, health science, sociology, criminology, education, political science, and administrative studies. The journal is an international and interdisciplinary focus and greatly welcomes papers from all countries. The journal offers an intellectual platform for researchers, practitioners, administrators, and policymakers to contribute and promote qualitative research and analysis.

ISSN: 2576-2141

Call for Papers- American Journal of Qualitative Research

American Journal of Qualitative Research (AJQR) welcomes original research articles and book reviews for its next issue. The AJQR is a quarterly and peer-reviewed journal published in February, May, August, and November.

We are seeking submissions for a forthcoming issue published in February 2024. The paper should be written in professional English. The length of 6000-10000 words is preferred. All manuscripts should be prepared in MS Word format and submitted online: https://www.editorialpark.com/ajqr

For any further information about the journal, please visit its website: https://www.ajqr.org

Submission Deadline: November 15, 2023

Announcement 

Dear AJQR Readers, 

Due to the high volume of submissions in the American Journal of Qualitative Research , the editorial board decided to publish quarterly since 2023.

Volume 8, Issue 2

Current issue - in progress.

The COVID-19 pandemic has highlighted and exacerbated the difficult juggling act women in the U.S. have to do between parenting their children and working outside the home. The pandemic has also led to a decline in maternal mental health, particularly among mothers with young children, mothers of color, and those with previous mental health issues. The authors noted these experiences in their own lives as mothers with children and observed them in the lives of the women around them. These observations informed the design of this narrative inquiry study, in which we used semi-structured interviews to explore mothers’ shifting ideas and experiences of mothering, work, and family life during a global pandemic. We used creative analytic practice (CAP) to compose reflexive researcher conversations around the interview data that enabled us to highlight nuances in the data, show more transparently our meaning-making, make visible our researcher subjectivities, show uncertainties about aspects of data interpretation, and create a more accessible data representation.

Keywords: Mothering, COVID-19 pandemic, U.S. women, Narrative inquiry, Creative analytic practice.

The COVID-19 pandemic put France’s healthcare system under extreme tension and led to significant levels of stress among healthcare professionals in general and nurses in particular. Research has shown how these elements affected nurses’ physical and psychological health and manifested as insomnia, anxiety, and depressive syndromes. The present qualitative study aimed to explore the lived experiences of France’s nurses as a function of their level of exposure to the virus and whether they worked in the hospital sector or practiced privately in the community during the pandemic’s first wave. It also sought to describe the resources nurses used to maintain their overall health. We administered 19 qualitative interviews to 19 nurses in the autumn of 2021. The present study revealed that nurses were subjected to significant stress during the pandemic. Our data analysis enabled us to draw out three principal themes: 1) Being on the edge in stormy period ; 2) Personal impact on several levels and 3) Floating together and learning. There were no significant differences between the groups that were subjected to different levels of exposure to COVID-19. All the groups were affected by the pandemic that struck a healthcare system that was already systematically fragile. Nurses were severely tested by the COVID-19 pandemic, but their consciousness of the importance of their role grew, despite questioning what meaning there was to their profession, perhaps even to their lives . The trauma still felt fresh 18 months later, during the interviews, and this cannot be ignored in future healthcare policymaking .

Keywords: COVID-19, nurses, salutogenesis, stressors, health resources.

Annual mammography screening is recommended by the US Preventive Services Task Force (USPSTF) and American Cancer Society (ACS) to reduce mortality through early detection of breast cancer. In rural Appalachia, rates of later-stage breast cancer incidence and mortality are higher than national averages. We explored the ways that providers and staff at breast cancer screening facilities employed novel approaches to overcome patient- and facility-level barriers to access to breast cancer screening in the Appalachian region. We conducted 23 semi-structured interviews with 28 clinical providers and staff of breast health facilities in Appalachia. Themes reflect how limiting features of breast screening facilities influenced access to care; the way patient-level barriers presented challenges to access to breast screening; and that external and regulatory forces presented obstacles to access to care. In addition, the unique geographical and geographical attributes of the Appalachian region shaped access and adherence to mammography screening recommendations. Thematic findings highlight that facilities implemented patient-centered strategies to overcome access-related barriers. Results may inform the ways breast cancer screening facilities address suboptimal access to breast health screening. They may also inform future resource allocations to enable facilities to reach breast cancer screening performance goals.

Keywords: rural health, breast cancer, preventive health care, women’s health.

Paternal parenting affects child development; hence, the father’s absence has a deleterious effect on the male child. The literature on parenting shows limited focus on how parenting impacts children by gender. This qualitative hermeneutic phenomenological study investigated the key question, “How does a father’s absence during childhood influence a man’s subsequent parenting of his son(s)?” An integrated theoretical framework was used to guide the study: Parenting Style Theory, Social-Cognitive Theory, and Bioecological Systems Theory. Nine Trinidadian males aged 20 to 35 years who were parenting sons were recruited to participate using snowball sampling. Data on men’s adverse childhood experiences were gathered using semi-structured interviews. Content and thematic analyses were done using DELVE software. Key findings include the influence of stereotypical cultural constructs, the church’s critical role in addressing childhood trauma, the transmission of father absence across generations, and the relationship between neurodevelopment and adverse childhood experiences. Implications of these findings will benefit child and adolescent advocacy, inform policymaking, aid professional intervention in mental health and education, and strengthen familial systems and ecclesiastical contexts. Future research should explore the lived experiences of men who crave emotional connection with their sons yet struggle with the stereotypical cultural perception of manhood.

Keywords: father absence, brain development, childhood trauma, intergenerational, the transmission of behavior.

The purpose of this qualitative transcendental phenomenological study was to understand the essence of the shared lived experiences of undergraduate college students with anxiety disorders at two universities in the Southeastern United States. Ellis’s cognitive theory, rational emotive behavior therapy, guided the study which took place at a mid-sized, public nonsectarian university and a small, private liberal arts college. The central research question elicited rich data regarding the shared lived experiences of the study participants. The four research sub-questions address participants’ perceptions regarding the impact of their disorders on their lifestyles and academic performance. A purposeful criterion sample was used to select the participants who completed a questionnaire, open-ended individual interviews, a single focus group interview, and participant journals. Phenomenological reduction was used to create a composite integration of meaning and the essence of the lived experience of the participants. Data results identified five themes: (a) social fears, (b) stressor issues, (c) generational issues, (d) academic performance barriers, and (e) institutional education and accommodation preferences.

Keywords: Alexithymia, anxiety, disorder, qualitative, stressors

School shootings are traumatic events that can lead to anxiety, depression, and post-traumatic stress disorder among students who experience these events. It is important to find effective strategies to help students cope with their return to school, as well as their anxiety and stress levels while on campus. There exists a gap in the literature on the effects of therapy dogs on students who have witnessed a school shooting. This current study used a retrospective mixed-methods survey that was sent to recent graduates of Marjory Stoneman Douglas High School (located in Parkland, Florida) who witnessed the February 2018 shooting. Data were collected to assess how the therapy dogs affected students' willingness to return to school and their stress/anxiety levels while on campus. Identified themes indicated that the therapy dogs helped with anxiety levels, stress levels, and overall moods of Marjory Stoneman Douglas High School students. These findings provide important implications for community leaders and school administrators who want to promote healing and well-being in a community that has experienced violence.

Keywords: Therapy dog, school shooting, community violence.

Identifying the relation between the processes of programming and foreign language writing may lead to new directions for programming language and natural language focused instructional design. The present qualitative case study supported by quantitative data investigated foreign language writing experiences of computer engineering students taking an object-oriented programming course. Forty-five sophomores learning programming and academic English simultaneously in a foundation university in Ankara, Turkey, were selected purposefully for the case study. There were two data sources (students’ opinions and documents) and three data collection tools (a semi-structured interview, a short diary, and a composition. In terms of the findings of the research, four themes were obtained; however, only the use of metacognitive strategies will be explained in detail due to the length of the study. Participants stated that they feel the positive effects of programming experience on the use of self-evaluation strategy and that there are similarities and differences between the processes of programming and foreign language writing. Participants’ views on the effect of programming on foreign language writing did not differ according to their writing and programming performance scores. Participants stated that programming experience may have an effect on the use of metacognitive language learning strategies in the writing process. Upon analyzing participants’ comments, it is understood that programming experience does not hinder the use of metacognitive strategies but has a role in supporting and reinforcing their use. It is suggested that multiple case studies be done for similar views on the effects of programming and that each finding be proven by quantitative studies.

Keywords: programming, foreign language writing, metacognitive strategies.

The significance of participatory decision-making in educational institutions is widely acknowledged as essential in school management and administration. This study aimed to determine how involved teachers are in making decisions in their schools and what role they think they play in shaping different parts of school policies and procedures. It also looked at their perspectives on how decisions made by others are carried out in schools. Semi-structured interviews with 10 secondary school teachers focused on teachers' role in decision-making related to their routine school tasks, strategic decision-making, participatory role in making school decisions, and their willingness to participate in decision-making. This study showed that teachers' low participation is attributed to their shared desire to be involved in school management and administration-related decisions. Teachers expressed that participatory school-based decision-making can promote collaboration and collectivism among the school staff, and it plays a significant role in shaping their work satisfaction and motivation. By gaining insights into teachers' perspectives, this study aims to contribute to the broader understanding of participatory school decision-making in the Rwandan secondary education system and communicate potential improvements for fostering a more collaborative and inclusive educational environment.

Keywords: teachers’ perceptions, qualitative research, decision-making, secondary schools.

One of the major inefficiencies in qualitative research is the accuracy and timeliness of transcribing audio files into analyzable text. However, researchers may now have the ability to leverage artificial intelligence to increase research efficiency through Chat GPT. As a result, this study performs feasibility and accuracy testing of Chat GPT versus human transcription to compare accuracy and timeliness. Results suggest that by using specific commands, Chat GPT can clean interview transcriptions in seconds with a <1% word error rate and near 0% syntactic error rate. Implications for research and ethics are addressed.

Keywords: Chat GPT, artificial intelligence, qualitative research, educational research, transcription

Alcohol misuse on college campuses has been shown to be the cause of physical, socio-emotional, and academic harms. Alcohol is also an issue at Gallaudet University but there is a gap in the literature describing this phenomenon. Using the social ecological model, this qualitative case study explored student perceptions and experiences with alcohol use through interviews with 24 deaf and hard of hearing college students at Gallaudet University. The main themes included: something to do, isolation, coping, communication, “playing catch up with life,” belonging, peer pressure, and university dynamics. The results of this study supported the research on alcohol use in the college environment, showing these themes to also be true at Gallaudet University. As a result, researchers recommend for Gallaudet University and other institutions use the education and interventions shown to be effective in the College Alcohol Intervention Matrix with deaf and hard of hearing students. Researchers also identified themes that were divergent from general college students and specific to the experience of being deaf and hard of hearing. This study highlighted the interpersonal level impact and importance of communication with alcohol and related harms. Researchers recommend further research on the spectrum of communication isolation on alcohol use, related harms, and the social-ecological impact of these experiences. In addition, researchers recommend programming and services to specifically address the issues that occur as a result of isolation, coping challenges, desire to belong, susceptibility to peer pressure, and wanting to catch up on life. It is hoped that the insights gained from this study will be used to inform interventions for deaf and hard of hearing college students, to reduce alcohol misuse, and thus to impact positive change.

Keywords: Deaf, hard of hearing, alcohol, college, university, isolation.

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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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• Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

• P. Gill 1 &
• J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

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Introduction.

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

Gussy M, Dickson-Swift V, Adams J . A scoping review of qualitative research in peer-reviewed dental publications. Int J Dent Hygiene 2013; 11 : 174–179.

Article   Google Scholar  

Burnard P, Gill P, Stewart K, Treasure E, Chadwick B . Analysing and presenting qualitative data. Br Dent J 2008; 204 : 429–432.

Gill P, Stewart K, Treasure E, Chadwick B . Methods of data collection in qualitative research: interviews and focus groups. Br Dent J 2008; 204 : 291–295.

Gill P, Stewart K, Treasure E, Chadwick B . Conducting qualitative interviews with school children in dental research. Br Dent J 2008; 204 : 371–374.

Stewart K, Gill P, Chadwick B, Treasure E . Qualitative research in dentistry. Br Dent J 2008; 204 : 235–239.

Masood M, Thaliath E, Bower E, Newton J . An appraisal of the quality of published qualitative dental research. Community Dent Oral Epidemiol 2011; 39 : 193–203.

Ellis J, Levine A, Bedos C et al. Refusal of implant supported mandibular overdentures by elderly patients. Gerodontology 2011; 28 : 62–68.

Macfarlane S, Bucknall T . Digital Technologies in Research. In Gerrish K, Lathlean J (editors) The Research Process in Nursing . 7th edition. pp. 71–86. Oxford: Wiley Blackwell; 2015.

Google Scholar  

Lee R, Fielding N, Blank G . Online Research Methods in the Social Sciences: An Editorial Introduction. In Fielding N, Lee R, Blank G (editors) The Sage Handbook of Online Research Methods . pp. 3–16. London: Sage Publications; 2016.

Creswell J . Qualitative inquiry and research design: Choosing among five designs . Thousand Oaks, CA: Sage, 1998.

Guest G, Namey E, Mitchell M . Qualitative research: Defining and designing In Guest G, Namey E, Mitchell M (editors) Collecting Qualitative Data: A Field Manual For Applied Research . pp. 1–40. London: Sage Publications, 2013.

Chapter   Google Scholar  

Pope C, Mays N . Qualitative research: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995; 311 : 42–45.

Giddings L, Grant B . A Trojan Horse for positivism? A critique of mixed methods research. Adv Nurs Sci 2007; 30 : 52–60.

Hammersley M, Atkinson P . Ethnography: Principles in Practice . London: Routledge, 1995.

Oltmann S . Qualitative interviews: A methodological discussion of the interviewer and respondent contexts Forum Qualitative Sozialforschung/Forum: Qualitative Social Research. 2016; 17 : Art. 15.

Patton M . Qualitative Research and Evaluation Methods . Thousand Oaks, CA: Sage, 2002.

Wang M, Vinall-Collier K, Csikar J, Douglas G . A qualitative study of patients' views of techniques to reduce dental anxiety. J Dent 2017; 66 : 45–51.

Lindenmeyer A, Bowyer V, Roscoe J, Dale J, Sutcliffe P . Oral health awareness and care preferences in patients with diabetes: a qualitative study. Fam Pract 2013; 30 : 113–118.

Gallagher J, Clarke W, Wilson N . Understanding the motivation: a qualitative study of dental students' choice of professional career. Eur J Dent Educ 2008; 12 : 89–98.

Tod A . Interviewing. In Gerrish K, Lacey A (editors) The Research Process in Nursing . Oxford: Blackwell Publishing, 2006.

Grey E, Harcourt D, O'Sullivan D, Buchanan H, Kipatrick N . A qualitative study of patients' motivations and expectations for dental implants. Br Dent J 2013; 214 : 10.1038/sj.bdj.2012.1178.

Farmer J, Peressini S, Lawrence H . Exploring the role of the dental hygienist in reducing oral health disparities in Canada: A qualitative study. Int J Dent Hygiene 2017; 10.1111/idh.12276.

McElhinney E, Cheater F, Kidd L . Undertaking qualitative health research in social virtual worlds. J Adv Nurs 2013; 70 : 1267–1275.

Health Research Authority. UK Policy Framework for Health and Social Care Research. Available at https://www.hra.nhs.uk/planning-and-improving-research/policies-standards-legislation/uk-policy-framework-health-social-care-research/ (accessed September 2017).

Baillie J, Gill P, Courtenay P . Knowledge, understanding and experiences of peritonitis among patients, and their families, undertaking peritoneal dialysis: A mixed methods study protocol. J Adv Nurs 2017; 10.1111/jan.13400.

Kvale S . Interviews . Thousand Oaks (CA): Sage, 1996.

Spradley J . The Ethnographic Interview . New York: Holt, Rinehart and Winston, 1979.

Goodman C, Evans C . Focus Groups. In Gerrish K, Lathlean J (editors) The Research Process in Nursing . pp. 401–412. Oxford: Wiley Blackwell, 2015.

Shaha M, Wenzell J, Hill E . Planning and conducting focus group research with nurses. Nurse Res 2011; 18 : 77–87.

Wang G, Gao X, Edward C . Public perception of dental implants: a qualitative study. J Dent 2015; 43 : 798–805.

Bailey E . Contemporary views of dental practitioners' on patient safety. Br Dent J 2015; 219 : 535–540.

Abrams K, Gaiser T . Online Focus Groups. In Field N, Lee R, Blank G (editors) The Sage Handbook of Online Research Methods . pp. 435–450. London: Sage Publications, 2016.

Poynter R . The Handbook of Online and Social Media Research . West Sussex: John Wiley & Sons, 2010.

Kevern J, Webb C . Focus groups as a tool for critical social research in nurse education. Nurse Educ Today 2001; 21 : 323–333.

Kitzinger J, Barbour R . Introduction: The Challenge and Promise of Focus Groups. In Barbour R S K J (editor) Developing Focus Group Research . pp. 1–20. London: Sage Publications, 1999.

Krueger R, Casey M . Focus Groups: A Practical Guide for Applied Research. 4th ed. Thousand Oaks, California: SAGE; 2009.

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Gill, P., Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J 225 , 668–672 (2018). https://doi.org/10.1038/sj.bdj.2018.815

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Accepted : 02 July 2018

Published : 05 October 2018

Issue Date : 12 October 2018

DOI : https://doi.org/10.1038/sj.bdj.2018.815

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Qualitative Study

Affiliations.

• 1 University of Nebraska Medical Center
• 2 GDB Research and Statistical Consulting
• 3 GDB Research and Statistical Consulting/McLaren Macomb Hospital
• PMID: 29262162
• Bookshelf ID: NBK470395

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. Instead of collecting numerical data points or intervening or introducing treatments just like in quantitative research, qualitative research helps generate hypothenar to further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a standalone study, purely relying on qualitative data, or part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and applications of qualitative research.

Qualitative research, at its core, asks open-ended questions whose answers are not easily put into numbers, such as "how" and "why." Due to the open-ended nature of the research questions, qualitative research design is often not linear like quantitative design. One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. Phenomena such as experiences, attitudes, and behaviors can be complex to capture accurately and quantitatively. In contrast, a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a particular time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify, and it is essential to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore "compete" against each other and the philosophical paradigms associated with each other, qualitative and quantitative work are neither necessarily opposites, nor are they incompatible. While qualitative and quantitative approaches are different, they are not necessarily opposites and certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated.

Copyright © 2024, StatPearls Publishing LLC.

• Introduction
• Issues of Concern
• Clinical Significance
• Enhancing Healthcare Team Outcomes
• Review Questions

Publication types

• Study Guide

• Research article
• Open access
• Published: 14 June 2021

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice

• Jannine van Schothorst–van Roekel 1 ,
• Anne Marie J.W.M. Weggelaar-Jansen 1 ,
• Carina C.G.J.M. Hilders 1 ,
• Antoinette A. De Bont 1 &
• Iris Wallenburg 1  

BMC Nursing volume  20 , Article number:  97 ( 2021 ) Cite this article

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Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.

A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.

Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.

Conclusions

Conducting small-change experiments, anchored by action and appraisal rather than by design , clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

Peer Review reports

The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [ 1 , 2 ]. Nurses play an important role in facing these contemporary challenges [ 3 , 4 ]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [ 5 , 6 ]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [ 7 , 8 ]. This issue has sparked renewed interest in nursing role development [ 9 , 10 , 11 ]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [ 12 , 9 ].

New nursing roles usually arise through task specialization [ 13 , 14 ] and the development of advanced nursing roles [ 15 , 16 ]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [ 17 , 18 ]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [ 19 , 20 ]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [ 21 , 22 , 23 ].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [ 24 , 25 ] but also in Australia [ 26 , 27 ], Singapore [ 20 ] and the United States of America [ 28 , 29 ]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [ 30 ]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [ 31 ].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [ 32 ]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [ 33 , 34 , 35 , 36 ], based on nurses’ thorough knowledge of professional practices [ 37 ] and leadership role [ 38 , 39 , 40 ].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [ 41 ]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [ 42 , 43 , 44 ]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [ 31 ]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.

The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.

We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [ 45 , 46 ]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [ 47 , 48 ]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table  1 . The project team, comprising nursing policy staff, coaches and HR staff ( N  = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers ( N  = 4), and the CEO ( N  = 1) in the meetings.

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [ 45 ] (see Table  2 ).

Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [ 49 , 50 ], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [ 46 ].

Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams ( n  = 2); (2) bi-monthly meetings ( n  = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed ( n  = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice ( n  = 15). Minutes and detailed notes also produced thick descriptions [ 51 ]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [ 52 ]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO ( n  = 1), middle managers ( n  = 4), VNs ( n  = 6), BNs ( n  = 9, including four senior nurses), paramedics ( n  = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards ( N  = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Data analysis

Data collection and inductive thematic analysis took place iteratively [ 45 , 53 ]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file ). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [ 54 ]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.

Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [ 48 ]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [ 55 ]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [ 56 , 57 ]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [ 54 ]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [ 48 ]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.

Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [ 32 ]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is , is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [ 58 ] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [ 59 ]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [ 49 ]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [ 1 , 60 ]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [ 61 ]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [ 62 ] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [ 63 ], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [ 64 ]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [ 65 ]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [ 1 ], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [ 66 ] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.

This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [ 49 ]. Usually, invisible work gets no formal recognition, for example in policy documents [ 55 ], whereas it is crucial in daily routines and organizational structures [ 49 , 60 ]. Second, experimenting triggers an accumulation of small changes [ 33 , 35 ] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [ 37 ]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [ 43 ] resulting in a subordinate position, power inequity and lack of autonomy [ 44 ]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [ 12 ] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [ 9 , 10 , 11 ] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [ 41 ] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [ 42 ] and Abbott [ 67 ] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [ 37 , 39 , 40 ]. Adding to Mannix et al. [ 38 ], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [ 64 , 65 ]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [ 34 , 68 ] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.

Limitations

Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.

This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design , the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

Allen D. Nursing and the future of ‘care’ in health care systems. J Health Serv Res Policy. 2015;20(3):129–30. https://doi.org/10.1177/1355819615577806 .

Article   PubMed   Google Scholar  

NHS England. Leading change, adding value. A framework for nursing, midwifery and care staff. 2016. https://www.england.nhs.uk/wp-content/uploads/2016/05/nursing-framework.pdf . Accessed 11 Nov 2020.

Institute of Medicine (IOM). The future of nursing; Leading change, advancing Health. Washington (DC): National Academies Press; 2011.

Google Scholar  

World Health Organization (WHO). Gloabal strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: WHO Press; 2016.

Dawson AJ, Stasa H, Roche MA, et al. Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies. BMC Nurs. 2014;13:11. https://doi.org/10.1186/1472-6955-13-11 .

Article   PubMed   PubMed Central   Google Scholar  

Hayes LJ, O’Brien-Pallas L, Duffield C, et al. Nurse turnover: a literature review–an update. Intern J Nurs Stud. 2012;49(7):887–905. https://doi.org/10.1016/j.ijnurstu.2011.10.001 .

Article   Google Scholar  

Persson U, Carlson E. Conceptions of professional work in contemporary health care—Perspectives from registered nurses in somatic care: A phenomenographic study. J Clin Nurs. 2019;28(1–2):201–8. https://doi.org/10.1111/jocn.14628 .

Senek M, Robertson S, Ryan T, et al. Determinants of nurse job dissatisfaction-findings from a cross-sectional survey analysis in the UK. BMC Nurs. 2020;19(1):1–10. https://doi.org/10.1186/s12912-020-00481-3 .

Jacob ER, McKenna L, D’Amore A. The changing skill mix in nursing: considerations for and against different levels of nurse. J Nurs Manag. 2015;23(4):421–6. https://doi.org/10.1111/jonm.12162 .

Sermeus W, Aiken LH, Van den Heede K, et al. Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology. BMC Nurs. 2011;10:6. https://doi.org/10.1186/1472-6955-10-6 .

de Bont A, van Exel Job, Coretti S, Ökem ZG, Janssen M, Hope KL, Ludwicki T, Zander B, Zvonickova M, Bond C, Wallenburg I. Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe. BMC Health Serv Res. 2016;16(1).

Poitras ME, Chouinard MC, Fortin M, et al. How to report professional practice in nursing? A scoping review. BMC Nurs. 2016;15(1):31. https://doi.org/10.1186/s12912-016-0154-6 .

Jones ML. Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis. J Adv Nurs. 2005;49(2):191–209. https://doi.org/10.1111/j.1365-2648.2004.03279.x .

Ranchal A, Jolley MJ, Keogh J, et al. The challenge of the standardization of nursing specializations in Europe. Int Nurs Rev. 2015;62(4):445–52. https://doi.org/10.1111/inr.12204 .

Article   CAS   PubMed   Google Scholar  

Lowe G, Plummer V, O’Brien AP, et al. Time to clarify–the value of advanced practice nursing roles in health care. J Adv Nurs. 2012;68(3):677–85. https://doi.org/10.1111/j.1365-2648.2011.05790.x .

Fealy GM, Casey M, O’Leary DF, et al. Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers. J Clin Nurs. 2018;27(19–20):3797–809. https://doi.org/10.1111/jocn.14550 .

Aiken LH, Sermeus W, Van den Heede K, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344;e1717. https://doi.org/10.1136/bmj.e1717

Lu H, Zhao Y, While A. Job satisfaction among hospital nurses: A literature review. Intern J Nurs Stud. 2019;94:21–31. https://doi.org/10.1016/j.ijnurstu.2019.01.011 .

Duffield C, Roche M, Twigg D, et al. Adding unregulated nursing support workers to ward staffing: Exploration of a natural experiment. J Clin Nurs. 2018;27(19–20):3768–79. https://doi.org/10.1111/jocn.14632 .

Chua WL, Legido-Quigley H, Ng PY, et al. Seeing the whole picture in enrolled and registered nurses’ experiences in recognizing clinical deterioration in general ward patients: A qualitative study. Intern J Nurs Stud. 2019;95:56–64. https://doi.org/10.1016/j.ijnurstu.2019.04.012 .

van Oostveen CJ, Mathijssen E, Vermeulen H. Nurse staffing issues are just the tip of the iceberg: a qualitative study about nurses’ perceptions of nurse staffing. Intern J Nurs Stud. 2015;52(8):1300–9. https://doi.org/10.1016/j.ijnurstu.2015.04.002 .

Saville CE, Griffiths P, Ball JE, et al. How many nurses do we need? A review and discussion of operational research techniques applied to nurse staffing. Intern J Nurs Stud. 2019;97:7–13. https://doi.org/10.1016/j.ijnurstu.2019.04.015 .

Vatnøy TK, Sundlisæter Skinner M, Karlsen T, et al. Nursing competence in municipal in-patient acute care in Norway: a cross-sectional study. BMC Nurs. 2020;9:70. https://doi.org/10.1186/s12912-020-00463-5 .

De Jong JHJ, Kerstens JAM, Sesink EM, et al. Deskundigheidsbevordering en professionalisering. In: Handboek verpleegkunde. Houten: Bohn Stafleu van Loghum; 2003. p. 396–421. https://doi.org/10.1007/978-90-313-9699-3_13 .

Lalleman P, Stalpers D, Goossens L, et al. RN2Blend: meerjarig onderzoek naar gedifferentieerde inzet van verpleegkundigen. Verpleegkunde. 2020;1:4–6.

Endacott R, O’Connor M, Williams A, et al. Roles and functions of enrolled nurses in Australia: Perspectives of enrolled nurses and registered nurses. J Clin Nurs. 2018;27(5–6):e913–20. https://doi.org/10.1111/jocn.13987 .

Jacob E, Sellick K, McKenna L. Australian registered and enrolled nurses: Is there a difference? Intern J Nurs Pract. 2012;18(3):303–7. https://doi.org/10.1111/j.1440-172X.2012.02037.x .

Matthias AD. Educational pathways for differentiated nursing practice: a continuing dilemma. In: Lewenson SB, McAllister A, Smith KM, editors. Nursing History for Contemporary Role Development. New York: Springer Publishing Company; 2017. p. 121–40.

Boston-Fleischhauer C. Another Look at Differentiating Nursing Practice. J Nurs Adm. 2019;49(6):291–3. https://doi.org/10.1097/NNA.0000000000000754 .

Gardner G, Duffield C, Doubrovsky A, et al. Identifying advanced practice: a national survey of a nursing workforce. Intern J Nurs Stud. 2016;55:60–70. https://doi.org/10.1016/j.ijnurstu.2015.12.001 .

Duffield C, Twigg D, Roche M, et al. Uncovering the disconnect between nursing workforce policy intentions, implementation, and outcomes: Lessons learned from the addition of a nursing assistant role. Policy Polit Nurs Pract. 2019;20(4):228–238. https://doi.org/10.1177/1527154419877571

Terpstra D, Van den Berg A, Van Mierlo C, et al. Toekomstbestendige beroepen in de verpleging en verzorging: rapport stuurgroep over de beroepsprofielen en de overgangsregeling. 2015. http://www.nfu.nl/img/pdf/Rapport_toekomstbestendige-beroepen-in-de-verpleging-en-verzorging.pdf

Bohmer RM. The hard work of health care transformation. N Engl J Med 2016;375(8):709–11. doi: https://doi.org/10.1056/NEJMp1606458

Ellström PE. Integrating learning and work: Problems and prospects. Hum Res Dev Q. 2001;12(4):421–35. https://doi.org/10.1002/hrdq.1006 .

Lyman B, Hammond E, Cox J. Organizational learning in hospitals: A concept analysis. J Nurs Manag. 2019;27:633–46. https://doi.org/10.1111/jonm.12722 .

van Schothorst J, van Roekel AM,  Weggelaar-Jansen JWM, de Bont A, Wallenburg I. The balancing act of organizing professionals and managers: An ethnographic account of nursing role development and unfolding nurse-manager relationships. J Professions an Orga. 2020;7(3):283–99.

Reay T, Golden-Biddle K, Germann K. Legitimizing a New Role: Small Wins and Microprocesses of Change. Acad Manag J. 2006;49(5):977–98. https://doi.org/10.5465/amj.2006.22798178 .

Mannix J, Wilkes L, Jackson D. Marking out the clinical expert/clinical leader/clinical scholar: perspectives from nurses in the clinical arena. BMC Nurs. 2013:12;12. https://doi.org/10.1186/1472-6955-12-12

Nelson-Brantley HV, Ford DJ. Leading change: a concept analysis. J Adv Nurs. 2017;73(4):834–46. https://doi.org/10.1111/jan.13223 .

Boamah SA. Emergence of informal clinical leadership as a catalyst for improving patient care quality and job satisfaction. J Adv Nurs. 2019;75(5):1000–9. https://doi.org/10.1111/jan.13895 .

Abbott A. Linked ecologies: States and universities as environments for professions. Sociol Theory. 2005;23(3):245–74. https://doi.org/10.1111/j.0735-2751.2005.00253.x .

Hughes D. Nursing and the division of labour: sociological perspectives. In: Allen D, Hughes D, editors. Nursing and the Division of Labour in Healthcare. Hampshire and New York: Palgrave Macmillan; 2017. p. 1–21.

Ayala RA. Towards a Sociology of Nursing. Palgrave Macmillan; 2020.

Chua WF, Clegg S. Professional closure. Theory Soc. 1990;19(2):135–72.

Roper JM, Shapira J. Ethnography in nursing research. Thousand Oaks: Sage Publications; 2000.

Book   Google Scholar  

Polit DF, Beck CT. Nursing research: Generating and assessing evidence for nursing practice, 8th Edition. Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2008.

Atkinson P, Hammersley M. Ethnography: Principles in practice. New York: Routledge; 2007.

Draper J. Ethnography: Principles, practice and potential. Nurs Stand. 2015;29(36):36–41. https://doi.org/10.7748/ns.29.36.36.e8937 .

Allen D. The invisible work of nurses: Hospitals, organisation and healthcare. The Invisible Work of Nurses: Hospitals, Organisation and Healthcare. Oxfordshire and New York: Routledge; 2014.

Lalleman P, Bouma J, Smid G, et al. Peer-to-peer shadowing as a technique for the development of nurse middle managers clinical leadership: An explorative study. Leader Health Serv. 2017;30(4):475–90. https://doi.org/10.1108/LHS-12-2016-0065 .

Atkins S, Lewin S, Smith H, et al. Conducting a meta-ethnography of qualitative literature: lessons learned. BMC Med Res Methodol. 2008;8:21. https://doi.org/10.1186/1471-2288-8-21

Houghton C, Casey D, Shaw D, et al. Rigour in qualitative case-study researh. Nurse Res. 2013;20(4):12–7. https://doi.org/10.7748/nr2013.03.20.4.12.e326 .

Denzin NK, Lincoln YS, editors. The Sage handbook of Qualitative research. Thousands Oak: Sage; 2011.

Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory Pract. 2000;39(3):124–30. https://doi.org/10.1207/s15430421tip3903_2 .

Baker L, Observation. A complex research method. Library Trends. 2006;55(1):171–89.

Kanuha VK. “Being” native versus “going native”: Conducting social work research as an insider. Social Work. 2000;45(5):439–47. https://doi.org/10.1093/sw/45.5.439 .

Dwyer SC, Buckle JL. The space between: On being an insider-outsider in qualitative research. Intern J Qual Methods. 2009;8(1):54–63. https://doi.org/10.1177/160940690900800105 .

Star SL, Strauss A. Layers of silence, arenas of voice: The ecology of visible and invisible work. Comp Support Coop Work. 1999;8(1–2):9–30. https://doi.org/10.1023/A:1008651105359 .

Allen DA, Lyne PA. Nurses’ flexible working practices: some ethnographic insights into clinical effectiveness. Clin Effective Nurs. 1997;1(3):131–8. https://doi.org/10.1016/S1361-9004(97)80048-9 .

Allen D. Translational mobilisation theory: a new paradigm for understanding the organisational elements of nursing work. Intern J Nurs Stud. 2018;79:36–42. https://doi.org/10.1016/j.ijnurstu.2017.10.010 .

Arrowsmith V, Lau-Walker M, Norman I, et al. Nurses’ perceptions and experiences of work role transitions: a mixed methods systematic review of the literature. J Adv Nurs. 2016;72(8):1735–50. https://doi.org/10.1111/jan.12912 .

Apker J, Propp KM, Ford WSZ, et al. Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. J Prof Nurs. 2006;22(3):180–9. https://doi.org/10.1016/j.profnurs.2006.03.002 .

Currie G, Koteyko N, Nerlich B. The dynamics of professions and development of new roles in public services organizations. The case of modern matrons in the English NHS. Public Adm. 2009;87(2):295–311. https://doi.org/10.1111/j.1467-9299.2009.01755.x .

Skela-Savič B, Hvalič-Touzery S, Pesjak K. Professional values and competencies as explanatory factors for the use of evidence-based practice in nursing. J Adv Nurs. 2017;73(8):1910–23. https://doi.org/10.1111/jan.13280 .

FURÅKER C. Registered Nurses’ views on their professional role. J Nurs Manag. 2008;16(8):933–41. https://doi.org/10.1111/j.1365-2834.2008.00872.x .

Stokke K, Olsen NR, Espehaug B, et al. Evidence based practice beliefs and implementation among nurses: a cross-sectional study. BMC Nurs. 2014;13(1):8.

Abbott A. The system of professions: an essay on the expert division of labor. Chicago: The University of Chicago Press; 1988.

Clegg SR, Kornberger M, Rhodes C. Learning/becoming/organizing. Organization. 2005;12(2):147–67. https://doi.org/10.1177/1350508405051186 .

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The authors would like to thank all participants for their contribution to this study.

The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

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A.W. and I.W. developed the study design. J.S. and A.W. were responsible for data collection, enhanced by I.W. for data analysis and drafting the manuscript. C.H. and A.B. critically revised the paper. All authors have read and approved the manuscript.

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van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20 , 97 (2021). https://doi.org/10.1186/s12912-021-00613-3

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Developing and enhancing societal capacity to understand, debate elements of, and take actionable steps toward a sustainable future at a scale beyond the individual are critical when addressing sustainability challenges such as climate change, resource scarcity, biodiversity loss, and zoonotic disease. Although mounting evidence exists for how to facilitate individual action to address sustainability challenges, there is less understanding of how to foster collective action in this realm. To support research and practice promoting collective action to address sustainability issues, we define the term “collective environmental literacy” by delineating four key potent aspects: scale, dynamic processes, shared resources, and synergy. Building on existing collective constructs and thought, we highlight areas where researchers, practitioners, and policymakers can support individuals and communities as they come together to identify, develop, and implement solutions to wicked problems. We close by discussing limitations of this work and future directions in studying collective environmental literacy.

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Introduction

For socio-ecologically intertwined issues—such as climate change, land conversion, biodiversity loss, resource scarcity, and zoonotic diseases—and their associated multi-decadal timeframes, individual action is necessary, yet not sufficient, for systemic, sustained change (Amel et al. 2017 ; Bodin 2017 ; Niemiec et al. 2020 ; Spitzer and Fraser 2020 ). Instead, collective action, or individuals working together toward a common good, is essential for achieving the scope and scale of solutions to current sustainability challenges. To support communities as they engage in policy and action for socio-environmental change, communicators, land managers, policymakers, and other practitioners need an understanding of how communities coalesce and leverage their shared knowledge, skills, connections, and experiences.

Engagement efforts, such as those grounded in behavior-change approaches or community-based social marketing initiatives, that address socio-environmental issues have often emphasized individuals as the pathway to change. Such efforts address a range of domains including, but not limited to, residential energy use, personal transportation choices, and workplace recycling efforts, often doing so in a stepwise fashion, envisioning each setting or suite of behaviors as discrete spheres of action and influence (Heimlich and Ardoin 2008 ; McKenzie-Mohr 2011 ). In this way, specific actions are treated incrementally and linearly, considering first the individual barriers to be removed and then the motivations to be activated (and, sometimes, sustained; Monroe 2003 ; Gifford et al. 2011 ). Once each behavior is successfully instantiated, the next barrier is then addressed. Proceeding methodically from one action to the next, such initiatives often quite successfully alter a series of actions or group of related behaviors (at least initially) by addressing them incrementally, one at a time (Byerly et al. 2018 ). Following this aspirational logic chain, many resources have been channeled into such programs under the assumption that, by raising awareness and knowledge, such information, communication, and educational outreach efforts will shift attitudes and behaviors to an extent that, ultimately, mass-scale change will follow. (See discussion in Wals et al. 2014 .)

Numerous studies have demonstrated, however, that challenges arise with these stepwise approaches, particularly with regard to their ability to address complex issues and persist over time (Heimlich and Ardoin 2008 ; Wals et al. 2014 ). Such approaches place a tremendous—and unrealistic—burden on individuals, ignoring key aspects not only of behavioral science but also of social science more broadly, including the view that humans exist nested within socio-ecological systems and, thus, are most successful at achieving lasting change when it is meaningful, relevant, and undertaken within a supportive context (Swim et al. 2011 ; Feola 2015 ). Individualized approaches often require multiple steps or nudges (Byerly et al. 2018 ), or ongoing reminders to retain their salience (Stern et al. 2008 ). Because of the emphasis on decontextualized action, such approaches can miss, ignore, obfuscate, or minimize the importance of the bigger picture, which includes the sociocultural, biophysical, and political economic contexts (Ardoin 2006 ; Amel et al. 2017 ). Although the tightly trained focus on small, actionable steps and reliance on individual willpower may help in initially achieving success with initial habit formation (Carden and Wood 2018 ), it becomes questionable in terms of bringing about a wave of transformation on larger scales in the longer term. For those decontextualized actions to persist, they require continued prompting, constancy, and support in the social and biophysical context (Schultz 2014 ; Manfredo et al. 2016 ; Wood and Rünger 2016 ).

Less common in practice are theoretically based initiatives that embrace the holistic nature of the human experience, which occurs within complex systems spanning time and space in a multidimensional, weblike fashion (Bronfenbrenner 1979 ; Rogoff 2003 ; Barron 2006 ; DeCaro and Stokes 2008 ; Gould et al. 2019 ; Hovardas 2020 ). These systems-thinking approaches, while varying across disciplines and epistemological perspectives, envision human experiences, including learning and behavior, as occurring within a milieu that include the social, political, cultural, and historical contexts (Rogoff 2003 ; Roth and Lee 2007 ; Swim et al. 2011 ; Gordon 2019 ). In such a view, people’s everyday practices continuously reflect and grow out of past learning and experiences, not only at the individual, but also at the collective level (Lave 1991 ; Gutiérrez and Rogoff 2003 ; Nasir et al. 2020 ; Ardoin and Heimlich 2021 ). The multidimensional context in which we exist—including the broader temporal and spatial ecosystem—both facilitates and constrains our actions.

Scholars across diverse areas of study discuss the need for and power of collective thought and action, using various conceptual frames, models, and terms, such as collective action, behavior, impact, and intelligence; collaborative governance; communities of practice; crowdsourcing; and social movement theory; among many others (Table 1 ). These scholars acknowledge and explore the influence of our multidimensional context on collective thought and action. In this paper, we explore the elements and processes that constitute collective environmental literacy . We draw on the vast, relevant literature and, in so doing, we attempt to invoke the power of the collective: by reviewing and synthesizing ideas from a variety of fields, we strive to leverage existing constructs and perspectives that explore notions of the “collective” (see Table 1 for a summary of constructs and theories reviewed to develop our working definition of collective environmental literacy). A primary goal of this paper is to dialogue with other researchers and practitioners working in this arena who are eager to uncover and further explore related avenues.

First, we present a formal definition of collective environmental literacy. Next, we briefly review the dominant view of environmental literacy at the individual level and, in support of a collective take on environmental literacy, we examine various collective constructs. We then delve more deeply into the definition of collective environmental literacy by outlining four key aspects: scale, dynamic processes, shared resources, and synergy. We conclude by providing suggestions for future directions in studying collective environmental literacy.

Defining collective environmental literacy

Decades of research in political science, economics, anthropology, sociology, psychology, and the learning sciences, among other fields (Chawla and Cushing 2007 ; Ostrom 2009 ; Sawyer 2014 ; Bamberg et al. 2015 ; Chan 2016 ; Jost et al. 2017 ) repeatedly demonstrates the effectiveness, and indeed necessity of, collective action when addressing problems that are inherently social in nature. Yet theoretical frameworks and empirical documentation emphasize that such collective activities rarely arise spontaneously and, when they do, are a result of preconditions that have sown fertile ground (van Zomeren et al. 2008 ; Duncan 2018 ). Persistent and effective collective action then requires scaffolding in the form of institutional, sociocultural, and political economic structure that provides ongoing support. To facilitate discussions of how to effectively support collective action around sustainability issues, we suggest the concept of “collective environmental literacy.” We conceptualize collective environmental literacy as more than collective action; rather, we suggest that the term encapsulates action along with its various supporting structures and resources. Additionally, we employ the word “literacy” as it connotes learning, intention, and the idea that knowledge, skills, attitudes, and behaviors can be enhanced iteratively over time. By using “literacy,” we strive to highlight the efforts, often unseen, that lead to effective collective action in communities. We draw on scholarship in science and health education, areas that have begun over the past two decades to theorize about related areas of collective science literacy (Roth and Lee 2002 , 2004 ; Lee and Roth 2003 ; Feinstein 2018 ) and health literacy (Freedman et al. 2009 ; Papen 2009 ; Chinn 2011 ; Guzys et al. 2015 ). Although these evolving constructs lack consensus definitions, they illuminate affordances and constraints that exist when conceptualizing collective environmental literacy (National Academies of Sciences, Engineering, and Medicine [NASEM] 2016 ).

Some of the key necessary—but not sufficient—conditions that facilitate aligned, collective actions include a common body of decision-making information; shared attitudes, values, and beliefs toward a motivating issue or concern; and efficacy skills that facilitate change-making (Sturmer and Simon 2004 ; van Zomeren et al. 2008 ; Jagers et al. 2020 ). In addition, other contextual factors are essential, such as trust, reciprocity, collective efficacy, and communication among group members and societal-level facilitators, such as social norms, institutions, and technology (Bandura 2000 ; Ostrom 2010 ; McAdam and Boudet 2012 ; Jagers et al. 2020 ). Taken together, we term this body of knowledge, dispositions, skills, and the context in which they flourish collective environmental literacy . More formally, we define collective environmental literacy as: a dynamic, synergistic process that occurs as group members develop and leverage shared resources to undertake individual and aggregate actions over time to address sustainability issues within the multi-scalar context of a socio-environmental system (Fig.  1 ).

Key elements of collective environmental literacy

Environmental literacy: Historically individual, increasingly collective

Over the past five decades, the term “environmental literacy” has come into increasingly frequent use. Breaking from the traditional association of “literacy” with reading and writing in formal school contexts, environmental literacy emphasizes associations with character and behavior, often in the form of responsible environmental stewardship (Roth 1992 ). Footnote 1 Such perspectives define the concept as including affective (attitudinal), cognitive (knowledge-based), and behavioral domains, emphasizing that environmental literacy is both a process and outcome that develops, builds, and morphs over time (Hollweg et al. 2011 ; Wheaton et al. 2018 ; Clark et al. 2020 ).

The emphasis on defining, measuring, and developing interventions to bring about environmental literacy has primarily remained at the individual scale, as evidenced by frequent descriptions of an environmentally literate person (Roth 1992 ; Hollweg et al. 2011 among others) rather than community or community member. In most understandings, discussions, and manifestations of environmental literacy, the implicit assumption remains that the unit of action, intervention, and therefore analysis occurs at the individual level. Yet instinctively and perhaps by nature, community members often seek information and, as a result, take action collectively, sharing what some scholars call “the hive mind” or “group mind,” relying on each other for distributed knowledge, expertise, motivation, and support (Surowiecki 2005 ; Sunstein 2008 ; Sloman and Fernbach 2017 ; Paul 2021 ).

As with the proverbial elephant (Saxe, n.d.), each person, household, or neighborhood group may understand or “see” a different part of an issue or challenge, bring a novel understanding to the table, and have a certain perspective or skill to contribute. Although some environmental literacy discussions allude to a collective lens (e.g., Hollweg et al. 2011 ; Ardoin et al. 2013 ; Wheaton et al. 2018 ; Bey et al. 2020 ), defining, developing frameworks, and creating measures to assess the efficacy of such collective-scale sustainability-related endeavors has remained elusive. Footnote 2 Looking to related fields and disciplines—such as ecosystem theory, epidemiology and public health, sociology, network theory, and urban planning, among others—can provide insight, theoretical frames, and empirical examples to assist in such conceptualizations (McAdam and Boudet 2012 ; National Research Council 2015 ) (See Table 1 for an overview of some of the many areas of study that informed our conceptualization of collective environmental literacy).

Seeking the essence of the collective: Looking to and learning from others

The social sciences have long focused on “the kinds of activities engaged in by sizable but loosely organized groups of people” (Turner et al. 2020 , para. 1) and addressed various collective constructs, such as collective behavior, action, intelligence, and memory (Table 1 ). Although related constructs in both the social and natural sciences—such as communities of practice (Wenger and Snyder 2000 ), collaborative governance (Ansell and Gash 2008 ; Emerson et al. 2012 ), and the collaboration–coordination continuum (Sadoff and Grey 2005 ; Prager 2015 ), as well as those from social movement theory and related areas (McAdam and Boudet 2012 ; de Moor and Wahlström 2019 )—lack the word “collective” in name, they too leverage the benefits of collectivity. A central tenet connects all of these areas: powerful processes, actions, and outcomes can arise when individuals coalesce around a common purpose or cause. This notion of a dynamic, potent force transcending the individual to enhance the efficacy of outcomes motivates the application of a collective lens to the environmental literacy concept.

Dating to the 1800s, discussions of collective behavior have explored connections to social order, structures, and norms (Park 1927 ; Smelser 2011 /1962; Turner and Killian 1987 ). Initially, the focus emphasized spontaneous, often violent crowd behaviors, such as riots, mobs, and rebellions. More contemporarily, sociologists, political scientists, and others who study social movements and collective behaviors acknowledge that such phenomena may take many forms, including those occurring in natural ecosystems, such as ant colonies, bird flocks, and even the human brain (Gordon 2019 ). In sociology, collective action represents a paradigm shift highlighting coordinated, purposeful pro-social movements, while de-emphasizing aroused emotions and crowd behavior (Miller 2014 ). In political science, Ostrom’s ( 1990 , 2000 , 2010 ) theory of collective action in the context of the management of shared resources extends the concept’s reach to economics and other fields. In education and the learning sciences, social learning and sociocultural theories tap into the idea of learning as a social-cognitive-cultural endeavor (Vygotsky 1980 ; Lave and Wenger 1991 ; Tudge and Winterhoff 1993 ; Rogoff 2003 ; Reed et al. 2010 ).

Collective action, specifically, and collective constructs, generally, have found their way into the research and practice in the fields of conservation, natural resources, and environmental management. Collective action theory has been applied in a range of settings and scenarios, including agriculture (Mills et al. 2011 ), invasive species management (Marshall et al. 2016 ; Sullivan et al. 2017 ; Lubeck et al. 2019 ; Clarke et al. 2021 ), fire management (Canadas et al. 2016 ; Charnley et al. 2020 ), habitat conservation (Raymond 2006 ; Niemiec et al. 2020 ), and water governance (Lopez-Gunn 2003 ; Baldwin et al. 2018 ), among others. Frameworks and methods that emphasize other collective-related ideas—like collaboration, co-production, and group learning—are also ubiquitous in natural resource and environmental management. These constructs include community-based conservation (DeCaro and Stokes 2008 ; Niemiec et al. 2016 ), community natural resource management (Kellert et al. 2000 ; Dale et al. 2020 ), collaboration/coordination (Sadoff and Grey 2005 ; Prager 2015 ), polycentricity (Galaz et al. 2012 ; Heikkila et al. 2018 ), knowledge co-production (Armitage et al. 2011 ; Singh et al. 2021 ), and social learning (Reed et al. 2010 ; Hovardas 2020 ). Many writings on collective efforts in the social sciences broadly, and applied in the area of environment specifically, provide insights into collective action’s necessary preconditions, which prove invaluable to further defining and later operationalizing collective environmental literacy.

Unpacking the definition of collective environmental literacy: Anchoring principles

As described, we propose the following working definition of collective environmental literacy drawing on our analysis of related literatures and informed by scholarly and professional experience in the sustainability and conservation fields: a dynamic, synergistic process that occurs as group members develop and leverage shared resources to undertake individual and aggregate actions over time to address sustainability issues within the multi-scalar context of a socio-environmental system (Fig.  1 ). This definition centers on four core, intertwined ideas: the scale of the group involved; the dynamic nature of the process; shared resources brought by, available to, and needed by the group; and the synergy that arises from group interaction.

Multi-scalar

When transitioning from the focus on individual to collective actions—and, herein, principles of environmental literacy—the most obvious and primary requisite shift is one of scale. Yet, moving to a collective scale does not mean abandoning action at the individual scale; rather, success at the collective level is intrinsically tied to what occurs at an individual level. Such collective-scale impacts leverage the power of the hive, harnessing people’s willingness, ability, and motivation to take action alongside others, share their ideas and resources to build collective ideas and resources, contribute to making a difference in an impactful way, and participate communally in pro-social activities.

Collective environmental literacy is likely dynamic in its orientation to scale, incorporating place-based notions, such as ecoregional or community-level environmental literacy (with an emphasis on geographic boundaries). On the other hand, it may encapsulate environmental literacy of a group or organization united by a common identity (e.g., organizational membership) or cause (e.g., old-growth forests, coastal protection), rather than solely or even primarily by geography. Although shifting scales can make measuring collective environmental literacy more difficult, dynamic levels may be a benefit when addressing planetary boundary issues such as climate change, biodiversity, and ocean acidification (Galaz et al. 2012 ). Some scholars have called for a polycentric approach to these large-scale issues in response to a perceived failure of global-wide, top-down solutions (Ostrom 2010 , 2012 ; Jordan et al. 2018 ). Conceptualizing and consequently supporting collective environmental literacy at multiple scales can facilitate such desired polycentricity.

Rather than representing a static outcome, environmental literacy is a dynamic process that is fluctuating and complex, reflective of iterative interactions among community members, whose discussions and negotiations reflect the changing context of sustainability issues. Footnote 3 Such open-minded processes allow for, and indeed welcome, adaptation in a way that builds social-ecological resilience (Berkes and Jolly 2002 ; Adger et al. 2005 ; Berkes 2007 ). Additionally, this dynamism allows for collective development and maturation, supporting community growth in collective knowledge, attitudes, skills, and actions via new experiences, interactions, and efforts (Berkman et al. 2010 ). With this mindset, and within a sociocultural perspective, collective environmental literacy evolves through drawing on and contributing to the community’s funds of knowledge (González et al. 2006 ). Movement and actions within and among groups impact collective literacy, as members share knowledge and other resources, shifting individuals and the group in the course of their shared practices (Samerski 2019 ).

In a collective mode, effectiveness is heightened as shared resources are streamlined, waste is minimized, and innovation maximized. Rather than each group member developing individual expertise in every matter of concern, the shared knowledge, skills, and behaviors can be distributed, pursued, and amplified among group members efficiently and effectively, with collective literacy emerging from the process of pooling diverse forms of capital and aggregating resources. This perspective builds on ideas of social capital as a collective good (Ostrom 1990 ; Putnam 2020 ), wherein relationships of trust and reciprocity are both inputs and outcomes (Pretty and Ward 2001 ). The shared resources then catalyze and sustain action as they are reassembled and coalesced at the group level for collective impact.

The pooled resources—likely vast—may include, but are not limited to, physical and human resources, funding, time, energy, and space and place (physical or digital). Shared resources may also include forms of theorized capital, such as intellectual and social (Putnam 2020 ). Also of note is the recognition that these resources extend far beyond information and knowledge. Of particular interest when building collective environmental literacy are resources previously ignored or overlooked by those in power in prior sustainability efforts. For example, collective environmental literacy can draw strength from shared resources unique to the community or even subgroups within the larger community. Discussions of Indigenous knowledge (Gadgil et al. 1993 ) and funds of knowledge (González et al. 2006 ; Cruz et al. 2018 ) suggest critical, shared resources that highlight strengths of an individual community and its members. Another dimension of shared resources relates to the strength of institutional connections, such as the benefits that accrue from leveraging the collective knowledge, expertise, and resources of organizational collaborators working in adjacent areas to further and amplify each other’s impact (Wojcik et al. 2021 ).

Synergistic

Finally, given the inherent complexities related to defining, deploying, implementing, and measuring these dynamic, at-times ephemeral processes, resources, and outcomes at a collective scale, working in such a manner must be clearly advantageous to pressing sustainability issues at hand. Numerous related constructs and approaches from a range of fields emphasize the benefits of diverse collaboration to collective thought and action, including improved solutions, more effective and fair processes, and more socioculturally just outcomes (Klein 1990 ; Jörg 2011 ; Wenger and Snyder 2000 ; Djenontin and Meadow 2018 ). These benefits go beyond efficient aggregation and distribution of resources, invoking an almost magical quality that defines synergy, resulting in robust processes and outcomes that are more than the sum of the parts.

This synergy relies on the diversity of a group across various dimensions, bringing power, strength, and insight to a decision-making process (Bear and Woolley 2011 ; Curşeu and Pluut 2013 ; Freeman and Huang 2015 ; Lu et al. 2017 ; Bendor and Page 2019 ). Individuals are limited not only to singular knowledge-perspectives and skillsets, but also to their own experiences, which influence their self-affirming viewpoints and tendencies to seek out confirmatory information for existing beliefs (Kahan et al. 2011 ). Although the coming together of those from different racial, cultural, social, and economic backgrounds facilitates a collective literacy process that draws on a wider range of resources and equips a gestalt, it also sets up the need to consider issues of power, privilege, voice, and representation (Bäckstrand 2006 ) and the role of social capital, leading to questions related to trust and reciprocity in effective collectives (Pretty and Ward 2001 ; Folke et al. 2005 ).

Leveraging the ‘Hive’: Proceeding with collective environmental literacy

This paper presents one conceptualization of collective environmental literacy, with the understanding that numerous ways exist to envision its definition, formation, deployment, and measurement. Characterized by a collective effort, such literacies at scale offer a way to imagine, measure, and support the synergy that occurs when the emphasis moves from an individual to a larger whole. By expanding the scale and focusing on shared responsibility among actors at the systems level, opportunities arise for inspiring and enabling a broader contribution to a sustainable future. These evolving notions serve to invite ongoing conversation, both in research and practice, about how to enact our collective responsibility toward, as well as vision of, a thriving future.

Emerging from the many discussions of shared and collaborative efforts to address socio-environmental issues, our conceptualization of collective environmental literacy is a first step toward supporting communities as they work to identify, address, and solve sustainability problems. We urge continued discussions on this topic, with the goal of understanding the concept of collective environmental literacy, how to measure it, and the implications of this work for practitioners. The conceptual roots of collective environmental literacy reach into countless fields of study and, as such, a transdisciplinary approach, which includes an eye toward practice, is necessary to fully capture and maximize the tremendous amount of knowledge, wisdom, and experience around this topic. Specifically, next steps to evolve the concept include engaging sustainability researchers and practitioners in discussions of the saliency of the presented definition of collective environmental literacy. These discussions include verifying the completeness of the definition and ensuring a thorough review of relevant research: Are parts of the definition missing or unclear? What are the “blank, blind, bald, and bright spots” in the literature (Reid 2019 p. 158)? Additionally, recognizing and leveraging literacy at a collective scale most certainly is not unique to environmental work, nor is adopting literacy-related language to conceptualize and measure process outcomes, although the former has consistently proven more challenging. Moreover, although we (the authors) appreciate the connotations and structures gained by using a literacy framework, we struggle with whether “environmental literacy” is the most appropriate and useful term for the conceptualizations as described herein; we, thus, welcome lively discussions about the need for new terminology.

Even at this early stage of conceptualization, this work has implications for practitioners. For scientists, communicators, policymakers, land managers, and other professionals desiring to work with communities to address sustainability issues, a primary take-away message concerns the holistic nature of what is needed for effective collective action in the environmental realm. Many previous efforts have focused on conveying information and, while a lack of knowledge and awareness may be a barrier to action in some cases, the need for a more holistic lens is increasingly clear. This move beyond an individually focused, information-deficit model is essential for effective impact (Bolderdijk et al. 2013 ; van der Linden 2014 ; Geiger et al. 2019 ). The concept of collective environmental literacy suggests a role for developing shared resources that can foster effective collective action. When working with communities, a critical early step includes some form of needs assessment—a systematic, in-depth process that allows for meaningfully gauging gaps in shared resources required to tackle sustainability issues (Braus 2011). Following this initial, evaluative step, an understanding of the components of collective environmental literacy, as outlined in this paper, can be used to guide the development of interventions to support communities in their efforts to address those issues.

Growing discussion of collective literacy constructs, and related areas, suggests researchers, practitioners, and policymakers working in pro-social areas recognize and value collective efforts, despite the need for clearer definitions and effective measures. This definitional and measurement work, in both research and practice, is not easy. The ever-changing, dynamic contexts in which collective environmental literacy exists make defining the concept a moving target, compounded by a need to draw upon work in countless, often distinct academic fields of study. Furthermore, the hard-to-see, inner workings of collective constructs make measurement difficult. Yet, the “power of the hive” is intriguing, as the synergism that arises from communities working in an aligned manner toward a unified vision suggests a potency and wave of motivated action essential to coalescing and leveraging individual goodwill, harnessing its power and potential toward effective sustainability solutions.

See Stables and Bishop’s ( 2001 ) idea of defining environmental literacy by viewing the environment as “text.”

The climate change education literature also includes a nascent, but growing, discussion of collective-lens thinking and literacy. See, for example, Waldron et al. ( 2019 ), Mochizuki and Bryan ( 2015 ), and Kopnina ( 2016 ).

This conceptualization is similar to how some scholars describe collective health literacy (Berkman et al., 2010 ; Mårtensson and Hensing, 2012 ).

Adger, W.N. 2003. Social capital, collective action, and adaptation to climate change. Economic Geography 79: 387–404.

Article   Google Scholar  

Adger, W.N., T.P. Hughes, C. Folke, S.R. Carpenter, and J. Rockström. 2005. Social-ecological resilience to coastal disasters. Science 309: 1036–1039. https://doi.org/10.1126/science.1112122 .

Article   CAS   Google Scholar  

Adler, P.S., and S.-W. Kwon. 2002. Social capital: Prospects for a new concept. Academy of Management Review 27: 17–40. https://doi.org/10.5465/amr.2002.5922314 .

Agrawal, A. 1995. Dismantling the divide between Indigenous and scientific knowledge. Development and Change 26: 413–439. https://doi.org/10.1111/j.1467-7660.1995.tb00560.x .

Aguilar, O.M. 2018. Examining the literature to reveal the nature of community EE/ESD programs and research. Environmental Education Research 24: 26–49. https://doi.org/10.1080/13504622.2016.1244658 .

Aguilar, O., A. Price, and M. Krasny. 2015. Perspectives on community environmental education. In M.C. Monroe & M.E. Krasny (Eds.), Across the spectrum: Resources for environmental educators (3rd edn., pp. 235–249). North American Association for Environmental Education.

Aldrich, D.P., and M.A. Meyer. 2015. Social capital and community resilience. American Behavioral Scientist 59: 254–269. https://doi.org/10.1177/0002764214550299 .

Amel, E., C. Manning, B. Scott, and S. Koger. 2017. Beyond the roots of human inaction: Fostering collective effort toward ecosystem conservation. Science 356: 275–279. https://doi.org/10.1126/science.aal1931 .

Ansell, C., and A. Gash. 2008. Collaborative governance in theory and practice. Journal of Public Administration Research and Theory 18: 543–571. https://doi.org/10.1093/jopart/mum032 .

Ardoin, N.M. 2006. Toward an interdisciplinary understanding of place: Lessons for environmental education. Canadian Journal of Environmental Education 11: 112–126.

Google Scholar  

Ardoin, N.M., and J.E. Heimlich. 2021. Environmental learning in everyday life: Foundations of meaning and a context for change. Environmental Education Research 27: 1681–1699. https://doi.org/10.1080/13504622.2021.1992354 .

Ardoin, N.M., C. Clark, and E. Kelsey. 2013. An exploration of future trends in environmental education research. Environmental Education Research 19: 499–520. https://doi.org/10.1080/13504622.2012.709823 .

Armitage, D., F. Berkes, A. Dale, E. Kocho-Schellenberg, and E. Patton. 2011. Co-management and the co-production of knowledge: Learning to adapt in Canada’s Arctic. Global Environmental Change 21: 995–1004. https://doi.org/10.1016/j.gloenvcha.2011.04.006 .

Assis Neto, F.R., and C.A.S. Santos. 2018. Understanding crowdsourcing projects: A systematic review of tendencies, workflow, and quality management. Information Processing & Management 54: 490–506. https://doi.org/10.1016/j.ipm.2018.03.006 .

Bäckstrand, K. 2006. Multi-stakeholder partnerships for sustainable development: Rethinking legitimacy, accountability and effectiveness. European Environment 16: 290–306. https://doi.org/10.1002/eet.425 .

Baldwin, E., P. McCord, J. Dell’Angelo, and T. Evans. 2018. Collective action in a polycentric water governance system. Environmental Policy and Governance 28: 212–222. https://doi.org/10.1002/eet.1810 .

Bamberg, S., J. Rees, and S. Seebauer. 2015. Collective climate action: Determinants of participation intention in community-based pro-environmental initiatives. Journal of Environmental Psychology 43: 155–165. https://doi.org/10.1016/j.jenvp.2015.06.006 .

Bandura, A. 1977. Social learning theory . Englewood Cliffs: Prentice Hall.

Bandura, A. 2000. Exercise of human agency through collective efficacy. Current Directions in Psychological Science 9: 75–78. https://doi.org/10.1111/1467-8721.00064 .

Barron, B. 2006. Interest and self-sustained learning as catalysts of development: A learning ecology perspective. Human Development 49: 193–224. https://doi.org/10.1159/000094368 .

Barry, M.M., M. D’Eath, and J. Sixsmith. 2013. Interventions for improving population health literacy: Insights from a rapid review of the evidence. Journal of Health Communication 18: 1507–1522. https://doi.org/10.1080/10810730.2013.840699 .

Barton, A.C., and E. Tan. 2009. Funds of knowledge and discourses and hybrid space. Journal of Research in Science Teaching 46: 50–73. https://doi.org/10.1002/tea.20269 .

Bear, J.B., and A.W. Woolley. 2011. The role of gender in team collaboration and performance. Interdisciplinary Science Reviews 36: 146–153. https://doi.org/10.1179/030801811X13013181961473 .

Bendor, J., and S.E. Page. 2019. Optimal team composition for tool-based problem solving. Journal of Economics & Management Strategy 28: 734–764. https://doi.org/10.1111/jems.12295 .

Berkes, F. 2007. Understanding uncertainty and reducing vulnerability: Lessons from resilience thinking. Natural Hazards 41: 283–295. https://doi.org/10.1007/s11069-006-9036-7 .

Berkes, F., and D. Jolly. 2002. Adapting to climate change: Social-ecological resilience in a Canadian western Arctic community. Conservation Ecology 5: 45.

Berkes, F., and H. Ross. 2013. Community resilience: Toward an integrated approach. Society & Natural Resources 26: 5–20. https://doi.org/10.1080/08941920.2012.736605 .

Berkes, F., M.K. Berkes, and H. Fast. 2007. Collaborative integrated management in Canada’s north: The role of local and traditional knowledge and community-based monitoring. Coastal Management 35: 143–162.

Berkman, N.D., T.C. Davis, and L. McCormack. 2010. Health literacy: What is it? Journal of Health Communication 15: 9–19. https://doi.org/10.1080/10810730.2010.499985 .

Bey, G., C. McDougall, and S. Schoedinger. 2020. Report on the NOAA office of education environmental literacy program community resilience education theory of change. National Oceanic and Atmospheric Administration . https://doi.org/10.25923/mh0g-5q69 .

Blumer, H. 1971. Social problems as collective behavior. Social Problems 18: 298–306.

Bodin, Ö. 2017. Collaborative environmental governance: Achieving collective action in social-ecological systems. Science . https://doi.org/10.1126/science.aan1114 .

Bolderdijk, J.W., M. Gorsira, K. Keizer, and L. Steg. 2013. Values determine the (in)effectiveness of informational interventions in promoting pro-environmental behavior. PLoS ONE 8: e83911. https://doi.org/10.1371/journal.pone.0083911 .

Brabham, D.C. 2013. Crowdsourcing . Cambridge: MIT Press.

Book   Google Scholar  

Braus, J. (Ed.). 2011. Tools of engagement: A toolkit for engaging people in conservation. NAAEE/Audubon. https://cdn.naaee.org/sites/default/files/eepro/resource/files/toolsofengagement.pdf .

Brieger, S.A. 2019. Social identity and environmental concern: The importance of contextual effects. Environment and Behavior 51: 828–855. https://doi.org/10.1177/0013916518756988 .

Briggs, J. 2005. The use of Indigenous knowledge in development: Problems and challenges. Progress in Development Studies 5: 99–114. https://doi.org/10.1191/1464993405ps105oa .

Briggs, J., and J. Sharp. 2004. Indigenous knowledges and development: A postcolonial caution. Third World Quarterly 25: 661–676. https://doi.org/10.1080/01436590410001678915 .

Bronfenbrenner, U. 1979. The ecology of human development: Experiments by nature and design . Cambridge: Harvard University Press.

Bruce, C., and P. Chesterton. 2002. Constituting collective consciousness: Information literacy in university curricula. International Journal for Academic Development 7: 31–40. https://doi.org/10.1080/13601440210156457 .

Byerly, H., A. Balmford, P.J. Ferraro, C.H. Wagner, E. Palchak, S. Polasky, T.H. Ricketts, A.J. Schwartz, et al. 2018. Nudging pro-environmental behavior: Evidence and opportunities. Frontiers in Ecology and the Environment 16: 159–168. https://doi.org/10.1002/fee.1777 .

Canadas, M.J., A. Novais, and M. Marques. 2016. Wildfires, forest management and landowners’ collective action: A comparative approach at the local level. Land Use Policy 56: 179–188. https://doi.org/10.1016/j.landusepol.2016.04.035 .

Carden, L., and W. Wood. 2018. Habit formation and change. Current Opinion in Behavioral Sciences 20: 117–122. https://doi.org/10.1016/j.cobeha.2017.12.009 .

Chan, M. 2016. Psychological antecedents and motivational models of collective action: Examining the role of perceived effectiveness in political protest participation. Social Movement Studies 15: 305–321. https://doi.org/10.1080/14742837.2015.1096192 .

Charnley, S., E.C. Kelly, and A.P. Fischer. 2020. Fostering collective action to reduce wildfire risk across property boundaries in the American West. Environmental Research Letters 15: 025007. https://doi.org/10.1088/1748-9326/ab639a .

Chawla, L., and D.F. Cushing. 2007. Education for strategic environmental behavior. Environmental Education Research 13: 437–452. https://doi.org/10.1080/13504620701581539 .

Chinn, D. 2011. Critical health literacy: A review and critical analysis. Social Science & Medicine 73: 60–67. https://doi.org/10.1016/j.socscimed.2011.04.004 .

Clark, C.R., J.E. Heimlich, N.M. Ardoin, and J. Braus. 2020. Using a Delphi study to clarify the landscape and core outcomes in environmental education. Environmental Education Research 26: 381–399. https://doi.org/10.1080/13504622.2020.1727859 .

Clarke, M., Z. Ma, S.A. Snyder, and K. Floress. 2021. Factors influencing family forest owners’ interest in community-led collective invasive plant management. Environmental Management 67: 1088–1099. https://doi.org/10.1007/s00267-021-01454-1 .

Cruz, A.R., S.T. Selby, and W.H. Durham. 2018. Place-based education for environmental behavior: A ‘funds of knowledge’ and social capital approach. Environmental Education Research 24: 627–647. https://doi.org/10.1080/13504622.2017.1311842 .

Curşeu, P.L., and H. Pluut. 2013. Student groups as learning entities: The effect of group diversity and teamwork quality on groups’ cognitive complexity. Studies in Higher Education 38: 87–103. https://doi.org/10.1080/03075079.2011.565122 .

Cutter, S.L., L. Barnes, M. Berry, C. Burton, E. Evans, E. Tate, and J. Webb. 2008. A place-based model for understanding community resilience to natural disasters. Global Environmental Change 18: 598–606. https://doi.org/10.1016/j.gloenvcha.2008.07.013 .

Dale, A., K. Vella, S. Ryan, K. Broderick, R. Hill, R. Potts, and T. Brewer. 2020. Governing community-based natural resource management in Australia: International implications. Land 9: 234. https://doi.org/10.3390/land9070234 .

de Moor, J., and M. Wahlström. 2019. Narrating political opportunities: Explaining strategic adaptation in the climate movement. Theory and Society 48: 419–451. https://doi.org/10.1007/s11186-019-09347-3 .

DeCaro, D., and M. Stokes. 2008. Social-psychological principles of community-based conservation and conservancy motivation: Attaining goals within an autonomy-supportive environment. Conservation Biology 22: 1443–1451.

Djenontin, I.N.S., and A.M. Meadow. 2018. The art of co-production of knowledge in environmental sciences and management: Lessons from international practice. Environmental Management 61: 885–903. https://doi.org/10.1007/s00267-018-1028-3 .

Duncan, L.E. 2018. The psychology of collective action. In The Oxford handbook of personality and social psychology , ed. K. Deaux and M. Snyder. Oxford: Oxford University Press.

Edwards, M., F. Wood, M. Davies, and A. Edwards. 2015. ‘Distributed health literacy’: Longitudinal qualitative analysis of the roles of health literacy mediators and social networks of people living with a long-term health condition. Health Expectations 18: 1180–1193. https://doi.org/10.1111/hex.12093 .

Emerson, K., T. Nabatchi, and S. Balogh. 2012. An integrative framework for collaborative governance. Journal of Public Administration Research and Theory 22: 1–29.

Engeström, Y. 2001. Expansive learning at work: Toward an activity theoretical reconceptualization. Journal of Education and Work 14: 133–156. https://doi.org/10.1080/13639080020028747 .

Ensor, J., and B. Harvey. 2015. Social learning and climate change adaptation: Evidence for international development practice. Wires Climate Change 6: 509–522. https://doi.org/10.1002/wcc.348 .

Fanta, V., M. Šálek, and P. Sklenicka. 2019. How long do floods throughout the millennium remain in the collective memory? Nature Communications 10: 1105. https://doi.org/10.1038/s41467-019-09102-3 .

Feinstein, N.W. 2018. Collective science literacy: A key to community science capacity [Conference session]. American Association for the Advancement of Science Annual Meeting, Austin, TX, USA https://d32ogoqmya1dw8.cloudfront.net/files/earthconnections/collective_science_literacy_key.pdf .

Feola, G. 2015. Societal transformation in response to global environmental change: A review of emerging concepts. Ambio 44: 376–390. https://doi.org/10.2139/ssrn.2689741 .

Fernandez-Gimenez, M.E., H.L. Ballard, and V.E. Sturtevant. 2008. Adaptive management and social learning in collaborative and community-based monitoring: A study of five community-based forestry organizations in the western USA. Ecology and Society 13: 15.

Folke, C., T. Hahn, P. Olsson, and J. Norberg. 2005. Adaptive governance of social-ecological systems. Annual Review of Environment and Resources 30: 441–473. https://doi.org/10.1146/annurev.energy.30.050504.144511 .

Freedman, D.A., K.D. Bess, H.A. Tucker, D.L. Boyd, A.M. Tuchman, and K.A. Wallston. 2009. Public health literacy defined. American Journal of Preventive Medicine 36: 446–451. https://doi.org/10.1016/j.amepre.2009.02.001 .

Freeman, R.B., and W. Huang. 2015. Collaborating with people like me: Ethnic coauthorship within the United States. Journal of Labor Economics 33: S289–S318.

Gadgil, M., F. Berkes, and C. Folke. 1993. Indigenous knowledge for biodiversity conservation. Ambio 22: 151–156.

Galaz, V., B. Crona, H. Österblom, P. Olsson, and C. Folke. 2012. Polycentric systems and interacting planetary boundaries—Emerging governance of climate change–ocean acidification–marine biodiversity. Ecological Economics 81: 21–32. https://doi.org/10.1016/j.ecolecon.2011.11.012 .

Geiger, S.M., M. Geiger, and O. Wilhelm. 2019. Environment-specific vs general knowledge and their role in pro-environmental behavior. Frontiers in Psychology 10: 718. https://doi.org/10.3389/fpsyg.2019.00718 .

Gifford, R., C. Kormos, and A. McIntyre. 2011. Behavioral dimensions of climate change: Drivers, responses, barriers, and interventions. Wires Climate Change 2: 801–827. https://doi.org/10.1002/wcc.143 .

González, N., L.C. Moll, and C. Amanti. 2006. Funds of knowledge: Theorizing practices in households, communities, and classrooms . New York: Routledge.

Gordon, D.M. 2019. Measuring collective behavior: An ecological approach. Theory in Biosciences . https://doi.org/10.1007/s12064-019-00302-5 .

Gould, R.K., N.M. Ardoin, J.M. Thomsen, and N. Wyman Roth. 2019. Exploring connections between environmental learning and behavior through four everyday-life case studies. Environmental Education Research 25: 314–340.

Graham, S., A.L. Metcalf, N. Gill, R. Niemiec, C. Moreno, T. Bach, V. Ikutegbe, L. Hallstrom, et al. 2019. Opportunities for better use of collective action theory in research and governance for invasive species management. Conservation Biology 33: 275–287. https://doi.org/10.1111/cobi.13266 .

Granovetter, M. 1978. Threshold models of collective behavior. American Journal of Sociology 83: 1420–1443.

Groulx, M., M.C. Brisbois, C.J. Lemieux, A. Winegardner, and L. Fishback. 2017. A role for nature-based citizen science in promoting individual and collective climate change action? A systematic review of learning outcomes. Science Communication 39: 45–76. https://doi.org/10.1177/1075547016688324 .

Gutiérrez, K.D., and B. Rogoff. 2003. Cultural ways of learning: Individual traits or repertoires of practice. Educational Researcher 32: 19–25. https://doi.org/10.3102/0013189X032005019 .

Guzys, D., A. Kenny, V. Dickson-Swift, and G. Threlkeld. 2015. A critical review of population health literacy assessment. BMC Public Health 15: 1–7. https://doi.org/10.1186/s12889-015-1551-6 .

Halbwachs, M. 1992. On collective memory (L. A. Coser, Ed. & Trans.). University of Chicago Press. (Original works published 1941 and 1952).

Heikkila, T., S. Villamayor-Tomas, and D. Garrick. 2018. Bringing polycentric systems into focus for environmental governance. Environmental Policy and Governance 28: 207–211. https://doi.org/10.1002/eet.1809 .

Heimlich, J.E., and N.M. Ardoin. 2008. Understanding behavior to understand behavior change: A literature review. Environmental Education Research 14: 215–237. https://doi.org/10.1080/13504620802148881 .

Hill, R., F.J. Walsh, J. Davies, A. Sparrow, M. Mooney, R.M. Wise, and M. Tengö. 2020. Knowledge co-production for Indigenous adaptation pathways: Transform post-colonial articulation complexes to empower local decision-making. Global Environmental Change 65: 102161. https://doi.org/10.1016/j.gloenvcha.2020.102161 .

Hollweg, K.S., J. Taylor, R.W. Bybee, T.J. Marcinkowski, W.C. McBeth, and P. Zoido. 2011. Developing a framework for assessing environmental literacy: Executive summary . North American Association for Environmental Education. https://cdn.naaee.org/sites/default/files/envliteracyexesummary.pdf .

Hovardas, T. 2020. A social learning approach for stakeholder engagement in large carnivore conservation and management. Frontiers in Ecology and Evolution 8: 436. https://doi.org/10.3389/fevo.2020.525278 .

Jagers, S.C., N. Harring, Å. Löfgren, M. Sjöstedt, F. Alpizar, B. Brülde, D. Langlet, A. Nilsson, et al. 2020. On the preconditions for large-scale collective action. Ambio 49: 1282–1296. https://doi.org/10.1007/s13280-019-01284-w .

Jordan, A., D. Huitema, H. van Asselt, and J. Forster. 2018. Governing climate change: Polycentricity in action? Cambridge: Cambridge University Press.

Jörg, T. 2011. New thinking in complexity for the social sciences and humanities: A generative, transdisciplinary approach . New York: Springer Science & Business Media.

Jost, J.T., J. Becker, D. Osborne, and V. Badaan. 2017. Missing in (collective) action: Ideology, system justification, and the motivational antecedents of two types of protest behavior. Current Directions in Psychological Science 26: 99–108. https://doi.org/10.1177/0963721417690633 .

Jull, J., A. Giles, and I.D. Graham. 2017. Community-based participatory research and integrated knowledge translation: Advancing the co-creation of knowledge. Implementation Science 12: 150. https://doi.org/10.1186/s13012-017-0696-3 .

Kahan, D.M., H. Jenkins-Smith, and D. Braman. 2011. Cultural cognition of scientific consensus. Journal of Risk Research 14: 147–174. https://doi.org/10.1080/13669877.2010.511246 .

Kania, J., and M. Kramer. 2011. Collective impact. Stanford Social Innovation Review 9: 36–41.

Karachiwalla, R., and F. Pinkow. 2021. Understanding crowdsourcing projects: A review on the key design elements of a crowdsourcing initiative. Creativity and Innovation Management 30: 563–584. https://doi.org/10.1111/caim.12454 .

Kellert, S.R., J.N. Mehta, S.A. Ebbin, and L.L. Lichtenfeld. 2000. Community natural resource management: Promise, rhetoric, and reality. Society & Natural Resources 13: 705–715.

Klein, J.T. 1990. Interdisciplinarity: History, theory, and practice . Detroit: Wayne State University Press.

Knapp, C.N., R.S. Reid, M.E. Fernández-Giménez, J.A. Klein, and K.A. Galvin. 2019. Placing transdisciplinarity in context: A review of approaches to connect scholars, society and action. Sustainability 11: 4899. https://doi.org/10.3390/su11184899 .

Koliou, M., J.W. van de Lindt, T.P. McAllister, B.R. Ellingwood, M. Dillard, and H. Cutler. 2020. State of the research in community resilience: Progress and challenges. Sustainable and Resilient Infrastructure 5: 131–151. https://doi.org/10.1080/23789689.2017.1418547 .

Kopnina, H. 2016. Of big hegemonies and little tigers: Ecocentrism and environmental justice. The Journal of Environmental Education 47: 139–150. https://doi.org/10.1080/00958964.2015.1048502 .

Krasny, M.E., M. Mukute, O. Aguilar, M.P. Masilela, and L. Olvitt. 2017. Community environmental education. In Urban environmental education review , ed. A. Russ and M.E. Krasny, 124–132. Ithaca: Cornell University Press.

Chapter   Google Scholar  

Lave, J. 1991. Situating learning in communities of practice.

Lave, J., and E. Wenger. 1991. Situated learning: Legitimate peripheral participation . Cambridge: Cambridge University Press.

Lee, S., and W.-M. Roth. 2003. Science and the “good citizen”: Community-based scientific literacy. Science, Technology, & Human Values 28: 403–424. https://doi.org/10.1177/0162243903028003003 .

Lévy, P., and R. Bononno. 1997. Collective intelligence: Mankind’s emerging world in cyberspace . New York: Perseus Books.

Lloyd, A. 2005. No man (or woman) is an island: Information literacy, affordances and communities of practice. The Australian Library Journal 54: 230–237. https://doi.org/10.1080/00049670.2005.10721760 .

Lopez-Gunn, E. 2003. The role of collective action in water governance: A comparative study of groundwater user associations in La Mancha aquifers in Spain. Water International 28: 367–378. https://doi.org/10.1080/02508060308691711 .

Lu, J.G., A.C. Hafenbrack, P.W. Eastwick, D.J. Wang, W.W. Maddux, and A.D. Galinsky. 2017. “Going out” of the box: Close intercultural friendships and romantic relationships spark creativity, workplace innovation, and entrepreneurship. Journal of Applied Psychology 102: 1091–1108. https://doi.org/10.1037/apl0000212 .

Lubeck, A., A. Metcalf, C. Beckman, L. Yung, and J. Angle. 2019. Collective factors drive individual invasive species control behaviors: Evidence from private lands in Montana, USA. Ecology and Society . https://doi.org/10.5751/ES-10897-240232 .

Mackay, C.M.L., M.T. Schmitt, A.E. Lutz, and J. Mendel. 2021. Recent developments in the social identity approach to the psychology of climate change. Current Opinion in Psychology 42: 95–101. https://doi.org/10.1016/j.copsyc.2021.04.009 .

Magis, K. 2010. Community resilience: An indicator of social sustainability. Society & Natural Resources 23: 401–416. https://doi.org/10.1080/08941920903305674 .

Manfredo, M.J., T.L. Teel, and A.M. Dietsch. 2016. Implications of human value shift and persistence for biodiversity conservation. Conservation Biology 30: 287–296. https://doi.org/10.1111/cobi.12619 .

Marshall, G.R., M.J. Coleman, B.M. Sindel, I.J. Reeve, and P.J. Berney. 2016. Collective action in invasive species control, and prospects for community-based governance: The case of serrated tussock ( Nassella trichotoma ) in New South Wales, Australia. Land Use Policy 56: 100–111. https://doi.org/10.1016/j.landusepol.2016.04.028 .

Mårtensson, L., and G. Hensing. 2012. Health literacy: A heterogeneous phenomenon: A literature review. Scandinavian Journal of Caring Sciences 26: 151–160. https://doi.org/10.1111/j.1471-6712.2011.00900.x .

Martin, C., and C. Steinkuehler. 2010. Collective information literacy in massively multiplayer online games. E-Learning and Digital Media 7: 355–365. https://doi.org/10.2304/elea.2010.7.4.355 .

Masson, T., and I. Fritsche. 2021. We need climate change mitigation and climate change mitigation needs the ‘We’: A state-of-the-art review of social identity effects motivating climate change action. Current Opinion in Behavioral Sciences 42: 89–96. https://doi.org/10.1016/j.cobeha.2021.04.006 .

Massung, E., D. Coyle, K.F. Cater, M. Jay, and C. Preist. 2013. Using crowdsourcing to support pro-environmental community activism. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems . https://doi.org/10.1145/2470654.2470708 .

McAdam, D. 2017. Social movement theory and the prospects for climate change activism in the United States. Annual Review of Political Science 20: 189–208. https://doi.org/10.1146/annurev-polisci-052615-025801 .

McAdam, D., and H. Boudet. 2012. Putting social movements in their place: Explaining opposition to energy projects in the United States, 2000–2005 . Cambridge University Press.

McKenzie-Mohr, D. 2011. Fostering sustainable behavior: An introduction to community-based social marketing (3rd edn.). New Society Publishers.

McKinley, D.C., A.J. Miller-Rushing, H.L. Ballard, R. Bonney, H. Brown, S.C. Cook-Patton, D.M. Evans, R.A. French, et al. 2017. Citizen science can improve conservation science, natural resource management, and environmental protection. Biological Conservation 208: 15–28.

Miller, D.L. 2014. Introduction to collective behavior and collective action (3rd ed.). Waveland Press.

Mills, J., D. Gibbon, J. Ingram, M. Reed, C. Short, and J. Dwyer. 2011. Organising collective action for effective environmental management and social learning in Wales. The Journal of Agricultural Education and Extension 17: 69–83. https://doi.org/10.1080/1389224X.2011.536356 .

Mistry, J., and A. Berardi. 2016. Bridging Indigenous and scientific knowledge. Science 352: 1274–1275. https://doi.org/10.1126/science.aaf1160 .

Mochizuki, Y., and A. Bryan. 2015. Climate change education in the context of education for sustainable development: Rationale and principles. Journal of Education for Sustainable Development 9: 4–26. https://doi.org/10.1177/0973408215569109 .

Monroe, M.C. 2003. Two avenues for encouraging conservation behaviors. Human Ecology Review 10: 113–125.

Nasir, N.S., M.M. de Royston, B. Barron, P. Bell, R. Pea, R. Stevens, and S. Goldman. 2020. Learning pathways: How learning is culturally organized. In Handbook of the cultural foundations of learning , ed. N.S. Nasir, C.D. Lee, R. Pea, and M.M. de Royston, 195–211. Routledge.

National Academies of Sciences, Engineering, and Medicine. 2016. Science literacy: Concepts, contexts, and consequences . https://doi.org/10.17226/23595

National Research Council. 2015. Collective behavior: From cells to societies: Interdisciplinary research team summaries . National Academies Press. https://doi.org/10.17226/21737

Niemiec, R.M., N.M. Ardoin, C.B. Wharton, and G.P. Asner G.P. 2016. Motivating residents to combat invasive species on private lands: Social norms and community reciprocity. Ecology and Society , 21. https://doi.org/10.5751/ES-08362-210230

Niemiec, R.M., S. McCaffrey, and M.S. Jones. 2020. Clarifying the degree and type of public good collective action problem posed by natural resource management challenges. Ecology and Society 25: 30. https://doi.org/10.5751/ES-11483-250130 .

Norström, A.V., C. Cvitanovic, M.F. Löf, S. West, C. Wyborn, P. Balvanera, A.T. Bednarek, E.M. Bennett, et al. 2020. Principles for knowledge co-production in sustainability research. Nature Sustainability 3: 182–190. https://doi.org/10.1038/s41893-019-0448-2 .

Olick, J.K. 1999. Collective memory: The two cultures. Sociological Theory 17: 333–348. https://doi.org/10.1111/0735-2751.00083 .

Ostrom, E. 1990. Governing the commons: The evolution of institutions for collective action . Cambridge University Press.

Ostrom, E. 2000. Collective action and the evolution of social norms. Journal of Economic Perspectives 14: 137–158. https://doi.org/10.1257/jep.14.3.137 .

Ostrom, E. 2009. A general framework for analyzing sustainability of social-ecological systems. Science 325: 419–422. https://doi.org/10.1126/science.1172133 .

Ostrom, E. 2010. Polycentric systems for coping with collective action and global environmental change. Global Environmental Change 20: 550–557. https://doi.org/10.1016/j.gloenvcha.2010.07.004 .

Ostrom, E. 2012. Nested externalities and polycentric institutions: Must we wait for global solutions to climate change before taking actions at other scales? Economic Theory 49: 353–369. https://doi.org/10.1007/s00199-010-0558-6 .

Ostrom, E., and T.K. Ahn. 2009. The meaning of social capital and its link to collective action. In Handbook of social capital: The troika of sociology, political science and economics , ed. G.T. Svendsen and G.L.H. Svendsen, 17–35. Edward Elgar Publishing.

Papen, U. 2009. Literacy, learning and health: A social practices view of health literacy. Literacy and Numeracy Studies . https://doi.org/10.5130/lns.v0i0.1275 .

Park, R.E. 1927. Human nature and collective behavior. American Journal of Sociology 32: 733–741.

Paul, A.M. 2021. The extended mind: The power of thinking outside the brain . Boston: Mariner Books.

Pawilen, G.T. 2021. Integrating Indigenous knowledge in the Philippine elementary science curriculum: Integrating Indigenous knowledge. International Journal of Curriculum and Instruction 13: 1148–1160.

Prager, K. 2015. Agri-environmental collaboratives for landscape management in Europe. Current Opinion in Environmental Sustainability 12: 59–66. https://doi.org/10.1016/j.cosust.2014.10.009 .

Pretty, J., and H. Ward. 2001. Social capital and the environment. World Development 29: 209–227. https://doi.org/10.1016/S0305-750X(00)00098-X .

Putnam, R.D. 2020. Bowling alone: Revised and updated: The collapse and revival of American community . Anniversary. New York: Simon & Schuster.

Raymond, L. 2006. Cooperation without trust: Overcoming collective action barriers to endangered species protection. Policy Studies Journal 34: 37–57. https://doi.org/10.1111/j.1541-0072.2006.00144.x .

Reed, M.S., A.C. Evely, G. Cundill, I. Fazey, J. Glass, A. Laing, J. Newig, B. Parrish, et al. 2010. What is social learning? Ecology and Society 15: 12.

Reicher, S., R. Spears, and S.A. Haslam. 2010. The social identity approach in social psychology. In The SAGE handbook of identities (pp. 45–62). SAGE. https://doi.org/10.4135/9781446200889

Reid, A. 2019. Blank, blind, bald and bright spots in environmental education research. Environmental Education Research 25: 157–171. https://doi.org/10.1080/13504622.2019.1615735 .

Rogoff, B. 2003. The cultural nature of human development (Reprint edition) . Oxford: Oxford University Press.

Roth, C.E. 1992. Environmental literacy: Its roots, evolution and directions in the 1990s . http://eric.ed.gov/?id=ED348235

Roth, W.-M. 2003. Scientific literacy as an emergent feature of collective human praxis. Journal of Curriculum Studies 35: 9–23. https://doi.org/10.1080/00220270210134600 .

Roth, W.-M., and A.C. Barton. 2004. Rethinking scientific literacy . London: Psychology Press.

Roth, W.-M., and S. Lee. 2002. Scientific literacy as collective praxis. Public Understanding of Science 11: 33–56. https://doi.org/10.1088/0963-6625/11/1/302 .

Roth, W.-M., and S. Lee. 2004. Science education as/for participation in the community. Science Education 88: 263–291.

Roth, W.-M., and Y.-J. Lee. 2007. “Vygotsky’s neglected legacy”: Cultural-historical activity theory. Review of Educational Research 77: 186–232.

Sadoff, C.W., and D. Grey. 2005. Cooperation on international rivers: A continuum for securing and sharing benefits. Water International 30: 420–427.

Samerski, S. 2019. Health literacy as a social practice: Social and empirical dimensions of knowledge on health and healthcare. Social Science & Medicine 226: 1–8. https://doi.org/10.1016/j.socscimed.2019.02.024 .

Sawyer, R.K. 2014. The future of learning: Grounding educational innovation in the learning sciences. In The Cambridge handbook of the learning sciences , ed. R.K. Sawyer, 726–746. Cambridge: Cambridge University Press.

Saxe, J.G. n.d.. The blind man and the elephant . All Poetry. Retrieved October 6, 2020, from https://allpoetry.com/The-Blind-Man-And-The-Elephant .

Scheepers, D., and N. Ellemers. 2019. Social identity theory. In Social psychology in action: Evidence-based interventions from theory to practice , ed. K. Sassenberg and M.L.W. Vliek, 129–143. New York: Springer International Publishing.

Schipper, E.L.F., N.K. Dubash, and Y. Mulugetta. 2021. Climate change research and the search for solutions: Rethinking interdisciplinarity. Climatic Change 168: 18. https://doi.org/10.1007/s10584-021-03237-3 .

Schoerning, E. 2018. A no-conflict approach to informal science education increases community science literacy and engagement. Journal of Science Communication, Doi 10: 17030205.

Schultz, P.W. 2014. Strategies for promoting proenvironmental behavior: Lots of tools but few instructions. European Psychologist 19: 107–117. https://doi.org/10.1027/1016-9040/a000163 .

Sharifi, A. 2016. A critical review of selected tools for assessing community resilience. Ecological Indicators 69: 629–647. https://doi.org/10.1016/j.ecolind.2016.05.023 .

Sherrieb, K., F.H. Norris, and S. Galea. 2010. Measuring capacities for community resilience. Social Indicators Research 99: 227–247. https://doi.org/10.1007/s11205-010-9576-9 .

Singh, R.K., A. Singh, K.K. Zander, S. Mathew, and A. Kumar. 2021. Measuring successful processes of knowledge co-production for managing climate change and associated environmental stressors: Adaptation policies and practices to support Indian farmers. Journal of Environmental Management 282: 111679. https://doi.org/10.1016/j.jenvman.2020.111679 .

Sloman, S., and P. Fernbach. 2017. The knowledge illusion: Why we never think alone . New York: Riverhead Books.

Smelser, N.J. 2011. Theory of collective behavior . Quid Pro Books. (Original work published 1962).

Sørensen, K., S. Van den Broucke, J. Fullam, G. Doyle, J. Pelikan, Z. Slonska, H. Brand, and (HLS-EU) Consortium Health Literacy Project European. 2012. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 12: 80. https://doi.org/10.1186/1471-2458-12-80 .

Spitzer, W., and J. Fraser. 2020. Advancing community science literacy. Journal of Museum Education 45: 5–15. https://doi.org/10.1080/10598650.2020.1720403 .

Stables, A., and K. Bishop. 2001. Weak and strong conceptions of environmental literacy: Implications for environmental education. Environmental Education Research 7: 89. https://doi.org/10.1080/13504620125643 .

Stern, M.J., R.B. Powell, and N.M. Ardoin. 2008. What difference does it make? Assessing outcomes from participation in a residential environmental education program. The Journal of Environmental Education 39: 31–43. https://doi.org/10.3200/JOEE.39.4.31-43 .

Stets, J.E., and P.J. Burke. 2000. Identity theory and social identity theory. Social Psychology Quarterly 63: 224–237. https://doi.org/10.2307/2695870 .

Sturmer, S., and B. Simon. 2004. Collective action: Towards a dual-pathway model. European Review of Social Psychology 15: 59–99. https://doi.org/10.1080/10463280340000117 .

Sullivan, A., A. York, D. White, S. Hall, and S. Yabiku. 2017. De jure versus de facto institutions: Trust, information, and collective efforts to manage the invasive mile-a-minute weed (Mikania micrantha). International Journal of the Commons 11: 171–199. https://doi.org/10.18352/ijc.676 .

Sunstein, C.R. 2008. Infotopia: How many minds produce knowledge . Oxford: Oxford University Press.

Surowiecki, J. 2005. The wisdom of crowds . New York: Anchor.

Swim, J.K., S. Clayton, and G.S. Howard. 2011. Human behavioral contributions to climate change: Psychological and contextual drivers. American Psychologist 66: 251–264.

Thaker, J., P. Howe, A. Leiserowitz, and E. Maibach. 2019. Perceived collective efficacy and trust in government influence public engagement with climate change-related water conservation policies. Environmental Communication 13: 681–699. https://doi.org/10.1080/17524032.2018.1438302 .

Tudge, J.R.H., and P.A. Winterhoff. 1993. Vygotsky, Piaget, and Bandura: Perspectives on the relations between the social world and cognitive development. Human Development 36: 61–81. https://doi.org/10.1159/000277297 .

Turner, R.H., and L.M. Killian. 1987. Collective behavior , 3rd ed. Englewood Cliffs: Prentice Hall.

Turner, R.H., N.J. Smelser, and L.M. Killian. 2020. Collective behaviour. In Encyclopedia Britannica . Encyclopedia Britannica, Inc. https://www.britannica.com/science/collective-behaviour .

van der Linden, S. 2014. Towards a new model for communicating climate change. In Understanding and governing sustainable tourism mobility , ed. S. Cohen, J. Higham, P. Peeters, and S. Gössling, 263–295. Milton Park: Routledge.

van Zomeren, M., T. Postmes, and R. Spears. 2008. Toward an integrative social identity model of collective action: A quantitative research synthesis of three socio-psychological perspectives. Psychological Bulletin 134: 504–535. https://doi.org/10.1037/0033-2909.134.4.504 .

Vygotsky, L.S. 1980. Mind in society: The development of higher psychological processes . Cambridge: Harvard University Press.

Waldron, F., B. Ruane, R. Oberman, and S. Morris. 2019. Geographical process or global injustice? Contrasting educational perspectives on climate change. Environmental Education Research 25: 895–911. https://doi.org/10.1080/13504622.2016.1255876 .

Wals, A.E.J., M. Brody, J. Dillon, and R.B. Stevenson. 2014. Convergence between science and environmental education. Science 344: 583–584.

Wenger, E.C., and W.M. Snyder. 2000. Communities of practice: The organizational frontier. Harvard Business Review 78: 139–146.

Weschsler, D. 1971. Concept of collective intelligence. American Psychologist 26: 904–907. https://doi.org/10.1037/h0032223 .

Wheaton, M., A. Kannan, and N.M. Ardoin. 2018. Environmental literacy: Setting the stage (Environmental Literacy Brief, Vol. 1). Social Ecology Lab, Stanford University. https://ed.stanford.edu/sites/default/files/news/images/stanfordsocialecologylab-brief-1.pdf .

Wojcik, D.J., N.M. Ardoin, and R.K. Gould. 2021. Using social network analysis to explore and expand our understanding of a robust environmental learning landscape. Environmental Education Research 27: 1263–1283.

Wood, W., and D. Rünger. 2016. Psychology of habit. Annual Review of Psychology 67: 289–314. https://doi.org/10.1146/annurev-psych-122414-033417 .

Woolley, A.W., C.F. Chabris, A. Pentland, N. Hashmi, and T.W. Malone. 2010. Evidence for a collective intelligence factor in the performance of human groups. Science 330: 686–688. https://doi.org/10.1126/science.1193147 .

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Acknowledgements

We are grateful to Maria DiGiano, Anna Lee, and Becca Shareff for their feedback and contributions to early drafts of this paper. We appreciate the research and writing assistance supporting this paper provided by various members of the Stanford Social Ecology Lab, especially: Brennecke Gale, Pari Ghorbani, Regina Kong, Naomi Ray, and Austin Stack.

This work was supported by a grant from the Pisces Foundation.

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Ardoin, N.M., Bowers, A.W. & Wheaton, M. Leveraging collective action and environmental literacy to address complex sustainability challenges. Ambio 52 , 30–44 (2023). https://doi.org/10.1007/s13280-022-01764-6

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What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review

• Olivia R. Phillips 1 , 2   na1 ,
• Cerian Harries 2 , 3   na1 ,
• Jo Leonardi-Bee 1 , 2 , 4   na1 ,
• Holly Knight 1 , 2 ,
• Lauren B. Sherar 2 , 3 ,
• Veronica Varela-Mato 2 , 3 &
• Joanne R. Morling 1 , 2 , 5  

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There is increasing interest in using patient and public involvement (PPI) in research to improve the quality of healthcare. Ordinarily, traditional methods have been used such as interviews or focus groups. However, these methods tend to engage a similar demographic of people. Thus, creative methods are being developed to involve patients for whom traditional methods are inaccessible or non-engaging.

To determine the strengths and limitations to using creative PPI methods in health and social care research.

Electronic searches were conducted over five databases on 14th April 2023 (Web of Science, PubMed, ASSIA, CINAHL, Cochrane Library). Studies that involved traditional, non-creative PPI methods were excluded. Creative PPI methods were used to engage with people as research advisors, rather than study participants. Only primary data published in English from 2009 were accepted. Title, abstract and full text screening was undertaken by two independent reviewers before inductive thematic analysis was used to generate themes.

Twelve papers met the inclusion criteria. The creative methods used included songs, poems, drawings, photograph elicitation, drama performance, visualisations, social media, photography, prototype development, cultural animation, card sorting and persona development. Analysis identified four limitations and five strengths to the creative approaches. Limitations included the time and resource intensive nature of creative PPI, the lack of generalisation to wider populations and ethical issues. External factors, such as the lack of infrastructure to support creative PPI, also affected their implementation. Strengths included the disruption of power hierarchies and the creation of a safe space for people to express mundane or “taboo” topics. Creative methods are also engaging, inclusive of people who struggle to participate in traditional PPI and can also be cost and time efficient.

‘Creative PPI’ is an umbrella term encapsulating many different methods of engagement and there are strengths and limitations to each. The choice of which should be determined by the aims and requirements of the research, as well as the characteristics of the PPI group and practical limitations. Creative PPI can be advantageous over more traditional methods, however a hybrid approach could be considered to reap the benefits of both. Creative PPI methods are not widely used; however, this could change over time as PPI becomes embedded even more into research.

Plain English Summary

It is important that patients and public are included in the research process from initial brainstorming, through design to delivery. This is known as public and patient involvement (PPI). Their input means that research closely aligns with their wants and needs. Traditionally to get this input, interviews and group discussions are held, but this can exclude people who find these activities non-engaging or inaccessible, for example those with language challenges, learning disabilities or memory issues. Creative methods of PPI can overcome this. This is a broad term describing different (non-traditional) ways of engaging patients and public in research, such as through the use or art, animation or performance. This review investigated the reasons why creative approaches to PPI could be difficult (limitations) or helpful (strengths) in health and social care research. After searching 5 online databases, 12 studies were included in the review. PPI groups included adults, children and people with language and memory impairments. Creative methods included songs, poems, drawings, the use of photos and drama, visualisations, Facebook, creating prototypes, personas and card sorting. Limitations included the time, cost and effort associated with creative methods, the lack of application to other populations, ethical issues and buy-in from the wider research community. Strengths included the feeling of equality between academics and the public, creation of a safe space for people to express themselves, inclusivity, and that creative PPI can be cost and time efficient. Overall, this review suggests that creative PPI is worthwhile, however each method has its own strengths and limitations and the choice of which will depend on the research project, PPI group characteristics and other practical limitations, such as time and financial constraints.

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Introduction

Patient and public involvement (PPI) is the term used to describe the partnership between patients (including caregivers, potential patients, healthcare users etc.) or the public (a community member with no known interest in the topic) with researchers. It describes research that is done “‘with’ or ‘by’ the public, rather than ‘to,’ ‘about’ or ‘for’ them” [ 1 ]. In 2009, it became a legislative requirement for certain health and social care organisations to include patients, families, carers and communities in not only the planning of health and social care services, but the commissioning, delivery and evaluation of them too [ 2 ]. For example, funding applications for the National Institute of Health and Care Research (NIHR), a UK funding body, mandates a demonstration of how researchers plan to include patients/service users, the public and carers at each stage of the project [ 3 ]. However, this should not simply be a tokenistic, tick-box exercise. PPI should help formulate initial ideas and should be an instrumental, continuous part of the research process. Input from PPI can provide unique insights not yet considered and can ensure that research and health services are closely aligned to the needs and requirements of service users PPI also generally makes research more relevant with clearer outcomes and impacts [ 4 ]. Although this review refers to both patients and the public using the umbrella term ‘PPI’, it is important to acknowledge that these are two different groups with different motivations, needs and interests when it comes to health research and service delivery [ 5 ].

Despite continuing recognition of the need of PPI to improve quality of healthcare, researchers have also recognised that there is no ‘one size fits all’ method for involving patients [ 4 ]. Traditionally, PPI methods invite people to take part in interviews or focus groups to facilitate discussion, or surveys and questionnaires. However, these can sometimes be inaccessible or non-engaging for certain populations. For example, someone with communication difficulties may find it difficult to engage in focus groups or interviews. If individuals lack the appropriate skills to interact in these types of scenarios, they cannot take advantage of the participation opportunities it can provide [ 6 ]. Creative methods, however, aim to resolve these issues. These are a relatively new concept whereby researchers use creative methods (e.g., artwork, animations, Lego), to make PPI more accessible and engaging for those whose voices would otherwise go unheard. They ensure that all populations can engage in research, regardless of their background or skills. Seminal work has previously been conducted in this area, which brought to light the use of creative methodologies in research. Leavy (2008) [ 7 ] discussed how traditional interviews had limits on what could be expressed due to their sterile, jargon-filled and formulaic structure, read by only a few specialised academics. It was this that called for more creative approaches, which included narrative enquiry, fiction-based research, poetry, music, dance, art, theatre, film and visual art. These practices, which can be used in any stage of the research cycle, supported greater empathy, self-reflection and longer-lasting learning experiences compared to interviews [ 7 ]. They also pushed traditional academic boundaries, which made the research accessible not only to researchers, but the public too. Leavy explains that there are similarities between arts-based approaches and scientific approaches: both attempts to investigate what it means to be human through exploration, and used together, these complimentary approaches can progress our understanding of the human experience [ 7 ]. Further, it is important to acknowledge the parallels and nuances between creative and inclusive methods of PPI. Although creative methods aim to be inclusive (this should underlie any PPI activity, whether creative or not), they do not incorporate all types of accessible, inclusive methodologies e.g., using sign language for people with hearing impairments or audio recordings for people who cannot read. Given that there was not enough scope to include an evaluation of all possible inclusive methodologies, this review will focus on creative methods of PPI only.

We aimed to conduct a qualitative systematic review to highlight the strengths of creative PPI in health and social care research, as well as the limitations, which might act as a barrier to their implementation. A qualitative systematic review “brings together research on a topic, systematically searching for research evidence from primary qualitative studies and drawing the findings together” [ 8 ]. This review can then advise researchers of the best practices when designing PPI.

Public involvement

The PHIRST-LIGHT Public Advisory Group (PAG) consists of a team of experienced public contributors with a diverse range of characteristics from across the UK. The PAG was involved in the initial question setting and study design for this review.

Search strategy

For the purpose of this review, the JBI approach for conducting qualitative systematic reviews was followed [ 9 ]. The search terms were (“creativ*” OR “innovat*” OR “authentic” OR “original” OR “inclu*”) AND (“public and patient involvement” OR “patient and public involvement” OR “public and patient involvement and engagement” OR “patient and public involvement and engagement” OR “PPI” OR “PPIE” OR “co-produc*” OR “co-creat*” OR “co-design*” OR “cooperat*” OR “co-operat*”). This search string was modified according to the requirements of each database. Papers were filtered by title, abstract and keywords (see Additional file 1 for search strings). The databases searched included Web of Science (WoS), PubMed, ASSIA and CINAHL. The Cochrane Library was also searched to identify relevant reviews which could lead to the identification of primary research. The search was conducted on 14/04/23. As our aim was to report on the use of creative PPI in research, rather than more generic public engagement, we used electronic databases of scholarly peer-reviewed literature, which represent a wide range of recognised databases. These identified studies published in general international journals (WoS, PubMed), those in social sciences journals (ASSIA), those in nursing and allied health journals (CINAHL), and trials of interventions (Cochrane Library).

Inclusion criteria

Only full-text, English language, primary research papers from 2009 to 2023 were included. This was the chosen timeframe as in 2009 the Health and Social Reform Act made it mandatory for certain Health and Social Care organisations to involve the public and patients in planning, delivering, and evaluating services [ 2 ]. Only creative methods of PPI were accepted, rather than traditional methods, such as interviews or focus groups. For the purposes of this paper, creative PPI included creative art or arts-based approaches (e.g., e.g. stories, songs, drama, drawing, painting, poetry, photography) to enhance engagement. Titles were related to health and social care and the creative PPI was used to engage with people as research advisors, not as study participants. Meta-analyses, conference abstracts, book chapters, commentaries and reviews were excluded. There were no limits concerning study location or the demographic characteristics of the PPI groups. Only qualitative data were accepted.

Quality appraisal

Quality appraisal using the Critical Appraisal Skills Programme (CASP) checklist [ 10 ] was conducted by the primary authors (ORP and CH). This was done independently, and discrepancies were discussed and resolved. If a consensus could not be reached, a third independent reviewer was consulted (JRM). The full list of quality appraisal questions can be found in Additional file 2 .

Data extraction

ORP extracted the study characteristics and a subset of these were checked by CH. Discrepancies were discussed and amendments made. Extracted data included author, title, location, year of publication, year study was carried out, research question/aim, creative methods used, number of participants, mean age, gender, ethnicity of participants, setting, limitations and strengths of creative PPI and main findings.

Data analysis

The included studies were analysed using inductive thematic analysis [ 11 ], where themes were determined by the data. The familiarisation stage took place during full-text reading of the included articles. Anything identified as a strength or limitation to creative PPI methods was extracted verbatim as an initial code and inputted into the data extraction Excel sheet. Similar codes were sorted into broader themes, either under ‘strengths’ or ‘limitations’ and reviewed. Themes were then assigned a name according to the codes.

The search yielded 9978 titles across the 5 databases: Web of Science (1480 results), PubMed (94 results), ASSIA (2454 results), CINAHL (5948 results) and Cochrane Library (2 results), resulting in 8553 different studies after deduplication. ORP and CH independently screened their titles and abstracts, excluding those that did not meet the criteria. After assessment, 12 studies were included (see Fig.  1 ).

PRISMA flowchart of the study selection process

Study characteristics

The included studies were published between 2018 and 2022. Seven were conducted in the UK [ 12 , 14 , 15 , 17 , 18 , 19 , 23 ], two in Canada [ 21 , 22 ], one in Australia [ 13 ], one in Norway [ 16 ] and one in Ireland [ 20 ]. The PPI activities occurred across various settings, including a school [ 12 ], social club [ 12 ], hospital [ 17 ], university [ 22 ], theatre [ 19 ], hotel [ 20 ], or online [ 15 , 21 ], however this information was omitted in 5 studies [ 13 , 14 , 16 , 18 , 23 ]. The number of people attending the PPI sessions varied, ranging from 6 to 289, however the majority (ten studies) had less than 70 participants [ 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Seven studies did not provide information on the age or gender of the PPI groups. Of those that did, ages ranged from 8 to 76 and were mostly female. The ethnicities of the PPI group members were also rarely recorded (see Additional file 3 for data extraction table).

Types of creative methods

The type of creative methods used to engage the PPI groups were varied. These included songs, poems, drawings, photograph elicitation, drama performance, visualisations, Facebook, photography, prototype development, cultural animation, card sorting and creating personas (see Table  1 ). These were sometimes accompanied by traditional methods of PPI such as interviews and focus group discussions.

The 12 included studies were all deemed to be of good methodological quality, with scores ranging from 6/10 to 10/10 with the CASP critical appraisal tool [ 10 ] (Table  2 ).

Thematic analysis

Analysis identified four limitations and five strengths to creative PPI (see Fig.  2 ). Limitations included the time and resource intensity of creative PPI methods, its lack of generalisation, ethical issues and external factors. Strengths included the disruption of power hierarchies, the engaging and inclusive nature of the methods and their long-term cost and time efficiency. Creative PPI methods also allowed mundane and “taboo” topics to be discussed within a safe space.

Theme map of strengths and limitations

Limitations of creative PPI

Creative ppi methods are time and resource intensive.

The time and resource intensive nature of creative PPI methods is a limitation, most notably for the persona-scenario methodology. Valaitis et al. [ 22 ] used 14 persona-scenario workshops with 70 participants to co-design a healthcare intervention, which aimed to promote optimal aging in Canada. Using the persona method, pairs composed of patients, healthcare providers, community service providers and volunteers developed a fictional character which they believed represented an ‘end-user’ of the healthcare intervention. Due to the depth and richness of the data produced the authors reported that it was time consuming to analyse. Further, they commented that the amount of information was difficult to disseminate to scientific leads and present at team meetings. Additionally, to ensure the production of high-quality data, to probe for details and lead group discussion there was a need for highly skilled facilitators. The resource intensive nature of the creative co-production was also noted in a study using the persona scenario and creative worksheets to develop a prototype decision support tool for individuals with malignant pleural effusion [ 17 ]. With approximately 50 people, this was also likely to yield a high volume of data to consider.

To prepare materials for populations who cannot engage in traditional methods of PPI was also timely. Kearns et al. [ 18 ] developed a feedback questionnaire for people with aphasia to evaluate ICT-delivered rehabilitation. To ensure people could participate effectively, the resources used during the workshops, such as PowerPoints, online images and photographs, had to be aphasia-accessible, which was labour and time intensive. The author warned that this time commitment should not be underestimated.

There are further practical limitations to implementing creative PPI, such as the costs of materials for activities as well as hiring a space for workshops. For example, the included studies in this review utilised pens, paper, worksheets, laptops, arts and craft supplies and magazines and took place in venues such as universities, a social club, and a hotel. Further, although not limited to creative PPI methods exclusively but rather most studies involving the public, a financial incentive was often offered for participation, as well as food, parking, transport and accommodation [ 21 , 22 ].

Creative PPI lacks generalisation

Another barrier to the use of creative PPI methods in health and social care research was the individual nature of its output. Those who participate, usually small in number, produce unique creative outputs specific to their own experiences, opinions and location. Craven et al. [ 13 ], used arts-based visualisations to develop a toolbox for adults with mental health difficulties. They commented, “such an approach might still not be worthwhile”, as the visualisations were individualised and highly personal. This indicates that the output may fail to meet the needs of its end-users. Further, these creative PPI groups were based in certain geographical regions such as Stoke-on-Trent [ 19 ] Sheffield [ 23 ], South Wales [ 12 ] or Ireland [ 20 ], which limits the extent the findings can be applied to wider populations, even within the same area due to individual nuances. Further, the study by Galler et al. [ 16 ], is specific to the Norwegian context and even then, maybe only a sub-group of the Norwegian population as the sample used was of higher socioeconomic status.

However, Grindell et al. [ 17 ], who used persona scenarios, creative worksheets and prototype development, pointed out that the purpose of this type of research is to improve a certain place, rather than apply findings across other populations and locations. Individualised output may, therefore, only be a limitation to research wanting to conduct PPI on a large scale.

If, however, greater generalisation within PPI is deemed necessary, then social media may offer a resolution. Fedorowicz et al. [ 15 ], used Facebook to gain feedback from the public on the use of video-recording methodology for an upcoming project. This had the benefit of including a more diverse range of people (289 people joined the closed group), who were spread geographically around the UK, as well as seven people from overseas.

Creative PPI has ethical issues

As with other research, ethical issues must be taken into consideration. Due to the nature of creative approaches, as well as the personal effort put into them, people often want to be recognised for their work. However, this compromises principles so heavily instilled in research such as anonymity and confidentiality. With the aim of exploring issues related to health and well-being in a town in South Wales, Byrne et al. [ 12 ], asked year 4/5 and year 10 pupils to create poems, songs, drawings and photographs. Community members also created a performance, mainly of monologues, to explore how poverty and inequalities are dealt with. Byrne noted the risks of these arts-based approaches, that being the possibility of over-disclosure and consequent emotional distress, as well as people’s desire to be named for their work. On one hand, the anonymity reduces the sense of ownership of the output as it does not portray a particular individual’s lived experience anymore. On the other hand, however, it could promote a more honest account of lived experience. Supporting this, Webber et al. [ 23 ], who used the persona method to co-design a back pain educational resource prototype, claimed that the anonymity provided by this creative technique allowed individuals to externalise and anonymise their own personal experience, thus creating a more authentic and genuine resource for future users. This implies that anonymity can be both a limitation and strength here.

The use of creative PPI methods is impeded by external factors

Despite the above limitations influencing the implementation of creative PPI techniques, perhaps the most influential is that creative methodologies are simply not mainstream [ 19 ]. This could be linked to the issues above, like time and resource intensity, generalisation and ethical issues but it is also likely to involve more systemic factors within the research community. Micsinszki et al. [ 21 ], who co-designed a hub for the health and well-being of vulnerable populations, commented that there is insufficient infrastructure to conduct meaningful co-design as well as a dominant medical model. Through a more holistic lens, there are “sociopolitical environments that privilege individualism over collectivism, self-sufficiency over collaboration, and scientific expertise over other ways of knowing based on lived experience” [ 21 ]. This, it could be suggested, renders creative co-design methodologies, which are based on the foundations of collectivism, collaboration and imagination an invalid technique in the research field, which is heavily dominated by more scientific methods offering reproducibility, objectivity and reliability.

Although we acknowledge that creative PPI techniques are not always appropriate, it may be that their main limitation is the lack of awareness of these methods or lack of willingness to use them. Further, there is always the risk that PPI, despite being a mandatory part of research, is used in a tokenistic or tick-box fashion [ 20 ], without considering the contribution that meaningful PPI could make to enhancing the research. It may be that PPI, let alone creative PPI, is not at the forefront of researchers’ minds when planning research.

Strengths of creative PPI

Creative ppi disrupts power hierarchies.

One of the main strengths of creative PPI techniques, cited most frequently in the included literature, was that they disrupt traditional power hierarchies [ 12 , 13 , 17 , 19 , 23 ]. For example, the use of theatre performance blurred the lines between professional and lay roles between the community and policy makers [ 12 ]. Individuals created a monologue to portray how poverty and inequality impact daily life and presented this to representatives of the National Assembly of Wales, Welsh Government, the Local Authority, Arts Council and Westminster. Byrne et al. [ 12 ], states how this medium allowed the community to engage with the people who make decisions about their lives in an environment of respect and understanding, where the hierarchies are not as visible as in other settings, e.g., political surgeries. Creative PPI methods have also removed traditional power hierarchies between researchers and adolescents. Cook et al. [ 13 ], used arts-based approaches to explore adolescents’ ideas about the “perfect” condom. They utilised the “Life Happens” resource, where adolescents drew and then decorated a person with their thoughts about sexual relationships, not too dissimilar from the persona-scenario method. This was then combined with hypothetical scenarios about sexuality. A condom-mapping exercise was then implemented, where groups shared the characteristics that make a condom “perfect” on large pieces of paper. Cook et al. [ 13 ], noted that usually power imbalances make it difficult to elicit information from adolescents, however these power imbalances were reduced due to the use of creative co-design techniques.

The same reduction in power hierarchies was noted by Grindell et al. [ 17 ], who used the person-scenario method and creative worksheets with individuals with malignant pleural effusion. This was with the aim of developing a prototype of a decision support tool for patients to help with treatment options. Although this process involved a variety of stakeholders, such as patients, carers and healthcare professionals, creative co-design was cited as a mechanism that worked to reduce power imbalances – a limitation of more traditional methods of research. Creative co-design blurred boundaries between end-users and clinical staff and enabled the sharing of ideas from multiple, valuable perspectives, meaning the prototype was able to suit user needs whilst addressing clinical problems.

Similarly, a specific creative method named cultural animation was also cited to dissolve hierarchies and encourage equal contributions from participants. Within this arts-based approach, Keleman et al. [ 19 ], explored the concept of “good health” with individuals from Stoke-on Trent. Members of the group created art installations using ribbons, buttons, cardboard and straws to depict their idea of a “healthy community”, which was accompanied by a poem. They also created a 3D Facebook page and produced another poem or song addressing the government to communicate their version of a “picture of health”. Public participants said that they found the process empowering, honest, democratic, valuable and practical.

This dissolving of hierarchies and levelling of power is beneficial as it increases the sense of ownership experienced by the creators/producers of the output [ 12 , 17 , 23 ]. This is advantageous as it has been suggested to improve its quality [ 23 ].

Creative PPI allows the unsayable to be said

Creative PPI fosters a safe space for mundane or taboo topics to be shared, which may be difficult to communicate using traditional methods of PPI. For example, the hypothetical nature of condom mapping and persona-scenarios meant that adolescents could discuss a personal topic without fear of discrimination, judgement or personal disclosure [ 13 ]. The safe space allowed a greater volume of ideas to be generated amongst peers where they might not have otherwise. Similarly, Webber et al. [ 23 ], , who used the persona method to co-design the prototype back pain educational resource, also noted how this method creates anonymity whilst allowing people the opportunity to externalise personal experiences, thoughts and feelings. Other creative methods were also used, such as drawing, collaging, role play and creating mood boards. A cardboard cube (labelled a “magic box”) was used to symbolise a physical representation of their final prototype. These creative methods levelled the playing field and made personal experiences accessible in a safe, open environment that fostered trust, as well as understanding from the researchers.

It is not only sensitive subjects that were made easier to articulate through creative PPI. The communication of mundane everyday experiences were also facilitated, which were deemed typically ‘unsayable’. This was specifically given in the context of describing intangible aspects of everyday health and wellbeing [ 11 ]. Graphic designers can also be used to visually represent the outputs of creative PPI. These captured the movement and fluidity of people and well as the relationships between them - things that cannot be spoken but can be depicted [ 21 ].

Creative PPI methods are inclusive

Another strength of creative PPI was that it is inclusive and accessible [ 17 , 19 , 21 ]. The safe space it fosters, as well as the dismantling of hierarchies, welcomed people from a diverse range of backgrounds and provided equal opportunities [ 21 ], especially for those with communication and memory difficulties who might be otherwise excluded from PPI. Kelemen et al. [ 19 ], who used creative methods to explore health and well-being in Stoke-on-Trent, discussed how people from different backgrounds came together and connected, discussed and reached a consensus over a topic which evoked strong emotions, that they all have in common. Individuals said that the techniques used “sets people to open up as they are not overwhelmed by words”. Similarly, creative activities, such as the persona method, have been stated to allow people to express themselves in an inclusive environment using a common language. Kearns et al. [ 18 ], who used aphasia-accessible material to develop a questionnaire with aphasic individuals, described how they felt comfortable in contributing to workshops (although this material was time-consuming to make, see ‘Limitations of creative PPI’ ).

Despite the general inclusivity of creative PPI, it can also be exclusive, particularly if online mediums are used. Fedorowicz et al. [ 15 ], used Facebook to create a PPI group, and although this may rectify previous drawbacks about lack of generalisation of creative methods (as Facebook can reach a greater number of people, globally), it excluded those who are not digitally active or have limited internet access or knowledge of technology. Online methods have other issues too. Maintaining the online group was cited as challenging and the volume of responses required researchers to interact outside of their working hours. Despite this, online methods like Facebook are very accessible for people who are physically disabled.

Creative PPI methods are engaging

The process of creative PPI is typically more engaging and produces more colourful data than traditional methods [ 13 ]. Individuals are permitted and encouraged to explore a creative self [ 19 ], which can lead to the exploration of new ideas and an overall increased enjoyment of the process. This increased engagement is particularly beneficial for younger PPI groups. For example, to involve children in the development of health food products, Galler et al. [ 16 ] asked 9-12-year-olds to take photos of their food and present it to other children in a “show and tell” fashion. They then created a newspaper article describing a new healthy snack. In this creative focus group, children were given lab coats to further their identity as inventors. Galler et al. [ 16 ], notes that the methods were highly engaging and facilitated teamwork and group learning. This collaborative nature of problem-solving was also observed in adults who used personas and creative worksheets to develop the resource for lower back pain [ 23 ]. Dementia patients too have been reported to enjoy the creative and informal approach to idea generation [ 20 ].

The use of cultural animation allowed people to connect with each other in a way that traditional methods do not [ 19 , 21 ]. These connections were held in place by boundary objects, such as ribbons, buttons, fabric and picture frames, which symbolised a shared meaning between people and an exchange of knowledge and emotion. Asking groups to create an art installation using these objects further fostered teamwork and collaboration, both at an individual and collective level. The exploration of a creative self increased energy levels and encouraged productive discussions and problem-solving [ 19 ]. Objects also encouraged a solution-focused approach and permitted people to think beyond their usual everyday scope [ 17 ]. They also allowed facilitators to probe deeper about the greater meanings carried by the object, which acted as a metaphor [ 21 ].

From the researcher’s point of view, co-creative methods gave rise to ideas they might not have initially considered. Valaitis et al. [ 22 ], found that over 40% of the creative outputs were novel ideas brought to light by patients, healthcare providers/community care providers, community service providers and volunteers. One researcher commented, “It [the creative methods] took me on a journey, in a way that when we do other pieces of research it can feel disconnected” [ 23 ]. Another researcher also stated they could not return to the way they used to do research, as they have learnt so much about their own health and community and how they are perceived [ 19 ]. This demonstrates that creative processes not only benefit the project outcomes and the PPI group, but also facilitators and researchers. However, although engaging, creative methods have been criticised for not demonstrating academic rigour [ 17 ]. Moreover, creative PPI may also be exclusive to people who do not like or enjoy creative activities.

Creative PPI methods are cost and time efficient

Creative PPI workshops can often produce output that is visible and tangible. This can save time and money in the long run as the output is either ready to be implemented in a healthcare setting or a first iteration has already been developed. This may also offset the time and costs it takes to implement creative PPI. For example, the prototype of the decision support tool for people with malignant pleural effusion was developed using personas and creative worksheets. The end result was two tangible prototypes to drive the initial idea forward as something to be used in practice [ 17 ]. The use of creative co-design in this case saved clinician time as well as the time it would take to develop this product without the help of its end-users. In the development of this particular prototype, analysis was iterative and informed the next stage of development, which again saved time. The same applies for the feedback questionnaire for the assessment of ICT delivered aphasia rehabilitation. The co-created questionnaire, designed with people with aphasia, was ready to be used in practice [ 18 ]. This suggests that to overcome time and resource barriers to creative PPI, researchers should aim for it to be engaging whilst also producing output.

That useable products are generated during creative workshops signals to participating patients and public members that they have been listened to and their thoughts and opinions acted upon [ 23 ]. For example, the development of the back pain resource based on patient experiences implies that their suggestions were valid and valuable. Further, those who participated in the cultural animation workshop reported that the process visualises change, and that it already feels as though the process of change has started [ 19 ].

The most cost and time efficient method of creative PPI in this review is most likely the use of Facebook to gather feedback on project methodology [ 15 ]. Although there were drawbacks to this, researchers could involve more people from a range of geographical areas at little to no cost. Feedback was instantaneous and no training was required. From the perspective of the PPI group, they could interact however much or little they wish with no time commitment.

This systematic review identified four limitations and five strengths to the use of creative PPI in health and social care research. Creative PPI is time and resource intensive, can raise ethical issues and lacks generalisability. It is also not accepted by the mainstream. These factors may act as barriers to the implementation of creative PPI. However, creative PPI disrupts traditional power hierarchies and creates a safe space for taboo or mundane topics. It is also engaging, inclusive and can be time and cost efficient in the long term.

Something that became apparent during data analysis was that these are not blanket strengths and limitations of creative PPI as a whole. The umbrella term ‘creative PPI’ is broad and encapsulates a wide range of activities, ranging from music and poems to prototype development and persona-scenarios, to more simplistic things like the use of sticky notes and ordering cards. Many different activities can be deemed ‘creative’ and the strengths and limitations of one does not necessarily apply to another. For example, cultural animation takes greater effort to prepare than the use of sticky notes and sorting cards, and the use of Facebook is cheaper and wider reaching than persona development. Researchers should use their discretion and weigh up the benefits and drawbacks of each method to decide on a technique which suits the project. What might be a limitation to creative PPI in one project may not be in another. In some cases, creative PPI may not be suitable at all.

Furthermore, the choice of creative PPI method also depends on the needs and characteristics of the PPI group. Children, adults and people living with dementia or language difficulties all have different engagement needs and capabilities. This indicates that creative PPI is not one size fits all and that the most appropriate method will change depending on the composition of the group. The choice of method will also be determined by the constraints of the research project, namely time, money and the research aim. For example, if there are time constraints, then a method which yields a lot of data and requires a lot of preparation may not be appropriate. If generalisation is important, then an online method is more suitable. Together this indicates that the choice of creative PPI method is highly individualised and dependent on multiple factors.

Although the limitations discussed in this review apply to creative PPI, they are not exclusive to creative PPI. Ethical issues are a consideration within general PPI research, especially when working with more vulnerable populations, such as children or adults living with a disability. It can also be the case that traditional PPI methods lack generalisability, as people who volunteer to be part of such a group are more likely be older, middle class and retired [ 24 ]. Most research is vulnerable to this type of bias, however, it is worth noting that generalisation is not always a goal and research remains valid and meaningful in its absence. Although online methods may somewhat combat issues related to generalisability, these methods still exclude people who do not have access to the internet/technology or who choose not to use it, implying that online PPI methods may not be wholly representative of the general population. Saying this, however, the accessibility of creative PPI techniques differs from person to person, and for some, online mediums may be more accessible (for example for those with a physical disability), and for others, this might be face-to-face. To combat this, a range of methods should be implemented. Planning multiple focus group and interviews for traditional PPI is also time and resource intensive, however the extra resources required to make this creative may be even greater. Although, the rich data provided may be worth the preparation and analysis time, which is also likely to depend on the number of participants and workshop sessions required. PPI, not just creative PPI, often requires the provision of a financial incentive, refreshments, parking and accommodation, which increase costs. These, however, are imperative and non-negotiable, as they increase the accessibility of research, especially to minority and lower-income groups less likely to participate. Adequate funding is also important for co-design studies where repeated engagement is required. One barrier to implementation, which appears to be exclusive to creative methods, however, is that creative methods are not mainstream. This cannot be said for traditional PPI as this is often a mandatory part of research applications.

Regarding the strengths of creative PPI, it could be argued that most appear to be exclusive to creative methodologies. These are inclusive by nature as multiple approaches can be taken to evoke ideas from different populations - approaches that do not necessarily rely on verbal or written communication like interviews and focus groups do. Given the anonymity provided by some creative methods, such as personas, people may be more likely to discuss their personal experiences under the guise of a general end-user, which might be more difficult to maintain when an interviewer is asking an individual questions directly. Additionally, creative methods are by nature more engaging and interactive than traditional methods, although this is a blanket statement and there may be people who find the question-and-answer/group discussion format more engaging. Creative methods have also been cited to eliminate power imbalances which exist in traditional research [ 12 , 13 , 17 , 19 , 23 ]. These imbalances exist between researchers and policy makers and adolescents, adults and the community. Lastly, although this may occur to a greater extent in creative methods like prototype development, it could be suggested that PPI in general – regardless of whether it is creative - is more time and cost efficient in the long-term than not using any PPI to guide or refine the research process. It must be noted that these are observations based on the literature. To be certain these differences exist between creative and traditional methods of PPI, direct empirical evaluation of both should be conducted.

To the best of our knowledge, this is the first review to identify the strengths and limitations to creative PPI, however, similar literature has identified barriers and facilitators to PPI in general. In the context of clinical trials, recruitment difficulties were cited as a barrier, as well as finding public contributors who were free during work/school hours. Trial managers reported finding group dynamics difficult to manage and the academic environment also made some public contributors feel nervous and lacking confidence to speak. Facilitators, however, included the shared ownership of the research – something that has been identified in the current review too. In addition, planning and the provision of knowledge, information and communication were also identified as facilitators [ 25 ]. Other research on the barriers to meaningful PPI in trial oversight committees included trialist confusion or scepticism over the PPI role and the difficulties in finding PPI members who had a basic understanding of research [ 26 ]. However, it could be argued that this is not representative of the average patient or public member. The formality of oversight meetings and the technical language used also acted as a barrier, which may imply that the informal nature of creative methods and its lack of dependency on literacy skills could overcome this. Further, a review of 42 reviews on PPI in health and social care identified financial compensation, resources, training and general support as necessary to conduct PPI, much like in the current review where the resource intensiveness of creative PPI was identified as a limitation. However, others were identified too, such as recruitment and representativeness of public contributors [ 27 ]. Like in the current review, power imbalances were also noted, however this was included as both a barrier and facilitator. Collaboration seemed to diminish hierarchies but not always, as sometimes these imbalances remained between public contributors and healthcare staff, described as a ‘them and us’ culture [ 27 ]. Although these studies compliment the findings of the current review, a direct comparison cannot be made as they do not concern creative methods. However, it does suggest that some strengths and weaknesses are shared between creative and traditional methods of PPI.

Strengths and limitations of this review

Although a general definition of creative PPI exists, it was up to our discretion to decide exactly which activities were deemed as such for this review. For example, we included sorting cards, the use of interactive whiteboards and sticky notes. Other researchers may have a more or less stringent criteria. However, two reviewers were involved in this decision which aids the reliability of the included articles. Further, it may be that some of the strengths and limitations cannot fully be attributed to the creative nature of the PPI process, but rather their co-created nature, however this is hard to disentangle as the included papers involved both these aspects.

During screening, it was difficult to decide whether the article was utilising creative qualitative methodology or creative PPI , as it was often not explicitly labelled as such. Regardless, both approaches involved the public/patients refining a healthcare product/service. This implies that if this review were to be replicated, others may do it differently. This may call for greater standardisation in the reporting of the public’s involvement in research. For example, the NIHR outlines different approaches to PPI, namely “consultation”, “collaboration”, “co-production” and “user-controlled”, which each signify an increased level of public power and influence [ 28 ]. Papers with elements of PPI could use these labels to clarify the extent of public involvement, or even explicitly state that there was no PPI. Further, given our decision to include only scholarly peer-reviewed literature, it is possible that data were missed within the grey literature. Similarly, the literature search will not have identified all papers relating to different types of accessible inclusion. However, the intent of the review was to focus solely on those within the definition of creative.

This review fills a gap in the literature and helps circulate and promote the concept of creative PPI. Each stage of this review, namely screening and quality appraisal, was conducted by two independent reviewers. However, four full texts could not be accessed during the full text reading stage, meaning there are missing data that could have altered or contributed to the findings of this review.

Research recommendations

Given that creative PPI can require effort to prepare, perform and analyse, sufficient time and funding should be allocated in the research protocol to enable meaningful and continuous PPI. This is worthwhile as PPI can significantly change the research output so that it aligns closely with the needs of the group it is to benefit. Researchers should also consider prototype development as a creative PPI activity as this might reduce future time/resource constraints. Shifting from a top-down approach within research to a bottom-up can be advantageous to all stakeholders and can help move creative PPI towards the mainstream. This, however, is the collective responsibility of funding bodies, universities and researchers, as well as committees who approve research bids.

A few of the included studies used creative techniques alongside traditional methods, such as interviews, which could also be used as a hybrid method of PPI, perhaps by researchers who are unfamiliar with creative techniques or to those who wish to reap the benefits of both. Often the characteristics of the PPI group were not included, including age, gender and ethnicity. It would be useful to include such information to assess how representative the PPI group is of the population of interest.

Creative PPI is a relatively novel approach of engaging the public and patients in research and it has both advantages and disadvantages compared to more traditional methods. There are many approaches to implementing creative PPI and the choice of technique will be unique to each piece of research and is reliant on several factors. These include the age and ability of the PPI group as well as the resource limitations of the project. Each method has benefits and drawbacks, which should be considered at the protocol-writing stage. However, given adequate funding, time and planning, creative PPI is a worthwhile and engaging method of generating ideas with end-users of research – ideas which may not be otherwise generated using traditional methods.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Critical Appraisal Skills Programme

The Joanna Briggs Institute

National Institute of Health and Care Research

Public Advisory Group

Public and Patient Involvement

Web of Science

National Institute for Health and Care Research. What Is Patient and Public Involvement and Public Engagement? https://www.spcr.nihr.ac.uk/PPI/what-is-patient-and-public-involvement-and-engagement Accessed 01 Sept 2023.

Department of Health. Personal and Public Involvement (PPI) https://www.health-ni.gov.uk/topics/safety-and-quality-standards/personal-and-public-involvement-ppi#:~:text=The Health and Social Care Reform Act (NI) 2009 placed,delivery and evaluation of services . Accessed 01 Sept 2023.

National Institute for Health and Care Research. Policy Research Programme – Guidance for Stage 1 Applications https://www.nihr.ac.uk/documents/policy-research-programme-guidance-for-stage-1-applications-updated/26398 Accessed 01 Sept 2023.

Greenhalgh T, Hinton L, Finlay T, Macfarlane A, Fahy N, Clyde B, Chant A. Frameworks for supporting patient and public involvement in research: systematic review and co-design pilot. Health Expect. 2019. https://doi.org/10.1111/hex.12888

Article   PubMed   PubMed Central   Google Scholar  

Street JM, Stafinski T, Lopes E, Menon D. Defining the role of the public in health technology assessment (HTA) and HTA-informed decision-making processes. Int J Technol Assess Health Care. 2020. https://doi.org/10.1017/S0266462320000094

Article   PubMed   Google Scholar  

Morrison C, Dearden A. Beyond tokenistic participation: using representational artefacts to enable meaningful public participation in health service design. Health Policy. 2013. https://doi.org/10.1016/j.healthpol.2013.05.008

Leavy P. Method meets art: arts-Based Research Practice. New York: Guilford; 2020.

Google Scholar  

Seers K. Qualitative systematic reviews: their importance for our understanding of research relevant to pain. Br J Pain. 2015. https://doi.org/10.1177/2049463714549777

Lockwood C, Porritt K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M, Loveday H, Carrier J, Stannard D. Chapter 2: Systematic reviews of qualitative evidence. Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis JBI. 2020. https://synthesismanual.jbi.global . https://doi.org/10.46658/JBIMES-20-03

CASP. CASP Checklists https://casp-uk.net/images/checklist/documents/CASP-Qualitative-Studies-Checklist/CASP-Qualitative-Checklist-2018_fillable_form.pdf (2022).

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006. https://doi.org/10.1191/1478088706qp063oa

Article   Google Scholar  

Byrne E, Elliott E, Saltus R, Angharad J. The creative turn in evidence for public health: community and arts-based methodologies. J Public Health. 2018. https://doi.org/10.1093/pubmed/fdx151

Cook S, Grozdanovski L, Renda G, Santoso D, Gorkin R, Senior K. Can you design the perfect condom? Engaging young people to inform safe sexual health practice and innovation. Sex Educ. 2022. https://doi.org/10.1080/14681811.2021.1891040

Craven MP, Goodwin R, Rawsthorne M, Butler D, Waddingham P, Brown S, Jamieson M. Try to see it my way: exploring the co-design of visual presentations of wellbeing through a workshop process. Perspect Public Health. 2019. https://doi.org/10.1177/1757913919835231

Fedorowicz S, Riley V, Cowap L, Ellis NJ, Chambers R, Grogan S, Crone D, Cottrell E, Clark-Carter D, Roberts L, Gidlow CJ. Using social media for patient and public involvement and engagement in health research: the process and impact of a closed Facebook group. Health Expect. 2022. https://doi.org/10.1111/hex.13515

Galler M, Myhrer K, Ares G, Varela P. Listening to children voices in early stages of new product development through co-creation – creative focus group and online platform. Food Res Int. 2022. https://doi.org/10.1016/j.foodres.2022.111000

Grindell C, Tod A, Bec R, Wolstenholme D, Bhatnagar R, Sivakumar P, Morley A, Holme J, Lyons J, Ahmed M, Jackson S, Wallace D, Noorzad F, Kamalanathan M, Ahmed L, Evison M. Using creative co-design to develop a decision support tool for people with malignant pleural effusion. BMC Med Inf Decis Mak. 2020. https://doi.org/10.1186/s12911-020-01200-3

Kearns Á, Kelly H, Pitt I. Rating experience of ICT-delivered aphasia rehabilitation: co-design of a feedback questionnaire. Aphasiology. 2020. https://doi.org/10.1080/02687038.2019.1649913

Kelemen M, Surman E, Dikomitis L. Cultural animation in health research: an innovative methodology for patient and public involvement and engagement. Health Expect. 2018. https://doi.org/10.1111/hex.12677

Keogh F, Carney P, O’Shea E. Innovative methods for involving people with dementia and carers in the policymaking process. Health Expect. 2021. https://doi.org/10.1111/hex.13213

Micsinszki SK, Buettgen A, Mulvale G, Moll S, Wyndham-West M, Bruce E, Rogerson K, Murray-Leung L, Fleisig R, Park S, Phoenix M. Creative processes in co-designing a co-design hub: towards system change in health and social services in collaboration with structurally vulnerable populations. Evid Policy. 2022. https://doi.org/10.1332/174426421X16366319768599

Valaitis R, Longaphy J, Ploeg J, Agarwal G, Oliver D, Nair K, Kastner M, Avilla E, Dolovich L. Health TAPESTRY: co-designing interprofessional primary care programs for older adults using the persona-scenario method. BMC Fam Pract. 2019. https://doi.org/10.1186/s12875-019-1013-9

Webber R, Partridge R, Grindell C. The creative co-design of low back pain education resources. Evid Policy. 2022. https://doi.org/10.1332/174426421X16437342906266

National Institute for Health and Care Research. A Researcher’s Guide to Patient and Public Involvement. https://oxfordbrc.nihr.ac.uk/wp-content/uploads/2017/03/A-Researchers-Guide-to-PPI.pdf Accessed 01 Nov 2023.

Selman L, Clement C, Douglas M, Douglas K, Taylor J, Metcalfe C, Lane J, Horwood J. Patient and public involvement in randomised clinical trials: a mixed-methods study of a clinical trials unit to identify good practice, barriers and facilitators. Trials. 2021 https://doi.org/10.1186/s13063-021-05701-y

Coulman K, Nicholson A, Shaw A, Daykin A, Selman L, Macefield R, Shorter G, Cramer H, Sydes M, Gamble C, Pick M, Taylor G, Lane J. Understanding and optimising patient and public involvement in trial oversight: an ethnographic study of eight clinical trials. Trials. 2020. https://doi.org/10.1186/s13063-020-04495-9

Ocloo J, Garfield S, Franklin B, Dawson S. Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: a systematic review of reviews. Health Res Policy Sys. 2021. https://doi.org/10.1186/s12961-020-00644-3

National Institute for Health and Care Research. Briefing notes for researchers - public involvement in NHS, health and social care research. https://www.nihr.ac.uk/documents/briefing-notes-for-researchers-public-involvement-in-nhs-health-and-social-care-research/27371 Accessed 01 Nov 2023.

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Acknowledgements

With thanks to the PHIRST-LIGHT public advisory group and consortium for their thoughts and contributions to the design of this work.

The research team is supported by a National Institute for Health and Care Research grant (PHIRST-LIGHT Reference NIHR 135190).

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Olivia R. Phillips and Cerian Harries share joint first authorship.

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Nottingham Centre for Public Health and Epidemiology, Lifespan and Population Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK

Olivia R. Phillips, Jo Leonardi-Bee, Holly Knight & Joanne R. Morling

National Institute for Health and Care Research (NIHR) PHIRST-LIGHT, Nottingham, UK

Olivia R. Phillips, Cerian Harries, Jo Leonardi-Bee, Holly Knight, Lauren B. Sherar, Veronica Varela-Mato & Joanne R. Morling

School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK

Cerian Harries, Lauren B. Sherar & Veronica Varela-Mato

Nottingham Centre for Evidence Based Healthcare, School of Medicine, University of Nottingham, Nottingham, UK

Jo Leonardi-Bee

NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, NG7 2UH, UK

Joanne R. Morling

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Author contributions: study design: ORP, CH, JRM, JLB, HK, LBS, VVM, literature searching and screening: ORP, CH, JRM, data curation: ORP, CH, analysis: ORP, CH, JRM, manuscript draft: ORP, CH, JRM, Plain English Summary: ORP, manuscript critical review and editing: ORP, CH, JRM, JLB, HK, LBS, VVM.

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Phillips, O.R., Harries, C., Leonardi-Bee, J. et al. What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review. Res Involv Engagem 10 , 48 (2024). https://doi.org/10.1186/s40900-024-00580-4

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Responsible coordination of municipal health and care services for individuals with serious mental illness: a participatory qualitative study with service users and professionals

• Jorunn Nærland Skjærpe 1 ,
• Tatiana Aleksandrovna Iakovleva 2 &
• Marianne Storm 1 , 3 , 4  

BMC Health Services Research volume  24 , Article number:  633 ( 2024 ) Cite this article

Metrics details

Care coordination is crucial to ensure the health of individuals with serious mental illness. The aim of this study was to describe and analyze an inclusive innovation process for coordinating municipal health and care services for individuals with serious mental illness.

We conducted café dialogues with professionals and service users with serious mental illness. The café dialogues engaged participants in conversation and knowledge exchange about care coordination, adressing topics of efficiency, challenges, and improvement. We used a responsible innovation framework to analyze the innovation process.

Responsible coordination requires promoting service users’ health and ensuring communication and mutual awareness between professionals. Individual-level factors supporting responsible coordination included service users knowing their assigned professionals, personalized healthcare services, and access to meaningful activities. Provider-level factors included effective coordination routines, communication, information exchange, and professional familiarity. Results reflect professionals’ and service users’ perspectives on efficient care coordination, existing challenges, and measures to improve care coordination.

Café dialogues are an inclusive, participatory method that can produce insights into the responsible coordination of municipal health and care services for individuals with serious mental illness. The responsible innovation framework is helpful in identifying care coordination challenges and measures for responsible coordination.

Peer Review reports

Approximately one in eight individuals worldwide have a mental illness [ 1 ], with depressive disorders and anxiety disorders the most prevalent types [ 1 , 2 ]. Many individuals with serious mental illness (SMI) require coordinated care to ensure and improve their health [ 1 , 3 , 4 ]. We use the term SMI to refer to schizophrenia, schizoaffective disorder, psychotic disorders, major depressive disorders, and bipolar disorders [ 5 ]. In Norway, approximately 1-3.5% of the population meets the criteria for lifetime SMI [ 2 ].

Care coordination is defined as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services” [ 6 , p. 6]. Such coordination across services is essential to providing seamless healthcare [ 7 ]. Efficient care coordination relies on stakeholders sharing a common understanding and harnessing their skills, perspectives, experiences, and knowledge to address the needs of service users [ 8 ].

McDonald et al. [ 6 ] developed a framework of measures they deem essential for coordinated care, which has been applied in numerous studies on mental healthcare coordination [ 3 , 9 , 10 ]. The measures can be grouped into individual, provider, and system levels of care [ 6 , 9 , 11 , 12 ]. At the individual level, professionals tailor service delivery to meet service users’ needs [ 6 ]. Care coordination involves assessing individuals’ healthcare needs, resources, and goals, providing personalized services, supporting self-care, and encouraging health-promoting activities in the community [ 6 ]. At the provider level, care coordination involves establishing accountability, negotiating responsibility for service users’ care, allocating tasks and responsibilities, organizing patient transitions between services, and exchanging information among professionals and service users [ 6 ]. Coordination routines, communication platforms, and cooperative relationships are also important at this level [ 8 , 13 , 14 ]. Care coordination at the system level focuses on aligning healthcare and community resources with the population’s needs [ 6 ], health policy goals, economic factors, legislation, and regulations influencing professional action and decision-making [ 14 ].

Several challenges affect mental healthcare coordination [ 4 ]. These include a lack of access to services, issues with information exchange, and limited service user involvement in decision-making [ 4 ]. The latter is due to an asymmetrical power balance between professionals and service users and perceptions that individuals with SMI lack the capacity to be involved in decision-making due to their symptoms [ 15 ]. Moreover, professionals can at times act unilaterally in service users’ best interests or struggle to integrate their expertise with service user insights, making service users feel unheard or defined by diagnostic labels [ 15 ]. Efficient care coordination can also be hindered by professionals’ multiple simultaneous tasks, uncertainty regarding task prioritization, prioritizing treatment over prevention, and a deficit of expertise [ 16 ]. Knowledge differences, conflicts, and difficulties with perspective-taking are additional challenges [ 17 ]. Addressing these issues requires a more symmetrical power balance and ensuring equal influence of professionals from different services [ 17 , 18 ] and service users [ 15 , 17 ].

Improved care coordination is a stated health policy goal in Norway and internationally [ 19 , 20 , 21 ]. One way to achieve this goal is through responsible innovation processes that include stakeholders [ 22 ]. We define responsible innovation as “taking care of the future through collective stewardship of science and innovation in the present” [ 23 , p. 1570]. Stilgoe et al. [ 23 ] present a framework for responsible innovation with four integrated dimensions: inclusion, anticipation, reflexivity, and responsiveness. Inclusion refers to encouraging different perspectives, anchoring decisions, and promoting reflective innovation processes. Inclusion can occur through dialogues and by applying stakeholders’ ideas and knowledge. Anticipation is about assessing what is known, what is likely to occur, what one intends to achieve, how to address relevant issues, and discovering additional opportunities for innovation. Reflexivity integrates stakeholder perspectives about expectations, challenges, and other issues. Responsiveness refers to an open and flexible innovation process in which participants respect and adapt to each other’s perspectives and knowledge. Suitable responses may involve measures that address existing issues and potential future challenges.

This study builds upon literature demonstrating that responsible innovation and the inclusion of diverse stakeholders can effectively improve healthcare services [ 22 , 24 , 25 , 26 , 27 ]. We include professionals and service users with SMI in café dialogues, a participatory research method [ 28 , 29 , 30 , 31 , 32 , 33 ], to identify care coordination challenges, address shared coordination responsibilities, and develop improvement measures [ 34 , 35 , 36 ]. In health and social science, such participatory research methods have successfully captured varied perspectives and found sustainable solutions to challenges [ 31 , 37 , 38 , 39 , 40 , 41 , 42 ]. Service users have valuable knowledge based on their experiences, can offer insights into their needs and challenges, and can suggest potential improvement measures [ 24 , 43 ]. Involving professionals in café dialogues can enhance their understanding of service users’ perspectives and improve interactions between service users and healthcare services [ 44 ]. The aim of this study is to describe and analyze an inclusive innovation process for coordinating municipal health and care services for individuals with SMI.

Study setting: the Norwegian healthcare system

The Norwegian healthcare system consists of municipal health and care services and specialist health services. Municipalities are responsible for delivering primary healthcare services outside of hospital facilities. The municipal health and care services focus on disease prevention, health promotion, treatment, care, and assistance with daily life functions [ 45 ]. Municipal health and care services for people with SMI encompass general practitioners (GPs), emergency rooms, inpatient acute care, institutions, home-based healthcare, and supported housing with round-the-clock healthcare [ 45 ]. GPs serve as gatekeepers and coordinate referrals to municipal health and care services and specialist health services as per service users’ needs [ 45 ].

The study was conducted in municipal health and care services for individuals with SMI in a rural Norwegian municipality with nearly 20,000 inhabitants. Individuals with SMI frequently experience persistent and severe symptoms of mental illness [ 4 , 46 , 47 ]. They often have extensive physical healthcare needs and a higher mortality rate than the general population [ 2 , 48 , 49 , 50 , 51 ]. Their life expectancy is up to 30 years shorter, mainly because of physical health issues [ 48 , 49 , 50 , 52 ].

The severity of each individual’s mental health issues is based on their symptoms, challenges, and impact on social and daily functioning [ 53 ]. Severity determines the primary responsibility for care, services provided, level of care coordination required, and involvement of specialist health services [ 53 ]. If municipalities lack sufficient competence to meet service users’ needs, responsibility falls to specialist health services which, for individuals with SMI, encompass inpatient and outpatient treatment and care offered by psychiatric hospitals and community mental health centers [ 54 ]. Individuals with SMI often receive municipal and specialist health services [ 53 ].

Study design, recruitment, and participants

For this study, we employed a qualitative participatory design [ 55 ] to describe and analyze an inclusive innovation process for coordinating municipal health and care services for individuals with SMI. Café dialogues were used to collect data [ 28 , 29 , 30 , 31 , 32 , 33 ]. Café dialogues are well suited to explore topics and obtain knowledge through varied participant perspectives in a relatively short period [ 28 , 29 , 30 , 31 , 32 , 33 ]. Café dialogues were considered well suited for several reasons, including their potential for obtaining qualitative data, broadening the reference sample size, exploring topics, and enhancing the diversity of perspectives on the given topic [ 31 , 32 , 33 ]. Additionally, they provide an arena for participants to share their reflections on lived experiences and develop new ideas [ 28 , 29 , 30 , 31 , 32 , 33 ]. This inclusive approach ensures that the participants’ voices and perspectives are included in the innovation and research process [ 23 , 28 , 29 , 30 ].

We used purposive sampling [ 55 ] to recruit professionals and service users who were knowledgeable about care coordination and had experience with mental healthcare services. Recruiting a diverse range of professionals and service users aligns with the inclusion strategy of responsible innovation [ 23 ]. Our inclusion criteria for professionals were that they were employed in a municipal health and care service and were involved in care coordination and service delivery for individuals with SMI. For service users, inclusion criteria were that individuals currently or previously had a diagnosis of SMI and had received two or more municipal health and care services.

We recruited professionals through municipal health and care service leaders who were contacted by JNS via e-mail with information about the study. Service leaders then provided employees with this information and selected employees to participate based on willingness and interest. Service users were recruited through municipal health and care employees who were given information about the study by JNS via e-mail. These employees provided eligible participants with information about the study and the time and location of the café dialogue. Thirty professionals and seven service users were recruited for three café dialogues. Table  1 presents participants’ characteristics.

Café dialogues

JNS and MS conducted three café dialogues, two for professionals and one for service users, in May and June 2021. Café dialogues were inspired by the dialogue seminar method described by Storm [ 28 , 29 , 30 ] and the World Café method [ 31 , 32 , 33 ], which are participatory methods for engaging participants in brainstorming, conversation, and knowledge exchange [ 28 , 29 , 30 , 31 , 32 , 33 ]. Both methods, emphasizing diverse perspectives and mutual learning among participants, offer insights for scientific inquiries and changes and promote inclusivity [ 28 , 29 , 30 , 31 , 32 , 33 ]. These methods facilitate knowledge exchanges and constructive dialogue by encouraging exploration and discussion of important questions [ 28 , 29 , 30 , 31 , 32 , 33 ]. They are adaptable to various contexts and purposes, with event invitations, designs, and questions tailored to specific circumstances [ 28 , 29 , 30 , 31 , 32 , 33 ]. Brown & Isaacs [ 32 ] outline seven design principles for the World Café, including setting the context, creating a welcoming environment, exploring meaningful questions, encouraging contributions from all participants, connecting diverse perspectives, listening collectively for insights, and sharing discoveries as a group.

The café dialogues took place in meeting rooms provided by the municipality. These rooms represented a neutral space where participants could feel free to engage with each other [ 32 ]. Each café dialogue lasted for two hours with a break halfway. We started each café dialogue by welcoming participants, introducing ourselves, and presenting the agenda for the day. We gave a 30-minute teaching session on care coordination to establish a shared understanding of the concept [ 25 , 26 ], using PowerPoint slides to help explain care coordination [ 6 ], relevant health policy [ 19 ], and literature [ 56 , 57 ] that highlighted the importance of care coordination and the complexities of ensuring and improving the health of individuals with mental illness. Following this, we facilitated brainstorming and knowledge exchange conversations where participants articulated their perspectives on the topics of efficient care coordination, coordination challenges, and measures to improve care coordination.

Data collection

JNS led the café dialogues and took notes on a whiteboard throughout the sessions. MS took more detailed written notes to document participants’ ideas and knowledge. When necessary, we adjusted the dialogue to elicit participants’ perspectives on our topics of interest [ 23 ]. An important aspect was ensuring active participation and including each person’s perspectives in the innovation process [ 23 ]. All notes were subsequently synthesized into 13 pages of written text, constituting the qualitative empirical data material [ 55 ]. Table  2 illustrates the topics and activities of the café dialogues.

Data analysis

We conducted inductive and deductive thematic analyses [ 58 , 59 ]. For the inductive aspect, we analyzed the written notes from the café dialogues, focusing on participants’ perspectives on efficient care coordination, challenges, and improvement measures. The inductive analysis consisted of six stages: (1) reading through the material several times to become acquainted with it (2), coding meaning units relevant to the study aim (3), identifying themes and assigning meaning units to these themes (4), conducting a critical review of each theme to ensure that meaning units and themes comprehensively represented the data (5), labeling themes, and (6) summarizing into two themes and five sub-themes. Table  3 gives examples of the inductive thematic analysis.

For the deductive aspect, we analyzed the café dialogue innovation process by connecting themes and sub-themes from the inductive analysis to the dimensions of inclusion, anticipation, reflexivity, and responsiveness in Stilgoe et al.‘s [ 23 ] framework for responsible innovation.

Author reflexivity

Our understanding is built on the fact that we already have a relationship with the phenomena of coordination of healthcare services, and we can better understand existing concepts by relating reflexively to them [ 60 ]. In this study, reflexivity was embraced through collaborative efforts among the three authors in the data analysis [ 55 , 61 ]. Each author, with distinct educational backgrounds and professional experience, brought different perspectives to the analysis, stimulating varied interpretations during the theme development process. We considered alternative interpretations before reaching a consensus on results that aligned with the study’s aim. Consequently, themes were not influenced solely by the preunderstanding of a single researcher, thereby enhancing the trustworthiness of the results [ 62 ].

Ethical considerations

The study was approved through Sikt– the Norwegian Agency for Shared Services in Education and Research (formerly known as the Norwegian Centre for Research Data, or NSD) (project No. 132714). Sikt ensured that the research project adhered to ethical guidelines and regulations and approved information security and privacy services as part of the Norwegian Directorate for Higher Education and Skills (HK-dir). The study adhered to the principles of the Helsinki Declaration. All participants took part voluntarily and were provided with information regarding confidentiality. They were informed that participation was voluntary and that they retained the right to withdraw from the study without consequences. Written informed consent was obtained from all participants before the café dialogues.

The thematic analysis resulted in two themes and five sub-themes that reflected responsible coordination at individual and provider levels, participants’ anticipation of efficient care coordination, reflexivity to care coordination challenges, and responsiveness to improvement measures [ 23 ].

At the individual level, anticipation reflected a desire that services be personalized, with relationships built on trust and security between professionals and service users. Reflexivity encompassed care coordination challenges, which arose when service users refused healthcare or did not recognize their healthcare needs. Suggested improvement measures included activity centers, flexible healthcare, and professionals taking time to get to know service users.

At the provider level, anticipation involved clear responsibilities and tasks, coordination routines, and communication. Professionals described care coordination challenges related to a lack of routines, communication, unfamiliarity with one another, absence of shared health record-keeping systems, disagreements regarding service users’ healthcare, and not completing expected tasks. Improvement measures were responses related to information exchange, meeting points for communication, and a shared health record-keeping system across services.

Themes and sub-themes are described in more detail below. Table  4 illustrates themes, sub-themes, and the café dialogue innovation process.

Theme 1: Ensuring and promoting health - Responsible coordination at the individual level

Sub-theme 1: to be met and followed up with personalized healthcare.

Service users agreed that efficient care coordination required personalized healthcare with user involvement at every stage of their health journey. It can be challenging for service users to receive healthcare, even when they know their needs. When professionals approach service users in a way that makes them feel respected, seen, and heard, cooperation is easier. A service user elaborated on this:

It is crucial that professionals do not adopt a top-down attitude and that they communicate clearly without using complicated terminology. We feel stupid and hesitant to speak up when we do not understand what the professionals are saying.

Service users appreciated when healthcare was flexible and provided in environments where they felt safe. Service users suggested measures such as follow-ups at professionals’ offices, at home, or outdoors during activities that offered new experiences. They also mentioned video calls or double appointments with GPs. Using humor, even in serious situations, was seen as beneficial.

Several service users found communicating with professionals in writing easier than by phone. Both service users and professionals shared positive experiences using text messages and wanted to continue such measures. The ability to quickly and easily get in touch with professionals when needed was important for service users, and made easier through having direct numbers for their GP and other familiar professionals. Still, while these personalized and flexible measures were practical, service users emphasized that they were responsible for their health and that improved health required major effort on their part. One of them stated:

We must take control of our own lives. It can take a long time to realize that something needs to change. Waiting for someone else to fix me does not work. That just keeps us stuck in the same old mess. Having services available does not help if we are not willing to change.

Sub-theme 2: A balance between providing healthcare and allowing service users to take responsibility for their own lives

Professionals believed efficient care coordination involved personalized services adapted to service users’ goals, resources, preferences, and needs. One professional stated:

Some service users may have needs beyond standardized services. In such cases, we must be curious, stretch ourselves, think outside the box, prioritize the most critical aspects, try new measures, and find solutions together.

Several professionals noted that some service users needed assistance in managing their health. In such situations, efficient care coordination meant liaising with necessary services and assisting service users with daily needs. Professionals acknowledged that service users were responsible for their own lives but did not want to place too much pressure on them. One professional said:

It is a delicate balance to know how much help to provide while not assuming responsibilities that service users can handle themselves.

Professionals faced challenges in meeting service users’ needs if they refused healthcare, only accepted it from specific professionals, or had a different perspective on their needs compared to professional recommendations. These needs were often related to mental health but also to physical health. In such situations, it was essential for professionals to explain what was being refused.

Sub-theme 3: To know professionals and have access to meaningful activities

For service users, familiarity with professionals was crucial for efficient care coordination. Relationships built on trust and security, and professionals who took the time to get to know them made it easier to receive healthcare. Measures such as weekend getaways, holiday trips, and other meaningful activities were some suggested ways to get acquainted and build relationships. Engagement in meaningful activities promoted health, shifted focus away from illness, and placed a greater emphasis on service users’ strengths and resources. Conversely, a lack of meaningful activities posed coordination challenges.

Service users praised an activity center, often recommended by professionals, that helped establish contact. The activity center provided daily structure, social interaction, friendships, and belonging, helping service users discover they were not alone in their struggles and could support each other. In addition, they could receive support from peers and professionals, despite some instances of gossip and rumors among center users. Still, they were conscious of promoting each other positively and apologized if they said something they regretted. The center organized weekly group outings, which service users described as health-promoting and involving physical activity and fresh air, which, in turn, led to improved sleep and reduced symptoms of depression. Overall, attending the activity center had resulted in several service users needing less healthcare. One service user said:

I went to my GP every three months before– now I only go every six months.

While service users knew that such activities benefited them, actually engaging in such endeavors could still prove difficult. Nevertheless, doing so could instill a sense of accomplishment. One person spoke about challenging oneself:

It is important to stand up for oneself, take responsibility, and dare to set limits. To have the courage to say both yes and no. If you say yes to something that feels daunting, it is crucial to be able to step back when needed. Trying things that can be enjoyable and beneficial for oneself is essential.

Theme 2: Communication and knowledge of each other - Responsible coordination at the provider level

Sub-theme 4: coordination routines and information exchange.

Professionals reported that individuals with SMI often have complex needs and require multiple services. Determining priorities for mental or physical healthcare needs and identifying suitable services could be challenging. An absence of coordination routines, especially between mental and physical healthcare services, and coordination efforts being affected by personal and time constraints made it difficult for professionals to address complex needs. There were also challenges when professionals disagreed about service users’ healthcare and when they could not fulfill their expected tasks. Therefore, clarifying care responsibilities for each involved service was crucial.

Communication and regular information exchange were seen as elements of efficient care coordination. Information exchange often occurs through an electronic messaging system. However, several professionals have experienced issues with this system, such as messages not being sent as intended. Also, written information sometimes can fail to convey nuances present in face-to-face communication, leading to misinterpretation. In such cases, professionals needed to consult colleagues or messengers to ensure they had correctly understood the information. One professional said:

The information we receive and when it arrives can be quite random. Messages often get lost, or service users must provide the information themselves. Therefore, we spend extra time making calls and searching for necessary information.

Service users wanted access to updated health information and professionals to exchange relevant information. This exchange was contingent upon service users’ consent. They also wanted to simplify the consent process. Professionals discussed service users who do not consent to information exchange or withdraw their consent, citing this as a challenge hampering healthcare. They were committed to explaining to service users the importance of information exchange and the consequences of withholding consent.

For professionals, efficient care coordination meant providing service users with regularly updated information so they could be involved in adapting services to their needs. Service users valued professionals providing comprehensive information about available services and the consequences of choosing or not choosing them, as they could easily forget this information. Therefore, detailed written and oral information and access to quality-assured information about health, illness, and healthcare options could be helpful. Service users often had to deal with unfamiliar professionals who lacked updated health information about them. One explained:

Interacting with many professionals can be challenging when you feel emotionally unstable. It is exhausting to keep track of things and repeatedly explain your history when experiencing severe symptoms, such as telling professionals in the municipality what hospital doctors have said.

Consequently, service users wanted involved professionals to have access to their health records. However, care coordination challenges arose from an absence of up-to-date health information, primarily attributed to the lack of shared health record-keeping across services. Professionals reported positive experiences creating plans that outlined allocated services and described existing measures for when service users experienced severe symptoms. These plans could be used independently of a shared health record system.

Sub-theme 5: Being familiar with cooperating professionals

Professionals stated it was important that service users experienced efficient care coordination. They noted that care coordination worked best when involved professionals were familiar with each other, with challenges more likely to arise if they were not. Service users wished for involved professionals to cooperate closely and be familiar with each other’s roles. One service user said:

Professionals must clearly define their responsibilities so it is evident who does what. For example, we need to know who is responsible for our medications and who accompanies us to social services.

Professionals highlighted regular care coordination meetings in the municipality and with specialist health services as crucial measures for efficient care coordination. These meetings could be used for professionals to get to know each other, allocate responsibilities and tasks, develop and revise coordination routines, ensure information exchange, and verify information was understood. Meetings between professionals from mental health home care and home nursing were particularly relevant for coordinating mental and physical healthcare. Meeting locations could vary so that professionals would become acquainted with each other’s workplaces. One professional said:

Having common meeting points - meeting in person and talking together - makes it easier to initiate contact and know whom to reach out to electronically or by phone on future occasions.

The municipality has tried digital and hybrid meetings. Several professionals found these formats useful and reported receiving positive feedback from service users. Such meetings save time as participants can attend only the parts relevant to them. Digital meetings also eliminate the need for travel.

In this study, we conducted café dialogues with professionals and service users with the aim of outlining an inclusive innovation process for the responsible coordination of municipal health and care services for individuals with SMI. Our study highlights how including professionals and service users can help improve responsible care coordination through clarifying anticipation, encouraging reflexivity, and ensuring responsiveness [ 23 ]. Furthermore, we discuss our results in light of the dimensions in Stilgoe et al.‘s [ 23 ] framework for responsible innovation and previous research.

According to Stilgoe et al.‘s [ 23 ] framework, clarifying participant anticipation is central to responsible innovation. Our findings show that at the individual level, anticipation for efficient care coordination includes promoting health through personalized and flexible healthcare services and service users taking responsibility for their own lives. Balancing these anticipations can, however, prove challenging for professionals. Service user involvement in care coordination can promote health and reduce illness symptoms [ 63 ], but research indicates that some individuals with SMI prefer professionals to make care coordination decisions on their behalf [ 10 ]. Continuous assessment of service users’ capacities is therefore crucial to ensure any responsibilities they are given are appropriate [ 64 ].

Reflexivity to challenges, their causes, and how they might impact participant anticipation are essential in Stilgoe et al.‘s framework [ 23 ]. In our study, consideration of reflexivity revealed that professionals at times faced coordination challenges in meeting service users’ health needs when users did not accept or recognize these needs. Research shows that such challenges are common in care coordination [ 3 , 10 , 65 ].

At the provider level of responsible coordination, Stilgoe et al.‘s [ 23 ] anticipation dimension involves efficient communication and information exchange among professionals. These are essential for successful care coordination [ 66 ] and meeting service users’ needs [ 14 , 63 ]. Our study revealed that electronic messages were a preferred form of communication. Electronic communication can enhance efficient care coordination by providing quick access to up-to-date information [ 67 ]. However, participants reported communication challenges at the provider level, as problems with electronic messages resulted in professionals missing vital information and having to spend time gathering it. Further, electronic messages may not always suffice as essential information and details can be omitted or misunderstood [ 10 , 67 ].

Considering reflexivity at the provider level, we identified challenges whereby some service users declined to consent to information exchange among professionals, likely due to privacy concerns [ 67 ]. A lack of consent can limit shared health record-keeping, proving a challenge for coordination and weakening the quality of electronic information [ 66 ]. We found that service users found it burdensome to repeat their history when interacting with different professionals, an observation supported by prior research [ 68 ]. Shared health record-keeping can be particularly valuable if service users struggle to express themselves [ 67 ].

In our study, Stilgoe et al.‘s [ 23 ] responsiveness dimension represented measures to improve care coordination. Participants described measures for responsible coordination that focused on flexible and personalized services, such as simplifying contact with professionals, providing healthcare in a safe environment, and professionals getting to know service users. Customized services are vital in care coordination [ 14 ] and essential to meeting service users’ mental and physical health needs [ 10 ].

Our results suggest that improvement measures at the individual level should allow service users to communicate their needs to professionals in writing. Text messages could be used in personalized healthcare to quickly convey health information, increasing service user involvement and supporting self-care and recovery [ 69 ]. Our results highlight the use of activity centers as an improvement measure as these promote service users’ health and reduce the need for healthcare. Access to health-promoting services can help to engage individuals through shared interests and experiences, which is particularly important when service users have complex needs, as other needs may take precedence over health promotion [ 70 ].

Professionals in our study stated that lack of care coordination and unclear responsibilities made it challenging to determine the most suitable services for service users with complex needs. They responded to these challenges by developing coordination routines. This aligns with the literature indicating that efficient care coordination at the provider level depends on measures such as routines and transparent allocation of responsibilities and tasks [ 14 , 66 ]. Our results show that care plans that outline allocated services and measures accessible to professionals are important for efficient care coordination, supporting previous findings [ 66 ].

Service users in our study appreciated when involved professionals knew each other and highlighted the importance of having familiar professionals present. Considering the issue of responsiveness, participants reported that regular meetings allowed professionals to get to know each other, establish routines, communicate, and distribute tasks and responsibilities. Meetings where participants work toward common goals are essential for efficient coordination [ 3 , 9 , 10 , 63 ] and complement the care coordination process [ 8 ]. Our results show that digital and hybrid meetings increase meeting participation, with video meetings saving time and improving accessibility [ 71 ]. Research indicates that service user participation in care coordination meetings ensures that services align with the users’ wishes, needs, resources, and goals [ 63 ].

Strengths and limitations

A key strength of this study was the inclusion of service users and professionals from multiple municipal health and care services. The café dialogue method encouraged the integration of these participants’ perspectives into the innovation process [ 23 , 44 ]. During the café dialogues, participants discussed various aspects of care coordination. They were able to relate the teaching sessions to their own experiences. Additionally, they highlighted their own examples of coordinated care. Participants were willing to share their personal experiences, and the dialogues enabled them to build upon each other’s responses [ 31 , 55 , 72 ], fostering inclusiveness [ 23 ] and relevance to practice. Several participants offered valuable ideas and knowledge about how to improve care coordination [ 23 , 24 ].

However, some participants showed less engagement in conversations, and some required direct questions before sharing their perspectives. This may have been due to varying attitudes toward innovation, with some participants more passive and conservative and others more open to new ideas [ 25 ]. The teaching session at the café dialogues could have influenced participants’ conversations. It is also possible that relevant voices were not represented in our recruitment approach. The café dialogue for service users was conducted in a meeting room with access to professionals the users knew well and could contact if needed. We note that as participants were encouraged not to share experiences of a sensitive and private nature, some service user participants may have been reluctant to share opinions or negative experiences due to privacy concerns.

Looking back, we realize that audio recording of the café dialogues could have captured the participants’ viewpoints more thoroughly and preserved their ideas and knowledge. Furthermore, employing an interview guide covering a wider range of topics than those discussed in the dialogues could have enhanced our understanding of care coordination.

Due to constraints imposed in response to the COVID-19 pandemic, most participants in the first café dialogue were employed in mental health home care. Another potential limitation is that service users were a minority of our participants. Due to pandemic-related restrictions, we could not include more service users, and professionals and service users were not allowed to participate in the same café dialogue. In future research, we recommend including more service users to balance the number of service users and professionals. We also suggest that both professionals and service users participate in the same café dialogues. This could generate varied dynamics and potentially result in alternative suggestions for improvements. Finally, participants’ suggestions were not put into practice, so their impact on the improvement and coordination of services remains unknown.

This study shows that café dialogues that include professionals and service users are an inclusive, participatory method that can inform the responsible coordination of municipal health and care services for individuals with SMI. Our results indicate that responsible coordination at the individual level entails ensuring and promoting service users’ health, while at the provider level, communication and knowledge of each other are central. Findings demonstrate the relevance of the responsible innovation framework in identifying care coordination challenges and its utility in developing measures for responsible coordination of municipal health and care services for those with SMI. These results may be transferable to other contexts.

Data availability

Data are available to appropriate academic parties upon reasonable request to the corresponding author.

Abbreviations

General practitioner

Norwegian Directorate for Higher Education and Skills

Data Protection Official for Research at the Norwegian Centre for Research Data

Serious mental illness

World Health Organization. World mental health report: transforming mental health for all [Internet]. Geneva: World Health Organization. 2022. [Accessed July 20, 2023]. https://iris.who.int/bitstream/handle/10665/356119/9789240049338-eng.pdf?sequence=1

Norwegian Institute of Public Health. Public Health Report: Health Status in Norway 2023 [Internet]. Oslo: Norwegian Institute of Public Health. 2023. Norwegian. [Accessed Januar 8, 2023]. https://www.fhi.no/he/folkehelserapporten/psykisk-helse/psykiske-lidelser-voksne/?term=

Storm M, Fortuna KL, Gill EA, Pincus HA, Bruce ML, Bartels SJ. Coordination of services for people with serious mental illness and general medical conditions: perspectives from rural northeastern United States. Psychiatr Rehabil J. 2020;43(3):234–43. https://doi.org/10.1037/prj0000404 .

Article   PubMed   PubMed Central   Google Scholar  

Storm M, Husebø AML, Thomas EC, Elwyn G, Zisman-Ilani Y. Coordinating mental health services for people with serious mental illness: a scoping review of transitions from psychiatric hospital to community. Adm Policy Ment Health. 2019;46(3):352–67. https://doi.org/10.1007/s10488-018-00918-7 .

Article   PubMed   Google Scholar  

SAMHSA’s National Registry of Evidence-Based Programs and Practices. Behind the term: Serious mental illness [Internet]. Prepared in 2016 by Development Services Group, Inc., under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T. Rockville: Development Services Group. 2016. [Accessed January 10, 2024]. https://www.ahrq.gov/sites/default/files/publications/files/ccm_atlas.pdf .

McDonald KM, Schultz E, Albin L, Pineda N, Lonhart J, Vandana S et al. Care Coordination Measures Atlas Version 4 [Internet]. Prepared by Stanford University under subcontract to American Institutes for Research on Contract No. HHSA290-2010-00005I. AHRQ Publication No. 14-0037- EF. Rockville: Agency for Healthcare Research and Quality; 2014. [Accessed June 10, 2023]. https://www.ahrq.gov/sites/default/files/publications/files/ccm_atlas.pdf .

Khatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A, et al. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv Res. 2023;23:750. https://doi.org/10.1186/s12913-023-09718-8 .

Torgersen GE, Steiro TJ. Defining the term samhandling . In: Torgersen GE, editor. Interaction: ‘Samhandling’ under risk. A step ahead of the Unforeseen. Oslo: Cappelen Damm Akademisk; 2018. pp. 39–54. https://doi.org/10.23865/noasp.36.ch2 .

Chapter   Google Scholar  

Skjærpe JN, Kristoffersen M, Storm M. Service user involvement in mental healthcare coordination. J Clin Nurs. 2020. https://doi.org/10.4220/Sykepleienf.2020.80125 . https://sykepleien.no/en/forskning/2020/08/service-user-involvement-mental-healthcare-coordination .

Skjærpe JN, Joa I, Willumsen E, Hegelstad WV, Iakovleva T, Storm M. Perspectives on Coordinating Health Services for individuals with Serious Mental illness– a qualitative study. J Multidiscip Healthc. 2022;15:2735–50. https://doi.org/10.2147/JMDH.S384072 .

Samal L, Dykes PC, Greenberg JO, Hasan O, Venkatesh AK, Volk LA, et al. Care coordination gaps due to lack of interoperability in the United States: a qualitative study and literature review. BMC Health Serv Res. 2016;16:143. https://doi.org/10.1186/s12913-016-1373-y .

Gill E, Dykes PC, Rudin RS, Storm M, McGrath K, Bates DW. Technology-facilitated care coordination in rural areas: what is needed? Int J Med Inf. 2020;137:104102. https://doi.org/10.1016/j.ijmedinf.2020.104102 .

Article   Google Scholar  

Storm M, Siemsen IMD, Laugaland KA, Dyrstad DN, Aase K. Quality in transitional care of the elderly: key challenges and relevant improvement measures. Int J Integr Care. 2014;14:e013. https://doi.org/10.5334/ijic.1194 .

Øgar P, Hovland T. Mellom Kaos Og Kontroll: Ledelse Og kvalitetsutvikling i kommunehelsetjenesten. [Between chaos and control. Management and quality improvement in municipal health and care services]. Oslo: Gyldendal akademisk; 2013.

Google Scholar  

Heerings M, van de Bovenkamp H, Cardol M, Bal R. Ethical dilemmas of participation of service users with Serious Mental illness: a thematic synthesis. Issues Ment Health Nurs. 2020;41(4):283–95. https://doi.org/10.1080/01612840.2019.1667459 .

Thornicroft G, Ahuja S, Barber S, Chisholm D, Collins PY, Docrat S, et al. Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries. Lancet Psychiatry. 2019;6(2):174–86. https://doi.org/10.1016/S2215-0366(18)30298-0 .

Steihaug S, Johannessen AK, Ådnanes M, Paulsen B, Mannion R. Challenges in achieving collaboration in clinical practice: the case of Norwegian health care. Int J Integr Care. 2016;16(3):1–13. https://doi.org/10.5334/ijic.2217 .

Dragioti E, Radua J, Solmi M, Gosling CJ, Oliver D, Lascialfari F, et al. Impact of mental disorders on clinical outcomes of physical diseases: an umbrella review assessing population attributable fraction and generalized impact fraction. World Psychiatry. 2023;22(1):86–104. https://doi.org/10.1002/wps.21068 .

Report No. 7 to the Storting (White Paper) (2019–2020). National Health and Hospital Plan 2020–2023 Summary [Internet]. Oslo: Norwegian Ministry of Health and Care Services. 2019. [Accessed Mai 23, 2023]. https://www.regjeringen.no/contentassets/95eec808f0434acf942fca449ca35386/en-gb/pdfs/stm201920200007000engpdfs.pdf

Official Norwegian Reports (NOU). 2023:8. Fellesskapets sykehus. Styring, finansiering, samhandling og ledelse [Internet]. [Community Hospital. Management, financing, interaction and management]. Oslo: Norwegian Ministry of Health and Care Services; 2023. Norwegian. [Accessed June 15, 2023]. https://www.regjeringen.no/contentassets/dc00b0a95cf349748bf94d49189b6b2f/no/pdfs/nou202320230008000dddpdfs.pdf .

World Health Organization. Continuity and coordination of care: A practice brief to support implementation of the WHO Framework on integrated people-centred health services [Internet]. Geneva: World Health Organization. 2018. [Accessed June 22, 2023]. https://apps.who.int/iris/bitstream/handle/10665/274628/9789241514033-eng.pdf?ua=1 .

Iakovleva T, Oftedal E, Bessant J. Changing role of users—innovating responsibly in Digital Health. Sustainability. 2021;13(4):1616. https://doi.org/10.3390/su13041616 .

Stilgoe J, Owen R, Macnaghten P. Developing a framework for responsible innovation. Res Policy. 2013;42:1568–80. https://doi.org/10.1016/j.respol.2013.05.008 .

Lehoux P, Silva HP, Rocha de Oliveira R, Sabio RP, Malas K. Responsible innovation in health and health system sustainability: insights from health innovators’ views and practices. Health Serv Manage Res. 2022;35(4):196–205. https://doi.org/10.1177/09514848211048606 .

Bessant J, Iakovleva T, Oftedal EM. The future of responsible innovation. In: Iakovleva T, Oftedal EM, Bessant J, editors. Responsible Innovation in Digital Health: empowering the patient. Cheltenham/Northampton: Edward Elgar; 2019. pp. 232–50.

Oftedal EM, Iakovleva T, Bessant J. Challenges in healthcare - the changing role of patients. In: Iakovleva T, Oftedal EM, Bessant J, editors. Responsible Innovation in Digital Health: empowering the patient. Cheltenham/Northampton: Edward Elgar; 2019. pp. 23–41.

Silva HP, Lefebvre AA, Oliveira RR, Lehoux P. Fostering responsible Innovation in Health: an EvidenceInformed Assessment Tool for Innovation stakeholders. Int J Health Policy Manag. 2021;104:181–91. https://doi.org/10.34172/ijhpm.2020.34 .

Storm M. Brukermedvirkning i psykisk helsearbeid [Service user involvement in mental healthcare]. Oslo: Gyldendal akademisk; 2009.

Storm M, Davidson L. Inpatients’ and providers’ experiences with user involvement in Inpatient Care. Psychiatr Q. 2010;1(2):111–25. https://doi.org/10.1007/s11126-009-9122-6 .

Storm M. Service user involvement in in-patient mental health services [dissertation]. Stavanger: University of Stavanger; 2011.

Löhr K, Weinhardt M, Sieber S. The World Café as a participatory method for collecting qualitative data. Int J Qualitative Methods. 2020;19:1–15. https://doi.org/10.1177/1609406920916976 .

Brown J, Isaacs D. The World Café: shaping our futures through conversations that matter. Oakland, US: Berrett-Koehler; 2005.

The World Café Community Foundation. The World Café [Internet], Cerrito E. US; 2024 [Accessed February 25, 2024]. https://theworldcafe.com/ .

Iakovleva T, Oftedal EM, Bessant J. Responsible innovation as a catalyst of the firm innovation process. In: Iakovleva T, Oftedal EM, Bessant J, editors. Responsible Innovation in Digital Health: empowering the patient. Cheltenham/Northampton: Edward Elgar; 2019. pp. 9–22.

Owen R, Macnaghten P, Stilgoe J. Responsible research and innovation: from science in society to science for society, with society. Sci Public Policy. 2012;39(6):751–60. https://doi.org/10.1093/scipol/scs093 . https://doi-org.ezproxy.uis.no/ .

Von Schomberg R. A vision of responsible Research and Innovation. In: Owen R, Bessant J, Heintz M, editors. Responsible Innovation: managing the Responsible Emergence of Science and Innovation in Society. Chichester, UK: John Wiley & Sons, Inc; 2013. pp. 51–74. https://doi-org.ezproxy.uis.no/ . https://doi.org/10.1002/9781118551424.ch3 .

Bertotti M, Harden A, Renton A, Sheridan K. The contribution of a Social Enterprise to the Building of Social Capital in a Disadvantaged Urban Area of London. Community Dev J. 2012;47(2):168–83. https://doi.org/10.1093/cdj/bsr020 .

Broom M, Brady B, Kecskes Z, Kildea S. World Café Methodology engages stakeholders in designing a neonatal Intensive Care Unit. J Neonatal Nurs. 2013;19(5):253–8. https://doi.org/10.1016/j.jnn.2012.12.002 .

du Plessis E, Koen MP, Bester P. Exploring home visits in a faith community as a service-learning opportunity. Nurse Educ Today. 2013;33(8):766–71. https://doi.org/10.1016/j.nedt.2012.06.006 .

Fouché C, Light G. An invitation to dialogue: ‘The World Café’ in Social Work Research. Qual Soc Work. 2011;10(1):28–48. https://doi.org/10.1177/14733250103760 .

Roos V, Du Toit F. Perceptions of effective relationships in an institutional care setting for older people. SA j ind Psychol. 2014;40(1):1–9. https://doi.org/10.4102/sajip.v40i1.1139 .

Stöckigt B, Teut M, Witt CM. CAM use and suggestions for Medical Care of Senior citizens: a qualitative study using the World Café Method. Evid Based Complement Alternat Med. 2013;2013:951245. https://doi.org/10.1155/2013/951245 .

Thomas E, Skeie KB, Huang H. Inclusion of elderly users via virtual spaces in the early stages of the innovation process. R D Manag. 2022;1–13. https://doi.org/10.1111/radm.12551 . https://doi-org.ezproxy.uis.no/ .

Iakovleva T, Willumsen E. Pasienter Og brukere som digitale partnere. [Patients and users as digital partners]. In: Willumsen E, Ødegård A, editors. Samskaping - sosial innovasjon for helse og velferd. [Co-creation - social innovation in health and welfare]. Oslo: Universitetsforlaget; 2020. pp. 222–43.

Municipal Health and Care Services Act. Act No. 30 of June 24 2011 [Internet]. Norwegian. [Accessed June 20, 2023]. https://lovdata.no/dokument/NL/lov/2011-06-24-30?q=Helse-%20og%20omsorgstjenesteloven%20 .

Baltazar L, De Benedictis L, Abdel-Baki A, Lalonde P, Lesage A. Long term course and outcome of first episode schizophrenia: a 27-to-31-year follow-up. Soc Psychiatry Psychiatr Epidemiol. 2022;57(7):1319–28. https://doi.org/10.1007/s00127-021-02185-8 .

Isaacs A, Beauchamp A, Sutton K, Kocaali N. Care Coordination can reduce unmet needs of persons with severe and persistent Mental illness. Front Psychiatry. 2019;10:563. https://doi.org/10.3389/fpsyt.2019.00563 .

Dregan A, McNeill A, Gaughran F, et al. Potential gains in life expectancy from reducing amenable mortality among people diagnosed with serious mental illness in the United Kingdom. PLoS ONE. 2020;15(3):e0230674. https://doi.org/10.1371/journal.pone.0230674 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Firth J, Siddiqi N, Koyanagi A, Siskind D, Rosenbaum S, Galletly C, et al. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry. 2019;6(8):675–712. https://doi.org/10.1016/S2215-0366(19)30132-4 .

Flaws D, Patterson S, Bagshaw T, Boon K, Kenardy J, Sellers D, et al. Caring for critically ill patients with a mental illness: a discursive paper providing an overview and case exploration of the delivery of intensive care to people with psychiatric comorbidity. Nurs Open. 2023;10(11):7106–17. https://doi.org/10.1002/nop2.1935 .

Kroken RA, Hageberg IM, Gilje Lid T, Wiggen N, Midgard H, Thorsen PJB et al. Bedre helse og lengre liv for personer med alvorlig psykisk lidelse eller rusmiddel- og avhengighetslidelse [Internet]. [Better health and longer life for individuals with severe mental illness or substance use disorders]. Oslo: Den norske legeforening; 2023. Norwegian. [Accessed January 7, 2024]. https://www.legeforeningen.no/om-oss/publikasjoner/rapporter/bedre-helse-og-lengre-liv/ .

Schneider F, Erhart M, Hewer W, Loeffler LA, Jacobi F. Mortality and medical comorbidity in the severely mentally ill. Dtsch Arzebl Int. 2019;116(23–24):405–11. https://doi.org/10.3238/arztebl.2019.0405 .

Norwegian Directorate of Health. Sammen om mestring. Veileder i lokalt psykisk helsearbeid og rusarbeid for voksne. Et verktøy for kommuner og spesialisthelsetjenesten [Internet]. [Coping together. A guide for local adult mental health and substance abuse work. A tool for municipal health and care services and the specialist health services]. Oslo. 2014. Norwegian. [Accessed January 10, 2024]. https://www.helsedirektoratet.no/veiledere/sammen-om-mestring-lokalt-psykisk-helsearbeid-og-rusarbeid-for-voksne/Lokalt%20psykisk%20helsearbeid%20og%20rusarbeid%20for%20voksne%20%E2%80%93%20Veileder.pdf/_/attachment/inline/739b0cbe-9310-41c7-88cf-c6f44a3c5bfc:8f8b02ae7b26b730d27512d01420ec947d5ead97/Lokalt%20psykisk%20helsearbeid%20og%20rusarbeid%20for%20voksne%20%E2%80%93%20Veileder.pdf

Specialist Health Services Act. Act No. 64 of July 2 1999 [Internet]. Norwegian. [Accessed June 20, 2023]. https://lovdata.no/dokument/NL/lov/1999-07-02-61?q=spesialisthelsetjenesten .

Patton MQ. Qualitative research & evaluation methods: Integrating theory and practice. Fourth edition. Thousand Oaks, US: SAGE Publications; 2015.

Bjørkquist C, Hansen GV. Coordination of services for dual diagnosis clients in the interface between specialist and community care. J Multidiscip Healthc. 2018;11:233–43. https://doi.org/10.2147/JMDH.S157769 .

De Hert M, Cohen D, Bobes J, Cetkovich-Bakmas M, Leucht S, Ndetei DM, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry. 2011;10(2):138–51. https://doi.org/10.1002/j.2051-5545.2011.tb00036.x .

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa .

Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11(4):589–97. https://doi.org/10.1080/2159676X.2019.1628806 .

Kristiansen S. Interpretation, prejudice and the hermeneutic circle. In: Järvinen M, Mik-Meyer N, editors. Qualitative analysis– eight approaches for the Social Science. London: SAGE; 2020. pp. 135–54.

Braun V, Clarke V. Successful qualitative research: a practical guide for beginners. Los Angeles US: SAGE; 2013.

Lincoln YS, Guba EG. Naturalistic inquiry. Thousand Oaks, US: SAGE; 1985.

Book   Google Scholar  

Rawlinson C, Carron T, Cohidon C, Arditi C, Hong QN, Pluye P, et al. An overview of reviews on Interprofessional Collaboration in primary care: barriers and facilitators. Int J Integr Care. 2021;21(2):32. https://doi.org/10.5334/ijic.5589 .

Hannigan B, Simpson A, Coffey M, Barlow S, Jones A. Care Coordination as Imagined, Care Coordination as done: findings from a cross-national Mental Health systems Study. Int J Integr Care. 2018;18(3):12. https://doi.org/10.5334/ijic.3978 .

Wakida EK, Talib ZM, Akena D, Okello ES, Kinengyere A, Mindra A, et al. Barriers and facilitators to the integration of mental health services into primary health care: a systematic review. Syst Rev. 2018;7(1):211. https://doi.org/10.1186/s13643-018-0882-7 .

Schot E, Tummers L, Noordegraaf M. Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. J Interprof Care. 2020;34(3):332–42. https://doi.org/10.1080/13561820.2019.1636007 .

Zwaanswijk M, Verheij RA, Wiesman FJ, Friele RD. Benefits and problems of electronic information exchange as perceived by health care professionals: an interview study. BMC Health Serv Res. 2011;11(1):256. https://doi.org/10.1186/1472-6963-11-256 .

Biringer E, Hartveit M, Sundfør B, Ruud T, Borg M. Continuity of care as experienced by mental health service users - a qualitative study. BMC Health Serv Res. 2017;17(1):763. https://doi.org/10.1186/s12913-017-2719-9 .

Berrouiguet S, Baca-García E, Brandt S, Walter M, Courtet P. Fundamentals for Future Mobile-Health (mHealth): a systematic review of Mobile phone and web-based text messaging in Mental Health. J Med Internet Res. 2016;18(6):e135. https://doi.org/10.2196/jmir.5066 .

Storm M, Willumsen E. Deltakelse for helsefremming i helse Og Velferd. [Participation for health promotion in health and welfare]. In: Storm M, Willumsen E, editors. Deltakelse- et helsefremmende perspektiv. [Participation - a health-promoting perspective]. Bergen: Fagbokforlaget; 2023. pp. 13–28.

Storm M, Husebø AML. Digital innovasjon i helse [Digital innovation in health]. In: Samskaping Sosial innovasjon for helse og velferd [Co-creation - social innovation in health and welfare]. In: Willumsen E, Ødegård A, editors. Samskaping - sosial innovasjon for helse og velferd. [Co-creation - social innovation in health and welfare]. Oslo: Universitetsforlaget; 2020. pp. 163–76.

Liamputtong P. Researching the vulnerable: a guide to sensitive research methods. London, UK: SAGE; 2007.

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All authors significantly contributed to the study. The study was designed in collaboration between the study authors. JNS and MS conducted the café dialogues. All authors participated in the data analysis. JNS took the lead in drafting and revising the manuscript. MS and TAI contributed to writing, commenting, refining, and revising the manuscript. All authors approved the final manuscript.

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Skjærpe, J.N., Iakovleva, T.A. & Storm, M. Responsible coordination of municipal health and care services for individuals with serious mental illness: a participatory qualitative study with service users and professionals. BMC Health Serv Res 24 , 633 (2024). https://doi.org/10.1186/s12913-024-10999-w

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Qualitative Research in Healthcare: Necessity and Characteristics

1 Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

2 Ulsan Metropolitan City Public Health Policy’s Institute, Ulsan, Korea

3 Department of Nursing, Chung-Ang University, Seoul, Korea

Eun Young Choi

4 College of Nursing, Sungshin Women’s University, Seoul, Korea

Seung Gyeong Jang

5 Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Korea

Quantitative and qualitative research explore various social phenomena using different methods. However, there has been a tendency to treat quantitative studies using complicated statistical techniques as more scientific and superior, whereas relatively few qualitative studies have been conducted in the medical and healthcare fields. This review aimed to provide a proper understanding of qualitative research. This review examined the characteristics of quantitative and qualitative research to help researchers select the appropriate qualitative research methodology. Qualitative research is applicable in following cases: (1) when an exploratory approach is required on a topic that is not well known, (2) when something cannot be explained fully with quantitative research, (3) when it is necessary to newly present a specific view on a research topic that is difficult to explain with existing views, (4) when it is inappropriate to present the rationale or theoretical proposition for designing hypotheses, as in quantitative research, and (5) when conducting research that requires detailed descriptive writing with literary expressions. Qualitative research is conducted in the following order: (1) selection of a research topic and question, (2) selection of a theoretical framework and methods, (3) literature analysis, (4) selection of the research participants and data collection methods, (5) data analysis and description of findings, and (6) research validation. This review can contribute to the more active use of qualitative research in healthcare, and the findings are expected to instill a proper understanding of qualitative research in researchers who review qualitative research reports and papers.

Graphical abstract

INTRODUCTION

The definition of research varies among studies and scholars, and it is difficult to devise a single definition. The Oxford English Dictionary defines research as “a careful study of a subject, especially in order to discover new facts or information about it” [ 1 ], while Webster’s Dictionary defines research as “studious inquiry or examination - especially: investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories or laws in the light of new facts, or practical application of such new or revised theories or laws” [ 2 ]. Moreover, research is broadly defined as the process of solving unsolved problems to broaden human knowledge [ 3 ]. A more thorough understanding of research can be gained by examining its types and reasons for conducting it.

The reasons for conducting research may include practical goals, such as degree attainment, job promotion, and financial profit. Research may be based on one’s own academic curiosity or aspiration or guided by professors or other supervisors. Academic research aims can be further divided into the following: (1) accurately describing an object or phenomenon, (2) identifying general laws and establishing well-designed theories for understanding and explaining a certain phenomenon, (3) predicting future events based on laws and theories, and (4) manipulating causes and conditions to induce or prevent a phenomenon [ 3 ].

The appropriate type of research must be selected based on the purpose and topic. Basic research has the primary purpose of expanding the existing knowledge base through new discoveries, while applied research aims to solve a real problem. Descriptive research attempts to factually present comparisons and interpretations of findings based on analyses of the characteristics, progression, or relationships of a certain phenomenon by manipulating the variables or controlling the conditions. Experimental or analytical research attempts to identify causal relationships between variables through experiments by arbitrarily manipulating the variables or controlling the conditions [ 3 ]. In addition, research can be quantitative or qualitative, depending on the data collection and analytical methods. Quantitative research relies on statistical analyses of quantitative data obtained primarily through investigation and experiment, while qualitative research uses specific methodologies to analyze qualitative data obtained through participant observations and in-depth interviews. However, as these types of research are not polar opposites and the criteria for classifying research types are unclear, there is some degree of methodological overlap.

What is more important than differentiating types of research is identifying the appropriate type of research to gain a better understanding of specific questions and improve problems encountered by people in life. An appropriate research type or methodology is essential to apply findings reliably. However, quantitative research based on the philosophical ideas of empiricism and positivism has been the mainstay in the field of healthcare, with academic advancement achieved through the application of various statistical techniques to quantitative data [ 4 ]. In particular, there has been a tendency to treat complicated statistical techniques as more scientific and superior, with few qualitative studies in not only clinical medicine, but also primary care and social medicine, which are relatively strongly influenced by the social sciences [ 5 , 6 ].

Quantitative and qualitative research use different ways of exploring various social phenomena. Both research methodologies can be applied individually or in combination based on the research topic, with mixed quantitative and qualitative research methodologies becoming more widespread in recent years [ 7 ]. Applying these 2 methods through a virtuous cycle of integration from a complementary perspective can provide a more accurate understanding of human phenomena and solutions to real-world problems.

This review aimed to provide a proper understanding of qualitative research to assist researchers in selecting the appropriate research methodology. Specifically, this review examined the characteristics of quantitative and qualitative research, the applicability of qualitative research, and the data sources collected and analyzed in qualitative research.

COMPARISON OF QUALITATIVE AND QUANTITATIVE RESEARCH

A clearer understanding of qualitative research can be obtained by comparing qualitative and quantitative research, with which people are generally familiar [ 8 , 9 ]. Quantitative research focuses on testing the validity of hypotheses established by the researcher to identify the causal relationships of a specific phenomenon and discovering laws to predict that phenomenon ( Table 1 ). Therefore, it emphasizes controlling the influence of variables that may interfere with the process of identifying causality and laws. In contrast, qualitative research aims to discover and explore new hypotheses or theories based on a deep understanding of the meaning of a specific phenomenon. As such, qualitative research attempts to accept various environmental factors naturally. In quantitative research, importance is placed on the researcher acting as an outsider to take an objective view by keeping a certain distance from the research subject. In contrast, qualitative research encourages looking inside the research subjects to understand them deeply, while also emphasizing the need for researchers to take an intersubjective view that is formed and shared based on a mutual understanding with the research subjects.

Comparison of methodological characteristics between quantitative research and qualitative research

The data used in quantitative research can be expressed as numerical values, and data accumulated through questionnaire surveys and tests are often used in analyses. In contrast, qualitative research uses narrative data with words and images collected through participant observations, in-depth interviews, and focus group discussions used in the analyses. Quantitative research data are measured repeatedly to enhance their reliability, while the analyses of such data focus on superficial aspects of the phenomenon of interest. Qualitative research instead focuses on obtaining deep and rich data and aims to identify the specific contents, dynamics, and processes inherent within the phenomenon and situation.

There are clear distinctions in the advantages, disadvantages, and goals of quantitative and qualitative research. On one hand, quantitative research has the advantages of reliability and generalizability of the findings, and advances in data collection and analysis methods have increased reliability and generalizability. However, quantitative research presents difficulties with an in-depth analysis of dynamic phenomena that cannot be expressed by numbers alone and interpreting the results analyzed in terms numbers. On the other hand, qualitative research has the advantage of validity, which refers to how accurately or appropriately a phenomenon was measured. However, qualitative research also has the disadvantage of weak generalizability, which determines whether an observed phenomenon applies to other cases.

APPLICATIONS OF QUALITATIVE RESEARCH AND ITS USEFULNESS IN THE HEALTHCARE FIELD

Qualitative research cannot be the solution to all problems. A specific methodology should not be applied to all situations. Therefore, researchers need to have a good understanding of the applicability of qualitative research. Generally, qualitative research is applicable in following cases: (1) when an exploratory approach is required on a topic that is not well known, (2) when something cannot be explained fully with quantitative research, (3) when it is necessary to newly present a specific view on a research topic that is difficult to explain with existing views, (4) when it is inappropriate to present the rationale or theoretical proposition for designing hypotheses, as in quantitative research, and (5) when conducting research that requires detailed descriptive writing with literary expressions [ 7 ]. In particular, qualitative research is useful for opening new fields of research, such as important topics that have not been previously examined or whose significance has not been recognized. Moreover, qualitative research is advantageous for examining known topics from a fresh perspective.

In the healthcare field, qualitative research is conducted on various topics considering its characteristics and strengths. Quantitative research, which focuses on hypothesis validation, such as the superiority of specific treatments or the effectiveness of specific policies, and the generalization of findings, has been the primary research methodology in the field of healthcare. Qualitative research has been mostly applied for studies such as subjective disease experiences and attitudes with respect to health-related patient quality of life [ 10 - 12 ], experiences and perceptions regarding the use of healthcare services [ 13 - 15 ], and assessments of the quality of care [ 16 , 17 ]. Moreover, qualitative research has focused on vulnerable populations, such as the elderly, children, disabled [ 18 - 20 ], minorities, and socially underprivileged with specific experiences [ 21 , 22 ].

For instance, patient safety is considered a pillar of quality of care, which is an aspect of healthcare with increasing international interest. The ultimate goal of patient safety research should be the improvement of patient safety, for which it is necessary to identify the root causes of potential errors and adverse events. In such cases, qualitative rather than quantitative research is often required. It is also important to identify whether there are any barriers when applying measures for enhancing patient safety to clinical practice. To identify such barriers, qualitative research is necessary to observe healthcare workers directly applying the solutions step-by-step during each process, determine whether there are difficulties in applying the solutions to relevant stakeholders, and ask how to improve the process if there are difficulties.

Patient safety is a very broad topic, and patient safety issues could be categorized into preventing, recognizing, and responding to patient safety issues based on related metrics [ 23 ]. Responding to issues that pertain to the handling of patient safety incidents that have already occurred has received relatively less interest than other categories of research on this topic, particularly in Korea. Until 2017, almost no research was conducted on the experiences of and difficulties faced by patients and healthcare workers who have been involved in patient safety incidents. This topic can be investigated using qualitative research.

A study in Korea investigated the physical and mental suffering experienced during the process of accepting disability and medical litigation by a patient who became disabled due to medical malpractice [ 21 ]. Another qualitative case study was conducted with participants who lost a family member due to a medical accident and identified psychological suffering due to the incident, as well as secondary psychological suffering during the medical litigation process, which increased the expandability of qualitative research findings [ 24 ]. A quantitative study based on these findings confirmed that people who experienced patient safety incidents had negative responses after the incidents and a high likelihood of sleep or eating disorders, depending on their responses [ 25 ].

A study that applied the grounded theory to examine the second victim phenomenon, referring to healthcare workers who have experienced patient safety incidents, and presented the response stages experienced by second victims demonstrated the strength of qualitative research [ 26 ]. Subsequently, other studies used questionnaire surveys on physicians and nurses to quantify the physical, mental, and work-related difficulties experienced by second victims [ 27 , 28 ]. As such, qualitative research alone can produce significant findings; however, combining quantitative and qualitative research produces a synergistic effect. In the healthcare field, which remains unfamiliar with qualitative research, combining these 2 methodologies could both enhance the validity of research findings and facilitate open discussions with other researchers [ 29 ].

In addition, qualitative research has been used for diverse sub-topics, including the experiences of patients and guardians with respect to various diseases (such as cancer, myocardial infarction, chronic obstructive pulmonary disease, depression, falls, and dementia), awareness of treatment for diabetes and hypertension, the experiences of physicians and nurses when they come in contact with medical staff, awareness of community health environments, experiences of medical service utilization by the general public in medically vulnerable areas, the general public’s awareness of vaccination policies, the health issues of people with special types of employment (such as delivery and call center workers), and the unmet healthcare needs of persons with vision or hearing impairment.

GENERAL WORKFLOW OF QUALITATIVE RESEARCH

Rather than focusing on deriving objective information, qualitative research aims to discern the quality of a specific phenomenon, obtaining answers to “why” and “how” questions. Qualitative research aims to collect data multi-dimensionally and provide in-depth explanations of the phenomenon being researched. Ultimately, the purpose of qualitative research is set to help researchers gain an understanding of the research topic and reveal the implications of the research findings. Therefore, qualitative research is generally conducted in the following order: (1) selection of a research topic and question, (2) selection of a theoretical framework and methods, (3) literature analysis, (4) selection of the research participants (or participation target) and data collection methods, (5) data analysis and description of findings, and (6) research validation ( Figure 1 ) [ 30 ]. However, unlike quantitative research, in which hypothesis setting and testing take place unidirectionally, a major characteristic of qualitative research is that the process is reversible and research methods can be modified. In other words, the research topic and question could change during the literature analysis process, and theoretical and analytical methods could change during the data collection process.

General workflow of qualitative research.

Selection of a Research Topic and Question

As with any research, the first step in qualitative research is the selection of a research topic and question. Qualitative researchers can select a research topic based on their interests from daily life as a researcher, their interests in issues within the healthcare field, and ideas from the literature, such as academic journals. The research question represents a more specific aspect of the research topic. Before specifically starting to conduct research based on a research topic, the researcher should clarify what is being researched and determine what research would be desirable. When selecting a research topic and question, the research should ask: is the research executable, are the research topic and question worth researching, and is this a research question that a researcher would want to research?

Selection of Theoretical Framework and Methods

A theoretical framework refers to the thoughts or attitudes that a researcher has about the phenomenon being researched. Selecting the theoretical framework first could help qualitative researchers not only in selecting the research purpose and problem, but also in carrying out various processes, including an exploration of the precedent literature and research, selection of the data type to be collected, data analysis, and description of findings. In qualitative research, theoretical frameworks are based on philosophical ideas, which affect the selection of specific qualitative research methods. Representative qualitative research methods include the grounded theory, which is suitable for achieving the goal of developing a theory that can explain the processes involved in the phenomenon being researched; ethnographic study, which is suitable for research topics that attempt to identify and interpret the culture of a specific group; phenomenology, which is suitable for research topics that attempt to identify the nature of research participants’ experiences or the phenomenon being researched; case studies, which aim to gain an in-depth understanding of a case that has unique characteristics and can be differentiated from other cases; action research, which aims to find solutions to problems faced by research participants, with the researchers taking the same position as the participants; and narrative research, which is suitable for research topics that attempt to interpret the entire life or individual experiences contained within the stories of research participants. Other methodologies include photovoice research, consensual qualitative research, and auto-ethnographic research.

Literature Analysis

Literature analysis results can be helpful in specifically selecting the research problem, theoretical framework, and research methods. The literature analysis process compels qualitative researchers to contemplate the new knowledge that their research will add to the academic field. A comprehensive literature analysis is encouraged both in qualitative and quantitative research, and if the prior literature related to the subject to be studied is insufficient, it is sometimes evaluated as having low research potential or research value. Some have claimed that a formal literature review should not be performed before the collection of field data, as it could create bias, thereby interfering with the investigation. However, as the qualitative research process is cyclic rather than unidirectional, the majority believes that a literature review can be performed at any time. Moreover, an ethical review prior to starting the research is a requirement; therefore, the research protocol must be prepared and submitted for review and approval prior to conducting the research. To prepare research protocols, the existing literature must be analyzed at least to a certain degree. Nonetheless, qualitative researchers must keep in mind that their emotions, bias, and expectations may interject themselves during the literature review process and should strive to minimize any bias to ensure the validity of the research.

Selection of the Research Participants and Data Collection Methods

The subjects of qualitative research are not necessarily humans. It is more important to find the research subject(s) from which the most in-depth answers to the research problem can be obtained. However, the subjects in most qualitative studies are humans, as most research question focus on humans. Therefore, it is important to obtain research participants with sufficient knowledge, experience, and attitudes to provide the most appropriate answers to the research question. Quantitative research, which views generalizability as a key research goal, emphasizes the selection of research participants (i.e., the research sample that can represent the study’s population of interest), whereas qualitative research emphasizes finding research participants who can best describe and demonstrate the phenomenon of interest.

In qualitative research, the participant selection method is referred to as purposeful sampling (or purposive sampling), which can be divided into various types. Sampling methods have various advantages, disadvantages, and characteristics. For instance, unique sampling (extreme case sampling) has the advantage of being able to obtain interesting research findings by researching phenomena that have previously received little or no interest, and the disadvantage of deriving research findings that are interesting to only some readers if the research is conducted on an overly unique situation. Maximum variation sampling, also referred to as theoretical sampling, is commonly used in qualitative research based on the grounded theory. Selecting the appropriate participant sampling method that suits the purpose of research is crucial ( Table 2 ).

Sampling methods of selecting research participants in qualitative research

Once the researcher has decided how to select study participants, the data collection methods must be determined. Just as with participant sampling, various data collection methods are available, all of which have various advantages and disadvantages; therefore, the method must be selected based on the research question and circumstances. Unlike quantitative research, which usually uses a single data source and data collection method, the use of multiple data sources and data collection methods is encouraged in qualitative research [ 30 ]. Using a single data source and data collection method could cause data collection to be skewed by researcher bias; therefore, using multiple data sources and data collection methods is ideal. In qualitative research, the following data types are commonly used: (1) interview data obtained through one-on-one in-depth interviews and focus group discussions, (2) observational data from various observation levels, (3) documented data collected from personal or public documents, and (4) image data, such as photographs and videos.

Interview data are the most commonly used data source in qualitative research [ 31 ]. In qualitative research, an interview refers to communication that takes place based on a clear sense of purpose of acquiring certain information, unlike conversations that typically take place in daily life. The level of data acquired through interviews varies significantly depending on the researcher’s personal qualifications and abilities, as well as his or her level of interest and knowledge regarding the research topic. Therefore, interviewers must be trained to go beyond simply identifying the clearly expressed experiences of research participants to exploring their inner experiences and emotions [ 32 ]. Interview data can be classified based on the level of structuralization of the data collection method, sample size, and interview method. The characteristics of each type of interview are given in Table 3 .

Detailed types of interview methods according to the characteristics of in-depth interviews and focus group discussion

Observations, which represent a key data collection method in anthropology, refer to a series of actions taken by the researcher in search of a deep understanding by systematically examining the appearances of research participants that take place in natural situations [ 33 ]. Observations can be categorized as participant and non-participant, insider and outsider, disguised and undisguised, short- and long-term, and structured and unstructured. However, a line cannot be drawn clearly to differentiate these categories, and the degree of each varies along a single spectrum. Therefore, it is necessary for a qualitative researcher to select the appropriate data collection method based on the circumstances and characteristics of the research topic.

Various types of document data can be used in qualitative research. Personal documents include diaries, letters, and autobiographies, while public documents include legal documents, public announcements, and civil documents. Online documents include emails and blog or bulletin board postings, while other documents include graffiti. All these document types may be used as data sources in qualitative research. In addition, image data acquired by the research participant or researcher, such as photographs and videos, serve as useful data sources in qualitative research. Such data sources are relatively objective and easily accessible, while they contain a significant amount of qualitative meaning despite the low acquisition cost. While some data may have been collected for research purposes, other data may not have been originally produced for research. Therefore, the researcher must not distort the original information contained in the data source and must verify the accuracy and authenticity of the data source in advance [ 30 ].

This review examined the characteristics of qualitative research to help researchers select the appropriate qualitative research methodology and identify situations suitable for qualitative research in the healthcare field. In addition, this paper analyzed the selection of the research topic and problem, selection of the theoretical framework and methods, literature analysis, and selection of the research participants and data collection methods. A forthcoming paper will discuss more specific details regarding other qualitative research methodologies, such as data analysis, description of findings, and research validation. This review can contribute to the more active use of qualitative research in the healthcare field, and the findings are expected to instill a proper understanding of qualitative research in researchers who review and judge qualitative research reports and papers.

Ethics Statement

Since this study used secondary data source, we did not seek approval from the institutional review board. We also did not have to ask for the consent of the participants.

Acknowledgments

CONFLICT OF INTEREST

The authors have no conflicts of interest associated with the material presented in this paper.

AUTHOR CONTRIBUTIONS

Conceptualization: Pyo J, Lee W, Choi EY, Jang SG, Ock M. Data curation: Pyo J, Ock M. Formal analysis: Pyo J, Ock M. Funding acquisition: None. Validation: Lee W, Choi EY, Jang SG. Writing - original draft: Pyo J, Ock M. Writing - review & editing: Pyo J, Lee W, Choi EY, Jang SG, Ock M.

Not all data are created equal; some are structured, but most of them are unstructured. Structured and unstructured data are sourced, collected and scaled in different ways and each one resides in a different type of database.

In this article, we will take a deep dive into both types so that you can get the most out of your data.

Structured data—typically categorized as quantitative data—is highly organized and easily decipherable by  machine learning algorithms .  Developed by IBM® in 1974 , structured query language (SQL) is the programming language used to manage structured data. By using a  relational (SQL) database , business users can quickly input, search and manipulate structured data.

Examples of structured data include dates, names, addresses, credit card numbers, among others. Their benefits are tied to ease of use and access, while liabilities revolve around data inflexibility:

• Easily used by machine learning (ML) algorithms:  The specific and organized architecture of structured data eases the manipulation and querying of ML data.
• Easily used by business users:  Structured data do not require an in-depth understanding of different types of data and how they function. With a basic understanding of the topic relative to the data, users can easily access and interpret the data.
• Accessible by more tools:  Since structured data predates unstructured data, there are more tools available for using and analyzing structured data.
• Limited usage:  Data with a predefined structure can only be used for its intended purpose, which limits its flexibility and usability.
• Limited storage options:  Structured data are usually stored in data storage systems with rigid schemas (for example, “ data warehouses ”). Therefore, changes in data requirements necessitate an update of all structured data, which leads to a massive expenditure of time and resources.
• OLAP :  Performs high-speed, multidimensional data analysis from unified, centralized data stores.
• SQLite : (link resides outside ibm.com)  Implements a self-contained,  serverless , zero-configuration, transactional relational database engine.
• MySQL :  Embeds data into mass-deployed software, particularly mission-critical, heavy-load production system.
• PostgreSQL :  Supports SQL and JSON querying as well as high-tier programming languages (C/C+, Java,  Python , among others.).
• Customer relationship management (CRM):  CRM software runs structured data through analytical tools to create datasets that reveal customer behavior patterns and trends.
• Online booking:  Hotel and ticket reservation data (for example, dates, prices, destinations, among others.) fits the “rows and columns” format indicative of the pre-defined data model.
• Accounting:  Accounting firms or departments use structured data to process and record financial transactions.

Unstructured data, typically categorized as qualitative data, cannot be processed and analyzed through conventional data tools and methods. Since unstructured data does not have a predefined data model, it is best managed in  non-relational (NoSQL) databases . Another way to manage unstructured data is to use  data lakes  to preserve it in raw form.

The importance of unstructured data is rapidly increasing.  Recent projections  (link resides outside ibm.com) indicate that unstructured data is over 80% of all enterprise data, while 95% of businesses prioritize unstructured data management.

Examples of unstructured data include text, mobile activity, social media posts, Internet of Things (IoT) sensor data, among others. Their benefits involve advantages in format, speed and storage, while liabilities revolve around expertise and available resources:

• Native format:  Unstructured data, stored in its native format, remains undefined until needed. Its adaptability increases file formats in the database, which widens the data pool and enables data scientists to prepare and analyze only the data they need.
• Fast accumulation rates:  Since there is no need to predefine the data, it can be collected quickly and easily.
• Data lake storage:  Allows for massive storage and pay-as-you-use pricing, which cuts costs and eases scalability.
• Requires expertise:  Due to its undefined or non-formatted nature, data science expertise is required to prepare and analyze unstructured data. This is beneficial to data analysts but alienates unspecialized business users who might not fully understand specialized data topics or how to utilize their data.
• Specialized tools:  Specialized tools are required to manipulate unstructured data, which limits product choices for data managers.
• MongoDB :  Uses flexible documents to process data for cross-platform applications and services.
• DynamoDB :  (link resides outside ibm.com) Delivers single-digit millisecond performance at any scale through built-in security, in-memory caching and backup and restore.
• Hadoop :  Provides distributed processing of large data sets using simple programming models and no formatting requirements.
• Azure :  Enables agile cloud computing for creating and managing apps through Microsoft’s data centers.
• Data mining :  Enables businesses to use unstructured data to identify consumer behavior, product sentiment and purchasing patterns to better accommodate their customer base.
• Predictive data analytics :  Alert businesses of important activity ahead of time so they can properly plan and accordingly adjust to significant market shifts.
• Chatbots :  Perform text analysis to route customer questions to the appropriate answer sources.

While structured (quantitative) data gives a “birds-eye view” of customers, unstructured (qualitative) data provides a deeper understanding of customer behavior and intent. Let’s explore some of the key areas of difference and their implications:

• Sources:  Structured data is sourced from GPS sensors, online forms, network logs, web server logs,  OLTP systems , among others; whereas unstructured data sources include email messages, word-processing documents, PDF files, and others.
• Forms:  Structured data consists of numbers and values, whereas unstructured data consists of sensors, text files, audio and video files, among others.
• Models:  Structured data has a predefined data model and is formatted to a set data structure before being placed in data storage (for example, schema-on-write), whereas unstructured data is stored in its native format and not processed until it is used (for example, schema-on-read).
• Storage:  Structured data is stored in tabular formats (for example, excel sheets or SQL databases) that require less storage space. It can be stored in data warehouses, which makes it highly scalable. Unstructured data, on the other hand, is stored as media files or NoSQL databases, which require more space. It can be stored in data lakes, which makes it difficult to scale.
• Uses:  Structured data is used in machine learning (ML) and drives its algorithms, whereas unstructured data is used in  natural language processing  (NLP) and text mining.

Semi-structured data (for example, JSON, CSV, XML) is the “bridge” between structured and unstructured data. It does not have a predefined data model and is more complex than structured data, yet easier to store than unstructured data.

Semi-structured data uses “metadata” (for example, tags and semantic markers) to identify specific data characteristics and scale data into records and preset fields. Metadata ultimately enables semi-structured data to be better cataloged, searched and analyzed than unstructured data.

• Example of metadata usage:  An online article displays a headline, a snippet, a featured image, image alt-text, slug, among others, which helps differentiate one piece of web content from similar pieces.
• Example of semi-structured data vs. structured data:  A tab-delimited file containing customer data versus a database containing CRM tables.
• Example of semi-structured data vs. unstructured data:  A tab-delimited file versus a list of comments from a customer’s Instagram.

Recent developments in  artificial intelligence  (AI) and machine learning (ML) are driving the future wave of data, which is enhancing business intelligence and advancing industrial innovation. In particular, the data formats and models that are covered in this article are helping business users to do the following:

• Analyze digital communications for compliance:  Pattern recognition and email threading analysis software that can search email and chat data for potential noncompliance.
• Track high-volume customer conversations in social media:  Text analytics and sentiment analysis that enables monitoring of marketing campaign results and identifying online threats.
• Gain new marketing intelligence:  ML analytics tools that can quickly cover massive amounts of data to help businesses analyze customer behavior.

Furthermore, smart and efficient usage of data formats and models can help you with the following:

• Understand customer needs at a deeper level to better serve them
• Create more focused and targeted marketing campaigns
• Track current metrics and create new ones
• Create better product opportunities and offerings
• Reduce operational costs

Whether you are a seasoned data expert or a novice business owner, being able to handle all forms of data is conducive to your success. By using structured, semi-structured and unstructured data options, you can perform optimal data management that will ultimately benefit your mission.

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