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• How to appraise qualitative research
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• Calvin Moorley 1 ,
• Xabi Cathala 2
• 1 Nursing Research and Diversity in Care, School of Health and Social Care , London South Bank University , London , UK
• 2 Institute of Vocational Learning , School of Health and Social Care, London South Bank University , London , UK
• Correspondence to Dr Calvin Moorley, Nursing Research and Diversity in Care, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; Moorleyc{at}lsbu.ac.uk

https://doi.org/10.1136/ebnurs-2018-103044

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Introduction

In order to make a decision about implementing evidence into practice, nurses need to be able to critically appraise research. Nurses also have a professional responsibility to maintain up-to-date practice. 1 This paper provides a guide on how to critically appraise a qualitative research paper.

What is qualitative research?

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Useful terms

Some of the qualitative approaches used in nursing research include grounded theory, phenomenology, ethnography, case study (can lend itself to mixed methods) and narrative analysis. The data collection methods used in qualitative research include in depth interviews, focus groups, observations and stories in the form of diaries or other documents. 3

Authenticity

Title, keywords, authors and abstract.

In a previous paper, we discussed how the title, keywords, authors’ positions and affiliations and abstract can influence the authenticity and readability of quantitative research papers, 4 the same applies to qualitative research. However, other areas such as the purpose of the study and the research question, theoretical and conceptual frameworks, sampling and methodology also need consideration when appraising a qualitative paper.

Purpose and question

The topic under investigation in the study should be guided by a clear research question or a statement of the problem or purpose. An example of a statement can be seen in table 2 . Unlike most quantitative studies, qualitative research does not seek to test a hypothesis. The research statement should be specific to the problem and should be reflected in the design. This will inform the reader of what will be studied and justify the purpose of the study. 5

Example of research question and problem statement

An appropriate literature review should have been conducted and summarised in the paper. It should be linked to the subject, using peer-reviewed primary research which is up to date. We suggest papers with a age limit of 5–8 years excluding original work. The literature review should give the reader a balanced view on what has been written on the subject. It is worth noting that for some qualitative approaches some literature reviews are conducted after the data collection to minimise bias, for example, in grounded theory studies. In phenomenological studies, the review sometimes occurs after the data analysis. If this is the case, the author(s) should make this clear.

Theoretical and conceptual frameworks

Most authors use the terms theoretical and conceptual frameworks interchangeably. Usually, a theoretical framework is used when research is underpinned by one theory that aims to help predict, explain and understand the topic investigated. A theoretical framework is the blueprint that can hold or scaffold a study’s theory. Conceptual frameworks are based on concepts from various theories and findings which help to guide the research. 6 It is the researcher’s understanding of how different variables are connected in the study, for example, the literature review and research question. Theoretical and conceptual frameworks connect the researcher to existing knowledge and these are used in a study to help to explain and understand what is being investigated. A framework is the design or map for a study. When you are appraising a qualitative paper, you should be able to see how the framework helped with (1) providing a rationale and (2) the development of research questions or statements. 7 You should be able to identify how the framework, research question, purpose and literature review all complement each other.

There remains an ongoing debate in relation to what an appropriate sample size should be for a qualitative study. We hold the view that qualitative research does not seek to power and a sample size can be as small as one (eg, a single case study) or any number above one (a grounded theory study) providing that it is appropriate and answers the research problem. Shorten and Moorley 8 explain that three main types of sampling exist in qualitative research: (1) convenience (2) judgement or (3) theoretical. In the paper , the sample size should be stated and a rationale for how it was decided should be clear.

Methodology

Qualitative research encompasses a variety of methods and designs. Based on the chosen method or design, the findings may be reported in a variety of different formats. Table 3 provides the main qualitative approaches used in nursing with a short description.

Different qualitative approaches

The authors should make it clear why they are using a qualitative methodology and the chosen theoretical approach or framework. The paper should provide details of participant inclusion and exclusion criteria as well as recruitment sites where the sample was drawn from, for example, urban, rural, hospital inpatient or community. Methods of data collection should be identified and be appropriate for the research statement/question.

Data collection

Overall there should be a clear trail of data collection. The paper should explain when and how the study was advertised, participants were recruited and consented. it should also state when and where the data collection took place. Data collection methods include interviews, this can be structured or unstructured and in depth one to one or group. 9 Group interviews are often referred to as focus group interviews these are often voice recorded and transcribed verbatim. It should be clear if these were conducted face to face, telephone or any other type of media used. Table 3 includes some data collection methods. Other collection methods not included in table 3 examples are observation, diaries, video recording, photographs, documents or objects (artefacts). The schedule of questions for interview or the protocol for non-interview data collection should be provided, available or discussed in the paper. Some authors may use the term ‘recruitment ended once data saturation was reached’. This simply mean that the researchers were not gaining any new information at subsequent interviews, so they stopped data collection.

The data collection section should include details of the ethical approval gained to carry out the study. For example, the strategies used to gain participants’ consent to take part in the study. The authors should make clear if any ethical issues arose and how these were resolved or managed.

The approach to data analysis (see ref  10 ) needs to be clearly articulated, for example, was there more than one person responsible for analysing the data? How were any discrepancies in findings resolved? An audit trail of how the data were analysed including its management should be documented. If member checking was used this should also be reported. This level of transparency contributes to the trustworthiness and credibility of qualitative research. Some researchers provide a diagram of how they approached data analysis to demonstrate the rigour applied ( figure 1 ).

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Example of data analysis diagram.

Validity and rigour

The study’s validity is reliant on the statement of the question/problem, theoretical/conceptual framework, design, method, sample and data analysis. When critiquing qualitative research, these elements will help you to determine the study’s reliability. Noble and Smith 11 explain that validity is the integrity of data methods applied and that findings should accurately reflect the data. Rigour should acknowledge the researcher’s role and involvement as well as any biases. Essentially it should focus on truth value, consistency and neutrality and applicability. 11 The authors should discuss if they used triangulation (see table 2 ) to develop the best possible understanding of the phenomena.

Themes and interpretations and implications for practice

In qualitative research no hypothesis is tested, therefore, there is no specific result. Instead, qualitative findings are often reported in themes based on the data analysed. The findings should be clearly linked to, and reflect, the data. This contributes to the soundness of the research. 11 The researchers should make it clear how they arrived at the interpretations of the findings. The theoretical or conceptual framework used should be discussed aiding the rigour of the study. The implications of the findings need to be made clear and where appropriate their applicability or transferability should be identified. 12

Discussions, recommendations and conclusions

The discussion should relate to the research findings as the authors seek to make connections with the literature reviewed earlier in the paper to contextualise their work. A strong discussion will connect the research aims and objectives to the findings and will be supported with literature if possible. A paper that seeks to influence nursing practice will have a recommendations section for clinical practice and research. A good conclusion will focus on the findings and discussion of the phenomena investigated.

Qualitative research has much to offer nursing and healthcare, in terms of understanding patients’ experience of illness, treatment and recovery, it can also help to understand better areas of healthcare practice. However, it must be done with rigour and this paper provides some guidance for appraising such research. To help you critique a qualitative research paper some guidance is provided in table 4 .

Some guidance for critiquing qualitative research

• ↵ Nursing and Midwifery Council . The code: Standard of conduct, performance and ethics for nurses and midwives . 2015 https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ( accessed 21 Aug 18 ).
• Barrett D ,
• Cathala X ,
• Shorten A ,

Patient consent for publication Not required.

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Introduction to qualitative nursing research

This type of research can reveal important information that quantitative research can’t.

• Qualitative research is valuable because it approaches a phenomenon, such as a clinical problem, about which little is known by trying to understand its many facets.
• Most qualitative research is emergent, holistic, detailed, and uses many strategies to collect data.
• Qualitative research generates evidence and helps nurses determine patient preferences.

Research 101: Descriptive statistics

Differentiating research, evidence-based practice, and quality improvement

How to appraise quantitative research articles

All nurses are expected to understand and apply evidence to their professional practice. Some of the evidence should be in the form of research, which fills gaps in knowledge, developing and expanding on current understanding. Both quantitative and qualitative research methods inform nursing practice, but quantitative research tends to be more emphasized. In addition, many nurses don’t feel comfortable conducting or evaluating qualitative research. But once you understand qualitative research, you can more easily apply it to your nursing practice.

What is qualitative research?

Defining qualitative research can be challenging. In fact, some authors suggest that providing a simple definition is contrary to the method’s philosophy. Qualitative research approaches a phenomenon, such as a clinical problem, from a place of unknowing and attempts to understand its many facets. This makes qualitative research particularly useful when little is known about a phenomenon because the research helps identify key concepts and constructs. Qualitative research sets the foundation for future quantitative or qualitative research. Qualitative research also can stand alone without quantitative research.

Although qualitative research is diverse, certain characteristics—holism, subjectivity, intersubjectivity, and situated contexts—guide its methodology. This type of research stresses the importance of studying each individual as a holistic system (holism) influenced by surroundings (situated contexts); each person develops his or her own subjective world (subjectivity) that’s influenced by interactions with others (intersubjectivity) and surroundings (situated contexts). Think of it this way: Each person experiences and interprets the world differently based on many factors, including his or her history and interactions. The truth is a composite of realities.

Qualitative research designs

Because qualitative research explores diverse topics and examines phenomena where little is known, designs and methodologies vary. Despite this variation, most qualitative research designs are emergent and holistic. In addition, they require merging data collection strategies and an intensely involved researcher. (See Research design characteristics .)

Although qualitative research designs are emergent, advanced planning and careful consideration should include identifying a phenomenon of interest, selecting a research design, indicating broad data collection strategies and opportunities to enhance study quality, and considering and/or setting aside (bracketing) personal biases, views, and assumptions.

Many qualitative research designs are used in nursing. Most originated in other disciplines, while some claim no link to a particular disciplinary tradition. Designs that aren’t linked to a discipline, such as descriptive designs, may borrow techniques from other methodologies; some authors don’t consider them to be rigorous (high-quality and trustworthy). (See Common qualitative research designs .)

Sampling approaches

Sampling approaches depend on the qualitative research design selected. However, in general, qualitative samples are small, nonrandom, emergently selected, and intensely studied. Qualitative research sampling is concerned with accurately representing and discovering meaning in experience, rather than generalizability. For this reason, researchers tend to look for participants or informants who are considered “information rich” because they maximize understanding by representing varying demographics and/or ranges of experiences. As a study progresses, researchers look for participants who confirm, challenge, modify, or enrich understanding of the phenomenon of interest. Many authors argue that the concepts and constructs discovered in qualitative research transcend a particular study, however, and find applicability to others. For example, consider a qualitative study about the lived experience of minority nursing faculty and the incivility they endure. The concepts learned in this study may transcend nursing or minority faculty members and also apply to other populations, such as foreign-born students, nurses, or faculty.

Qualitative nursing research can take many forms. The design you choose will depend on the question you’re trying to answer.

A sample size is estimated before a qualitative study begins, but the final sample size depends on the study scope, data quality, sensitivity of the research topic or phenomenon of interest, and researchers’ skills. For example, a study with a narrow scope, skilled researchers, and a nonsensitive topic likely will require a smaller sample. Data saturation frequently is a key consideration in final sample size. When no new insights or information are obtained, data saturation is attained and sampling stops, although researchers may analyze one or two more cases to be certain. (See Sampling types .)

Some controversy exists around the concept of saturation in qualitative nursing research. Thorne argues that saturation is a concept appropriate for grounded theory studies and not other study types. She suggests that “information power” is perhaps more appropriate terminology for qualitative nursing research sampling and sample size.

Data collection and analysis

Researchers are guided by their study design when choosing data collection and analysis methods. Common types of data collection include interviews (unstructured, semistructured, focus groups); observations of people, environments, or contexts; documents; records; artifacts; photographs; or journals. When collecting data, researchers must be mindful of gaining participant trust while also guarding against too much emotional involvement, ensuring comprehensive data collection and analysis, conducting appropriate data management, and engaging in reflexivity.

Data usually are recorded in detailed notes, memos, and audio or visual recordings, which frequently are transcribed verbatim and analyzed manually or using software programs, such as ATLAS.ti, HyperRESEARCH, MAXQDA, or NVivo. Analyzing qualitative data is complex work. Researchers act as reductionists, distilling enormous amounts of data into concise yet rich and valuable knowledge. They code or identify themes, translating abstract ideas into meaningful information. The good news is that qualitative research typically is easy to understand because it’s reported in stories told in everyday language.

Evaluating a qualitative study

Evaluating qualitative research studies can be challenging. Many terms—rigor, validity, integrity, and trustworthiness—can describe study quality, but in the end you want to know whether the study’s findings accurately and comprehensively represent the phenomenon of interest. Many researchers identify a quality framework when discussing quality-enhancement strategies. Example frameworks include:

• Trustworthiness criteria framework, which enhances credibility, dependability, confirmability, transferability, and authenticity
• Validity in qualitative research framework, which enhances credibility, authenticity, criticality, integrity, explicitness, vividness, creativity, thoroughness, congruence, and sensitivity.

With all frameworks, many strategies can be used to help meet identified criteria and enhance quality. (See Research quality enhancement ). And considering the study as a whole is important to evaluating its quality and rigor. For example, when looking for evidence of rigor, look for a clear and concise report title that describes the research topic and design and an abstract that summarizes key points (background, purpose, methods, results, conclusions).

Application to nursing practice

Qualitative research not only generates evidence but also can help nurses determine patient preferences. Without qualitative research, we can’t truly understand others, including their interpretations, meanings, needs, and wants. Qualitative research isn’t generalizable in the traditional sense, but it helps nurses open their minds to others’ experiences. For example, nurses can protect patient autonomy by understanding them and not reducing them to universal protocols or plans. As Munhall states, “Each person we encounter help[s] us discover what is best for [him or her]. The other person, not us, is truly the expert knower of [him- or herself].” Qualitative nursing research helps us understand the complexity and many facets of a problem and gives us insights as we encourage others’ voices and searches for meaning.

When paired with clinical judgment and other evidence, qualitative research helps us implement evidence-based practice successfully. For example, a phenomenological inquiry into the lived experience of disaster workers might help expose strengths and weaknesses of individuals, populations, and systems, providing areas of focused intervention. Or a phenomenological study of the lived experience of critical-care patients might expose factors (such dark rooms or no visible clocks) that contribute to delirium.

Successful implementation

Qualitative nursing research guides understanding in practice and sets the foundation for future quantitative and qualitative research. Knowing how to conduct and evaluate qualitative research can help nurses implement evidence-based practice successfully.

When evaluating a qualitative study, you should consider it as a whole. The following questions to consider when examining study quality and evidence of rigor are adapted from the Standards for Reporting Qualitative Research.

Jennifer Chicca is a PhD candidate at the Indiana University of Pennsylvania in Indiana, Pennsylvania, and a part-time faculty member at the University of North Carolina Wilmington.

Amankwaa L. Creating protocols for trustworthiness in qualitative research. J Cult Divers. 2016;23(3):121-7.

Cuthbert CA, Moules N. The application of qualitative research findings to oncology nursing practice. Oncol Nurs Forum . 2014;41(6):683-5.

Guba E, Lincoln Y. Competing paradigms in qualitative research . In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. Thousand Oaks, CA: SAGE Publications, Inc.;1994: 105-17.

Lincoln YS, Guba EG. Naturalistic Inquiry . Thousand Oaks, CA: SAGE Publications, Inc.; 1985.

Munhall PL. Nursing Research: A Qualitative Perspective . 5th ed. Sudbury, MA: Jones & Bartlett Learning; 2012.

Nicholls D. Qualitative research. Part 1: Philosophies. Int J Ther Rehabil . 2017;24(1):26-33.

Nicholls D. Qualitative research. Part 2: Methodology. Int J Ther Rehabil . 2017;24(2):71-7.

Nicholls D. Qualitative research. Part 3: Methods. Int J Ther Rehabil . 2017;24(3):114-21.

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. Acad Med . 2014;89(9):1245-51.

Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice . 10th ed. Philadelphia, PA: Wolters Kluwer; 2017.

Thorne S. Saturation in qualitative nursing studies: Untangling the misleading message around saturation in qualitative nursing studies. Nurse Auth Ed. 2020;30(1):5. naepub.com/reporting-research/2020-30-1-5

Whittemore R, Chase SK, Mandle CL. Validity in qualitative research. Qual Health Res . 2001;11(4):522-37.

Williams B. Understanding qualitative research. Am Nurse Today . 2015;10(7):40-2.

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Appraising the quality of mixed methods research in nursing: A qualitative case study of nurse researchers' views

Affiliations.

• 1 Department of Psychology and Education, Universitat Oberta de Catalunya (UOC), Barcelona, Spain.
• 2 The Qualitative Analyst, Barcelona, Spain.
• PMID: 29927008
• DOI: 10.1111/nin.12247

While a growing number of works have been published about the use of mixed methods research in nursing, scarce attention has been devoted to the issue of the quality of mixed methods within the discipline. The quality appraisal of mixed methods research poses two problems to nursing science: first, current quality criteria are not nursing-specific and consequently, they might not facilitate the application of mixed methods research findings into nursing practice. Second, criteria were theoretically derived and as such, they might not faithfully account for the decisions that nurse researchers take when appraising mixed methods research studies. This qualitative, within-case study explored the views of nurse researchers about mixed methods research in general and, more specifically, the question of quality in mixed methods research. An international sample of 13 nurse researchers was interviewed via Skype and phone. Thematic analysis revealed that the participants favored universal, cross-disciplinary quality criteria, and not criteria specific to the nursing discipline, and a consensual and standardized approach to appraising the quality of mixed methods research. Recommendations are put forward to strengthen the quality appraisal of mixed methods research studies by nurse researchers, as well as future works on this topic within nursing science.

© 2018 John Wiley & Sons Ltd.

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• Published: 28 August 2024

Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study

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

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

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

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

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

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

Peer Review reports

Introduction

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

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

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

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

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

Study design

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

Sample and settings

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

Data collection procedure

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

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

Data analysis

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

Ethical considerations

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

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

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

Category 1: Individual factors

Subcategory a. knowledge of healthcare workers.

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

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

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

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

Subcategory B. Healthcare workers’ attitude

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

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

Subcategory C. Healthcare workers’ cognitive ability

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

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

Category 2: Team factors

Subcategory a. behavioral norms and patterns.

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

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

Subcategory B. Participative leadership

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

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

Subcategory C. Effective communication

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

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

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

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

Category 3: Work environment factors

Subcategory a. heavy workload.

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

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

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

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

Subcategory B. Shift pattern

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

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

Subcategory C. Wards layout and physical design

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

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

Category 4: Task factors

Subcategory a. hand hygiene frequency.

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

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

Subcategory B. Physical damage and consequence

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

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

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

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

Category 5: Organizational and management factors

Subcategory a. equipment availability.

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

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

Subcategory B. Equipment quality

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

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

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

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

Subcategory C. Supervision and monitoring

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

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

Subcategory D. Safety and Just Culture

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Data availability

Date are available on reasonable request.

Mertz D, et al. Adherence to hand hygiene and risk factors for poor adherence in 13 Ontario acute care hospitals. Am J Infect Control. 2011;39(8):693–6.

Article   PubMed   Google Scholar  

Geraei M, Sadeghi M, Ravangard R. Barriers to the hand washing from the viewpoint of nurses: a cross-sectional study. Sadra Med J. 2019;7(2):133–44.

Google Scholar  

Wenzel RP. Prevention and control of nosocomial infections. Williams and (1997).

Richards AM, Prasek D, Mamon R. Increased hand hygiene performance decreases nosocomial infection markers and cost after the implementation of an automated hand hygiene monitoring system. Am J Infect Control 42.6 (2014): S138.

Sadeghi-Moghaddam P, et al. Does training improve compliance with hand hygiene and decrease infections in the neonatal intensive care unit? A prospective study. J neonatal-perinatal Med. 2015;8(3):221–5.

Article   CAS   PubMed   Google Scholar  

Lambe K, Ann, et al. Hand hygiene compliance in the ICU: a systematic review. Crit Care Med. 2019;47(9):1251–7.

Albughbish M, Neisi A, Borvayeh H. Hand hygiene compliance among ICU health workers in Golestan hospital in 2013. Jundishapur Sci Med J. 2016;15(3):355–62.

Vandijck DM, et al. Prevention of nosocomial infections in intensive care patients. Nurs Crit Care. 2010;15(5):251–6.

Sax H, et al. The World Health Organization hand hygiene observation method. Am J Infect Control. 2009;37(10):827–34.

Magnus T, Pereira, et al. Measuring hand hygiene compliance rates in different special care settings: a comparative study of methodologies. Int J Infect Dis. 2015;33:205–8.

Muller MP, et al. Hand hygiene compliance in an emergency department: the effect of crowding. Acad Emerg Med. 2015;22(10):1218–21.

Ghaffari M, et al. Exploring determinants of hand hygiene among hospital nurses: a qualitative study. BMC Nurs. 2020;19:1–9.

Article   Google Scholar  

Erasmus V, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31(3):283–94.

Pittet D, Liam Donaldson. Clean care is safer care: a worldwide priority. Lancet. 2005;366(9493):1246–7.

Article   PubMed   PubMed Central   Google Scholar  

Jang T-H, et al. Focus group study of hand hygiene practice among healthcare workers in a teaching hospital in Toronto. Can Infect Control Hosp Epidemiol. 2010;31(2):144–50.

Nair S, Sasidharan et al. Knowledge, attitude, and practice of hand hygiene among medical and nursing students at a tertiary health care centre in Raichur. India Int Sch Res Notices 2014 (2014).

Ravaghi H, Abdi Z, Heyrani A. Hand hygiene practice among healthcare workers in intensive care units: a qualitative study. J Hosp 13.4 (2015): 41–52.

Zhou Q, et al. Compliance measurement and observed influencing factors of hand hygiene based on COVID-19 guidelines in China. Am J Infect Control. 2020;48(9):1074–9.

Ali S et al. Risk assessment of healthcare workers at the frontline against COVID-19. Pakistan journal of medical sciences 36.COVID19-S4 (2020): S99.

Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol. 2000;21(6):381–6.

Martín-Madrazo C, et al. Effectiveness of a training program to improve hand hygiene compliance in primary healthcare. BMC Public Health. 2009;9:1–8.

Borg MA, et al. Health care worker perceptions of hand hygiene practices and obstacles in a developing region. Am J Infect Control. 2009;37(10):855–7.

Barrett R, Randle J. Hand hygiene practices: nursing students’ perceptions. J Clin Nurs. 2008;17(14):1851–7.

Malekmakan L, et al. Hand hygiene in Iranian health care workers. Am J Infect Control. 2008;36(8):602–3.

Pittet D. Compliance with hand disinfection and its impact on hospital-acquired infections. J Hosp Infect. 2001;48:S40–6.

Madden C, et al. What are the predictors of hand hygiene compliance in the Intensive Care Unit? A cross-sectional observational study. J Infect Prev. 2021;22(6):252–8.

Tyagi M, et al. Hand hygiene in hospitals: an observational study in hospitals from two southern states of India. BMC Public Health. 2018;18:1–9.

Mitharwal SM, et al. Intensive care unit-acquired infections in a tertiary care hospital: an epidemiologic survey and influence on patient outcomes. Am J Infect Control. 2016;44(7):e113–7.

Renz SM, Jane M, Carrington, Terry A, Badger. Two strategies for qualitative content analysis: an intramethod approach to triangulation. Qual Health Res. 2018;28(5):824–31.

Boddy CR. Sample size for qualitative research. Qualitative Market Research: Int J. 2016;19(4):426–32.

Alshehri AA. Factors impacting compliance with Infection Control Guidelines among healthcare providers in neonatal intensive care unit, referral hospital, Saudi Arabia. Saudi J Nurs Health Care. 2023;6(12):455–60.

Thyme K, Egberg, et al. Qualitative content analysis in art psychotherapy research: concepts, procedures, and measures to reveal the latent meaning in pictures and the words attached to the pictures. Arts Psychother. 2013;40(1):101–7.

Hsieh H-F, Sarah E. Shannon. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.

Anney VN. Ensuring the quality of the findings of qualitative research: Looking at trustworthiness criteria. (2014).

Ravaghi H, Abdi Z, Heyrani A. Hand hygiene practice among healthcare workers in intensive care units: a qualitative study. J Hosp. 2015;13(4):41–52.

Nabavi M, et al. Knowledge, attitudes, and practices study on hand hygiene among Imam Hossein Hospital’s residents in 2013. Iran Red Crescent Med J. 2015;17:10.

Nazari R, et al. Study of hand hygiene behavior among nurses in critical care units. Iran J Crit Care Nurs. 2011;4(2):95–8.

McLaws M-L, et al. Predicting hand hygiene among Iranian health care workers using the theory of planned behavior. Am J Infect Control. 2012;40(4):336–9.

Burnett E. Perceptions, attitudes, and behavior towards patient hand hygiene. Am J Infect Control. 2009;37:638–42.

Yuan CT, et al. Perceptions of hand hygiene practices in China. J Hosp Infect. 2009;71(2):157–62.

Jenner E, Anne, et al. Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals. J Hosp Infect. 2006;63(4):418–22.

Creedon SA. Healthcare workers’ hand decontamination practices: compliance with recommended guidelines. J Adv Nurs. 2005;51(3):208–16.

Kingston LM, Nuala H, O’Connell, Colum P, Dunne. Survey of attitudes and practices of Irish nursing students towards hand hygiene, including handrubbing with alcohol-based hand rub. Nurse Educ Today. 2017;52:57–62.

Pittet D, et al. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med. 2004;141(1):1–8.

Qasmi S, Arfin, et al. Guiding hand hygiene interventions among future healthcare workers: implications of knowledge, attitudes, and social influences. Am J Infect Control. 2018;46(9):1026–31.

Zhang L, Peng M, Hou M. Qualitative study on compliance and influencing factors of hand washing in hospital nursing assistants. Chin J Practical Nurs (2018): 1969–73.

Roberto MS, Kathryn Mearns. Work experience and physician’s intention to comply with hand hygiene: an extended application of the Theory of planned behaviour. New challenges for a healthy workplace in human services . Rainer Hampp; 2011.

Perkins MB, et al. Applying theory-driven approaches to understanding and modifying clinicians’ behavior: what do we know? Psychiatric Serv. 2007;58(3):342–8.

Whitby M, et al. Behavioural considerations for hand hygiene practices: the basic building blocks. J Hosp Infect. 2007;65(1):1–8.

Erasmus V, et al. A qualitative exploration of reasons for poor hand hygiene among hospital workers lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Infect Control Hosp Epidemiol. 2009;30(5):415–9.

Lankford MG, et al. Influence of role models and hospital design on the hand hygiene of health-care workers. Emerg Infect Dis. 2003;9(2):217.

Kurtz SL. Identification of low, high, and super gelers and barriers to hand hygiene among intensive care unit nurses. Am J Infect Control. 2017;45(8):839–43.

Fuller C, et al. Application of a theoretical framework for behavior change to hospital workers’ real-time explanations for noncompliance with hand hygiene guidelines. Am J Infect Control. 2014;42(2):106–10.

Son C, et al. Practically speaking: rethinking hand hygiene improvement programs in health care settings. Am J Infect Control. 2011;39(9):716–24.

Smiddy MP, Rhona OC, Sile A. Creedon. Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines. Am J Infect Control. 2015;43(3):269–74.

González ML, et al. Understanding hand hygiene behavior in a pediatric oncology unit in a low-to mid-income country. J Nurs Educ Pract. 2016;6:1.

PubMed   PubMed Central   Google Scholar  

Kwok YL, Angela P, Harris, Mary-Louise ML. Social cohesion: the missing factor required for a successful hand hygiene program. Am J Infect Control. 2017;45(3):222–7.

Ay P, et al. A qualitative study of hand hygiene compliance among health care workers in intensive care units. J Infect Developing Ctries. 2019;13:111–7.

Bernard L, et al. Exploring canadians’ and europeans’ health care professionals’ perception of biological risks, patient safety, and professionals’ safety practices. Health Care Manag. 2017;36(2):129–39.

Bernard L, et al. An exploratory study of safety culture, biological risk management and hand hygiene of healthcare professionals. J Adv Nurs. 2018;74(4):827–37.

Nicol PW, et al. The power of vivid experience in hand hygiene compliance. J Hosp Infect. 2009;72(1):36–42.

Dai H, Milkman KL, Hofmann DA, Staats BR. The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health care. J Appl Psychol. 2015;100(3):846.

Dehghan M, Ahmadinejad M, and Mahbubeh Mazallahi. Barriers to Hand Hygiene Compliance in Intensive Care Units From the Perspective of Healthcare Workers: A Qualitative Study. (2021).

Marjadi B, McLaws M-L. Hand hygiene in rural Indonesian healthcare workers: barriers beyond sinks, hand rubs and in-service training. J Hosp Infect. 2010;76(3):256–60.

Rosenthal VD, et al. Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51 cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe. Infect Control Hosp Epidemiol. 2013;34(4):415–23.

Atif S, Lorcy A, Dubé E. Healthcare workers’ attitudes toward hand hygiene practices: Results of a multicentre qualitative study in Quebec. Can J Infect Control 34.1 (2019).

Larson EL, Albrecht S, Mary O’Keefe. Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems. Am J Crit Care. 2005;14(4):304–11.

Salmon S, Mary-Louise ML. Qualitative findings from focus group discussions on hand hygiene compliance among health care workers in Vietnam. Am J Infect Control. 2015;43(10):1086–91.

Wilson S, Jacob CJ, Douglas Powell. Behavior-change interventions to improve hand-hygiene practice: a review of alternatives to education. Crit Public Health. 2011;21(1):119–27.

Joshi SC, et al. Qualitative study on perceptions of hand hygiene among hospital staff in a rural teaching hospital in India. J Hosp Infect. 2012;80(4):340–4.

McLaws M-L, et al. Iranian healthcare workers’ perspective on hand hygiene: a qualitative study. J Infect Public Health. 2015;8(1):72–9.

Oliveira AC, Cardoso CS, Mascarenhas D. Contact precautions in Intensive Care units: facilitating and inhibiting factors for professionals’ adherence. Revista Da Escola De Enfermagem Da USP. 2010;44:161–5.

Uchida M, et al. Exploring infection prevention: policy implications from a qualitative study. Policy Politics Nurs Pract. 2011;12(2):82–9.

Larson EL, et al. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med. 2000;26(1):14–22.

Allegranzi B, Sax H, Pittet D. Hand hygiene and healthcare system change within multi-modal promotion: a narrative review. J Hosp Infect. 2013;83:S3–10.

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

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Clinical supervisor’s experiences of peer group clinical supervision during COVID-19: a mixed methods study

• Owen Doody   ORCID: orcid.org/0000-0002-3708-1647 1 ,
• Kathleen Markey   ORCID: orcid.org/0000-0002-3024-0828 1 ,
• James Turner   ORCID: orcid.org/0000-0002-8360-1420 2 ,
• Claire O. Donnell   ORCID: orcid.org/0000-0003-2386-7048 1 &
• Louise Murphy   ORCID: orcid.org/0000-0003-2381-3963 1  

BMC Nursing volume  23 , Article number:  612 ( 2024 ) Cite this article

Metrics details

Providing positive and supportive environments for nurses and midwives working in ever-changing and complex healthcare services is paramount. Clinical supervision is one approach that nurtures and supports professional guidance, ethical practice, and personal development, which impacts positively on staff morale and standards of care delivery. In the context of this study, peer group clinical supervision provides allocated time to reflect and discuss care provided and facilitated by clinical supervisors who are at the same grade/level as the supervisees.

To explore the clinical supervisor’s experiences of peer group clinical supervision a mixed methods study design was utilised within Irish health services (midwifery, intellectual disability, general, mental health). The Manchester Clinical Supervision Scale was used to survey clinical supervisors ( n  = 36) and semi-structured interviews ( n  = 10) with clinical supervisors were conducted. Survey data were analysed through SPSS and interview data were analysed utilising content analysis. The qualitative and quantitative data’s reporting rigour was guided by the CROSS and SRQR guidelines.

Participants generally had a positive encounter when providing clinical supervision. They highly appreciated the value of clinical supervision and expressed a considerable degree of contentment with the supervision they provided to supervisees. The advantages of peer group clinical supervision encompass aspects related to self (such as confidence, leadership, personal development, and resilience), service and organisation (including a positive working environment, employee retention, and safety), and patient care (involving critical thinking and evaluation, patient safety, adherence to quality standards, and elevated levels of care).

There are many benefits of peer group clinical supervision at an individual, service, organisation, and patient level. Nevertheless, there is a need to address a lack of awareness and misconceptions surrounding clinical supervision to create an environment and culture conducive to realising its full potential. It is crucial that clinical supervision be accessible to nurses and midwives of all grades across all healthcare services, with national planning to address capacity and sustainability.

Peer Review reports

Within a dynamic healthcare system, nurses and midwives face growing demands, underscoring the necessity for ongoing personal and professional development. This is essential to improve the effectiveness and efficiency of care delivery for patients, families, and societies. Despite the increased emphasis on increasing the quality and safety of healthcare services and delivery, there is evidence highlighting declining standards of nursing and midwifery care [ 1 ]. The recent focus on re-affirming and re-committing to core values guiding nursing and midwifery practice is encouraging such as compassion, care and commitment [ 2 ], competence, communication, and courage [ 3 ]. However, imposing value statements in isolation is unlikely to change behaviours and greater consideration needs to be given to ways in which compassion, care, and commitment are nurtured and ultimately applied in daily practice. Furthermore, concerns have been raised about global staff shortages [ 4 ], the evidence suggesting several contributing factors such as poor workforce planning [ 5 ], job dissatisfaction [ 6 ], and healthcare migration [ 7 ]. Without adequate resources and staffing, compromising standards of care and threats to patient safety will be imminent therefore the importance of developing effective strategies for retaining competent registered nurses and midwives is paramount in today’s climate of increased staff shortages [ 4 ]. Clinical supervision serves as a means to facilitate these advancements and has been linked to heightened job satisfaction, enhanced staff retention, improved staff effectiveness, and effective clinical governance, by aiding in quality improvements, risk management, and heightened accountability [ 8 ].

Clinical supervision is a key component of professional practice and while the aim is largely known, there is no universally accepted definition of clinical supervision [ 8 ]. Clinical supervision is a structured process where clinicians are allowed protected time to reflect on their practice within a supportive environment and with the purpose of developing high-quality clinical care [ 9 ]. Recent literature published on clinical supervision [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ] highlights the advantages and merits of clinical supervision. However, there are challenges also identified such as a lack of consensus regarding the meaning and goal, implementation issues, variations in approaches in its operationalisation, and an absence of research evidence on its effectiveness. Duration and experience in clinical supervision link to positive benefits [ 8 ], but there is little evidence of how clinical supervision altered individual behaviours and practices. This is reinforced by Kuhne et al., [ 15 ] who emphasise that satisfaction rather than effectiveness is more commonly examined. It is crucial to emphasise that reviews have pinpointed that clinical supervision lowers the risks of adverse patient outcomes [ 9 ] and demonstrates enhancements in the execution of certain care processes. Peer group clinical supervision is a form of clinical supervision whereby two or more practitioners engage in a supervision or consultation process to improve their professional practice [ 17 ]. There is limited evidence regarding peer group clinical supervision and research on the experiences of peer clinical supervision and stakeholders is needed [ 13 ]. In Ireland, peer group clinical supervision has been recommended and guidelines have been developed [ 18 ]. In the Irish context, peer clinical supervision is where both clinical supervisees and clinical supervisors are peers at the same level/grade. However, greater evidence is required to inform future decisions on the implementation of peer group clinical supervision and the purpose of this study is to explore clinical supervisors’ experiences of peer group clinical supervision. As the focus is on peer group supervisors and utilising mixed methods the experiences of the other stakeholders were investigated and reported separately.

A mixed methods approach was used (survey and semi-structured interviews) to capture clinical supervisor’s experiences of clinical supervision. The study adhered to the Consensus-Based Checklist for Reporting of Survey Studies guidelines [ 19 ] (Supplementary File S1 ) and Standards for Reporting Qualitative Research guidelines [ 20 ] (Supplementary File S2 ).

Participants

This study was conducted with participants who successfully completed a professionally credited award: clinical supervision module run by a university in Ireland (74 clinical supervisors across 5 programmes over 3 years). The specific selection criteria for participants were that they were registered nurses/midwives delivering peer group clinical supervision within the West region of Ireland. The specific exclusion criteria were as follows: (1) nurses and midwives who haven’t finished the clinical supervision module at the University, (2) newly appointed peer group clinical supervisors who have yet to establish their groups and initiate the delivery of peer group clinical supervision.

Measures and procedures

The Manchester Clinical Supervision Scale-26 was used to survey participants in February/March 2022 and measure the peer group clinical supervisors’ overall experiences of facilitating peer group clinical supervision. The Manchester Clinical Supervision Scale-26 is a validated 26-item self-report questionnaire with a Likert-type (1–5) scale ranging from strongly disagree (1) to strongly agree (5) [ 21 ]. The Manchester Clinical Supervision Scale-26 measures the efficiency of and satisfaction with supervision, to investigate the skills acquisition aspect of clinical supervision and its effect on the quality of clinical care [ 21 ]. The instrument consists of two main sections to measure three (normative, restorative, and formative) dimensions of clinical supervision utilising six sub-scales: (1) trust and rapport, (2) supervisor advice/support, (3) improved care/skills, (4) importance/value of clinical supervision, (5) finding time, (6) personal issues/reflections and a total score for the Manchester Clinical Supervision Scale-26 is also calculated. Section two consisted of the demographic section of the questionnaire and was tailored to include eight demographic questions concerning the supervisor’s demographics, supervisee characteristics, and characteristics of clinical supervision sessions. There were also two open field questions on the Manchester Clinical Supervision Scale-26 (model of clinical supervision used and any other comments about experience of peer group clinical supervision). The main question about participants’ experiences with peer clinical supervision was “What was your experience of peer clinical supervision?” This was gathered through individual semi-structured interviews lasting between 20 and 45 min, in March/April 2022 (Supplementary file 3 ).

Ethical considerations

Health service institutional review boards of two University hospitals approved this study (Ref: 091/19 and Ref: C.A. 2199). Participants were recruited after receiving a full explanation of the study’s purpose and procedure and all relevant information. Participants were aware of potential risks and benefits and could withdraw from the study, or the survey could be stopped at any time. Informed consent was recorded, and participant identities were protected by using a pseudonym to protect anonymity.

Data analysis method

Survey data was analysed using the data analysis software package Statistical Package for the Social Sciences, version 26 (SPSS Inc., Chicago, Il, USA). Descriptive analysis was undertaken to summarise responses to all items and categorical variables (nominal and ordinal) were analysed using frequencies to detail the number and percentage of responses to each question. Scores on the Manchester Clinical Supervision Scale-26 were reverse scored for 9 items (Q1-Q6, Q8, Q20,21) and total scores for each of the six sub-scales were calculated by adding the scores for each item. Raw scores for the individual sub-scales varied in range from 0 to 20 and these raw scores were then converted to percentages which were used in addition to the raw scores for each sub-scale to describe and summarise the results of the Manchester Clinical Supervision Scale-26. Cronbach’s alpha coefficient was undertaken with the 26 questions included within the Manchester Clinical Supervision Scale-26 and more importantly with each of the dimensions in the Manchester Clinical Supervision Scale-26. The open-ended questions on the Manchester Clinical Supervision Scale-26 and interviews were analysed using content analysis guided by Colorafi and Evans [ 22 ] and categories were generated using their eight steps, (1) creating a coding framework, (2) adding codes and memos, (3) applying the first level of coding, (4) categorising codes and applying the second level of coding, (5) revising and redefining the codes, (6) adding memos, (7) visualising data and (8) representing the data.

Research rigour

To ensure the validity and rigour of this study the researchers utilised the Manchester Clinical Supervision Scale-26 a recognised clinical supervision tool with good reliability and wide usage. Interviews were recorded, transcribed, and verified by four participants, data were collected until no new components appeared, data collection methods and analysis procedures were described, and the authors’ biases were minimised throughout the research process. The Manchester Clinical Supervision Scale-26 instrument internal consistency reliability was assessed which was overall good (α = 0.878) with individual subscale also good e.g., normative domain 0.765, restorative domain 0.864, and formative domain 0.900. Reporting rigour was demonstrated using the Consensus-Based Checklist for Reporting of Survey Studies guidelines [ 19 ] and Standards for Reporting Qualitative Research guidelines [ 20 ].

Quantitative data

Participant and clinical supervision characteristics.

Thirty-six of the fifty-two (69.2%) peer group clinical supervisors working across a particular region of Ireland responded to the Manchester Clinical Supervision Scale-26 survey online via Qualtrics. Table 1 identifies the demographics of the sample who were predominantly female (94.4%) with a mean age of 44.7 years (SD. 7.63).

Peer group clinical supervision session characteristics (Table  2 ) highlight over half of peer group clinical supervisors ( n  = 20, 55.6%) had been delivering peer group clinical supervision for less than one year and were mainly delivered to female supervisees ( n  = 28, 77.8%). Most peer group clinical supervision sessions took place monthly ( n  = 32, 88.9%) for 31–60 min ( n  = 27, 75%).

Manchester Clinical Supervision Scale-26 results

Participants generally viewed peer group clinical supervision as effective (Table  3 ), the total mean Manchester Clinical Supervision Scale-26 score among all peer group clinical supervisors was 76.47 (SD. 12.801) out of 104, Surpassing the clinical supervision threshold score of 73, which was established by the developers of the Manchester Clinical Supervision Scale-26 as the benchmark indicating proficient clinical supervision provision [ 21 ]. Of the three domains; normative, formative, and restorative, the restorative domain scored the highest (mean 28.56, SD. 6.67). The mean scores compare favourably to that of the Manchester Clinical Supervision Scale-26 benchmark data and suggest that the peer group clinical supervisors were satisfied with both the level of support, encouragement, and guidance they provided and the level of trust/rapport they had developed during the peer group clinical supervision sessions. 83.3% ( n  = 30) of peer group clinical supervisors reported being either very satisfied ( n  = 12, 33.3%) or moderately satisfied ( n  = 18, 50%) with the peer group clinical supervision they currently delivered. Within the peer group clinical supervisor’s supervisee related issues ( n  = 17, 47.2%), work environment-related issues ( n  = 16, 44.4%), staff-related issues ( n  = 15, 41.7%) were reported as the most frequent issues, with patient/client related issues being less frequent ( n  = 8, 22.2%). The most identified model used to facilitate peer group clinical supervision was the Proctors model ( n  = 8, 22.22%), which was followed by group ( n  = 2, 5.55%), peer ( n  = 2, 5.55%), and a combination of the seven-eyed model of clinical supervision and Proctors model ( n  = 1, 2.77%) with some not sure what model they used ( n  = 2, 5.553%) and 58.33% ( n  = 21) did not report what model they used.

Survey open-ended question

‘Please enter any additional comments , which are related to your current experience of delivering Peer Group Clinical Supervision.’ There were 22 response comments to this question, which represented 61.1% of the 36 survey respondents, which were analysed using content analysis guided by Colorafi & Evans [ 22 ]. Three categories were generated. These included: personal value/benefit of peer group clinical supervision, challenges with facilitating peer group clinical supervision, and new to peer group clinical supervision.

The first category ‘personal value/benefit of peer group clinical supervision’ highlighted positive experiences of both receiving and providing peer group clinical supervision. Peer group clinical supervisors reported that they enjoyed the sessions and found them both worthwhile and beneficial for both the group and them as peer group clinical supervisors in terms of creating a trusted supportive group environment and motivation to develop. Peer group clinical supervision was highlighted as very important for the peer group clinical supervisors working lives and they hoped that there would be more uptake from all staff. One peer group clinical supervisor expressed that external clinical supervision was a ‘lifeline’ to shaping their supervisory journey to date.

The second category ‘challenges with facilitating peer group clinical supervision’, identified time constraints, lack of buy-in/support from management, staff shortages, lack of commitment by supervisees, and COVID-19 pandemic restrictions and related sick leave, as potential barriers to facilitating peer group clinical supervision. COVID-19 was perceived to have a negative impact on peer group clinical supervision sessions due to staff shortages, which resulted in difficulties for supervisees attending the sessions during work time. Peer group clinical supervisors felt that peer group clinical supervision was not supported by management and there was limited ‘buy-in’ at times. There was also a feeling expressed that peer group clinical supervision was in its infancy, as COVID-19 and its related restrictions impacted on this by either slowing down the process of commencing peer group clinical supervision in certain areas or having to move online. However, more recently improvements in managerial support and supervisee engagement with the peer group clinical supervision process are noted.

The final category ‘new to peer group clinical supervision’ highlighted that some peer group clinical supervisors were new to the process of providing peer group clinical supervision and some felt that this survey was not a true reflection of their experience of delivering peer group clinical supervision, as they were not fully established yet as clinical supervisors due to the impact of COVID-19. Peer group clinical supervisors identified that while they were new to providing peer group clinical supervision, they were enjoying it and that it was a learning curve for them.

Qualitative data

The qualitative phase explored peer group clinical supervisors’ ( n  = 10) own experiences of preparation received and experiences of being a peer group clinical supervisor. Three themes were identified through data analysis, building the foundations, enacting engagement and actions, and realities (Table  4 ).

Building the foundations

This theme highlights the importance of prior knowledge, awareness, and training but also the recruitment process and education in preparing peer group clinical supervisors.

Knowledge and awareness

Participant’s prior knowledge and awareness of peer group clinical supervision was mixed with some reporting having little or no knowledge of clinical supervision.

I’m 20 years plus trained as a nurse , and I had no awareness of clinical supervision beforehand , I really hadn’t got a clue what all of this was about , so it was a very new concept to me (Bernie) .

Others were excited about peer group clinical supervision and while they could see the need they were aware that there may be limited awareness of the value and process of clinical supervision among peers.

I find that there’s great enthusiasm and passion for clinical supervision as it’s a great support mechanism for staff in practice , however , there’s a lack of awareness of clinical supervision (Jane) .

Recruitment

Some participants highlighted that the recruitment process to become a peer group clinical supervisor was vague in some organisations with an unclear and non-transparent process evident where people were chosen by the organisation’s management rather than self-selecting interested parties.

It was just the way the training was put to the people , they were kind of nominated and told they were going and there was a lot of upset over that , so they ended up in some not going at all (Ailbhe) .

In addition, the recruitment process was seen as top loaded where senior grades of staff were chosen, and this limited staff nurse grade opportunities where there was a clear need for peer group clinical supervisors and support.

We haven’t got down to the ground level like you know we’ve done the directors , we’ve done the CNM3s the CNM2s we are at the CNM1s , so we need to get down to the staff nurse level so the nurses at the direct frontline are left out and aren’t receiving supervision because we don’t have them trained (Bernie) .

Training and education

Participants valued the training and education provided but there was a clear sense of ‘imposter syndrome’ for some peer group clinical supervisors starting out. Participants questioned their qualifications, training duration, and confidence to undertake the role of peer group clinical supervisor.

Because it is group supervision and I know that you know they say that we are qualified to do supervision and you know we’re now qualified clinical supervisors but I’m not sure that a three-month module qualifies you to be at the top of your game (Maria) .

Participants when engaged in the peer group clinical supervisor educational programme did find it beneficial and the true benefit was the actual re-engagement in education and published evidence along with the mix of nursing and midwifery practice areas.

I found it very beneficial , I mean I hadn’t been engaged in education here in a while , so it was great to be back in that field and you know with the literature that’s big (Claire) .

Enacting engagement and actions

This theme highlights the importance of forming the groups, getting a clear message out, setting the scene, and grounding the group.

Forming the groups

Recruitment for the group was of key importance to the peer group clinical supervisor and they all sent out a general invitation to form their group. Some supervisors used invitation letters or posters in addition to a general email and this was effective in recruiting supervisees.

You’re reaching out to people , I linked in with the ADoN and I put together a poster and circulated that I wasn’t ‘cherry picking , and I set up a meeting through Webex so people could get a sense of what it was if they were on the fence about it or unsure if it was for them (Karen) .

In forming the peer clinical supervision groups consideration needs to be given to the actual number of supervisees and participants reported four to six supervisees as ideal but that number can alter due to attendance.

The ideal is having five or six consistent people and that they all come on board and that you get the dynamics of the group and everything working (Claire) .

Getting a clear message out

Within the recruitment process, it was evident that there was a limited and often misguided understanding or perception of peer group clinical supervision.

Greater awareness of what actually clinical supervision is , people misjudge it as a supervision where someone is appraising you , when in fact it is more of a support mechanism , I think peer support is the key element that needs to be brought out (Jane) .

Given the lack of clarity and understanding regarding peer group clinical supervision, the participants felt strongly that further clarity is needed and that the focus needs to be on the support it offers to self, practice, and the profession.

Clinical supervision to me is clinical leadership (Jane) .

Setting the scene and grounding the group

In the initial phase of the group coming together the aspect of setting the scene and grounding the group was seen as important. A key aspect of this process was establishing the ground rules which not only set the boundaries and gave structure but also ensured the adoption of principles of trust, confidentiality, and safety.

We start with the ground rules , they give us structure it’s our contract setting out the commitment the expectation for us all , and the confidentiality as that’s so important to the trust and safety and building the relationships (Brid) .

Awareness of group dynamics is important in this process along with awareness of the group members (supervisees) as to their role and expectations.

I reiterate the role of each person in relation to confidentiality and the relationship that they would have with each other within the group and the group is very much aware that it is based on respect for each person’s point of view people may have a fear of contributing to the group and setting the ground rules is important (Jane) .

To ground the group, peer group clinical supervisors saw the importance of being present and allowing oneself to be in the room. This was evident in the time allocated at the start of each session to allow ‘grounding’ to occur in the form of techniques such as a short meditation, relaxation, or deep breathing.

At the start , I do a bit of relaxation and deep breathing , and I saw that with our own external supervisor how she settled us into place so very much about connecting with your body and you’ve arrived , then always come in with the contract in my first sentence , remember today you know we’re in a confidential space , of course , you can take away information , but the only information you will take from today is your own information and then the respect aspect (Mary Rose) .

This settling in and grounding was seen as necessary for people to feel comfortable and engage in the peer group clinical supervision process where they could focus, be open, converse, and be aware of their role and the role of peer group clinical supervision.

People have to be open, open about their practice and be willing to learn and this can only occur by sharing, clinical supervision gives us the space to do it in a space where we know we will be respected, and we can trust (Claire) .

This theme highlights the importance of the peer group clinical supervisors’ past experiences, delivering peer group clinical supervision sessions, responding to COVID-19, personal and professional development, and future opportunities.

Past experiences

Past experiences of peer group clinical supervisors were not always positive and for one participant this related to the lack of ground rules or focus of the sessions and the fact it was facilitated by a non-nurse.

In the past , I suppose I would have found it very frustrating as a participant because I just found that it was going round in circles , people moaning and you know it wasn’t very solution focused so I came from my situation where I was very frustrated with clinical supervision , it was facilitated by somebody that was non-nursing then it wasn’t very , there wasn’t the ground rules , it was very loose (Caroline) .

However, many did not have prior experience of peer group clinical supervision. Nonetheless, through the education and preparation received, there was a sense of commitment to embrace the concept, practice, and philosophy.

I did not really have any exposure or really much information on clinical supervision , but it has opened my eyes , and as one might say I am now a believer (Brid) .

Delivering peer group clinical supervision

In delivering peer group clinical supervision, participants felt supervisees were wary, as they did not know what peer group clinical supervision was, and they had focused more on the word supervision which was misleading to them. Nonetheless, the process was challenging, and buy-in was questioned at an individual and managerial level.

Buy-in wasn’t great I think now of course people will blame the pandemic , but this all happened before the pandemic , there didn’t seem to be you know , the same support from management that I would have expected so I kind of understood it in a way because then there wasn’t the same real respect from the practitioners either (Mary Rose) .

From the peer group clinical supervisor’s perspective, they were all novices in delivering/facilitating peer group clinical supervision sessions, and the support of the external clinical supervisors, and their own peer group clinical supervision sessions were invaluable along with a clinical supervision model.

Having supervision myself was key and something that is vital and needed , we all need to look at our practice and how we work it’s no good just facilitating others without being part of the process yourself but for me I would say the three principles of clinical supervision , you know the normative , formative and restorative , I keep hammering that home and bring that in regularly and revisit the contract and I have to do that often you know (Claire) .

All peer group clinical supervisors commented on the preparation for their peer group clinical supervision sessions and the importance of them having the right frame of mind and that often they needed to read over their course work and published evidence.

I want everybody to have a shared voice and you know that if one person , there is something that somebody feels very strongly and wants to talk about it that they e-mail in advance like we don’t have a set agenda but that’s agreed from the participant at the start (Caroline) .

To assist this, the peer group clinical supervisors noted the importance of their own peer group clinical supervision, the support of their peers, and external clinical supervisors. This preparation in an unpredictable situation can be difficult but drawing on one’s experience and the experience within the group can assist in navigating beyond unexpected situations.

I utilise the models of clinical supervision and this helps guide me , I am more of a facilitator of the group we are experts in our own area and our own role but you can only be an expert if you take the time to examine your practice and how you operate in your role (Brid) .

All clinical supervisors noted that the early sessions can be superficial, and the focus can be on other practice or management issues, but as time moves on and people become more engaged and involved it becomes easier as their understanding of supervision becomes clearer. In addition, there may be hesitancy and people may have difficulty opening up with certain people in the group and this is a reality that can put people off.

Initially there was so much managerial bashing and I think through supervision , I began to kind of think , I need the pillars of supervision , the governance , bringing more knowledge and it shifted everything in the room , trying to marry it with all the tensions that people have (Mary Rose) .

For some clinical supervisors, there were expected and unexpected challenges for them as clinical supervisors in terms of the discussions veering off course and expectations of their own ability.

The other big challenge is when they go off , how do you bring him back , you know when they veer off and you’re expected to be a peer , but you have to try and recoil that you have to get the balance with that right (Mary Rose) .

While peer group clinical supervision is accepted and seen as a valuable process by the peer group clinical supervisors, facilitating peer group supervision with people known to you can be difficult and may affect the process.

I’d love to supervise a group where I actually don’t know the people , I don’t know the dynamics within the group , and I’d love to see what it would be like in a group (Bernie) .

Of concern to clinical supervisors was the aspect of non-attendance and while there may be valid reasons such as COVID-19 the absence of a supervisee for several sessions can affect the group dynamics, especially if the supervisee has only engaged with early group sessions.

One of the ones that couldn’t attend because of COVID and whatever , but she’s coming to the next one and I just feel there’s a lot of issues in her area and I suppose I’m mindful that I don’t want that sort of thing to seep in , so I suppose it’s just for me just to keep reiterating the ground rules and the boundaries , that’s something I just have to manage as a facilitator , but what if they don’t attend how far will the group have progressed before she attends (Caroline) .

Responding to COVID-19

The advent of COVID-19 forced peer group clinical supervisors to find alternative means of providing peer group clinical supervision sessions which saw the move from face-to-face to online sessions. The online transition was seen as seamless for many established groups while others struggled to deliver sessions.

With COVID we did online for us it was fine because we were already formed (Corina) .

While the transition may have been positive many clinical supervisors came across issues because they were using an online format that would not be present in the face-to-face session.

We did have a session where somebody was in the main office and they have a really loud booming voice and they were saying stuff that was not appropriate to say outside of clinical supervision and I was like are you in the office can you lower it down a bit can you put your headphones on (Maria) .

However, two peer group clinical supervisors ceased or hasted the progress of rolling out peer group clinical supervision sessions mainly due to redeployment and staff availability.

With COVID it just had to be canceled here , it’s just the whole thing was canceled so it was very , very difficult for people (Mary Rose) .

It was clear from clinical supervisors that online sessions were appropriate but that they felt they were only appropriate for existing established groups that have had the opportunity to build relationships, develop trust, embed the ground rules, and create the space for open communication and once established a combined approach would be appropriate.

Since we weren’t as established as a group , not everybody knew each other it would be difficult to establish that so we would hold off/reschedule , obviously COVID is a major one but also I suppose if you have an established group now , and again , you could go to a remote one , but I felt like since we weren’t established as a group it would be difficult to develop it in that way (Karen) .

Within practice COVID-19 took priority and other aspects such as peer group clinical supervision moved lower down on the priority list for managers but not for the clinical supervisors even where redeployment occurred.

With COVID all the practical side , if one of the managers is dealing with an outbreak , they won’t be attending clinical supervision , because that has to be prioritised , whereas we’ve prioritised clinical supervision (Maria) .

The valuing of peer group clinical supervision was seen as important by clinical supervisors, and they saw it as particularly needed during COVID-19 as staff were dealing with many personal and professional issues.

During the height of COVID , we had to take a bit of a break for four months as things were so demanding at work for people but then I realised that clinical supervision was needed and started back up and they all wanted to come back (Brid) .

Having peer group clinical supervision during COVID-19 supported staff and enabled the group to form supportive relationships.

COVID has impacted over the last two years in every shape and they needed the supervision and the opportunity to have a safe supportive space and it gelled the group I think as we all were there for each other (Claire) .

While COVID-19 posed many challenges it also afforded clinical supervisors and supervisees the opportunity for change and to consider alternative means of running peer group clinical supervision sessions. This change resulted in online delivery and in reflecting on both forms of delivery (face-to-face and online) clinical supervisors saw the benefit in both. Face-to-face was seen as being needed to form the group and then the group could move online once the group was established with an occasional periodic face-to-face session to maintain motivation commitment and reinforce relationships and support.

Online formats can be effective if the group is already established or the group has gone through the storming and forming phase and the ground rules have been set and trust built , then I don’t see any problem with a blended online version of clinical supervision , and I think it will be effective (Jane) .

Personal and professional development

Growth and development were evident from peer group clinical supervisors’ experiences and this growth and development occurred at a personal, professional, and patient/client level. This development also produced an awakening and valuing of one’s passion for self and their profession.

I suppose clinical supervision is about development I can see a lot of development for me and my supervisees , you know personally and professionally , it’s the support really , clinical supervision can reinvigorate it’s very exciting and a great opportunity for nursing to support each other and in care provision (Claire) .

A key to the peer group clinical supervisor’s development was the aspect of transferable skills and the confidence they gained in fulfilling their role.

All of these skills that you learn are transferable and I am a better manager because of clinical supervision (Maria) .

The confidence and skills gained translated into the clinical supervisor’s own practice as a clinical practitioner and clinical supervisor but they were also realistic in predicting the impact on others.

I have empowered my staff , I empower them to use their voice and I give my supervisees a voice and hope they take that with them (Corina) .

Fundamental to the development process was the impact on care itself and while this cannot always be measured or identified, the clinical supervisors could see that care and support of the individual practitioner (supervisee) translated into better care for the patient/client.

Care is only as good as the person delivering it and what they know , how they function and what energy and passion they have , and clinical supervision gives the person support to begin to understand their practice and how and why they do things in a certain way and when they do that they can begin to question and even change their way of doing something (Brid) .

Future opportunities

Based on the clinical supervisor’s experiences there was a clear need identified regarding valuing and embedded peer group clinical supervision within nursing/midwifery practice.

There has to be an emphasis placed on supervision it needs to be part of the fabric of a service and valued by all in that service , we should be asking why is it not available if it’s not there but there is some work first on promoting it and people knowing what it actually is and address the misconceptions (Claire) .

While such valuing and buy-in are important, it is not to say that all staff need to have peer group clinical supervision so as to allow for personal choice. In addition, to value peer group clinical supervision it needs to be evident across all staffing grades and one could question where the best starting point is.

While we should not mandate that all staff do clinical supervision it should become embedded within practice more and I suppose really to become part of our custom and practice and be across all levels of staff (Brid) .

When peer group clinical supervision is embedded within practice then it should be custom and practice, where it is included in all staff orientations and is nationally driven.

I suppose we need to be driving it forward at the coal face at induction , at orientation and any development for the future will have to be driven by the NMPDUs or nationally (Ailbhe) .

A formalised process needs to address the release of peer group clinical supervisors but also the necessity to consider the number of peer group clinical supervisors at a particular grade.

The issue is release and the timeframe as they have a group but they also have their external supervision so you have to really work out how much time you’re talking about (Maria) .

Vital within the process of peer group clinical supervision is receiving peer group clinical supervision and peer support and this needs to underpin good peer group clinical supervision practice.

Receiving peer group supervision helps me , there are times where I would doubt myself , it’s good to have the other group that I can go to and put it out there to my own group and say , look at this , this is what we did , or this is what came up and this is how (Bernie) .

For future roll out to staff nurse/midwife grade resourcing needs to be considered as peer group clinical supervisors who were managers could see the impact of having several peer group clinical supervisors in their practice area may have on care delivery.

Facilitating groups is an issue and needs to be looked at in terms of the bigger picture because while I might be able to do a second group the question is how I would be supported and released to do so (Maria) .

While there was ambiguity regarding peer group clinical supervision there was an awareness of other disciplines availing of peer group clinical supervision, raising questions about the equality of supports available for all disciplines.

I always heard other disciplines like social workers would always have been very good saying I can’t meet you I have supervision that day and I used to think my God what’s this fabulous hour that these disciplines are getting and as a nursing staff it just wasn’t there and available (Bernie) .

To address this equity issue and the aspect of low numbers of certain grades an interdisciplinary approach within nursing and midwifery could be used or a broader interdisciplinary approach across all healthcare professionals. An interdisciplinary or across-services approach was seen as potentially fruitful.

I think the value of interprofessional or interdisciplinary learning is key it addresses problem-solving from different perspectives that mix within the group is important for cross-fertilisation and embedding the learning and developing the experience for each participant within the group (Jane) .

As we move beyond COVID-19 and into the future there is a need to actively promote peer group clinical supervision and this would clarify what peer group clinical supervision actually is, its uptake and stimulate interest.

I’d say it’s like promoting vaccinations if you could do a roadshow with people , I think that would be very beneficial , and to launch it , like you have a launch an official launch behind it (Mary Rose) .

The advantages of peer group clinical supervision highlighted in this study pertain to self-enhancement (confidence, leadership, personal development, resilience), organisational and service-related aspects (positive work environment, staff retention, safety), and professional patient care (critical thinking and evaluation, patient safety, adherence to quality standards, elevated care standards). These findings align with broader literature that acknowledges various areas, including self-confidence and facilitation [ 23 ], leadership [ 24 ], personal development [ 25 ], resilience [ 26 ], positive/supportive working environment [ 27 ], staff retention [ 28 ], sense of safety [ 29 ], critical thinking and evaluation [ 30 ], patient safety [ 31 ], quality standards [ 32 ] and increased standards of care [ 33 ].

In this study, peer group clinical supervision appeared to contribute to the alleviation of stress and anxiety. Participants recognised the significance of these sessions, where they could openly discuss and reflect on professional situations both emotionally and rationally. Central to these discussions was the creation of a safe, trustworthy, and collegial environment, aligning with evidence in the literature [ 34 ]. Clinical supervision provided a platform to share resources (information, knowledge, and skills) and address issues while offering mutual support [ 35 ]. The emergence of COVID-19 has stressed the significance of peer group clinical supervision and support for the nursing/midwifery workforce [ 36 ], highlighting the need to help nurses/midwifes preserve their well-being and participate in collaborative problem-solving. COVID-19 impacted and disrupted clinical supervision frequency, duration and access [ 37 ]. What was evident during COVID-19 was the stress and need for support for staff and given the restorative or supportive functions of clinical supervision it is a mechanism of support. However, clinical supervisors need support themselves to be able to better meet the supervisee’s needs [ 38 ].

The value of peer group clinical supervision in nurturing a conducive working environment cannot be overstated, as it indorses the understanding and adherence to workplace policies by empowering supervisees to understand the importance and rationale behind these policies [ 39 ]. This becomes vital in a continuously changing healthcare landscape, where guidelines and policies may be subject to change, especially in response to situations such as COVID-19. In an era characterised by international workforce mobility and a shortage of healthcare professionals, a supportive and positive working environment through the provision of peer group clinical supervision can positively influence staff retention [ 40 ], enhance job satisfaction [ 41 ], and mitigate burnout [ 42 ]. A critical aspect of the peer group clinical supervision process concerns providing staff the opportunity to reflect, step back, problem-solve and generate solutions. This, in turn, ensures critical thinking and evaluation within clinical supervision, focusing on understanding the issues and context, and problem-solving to draw constructive lessons for the future [ 30 ]. Research has determined a link between clinical supervision and improvements in the quality and standards of care [ 31 ]. Therefore, peer group clinical supervision plays a critical role in enhancing patient safety by nurturing improved communication among staff, facilitating reflection, promoting greater self-awareness, promoting the exchange of ideas, problem-solving, and facilitating collective learning from shared experiences.

Starting a group arose as a foundational aspect emphasised in this study. The creation of the environment through establishing ground rules, building relationships, fostering trust, displaying respect, and upholding confidentiality was evident. Vital to this process is the recruitment of clinical supervisees and deciding the suitable group size, with a specific emphasis on addressing individuals’ inclination to engage, their knowledge and understanding of peer group clinical supervision, and dissipating any lack of awareness or misconceptions regarding peer group supervision. Furthermore, the educational training of peer group clinical supervisors and the support from external clinical supervisors played a vital role in the rollout and formation of peer group clinical supervision. The evidence stresses the significance of an open and safe environment, wherein supervisees feel secure and trust their supervisor. In such an environment, they can effectively reflect on practice and related issues [ 41 ]. This study emphasises that the effectiveness of peer group supervision is more influenced by the process than the content. Clinical supervisors utilised the process to structure their sessions, fostering energy and interest to support their peers and cultivate new insights. For peer group clinical supervision to be effective, regularity is essential. Meetings should be scheduled in advance, allocate protected time, and take place in a private space [ 35 ]. While it is widely acknowledged that clinical supervisors need to be experts in their professional field to be credible, this study highlights that the crucial aspects of supervision lie in the quality of the relationship with the supervisor. The clinical supervisor should be supportive, caring, open, collaborative, sensitive, flexible, helpful, non-judgmental, and focused on tacit knowledge, experiential learning, and providing real-time feedback.

Critical to the success of peer group clinical supervision is the endorsement and support from management, considering the organisational culture and attitudes towards the practice of clinical supervision as an essential factor [ 43 ]. This support and buy-in are necessary at both the management and individual levels [ 28 ]. The primary obstacles to effective supervision often revolve around a lack of time and heavy workloads [ 44 ]. Clinical supervisors frequently struggle to find time amidst busy environments, impacting the flexibility and quality of the sessions [ 45 ]. Time constraints also limit the opportunity for reflection within clinical supervision sessions, leaving supervisees feeling compelled to resolve issues on their own without adequate support [ 45 ]. Nevertheless, time-related challenges are not unexpected, prompting a crucial question about the value placed on clinical supervision and its integration into the culture and fabric of the organisation or profession to make it a customary practice. Learning from experiences like those during the COVID-19 pandemic has introduced alternative ways of working, and the use of technology (such as Zoom, Microsoft Teams, Skype) may serve as a means to address time, resource, and travel issues associated with clinical supervision.

Despite clinical supervision having a long international history, persistent misconceptions require attention. Some of these include not considering clinical supervision a priority [ 46 ], perceiving it as a luxury [ 41 ], deeming it self-indulgent [ 47 ], or viewing it as mere casual conversation during work hours [ 48 ]. A significant challenge lies in the lack of a shared understanding regarding the role and purpose of clinical supervision, with past perceptions associating it with surveillance and being monitored [ 48 ]. These negative connotations often result in a lack of engagement [ 41 ]. Without encouragement and recognition of the importance of clinical supervision from management or the organisation, it is unlikely to become embedded in the organisational culture, impeding its normalisation [ 39 ].

In this study, some peer group clinical supervisors expressed feelings of being impostors and believed they lacked the knowledge, skills, and training to effectively fulfil their roles. While a deficiency in skills and competence are possible obstacles to providing effective clinical supervision [ 49 ], the peer group clinical supervisors in this study did not report such issues. Instead, their concerns were more about questioning their ability to function in the role of a peer group clinical supervisor, especially after a brief training program. The literature acknowledges a lack of training where clinical supervisors may feel unprepared and ill-equipped for their role [ 41 ]. To address these challenges, clinical supervisors need to be well-versed in professional guidelines and ethical standards, have clear roles, and understand the scope of practice and responsibilities associated with being a clinical supervisor [ 41 ].

The support provided by external clinical supervisors and the peer group clinical supervision sessions played a pivotal role in helping peer group clinical supervisors ease into their roles, gain experiential learning, and enhance their facilitation skills within a supportive structure. Educating clinical supervisors is an investment, but it should not be a one-time occurrence. Ongoing external clinical supervision for clinical supervisors [ 50 ] and continuous professional development [ 51 ] are crucial, as they contribute to the likelihood of clinical supervisors remaining in their roles. However, it is important to interpret the results of this study with caution due to the small sample size in the survey. Generalising the study results should be approached with care, particularly as the study was limited to two regions in Ireland. However, the addition of qualitative data in this mixed-methods study may have helped offset this limitation.

This study highlights the numerous advantages of peer group clinical supervision at individual, service, organisational, and patient/client levels. Success hinges on addressing the initial lack of awareness and misconceptions about peer group clinical supervision by creating the right environment and establishing ground rules. To unlock the full potential of peer group clinical supervision, it is imperative to secure management and organisational support for staff release. More crucially, there is a need for valuing and integrating peer group clinical supervision into nursing and midwifery education and practice. Making peer group clinical supervision accessible to all grades of nurses and midwives across various healthcare services is essential, necessitating strategic planning to tackle capacity and sustainability challenges.

Data availability

Data are available from the corresponding author upon request owing to privacy or ethical restrictions.

Zelenikova R, Gurkova E, Friganovic A, Uchmanowicz I, Jarosova D, Ziakova K, Plevova I, Papastavrou E. Unfinished nursing care in four central European countries. J Nurs Manage. 2020;28(8):1888–900. https://doi.org/10.1111/jonm.12896 .

Article   Google Scholar  

Department of Health, Office of the Chief Nursing Officer. Position paper 1: values for nurses and midwives in Ireland. Dublin: The Stationery Office; 2016.

Google Scholar  

Cummings J, Bennett V. Developing the culture of compassionate care: creating a new vision for nurses, midwives and care-givers. London: Department of Health; 2012.

Both-Nwabuwe JM, Dijkstra MT, Klink A, Beersma B. Maldistribution or scarcity of nurses: the devil is in the detail. J Nurs Manage. 2018;26(2):86–93. https://doi.org/10.1111/jonm.12531 .

Squires A, Jylha V, Jun J, Ensio A, Kinnunen J. A scoping review of nursing workforce planning and forecasting research. J Nurs Manage. 2017;25:587–96. https://doi.org/10.1111/jonm.12510 .

Sasso L, Bagnasco A, Catania G, Zanini M, Aleo G, Watson R. Push and pull factors of nurses’ intention to leave. J Nurs Manage. 2019;27:946–54. https://doi.org/10.1111/jonm.12745 .

Gea-Caballero V, Castro-Sánchez E, Díaz‐Herrera MA, Sarabia‐Cobo C, Juárez‐Vela R, Zabaleta‐Del Olmo E. Motivations, beliefs, and expectations of Spanish nurses planning migration for economic reasons: a cross‐sectional, web‐based survey. J Nurs Scholarsh. 2019;51(2):178–86. https://doi.org/10.1111/jnu.12455 .

Article   PubMed   Google Scholar  

Cutcliffe J, Sloan G, Bashaw M. A systematic review of clinical supervision evaluation studies in nursing. Int J Ment Health Nurs. 2018;27:1344–63. https://doi.org/10.1111/inm.12443 .

Snowdon DA, Hau R, Leggat SG, Taylor NF. Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis. Int J Qual Health C. 2016;28(4):447–55. https://doi.org/10.1093/intqhc/mzw059 .

Turner J, Hill A. Implementing clinical supervision (part 1): a review of the literature. Ment Health Nurs. 2011;31(3):8–12.

Dilworth S, Higgins I, Parker V, Kelly B, Turner J. Finding a way forward: a literature review on the current debates around clinical supervision. Contemp Nurse. 2013;45(1):22–32. https://doi.org/10.5172/conu.2013.45.1.22 .

Buss N, Gonge H. Empirical studies of clinical supervision in psychiatric nursing: a systematic literature review and methodological critique. Int J Ment Health Nurs. 2009;18(4):250–64. https://doi.org/10.1111/j.1447-0349.2009.00612.x .

Pollock A, Campbell P, Deery R, Fleming M, Rankin J, Sloan G, Cheyne H. A systematic review of evidence relating to clinical supervision for nurses, midwives and allied health professionals. J Adv Nurs. 2017;73(8):1825–37. https://doi.org/10.1111/jan.13253 .

Snowdon DA, Leggat SG, Taylor NF. Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience: a systematic review. BMC Health Serv Res. 2017;17(1):1–11. https://doi.org/10.1186/s12913-017-2739-5 .

Kühne F, Maas J, Wiesenthal S, Weck F. Empirical research in clinical supervision: a systematic review and suggestions for future studies. BMC Psychol. 2019;7(1):1–11. https://doi.org/10.1186/s40359-019-0327-7 .

Snowdon DA, Sargent M, Williams CM, Maloney S, Caspers K, Taylor NF. Effective clinical supervision of allied health professionals: a mixed methods study. BMC Health Serv Res. 2020;20(1):1–11. https://doi.org/10.1186/s12913-019-4873-8 .

Borders LD. Dyadic, triadic, and group models of peer supervision/consultation: what are their components, and is there evidence of their effectiveness? Clin Psychol. 2012;16(2):59–71.

Health Service Executive. Guidance document on peer group clinical supervision. Mayo: Nursing and Midwifery Planning and Development Unit Health Service Executive West Mid West; 2023.

Sharma A, Minh Duc NT, Lam Thang L, Nam T, Ng NH, Abbas SJ, Huy KS, Marušić NT, Paul A, Kwok CL. Karamouzian, M. A consensus-based checklist for reporting of survey studies (CROSS). J Gen Intern Med. 2021;36(10):3179–87. https://doi.org/10.1007/s11606-021-06737-1 .

Article   PubMed   PubMed Central   Google Scholar  

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;899:1245–51. https://doi.org/10.1097/ACM.0000000000000388 .

Winstanley J, White E. The MCSS-26©: revision of the Manchester Clinical Supervision Scale© using the Rasch Measurement Model. J Nurs Meas. 2011;193(2011):160–78. https://doi.org/10.1891/1061-3749.19.3.160 .

Colorafi KJ, Evans B. Qualitative descriptive methods in health science research. HERD-Health Env Res. 2016;9:16–25. https://doi.org/10.1177/1937586715614171 .

Agnew T, Vaught CC, Getz HG, Fortune J. Peer group clinical supervision program fosters confidence and professionalism. Prof Sch Couns. 2000;4(1):6–12.

Mc Carthy V, Goodwin J, Saab MM, Kilty C, Meehan E, Connaire S, O’Donovan A. Nurses and midwives’ experiences with peer-group clinical supervision intervention: a pilot study. J Nurs Manage. 2021;29:2523–33. https://doi.org/10.1111/jonm.13404 .

Rothwell C, Kehoe A, Farook SF, Illing J. Enablers and barriers to effective clinical supervision in the workplace: a rapid evidence review. BMJ Open. 2021;119:e052929. https://doi.org/10.1136/bmjopen-2021-052929 .

Francis A, Bulman C. In what ways might group clinical supervision affect the development of resilience in hospice nurses. Int J Palliat Nurs. 2019;25:387–96. https://doi.org/10.12968/ijpn.2019.25.8.387 .

Chircop Coleiro A, Creaner M, Timulak L. The good, the bad, and the less than ideal in clinical supervision: a qualitative meta-analysis of supervisee experiences. Couns Psychol Quart. 2023;36(2):189–210. https://doi.org/10.1080/09515070.2021.2023098 .

Stacey G, Cook G, Aubeeluck A, Stranks B, Long L, Krepa M, Lucre K. The implementation of resilience based clinical supervision to support transition to practice in newly qualified healthcare professionals. Nurs Educ Today. 2020;94:104564. https://doi.org/10.1016/j.nedt.2020.104564 .

Feerick A, Doyle L, Keogh B. Forensic mental health nurses’ perceptions of clinical supervision: a qualitative descriptive study. Issues Ment Health Nurs. 2021;42:682–9. https://doi.org/10.1080/01612840.2020.1843095 .

Corey G, Haynes RH, Moulton P, Muratori M. Clinical supervision in the helping professions: a practical guide. Alexandria, VA: American Counseling Association; 2021.

Sturman N, Parker M, Jorm C. Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning. Adv Health Sci Educ. 2021;26:297–311. https://doi.org/10.1007/s10459-020-09986-7 .

Alfonsson S, Parling T, Spännargård Å, Andersson G, Lundgren T. The effects of clinical supervision on supervisees and patients in cognitive behavioral therapy: a systematic review. Cogn Behav Therapy. 2018;47(3):206–28. https://doi.org/10.1080/16506073.2017.1369559 .

Coelho M, Esteves I, Mota M, Pestana-Santos M, Santos MR, Pires R. Clinical supervision of the nurse in the community to promote quality of care provided by the caregiver: scoping review protocol. Millenium J Educ Technol Health. 2022;2:83–9. https://doi.org/10.29352/mill0218.26656 .

Toros K, Falch-Eriksen A. Structured peer group supervision: systematic case reflection for constructing new perspectives and solutions. Int Soc Work. 2022;65:1160–5. https://doi.org/10.1177/0020872820969774 .

Bifarin O, Stonehouse D. Clinical supervision: an important part of every nurse’s practice. Brit J Nurs. 2017;26(6):331–5. https://doi.org/10.12968/bjon.2017.26.6.331 .

Turner J, Simbani N, Doody O, Wagstaff C, McCarthy-Grunwald S. Clinical supervision in difficult times and at all times. Ment Health Nurs. 2022;42(1):10–3.

Martin P, Tian E, Kumar S, Lizarondo L. A rapid review of the impact of COVID-19 on clinical supervision practices of healthcare workers and students in healthcare settings. J Adv Nurs. 2022;78:3531–9. https://doi.org/10.1111/jan.15360 .

van Dam M, van Hamersvelt H, Schoonhoven L, Hoff RG, Cate OT, Marije P. Hennus. Clinical supervision under pressure: a qualitative study amongst health care professionals working on the ICU during COVID-19. Med Edu Online. 2023;28:1. https://doi.org/10.1080/10872981.2023.2231614 .

Martin P, Lizarondo L, Kumar S, Snowdon D. Impact of clinical supervision on healthcare organisational outcomes: a mixed methods systematic review. PLoS ONE. 2021;1611:e0260156. https://doi.org/10.1371/journal.pone.0260156 .

Article   CAS   Google Scholar  

Hussein R, Salamonson Y, Hu W, Everett B. Clinical supervision and ward orientation predict new graduate nurses’ intention to work in critical care: findings from a prospective observational study. Aust Crit Care. 2019;325:397–402. https://doi.org/10.1016/j.aucc.2018.09.003 .

Love B, Sidebotham M, Fenwick J, Harvey S, Fairbrother G. Unscrambling what’s in your head: a mixed method evaluation of clinical supervision for midwives. Women Birth. 2017;30:271–81. https://doi.org/10.1016/j.wombi.2016.11.002 .

Berry S, Robertson N. Burnout within forensic psychiatric nursing: its relationship with ward environment and effective clinical supervision? J Psychiatr Ment Health Nurs. 2019;26:7–8. https://doi.org/10.1111/jpm.12538 .

Markey K, Murphy L, O’Donnell C, Turner J, Doody O. Clinical supervision: a panacea for missed care. J Nurs Manage. 2020;28:2113–7. https://doi.org/10.1111/jonm.13001 .

Brody AA, Edelman L, Siegel EO, Foster V, Bailey DE Jr., Bryant AL, Bond SM. Evaluation of a peer mentoring program for early career gerontological nursing faculty and its potential for application to other fields in nursing and health sciences. Nurs Outlook. 2016;64(4):332–8. https://doi.org/10.1016/j.outlook.2016.03.004 .

Bulman C, Forde-Johnson C, Griffiths A, Hallworth S, Kerry A, Khan S, Mills K, Sharp P. The development of peer reflective supervision amongst nurse educator colleagues: an action research project. Nurs Educ Today. 2016;45:148–55. https://doi.org/10.1016/j.nedt.2016.07.010 .

Pack M. Unsticking the stuckness’: a qualitative study of the clinical supervisory needs of early-career health social workers. Brit J Soc Work. 2015;45:1821–36. https://doi.org/10.1093/bjsw/bcu069 .

Bayliss J. Clinical supervision for palliative care. London: Quay Books; 2006.

Kenny A, Allenby A. Implementing clinical supervision for Australian rural nurses. Nurs Educ Pract. 2013;13(3):165–9. https://doi.org/10.1016/j.nepr.2012.08.009 .

MacLaren J, Stenhouse R, Ritchie D. Mental health nurses’ experiences of managing work-related emotions through supervision. J Adv Nurs. 2016;72:2423–34. https://doi.org/10.1111/jan.12995 .

Wilson HM, Davies JS, Weatherhead S. Trainee therapists’ experiences of supervision during training: a meta-synthesis. Clinl Psychol Psychother. 2016;23:340–51. https://doi.org/10.1002/cpp.1957 .

Noelker LS, Ejaz FK, Menne HL, Bagaka’s JG. Factors affecting frontline workers’ satisfaction with supervision. J Aging Health. 2009;21(1):85–101. https://doi.org/10.1177/0898264308328641 .

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Acknowledgements

The research team would like to thank all participants for their collaboration, the HSE steering group members and Carmel Hoey, NMPDU Director, HSE West Mid West, Dr Patrick Glackin, NMPD Area Director, HSE West, Annette Cuddy, Director, Centre of Nurse and Midwifery Education Mayo/Roscommon; Ms Ruth Hoban, Assistant Director of Nursing and Midwifery (Prescribing), HSE West; Ms Annette Connolly, NMPD Officer, NMPDU HSE West Mid West.

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OD: Conceptualization, Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Project administration, Funding acquisition. COD: Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Funding acquisition. KM: Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Funding acquisition. JT: Methodology, Formal analysis, Writing - Original Draft, Writing - Review & Editing. LM: Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Funding acquisition.

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This study was approved by two health service institutional review boards University Hospital Limerick (Ref: 091/19) and Galway University Hospitals (Ref: C.A. 2199). The study was conducted in accordance with the principles of the Declaration of Helsinki and all study details were fully disclosed to participants, who were assured of the voluntary nature of participation and withdrawal. The study questionnaires were coded, and identities were not disclosed to guarantee participants’ anonymity and all participants provided written informed consent before interviews.

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Doody, O., Markey, K., Turner, J. et al. Clinical supervisor’s experiences of peer group clinical supervision during COVID-19: a mixed methods study. BMC Nurs 23 , 612 (2024). https://doi.org/10.1186/s12912-024-02283-3

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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.