characteristics of phenomenology qualitative research

What is phenomenology in qualitative research?

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Take a closer look at this type of qualitative research along with characteristics, examples, uses, and potential disadvantages.

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• What is phenomenological qualitative research?

Phenomenological research is a qualitative research approach that builds on the assumption that the universal essence of anything ultimately depends on how its audience experiences it .

Phenomenological researchers record and analyze the beliefs, feelings, and perceptions of the audience they’re looking to study in relation to the thing being studied. Only the audience’s views matter—the people who have experienced the phenomenon. The researcher’s personal assumptions and perceptions about the phenomenon should be irrelevant.

Phenomenology is a type of qualitative research as it requires an in-depth understanding of the audience’s thoughts and perceptions of the phenomenon you’re researching. It goes deep rather than broad, unlike quantitative research . Finding the lived experience of the phenomenon in question depends on your interpretation and analysis.

• What is the purpose of phenomenological research?

The primary aim of phenomenological research is to gain insight into the experiences and feelings of a specific audience in relation to the phenomenon you’re studying. These narratives are the reality in the audience’s eyes. They allow you to draw conclusions about the phenomenon that may add to or even contradict what you thought you knew about it from an internal perspective.

• How is phenomenology research design used?

Phenomenological research design is especially useful for topics in which the researcher needs to go deep into the audience’s thoughts, feelings, and experiences.

It’s a valuable tool to gain audience insights, generate awareness about the item being studied, and develop new theories about audience experience in a specific, controlled situation.

• Examples of phenomenological research

Phenomenological research is common in sociology, where researchers aim to better understand the audiences they study.

An example would be a study of the thoughts and experiences of family members waiting for a loved one who is undergoing major surgery. This could provide insights into the nature of the event from the broader family perspective.

However, phenomenological research is also common and beneficial in business situations. For example, the technique is commonly used in branding research. Here, audience perceptions of the brand matter more than the business’s perception of itself.

In branding-related market research, researchers look at how the audience experiences the brand and its products to gain insights into how they feel about them. The resulting information can be used to adjust messaging and business strategy to evoke more positive or stronger feelings about the brand in the future.

• The 4 characteristics of phenomenological research design

The exact nature of phenomenological research depends on the subject to be studied. However, every research design should include the following four main tenets to ensure insightful and actionable outcomes:

A focus on the audience’s interpretation of something . The focus is always on what an experience or event means to a strictly defined audience and how they interpret its meaning.

A lack of researcher bias or prior influence . The researcher has to set aside all prior prejudices and assumptions. They should focus only on how the audience interprets and experiences the event.

Connecting objectivity with lived experiences . Researchers need to describe their observations of how the audience experienced the event as well as how the audience interpreted their experience themselves.

• Types of phenomenological research design

Each type of phenomenological research shares the characteristics described above. Social scientists distinguish the following three types:

Existential phenomenology —focuses on understanding the audience’s experiences through their perspective. 

Hermeneutic phenomenology —focuses on creating meaning from experiences through the audience’s perspective.

Transcendental phenomenology —focuses on how the phenomenon appears in one consciousness on a broader, scientific scale.

Existential phenomenology is the most common type used in a business context. It’s most valuable to help you better understand your audience.

You can use hermeneutic phenomenology to gain a deeper understanding of how your audience perceives experiences related to your business.

Transcendental phenomenology is largely reserved for non-business scientific applications.

• Data collection methods in phenomenological research

Phenomenological research draws from many of the most common qualitative research techniques to understand the audience’s perspective.

Here are some of the most common tools to collect data in this type of research study:

Observing participants as they experience the phenomenon

Interviewing participants before, during, and after the experience

Focus groups where participants experience the phenomenon and discuss it afterward

Recording conversations between participants related to the phenomenon

Analyzing personal texts and observations from participants related to the phenomenon

You might not use these methods in isolation. Most phenomenological research includes multiple data collection methods. This ensures enough overlap to draw satisfactory conclusions from the audience and the phenomenon studied.

Get started collecting, analyzing, and understanding qualitative data with help from quickstart research templates.

• Limitations of phenomenological research

Phenomenological research can be beneficial for many reasons, but its downsides are just as important to discuss.

This type of research is not a solve-all tool to gain audience insights. You should keep the following limitations in mind before you design your research study and during the design process:

These audience studies are typically very small. This results in a small data set that can make it difficult for you to draw complete conclusions about the phenomenon.

Researcher bias is difficult to avoid, even if you try to remove your own experiences and prejudices from the equation. Bias can contaminate the entire outcome.

Phenomenology relies on audience experiences, so its accuracy depends entirely on how well the audience can express those experiences and feelings.

The results of a phenomenological study can be difficult to summarize and present due to its qualitative nature. Conclusions typically need to include qualifiers and cautions.

This type of study can be time-consuming. Interpreting the data can take days and weeks.

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Home » Phenomenology – Methods, Examples and Guide

Phenomenology – Methods, Examples and Guide

Table of Contents

Phenomenology

Definition:

Phenomenology is a branch of philosophy that is concerned with the study of subjective experience and consciousness. It is based on the idea that the essence of things can only be understood through the way they appear to us in experience, rather than by analyzing their objective properties or functions.

Phenomenology is often associated with the work of philosopher Edmund Husserl, who developed a method of phenomenological inquiry that involves suspending one’s preconceptions and assumptions about the world and focusing on the pure experience of phenomena as they present themselves to us. This involves bracketing out any judgments, beliefs, or theories about the phenomena, and instead attending closely to the subjective qualities of the experience itself.

Phenomenology has been influential not only in philosophy but also in other fields such as psychology, sociology, and anthropology, where it has been used to explore questions of perception, meaning, and human experience.

History of Phenomenology

Phenomenology is a philosophical movement that began in the early 20th century, primarily in Germany. It was founded by Edmund Husserl, a German philosopher who is often considered the father of phenomenology.

Husserl’s work was deeply influenced by the philosophy of Immanuel Kant, particularly his emphasis on the importance of subjective experience. However, Husserl sought to go beyond Kant’s transcendental idealism by developing a rigorous method of inquiry that would allow him to examine the structures of consciousness and the nature of experience in a systematic way.

Husserl’s first major work, Logical Investigations (1900-1901), laid the groundwork for phenomenology by introducing the idea of intentional consciousness, or the notion that all consciousness is directed towards objects in the world. He went on to develop a method of “bracketing” or “epoche,” which involved setting aside one’s preconceptions and assumptions about the world in order to focus on the pure experience of phenomena as they present themselves.

Other philosophers, such as Martin Heidegger and Jean-Paul Sartre, built on Husserl’s work and developed their own versions of phenomenology. Heidegger, in particular, emphasized the importance of language and the role it plays in shaping our understanding of the world, while Sartre focused on the relationship between consciousness and freedom.

Today, phenomenology continues to be an active area of philosophical inquiry, with many contemporary philosophers drawing on its insights to explore questions of perception, meaning, and human experience.

Types of Phenomenology

There are several types of phenomenology that have emerged over time, each with its own focus and approach. Here are some of the most prominent types of phenomenology:

Transcendental Phenomenology

This is the type of phenomenology developed by Edmund Husserl, which aims to investigate the structures of consciousness and experience in a systematic way by using the method of epoche or bracketing.

Existential Phenomenology

This type of phenomenology, developed by philosophers such as Martin Heidegger and Jean-Paul Sartre, focuses on the subjective experience of individual existence, emphasizing the role of freedom, authenticity, and the search for meaning in human life.

Hermeneutic Phenomenology

This type of phenomenology, developed by philosophers such as Hans-Georg Gadamer and Paul Ricoeur, emphasizes the role of interpretation and understanding in human experience, particularly in the context of language and culture.

Phenomenology of Perception

This type of phenomenology, developed by Maurice Merleau-Ponty, emphasizes the embodied and lived nature of perception, arguing that perception is not simply a matter of passive reception but is instead an active and dynamic process of engagement with the world.

Phenomenology of Sociality

This type of phenomenology, developed by philosophers such as Alfred Schutz and Emmanuel Levinas, focuses on the social dimension of human experience, exploring how we relate to others and how our understanding of the world is shaped by our interactions with others.

Methods of Phenomenology

Here are some of the key methods that phenomenologists use to investigate human experience:

Epoche (Bracketing)

This is a key method in phenomenology, which involves setting aside one’s preconceptions and assumptions about the world in order to focus on the pure experience of phenomena as they present themselves. By bracketing out any judgments, beliefs, or theories about the phenomena, one can attend more closely to the subjective qualities of the experience itself.

Introspection

Phenomenologists often rely on introspection, or a careful examination of one’s own mental states and experiences, as a way of gaining insight into the nature of consciousness and subjective experience.

Descriptive Analysis

Phenomenology also involves a careful description and analysis of subjective experiences, paying close attention to the way things appear to us in experience, rather than analyzing their objective properties or functions.

Another method used in phenomenology is the variation technique, in which one systematically varies different aspects of an experience in order to gain a deeper understanding of its structure and meaning.

Phenomenological Reduction

This method involves reducing a phenomenon to its essential features or structures, in order to gain a deeper understanding of its nature and significance.

Epoché Variations

This method involves examining different aspects of an experience through the process of epoché or bracketing, to gain a more nuanced understanding of its subjective qualities and significance.

Applications of Phenomenology

Phenomenology has a wide range of applications across many fields, including philosophy, psychology, sociology, education, and healthcare. Here are some of the key applications of phenomenology:

• Philosophy : Phenomenology is primarily a philosophical approach, and has been used to explore a wide range of philosophical issues related to consciousness, perception, identity, and the nature of reality.
• Psychology : Phenomenology has been used in psychology to study human experience and consciousness, particularly in the areas of perception, emotion, and cognition. It has also been used to develop new forms of psychotherapy, such as existential and humanistic psychotherapy.
• Sociology : Phenomenology has been used in sociology to study the subjective experience of individuals within social contexts, particularly in the areas of culture, identity, and social change.
• Education : Phenomenology has been used in education to explore the subjective experience of students and teachers, and to develop new approaches to teaching and learning that take into account the individual experiences of learners.
• Healthcare : Phenomenology has been used in healthcare to explore the subjective experience of patients and healthcare providers, and to develop new approaches to patient care that are more patient-centered and focused on the individual’s experience of illness.
• Design : Phenomenology has been used in design to better understand the subjective experience of users and to create more user-centered products and experiences.
• Business : Phenomenology has been used in business to better understand the subjective experience of consumers and to develop more effective marketing strategies and user experiences.

Purpose of Phenomenology

The purpose of phenomenology is to understand the subjective experience of human beings. Phenomenology is concerned with the way things appear to us in experience, rather than their objective properties or functions. The goal of phenomenology is to describe and analyze the essential features of subjective experience, and to gain a deeper understanding of the nature of consciousness, perception, and human existence.

Phenomenology is particularly concerned with the ways in which subjective experience is structured, and with the underlying meanings and significance of these structures. Phenomenologists seek to identify the essential features of subjective experience, such as intentionality, embodiment, and lived time, and to explore the ways in which these features give rise to meaning and significance in human life.

Phenomenology has a wide range of applications across many fields, including philosophy, psychology, sociology, education, healthcare, and design. In each of these fields, phenomenology is used to gain a deeper understanding of human experience, and to develop new approaches and strategies that are more focused on the subjective experiences of individuals.

Overall, the purpose of phenomenology is to deepen our understanding of human experience and to provide insights into the nature of consciousness, perception, and human existence. Phenomenology offers a unique perspective on the subjective aspects of human life, and its insights have the potential to transform our understanding of ourselves and the world around us.

Examples of Phenomenology

Phenomenology has many real-life examples across different fields. Here are some examples of phenomenology in action:

• Psychology : In psychology, phenomenology is used to study the subjective experience of individuals with mental health conditions. For example, a phenomenological study might explore the experience of anxiety in individuals with generalized anxiety disorder, or the experience of depression in individuals with major depressive disorder.
• Healthcare : In healthcare, phenomenology is used to explore the subjective experience of patients and to develop more patient-centered approaches to care. For example, a phenomenological study might explore the experience of chronic pain in patients, in order to develop more effective pain management strategies that are based on the patient’s individual experience of pain.
• Education : In education, phenomenology is used to study the subjective experience of students and to develop more effective teaching and learning strategies. For example, a phenomenological study might explore the experience of learning in students, in order to develop teaching methods that are more focused on the individual needs and experiences of learners.
• Business : In business, phenomenology is used to better understand the subjective experience of consumers, and to develop more effective marketing strategies and user experiences. For example, a phenomenological study might explore the experience of using a particular product or service, in order to identify areas for improvement and to create a more user-centered experience.
• Design : In design, phenomenology is used to better understand the subjective experience of users, and to create more user-centered products and experiences. For example, a phenomenological study might explore the experience of using a particular app or website, in order to identify ways to improve the user interface and user experience.

When to use Phenomenological Research

Here are some situations where phenomenological research might be appropriate:

• When you want to explore the meaning and significance of an experience : Phenomenological research is particularly useful when you want to gain a deeper understanding of the subjective experience of individuals and the meanings and significance that they attach to their experiences. For example, if you want to understand the experience of being a first-time parent, phenomenological research can help you explore the various emotions, challenges, and joys that are associated with this experience.
• When you want to develop more patient-centered healthcare: Phenomenological research can be useful in healthcare settings where there is a need to develop more patient-centered approaches to care. For example, if you want to improve pain management strategies for patients with chronic pain, phenomenological research can help you gain a better understanding of the individual experiences of pain and the different ways in which patients cope with this experience.
• When you want to develop more effective teaching and learning strategies : Phenomenological research can be used in education settings to explore the subjective experience of students and to develop more effective teaching and learning strategies that are based on the individual needs and experiences of learners.
• When you want to improve the user experience of a product or service: Phenomenological research can be used in design settings to gain a deeper understanding of the subjective experience of users and to develop more user-centered products and experiences.

Characteristics of Phenomenology

Here are some of the key characteristics of phenomenology:

• Focus on subjective experience: Phenomenology is concerned with the subjective experience of individuals, rather than objective facts or data. Phenomenologists seek to understand how individuals experience and interpret the world around them.
• Emphasis on lived experience: Phenomenology emphasizes the importance of lived experience, or the way in which individuals experience the world through their own unique perspectives and histories.
• Reduction to essence: Phenomenology seeks to reduce the complexities of subjective experience to their essential features or structures, in order to gain a deeper understanding of the nature of consciousness, perception, and human existence.
• Emphasis on description: Phenomenology is primarily concerned with describing the features and structures of subjective experience, rather than explaining them in terms of underlying causes or mechanisms.
• Bracketing of preconceptions: Phenomenology involves bracketing or suspending preconceptions and assumptions about the world, in order to approach subjective experience with an open and unbiased perspective.
• Methodological approach: Phenomenology is both a philosophical and methodological approach, which involves a specific set of techniques and procedures for studying subjective experience.
• Multiple approaches: Phenomenology encompasses a wide range of approaches and variations, including transcendental phenomenology, hermeneutic phenomenology, and existential phenomenology, among others.

Advantages of Phenomenology

Phenomenology offers several advantages as a research approach, including:

• Provides rich, in-depth insights: Phenomenology is focused on understanding the subjective experiences of individuals in a particular context, which allows for a rich and in-depth exploration of their experiences, emotions, and perceptions.
• Allows for participant-centered research: Phenomenological research prioritizes the experiences and perspectives of the participants, which makes it a participant-centered approach. This can help to ensure that the research is relevant and meaningful to the participants.
• Provides a flexible approach: Phenomenological research offers a flexible approach that can be adapted to different research questions and contexts. This makes it suitable for use in a wide range of fields and research areas.
• Can uncover new insights : Phenomenological research can uncover new insights into subjective experience and can challenge existing assumptions and beliefs about a particular phenomenon or experience.
• Can inform practice and policy: Phenomenological research can provide insights that can be used to inform practice and policy decisions in fields such as healthcare, education, and design.
• Can be used in combination with other research approaches : Phenomenological research can be used in combination with other research approaches, such as quantitative methods, to provide a more comprehensive understanding of a particular phenomenon or experience.

Limitations of Phenomenology

Despite the many advantages of phenomenology, there are also several limitations that should be taken into account, including:

• Subjective nature: Phenomenology is focused on subjective experience, which means that it can be difficult to generalize findings to a larger population or to other contexts.
• Limited external validity: Because phenomenological research is focused on a specific context or experience, the findings may have limited external validity or generalizability.
• Potential for researcher bias: Phenomenological research relies heavily on the researcher’s interpretations and analyses of the data, which can introduce potential for bias and subjectivity.
• Time-consuming and resource-intensive: Phenomenological research is often time-consuming and resource-intensive, as it involves in-depth data collection and analysis.
• Difficulty with data analysis: Phenomenological research involves a complex process of data analysis, which can be difficult and time-consuming.
• Lack of standardized procedures: Phenomenology encompasses a range of approaches and variations, which can make it difficult to compare findings across studies or to establish standardized procedures.

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Narrative Inquiry, Phenomenology, and Grounded Theory in Qualitative Research

• First Online: 27 October 2022

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• Md. Sayeed Akhter 5  

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Narrative inquiry, phenomenology, and grounded theory are the basic types of qualitative research. This chapter discusses the three major types of qualitative research—narrative inquiry, phenomenology, and grounded theory. Firstly, this chapter briefly discusses the issue of qualitative research and types. Secondly, it offers a conceptual understanding of narrative inquiry, phenomenology, and grounded theory including their basic characteristics. Finally, the chapter provides an outline of how these three types of qualitative research are applied in the field.

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Qualitative Research: Characteristics, Design, Methods & Examples

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On This Page:

“Not everything that can be counted counts, and not everything that counts can be counted“ (Albert Einstein)

Qualitative research is a process used for the systematic collection, analysis, and interpretation of non-numerical data (Punch, 2013). 

Qualitative research can be used to: (i) gain deep contextual understandings of the subjective social reality of individuals and (ii) to answer questions about experience and meaning from the participant’s perspective (Hammarberg et al., 2016).

Unlike quantitative research, which focuses on gathering and analyzing numerical data for statistical analysis, qualitative research focuses on thematic and contextual information.

Characteristics of Qualitative Research 

Reality is socially constructed.

Qualitative research aims to understand how participants make meaning of their experiences – individually or in social contexts. It assumes there is no objective reality and that the social world is interpreted (Yilmaz, 2013). 

The primacy of subject matter 

The primary aim of qualitative research is to understand the perspectives, experiences, and beliefs of individuals who have experienced the phenomenon selected for research rather than the average experiences of groups of people (Minichiello, 1990).

Variables are complex, interwoven, and difficult to measure

Factors such as experiences, behaviors, and attitudes are complex and interwoven, so they cannot be reduced to isolated variables , making them difficult to measure quantitatively.

However, a qualitative approach enables participants to describe what, why, or how they were thinking/ feeling during a phenomenon being studied (Yilmaz, 2013). 

Emic (insider’s point of view)

The phenomenon being studied is centered on the participants’ point of view (Minichiello, 1990).

Emic is used to describe how participants interact, communicate, and behave in the context of the research setting (Scarduzio, 2017).

Why Conduct Qualitative Research? 

In order to gain a deeper understanding of how people experience the world, individuals are studied in their natural setting. This enables the researcher to understand a phenomenon close to how participants experience it. 

Qualitative research allows researchers to gain an in-depth understanding, which is difficult to attain using quantitative methods. 

An in-depth understanding is attained since qualitative techniques allow participants to freely disclose their experiences, thoughts, and feelings without constraint (Tenny et al., 2022). 

This helps to further investigate and understand quantitative data by discovering reasons for the outcome of a study – answering the why question behind statistics. 

The exploratory nature of qualitative research helps to generate hypotheses that can then be tested quantitatively (Busetto et al., 2020).

To design hypotheses, theory must be researched using qualitative methods to find out what is important in order to begin research. 

For example, by conducting interviews or focus groups with key stakeholders to discover what is important to them. 

Examples of qualitative research questions include: 

• How does stress influence young adults’ behavior?
• What factors influence students’ school attendance rates in developed countries?
• How do adults interpret binge drinking in the UK?
• What are the psychological impacts of cervical cancer screening in women?
• How can mental health lessons be integrated into the school curriculum? 

Collecting Qualitative Data

There are four main research design methods used to collect qualitative data: observations, interviews,  focus groups, and ethnography.

Observations

This method involves watching and recording phenomena as they occur in nature. Observation can be divided into two types: participant and non-participant observation.

In participant observation, the researcher actively participates in the situation/events being observed.

In non-participant observation, the researcher is not an active part of the observation and tries not to influence the behaviors they are observing (Busetto et al., 2020). 

Observations can be covert (participants are unaware that a researcher is observing them) or overt (participants are aware of the researcher’s presence and know they are being observed).

However, awareness of an observer’s presence may influence participants’ behavior. 

Interviews give researchers a window into the world of a participant by seeking their account of an event, situation, or phenomenon. They are usually conducted on a one-to-one basis and can be distinguished according to the level at which they are structured (Punch, 2013). 

Structured interviews involve predetermined questions and sequences to ensure replicability and comparability. However, they are unable to explore emerging issues.

Informal interviews consist of spontaneous, casual conversations which are closer to the truth of a phenomenon. However, information is gathered using quick notes made by the researcher and is therefore subject to recall bias. 

Semi-structured interviews have a flexible structure, phrasing, and placement so emerging issues can be explored (Denny & Weckesser, 2022).

The use of probing questions and clarification can lead to a detailed understanding, but semi-structured interviews can be time-consuming and subject to interviewer bias. 

Focus groups 

Similar to interviews, focus groups elicit a rich and detailed account of an experience. However, focus groups are more dynamic since participants with shared characteristics construct this account together (Denny & Weckesser, 2022).

A shared narrative is built between participants to capture a group experience shaped by a shared context. 

The researcher takes on the role of a moderator, who will establish ground rules and guide the discussion by following a topic guide to focus the group discussions.

Typically, focus groups have 4-10 participants as a discussion can be difficult to facilitate with more than this, and this number allows everyone the time to speak.

Ethnography

Ethnography is a methodology used to study a group of people’s behaviors and social interactions in their environment (Reeves et al., 2008).

Data are collected using methods such as observations, field notes, or structured/ unstructured interviews.

The aim of ethnography is to provide detailed, holistic insights into people’s behavior and perspectives within their natural setting. In order to achieve this, researchers immerse themselves in a community or organization. 

Due to the flexibility and real-world focus of ethnography, researchers are able to gather an in-depth, nuanced understanding of people’s experiences, knowledge and perspectives that are influenced by culture and society.

In order to develop a representative picture of a particular culture/ context, researchers must conduct extensive field work. 

This can be time-consuming as researchers may need to immerse themselves into a community/ culture for a few days, or possibly a few years.

Qualitative Data Analysis Methods

Different methods can be used for analyzing qualitative data. The researcher chooses based on the objectives of their study. 

The researcher plays a key role in the interpretation of data, making decisions about the coding, theming, decontextualizing, and recontextualizing of data (Starks & Trinidad, 2007). 

Grounded theory

Grounded theory is a qualitative method specifically designed to inductively generate theory from data. It was developed by Glaser and Strauss in 1967 (Glaser & Strauss, 2017).

 This methodology aims to develop theories (rather than test hypotheses) that explain a social process, action, or interaction (Petty et al., 2012). To inform the developing theory, data collection and analysis run simultaneously. 

There are three key types of coding used in grounded theory: initial (open), intermediate (axial), and advanced (selective) coding. 

Throughout the analysis, memos should be created to document methodological and theoretical ideas about the data. Data should be collected and analyzed until data saturation is reached and a theory is developed. 

Content analysis

Content analysis was first used in the early twentieth century to analyze textual materials such as newspapers and political speeches.

Content analysis is a research method used to identify and analyze the presence and patterns of themes, concepts, or words in data (Vaismoradi et al., 2013). 

This research method can be used to analyze data in different formats, which can be written, oral, or visual. 

The goal of content analysis is to develop themes that capture the underlying meanings of data (Schreier, 2012). 

Qualitative content analysis can be used to validate existing theories, support the development of new models and theories, and provide in-depth descriptions of particular settings or experiences.

The following six steps provide a guideline for how to conduct qualitative content analysis.

• Define a Research Question : To start content analysis, a clear research question should be developed.
• Identify and Collect Data : Establish the inclusion criteria for your data. Find the relevant sources to analyze.
• Define the Unit or Theme of Analysis : Categorize the content into themes. Themes can be a word, phrase, or sentence.
• Develop Rules for Coding your Data : Define a set of coding rules to ensure that all data are coded consistently.
• Code the Data : Follow the coding rules to categorize data into themes.
• Analyze the Results and Draw Conclusions : Examine the data to identify patterns and draw conclusions in relation to your research question.

Discourse analysis

Discourse analysis is a research method used to study written/ spoken language in relation to its social context (Wood & Kroger, 2000).

In discourse analysis, the researcher interprets details of language materials and the context in which it is situated.

Discourse analysis aims to understand the functions of language (how language is used in real life) and how meaning is conveyed by language in different contexts. Researchers use discourse analysis to investigate social groups and how language is used to achieve specific communication goals.

Different methods of discourse analysis can be used depending on the aims and objectives of a study. However, the following steps provide a guideline on how to conduct discourse analysis.

• Define the Research Question : Develop a relevant research question to frame the analysis.
• Gather Data and Establish the Context : Collect research materials (e.g., interview transcripts, documents). Gather factual details and review the literature to construct a theory about the social and historical context of your study.
• Analyze the Content : Closely examine various components of the text, such as the vocabulary, sentences, paragraphs, and structure of the text. Identify patterns relevant to the research question to create codes, then group these into themes.
• Review the Results : Reflect on the findings to examine the function of the language, and the meaning and context of the discourse. 

Thematic analysis

Thematic analysis is a method used to identify, interpret, and report patterns in data, such as commonalities or contrasts. 

Although the origin of thematic analysis can be traced back to the early twentieth century, understanding and clarity of thematic analysis is attributed to Braun and Clarke (2006).

Thematic analysis aims to develop themes (patterns of meaning) across a dataset to address a research question. 

In thematic analysis, qualitative data is gathered using techniques such as interviews, focus groups, and questionnaires. Audio recordings are transcribed. The dataset is then explored and interpreted by a researcher to identify patterns. 

This occurs through the rigorous process of data familiarisation, coding, theme development, and revision. These identified patterns provide a summary of the dataset and can be used to address a research question.

Themes are developed by exploring the implicit and explicit meanings within the data. Two different approaches are used to generate themes: inductive and deductive. 

An inductive approach allows themes to emerge from the data. In contrast, a deductive approach uses existing theories or knowledge to apply preconceived ideas to the data.

Phases of Thematic Analysis

Braun and Clarke (2006) provide a guide of the six phases of thematic analysis. These phases can be applied flexibly to fit research questions and data. 

Template analysis

Template analysis refers to a specific method of thematic analysis which uses hierarchical coding (Brooks et al., 2014).

Template analysis is used to analyze textual data, for example, interview transcripts or open-ended responses on a written questionnaire.

To conduct template analysis, a coding template must be developed (usually from a subset of the data) and subsequently revised and refined. This template represents the themes identified by researchers as important in the dataset. 

Codes are ordered hierarchically within the template, with the highest-level codes demonstrating overarching themes in the data and lower-level codes representing constituent themes with a narrower focus.

A guideline for the main procedural steps for conducting template analysis is outlined below.

• Familiarization with the Data : Read (and reread) the dataset in full. Engage, reflect, and take notes on data that may be relevant to the research question.
• Preliminary Coding : Identify initial codes using guidance from the a priori codes, identified before the analysis as likely to be beneficial and relevant to the analysis.
• Organize Themes : Organize themes into meaningful clusters. Consider the relationships between the themes both within and between clusters.
• Produce an Initial Template : Develop an initial template. This may be based on a subset of the data.
• Apply and Develop the Template : Apply the initial template to further data and make any necessary modifications. Refinements of the template may include adding themes, removing themes, or changing the scope/title of themes. 
• Finalize Template : Finalize the template, then apply it to the entire dataset. 

Frame analysis

Frame analysis is a comparative form of thematic analysis which systematically analyzes data using a matrix output.

Ritchie and Spencer (1994) developed this set of techniques to analyze qualitative data in applied policy research. Frame analysis aims to generate theory from data.

Frame analysis encourages researchers to organize and manage their data using summarization.

This results in a flexible and unique matrix output, in which individual participants (or cases) are represented by rows and themes are represented by columns. 

Each intersecting cell is used to summarize findings relating to the corresponding participant and theme.

Frame analysis has five distinct phases which are interrelated, forming a methodical and rigorous framework.

• Familiarization with the Data : Familiarize yourself with all the transcripts. Immerse yourself in the details of each transcript and start to note recurring themes.
• Develop a Theoretical Framework : Identify recurrent/ important themes and add them to a chart. Provide a framework/ structure for the analysis.
• Indexing : Apply the framework systematically to the entire study data.
• Summarize Data in Analytical Framework : Reduce the data into brief summaries of participants’ accounts.
• Mapping and Interpretation : Compare themes and subthemes and check against the original transcripts. Group the data into categories and provide an explanation for them.

Preventing Bias in Qualitative Research

To evaluate qualitative studies, the CASP (Critical Appraisal Skills Programme) checklist for qualitative studies can be used to ensure all aspects of a study have been considered (CASP, 2018).

The quality of research can be enhanced and assessed using criteria such as checklists, reflexivity, co-coding, and member-checking. 

Co-coding 

Relying on only one researcher to interpret rich and complex data may risk key insights and alternative viewpoints being missed. Therefore, coding is often performed by multiple researchers.

A common strategy must be defined at the beginning of the coding process  (Busetto et al., 2020). This includes establishing a useful coding list and finding a common definition of individual codes.

Transcripts are initially coded independently by researchers and then compared and consolidated to minimize error or bias and to bring confirmation of findings. 

Member checking

Member checking (or respondent validation) involves checking back with participants to see if the research resonates with their experiences (Russell & Gregory, 2003).

Data can be returned to participants after data collection or when results are first available. For example, participants may be provided with their interview transcript and asked to verify whether this is a complete and accurate representation of their views.

Participants may then clarify or elaborate on their responses to ensure they align with their views (Shenton, 2004).

This feedback becomes part of data collection and ensures accurate descriptions/ interpretations of phenomena (Mays & Pope, 2000). 

Reflexivity in qualitative research

Reflexivity typically involves examining your own judgments, practices, and belief systems during data collection and analysis. It aims to identify any personal beliefs which may affect the research. 

Reflexivity is essential in qualitative research to ensure methodological transparency and complete reporting. This enables readers to understand how the interaction between the researcher and participant shapes the data.

Depending on the research question and population being researched, factors that need to be considered include the experience of the researcher, how the contact was established and maintained, age, gender, and ethnicity.

These details are important because, in qualitative research, the researcher is a dynamic part of the research process and actively influences the outcome of the research (Boeije, 2014). 

Reflexivity Example

Who you are and your characteristics influence how you collect and analyze data. Here is an example of a reflexivity statement for research on smoking. I am a 30-year-old white female from a middle-class background. I live in the southwest of England and have been educated to master’s level. I have been involved in two research projects on oral health. I have never smoked, but I have witnessed how smoking can cause ill health from my volunteering in a smoking cessation clinic. My research aspirations are to help to develop interventions to help smokers quit.

Establishing Trustworthiness in Qualitative Research

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability.

Credibility in Qualitative Research

Credibility refers to how accurately the results represent the reality and viewpoints of the participants.

To establish credibility in research, participants’ views and the researcher’s representation of their views need to align (Tobin & Begley, 2004).

To increase the credibility of findings, researchers may use data source triangulation, investigator triangulation, peer debriefing, or member checking (Lincoln & Guba, 1985). 

Transferability in Qualitative Research

Transferability refers to how generalizable the findings are: whether the findings may be applied to another context, setting, or group (Tobin & Begley, 2004).

Transferability can be enhanced by giving thorough and in-depth descriptions of the research setting, sample, and methods (Nowell et al., 2017). 

Dependability in Qualitative Research

Dependability is the extent to which the study could be replicated under similar conditions and the findings would be consistent.

Researchers can establish dependability using methods such as audit trails so readers can see the research process is logical and traceable (Koch, 1994).

Confirmability in Qualitative Research

Confirmability is concerned with establishing that there is a clear link between the researcher’s interpretations/ findings and the data.

Researchers can achieve confirmability by demonstrating how conclusions and interpretations were arrived at (Nowell et al., 2017).

This enables readers to understand the reasoning behind the decisions made. 

Audit Trails in Qualitative Research

An audit trail provides evidence of the decisions made by the researcher regarding theory, research design, and data collection, as well as the steps they have chosen to manage, analyze, and report data. 

The researcher must provide a clear rationale to demonstrate how conclusions were reached in their study.

A clear description of the research path must be provided to enable readers to trace through the researcher’s logic (Halpren, 1983).

Researchers should maintain records of the raw data, field notes, transcripts, and a reflective journal in order to provide a clear audit trail. 

Discovery of unexpected data

Open-ended questions in qualitative research mean the researcher can probe an interview topic and enable the participant to elaborate on responses in an unrestricted manner.

This allows unexpected data to emerge, which can lead to further research into that topic. 

Flexibility

Data collection and analysis can be modified and adapted to take the research in a different direction if new ideas or patterns emerge in the data.

This enables researchers to investigate new opportunities while firmly maintaining their research goals. 

Naturalistic settings

The behaviors of participants are recorded in real-world settings. Studies that use real-world settings have high ecological validity since participants behave more authentically. 

Limitations

Time-consuming .

Qualitative research results in large amounts of data which often need to be transcribed and analyzed manually.

Even when software is used, transcription can be inaccurate, and using software for analysis can result in many codes which need to be condensed into themes. 

Subjectivity 

The researcher has an integral role in collecting and interpreting qualitative data. Therefore, the conclusions reached are from their perspective and experience.

Consequently, interpretations of data from another researcher may vary greatly. 

Limited generalizability

The aim of qualitative research is to provide a detailed, contextualized understanding of an aspect of the human experience from a relatively small sample size.

Despite rigorous analysis procedures, conclusions drawn cannot be generalized to the wider population since data may be biased or unrepresentative.

Therefore, results are only applicable to a small group of the population. 

Extraneous variables

Qualitative research is often conducted in real-world settings. This may cause results to be unreliable since extraneous variables may affect the data, for example:

• Situational variables : different environmental conditions may influence participants’ behavior in a study. The random variation in factors (such as noise or lighting) may be difficult to control in real-world settings.
• Participant characteristics : this includes any characteristics that may influence how a participant answers/ behaves in a study. This may include a participant’s mood, gender, age, ethnicity, sexual identity, IQ, etc.
• Experimenter effect : experimenter effect refers to how a researcher’s unintentional influence can change the outcome of a study. This occurs when (i) their interactions with participants unintentionally change participants’ behaviors or (ii) due to errors in observation, interpretation, or analysis. 

What sample size should qualitative research be?

The sample size for qualitative studies has been recommended to include a minimum of 12 participants to reach data saturation (Braun, 2013).

Are surveys qualitative or quantitative?

Surveys can be used to gather information from a sample qualitatively or quantitatively. Qualitative surveys use open-ended questions to gather detailed information from a large sample using free text responses.

The use of open-ended questions allows for unrestricted responses where participants use their own words, enabling the collection of more in-depth information than closed-ended questions.

In contrast, quantitative surveys consist of closed-ended questions with multiple-choice answer options. Quantitative surveys are ideal to gather a statistical representation of a population.

What are the ethical considerations of qualitative research?

Before conducting a study, you must think about any risks that could occur and take steps to prevent them. Participant Protection : Researchers must protect participants from physical and mental harm. This means you must not embarrass, frighten, offend, or harm participants. Transparency : Researchers are obligated to clearly communicate how they will collect, store, analyze, use, and share the data. Confidentiality : You need to consider how to maintain the confidentiality and anonymity of participants’ data.

What is triangulation in qualitative research?

Triangulation refers to the use of several approaches in a study to comprehensively understand phenomena. This method helps to increase the validity and credibility of research findings. 

Types of triangulation include method triangulation (using multiple methods to gather data); investigator triangulation (multiple researchers for collecting/ analyzing data), theory triangulation (comparing several theoretical perspectives to explain a phenomenon), and data source triangulation (using data from various times, locations, and people; Carter et al., 2014).

Why is qualitative research important?

Qualitative research allows researchers to describe and explain the social world. The exploratory nature of qualitative research helps to generate hypotheses that can then be tested quantitatively.

In qualitative research, participants are able to express their thoughts, experiences, and feelings without constraint.

Additionally, researchers are able to follow up on participants’ answers in real-time, generating valuable discussion around a topic. This enables researchers to gain a nuanced understanding of phenomena which is difficult to attain using quantitative methods.

What is coding data in qualitative research?

Coding data is a qualitative data analysis strategy in which a section of text is assigned with a label that describes its content.

These labels may be words or phrases which represent important (and recurring) patterns in the data.

This process enables researchers to identify related content across the dataset. Codes can then be used to group similar types of data to generate themes.

What is the difference between qualitative and quantitative research?

Qualitative research involves the collection and analysis of non-numerical data in order to understand experiences and meanings from the participant’s perspective.

This can provide rich, in-depth insights on complicated phenomena. Qualitative data may be collected using interviews, focus groups, or observations.

In contrast, quantitative research involves the collection and analysis of numerical data to measure the frequency, magnitude, or relationships of variables. This can provide objective and reliable evidence that can be generalized to the wider population.

Quantitative data may be collected using closed-ended questionnaires or experiments.

What is trustworthiness in qualitative research?

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability. 

Credibility refers to how accurately the results represent the reality and viewpoints of the participants. Transferability refers to whether the findings may be applied to another context, setting, or group.

Dependability is the extent to which the findings are consistent and reliable. Confirmability refers to the objectivity of findings (not influenced by the bias or assumptions of researchers).

What is data saturation in qualitative research?

Data saturation is a methodological principle used to guide the sample size of a qualitative research study.

Data saturation is proposed as a necessary methodological component in qualitative research (Saunders et al., 2018) as it is a vital criterion for discontinuing data collection and/or analysis. 

The intention of data saturation is to find “no new data, no new themes, no new coding, and ability to replicate the study” (Guest et al., 2006). Therefore, enough data has been gathered to make conclusions.

Why is sampling in qualitative research important?

In quantitative research, large sample sizes are used to provide statistically significant quantitative estimates.

This is because quantitative research aims to provide generalizable conclusions that represent populations.

However, the aim of sampling in qualitative research is to gather data that will help the researcher understand the depth, complexity, variation, or context of a phenomenon. The small sample sizes in qualitative studies support the depth of case-oriented analysis.

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Examining characteristics of descriptive phenomenological nursing studies: A scoping review

Affiliation.

• 1 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
• PMID: 35405036
• PMCID: PMC9320962
• DOI: 10.1111/jan.15244

Aim: To evaluate the characteristics and methodology consistency in nursing research with descriptive phenomenological design.

Design: Scoping review methodology.

Data sources: Three electronic databases (CINAHL, Embase, PubMed) were systematically searched for qualitative studies with a descriptive phenomenological design published in nursing journals between January 2021 and December 2021.

Review methods: Quality appraisal of each study was conducted using the Critical Appraisal Skills Programme checklist. Data were extracted and presented narratively based on research objective, design justification and consistency, theoretical framework, sampling method and sample size, data collection method, data analysis approach and presentation of findings.

Results: One hundred and three studies were included in the review. Overall, the characteristics of the studies are mostly consistent with Husserl's phenomenology approach in terms of research objectives, the use of other theoretical frameworks, sampling and data collection methods. However, the findings revealed several inconsistencies between research design and data analysis techniques, the lack of design justification and the lack of mention of bracketing.

Conclusions: Apart from the need for more research and standardized guidelines to clarify the various qualitative research methods, future nurse researchers are urged to provide more methodological details when publishing a descriptive phenomenological study so that readers can examine the effectiveness and quality of the method.

Keywords: methods; nursing research; peer-review; qualitative research; scoping review.

© 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.

Publication types

• Nursing Research* / methods
• Qualitative Research

• Open access
• Published: 26 April 2024

Factors influencing the development of nursing professionalism: a descriptive qualitative study

• Xingyue He 1 ,
• Huili Cao 2 ,
• Linbo Li 1 ,
• Yanming Wu 1 &
• Hui Yang 1 , 3  

BMC Nursing volume  23 , Article number:  283 ( 2024 ) Cite this article

82 Accesses

Metrics details

The shortage of nurses threatens the entire healthcare system, and nursing professionalism can improve nurse retention and enhance the quality of care. However, nursing professionalism is dynamic, and the factors influencing its development are not fully understood.

A qualitative descriptive study was conducted. Using maximum variation and purposive sampling, 14 southern and northern China participants were recruited. Semi-structured interviews were conducted from May 2022 to August 2023 in face-to-face conversations in offices in the workplace or via voice calls. The interviews were transcribed verbatim and analyzed via thematic analysis.

Three main themes emerged: (1) nourishment factors: promoting early sprouting; (2) growth factors: the power of self-activation and overcoming challenges; and (3) rootedness factors: stability and upward momentum. Participants described the early acquisition of nursing professionalism as derived from personality traits, family upbringing, and school professional education, promoting the growth of nursing professionalism through self-activation and overcoming challenges, and maintaining the stable and upward development of nursing professionalism through an upward atmosphere and external motivation.

We revealed the dynamic factors that influence the development of nursing professionalism, including “nourishment factors”, “growth factors”, and “rootedness factors”. Our findings provide a foundation for future development of nursing professionalism cultivation strategies. Nursing administrators can guide the development of nurses’ professionalism from many angles according to the stage they are in, and the development of professionalism deserves more attention. In the future, we can no longer consider the development of nursing professionalism solely as the responsibility of individual nurses; the power of families, organizations, and society is indispensable to jointly promoting nursing professionalism among nurses.

Peer Review reports

Introduction

The number of nurses leaving hospitals has been increasing, and the shortage of nurses is a significant problem faced globally [ 1 , 2 ]. According to earlier studies, professionalism improves nurses’ clinical performance [ 3 ] and positively affects their adaptability (Park et al. 2021), reducing nurses’ burnout and turnover rates. Therefore, fostering professionalism in nurses and the factors that influence the development of professionalism are essential to producing effective nurses.

Nurses comprise the largest group of healthcare providers [ 4 ]. Nurses are a vital part of the healthcare system, with 27.9 million caregivers worldwide, according to the World Health Organisation’s Global Status of Nursing Report 2020 [ 5 ]. However, an unbalanced number of nurses and patients, high work pressure, and the fact that nurses face patients’ suffering, grief, and death each day have exacerbated burnout and led to the resignation of many nurses [ 6 ]. The COVID-19 outbreak has further exposed the shortage of nursing staff, especially in low- and middle-income countries where the scarcity of nurses remains acute. The lack of nurses not only has direct negative impacts on patients but also poses a threat to the entire healthcare system.

Nursing professionalism is closely associated with nurse retention and nursing practice [ 7 , 8 , 9 ]. Nursing professionalism is defined as providing individuals care based on the principles of professionalism, caring, and altruism [ 6 ]. As a belief in the profession, nursing professionalism is a systematic view of nursing that represents the practice standards and value orientation nurses utilize [ 10 , 11 ]. According to previous research, nursing professionalism can enhance nurses’ clinical performance and positively impact their adaptability, reducing job burnout and turnover rates [ 6 ]. Furthermore, as nurses are the ones who provide “presence” care, cultivating nursing professionalism among nurses can promote interactions between nurses and patients, further improving the quality of nursing care and patient outcomes and injecting new vitality and hope into the entire healthcare system [ 12 ].

However, nursing professionalism is dynamic, and the cultural context also shapes nursing professionalism to some extent, leading to ambiguity in the factors influencing nursing professionalism. Initially perceived as mere “caregivers,” nurses have transformed into “professional practitioners,” emphasizing the nursing field’s seriousness and distinct professional characteristics [ 13 , 14 ]. Nursing professionalism is also the foundation for developing the nursing profession [ 15 ]. Focusing on the factors influencing the development of nursing professionalism is one of the essential elements in providing an optimal environment for nurses’ professional growth and development in clinical practice [ 16 ]. Although some scales, such as the Hall Professionalism Inventory (HPI) [ 17 ], Miller’s Wheel of Professionalism in Nursing (BIPN) [ 18 ], Hwang’s Nurse Professional Values Scale (NPVS) [ 19 ], and Fantahun’s Nursing Professionalism Questionnaire [ 20 ] have been used to measure factors influencing the awareness, attitudes, and behaviors, they have their limitations. They struggle to encompass professionalism’s multidimensionality and complexity fully, overlook multilayered background factors, are constrained by standardization issues, may not account for individual differences, and often fail to capture dynamic changes over time [ 21 , 22 , 23 ].Compared with quantitative research methods, qualitative research can provide insights into the “unique phenomenology and context of the individual being tested,” which can help the researcher stay close to nurses’ professional lives during the research process and understand the personal, familial, and societal factors that influence nursing professionalism [ 24 ].Additionally, the understanding of nursing professionalism varies across different cultural and social contexts. In Western countries, research on nursing professionalism tends to incorporate professionalism across the entire nursing industry. In contrast, within China, research on professionalism tends to focus more on the individual level, with less attention to the perspectives of groups or the industry [ 25 ]. Therefore, through qualitative research, we can present nursing professionalism in a deeper, more affluent, and more transparent manner. Secondly, it is more authentic to understand the factors influencing nursing professionalism by directly obtaining relevant information from the perspective of nurses through dialogue with research participants as mutual subjects.

Given these considerations, we aim to answer the question of what factors influence the development of nursing professionalism. To provide more targeted strategies and recommendations for optimizing the nursing professional environment, enhancing nurses’ job satisfaction, improving t nursing quality, and contributing sustainably to patients’ and nurses’ health and well-being.

To explore the factors influencing the development of nursing professionalism. By incorporating nurses’ perspectives, we aim to improve our understanding of professionalism as individual, family, and socio-cultural influences. With this knowledge, we can inform strategies for developing nursing professionalism.

Study design

A descriptive qualitative approach was adopted based on naturalistic inquiry [ 26 , 27 ] and analyzed using the thematic analysis method described by Braun and Clarke [ 28 ]. Semi-structured interviews were conducted between May 2022 and August 2023 with nurses in southern and northern China hospitals. Furthermore, the research findings were reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) (Supplementary Material S1 ) [ 29 ].

Participants and settings

We chose hospital nurses as study participants based on considerations of their nursing experience. Firstly, the Chinese government has implemented a policy of accountable holistic care, whereby registered nurses take on the entire cycle of a patient’s physical, mental, and spiritual care [ 30 ]. Secondly, new nurses must undergo two weeks to one month of basic training and a 12–24 month specialty rotation (for most new nurses who graduated before 2016, their training was completed by their departments). During this time, they are under the supervision of a superior nurse for holistic and responsible care [ 31 ].

We used maximum variance purposive sampling to recruit a heterogeneous sample of information-rich key participants [ 32 ]. Participant selection considered variations in role classification, years of experience, and educational levels of Chinese nurses [ 33 ]. The purposive variation allowed the discovery of Chinese nurses’ unique perceptions of nursing professionalism. Inclusion criteria: (1) registered nurses (providing direct services to patients within the unit), nurse managers (directly supervising and guiding the clinical work of registered nurses), nursing department managers (managing nurse managers throughout the hospital), with at least one year of nursing experience; (2) voluntary participation. Exclusion criteria: (1) nurses not working during the hospital’s study period (holidays, maternity leave, or sick leave); (2) refresher nurses.

Data collection

The same researcher conducted each interview to ensure consistency. Before the interviews, the interviewers systematically conducted in-depth theoretical research on relevant studies. The interviewer received guidance from professors with rich experience in qualitative research and undertook practice interviews to improve her interviewing skills. Interviewers encouraged interviewees to talk freely about their perceptions and used an interview guide (Supplementary Material S2 ), which was based on the findings of previous research on the conceptual analysis of nursing professionalism [ 6 ]. The questions were open-ended and general; ample space was left between questions to respond to interviewees’ comments. Semi-structured interviews began with a brief introduction to the topic (e.g., definition and explanation of nursing professionalism). Although the interviewer had an agenda for discussion, this format allowed the interviewee to deviate from this agenda and direct follow-up questions [ 34 ].

All interviews were conducted from May 2022 to August 2023 in face-to-face conversations in offices in the workplace or via voice calls and lasted between 35 and 94 min. Participants were asked to complete the main demographic questionnaire at the end of the interviews. The researcher recorded participants’ expressions, body language, and pauses during the interviews. Memos written by the researcher during the study were also used as analytical material.

Data analysis

For rigorous qualitative sampling and data saturation, Braun et al. [ 35 ] propose that qualitative researchers require a sample appropriate to the research questions and the theoretical aims of the study and that can provide an adequate amount of data to answer the question and analyze the issue entirely. We reached thematic saturation after 14 interviews when no new codes or themes emerged.

A thematic analysis approach was used, following the phases described by Braun and Clarke [ 28 ]. The analysis comprised six stages: (1) immersing in the data; (2) creating initial codes; (3) identifying themes; (4) reviewing; (5) defining and labeling these themes; and (6) finally, composing the analysis report. Two researchers transcribed and analyzed the textual data. In the first stage, the researchers carefully read the interview transcripts to familiarize themselves with the depth and breadth of the content. In the second stage, preliminary codes were generated based on the research questions, initial interpretation of the data, and discussion of initial emerging patterns. At this stage, ensuring that all actual data extracts were coded and organized within each code was necessary. In addition, the following principles were used as guidelines: (1) code for as many potential themes/patterns as possible; (2) code extracts of data inclusively, i.e., preserve small sections of the surrounding data when relevant; and (3) code individual extracts of data for as many different “themes” as appropriate [ 36 ]. In the third phase, the two authors analyzed the initial codes, sorted them into potential themes, and debated their meanings and emerging patterns to reach a consensus. This phase, which refocused the analysis on the broader level of themes rather than that of codes, involved sorting the different codes into potential themes. In the fourth stage, reviewing themes ensures that the data supports the themes and allows an iterative process between different levels of abstraction without losing grounding in the raw data. Finally, defining the “essence” of each theme during the development of the main themes by identifying the “story” as consistent with the data and the research question while ensuring that the themes did not overlap but still fit together in the overall “story” of the data. It told the “story” by writing analytical narratives with illustrative quotes.

This study achieved credibility by selecting a heterogeneous sample, performing member checks, and taking field notes [ 37 ]. This study ensured dependability by verifying the findings with the researchers and participants, appropriately numbering the direct quotations (e.g., DN1), and comparing the results with the previous literature. This study established confirmability via audit trails [ 38 ] and the comprehensive reporting of all research processes. This study ensured transferability by describing the data collection process and seeking a heterogeneous sample.

Fourteen participants were interviewed (the demographic information is presented in Table  1 ). The thematic analysis identifies three major themes (Fig.  1 ). These interconnected topics illuminate the growth process and factors influencing nursing professionalism. The first theme, “nourishment factors: promoting early sprouting,” includes personal traits, family upbringing, and professional education at school and emphasizes early factors influencing nursing professionalism. The second theme, “growth factors: the power of self-activation and overcoming challenges,” included self-activation and overcoming difficulties, focusing on the dual attributes of the growth process of nursing professionalism. The final theme, “rootedness factors: stability and upward momentum,” includes an upward atmosphere and external motivation and explores the factors that maintain the stability and sustainability of nursing professionalism.

Factors influencing the development of nursing professionalism

Nourishment factors: promoting early sprouting

Personal traits.

Personal traits are called “nature” [ 23 ]. There exists a close connection between personal traits and professional behavior. When nurses confront patients’ physiological and emotional needs, innate qualities like kindness and compassion predispose them to be more sensitive to patients’ suffering and needs. Nursing professionalism transcends mere task fulfillment; this inner emotional drive compels nurses to fulfill their duties and engage in nursing work out of a genuine desire and sense of responsibility, practicing the nursing mission nobly. Thus, whether individual traits align with the nursing mission profoundly influences the nursing professionalism of nurses in their work.

“At 32, I became a head nurse, full of vitality and boundless enthusiasm, particularly compassion. I have no idea where this compassion comes from.” (ND1) .

Family upbringing

Education begins in the family, and it is through family education that nurses develop an early sense of professionalism. China has a “family culture” that defines the responsibility of family education. The study participants recalled that in childhood, the “living” nature of family education shaped early professionalism, in which the concepts of “kindness” and “altruism” were acquired through interactions with family members.

“My mother was an early childhood educator, and when she told me fairy tales, it was to promote kindness. Loving others and being selfless, you can’t be a bad person. That’s what altruistic education is about.” (ND1) .

The impact of family education on the acquisition of nursing professionalism extends into adulthood. In Chinese Confucianism and collectivism, family members usually have close emotional ties, and this “strong bond” family structure promotes nurses’ understanding and care for others and their ability to be wiser and more caring in the nursing profession. This strong bonding plays a catalytic role in the emergence of nursing professionalism.

“Some nurses are very adept at expressing care, perhaps because grandparents and parents live together. Since childhood, parents have taught them how to express care.” (N4) .

School professional education

Nursing professionalism is further acquired through professional education in schools. Nursing professional education emphasizes respect and care for patients, adherence to social responsibility, and the integration of traditional Chinese oriental medical thought and Western nursing concepts, internalized into behaviors to form the concept of professional nursing spirit. Participants indicated that the virtues of dedication, responsibility, respect, and caring that permeate school professional education are incorporated by nurses into nursing practice.

“The best nursing comes from the heart. When I was administering injections, I thought about how to alleviate the patient’s pain. Later, I learned that if I entered the needle quickly, it would be less painful, so I often practiced in the operating room.” (N8) .

Other participants also shared that they felt positively guided by professional education at school, constructing a comprehensive nursing philosophy system within the educational context. They realized that nursing is a multidisciplinary field encompassing human care, social responsibility, and ethical values.

“University was my most unforgettable learning experience. I studied 36 courses here, including nursing aesthetics, literature, sociology, ethics, education, etc. I realized that the nursing work we engage in has such rich depth! has become an invaluable treasure in my nursing career.” (ND1) .

Growth factors: the power of self-activation and overcoming challenges

Self-activation, professional benefits.

Professional benefit perception refers to the advantages nurses perceive while engaging in nursing work, acknowledging that their involvement in nursing promotes their holistic personal growth [ 39 ]. Consistent with traditional perspectives, this study finds that nurses generate a sense of professional benefit through both “tangible benefits” and “spiritual benefits,” recognizing the value and significance of nursing work, thereby furthering the development of nursing professionalism.

The dynamic updating achieves “tangible benefits.” Nurses require outstanding professional competence and ongoing continuing education. Participants mentioned that nurses utilize their professional knowledge and clinical experience to save patients’ lives, and exceptional professional competence can rekindle their enthusiasm for work. Continuous and dynamic continuing education, supplementing the latest technology and knowledge in the nursing field, can generate positive professional emotions.

“There’s only one doctor on duty at night, and nurses are the first responders when we encounter emergencies. Even before the doctor arrives in the ward, I must act quickly and urgently. Every time I bring a patient back from the brink of death, I feel excited throughout the night.” (N6) . “Experience is und oubtedly important. I’ve been working for over a decade, and I undergo training every year. No one likes stagnation; we can forge ahead only by continually moving forward.” (NM3) .

Self-worth realization through “spiritual benefits.” Experiencing a sense of value in nursing practice provides nurses with positive reinforcement, enhancing nursing professionalism behavior. Moreover, as healthcare practitioners, the ability of relatives and family members to benefit from it distinguishes Chinese nurses’ unique approach to self-worth realization from nurses in other countries. This unexpected feedback, whether in material or spiritual forms, enables nurses to fulfill their sense of worth.

“Sometimes, friends and relatives ask me about hospitalization-related questions, and I am more than willing to help them.” (N2) . “ I changed my mother’s gastric tube without any complications.” (NM3) .

Professional identity

Nursing professional identity refers to nurses acknowledging their work and affirming their self-worth [ 40 ]. This study defines professional identity as a gradual “process” and a “state.”

One participant mentioned that professional identity is a psychological “process” that nurses develop and confirm their professional roles through their personal experiences. It is closely related to the individual experiences of nurses. Nurses’ gradual recognition of their work prompts them to progress and develop a positive work attitude and professionalism.

“Gradually, I discovered that being a nurse makes me realize my significance, which keeps me moving forward, time and time again.” (ND2) .

Simultaneously, as a “state,” professional identity represents the degree to which nurses identify with the nursing profession. This “state” of professional identity reflects nursing professionalism’s long-term accumulation and formation. It indicates nurses’ long-standing dedication and emotional involvement in nursing, leading to higher professional competence and a sense of responsibility in their work.

“It’s not just a job to make a living; it’s about wholeheartedly identifying with this profession, unleashing one’s potential, which results in better professional conduct.”(N5) .

Overcoming challenges

Balancing roles.

Balancing roles refers to the equilibrium individuals establish between their roles in the nursing profession, family, and organization. Nursing professional roles are inherently multifaceted, and when faced with multiple responsibilities, such as family demands and organizational tasks, nurses must balance these roles. The tension and complexity between personal and organizational roles can potentially inhibit their emotions and professional motivation. However, in China, families are tightly knit, and strong family support can help reconcile this tension.

“To be a good nursing department manager, you need strong family support. The commitment to one’s career and the dedication to family don’t always align. For instance, my job keeps me busy regarding family matters, and I have limited time to care for my children. My parents-in-law take care of them more. I do rounds every Sunday, and the phone never stops ringing, even on my days off. There’s no way around it; this is the role I’ve taken on. Family support allows me to work with peace of mind.” (ND3) .

Adaptation organization

Nurses also face challenges in adapting to organizational systems. These adaptability challenges include rapidly learning new technologies, processes, and the culture of practice in different departments. This “unfamiliarity” impedes the manifestation of nursing professionalism. Participants indicated that the inability to adapt to clinical work quickly affects new graduate nurses’ transition into practice. Initially, there is a “honeymoon period” when becoming a registered nurse, but as actual capabilities do not align with expected performance, the excitement gradually wanes.

“I didn’t know the routine procedures in ophthalmology, I couldn’t measure eye pressure, and I didn’t know how to perform eye injections. I was terrified, which brought various challenges when I started working.” (N4) .

Furthermore, nurses must adapt to the practice culture of “this is how things are done” and “it’s always been done this way” in their workplace. Due to the promotion and title system requirements in Chinese hospitals, nurses with several years of experience often need to rotate through departments such as Intensive Care Unit and emergency for a period. The differences in operations and management between different departments also frustrate these nurses during rotations. However, a certain social prestige is attached, making it challenging for the nurses from the original department to provide direct guidance to the rotating nurses, leading to isolation for the latter in new departments.

“A blank slate regarding the department’s hierarchy, administrative procedures, and so on.” (N3) . “Although there’s a set of procedures, mostly similar, it’s the slight differences that always set me apart.” (N6) .

Rootedness factors: stability and upward momentum

Upward atmosphere, peer support.

Peer support has a positive impact on nursing professionalism. Peers are individuals of the same age group who have formed a connection due to shared experiences in similar socio-cultural environments, with emotional support, mutual assistance, and understanding constituting the core elements of peer support [ 41 ]. Firstly, nursing work often involves highly stressful situations, including heavy workloads, complex patient conditions, and urgent medical cases. Peer support provides emotional support, allowing nurses to find comfort and encouragement when facing stress and difficulties. Secondly, peer support cultivates a positive work atmosphere and team spirit. In a mutually supportive, trusting, and cooperative team, nurses are more likely to experience a sense of accomplishment in their work. They feel they are not isolated but part of a united and collaborative whole. Furthermore, peer support also promotes professional development and knowledge exchange among nurses. In an open and supportive team environment, nurses are more willing to share their experiences and knowledge, learn from each other, and grow.

“The spirit influences the spirit, especially those of my age group who have left a deep impression on me with their admirable qualities in their work. It makes me reflect on my shortcomings in my work and constantly strive to improve and adjust myself.” (N2) .

Intergenerational role models

Inter-generational refers to the relationships between generations [ 42 ]. In nursing practice, inter-generational relationships exist, such as those among nurses of different ages and levels of experience. This study’s inter-generational role models include managerial role models and senior nurses.

Participants believe that managers’ professionalism influences subordinate nurses’ attitudes and performance. The professionalism of managers not only plays a guiding and leadership role in daily work but, more importantly, sets an example, inspiring and encouraging subordinate nurses who are willing to follow and inherit professionalism.

“The department’s leadership has a significant impact on professionalism. When managers have a strong sense of professionalism, the nurses they oversee follow suit. Because leadership represents the management level and higher things, it’s difficult for things at the bottom to go well if it’s not well-controlled at the top.” (N8) .

On the other hand, senior nurses, as role models within the nursing generation, also significantly impact the upward development of professionalism. Senior nurses’ rich experience and professional competence guide new nurses to maintain a rigorous attitude at work. New nurses often draw from and learn senior nurses’ work attitudes and behaviors, catalyzing the elevation of nursing professionalism.

“Senior nurses have a role model effect because new nurses learn from the older ones. If senior nurses work rigorously and new nurses make mistakes or lack a sense of dedication, they will immediately point it out. Over time, you also become more rigorous.” (NM3) .

Perceived professional respect

Societal respect for nursing work creates an atmosphere of care and emphasis on nursing. Nurses within this atmosphere become aware of the importance of nursing work and the profound significance of patient care. They are inclined to exhibit positive nursing professionalism behaviors to meet the expectations of society and the general public.

“The nursing industry has experienced the COVID-19 pandemic, and during the anti-epidemic efforts, nurses were at the forefront, risking their lives to care for patients, receiving acclaim from patients, doctors, and the public.” (N2) .

Professional respect is the manifestation of nurses’ self-acknowledgment of nursing values. It is more than an external acknowledgment; it is an internal affirmation. This mutual respect aligns nurses’ professional and societal worth, catalyzing increased potential and motivation.

External motivation

The stability of nursing professionalism relies on external resources, including the diverse support from nursing managers and the guidance of national healthcare policies. Nursing managers are the frontline leaders who interact with nurses, and their support serves as a management tool and a direct means to sustain nursing professionalism. This multifaceted support encompasses economic incentives such as compensation and reward mechanisms. It extends to non-material motivations such as career advancement opportunities, adequate staffing, modern equipment provision, and fair and equitable treatment form crucial aspects of managerial support. Providing nurses with stable external support creates a space to focus on their professional mission and responsibilities, thus maintaining the stability of nursing professionalism.

“Economic foundation determines the superstructure(spiritual world)).” (NM1) .

Furthermore, the guidance of national healthcare policies serves as a beacon for the development of the nursing profession. At the national level, healthcare policies can regulate the organization and operation of healthcare systems and services, providing nurses with a more stable and favorable working environment. This environment allows nurses to fulfill their professional roles better and maximize their value. The environmental changes brought about by policy guidance offer nurses more favorable professional conditions, effectively promoting the upward development of nursing professionalism.

“Government documents summarize the needs of our society, and nursing will continue to improve in the direction of policy guidance.” (NM3) .

Discussions

This study provides insights for understanding the factors that influence the development of nursing professionalism. We emphasize the themes of early nourishment factors that promote the emergence of nursing professionalism, growth factors associated with self-activation and overcoming challenges, and rootedness factors that stabilize upward, which reveal the dynamic factors that influence the development of nursing professionalism.

We added the early influence of personality traits, family upbringing, and school professional education in the development of nursing professionalism, which is similar to the pathway through which nurses’ foundational values are acquired [ 43 , 44 ]. Building on previous research, we highlight the sequential order of socialization in family education and school professional education, with individual socialization within the family achieving individual socialization before school professional education, emphasizing the importance of intergenerational family transmission on the development of nursing professionalism [ 45 ]. Education commences within the family, a social organization with an educational function. China values its “family culture” and emphasizes defining parental responsibilities for family education based on blood relations. It is a common folk law in China that parents are regarded as the first teachers. In addition, Chinese society promotes Confucianism, which emphasizes instilling the concept of “self-improvement” through “educational living” [ 46 ], as mentioned in our study, the interpersonal interactions such as “altruism” and “caring” arising from family interactions can help nurses establish a deeper emotional connection with their patients. Therefore, future consideration could be given to incorporating programs that foster culture and emotions into professional education. Similar studies are necessary in East Asian countries and other countries with similar cultures to broaden the results of factors influencing nursing professionalism.

The growth of nursing professionalism requires real work scenarios. Our results present the dual factors of nursing professionalism upon entering the workplace. Regarding self-activation factors, we delve into the significance of “professional identity” and, for the first time from the perspective of Chinese collectivism, explain the unique influence of “professional benefits” on nursing professionalism. Our study aligns with previous research, viewing professional identity as an ongoing “process” [ 47 ]. By developing a professional identity, nurses can exhibit “stateful” self-satisfaction and self-motivation, contributing to their job satisfaction and professionalism [ 48 ]. The “professional benefits” involve integrating rational and emotional aspects. The “tangible benefits” of professionalism and technical competence at work lead to positive experiences and emotions among nurses. Nurses voluntarily invest more passion and energy in their work [ 49 ]. In addition, what sets our results apart is how Chinese nurses obtain ‘spiritual benefits,’ which come from the convenience of medical access that their relatives enjoy due to their work. Some studies have shown that “spiritual benefits” are more apparent among nurses aged 40 and above and those with higher professional titles [ 50 ]. The accumulation of clinical experience and the harmonious interpersonal relationships achieved through medical collaboration can help family members access reliable medical resources, leading to greater professional gain. This phenomenon is closely related to the collective consciousness of Chinese nurses, revealing that people are not always “self-interested and rational”; their behavior is influenced by more complex factors such as intuition, emotions, and attitudes [ 49 ].

In terms of the challenges faced, on the one hand, we emphasized the supportive role of intergenerational relationships in nurses’ work-family conflicts. Previous studies have shown that Chinese nurses perceive nursing work as a means to fulfill family responsibilities rather than the ultimate goal, reflecting a prioritization of family over work [ 51 ]. Consequently, nurses are more likely to resign during work-family conflicts, reallocating their resources from work to family [ 52 ]. Compared with previous studies, we found that China is a highly connected society, and multi-generational households are relatively common [ 53 ]. Hence, the importance of maintaining good intergenerational relationships cannot be ignored in Chinese society and culture, substantially impacting nursing professionalism. On the other hand, we reveal the underlying reasons for the restricted development of nursing professionalism among nurses during the transition period. Newly graduated nurses face negative experiences such as incompetence, lack of preparation, exhaustion, and disappointment in their work, hindering the development of nursing professionalism, which is especially evident in departments such as obstetrics and gynecology, ophthalmology, and emergency, where teaching hours for these specialties fall significantly below those for general internal medicine and surgical nursing [ 54 ]. The educational experiences of nurses are insufficient to meet clinical demands [ 55 ]. Moreover, this is compounded by differences in the structure and content of the 12–24 month “standardized training” for new nurses that has already begun in most cities in China, further exacerbating the experience of separation of new nurses from their organizations [ 56 ]. The development of rotational nurses is often neglected, and transfer systems are a mere formality [ 57 ]. Therefore, developing nursing adaptability and creating a supportive work environment should be incorporated into the content and structure of different organizational transition programs to make a positive work environment and promote nurses’ engagement, enhancing nursing professionalism.

It is worth noting that the rootedness factor involves individual, organizational, and societal dimensions. At the personal level, peer support and intergenerational role models integrate the demonstration of actual “peers” and “role models” with nurses’ self-awareness and agency to achieve upward mobility in nursing professionalism [ 58 ]. However, while peer support offers emotional and social cognitive consistency based on age, background, and learning experiences, it may lack experiential depth [ 59 ]. In contrast, intergenerational role models involving a “superior-subordinate” relationship can initially lead to “nurturing” relationships, potentially leading to lateral violence and bullying [ 60 ]. At the organizational level, our findings highlight that professional respect in the workplace is more relevant to nurses’ professionalism than social appraisal. Professional respect is the nurses’ perception of their subjective social status within the profession and an analysis of the social value associated with the nursing profession [ 61 ]. However, nurses are not always respected, especially as insults and disregard from patients, superiors, or physicians can lead to negative emotions, professional burnout, and a desire to quit [ 62 , 63 , 64 ]. Regarding the societal dimension, providing external motivation tailored to nurses’ specific backgrounds and needs is beneficial for the stable development of nursing professionalism. Financial incentives are often considered a common strategy to improve nurses’ motivation and retention in motivation management [ 65 ]. However, the effectiveness of incentives is, more importantly, dependent on the response of nurses after implementation, and it is crucial to understand the needs and preferences of nurses in terms of incentives as well as the level of nurses’ participation in policy development, in addition to material rewards [ 66 , 67 ].Therefore, maintaining the stability of nursing professionalism is therefore complex, and nursing managers should consider ways to deepen peer support and reduce workplace bullying through “intergenerational parenting”, and should develop policies that support nurses, have zero-tolerance for disruptive behaviours, uphold the professional dignity of nurses, and ensure that their voices are heard and valued, which contributes to a more positive, fulfilling, and motivating nursing work environment.

Limitations

Given the persistently low number of men in nursing, all participants recruited for our study were female. However, considering the relatively narrow focus of the research, The purposive variation, and the richness of the generated data, the sample size was deemed sufficient to achieve our objectives. In addition, although the study results reveal dynamic influences on the development of nursing professionalism, they do not differentiate between nurses at different career stages, such as novice and expert nurses. We consider these factors as “common characteristics” for them, intertwined with each other, which can be further clarified in future research.

Conclusions

This study is an important addition to previous research in that we reveal the dynamics of factors that influence the development of nursing professionalism, including the “nourishment factor,” “growth factor,” and “rootedness factor.” Our findings provide contextual factors that can be changed during the development of nursing professionalism and lay the foundation for future strategies to foster nursing professionalism.

Relevance to clinical practice

The findings of this study have important implications for exploring the development of nursing professionalism. Nursing managers can support nurses’ professionalism from various perspectives, depending on the stage of the nurse’s life, such as valuing nurses’ family relationships, focusing on nurses in transition, listening to nurses’ voices, and creating a “magnetic nursing” work environment. These measures will not only positively impact the careers of individual nurses but will also help improve the standard and quality of health care in general. In the future, we should no longer view the development of nursing professionalism as solely the responsibility of individual nurses; the influence of family, organizations, and society is indispensable in collectively promoting the development of nurses’ nursing professionalism.

Data availability

Data used to support the findings of this study are available from the corresponding author upon request.

Abbreviations

The Hall Professionalism Inventory

Miller’s Wheel of Professionalism in Nursing

SHwang’s Nurse Professional Values Scale

The consolidated criteria for reporting qualitative research

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Xingyue He, Ya Mao, Linbo Li, Yanming Wu & Hui Yang

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XYH, YM, and HLC were responsible for the study’s inception, study design, and data collection. All authors analyzed the data. XYH wrote the first draft of the manuscript, LBL, YMW, and HY reviewed the manuscript, and HY finalized the final version. All authors reviewed and approved the manuscript prior to submission.

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ORIGINAL RESEARCH article

How do exhausted parents experience their interactions with their children a qualitative and participative study.

• 1 Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
• 2 Institute for the Analysis of Change in History and Contemporary Societies, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
• 3 Psychological Sciences Research Institute, Université Catholique de Louvain, Louvain-la-Neuve, Belgium

Introduction: Parental burnout, known as a state of physical and psychological exhaustion, results in an imbalance between the parent’s perceived stressors in relation to parenting, and the resources available to the parent to cope with such stressors. The causes and consequences of parental burnout for the parents themselves have been studied from the parents’ point of view, but the perception of parents regarding the impact of parental burnout on the parent-child relationship has not yet been documented.

Methods: We conducted a qualitative study through semi-structured interviews with exhausted parents (n=21). We aimed to better understand their general interactions with their children, as well as the way they communicate with them about their state of exhaustion, knowing that dealing with parental suffering can have a long-term impact on the child.

Results: Our results reveal that exhausted parents experience a widespread loss of control in all areas of their lives, particularly in their interaction with their children, which generates feelings of guilt and shame. Communicating their experience to their children can create various difficulties for both parents and children. This may complicate the process of seeking help and reinforce the feeling of isolation.

Discussion: An emerging result from our analysis leads us to identify a need for the parents to be heard and validated in their suffering who took part in this research.

1 Introduction

Parental burnout (PBO) defined as a state of physical and psychological exhaustion of the parent, has been described by psychologists and researchers as a syndrome related to stress experienced by parents in parenting, resulting in an imbalance between parental stressors and the resources available to the parent to cope ( 1 ).

The emergence of parental burnout is part of a historical evolution in the concept of parenthood ( 2 ) and is related to the place given to children in our societies ( 3 ). PBO is known to impact parents’ physical health (e.g., sleep disorders, physiological complaints), mental health (e.g., addictive behaviors, suicidal ideation), and well-being (e.g., reduced psychological well-being, low sense of life satisfaction) ( 4 , 5 ). A combination of socio-economic, family, and/or personal characteristics is associated with PBO ( 6 ). At the socio-economic level studies have highlighted, among other things, the stress felt by parents in balancing their family and professional lives ( 7 ), and low income ( 8 ). At the individual level, authors have shown that a tendency toward self and socially prescribed perfectionism ( 9 ) and low emotional intelligence scores ( 10 ) are associated with a higher risk of PBO. At the family level, parenting a child with specific needs (chronic illness, disability, learning disabilities, behavioral disorders, emotional difficulties) increases the risk of developing PBO ( 4 , 11 ).

Regarding the quality of social and family relationships, studies have shown that parental exhaustion affects romantic relationships, particularly by causing partner estrangement or increasing tensions and conflicts ( 4 , 12 ), creates role confusion, and discourages asking for or receiving social support from family and friends ( 5 , 13 ).

Much less is known regarding the interactions of exhausted parents with their children. The results of two separate studies suggest that parents may externalize their exhaustion through behaviors that could ultimately lead to neglect, as well as verbal or physical abuse ( 14 , 15 ). Although these findings highlight the potentially adverse consequences of PBO on children and parent–child interactions within the family, this issue remains largely under-investigated in the literature ( 16 ). Moreover, while many quantitative studies have examined the various facets of PBO, few research studies have questioned parents in depth, particularly about their interactions with their children and how they communicate their exhaustion to them. Therefore, a better understanding of the impact of PBO on the child and the parent–child relationship remains a major challenge for societies that place children and their well-being at the heart of their concerns and public policies. Given the knowledge gap in the literature, we wanted to understand what parents themselves say about parental burnout and how they talk about their children’s experiences when they are faced with parental exhaustion.

2 Materials and methods

The study of parents’ experience of their interactions with their children in the context of PBO is a complex and delicate issue. To date, the parents’ perceptions of the consequences on their interactions with their children remain yet an underinvestigated issue. Inviting burnt-out parents to talk about their experiences, feelings and perceptions of their parenting and family dynamics requires special care, so as not to further undermine their perceived parental competence. That is why we opted for qualitative methods, as these are particularly suited to explore sensitive and underinvestigated issues related to human experience ( 17 ), without imposing predefined theoretical categories on them, as is the case with survey questionnaires.

2.1 Recruitment methods

Potential participants were recruited through a network of professionals who disseminated the information through written materials, posts on social media, or personal contact with the families. A total of 56 professionals were personally met by the first author and agreed to act as facilitators in the recruitment phase. The professionals gave the information to the parents, who contacted us by e-mail or telephone to set up an appointment for the interview, once they had indicated their interest in the research and their agreement to participate.

2.2 Sample characteristics

To be included in our study, the participants had to be the parents of one or several children aged less than 18, in health (HC) or with a chronic illness or disability (CC), be aware of being exhausted in their parental role, be willing to share their experience with us, and be fluent in French.

Following an initial contact by phone or e-mail with 28 parents, 21 parents (13 individual parents and 4 parental dyads) eventually agreed to participate. The drop-out of the 7 remaining parents was due to a lack of time ( n  = 4) or refusal by the partner ( n  = 1). A further 2 parents did not follow up after the first contact, despite the first author’s efforts to keep in contact. Among the 21 parents, 11 parents had HC, 7 parents had one ( n  = 6) or two ( n  = 1) children with CC and 3 parents reported learning difficulties or behavioral disorders (LBD) in one ( n  = 2) or two ( n  = 1) of their children. The characteristics of the participants and their families are presented in Table 1 .

Table 1 . Summary of participants’ characteristics at time of interviews ( n  = 21).

In addition to general sociodemographic characteristics, the results of the Parent Burnout Assessment (PBA) ( 18 ) are also presented in Table 1 . The PBA was not used as a recruitment tool to validate the parent’s inclusion in the study, but to characterize our sample. This means that parents with a low PBA score who wished to participate in the research were nevertheless included in our study. From an ethical point of view, we felt that by doing so, we were enabling parents to be recognized and heard in their suffering.

2.3 Data collection

We conducted 17 in-depth interviews, both with individual burnt-out parents ( n  = 13) and with parental dyads, both in PBO ( n  = 4 parents), followed by a focus group to discuss our results with the concerned parents.

2.3.1 Interviews

An interview guide was developed around two main open questions to ask participants about how they experienced their state of exhaustion, and how they viewed their interactions with their children as a result of this. The in-depth interviews were conducted either virtually on Teams ( n  = 16) or at the researcher’s office ( n  = 1), according to the participants’ preferences. The mean duration of the interviews was 69 min (min. 36 – max. 125).

2.3.2 Focus group

A focus group discussion (FGD) took place to discuss with the participants the results and hypotheses generated by the analysis of the collected data. This FGD took place after an average number of 14 months (min. 10 months – max. 17 months) following the in-depth interview. Out of the 21 parents who had participated in an interview, 10 parents representing 8 families, agreed to participate in the FGD. Of the 9 remaining families, six participants were unavailable at the time of the focus group, one participant was not interested, one participant did not respond to the invitation, and one participant canceled at the last minute due to unforeseen circumstances.

The FGD of parents gathered 6 individual mothers and two parental dyads, representing 8 families, of which two had a child with LBD and two had a child with a CC. The FGD lasted 1 h and 38 min.

After setting up a safety framework, a PowerPoint presentation was used to expose the research findings to the parents. We used different tools designed by our research team, like a visual scale, to make exchanges between parents more concrete and active. Participants were invited to discuss and validate our results.

2.4 Analysis

All interviews were transcribed verbatim. The transcripts were analyzed according to the principles of phenomenological interpretive analysis ( 19 ). The first and last authors analyzed the two first interviews independently and agreed on a starting list of thematic categories to describe how the participants experience being exhausted in relation to their children and how they view their interactions with their children. As a result of this first step of the analysis, a slight evolution of the interview guide was agreed to elicit more precise responses in relation to the parents’ interactions with their children, as well as how they would describe and experience their children’s behaviors. Further, all interviews were read and discussed between the first and second author, and during co-authors’ meetings, to discuss emerging results. These discussions were intended to enrich the understanding of what had been conveyed by the participants, not to reach a consensus ( 20 ). An additional way of validating the results was implemented during the focus group through feedback and validation of the results by the participants. In addition to researcher and participant triangulation in the process of analysis, the first author also regularly met with the sixth author, a clinical psychologist, and lecturer in family psychology. This was to support reflexivity and minimize the risk of subjectivity bias, discussing emotional and possible transference issues arising during the interviews.

Following these multiple reviews and discussions, four meaningful categories of analysis were created: (i) losing control in interactions and communication with their children, (ii) encountering difficulties in communicating with their children about their experience of parental burnout, (iii) trying to make sense of their current experiences by looking at their past experiences as children, and (iv) a need to be heard and validated in their suffering: an emerging result.

2.5 Ethical considerations

Our research protocol was approved by the ethics committee of our university (ref. 2021/24JUI/286). An informed consent form was signed by the parents. In order to guarantee their psychological safety and not reinforce their guilt, we had the possibility of directing parents to professionals trained in supporting parental burnout, if they wished.

Our results are presented according to the four themes listed above, namely (i) losing control in interactions and communication with their children, (ii) encountering difficulties in communicating with their children about their experience of parental burnout, (iii) trying to make sense of their current experiences by looking at their past experiences as children, and (iv) need to be heard and validated in their suffering: an emerging result. The results are illustrated by quotes from the parents during the interviews or the FGD who are identified as parents of healthy children (HC), parents of children with chronic conditions (CC), or parents of children with learning or behavioral difficulties (LBD).

3.1 Losing control in interactions and communication with their children

First, it is to be acknowledged that the participants reported experiencing a widespread loss of control that would impact their social roles in their personal, professional, and family lives: “ It is exhausting! When you slip up on one side, it affects your other identities” (Parent of a child with LBD, FGD) Yet, as the difficulties described by exhausted parents in their personal and social lives have already been documented in the literature, the results presented hereafter mainly focus on the burden explicitly related to the interactions between parents and their children, the loss of control in these interactions, and the way parents perceive the consequences of this loss of control on their children, particularly when describing their reactions.

Some parents reported that the emotions and tensions experienced in their interactions with their children would sometimes lead to losing patience, shouting, crying, as well as verbal or physical loss of control manifested through hurtful words or inappropriate gestures (e.g., grabbing the child, hitting the child, throwing objects across the room). “ It happened to me once that I hit one of my children and after I realized what I had just done, it followed me for a long time, to see how far I had gone to get to that point ” (Parent of a child with CC, interview). Such losses of control were described by the participants as a major symptom of their exhaustion, which would act as a real alarm bell: “ There is nothing worse ” (Parent of a HC, FGD). Some participants reported awareness of the impact of their attitudes on their child’s behavior: “ She had to make up for my unavailability for such a long time ” (Parent of a HC, interview). In connection with their loss of control, some participants noticed that their children would feel alarmed or be prone to panic as soon as they would raise their voices (Parent of a HC, FGD). Moreover, even when everything was fine, some children would ask back “ Are you okay, Mom? ” or “ Is there anything I can do to help? ” (Parent of a child with LBD, interview). Some participants mentioned their children’s emotional reaction when they lose control: “ She also went through a phase of feeling angry, so angry… this went on for several months ” (Parent of a HC, interview). “ For our second child, if we are not doing well, my husband or I, it is an explosion (...) He takes on all the emotions (...) In the beginning, we did not see that. We just saw a child who was in crisis in addition to what we were going through ” (Parent of a HC, interview). Moreover, some participants reported that their children would sometimes reproduce their parents’ behaviors in losing control when relating to their siblings (e.g., arguing, shouting) “ It is confrontational and very complicated ” (Parent of a HC, FGD).

By contrast, other participants identified the development of a protective attitude among the siblings, in reaction to the parent’s loss of control: “ They both love each other, they have a great bond ” (Parent of a child with CC, interview) or a protective attitude of the children toward their parents. “ My daughter tends to protect me when I’m exhausted ” (Parent of a child with CC, interview). For some participants, the protection given by their child could lead to “ a savior attitude on the part of the eldest one ” (Parent of a child with LBD, FGD).

Regarding their interactions with their children, some participants feared that their loss of control might leave traces of trauma in their children’s adult life. This in turn would further increase their guilt and helplessness: “ I feel that for her [daughter] this period has been traumatic ” (Parent of a HC, interview) or “ When she expresses doubts about herself, I ask myself: ‘Am I responsible for this as a parent?’ ” (Parent of a HC, FGD). The participants also listed the responsibilities that would rest on their children’s shoulders when exposed to parental exhaustion: “ I ask a lot of him in the end, I realize that in order to prevent me from going crazy, I ask a lot of him ” (Parent of a child with LBD, interview) or the expectations they have of their child: “ I had to get them to participate in house chores ” (Parent of a HC, interview).

3.2 Encountering difficulties in communicating with their children about their experience of parental burnout

Parents find it difficult to communicate about their experience with their children. The feelings of shame and guilt that were reported by the participants in relation to their experiences of losing control were further described as making their experience of exhaustion barely communicable to their children: “ I feel guilty almost all the time ” (Parent of a HC, interview). The participants described how they would come to doubt themselves, and to be afraid of failing in their parental role, to the point of feeling that they are no longer up to the task. “ I have always had doubts about what I was doing, from the very beginning of parenthood ” (Parent of a HC, interview). Some participants even said they no longer recognized themselves, that they felt they had become strangers: “ I had become someone I was not, a person who was unknown to me … ” (Parent of a HC, interview). Moreover, the participants also talked about sadness, crying, and a sense of failure that would undermine their self-esteem: “ You have no understanding of yourself, you think you suck ” (Parent of a child with behavioral or learning difficulties, interview). All this, they said, would contribute to making their experience uncommunicable, in particular to their children.

To talk about their experience of PBO, to find words to explain this psychological state to their children, and to name their emotions in such a situation is no easy task for burnt-out parents. Some participants reported that they would not reveal in front of their children that they were exhausted. “ Talking about it, no, we do not talk about it ” (Parent of a HC, interview). Other participants sometimes resort, without always being aware of it, to emotional communication centered on their own experiences or feelings “‘I cannot take it anymore’, I would often say to my children, before staying on my own for a little while (Parent of a HC, FGD). They talked about their difficulties in putting into words their experience of losing control, in explaining to their children that they are not responsible: “ I still have trouble reassuring him with this (...) It is not a life, well, it is not nice for him (...) My son has always tested the limits because he never felt safe ” (Parent of a child with LBD, interview). They spoke of their difficulties in recreating a bond with their child following an outburst: “ Telling your child that you are sorry is not enough ” (Parent of a child with LBD, FGD). When they lose control while interacting with their children, either physically or verbally with emotionally loaded communication, participants tended to think that “ the child does not understand that he/she is not the cause of our anger ” (Parent of a HC, FGD).

Some participants reported communicating their feelings to their children, acknowledging that this might be too much for their children to some extent: “ Sharing my emotions with my children has become more and more important over time. But I think I feel the need to share more than my children need to hear what I’m going through ” (Parent of a child with LBD, FGD).

Some participants reported not having any filter while sharing their own emotional experiences with one or several of their children. They tend to explain everything to their children, often inconsistently between children, as the eldest most of the time would receive more explanation than the younger and sometimes even be designated by the exhausted parent as his/her confidant: “ I really do talk to them without secrecy (...) I think I have really confided in them a lot more, especially with my eldest child ” (Parent of a child with LBD, interview). It should be noted that the quality of the communication may vary, as this participant indicated: “ Sometimes, I manage to say it, to verbalize it. Perhaps more with my little one (who is in good health) than with my older one (who has a CC). And sometimes I cannot, and I tell them I need a moment to myself, and I close the door. And sometimes I do not even tell them, and things get out of hand ” (Parent of a child with CC, interview).

Tuning in to their children’s own experiences was also described as difficult by some: “ When he expresses himself, I cannot listen ” (Parent of a child with LBD, FGD). Conversely, some participants reported that they would give their children tools to express their emotions but fail to express their own feelings: “ Every child has his own ‘emotion cards’ with the seven basic emotions, and every evening we take out the cards and they express their emotions ” (Parent of a child with LBD, interview).

3.3 Trying to make sense of their current experiences by looking at their past experiences as children

Reflecting on their interactions with and responsibilities toward their children, most participants recalled certain emotional experiences from their own childhood, linked either to adverse events or to their own parents’ parenting style. When they realize the impact of their loss of control on their children, they cannot help but think of what they experienced or felt during their childhood in the face of similar or different events that left their mark. It seems that family history has an impact on the way parents interact with their children. Some participants reported that they had experienced a parenting style that they described as being demanding, rigid, authoritarian, and perfectionist: “ With my parents, it was ‘The more perfect you are, the more we will love you ’“(Parent of a HC, interview). Some participants linked these childhood experiences to difficulties in expressing their own emotions. They reported to have felt pressure and anxiety during their childhood, and often a lack of space to express their own emotions, experiences, and feelings. “ We had no space for emotion ” (Parent of a HC, interview) or “ What you also missed was being able to put things into words. You did not talk about your feelings in your family ” (Parent of a child with CC, interview). These participants reported that their own parenting styles tended to be shaped in part by that of their parents, but not exclusively: “ It is not as if I would dismiss it all; rather I tend to add to what I received ” (Parent of a HC, interview) or “I know that I make high demands on myself and that comes from my education ” (Parent of a child with CC, interview).

Other participants, on the contrary, described the education they had received as chaotic, and neglectful, with a lack of structure and limits. The recalled lack of presence and structure was acknowledged as a source of pressure for their own parenting by those who had experienced it: “ Clearly, my parents were not present at all. And so I do not want to put my son through that ” (Parent of a child with LBD, interview).

A few participants reported having experienced traumas during their childhood, related to the mental health problems of their parents. They think that this experience contributes to their parental burnout and influences their loss of control, similar to those they observed in their parents during their childhood: “ I started carrying my mom on my shoulders at the age of 10. My mom had psychiatric problems, physical problems as well ” (Parent of a child with CC, interview). “ My dad had major depressive episodes when I was young, which is probably why I wasn’t very close to him. But I never knew about it, and it was only as an adult that I really understood some of it ” (Parent of a child with LBD, interview); “ My father died 15 years ago. He committed suicide ” (Parent of a HC, interview). On several occasions, it was not until the participants had become parents themselves that they became aware of the impact of family trauma on their own lives: “I experienced a lot of traumas, however, it took some time before I became aware of it. (...) My therapist once said to me: ‘You’re in survival mode ’“(Parent of a child with LBD, interview). Sometimes family secrets were discovered or understood later in adolescence or adulthood: “ There are really very difficult things that have happened in the family and that had never been discussed, a lot of unspoken things and even family traumas that are passed on from one generation to the next one without being understood because they remain unsaid” (Parent of a HC, interview).

Thus, the parents with a difficult personal and family history in our sample were inclined to try and fix what had been broken in their own childhood by putting a lot of pressure on themselves to do better than their parents. “ I try to correct what my parents did not do right ” (Parent of a HC, interview).

Some participants tended to view their own parents as superheroes whose level of perfection they could never reach: “ I really did not want to give the kids the feeling I had, that parents are everyday superheroes and that they never fail ” (Parent of a HC, interview).

Finally, childhood experiences also influence interactions within the couple, sometimes creating additional communication difficulties with their children on top of those already experienced. For example, if the two partners had contrasting experiences of parenting styles and family models in their own childhood, this could generate additional stress and even conflicting communication: “S he comes from a very loving family, it was the opposite in my family. As a result, our way of seeing things often oppose. Something that does not seem very serious to me will be serious to her and vice versa” (Parent of a child with LBD, FGD). Moreover, a traumatic event experienced during childhood, such as the absence or loss of a parent, calls into question the place given to the spouse in the parental couple, as one mother who was raised without a father explains: “ Oh yes, there’s a father here! What place should I give him or not give him? While it suits me well to manage my own things, I tend to blame him afterward for it: ‘But you did not do anything!’ If I have taken up all the space, it is a bit difficult to ask my spouse to be there to o” (Parent of a HC, FGD).

3.4 Seeking to be heard and validated in their experience of parental burnout: an emerging hypothesis of our results

The intensity of the feelings of shame and guilt that the participants associated with their experience of losing control, which would lead to making their experience incommunicable to their children and in turn add feelings of isolation to the burden of feeling exhausted, led us to question whether the experience of burnout might be perceived as something that should not be experienced and may not be expressed. This hypothesis was further discussed and validated during the focus group: “ I do not feel legitimate because I think I’m the problem’ “(Parent of a HC, FGD).

During the interviews, the parents expressed their need and difficulties in finding circumstances that in their eyes would justify their exhaustion or give them the right to be exhausted. According to the participants, parents have no right to be exhausted in their parental role: “ To be a good parent, I told myself I had to do everything: And I have to go to the dump, and I have to do the laundry, and I have to do the shopping, and I have to cook, and this and that... .” (Parent of a HC, interview).

They tended to judge themselves, to compare themselves with other parents who were doing better while experiencing similar difficulties. These different elements were confirmed during the FGD, where parents expressed that they believed they were the problem at the heart of the situation while struggling to identify valid reasons for exhaustion in the eyes of society.

Our results suggest that participants who were able to point out difficulties in their lives that would justify their exhaustion were able to judge themselves kindlier than those who could not identify any mitigating circumstances. To be able to identify an external cause that explains exhaustion seems to reduce the parent’s feelings of shame, guilt, and self-blame. In our sample, parents of a child with CC, parents of twins, and single parents reported a lower sense of guilt and less influence from perceived social pressure: “ Learning that my wife was pregnant with twins, that the third one had turned into three AND four, we had not thought of that. Very clearly, the feeling of fatigue is there since they are four and I never had this feeling before, never. In terms of logistics, it is clear that everything is multiplied by four. So it is exhausting ” (Parent of a HC, interview). Yet, they would still tend to compare their own situation with that of other parents whom they would consider having more reasons (and rights) to be exhausted than themselves. “ Knowing that my situation is complex, and help is not always available, I feel relatively legitimate. I tend to compare myself to other families who are going through more difficult things, which is why I do not feel entirely legitimate ” (Parent of a child with CC, FGD).

The parents who had a child with a CC reported feeling more pressure from their child’s chronic condition than social pressure linked to their parenthood.

Some parents reported to have needed a medical order to accept a prescribed work break and feeling less shamed to stop work: “ The fact that a doctor stops us makes the situation legitimate and shows us that we are not superheroes ” (Parent of a child with LBD, FGD). The presence or absence of a partner was another mitigating factor reported by the single mothers in our sample who were raising their children alone that would justify an increased risk of exhaustion and make it more acceptable: “ I am a single mum (...) It was one of the elements that generated burnout » (Parent of a HC, interview).

The parents’ interviews, illustrated by the various verbatims above, show that exhausted parents do not give themselves the right to be exhausted, or to talk about it, which reinforces their sense of isolation. Based on our results we formulated the hypothesis of a need for parents to be heard and validated in their suffering, which was validated by the parents in the focus group. Parents expressed that they need to feel they have right to be exhausted. They also validated their difficulties in talking to their children about their experiences and emotions. At the end of this study, we believe that a greater sense of validation of their suffering could have a positive impact on feelings of isolation and loss of control, and could perhaps change the way parents communicate with their children.

4 Discussion

Our results highlight that exhausted parents experience a widespread loss of control. This loss of control, which occurs in different spheres of their lives and especially in their interactions with their children, gives rise to feelings of shame and guilt, among others, which impact further interactions with their children. Such feelings may be influenced by emotional experiences from their own childhood. When parents lose control of their interactions with their children and feel ashamed and guilty, they tend to flee or isolate themselves. Communicating their experiences to their children and talking to them about their emotions, while listening to their children’s own experiences, can create various difficulties for both parents and children. This may complicate the process of seeking help and reinforce the feeling of isolation. An emerging result of our analysis that was validated by the participants during the focus group led us to hypothesize that burnt-out parents may experience difficulties in being heard and validated in their suffering, which is likely to impact their loss of control, their sense of isolation, and maybe the way they communicate about their experience to their children. All this can delay their request for help for themselves and their children.

4.1 The repercussions of loss of control

Our results reveal a loss of control in the exhausted parents’ interactions with their children. While a risk of violence or neglect has been reported in relation to parental burnout ( 15 ), our results point to the suffering experienced by exhausted parents as they lose control – or fear to lose control – in their interactions with their children. This echoes the results of another qualitative study, which evidenced that suffering and fear were central to the experience of burnt-out mothers ( 14 ). We wish to emphasize the importance of carefully choosing the words to use when addressing parents and society about PBO and when discussing possible consequences for their children. Inviting parents to reflect and talk about possible losses of control and the suffering associated with it might be a way to open the dialog about parents’ suffering, in an empathetic and non-judgmental posture less likely to stigmatize the parents, thus contributing to support the parents’ self-awareness and a need for help.

It is also important to remember that witnessing parental loss of control as a child can be traumatic. The experience of adverse events in childhood can lead to trauma and impact a child’s security and attachment, resulting in a decreased ability to regulate emotions in adulthood and difficulties in relating to others ( 21 – 23 ). A traumatic childhood event, regardless of its intensity, if left unresolved, can be reactivated during adulthood or parenthood. We have observed a tendency among suffering parents to re-interrogate their own childhood experiences and their own suffering. This highlights the importance of giving children a voice, to enable them to express and understand what they are going through when their parents are exhausted. Moreover, the participants in our study acknowledged facing difficulties in expressing or regulating their emotions, sometimes specifying that there had been no room for emotions in their childhood. Emotional competence has been identified as a protective factor for PBO ( 4 , 24 ). These authors emphasize the crucial role of emotions for the survival of the individual, as emotions inform us of our needs and invite us to respond to them. They further point to the need to become aware of one’s own emotions and to communicate them in an appropriate manner to avoid becoming overwhelmed by them and being able to identify other people’s emotions, dealing with them appropriately. This is another essential competency for the parent–child relationship, which needs to be promoted to help parents come to terms with their state of exhaustion and the consequences of it.

4.2 A need for parents to be heard and validated in their suffering: an emerging result

As already mentioned, our study generated the hypothesis that burnt-out parents may experience a need to be heard and validated in their suffering that is likely to impact their ability to communicate about their experience and seek help for themselves or their children in a timely manner. To the best of our knowledge, scientific literature on burnout sufferers’ sense of validation of their lived experience is rather scarce. The legitimacy of professional burnout has been studied by Friberg in Sweden in 2009. Friberg identifies two processes by which the concept of burnout moved to a psychiatric diagnosis, making this state of exhaustion more acceptable: (i) the scientific investigations that lead to the diagnosis, and (ii) the responses made by political decision-makers to improve the preventive and curative management of this diagnosis ( 25 ). From a public health perspective, to be perceived as legitimate, the suffering caused by a disease must be recognized both explicitly and socially and must have been scientifically explained ( 26 ). This brings us back to the social construction of illness as described by Monaghan & Gabe ( 27 ) as “ the way in which people experience illness, recognize and interpret symptoms, interact with their var ious networks, by coping with and accommodating these symptoms .”

In this respect, we could consider that the multiplicity of symptoms and effects associated with PBO, as Kirouac ( 28 ) has highlighted for burnout at work, may lead to a rather vague definition and symptomatology, presenting general realities that are not exclusive to PBO (e.g., relationship problems, tensions, withdrawal, etc.). This ‘vagueness’ makes it difficult to distinguish between those who suffer from it and those who do not and leads to skepticism about its existence as a syndrome, and even suspicion of those who claim to suffer from it ( 28 ). In the same vein, it should be remembered that the participants in our research who felt the greatest suffering were those for whom this ‘vagueness’ was all the greater because they could not clearly identify any causes, such as a child’s illness for instance. This corroborates the rationale behind our decision to include parents who were not diagnosed according to the PBA test, but who nevertheless expressed distress in their role as parents. The discrepancy between the scores obtained with the PBA scale and the experience reported by the participants demonstrates some restrictions in a measurement tool used to diagnose PBO. Kirouac ( 28 ), speaking of the psychometric tools used to diagnose professional burnout, notes that they fail to identify the psychological needs of the individual and are more a reflection of the expectations and constraints that characterize the experience of contemporary work. When it comes to family dynamics, standardized measurement tools may be insufficient because the situation being studied is too complex ( 28 ). Position on professional burnout seems therefore fully transferable to PBO: the essential thing is to take it seriously as a social phenomenon that reveals contemporary attitudes to parenting – namely that some parents associate suffering with it.

As for professional burnout, and in addition to the factors related to one’s personal history, as reported in our results section, the parents’ sense of being heard and validated in their experience of exhaustion may be influenced by perceived social pressure and the normative demands conveyed by society ( 29 ). Indeed, the many expectations perceived by parents in their environment may constitute a source of considerable pressure, even if they apply to them in very different ways ( 30 ). The tendency to make parents responsible for the future of their children is not a new phenomenon in the history of industrialized societies. To take the example of Belgium, where this study was carried out, it should be remembered that at the turn of the 19 th and 20 th centuries, mothers were heavily involved in public policies aimed at reducing infant mortality ( 31 ). In the interests of social regulation, the state also took an interest in families considered dysfunctional, and developed measures ranging from support to control, and from accompaniment to punishment ( 32 ). Knowledge about children’s development and well-being was built up and widely disseminated, while the family was maintained as the privileged and “natural” place to grow up: the need for a relational ( 33 ) and loving family was increasingly asserted throughout the 20 th century, in addition to the need to care for and educate children ( 3 ). Children, thanks to the availability of contraceptive methods, have become a project in themselves: we no longer “have” children, we “make” them, and their development requires multiple skills, first from mothers ( 30 ), then progressively from parents, who are widely considered responsible for the success (or failure) of this development. Even if the political and media discourses tend to support parenthood, the resulting model of the ‘good parent’ leaves little room for mistakes or feelings of failure. Suffering from burnout is not validated since it is still considered a taboo subject, about which there is little communication ( 34 ). In addition, they feel obliged to thrive in their other social roles, that of husband or wife, professional, or friend... These different elements make us think that it is important to act by not reducing parental burnout to an individual or family problem but by also considering it as a social fact that deserves attention at the macro, meso and micro levels.

5 Strengths and limitations

One of the main strengths of this qualitative study is that it is one of the first to have given voice to parents experiencing burnout, by taking the time to listen to them in a semi-structured interview. Numerous quantitative studies have made it possible to examine multiple facets of parental burnout through questionnaire surveys. Another strength of this research lies in the deployment of data collection and analysis methods where triangulation with researchers, clinical experts, and participants enabled us to develop a collaborative approach that allowed the participants to validate the results. Multidisciplinary interactions and exchanges throughout the research also contributed to enriching our methods and results. Indeed, an important aspect of the qualitative approach is to demonstrate the credibility of the results presented, to reduce the risk of interpretation bias linked to the researchers’ subjectivity ( 35 36 ). Subjectivity always comes into play. It is not a bias if the researcher is aware of it ( 37 ). To manage subjectivity, the researcher must take a reflexive step back from his/her situation to question the influence he/she is likely to exert on the conclusions he/she will reach ( 38 ). A phase of introspection, also known as self-analysis, enables the researcher to become aware of his/her position regarding a phenomenon being studied and to mark a decoupling between him/herself and the phenomenon ( 39 ). Another strength of our study lies precisely in the reflexivity that supports the entire research process.

They were sometimes experienced by the participants as an opportunity to put into words their exhaustion or to relive the path taken since they had become aware of their state of PBO.

One limitation of our study concerns our small sample size and limited characteristics, which did not allow us to reach theoretical saturation. Most of the participants were enjoying rather high standards of living (self-reported), as well as having higher levels of education. They were homogeneous from the cultural point of view, with a lack of diversity. Moreover, following the results of our literature review ( 40 ), we decided to recruit the parents through our own network of professionals to ensure their psychological safety, to avoid the risk of destabilizing their personal and family balance, as this had already been shaken by the exhaustion they were experiencing. Consequently, we had to deal with parents who were aware of their exhaustion and often already engaged in a process of psychological support. This observation leads us to question how to recruit, and interview in the future, parents who do not recognize themselves as exhausted or who deny it, as well as how to increase the socio-economic and cultural diversity of the sample. The fact that we conducted most of our interviews on Teams to meet the challenges of the COVID-19 pandemic could be perceived as a brake on parent participation and the quality of exchanges. But we found that for exhausted parents, there was something comfortable about not having to travel and staying in their usual environment to talk to us, both in terms of the time constraints parents face, and in terms of emotional security ( 41 ). What seems important to us in our context is that the participants feel comfortable with the conditions in which they share their experiences, and that the researcher who interviews and listens to them is trained and supervised in his work. Offering researchers a supervisory space in which to reflect and debrief promotes their well-being ( 42 ).

6 Perspectives

Further research on a larger sample is needed to better understand what is transversal and specific to the experiences of parental burnout of parents of HC compared to parents of children with CC.

The hypotheses that emerged during this research concerning the need for parents to be heard and validated in their suffering and regarding the way exhausted parents communicate and interact with their children need to be explored from the children’s point of view to better understand the lived experience of children exposed to parental exhaustion. Knowing more about children’s experiences would make it possible to consider support to allow them to express their perceptions and needs in this context of parental burnout.

Also, it seems essential to us to act on the feelings of guilt and shame felt by exhausted parents, by questioning the parents’ personal and family histories, in interviews with psychologists trained in parental burnout, and by allowing them to identify the pressure perceived in their environments to act on them, as part of a health promotion approach. So far, the interventions proposed have been targeted for each parent, on an individual basis. We need to go further than this person-centered approach. To reach this goal, we could draw inspiration from the ( 48 ), which defines health promotion as a combination of actions aimed at the individual, through empowerment, participation, and the development of skills, as well as actions in the living environment, involving the political sphere. Furthermore, the methodology of this research could inspire an interesting clinical approach, in particular by allowing spaces for exchanges between exhausted parents, supervised by professionals, as we did in the closing phase of this study.

7 Conclusion

Our results suggest that exhausted parents need to be supported to make their experience more recognizable, and therefore more likely to be communicated. Not feeling heard and validated in what they are experiencing could explain parents’ loss of control in interactions with their children, as well as feelings of shame and guilt that may be influenced by emotions experienced during their own childhood. This could lead to isolation and doubt in themselves. Communicating their experience with their children can create various difficulties for both parents and children. Feeling more heard and validated in their experience, feeling that they have the right to be exhausted would allow exhausted parents to seek help earlier, reduce their feeling of guilt and thus act on the impact of the loss of control and on communication in the parent–child relationship. Knowing that the family is an important determinant of health, beyond this individual approach to supporting burnt-out parents, we suggest a more global public health approach, from the angle of health promotion, through protective measures (policies, environment, reorientation of services) that would complement actions on the individual (education, participation...).

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Comité d’éthique hospitalo-facultaire des Cliniques Universitaires Saint-Luc, UCLouvain. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

A-CD: Writing – original draft. MR-L: Writing – review & editing. ZM: Writing – review & editing. AF: Writing – review & editing. ML: Writing – review & editing. JM: Writing – review & editing. IA: Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by a Coordinated Research Grant (“B-Parent”—a concerted research action led by UCLouvain) from the French Community of Belgium (ARC Grant 19/24–100). This fund did not exert any influence or censorship of any kind on the present work.

Acknowledgments

We are grateful to all the parents who participated in the study and to all professionals who contributed to the project.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: parental burnout, parents, children, interactions, loss of control, suffering

Citation: Dubois A-C, Roberti-Lintermans M, Mallien Z, François A, Lahaye M, De Mol J and Aujoulat I (2024) How do exhausted parents experience their interactions with their children? A qualitative and participative study. Front. Public Health . 12:1340748. doi: 10.3389/fpubh.2024.1340748

Received: 18 November 2023; Accepted: 29 March 2024; Published: 01 May 2024.

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Copyright © 2024 Dubois, Roberti-Lintermans, Mallien, François, Lahaye, De Mol and Aujoulat. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Anne-Catherine Dubois, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Open access
• Published: 30 April 2024

Victimisation in the life of persons with severe mental illness in Uganda: a pluralistic qualitative study

• Rwamahe Rutakumwa 1 ,
• Birthe Loa Knizek 2 ,
• Christine Tusiime 1 , 3 ,
• Richard Stephen Mpango 1 ,
• Carol Birungi 4 &
• Eugene Kinyanda 1 , 5  

BMC Psychiatry volume  24 , Article number:  329 ( 2024 ) Cite this article

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Introduction

Victimisation of persons with severe mental illness is recognised as an urgent global concern, with literature pointing to higher rates of violent victimisation of persons with severe mental illness than those of the general population. Yet, for low income countries, there is a huge gap in the literature on the risk, character and victims’ in-depth experiences of victimisation of persons with severe mental illness. We explore the lived experiences and meanings of victimisation of persons with severe mental illness in Uganda, and discuss their implications for care of the mentally ill.

A pluralistic qualitative study was undertaken to explore victimisation among patients with severe mental illness. Patients who had suffered victimisation were purposively sampled from Butabika National Referral Mental Clinic and Masaka Regional Referral Hospital, following confirmation of symptom remission. In-depth interviews were held with 18 participants, comprising 13 females and 5 males from low to moderate socioeconomic status. Interpretative phenomenological analysis and thematic content analysis were conducted.

Victimisation was exhibited in three main forms: (a) psychological, expressed in attitudes towards mentally ill family members as valueless and dispensable, and stigmatisation, (b) physical, as manifested in beatings, indoor confinement and tethering mostly by family members and (c) sexual victimisation, particularly rape. Also observed were victim’s various responses that pointed to the negative impact of victimisation, including a heightened risk of suicide, social withdrawal, a sense of hatefulness and a predisposition to more victimisation.

The family environment plays a predominant role in perpetrating victimisation of the mentally ill in some sub-Saharan African contexts such as Uganda. We propose a holistic framework for mental health interventions, incorporating biomedical but notably also social determinants of mental health, and targeted at improving familial relationships, social support and a sense of belongingness both within the family and the broader community.

Peer Review reports

Victimisation of persons with severe mental illness (including bipolar disorder, schizophrenia and other psychotic disorders) has been recognised as an urgent global concern [ 1 ], with a review of literature unequivocally pointing to higher rates of violent victimisation of persons with severe mental illness than those of the general population [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 ]. In a Dutch study, for example [ 4 ] the annual rate of prevalence of victimisation of outpatients with severe mental illness was 47% as compared to 32% of the general population. In a Greek study [ 10 ], 59% of persons living with severe mental illness reported having been victimised as compared to 46% of healthy controls. In the context of low and middle income countries (LMICs), there is a huge gap in the literature about the risk of violent victimisation of persons with severe mental illness [ 11 ]. Even so, findings from the few studies conducted in this region have been consistent with those from high income countries. For example, in an Ethiopian study, the prevalence rate of violent victimisation among persons with severe mental illness was 61% against 42% for those without the illness [ 11 ].

Certain risk factors have been identified in explaining predisposition to victimisation of persons with severe mental illness, including substance abuse, symptom severity, young age, unemployment, criminal history and homelessness [ 12 , 13 ]. Also well documented are the effects of victimisation, with the vice having been found to adversely impact the course of mental illness in the long term, further diminishing the quality of life of persons with severe mental illness and their families [ 2 , 14 , 15 ]. Relatedly, victimisation has been cited in exacerbating distress among the mentally ill [ 10 , 12 ] thereby aggravating the patients’ mental illness [ 12 , 16 ]. Furthermore, abuse of the mentally ill has been known to escalate the cost of healthcare and demand for services, putting a strain on the healthcare system [ 17 ], a phenomenon impacting sub-Saharan Africa even more given that mental health services in the region are still underdeveloped [ 18 , 19 , 20 ].

In spite of the apparently large volume of literature on victimisation of persons with severe mental illness, gaps in research on the subject still exist. First, much of the work on this subject has been conducted in high income countries, hence little is known about the situation in LMICs, where the sociocultural, structural and legal conditions impacting the risk of violence differ markedly from those in high income countries [ 11 ]. Indeed, this dearth of literature on LMICs was underscored by Tsigebrhan and colleagues [ 11 ] who as of 2014 were able to identify only one study in sub-Saharan Africa that focused on violent victimization of the mentally ill. Our current review of literature suggests very little change since then. Second, a lot more attention in these studies has been on persons with severe mental illness as perpetrators than as victims of the abuse [ 10 , 21 , 22 ]. Third, our review of literature suggests that majority of the publications are from studies using quantitative methods, implying that victims’ deeper experiences and interpretations of abuse, especially in the sub-Saharan African context, remain largely unexplored. Yet, this knowledge of the victims’ “life-world” [ 23 ] – that is, the way the phenomenon of victimisation appears to those experiencing it – is critical for designing fully informed, contextually appropriate interventions for addressing this important social problem. Fourth, literature has been scanty on the profile of abusers and how they relate to the victim [ 13 ].

Our purpose in this paper was to explore the lived experiences and meanings of victimisation of persons with severe mental illness in Uganda, including the history and the typical abuser, and to discuss their implications for care of the mentally ill.

This was a pluralistic qualitative sub-study to explore victimisation among patients with severe mental illness. The sub-study was an offshoot of a bigger project comprising two studies: (i) the Main Study which investigated the epidemiology of HIV infection and risky sexual behaviour among patients with severe mental illness (SMI) and (ii) the Clinical Trials Preparedness study which examined the feasibility and acceptability of undertaking clinical trials among patients with comorbid SMI/HIV [ 24 , 25 ].

Study setting

The study was conducted at Butabika National Psychiatric Referral Hospital and the Mental Health section of Masaka Regional Referral Hospital. Butabika Hospital is the only tertiary referral facility for psychiatric care in Uganda and handles patients from all over the country. In addition to the general psychiatric service, the hospital has specialised psychiatric units such as the forensic unit, alcohol and substance abuse unit, the child and adolescent unit and an infectious disease clinic (IDC clinic) that manages patients with comorbid SMI/HIV. Butabika Hospital also provides general outpatient services to the community through a daily out-patient clinic. Masaka Regional Referral Hospital, on the other hand, offers all services expected of a regional referral health facility, including psychiatric services for both adults and children. Psychiatric services at the Mental Health section of the hospital are provided by a team of psychiatric clinical officers and psychiatric nurses who receive quarterly support supervision from Butabika tertiary referral hospital.

The sample for this sub-study was drawn from a large pool of 1,201 participants who had been recruited for the Main Study and were attending mental health clinics at Butabika National Referral Mental Clinic and Masaka Regional Referral Hospital. The initial sample for the qualitative sub-study was purposive, comprising 409 (of the 1,201) participants who had met criteria for ‘ever suffered adulthood physical abuse’ and 263 participants from the same large sample who had ‘ever suffered adulthood sexual abuse’. In both cases, the participants had suffered the abuse before they acquired a mental illness or while they suffered a mental illness or both. From the purposive sample totalling 672 participants above, 18 participants were selected for the qualitative interviews on the day of their visitation at the mental health clinic following confirmation of symptom remission by an attending psychiatrist or psychiatric clinical officer. Selection of the participants was done in such a way as to ensure that the sample was fairly balanced in featuring both those with a history of physical and of sexual abuse. The total number of interviewees was determined when it became apparent that additional interviews were not yielding new information. No attempt was made to interview the primary caregiver, as this was not provided for in the study design.

Data collection procedures

In-depth interviews were conducted with the 18 participants reporting victimisation, which had been categorised as either physical or sexual. An interview guide was used to collect data. The guide was developed by the researcher who brainstormed and listed questions and topics based primarily on the study’s research questions, but also on scholarly literature on related previous work. Informed consent was obtained at least one week after individuals received the study information sheet in order to allow them sufficient time to read and internalise the content. Participants were interviewed at the health facility where they received care or any other venue of their choice by a trained research assistant who was either a psychiatric nurse or a clinical psychologist. The interview explored events leading to victimisation, how it occurred, the abuser, and the impact of such victimisation on the mental health of the participant. All the interviews were voice-recorded, upon obtaining consent from the respective participants.

Data management and analysis

Data were transcribed verbatim by the research assistant who conducted the interview and stored the data according to the MRC guidelines. We adopted a pluralistic analytical approach that combined interpretative phenomenological analysis (IPA) with thematic content analysis (TCA). As Frost [ 26 ] observes, the pluralistic approach enables flexibility “by building up multi-perspective layers of insight,” with each layer contributing to the understanding of the reality of those being studied. We used primarily IPA to explore the individuals’ lived experiences in depth, and to subsequently take the analysis to a broader level, where applicable, by using TCA to identify the broad themes that were emerging across the dataset. We conducted IPA as postulated by Smith and colleagues [ 27 ], in which the aim is to explore in detail participants’ life-worlds and the meanings they attach to these, in this case victimisation experiences of persons living with severe mental illness. The IPA has been found to be an appropriate method for analysing emotionally laden topics [ 28 ] pertinently including victimisation.

A detailed, case-by-case analysis was conducted by an experienced qualitative data analyst (first author) who read each of the transcripts iteratively to obtain a full picture of the participant’s experience of victimisation. While the analytical focus revolved around episodes of victimisation, both before and after onset of severe mental illness, analytical interest was also on issues that were found to have an influence on or were themselves influenced by victimisation. These were considered essential in constructing the participant’s entire story of victimisation and the meaning they made out of it, and included the participant’s life history, living conditions, family relationships, migration between households and livelihood activities. Within each individual’s narrative, nuances, patterns and themes were established. With the help of MS Excel, the analyst classified themes and sub-themes on a matrix, capturing each participant’s experiences (as reflected in verbatim quotes from the data) to illustrate the respective theme. These themes and sub-themes from each participant’s narrative/transcript were then discussed among team members before consensus was achieved. This was followed by the thematic content analysis phase, during which coding and analysis of the data was conducted across the individual cases with a view to identifying broader patterns and themes. This process also involved comparison of the themes from each individual’s narratives across the cases to establish consistencies and divergences, from which shared themes (those cutting across the different cases) were developed and illustrated by verbatim quotes from the data. The following three themes were discussed and eventually agreed upon by the research team as the key themes that constituted the essential character of the phenomenon of victimisation of persons with severe mental illness. They included psychological, physical and sexual victimisation.

Validity and reliability

Validity in qualitative research is about accuracy of the findings, while reliability speaks to consistency of the analytical procedures irrespective of the researcher or dataset involved [ 29 ]. We promoted internal validity by recruiting and interviewing study participants until such a time that data saturation was achieved, a point at which no new information was obtained from additional interviewing. Additionally, external validity or transferability (the degree to which the findings from qualitative research are generalizable or transferable to other contexts) – was enhanced by providing a “thick description” [ 30 ] or full account of our methodological procedures, participants and findings. Thick description would allow the reader to assess the extent to which our inferences and conclusions are transferable to other settings. Relatedly, reliability was upheld through a systematic documentation of the research process from data collection to analysis, thereby creating an audit trail to enable other researchers to make informed judgments about the soundness of the process, and to replicate these as needed.

As mentioned earlier, three forms of abuse were evident from the data, including psychological (emotional), physical and sexual victimisation. Psychological victimisation – defined as “the infliction of anguish, pain, or distress through verbal or non-verbal acts… [and] includes but is not limited to verbal assaults, insults, threats, intimidation, humiliation, and harassment” [ 31 ] – was usually exhibited in the demeaning and rejection of persons with severe mental illness. Physical victimisation manifested in the form of beatings including forced indoor confinement and tethering, while sexual victimisation basically took the form of rape at the hands of either a member of the public or, notably, a relative.

In Table  1 we summarise the broader demographic characteristics of our participants. Overall, 12 of the 18 study participants reported victimisation while suffering from severe mental illness. One participant reported having experienced all the above three forms of victimisation; seven participants reported two of the three forms of victimisation; and five participants reported one of the three forms of victimisation. Furthermore, a total of eight participants reported a history of victimisation, with four of these subsequently being victimised in their later years while suffering from severe mental illness. Ten participants reported victimisation as having impacted their lives. It is worth noting that participants in this study were not stratified by gender, as we did not aim at the outset to explore gender – only five of a total of 18 study participants were male. This notwithstanding, some gender-based difference in the experience of victimisation could still be gleaned from the data, whereby only female participants reported sexual victimisation.

In presenting our key findings below, we primarily focus in depth on specific cases and later, on findings from our analysis across the cases. The specific cases were carefully selected to highlight the full spectrum of victimisation as reported by our study participants. Our purpose in taking this mainly case-intensive approach was to shed light on the context of victimisation, not just the act of victimisation, that is to say the circumstances or events leading to and following victimisation as the act of victimisation in itself is hardly sufficient in understanding the entire phenomenon of victimisation. But this detailed focus on a select few individual cases was also in keeping with phenomenology’s “idiographic sensibility” that is, a mindfulness of the uniqueness of participants’ life-worlds and, therefore, the need for an in-depth exploration of each case as a way of gaining a full understanding of the case, and only then seeking to establish patterns and themes across the cases [ 32 , 33 ]. Moreover, the in-depth, case-intensive approach afforded us the ability to capture victimisation both in the context of severe mental illness and, where applicable, across the life course. The key themes and subthemes emerging from the data are summarised in Table  2 (below), and subsequently presented in more depth.

Key findings from an interpretative phenomenological analysis

Psychological victimisation.

Our analysis reveals that psychological victimisation was almost invariably blamed on the family – out of seven participants reporting this form of victimisation, six pointed to family as a source, with only two citing members of the public. Psychological victimisation manifested mainly in two ways. One of these was in attitudes towards mentally ill family members as valueless and dispensable. Two cases stood out in illustrating this type of psychological victimisation. One of the cases is that of Participant P1. This participant was a young woman in her second marriage. The marriage followed shortly after an earlier tumultuous marriage during which P1 gave birth to a baby at 15 years and conceived again eight months after delivery. This marriage would eventually end owing to her disagreement with the husband over his proposal to abort the second pregnancy. Although she was living with her parents at the time of this interview, P1 reported having developed mental illness during her second marriage, when she started “ walk[ing] through the streets of XX and all people got to know that [she] was mentally sick .” She clarified having relocated from her matrimonial home purposely for the treatment of her mental health condition, and that she routinely left the matrimonial home every time she experienced a relapse of her mental illness. The participant shared about her run-ins with the current husband who at times verbally assaulted her with reminders of her mental illness, which “ made [her] feel so bad .” It is these incidents, as P1 narrates, that eventually culminated in her husband asking her to go to her parents’ home for treatment during her latest illness episode. Yet, even at her parents’ home P1 still had distressful encounters with the caregiving mother:

Sometimes in the morning my next dose may be due, and I must take morning tablets. I may be in need of something to eat. She says there is nothing. So, instead of taking tablets twice a day, I only take for the night after getting something to eat…. Even when am sick she just tells me, ‘Go, buy poison and kill yourself’. Not that I always have it [money], but I may have Shillings10,000; she says ‘use it and buy poison and kill yourself’…. She means it! She tells me ‘Go, and buy… if you are to kill or not to kill yourself, don’t tell me. I have said go buy and drink it’… ‘if we surrendered you as a sacrifice, there is no problem’… I only want you people to talk to my mother on how to handle patients with mental illness. She gives me stress. She can tell me a word at a time when am sick and I hear something telling me to go and throw myself into a car [traffic].

As depicted in the above narrative, victimisation was apparent in terms of the patient’s psychological pain arising from a sense that her mental health condition was not being understood by the caregiver. Also notable in the excerpt is the victim’s allusion to the potential impact of the victimisation on prospects for her recovery and general wellbeing. This is particularly so when she expresses her perception of her mother rejecting and taunting her to end her life as a risk factor for suicide on account of its likelihood of triggering or coinciding with her hallucinations (the urge to throw herself into oncoming traffic).

What we read from the preceding excerpt is that victimisation can be uniquely impactful among some persons with severe mental illness. This is particularly so considering that the patient is dealing with a pre-existing health condition (severe mental illness) that primarily undermines their resilience or ability to adaptively navigate daily threats to their mental wellbeing. It was evident in this case that when such a patient encounters victimisation in any form, the impact may not always be attributable entirely to such victimisation but rather, to a synergy of factors, with victimisation only being an immediate cause.

Another case that illustrated attitudes of dispensability of mentally ill family members is that of P2, a female participant. This participant had been married for years and has children, but parted ways with the spouse on account of her mental illness. She also transferred her children to the care of her mother when she developed mental illness. At the time of this interview, P2 was living independently, and earned a living by engaging in trade. She shared about her life, highlighting significant historical events that could have led to her mental illness as well as her current experience with the mental illness and victimisation. Citing the former spouse as the abuser, she narrates about a fallout with him as a result of her mental health condition.

He [former spouse] married that woman like four years back…. Because right now they have three children. When I found him in the house, he told me: ‘omusajja tabeera n’abalalu’ meaning that ‘a man cannot live with a mad [mentally sick] person [wife]’. He told me to immediately leave his house. When he talked to me like that, I felt so stressed, and I relapsed and was brought back to hospital. Because of having very many thoughts about my husband, I would keep on relapsing; I was thinking about my children, I was not working at that time, it was the man [spouse] who used to look after us – so that made me relapse. After receiving treatment, I improved and was discharged. But on reaching home, now my children were looking up to me for food and all other requirements, which made me relapse again.

In this narrative, we observe that the participant was not only mistreated as worthless and dispensable because of her mental health condition but further asked to permanently leave her matrimonial home. Reflecting on this experience with the husband, the participant notably highlights her perception of a mutually reinforcing relationship between victimisation and mental illness. In this case, she attributes her victimisation – the psychological abuse of being denigrated by the husband and being evicted from her matrimonial home – to her mental illness, while at the same time blaming the victimisation for her (relapse in) mental illness. Victimisation, therefore, appeared to be perceived by the victim as resulting in a difficult-to-escape vicious cycle of mental illness. As well, the narrative brings to light the participant’s/victim’s sense of the multiple social factors that undermine recovery from mental illness, including poverty and related failure to take care of her offspring.

It is important to note that P2 not only encountered victimisation while suffering from severe mental illness; she also reported a history of sexual victimisation (rape) by the same man who would eventually marry her, only for him to ask her to leave their matrimonial home when she developed severe mental illness. In the following excerpt, for example, the participant narrates this history of victimisation and its impact, notably citing her mental illness as one such impact of being victimised.

When I think about that rape right now, I feel so bad…. I grew up not loving men. I was still a virgin. I had never loved any man [when I was raped]…[crying] … in fact [ever since that rape] I have never felt happy in my whole life [crying]. Not even on Christmas day have I ever been happy. That is the reason as to why I even became born again [crying]. Even after getting mental illness, I continued thinking about such abuses…. Those thoughts caused my mental illness because since that time I have never felt happy…. I still experience the thoughts about the abuse I suffered. [And] the person who would have comforted me would have been my husband, but we separated…. Whenever I think about this I cry.

Also remarkable is that the participant seemed to perceive the psychological victimisation – exhibited in her rejection by her former spouse – in more complex terms, not just in terms of the distress from being abandoned by a loved one because of a mental illness, which itself caused a series of relapses as reflected in her earlier narrative. The victimisation was also perceived in terms of denial by the spouse of a crucial form of (emotional) support that would have moderated the enduring psychological impact of the victimisation she had suffered in the earlier years (including rape) at the hands of the same man before the onset of her mental illness. We note, therefore, that the psychological pain the participant/victim suffered appeared to have been compounded by the ubiquity of the same man throughout her history of victimisation. This was not only the spouse who was rejecting her because of her mental illness, but he was the same man at whose hands she suffered rape several years before the onset of her mental illness. Indeed, we read from the victim’s account her sense that the very minimum the man behind her long history of victimisation, which culminated in mental illness, should have done was to provide emotional support.

Another way in which psychological victimisation manifested was stigmatisation. Two cases are featured to illustrate this type of abuse. One of which is that of Participant P3, a self-reliant, single young man who earned a living from selling produce from his own garden. This participant appeared to still be in denial about his condition when he disclosed: “ they [health workers] deceived me that it is mental illness…. I’m not very sure about my disorder .” Nonetheless, P3 reported having been on medication for his mental health condition but admitted occasionally not adhering, which had caused relapses. It was noteworthy that the participant’s non-adherence had been reportedly driven by concerns about the drugs’ sedative effects (excessive sleep), which often kept him away from income-generating activities. We observed from P3’s narrative that this motivation to work hard arose at least in part from the poor relationship he had had with his relatives and, consequently, the frustration that no one was there to help him. He expresses this frustration with a proposal for how health workers could help with relatives.

It would be good for a health worker after treating someone with mental illness to also take time and call up his or her relatives and advise them on how to look after such a person. If a mentally ill person asks for new clothes, the caretakers should be able to provide them with such needs. If you [health workers] counsel them on how to handle mentally sick persons even those cases of beating up mentally sick persons will not happen.

While P3 responded rather adaptively to the anguish from the perceived lack of support from relatives by working hard to be self-sufficient and not have to seek support from elsewhere, he helplessly lamented the apparent psychological victimisation he encountered from community members who habitually stigmatised him because of his mental illness. These sometimes described him overtly in his presence as a mentally disturbed person.

You know where I stay people take me as a mentally disturbed person, that affects me a lot, some talk when you are hearing, and you really feel bad. I even had to forego attending church because of the same, I have spent nearly a year without going to church…. I am a Christian and I used to go to church since childhood, but it got to a point when I felt like God had forgotten me and as such I did not need to go to church.

As with all other cases, our interest in this case was in the experience but also the impact of such victimisation. We characterised this impact in two ways. First, we note that in withdrawing from church engagements the participant might have delinked and lost contact with some community members who constituted a potential source of social support networks. Second, and more profoundly, we observe that another impact of this victimisation might have been in P3 being prompted to question the essence of his very existence when, as highlighted in the preceding excerpt, he expressed having felt forgotten by God. This point will be better appreciated in light of the exceptionally high degree of religiosity in Africa [ 34 ]. In such a setting, therefore, where a relationship with God is usually of existential importance, the decision by P3 to stop attending church because of the victimisation was interpreted as the culmination of an existential crisis in which he felt abandoned not only by family and community but also, perhaps more importantly, by God.

The second case illustrating victimisation by way of stigmatisation was that of Participant P1. As cited earlier, P1 was a young, married woman who had relocated to her parents’ home and was living with the parents. Like her counterpart, P3, this participant was one of few cases who experienced victimisation both within the family and the broader community contexts. In addition to the victimisation she suffered at the hands of a family member who treated her as valueless and dispensable, P1 narrated about her encounters of victimisation by way of stigmatisation. She cited some man within the community who tried without success to take advantage of her vulnerability due to mental illness by renewing his previously unsuccessful sexual advances towards her after she developed mental illness.

What I see especially among men who are adults [is that] they usually use this opportunity – the fact that you are sick with mental illness [and that] maybe you will have low self-esteem and accept him, especially if you had refused him before…. Because he may think you have already lost hope. There is one that sweet talked me and I refused. Then he got my phone number and called, and he said, “no wonder you got mad.” So, I said to myself that let me not get discouraged because of his words, or quarrel with him.

The case of P1 was particularly intriguing, in that unlike the normal expectation that such victimisation would worsen their mental health condition or at least undermine their recovery process by keeping them in a constant state of stress and hopelessness, the participant in this case seemed to have a sense of purpose, that is, to beat the odds and maintain the path to her recovery from mental illness. She did this by fighting back against her abusers in resisting sexual victimisation and not allowing the stigma to impact her mental health condition negatively.

Physical victimisation

Unlike psychological victimisation, physical victimisation was almost equally blamed on the family and the public. Six of nine participants reporting physical victimisation cited a family member as the culprit, while four of the nine blamed the abuse on members of the community/public who included a traditional healer. As indicated earlier, physical victimisation manifested in beatings, indoor confinement and tethering. We present two cases to illustrate this type of victimisation. The first is that of Participant P4, a male participant aged over 55 years. This participant reported having never married, and that neither had he been involved in a relationship with a woman in a very long time. He also cited a history of victimisation by his parents and his teachers during childhood. Yet these experiences notwithstanding, the participant reportedly would eventually grow up to become a successful farmer who grew crops for both home consumption and the market. However, P4 lamented about his experience of physical victimisation, particularly by his own brother, when he developed mental illness.

I was tied up in chains and left to stay indoors for a period of two months. I ended up destroying my own house because I was scared of dying in the house…. It was my elder brother. He beat me up and this finger is lame as a result of being beaten by him. He took my property and tied me up in chains for quite some time. He would not provide me with drinking water and would give very little food, just enough for survival, which he would pour on a banana leaf placed on the floor. And I would ease myself in the same place.

This participant’s experiences of victimisation stood out in several ways. First, as evident in the above excerpt, the character of the physical victimisation itself was complex, involving not just beatings but also indoor confinement using chains, as well as denial of nutrition and hydration. Second, contrary to what might have been expected, the abusive brother appeared to have made no effort to have P4 access health care, in effect contributing to the deterioration of P4’s mental but also physical health. This might explain another peculiar occurrence, namely that it would take the initiative of P4’s friends rather than of family members for him to be able to access health care.

I had my friends from church who understood that I had a mental problem, so they brought me here at [name of health facility]. During those days, our doctor used to come from Butabika on every first Tuesday of a month. When he assessed me, he advised them to take me to Butabika for further assessments. They then took me to Butabika where I spent close to one month receiving treatment.

Reflecting on his experiences of victimisation following his mental illness, P4 appeared to be most concerned about the impact the abuse had had on his financial/economic security. He narrated about the economic setbacks he has suffered because of the illness.

All my plans for my financial welfare were ruined by relatives and the community members. I had a plantation of sugar canes, bananas, and many fruits such as jackfruits which were ransacked by people after knowing that I was receiving treatment from Butabika Hospital…. I have suffered a lot!! People always take my property. Whatever I try to do at home people steal it. They steal things like food crops and fruits. So that has made me lag behind in terms of financial stability.

Although financial victimisation did not feature prominently in our data, it was clear from the preceding excerpt that this form of abuse by notably family members, in synergy with the physical victimisation, might have to a considerable extent adversely impacted the trajectory of P4’s recovery and life in general. This is in light of the fact that, as the participant revealed, his property or resources that he would have needed to transition back to mental stability and normal life, including marrying and having children, was lost to his family members.

The second case featuring physical victimisation was that of Participant P5, an unmarried woman in her late 30s. Having dropped out of school because her parents could not afford school fees, this participant would later marry formally and start a family but did not have a child after almost a decade in marriage. The marriage eventually ended, and the former husband married another woman. At the time of this interview P5 was living with her grandmother. On how she earned a living, P5 shared about her involvement in cultivation on land owned by the grandmother, but also highlighted the difficulty she and her grandmother were going through in an effort to make ends meet.

The participant reported no history of victimisation, adding that her experience of being victimised was within the context of her severe mental illness in which the husband was the abuser. Indeed, as she revealed, while the termination of her marriage was against the background of years of marital disharmony over her inability to conceive, the husband’s decision to end the marriage was in fact prompted by P5’s mental illness. She described the abuse by the husband preceding the termination of the marriage:

He [husband] used a stick to beat me up…. He was asking me why I had burnt the clothes, he decided to beat me up. In fact, he first tied me up with a rope and then beat me up with a stick. After beating me up he then abused me sexually; he had tied my legs.

The participant went further to explain:

[When I fell sick] he should have looked after me, he should not have beaten me up. He beat me up and abused me sexually which made me hate him. At that time, I was not understanding properly – I had a small lamp which accidentally started a fire on a mosquito net and by the time I tried to put off the fire most clothes had been burnt except the bed sheets. As I finished rescuing the children most of the clothes had been burnt, but surprisingly when he came back instead of appreciating my efforts he just beat me up and abused me sexually.

In the preceding excerpt, the participant laments the failure by the husband to understand her condition as someone with mental illness, noting that she did not deserve the violence from the husband whose children she had rescued. She also highlights the immediate impact of her victimisation by the husband, including “ hatefulness ” towards him. Although she later added that she had got over this traumatic phase of her life and moved on, her lamentation in the same excerpt was indicative of the enduring psychological impact the victimisation had on her.

Sexual victimisation

Of the three forms of victimisation presented in this paper, sexual victimisation was the least reported, with only five of the 18 study participants disclosing having encountered this form of victimisation. All the victims of sexual victimisation were female. It was remarkable that two of these suffered the abuse at the hands of a family member. We present below Participant P6, one of the five cases of sexual victimisation. P6 pointed to a history of victimisation, intimating that as a young girl she was sexually victimised by a man who used to visit her aunt’s home where she lived. She was a middle-aged woman with adult children, and pregnant at the time of the interview. This participant’s situation was rather nuanced, in that she disclosed having separated with her husband and no more sexual contact with him for the last few months, but that the two still lived together. Moreover, the husband had already expressed a strong will to divorce P6 because he was reportedly “ fed up with [her] behaviour .”

However, further analysis of data revealed that the baby that P6 was carrying might not have been the husband’s. Indeed, while the husband by implication acknowledged his paternity of the unborn child when he accompanied P6 to hospital and expressed to the health workers that he “ wanted us to stop on that number of children ,” P6 disclosed to the interviewer that the unborn child was her pastor’s. She further narrated the process leading to her sexual encounter with the pastor, revealing that she had sought counselling from him on how she might get her husband to accept conceiving one more child, but that instead the pastor visited her at home and engaged her in unprotected sex.

The participant also disclosed having had an earlier extramarital affair with another man when she and the husband lived separate lives but still shared a home. When rationalising the extramarital sexual relationship with the man, P6 depicted the husband as a man who was gradually abandoning his responsibilities and commitment to his wife. This depiction hinted at the thought process leading to her decision to accept the new man’s sexual advances, suggesting that her acceptance was, at least in part, the result of her perception of suboptimal care from her husband and the desire to make up for the shortfall in her care needs.

You see, for him he would use the trick of providing me with something to eat so I accepted [a sexual relationship with him] because I would be hungry, and I would want eats…. I would complain to him how my husband was making us to stay hungry during the day.

In this participant’s case, we observe the participant’s sense of victimisation by the husband by way of withholding assistance and marital commitment to his wife. But, despite what appeared like a consensual relationship as projected in the preceding excerpt, the participant also perceives victimisation by the man who was sexually exploiting her because of her vulnerability arising from her mental health condition and nutritional deprivation:

Sometimes he would want to force me – like when I was seven months pregnant, he forced me to have sex with him yet I had abdominal pains but he kept insisting on me having sex with him…. I felt very bad…. [He] used to force me against my own will…. Whenever I would ask him why he did it he would tell me that it was because he loved me so much, yet he had a wife, and I also had a husband.

In the context of P6’s severe mental illness and gaps in family support for mentally ill family members, we consider the victimisation by the two men who were sexually exploiting P6 as having been enabled by her husband’s abuse. This was reflected in her justification for her involvement with the men.

Interviewer: What do you think pushes you to have sex with other men, yet you are married? Respondent: I think it is because they are helping you in one way or the other…. I think in one way or another those people are helpful to the mentally sick person.

In this case, the husband’s withholding of assistance to P6 appears to have created a support gap of which the men were taking advantage.

Key findings from a thematic content analysis

Failure to be understood by family members.

One of the key findings from our thematic analysis of data across the different cases was the participants’/patients’ concern at the failure to be understood by family members. This concern was reflected in the narratives of all the cases presented except one (P3). Also of note was that the failure to be understood was cross-cutting, affecting both those patients in spousal and in blood relationships. We observed that the failure to be understood constituted an important source of stress on the part of the patients. It was also noted that all the cases reflecting this form of victimisation, except one, were females. Failure to be understood by family members emerged as a key factor undermining prospects for recovery, as already presented, often leading to physical violence and denial of basic necessities (food and water) by family members. Cases in point, presented in detail earlier, include P1, who appealed to the health workers to educate caregivers about how to handle mentally ill relatives. They also include P2, who lamented about the rejection by the spouse and his denial of even emotional support, in spite of him having raped her as a young girl and taken her for a wife. The other case is that of P5 who reported about the husband beating her up supposedly for not taking enough care to prevent a house fire when in fact, as she reasoned, she did her best given her mental health condition.

Differential experiences of victimization of women with severe mental illness

Another notable observation from our thematic analysis were the differential experiences of victimisation of women with severe mental illness. These differential experiences were based on the kind of relationship: we noticed that while all the mentally ill women who endured victimisation at the hands of blood relatives were still kept in the family fold and continued to receive some social care from the abusive family members, the women who suffered victimisation at the hands of a spouse were rejected by their spouses and made to leave their matrimonial homes. Cases in point, presented in detail earlier, include P1, who was victimised and ultimately asked by the spouse to leave their matrimonial home. However, when P1 moved in and started living with her mother, she still suffered victimisation at the hands of the mother but was notably tolerated. Another case is that of P2 who was also asked by the spouse to leave their matrimonial home after being told bluntly that a man cannot live with a mad wife, even though the man had raped her as a young girl and eventually took her for a wife. We note that the case of P6 yet again demonstrates differential experiences of victimisation of women with severe mental illness, with those in matrimonial homes more likely to encounter harsher treatment within the family than those living with blood relatives. Akin to the cases of P1 and P2, we observed in P6’s case perhaps the beginnings of the process that might lead to eventual termination of her marriage. This observation may be further appreciated in light of (i) her disclosure of the husband having stated that he wanted a divorce because he was tired of her behaviour, and (ii) the fact that the husband was restricting her food intake, which prompted her to accept extramarital sexual advances from other men. Our presumption was that the two still lived together following the husband’s calculated decision to delay the divorce process because she was carrying his baby.

In this paper, we set out to explore the lived experiences and meanings of victimisation of persons living with severe mental illness, including the history and the typical abuser, and to discuss their implications for care of the mentally ill. To explore these, we used an interpretative phenomenological approach during data collection, but adopted a pluralistic analysis featuring both interpretative phenomenological analysis (IPA) and thematic content analysis (TCA). Our aim was to leverage the strength of both analytical approaches, conducting IPA for depth and TCA for breadth in our understanding of the subject matter. With 12 of this study’s 18 participants reporting victimisation while suffering from mental illness, our findings build up on the large body of work that has been done globally [ 2 , 3 , 4 , 5 , 11 ] in pointing to the high prevalence of victimisation among the mentally ill.

Literature on victimisation of the mentally ill within the mental health care system has been scarce, with the incidence of victimisation of patients in the mental health care settings remaining largely obscure [ 35 ]. However, the reverse has been true in contexts outside of the mental health care system in both high income countries [ 36 ] and LMICs [ 11 , 37 ] where the perpetrators within the community have been extensively described, including intimate partners and other family members. Even then, our study contributes to the literature by illuminating the predominance of the family environment in perpetrating victimisation of the mentally ill in some sub-Saharan African contexts. This is especially so given that we were unable to identify any sub-Saharan African study reporting similar findings, but also in light of the depiction in the literature of the protective character of the family social system in the African setting [ 38 ]. Relatedly, our findings point to the importance of lack of social support within family and the victimisation associated with this in determining the recovery trajectory of persons with severe mental illness. Both the female patient who expressed the enduring psychological pain of being physically assaulted by the husband because of a house fire, and another who agonised about being habitually taunted by the caregiver to take her own life because she was too demanding, for example, alluded to this victimisation as negatively impacting their recovery. This finding echoes those from a systematic review by Rani and colleagues [ 39 ].

Our findings have also revealed some patterns of experience among women with mental illness that point to some notable intra-gender heterogeneities. The findings showed that mentally ill women living in matrimonial relationships were more prone to extreme forms of victimisation than those living with blood relatives. To the spouse, a woman’s mental illness was intolerable and justified her ejection from the matrimonial home, whereas to blood relatives, she was tolerated and, despite reports of victimisation of the mentally ill adult, the relatives always made room for her as a family member. Previous studies [ 40 , 41 , 42 , 43 ] have investigated the lived experiences of caregivers of the mentally ill but have also noted the “surprising” paucity of literature on this subject given the frequent occurrence of mental illness [ 40 ]. Our findings build on this literature by bringing to light the heterogeneities in the victimisation experiences of women, with important implications for care of the mentally ill.

On the other hand, by revealing men’s intolerance towards their mentally ill female spouses our findings lend credence to what Hailemariam and colleagues [ 44 ], in their rural Ethiopian study on gender, mental illness and marriage, categorise as “gendered experiences of marriageability.” By this the authors refer to the unique challenge mentally ill women encounter being in a spousal relationship owing to their incapacity to conform to gendered sociocultural obligations within marriage. Similarly, our findings are consistent with the preceding authors’ in pointing out the inability of a woman to sustain her marriage in the wake of her mental illness. Hailemariam and colleagues [ 44 ] have sought to explain this phenomenon, particularly in the sub-Saharan African context, from a normative cultural perspective. They observe the gendered double standards by which marital separation is culturally acceptable due to a wife’s mental illness, but unacceptable when it is the husband with the mental illness, because in the latter case society expects the woman to take care of the ill husband.

With regard to coping ability, our findings highlighted gendered experiences, with men depicting higher resilience and coping abilities. Nonetheless, we identified behaviour among men that might have resulted in loss of social support from at least some community members, as reflected in total withdrawal from community/church engagement on account of being overtly labelled a mentally ill person. This finding echoes those from previous studies [ 45 , 46 ] in pointing to the importance of stigma in mental illness, insofar as complicating the recovery process even for those who may be responding well to treatment and regaining normal functioning.

Our findings also illuminated the important role of basic human needs – food, water, sex and others – in the management of mental illness and shaping the recovery trajectory. While these basic/physiological needs are fundamental to human survival and general well-being [ 47 ] our study shows that these are even more key to the stability and recovery of persons with severe mental illness. This was illustrated by the woman who endured sometimes painful extramarital sex in exchange for food, as her husband was restricting her access to food. Our findings are consistent with those from previous work such as that of Williams and colleagues [ 48 ] in pointing to the importance of meeting basic needs in improving the quality of life of persons with severe mental illness. Relatedly, the failure to be understood was repeatedly highlighted in different patients’ narratives as a source of stress, raising concerns about poor coping and treatment outcomes. This echoes findings from Gaillard and colleagues’ [ 49 ] study where misunderstood mental health patients expressed frustrations of being “an object to be fixed, treated like a child.” The authors recommended efforts to heighten understanding and improve therapeutic relationships as a means of enhancing care for the mentally ill.

Implications for care

Strategies for addressing victimisation of persons with severe mental illness in Uganda need to be sensitive to the local realities, mainly the sociocultural practices and beliefs. They also need to reflect an understanding of mentally ill women as a heterogeneous group, with dissimilar experiences based on family environment and relationships. Necessarily, these strategies would adopt a holistic framework for mental health interventions, incorporating not just biomedical but also social determinants of mental health. An intervention framework incorporating social determinants would be predicated on the understanding that the environment in which individuals live and work influences their health outcomes [ 50 ]. Thus, interventions for addressing victimisation of the mentally ill would focus on improving familial relationships, and social support and a sense of belongingness both within the family and the broader community, as these and related interventions have been found to be protective against adverse mental health outcomes [ 51 , 52 ]. Indeed, these protective factors are recognised as being embedded in the African way of life [ 52 ]. For their part, mental health professionals would need to standardise “victimisation” in their tools for the assessment and psychosocial management of persons with severe mental illness.

However, our findings support those from previous work [ 53 , 54 ] in revealing that some environments in sub-Saharan Africa, especially in the rural settings, are not necessarily always protective with respect to mental health. With this in mind, we propose realistic interventions that take advantage of and strengthen the protective aspects of the cultural and family support system, while seeking to change those aspects with deleterious effects on the recovery and wellbeing of those with mental illness – such as beliefs/norms around dealing with a mentally ill wife.

Victimisation of persons with severe mental illness is an important social problem in sub-Saharan African settings such as Uganda, where the family environment plays a predominant role in its perpetration. Victimisation of the mentally ill has been found to impact negatively on their recovery and general wellbeing, by triggering victims’ harmful responses including a heightened risk of suicide, social withdrawal, a sense of hatefulness and worthlessness and a predisposition to more victimisation. We propose a holistic framework for mental health interventions, incorporating not just biomedical but also social determinants of mental health, and targeted at improving familial relationships, social support and a sense of belongingness both within the family and the broader community.

Limitations of the study

A limitation of this study was that we did not aim at the outset to explore gender, and consequently our sample was not stratified to ensure gender balance. With only five of a total of 18 study participants being male we feel constrained in making substantive inferences on gender. We therefore propose similar studies in Uganda and the broader sub-Saharan African region that explore gender in more depth, especially given that we were still able to observe from our data some gender-based differences in the experience of victimisation.

Data availability

The datasets generated and/or analysed during the current study are accessible at https://doi.org/10.17037/DATA.00002840 .

Abbreviations

Severe Mental Illness

Low and Middle Income Countries

Human Immunodeficiency Virus

Infectious Disease Clinic

Interpretative Phenomenological Analysis

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Acknowledgements

We acknowledge the contribution of managers of the two study sites (Butabika National Psychiatric Referral Hospital and Masaka Regional Referral Hospital) in granting permission for undertaking the study in these facilities. We also acknowledge the contribution of MRC/UVRI & LSHTM which funded and facilitated the study. Furthermore, our appreciation extends to staff of the outpatient departments of the facilities where the study was conducted, as well as the study participants for their time.

This study was funded by MRC core funding to the Mental Health Project of MRC/UVRI and LSHTM under the headship of Professor Eugene Kinyanda to undertake the ‘HIV clinical trials preparedness studies among patients with Severe Mental ILlnEss in HIV endemic Uganda (SMILE Study).

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R.R. analysed data, developed the idea for the topic of the manuscript, drafted the original manuscript and subsequent revisions. B.L.K., C.T., R.S.M., C.B., E.K. contributed in reviewing the different versions of the manuscript. C.T., R.S.M. and C.B. conducted the research. E.K. provided overall leadership and secured financial support for the project leading to this publication. All authors read and approved the final manuscript.

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Rutakumwa, R., Knizek, B.L., Tusiime, C. et al. Victimisation in the life of persons with severe mental illness in Uganda: a pluralistic qualitative study. BMC Psychiatry 24 , 329 (2024). https://doi.org/10.1186/s12888-024-05720-4

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DOI : https://doi.org/10.1186/s12888-024-05720-4

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