qualitative research visual content analysis

Perhaps what is missing in this context are the children’s direct voices and their own meaning-making through their work. As the dialogue with the teacher participants sometimes, takes place a period after the creation of their artwork and there was insufficient opportunity to take the time to dialogue directly with the children but rather to learn about the process through the teacher participants’ perspective at this stage. The meaning-making process here considers mainly the interpretation of the teacher and the researcher. The fact is that images should be acknowledged to be multi-vocal, having the ability to ‘speak’ to different audiences in a variety of contexts ( ; ).

In current times, digital media has reached into our mundane everyday existences, most obviously through the cell phone and modern-day gadgets, social media and these digital artefacts have engendered new forms of ethnographic enquiry. One of these includes what might be termed as the cultural politics of media and examines cultural identities, representations and imaginaries ( ). Fleer & Ridgway, (2014) outline and frame visual narrative data based on cultural-historical theory. Cultural historical theory acknowledges that the characteristics of individuals engaged in activities and interactions within a certain cultural setting can evolve and transform over a period of history. This can enable the researcher a better understanding on why certain practices and needs are defined as they are in a specific context and that different perspectives and priorities are taken in different cultures and times ( ; ).

Though field observation, particularly in Reggio-Emilia inspired centres and where children are given free reign of their imagination through encouragement and access to materials, it has been observed that the young can use the graphic and expressive languages of drawing, painting, collage and construction to record their ideas, observations, reflections, memories to further explore their understanding. Embedded in these activities are the processes of reconstructing and building on earlier knowledge so as to externalize their thoughts and what is learnt, to share their worlds with their peers and others ( ; ). The approach using ‘art as epistemology’ ( ) so that art experiences in the classroom can have both communicative and expressive goals, and the concept of art as a symbolic language is the subject of much debate. This highlights the potential of teachers facilitating children to develop the capacity in the ‘hundred language’ that is accessible to them so as to master the range of instruments and symbols ( ) that form the visual culture and an expressive language used in the curriculum. The potential for research based on visual methodologies is thus boundless.

I would like to thank niec, National Institute of Early Childhood Development, Singapore and the following teacher participant contributors Chandra Rai, Shauna Chen and Kavita Mogan.

SAGE. .)| false , M. (2011). Presenting visual research. In , 105–128. SAGE. 10.4135/9781526445933.n5.

SAGE. 10.4135/9781526445933.n5.)| false , U. , & Morris, P. A. (2006). The Bio ecological Model of Human Development. In . John Wiley.

John Wiley.)| false , K. (2015). (Second Ed, Vol. ). Elsevier.

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SAGE.)| false , R. , Griffin, C. , Hunter, J. , & Phoenix, A. (2008). Young people’s constructions of self: Notes on the use and analysis of the photo-elicitation methods. , (4), 345–356. .

Oxford University Press.)| false , M. , & Ridgway, A. (2014). . .

SAGE.)| false , K. (1991). Arts as Epistemology: Enabling Children to Know What They Know. , (1), 40–51. .

Polity Press.)| false , J. (2013). Visual research methods in education: In between difference and indifference. , (2), 63–78.

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& (Eds.), , (pp. – ).

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• 3.2 Researcher and Participant-generated Visual Material
• 3.3 Visual/Photo-elicited Data
• 4 Summary and Conclusions
• Acknowledgements

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• Am J Pharm Educ
• v.84(1); 2020 Jan

Demystifying Content Analysis

A. j. kleinheksel.

a The Medical College of Georgia at Augusta University, Augusta, Georgia

Nicole Rockich-Winston

Huda tawfik.

b Central Michigan University, College of Medicine, Mt. Pleasant, Michigan

Tasha R. Wyatt

Objective. In the course of daily teaching responsibilities, pharmacy educators collect rich data that can provide valuable insight into student learning. This article describes the qualitative data analysis method of content analysis, which can be useful to pharmacy educators because of its application in the investigation of a wide variety of data sources, including textual, visual, and audio files.

Findings. Both manifest and latent content analysis approaches are described, with several examples used to illustrate the processes. This article also offers insights into the variety of relevant terms and visualizations found in the content analysis literature. Finally, common threats to the reliability and validity of content analysis are discussed, along with suitable strategies to mitigate these risks during analysis.

Summary. This review of content analysis as a qualitative data analysis method will provide clarity and actionable instruction for both novice and experienced pharmacy education researchers.

INTRODUCTION

The Academy’s growing interest in qualitative research indicates an important shift in the field’s scientific paradigm. Whereas health science researchers have historically looked to quantitative methods to answer their questions, this shift signals that a purely positivist, objective approach is no longer sufficient to answer pharmacy education’s research questions. Educators who want to study their teaching and students’ learning will find content analysis an easily accessible, robust method of qualitative data analysis that can yield rigorous results for both publication and the improvement of their educational practice. Content analysis is a method designed to identify and interpret meaning in recorded forms of communication by isolating small pieces of the data that represent salient concepts and then applying or creating a framework to organize the pieces in a way that can be used to describe or explain a phenomenon. 1 Content analysis is particularly useful in situations where there is a large amount of unanalyzed textual data, such as those many pharmacy educators have already collected as part of their teaching practice. Because of its accessibility, content analysis is also an appropriate qualitative method for pharmacy educators with limited experience in educational research. This article will introduce and illustrate the process of content analysis as a way to analyze existing data, but also as an approach that may lead pharmacy educators to ask new types of research questions.

Content analysis is a well-established data analysis method that has evolved in its treatment of textual data. Content analysis was originally introduced as a strictly quantitative method, recording counts to measure the observed frequency of pre-identified targets in consumer research. 1 However, as the naturalistic qualitative paradigm became more prevalent in social sciences research and researchers became increasingly interested in the way people behave in natural settings, the process of content analysis was adapted into a more interesting and meaningful approach. Content analysis has the potential to be a useful method in pharmacy education because it can help educational researchers develop a deeper understanding of a particular phenomenon by providing structure in a large amount of textual data through a systematic process of interpretation. It also offers potential value because it can help identify problematic areas in student understanding and guide the process of targeted teaching. Several research studies in pharmacy education have used the method of content analysis. 2-7 Two studies in particular offer noteworthy examples: Wallman and colleagues employed manifest content analysis to analyze semi-structured interviews in order to explore what students learn during experiential rotations, 7 while Moser and colleagues adopted latent content analysis to evaluate open-ended survey responses on student perceptions of learning communities. 6 To elaborate on these approaches further, we will describe the two types of qualitative content analysis, manifest and latent, and demonstrate the corresponding analytical processes using examples that illustrate their benefit.

Qualitative Content Analysis

Content analysis rests on the assumption that texts are a rich data source with great potential to reveal valuable information about particular phenomena. 8 It is the process of considering both the participant and context when sorting text into groups of related categories to identify similarities and differences, patterns, and associations, both on the surface and implied within. 9-11 The method is considered high-yield in educational research because it is versatile and can be applied in both qualitative and quantitative studies. 12 While it is important to note that content analysis has application in visual and auditory artifacts (eg, an image or song), for our purposes we will largely focus on the most common application, which is the analysis of textual or transcribed content (eg, open-ended survey responses, print media, interviews, recorded observations, etc). The terminology of content analysis can vary throughout quantitative and qualitative literature, which may lead to some confusion among both novice and experienced researchers. However, there are also several agreed-upon terms and phrases that span the literature, as found in Table 1 .

Terms and Definitions Used in Qualitative Content Analysis

There is more often disagreement on terminology in the methodological approaches to content analysis, though the most common differentiation is between the two types of content: manifest and latent. In much of the literature, manifest content analysis is defined as describing what is occurring on the surface, what is and literally present, and as “staying close to the text.” 8,13 Manifest content analysis is concerned with data that are easily observable both to researchers and the coders who assist in their analyses, without the need to discern intent or identify deeper meaning. It is content that can be recognized and counted with little training. Early applications of manifest analysis focused on identifying easily observable targets within text (eg, the number of instances a certain word appears in newspaper articles), film (eg, the occupation of a character), or interpersonal interactions (eg, tracking the number of times a participant blinks during an interview). 14 This application, in which frequency counts are used to understand a phenomenon, reflects a surface-level analysis and assumes there is objective truth in the data that can be revealed with very little interpretation. The number of times a target (ie, code) appears within the text is used as a way to understand its prevalence. Quantitative content analysis is always describing a positivist manifest content analysis, in that the nature of truth is believed to be objective, observable, and measurable. Qualitative research, which favors the researcher’s interpretation of an individual’s experience, may also be used to analyze manifest content. However, the intent of the application is to describe a dynamic reality that cannot be separated from the lived experiences of the researcher. Although qualitative content analysis can be conducted whether knowledge is thought to be innate, acquired, or socially constructed, the purpose of qualitative manifest content analysis is to transcend simple word counts and delve into a deeper examination of the language in order to organize large amounts of text into categories that reflect a shared meaning. 15,16 The practical distinction between quantitative and qualitative manifest content analysis is the intention behind the analysis. The quantitative method seeks to generate a numerical value to either cite prevalence or use in statistical analyses, while the qualitative method seeks to identify a construct or concept within the text using specific words or phrases for substantiation, or to provide a more organized structure to the text being described.

Latent content analysis is most often defined as interpreting what is hidden deep within the text. In this method, the role of the researcher is to discover the implied meaning in participants’ experiences. 8,13 For example, in a transcribed exchange in an office setting, a participant might say to a coworker, “Yeah, here we are…another Monday. So exciting!” The researcher would apply context in order to discover the emotion being conveyed (ie, the implied meaning). In this example, the comment could be interpreted as genuine, it could be interpreted as a sarcastic comment made in an attempt at humor in order to develop or sustain social bonds with the coworker, or the context might imply that the sarcasm was meant to convey displeasure and end the interaction.

Latent content analysis acknowledges that the researcher is intimately involved in the analytical process and that the their role is to actively use mental schema, theories, and lenses to interpret and understand the data. 10 Whereas manifest analyses are typically conducted in a way that the researcher is thought to maintain distance and separation from the objects of study, latent analyses underscore the importance of the researcher co-creating meaning with the text. 17 Adding nuance to this type of content, Potter and Levine‐Donnerstein argue that within latent content analysis, there are two distinct types: latent pattern and latent projective . 14 Latent pattern content analysis seeks to establish a pattern of characteristics in the text itself, while latent projective content analysis leverages the researcher’s own interpretations of the meaning of the text. While both approaches rely on codes that emerge from the content using the coder’s own perspectives and mental schema, the distinction between these two types of analyses are in their foci. 14 Though we do not agree, some researchers believe that all qualitative content analysis is latent content analysis. 11 These disagreements typically occur where there are differences in intent and where there are areas of overlap in the results. For example, both qualitative manifest and latent pattern content analyses may identify patterns as a result of their application. Though in their research design, the researcher would have approached the content with different methodological approaches, with a manifest approach seeking only to describe what is observed, and the latent pattern approach seeking to discover an unseen pattern. At this point, these distinctions may seem too philosophical to serve a practical purpose, so we will attempt to clarify these concepts by presenting three types of analyses for illustrative purposes, beginning with a description of how codes are created and used.

Creating and Using Codes

Codes are the currency of content analysis. Researchers use codes to organize and understand their data. Through the coding process, pharmacy educators can systematically and rigorously categorize and interpret vast amounts of text for use in their educational practice or in publication. Codes themselves are short, descriptive labels that symbolically assign a summative or salient attribute to more than one unit of meaning identified in the text. 18 To create codes, a researcher must first become immersed in the data, which typically occurs when a researcher transcribes recorded data or conducts several readings of the text. This process allows the researcher to become familiar with the scope of the data, which spurs nascent ideas about potential concepts or constructs that may exist within it. If studying a phenomenon that has already been described through an existing framework, codes can be created a priori using theoretical frameworks or concepts identified in the literature. If there is no existing framework to apply, codes can emerge during the analytical process. However, emergent codes can also be created as addenda to a priori codes that were identified before the analysis begins if the a priori codes do not sufficiently capture the researcher’s area of interest.

The process of detecting emergent codes begins with identification of units of meaning. While there is no one way to decide what qualifies as a meaning unit, researchers typically define units of meaning differently depending on what kind of analysis is being conducted. As a general rule, when dialogue is being analyzed, such as interviews or focus groups, meaning units are identified as conversational turns, though a code can be as short as one or two words. In written text, such as student reflections or course evaluation data, the researcher must decide if the text should be divided into phrases or sentences, or remain as paragraphs. This decision is usually made based on how many different units of meaning are expressed in a block of text. For example, in a paragraph, if there are several thoughts or concepts being expressed, it is best to break up the paragraph into sentences. If one sentence contains multiple ideas of interest, making it difficult to separate one important thought or behavior from another, then the sentence can be divided into smaller units, such as phrases or sentence fragments. These phrases or sentence fragments are then coded as separate meaning units. Conversely, longer or more complex units of meaning should be condensed into shorter representations that still retain the original meaning in order to reduce the cognitive burden of the analytical process. This could entail removing verbal ticks (eg, “well, uhm…”) from transcribed data or simplifying a compound sentence. Condensation does not ascribe interpretation or implied meaning to a unit, but only shortens a meaning unit as much as possible while preserving the original meaning identified. 18 After condensation, a researcher can proceed to the creation of codes.

Many researchers begin their analyses with several general codes in mind that help guide their focus as defined by their research question, even in instances where the researcher has no a priori model or theory. For example, if a group of instructors are interested in examining recorded videos of their lectures to identify moments of student engagement, they may begin with using generally agreed upon concepts of engagement as codes, such as students “raising their hands,” “taking notes,” and “speaking in class.” However, as the instructors continue to watch their videos, they may notice other behaviors which were not initially anticipated. Perhaps students were seen creating flow charts based on information presented in class. Alternatively, perhaps instructors wanted to include moments when students posed questions to their peers without being prompted. In this case, the instructors would allow the codes of “creating graphic organizers” and “questioning peers” to emerge as additional ways to identify the behavior of student engagement.

Once a researcher has identified condensed units of meaning and labeled them with codes, the codes are then sorted into categories which can help provide more structure to the data. In the above example of recorded lectures, perhaps the category of “verbal behaviors” could be used to group the codes of “speaking in class” and “questioning peers.” For complex analyses, subcategories can also be used to better organize a large amount of codes, but solely at the discretion of the researcher. Two or more categories of codes are then used to identify or support a broader underlying meaning which develops into themes. Themes are most often employed in latent analyses; however, they are appropriate in manifest analyses as well. Themes describe behaviors, experiences, or emotions that occur throughout several categories. 18 Figure 1 illustrates this process. Using the same videotaped lecture example, the instructors might identify two themes of student engagement, “active engagement” and “passive engagement,” where active engagement is supported by the category of “verbal behavior” and also a category that includes the code of “raising their hands” (perhaps something along the lines of “pursuing engagement”), and the theme of “passive engagement” is supported by a category used to organize the behaviors of “taking notes” and “creating graphic organizers.”

The Process of Qualitative Content Analysis

To more fully demonstrate the process of content analysis and the generation and use of codes, categories, and themes, we present and describe examples of both manifest and latent content analysis. Given that there are multiple ways to create and use codes, our examples illustrate both processes of creating and using a predetermined set of codes. Regardless of the kind of content analysis instructors want to conduct, the initial steps are the same. The instructor must analyze the data using codes as a sense-making process.

Manifest Content Analysis

The first form of analysis, manifest content analysis, examines text for elements that exist on the surface of the text, the meaning of which is taken at face value. Schools and colleges of pharmacy may benefit from conducting manifest content analyses at a programmatic level, including analysis of student evaluations to determine the value of certain courses, or analysis of recruitment materials for addressing issues of cultural humility in a uniform manner. Such uses for manifest content analysis may help administrators make more data-based decisions about students and courses. However, for our example of manifest content analysis, we illustrate the use of content analysis in informing instruction for a single pharmacy educator ( Figure 2 ).

A Student’s Completed Beta-blocker Case with Codes in Underlined Bold Text

In the example, a pharmacology instructor is trying to assess students’ understanding of three concepts related to the beta-blocker class of drugs: indication of the drug, relevance of family history, and contraindications and precautions. To do so, the instructor asks the students to write a patient case in which beta-blockers are indicated. The instructor gives the students the following prompt: “Reverse-engineer a case in which beta-blockers would be prescribed to the patient. Include a history of the present illness, the patients’ medical, family, and social history, medications, allergies, and relevant lab tests.” Figure 2 is a hypothetical student’s completed assignment, in which they demonstrate their understanding of when and why a beta-blocker would be prescribed.

The student-generated cases are then treated as data and analyzed for the presence of the three previously identified indicators of understanding in order to help the instructor make decisions about where and how to focus future teaching efforts related to this drug class. Codes are created a priori out of the instructor’s interest in analyzing students’ understanding of the concepts related to beta-blocker prescriptions. A codebook ( Table 2 ) is created with the following columns: name of code, code description, and examples of the code. This codebook helps an individual researcher to approach their analysis systematically, but it can also facilitate coding by multiple coders who would apply the same rules outlined in the codebook to the coding process.

Example Code Book Created for Manifest Content Analysis

Using multiple coders introduces complexity to the analysis process, but it is oftentimes the only practical way to analyze large amounts of data. To ensure that all coders are working in tandem, they must establish inter-rater reliability as part of their training process. This process requires that a single form of text be selected, such as one student evaluation. After reviewing the codebook and receiving instruction, everyone on the team individually codes the same piece of data. While calculating percentage agreement has sometimes been used to establish inter-rater reliability, most publication editors require more rigorous statistical analysis (eg, Krippendorf’s alpha, or Cohen’s kappa). 19 Detailed descriptions of these statistics fall outside the scope of this introduction, but it is important to note that the choice depends on the number of coders, the sample size, and the type of data to be analyzed.

Latent Content Analysis

Latent content analysis is another option for pharmacy educators, especially when there are theoretical frameworks or lenses the educator proposes to apply. Such frameworks describe and provide structure to complex concepts and may often be derived from relevant theories. Latent content analysis requires that the researcher is intimately involved in interpreting and finding meaning in the text because meaning is not readily apparent on the surface. 10 To illustrate a latent content analysis using a combination of a priori and emergent codes, we will use the example of a transcribed video excerpt from a student pharmacist interaction with a standardized patient. In this example, the goal is for first-year students to practice talking to a customer about an over-the-counter medication. The case is designed to simulate a customer at a pharmacy counter, who is seeking advice on a medication. The learning objectives for the pharmacist in-training are to assess the customer’s symptoms, determine if the customer can self-treat or if they need to seek out their primary care physician, and then prescribe a medication to alleviate the patient’s symptoms.

To begin, pharmacy educators conducting educational research should first identify what they are looking for in the video transcript. In this case, because the primary outcome for this exercise is aimed at assessing the “soft skills” of student pharmacists, codes are created using the counseling rubric created by Horton and colleagues. 20 Four a priori codes are developed using the literature: empathy, patient-friendly terms, politeness, and positive attitude. However, because the original four codes are inadequate to capture all areas representing the skills the instructor is looking for during the process of analysis, four additional codes are also created: active listening, confidence, follow-up, and patient at ease. Figure 3 presents the video transcript with each of the codes assigned to the meaning units in bolded parentheses.

A Transcript of a Student’s (JR) Experience with a Standardized Patient (SP) in Which the Codes are Bolded in Parentheses

Following the initial coding using these eight codes, the codes are consolidated to create categories, which are depicted in the taxonomy in Figure 4 . Categories are relationships between codes that represent a higher level of abstraction in the data. 18 To reach conclusions and interpret the fundamental underlying meaning in the data, categories are then organized into themes ( Figure 1 ). Once the data are analyzed, the instructor can assign value to the student’s performance. In this case, the coding process determines that the exercise demonstrated both positive and negative elements of communication and professionalism. Under the category of professionalism, the student generally demonstrated politeness and a positive attitude toward the standardized patient, indicating to the reviewer that the theme of perceived professionalism was apparent during the encounter. However, there were several instances in which confidence and appropriate follow-up were absent. Thus, from a reviewer perspective, the student's performance could be perceived as indicating an opportunity to grow and improve as a future professional. Typically, there are multiple codes in a category and multiple categories in a theme. However, as seen in the example taxonomy, this is not always the case.

Example of a Latent Content Analysis Taxonomy

If the educator is interested in conducting a latent projective analysis, after identifying the construct of “soft skills,” the researcher allows for each coder to apply their own mental schema as they look for positive and negative indicators of the non-technical skills they believe a student should develop. Mental schema are the cognitive structures that provide organization to knowledge, which in this case allows coders to categorize the data in ways that fit their existing understanding of the construct. The coders will use their own judgement to identify the codes they feel are relevant. The researcher could also choose to apply a theoretical lens to more effectively conceptualize the construct of “soft skills,” such as Rogers' humanism theory, and more specifically, concepts underlying his client-centered therapy. 21 The role of theory in both latent pattern and latent projective analyses is at the discretion of the researcher, and often is determined by what already exists in the literature related to the research question. Though, typically, in latent pattern analyses theory is used for deductive coding, and in latent projective analyses underdeveloped theory is used to first deduce codes and then for induction of the results to strengthen the theory applied. For our example, Rogers describes three salient qualities to develop and maintain a positive client-professional relationship: unconditional positive regard, genuineness, and empathetic understanding. 21 For the third element, specifically, the educator could look for units of meaning that imply empathy and active listening. For our video transcript analysis, this is evident when the student pharmacist demonstrated empathy by responding, "Yeah, I understand," when discussing aggravating factors for the patient's condition. The outcome for both latent pattern and latent projective content analysis is to discover the underlying meaning in a text, such as social rules or mental models. In this example, both pattern and projective approaches can discover interpreted aspects of a student’s abilities and mental models for constructs such as professionalism and empathy. The difference in the approaches is where the precedence lies: in the belief that a pattern is recognizable in the content, or in the mental schema and lived experiences of the coder(s). To better illustrate the differences in the processes of latent pattern and projective content analyses, Figure 5 presents a general outline of each method beginning with the creation of codes and concluding with the generation of themes.

Flow Chart of the Stages of Latent Pattern and Latent Projective Content Analysis

How to Choose a Methodological Approach to Content Analysis

To determine which approach a researcher should take in their content analysis, two decisions need to be made. First, researchers must determine their goal for the analysis. Second, the researcher must decide where they believe meaning is located. 14 If meaning is located in the discrete elements of the content that are easily identified on the surface of the text, then manifest content analysis is appropriate. If meaning is located deep within the content and the researcher plans to discover context cues and make judgements about implied meaning, then latent content analysis should be applied. When designing the latent content analysis, a researcher then must also identify their focus. If the analysis is intended to identify a recognizable truth within the content by uncovering connections and characteristics that all coders should be able to discover, then latent pattern content analysis is appropriate. If, on the other hand, the researcher will rely heavily on the judgment of the coders and believes that interpretation of the content must leverage the mental schema of the coders to locate deeper meaning, then latent projective content analysis is the best choice.

To demonstrate how a researcher might choose a methodological approach, we have presented a third example of data in Figure 6 . In our two previous examples of content analysis, we used student data. However, faculty data can also be analyzed as part of educational research or for faculty members to improve their own teaching practices. Recall in the video data analyzed using latent content analysis, the student was tasked to identify a suitable over-the-counter medication for a patient complaining of heartburn symptoms. We have extended this example by including an interview with the pharmacy educator supervising the student who was videotaped. The goal of the interview is to evaluate the educator’s ability to assess the student’s performance with the standardized patient. Figure 6 is an excerpt of the interview between the course instructor and an instructional coach. In this conversation, the instructional coach is eliciting evidence to support the faculty member’s views, judgements, and rationale for the educator’s evaluation of the student’s performance.

A Transcript of an Interview in Which the Interviewer (IN) Questions a Faculty Member (FM) Regarding Their Student’s Standardized Patient Experience

Manifest content analysis would be a valid choice for this data if the researcher was looking to identify evidence of the construct of “instructor priorities” and defined discrete codes that described aspects of performance such as “communication,” “referrals,” or “accurate information.” These codes could be easily identified on the surface of the transcribed interview by identifying keywords related to each code, such as “communicate,” “talk,” and “laugh,” for the code of “communication.” This would allow coders to identify evidence of the concept of “instructor priorities” by sorting through a potentially large amount of text with predetermined targets in mind.

To conduct a latent pattern analysis of this interview, researchers would first immerse themselves in the data to identify a theoretical framework or concepts that represent the area of interest so that coders could discover an emerging truth underneath the surface of the data. After immersion in the data, a researcher might believe it would be interesting to more closely examine the strategies the coach uses to establish rapport with the instructor as a way to better understand models of professional development. These strategies could not be easily identified in the transcripts if read literally, but by looking for connections within the text, codes related to instructional coaching tactics emerge. A latent pattern analysis would require that the researcher code the data in a way that looks for patterns, such as a code of “facilitating reflection,” that could be identified in open-ended questions and other units of meaning where the coder saw evidence of probing techniques, or a code of “establishing rapport” for which a coder could identify nonverbal cues such as “[IN leans forward in chair].”

Conducting latent projective content analysis might be useful if the researcher was interested in using a broader theoretical lens, such as Mezirow’s theory of transformative learning. 22 In this example, the faculty member is understood to have attempted to change a learner’s frame of reference by facilitating cognitive dissonance or a disorienting experience through a standardized patient simulation. To conduct a latent projective analysis, the researcher could analyze the faculty member’s interview using concepts found in this theory. This kind of analysis will help the researcher assess the level of change that the faculty member was able to perceive, or expected to witness, in their attempt to help their pharmacy students improve their interactions with patients. The units of meaning and subsequent codes would rely on the coders to apply their own knowledge of transformative learning because of the absence in the theory of concrete, context-specific behaviors to identify. For this analysis, the researcher would rely on their interpretations of what challenging educational situations look like, what constitutes cognitive dissonance, or what the faculty member is really expecting from his students’ performance. The subsequent analysis could provide evidence to support the use of such standardized patient encounters within the curriculum as a transformative learning experience and would also allow the educator to self-reflect on his ability to assess simulated activities.

OTHER ASPECTS TO CONSIDER

Navigating terminology.

Among the methodological approaches, there are other terms for content analysis that researchers may come across. Hsieh and Shannon 10 proposed three qualitative approaches to content analysis: conventional, directed, and summative. These categories were intended to explain the role of theory in the analysis process. In conventional content analysis, the researcher does not use preconceived categories because existing theory or literature are limited. In directed content analysis, the researcher attempts to further describe a phenomenon already addressed by theory, applying a deductive approach and using identified concepts or codes from exiting research to validate the theory. In summative content analysis, a descriptive approach is taken, identifying and quantifying words or content in order to describe their context. These three categories roughly map to the terms of latent projective, latent pattern, and manifest content analyses respectively, though not precisely enough to suggest that they are synonyms.

Graneheim and colleagues 9 reference the inductive, deductive, and abductive methods of interpretation of content analysis, which are data-driven, concept-driven, and fluid between both data and concepts, respectively. Where manifest content produces phenomenological descriptions most often (but not always) through deductive interpretation, and latent content analysis produces interpretations most often (but not always) through inductive or abductive interpretations. Erlingsson and Brysiewicz 23 refer to content analysis as a continuum, progressing as the researcher develops codes, then categories, and then themes. We present these alternative conceptualizations of content analysis to illustrate that the literature on content analysis, while incredibly useful, presents a multitude of interpretations of the method itself. However, these complexities should not dissuade readers from using content analysis. Identifying what you want to know (ie, your research question) will effectively direct you toward your methodological approach. That said, we have found the most helpful aid in learning content analysis is the application of the methods we have presented.

Ensuring Quality

The standards used to evaluate quantitative research are seldom used in qualitative research. The terms “reliability” and “validity” are typically not used because they reflect the positivist quantitative paradigm. In qualitative research, the preferred term is “trustworthiness,” which is comprised of the concepts of credibility, transferability, dependability, and confirmability, and researchers can take steps in their work to demonstrate that they are trustworthy. 24 Though establishing trustworthiness is outside the scope of this article, novice researchers should be familiar with the necessary steps before publishing their work. This suggestion includes exploration of the concept of saturation, the idea that researchers must demonstrate they have collected and analyzed enough data to warrant their conclusions, which has been a focus of recent debate in qualitative research. 25

There are several threats to the trustworthiness of content analysis in particular. 14 We will use the terms “reliability and validity” to describe these threats, as they are conceptualized this way in the formative literature, and it may be easier for researchers with a quantitative research background to recognize them. Though some of these threats may be particular to the type of data being analyzed, in general, there are risks specific to the different methods of content analysis. In manifest content analysis, reliability is necessary but not sufficient to establish validity. 14 Because there is little judgment required of the coders, lack of high inter-rater agreement among coders will render the data invalid. 14 Additionally, coder fatigue is a common threat to manifest content analysis because the coding is clerical and repetitive in nature.

For latent pattern content analysis, validity and reliability are inversely related. 14 Greater reliability is achieved through more detailed coding rules to improve consistency, but these rules may diminish the accessibility of the coding to consumers of the research. This is defined as low ecological validity. Higher ecological validity is achieved through greater reliance on coder judgment to increase the resonance of the results with the audience, yet this often decreases the inter-rater reliability. In latent projective content analysis, reliability and validity are equivalent. 14 Consistent interpretations among coders both establishes and validates the constructed norm; construction of an accurate norm is evidence of consistency. However, because of this equivalence, issues with low validity or low reliability cannot be isolated. A lack of consistency may result from coding rules, lack of a shared schema, or issues with a defined variable. Reasons for low validity cannot be isolated, but will always result in low consistency.

Any good analysis starts with a codebook and coder training. It is important for all coders to share the mental model of the skill, construct, or phenomenon being coded in the data. However, when conducting latent pattern or projective content analysis in particular, micro-level rules and definitions of codes increase the threat of ecological validity, so it is important to leave enough room in the codebook and during the training to allow for a shared mental schema to emerge in the larger group rather than being strictly directed by the lead researcher. Stability is another threat, which occurs when coders make different judgments as time passes. To reduce this risk, allowing for recoding at a later date can increase the consistency and stability of the codes. Reproducibility is not typically a goal of qualitative research, 15 but for content analysis, codes that are defined both prior to and during analysis should retain their meaning. Researchers can increase the reproducibility of their codebook by creating a detailed audit trail, including descriptions of the methods used to create and define the codes, materials used for the training of the coders, and steps taken to ensure inter-rater reliability.

In all forms of qualitative analysis, coder fatigue is a common threat to trustworthiness, even when the instructor is coding individually. Over time, the cases may start to look the same, making it difficult to refocus and look at each case with fresh eyes. To guard against this, coders should maintain a reflective journal and write analytical memos to help stay focused. Memos might include insights that the researcher has, such as patterns of misunderstanding, areas to focus on when considering re-teaching specific concepts, or specific conversations to have with students. Fatigue can also be mitigated by occasionally talking to participants (eg, meeting with students and listening for their rationale on why they included specific pieces of information in an assignment). These are just examples of potential exercises that can help coders mitigate cognitive fatigue. Most researchers develop their own ways to prevent the fatigue that can seep in after long hours of looking at data. But above all, a sufficient amount of time should be allowed for analysis, so that coders do not feel rushed, and regular breaks should be scheduled and enforced.

Qualitative content analysis is both accessible and high-yield for pharmacy educators and researchers. Though some of the methods may seem abstract or fluid, the nature of qualitative content analysis encompasses these concerns by providing a systematic approach to discover meaning in textual data, both on the surface and implied beneath it. As with most research methods, the surest path towards proficiency is through application and intentional, repeated practice. We encourage pharmacy educators to ask questions suited for qualitative research and to consider the use of content analysis as a qualitative research method for discovering meaning in their data.

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4 Qualitative Content Analysis

• Published: November 2015
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This chapter examines qualitative content analysis, a recent methodological innovation. Qualitative content analysis is defined and distinguished here from basic and interpretive approaches to content analysis. Qualitative content analysis is also distinguished from other qualitative research methods, though features and techniques overlap with other qualitative methods. Key differences in the predominant use of newly collected data and use of non-quantitative analysis techniques are detailed. Differences in epistemology and the role of researcher self-awareness and reflexivity are also discussed. Methods of graphic data presentation are illustrated. Three short exemplar studies using qualitative content analysis are described and examined. Qualitative content analysis is explored in detail in terms of its characteristic components: (1) the research purposes of content analysis, (2) target audiences, (3) epistemological issues, (4) ethical issues, (5) research designs, (6) sampling issues and methods, (7) collecting data, (8) coding and categorization methods, (9) data analysis methods, and (10) the role of researcher reflection.

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Extract insights from Interviews. At Scale.

Qualitative content analysis coding: a step-by-step guide.

Home » Qualitative Content Analysis Coding: A Step-by-Step Guide

Textual Data Analysis serves as a powerful tool for understanding what lies beneath the surface of communication. In today’s information-driven world, organizations generate vast amounts of textual data, often stemming from customer interactions or internal discussions. Effectively analyzing this data can provide critical insights that drive decision-making and improve strategies.

This process involves systematically coding qualitative content to identify patterns, themes, and trends. By breaking down text into manageable parts, researchers can gain a deeper understanding of sentiments and motivations. Ultimately, mastering textual data analysis is essential for any organization aiming to convert raw data into actionable information, fostering data-informed decision-making across various domains.

Understanding Qualitative Content Analysis Coding

Qualitative content analysis coding is a systematic approach to interpreting textual data. This method enables researchers to dissect large volumes of text, identifying patterns, themes, and meaning in qualitative information. By organizing and coding this data, researchers can unearth insights that inform decision-making, enhance understanding, and illuminate complex social phenomena.

In this process, researchers typically follow several key steps. First, they familiarize themselves with the textual data, reading and re-reading to understand its context deeply. Next, they begin coding by tagging segments of text with labels. These codes can be descriptive or analytical, facilitating deeper analysis. As patterns emerge, researchers can categorize these codes into themes, ultimately leading to a more nuanced understanding of the collected data. By utilizing qualitative content analysis coding, researchers can transform raw data into actionable insights, driving effective conclusions and informed strategies.

Setting Up for Textual Data Analysis

Preparing for textual data analysis is crucial for conducting effective qualitative content analysis. Start by gathering the textual data you need. This may include interviews, focus group discussions, or other written material relevant to your study. Once you have collected the data, ensure it is well-organized and formatted for analysis, allowing you easy access during the coding process.

Next, develop a coding framework. This consists of categories and subcategories that represent the themes or patterns you intend to study. You can create this framework based on preliminary readings of your text or established theories relevant to your research. Engaging other team members during this phase can provide additional perspectives and help refine your categories.

Overall, setting up for textual data analysis involves careful preparation of your data and thoughtful planning of your coding strategy. These initial steps are fundamental in guiding your analysis and ensuring meaningful insights emerge from your research.

Choosing Your Textual Data Sources

When choosing your textual data sources, consider the type of information that aligns with your research objectives. Start by identifying the context and subject matter relevant to your analysis. Primary sources such as interviews, focus groups, or raw transcripts can provide rich insights directly from participants. Alternatively, secondary sources like articles, reports, or social media discussions can offer broader perspectives on your topic of interest. Each source has its strengths and limitations, making careful selection crucial.

Next, assess the reliability and authenticity of your chosen data sources. Reliable sources contribute to the credibility of your findings, so prioritize those backed by established research or expert opinions. It’s also important to consider the diversity of your texts, as this can enrich your analysis and provide multiple viewpoints. By making informed choices about your textual data sources, you lay a solid foundation for a thorough and meaningful qualitative content analysis.

Defining Your Research Questions

Defining your research questions is crucial for effective qualitative content analysis coding. Start by determining the specific objectives of your study. These objectives will guide the development of your research questions, ensuring they are clear and focused. Well-defined questions lead to meaningful data that can be analyzed to yield valuable insights.

Consider the broader context of your research. What are the key themes or issues you wish to explore? Ideally, your questions should address these themes directly. Aim for open-ended inquiries that allow for the exploration of various perspectives. This approach maximizes the potential of your textual data analysis, as it encourages a deeper understanding of the content. Remember, the clarity of your research questions significantly impacts the reliability and validity of your findings.

Steps in Qualitative Content Analysis Coding

Qualitative content analysis coding involves a systematic approach that helps researchers interpret textual data effectively. To begin, it’s essential to define your research questions clearly, as this will guide your entire coding process. Next, familiarize yourself with the textual data, identifying key themes and patterns that emerge during your initial review.

After thoroughly understanding the data, you can start the coding process. This involves categorizing the data based on identified themes. Use a coding framework to ensure consistency, and apply codes to segments of text that reflect the themes of your research. Subsequently, review the coded data regularly to refine your categories and ensure accuracy. Finally, synthesize your findings by analyzing the data through the lens of your research questions, allowing you to draw comprehensive conclusions. These steps in qualitative content analysis coding will lead to insightful understanding and clearer interpretation of your textual data analysis efforts.

Initial Steps in Textual Data Analysis Coding

Initial steps in textual data analysis coding lay the foundation for effective qualitative content analysis. Begin by immersing yourself in the textual data, familiarizing yourself with its nuances and themes. This comprehensive understanding becomes pivotal as you transition into the coding phase, where you categorize segments of text based on emerging patterns and insights.

Next, develop a coding scheme that reflects your fundamental themes. This scheme acts as a map, guiding your analysis by ensuring a structured approach. As you code the data, continuously compare new insights with existing themes to maintain relevance. This iterative process enhances the reliability of your analysis while allowing flexibility for new concepts to emerge. By following these steps, you position your qualitative content analysis for success, generating meaningful insights that truly reflect the depth of your data.

Familiarizing Yourself with the Data

Familiarizing yourself with the data is a crucial initial step in the qualitative content analysis process. It involves delving into the textual data to understand its context, themes, and nuances. Start by reading through the data thoroughly, absorbing the material rather than rushing through it. This immersion helps you grasp key concepts and identify recurring patterns that will inform your analysis later. It's essential to maintain an open mind, as initial perceptions may shift once you engage deeply with the content.

To facilitate this understanding, consider the following key points:

• Read with Purpose : Focus on extracting meaning rather than merely scanning for keywords.
• Identify Key Themes : Take note of significant ideas that emerge throughout the text.
• Contextual Understanding : Grasp the circumstances surrounding the data to enhance your analysis.
• Documentation : Annotate your findings to reference them easily during the coding process.

Engaging with the data in this structured manner will enhance your ability to code and interpret the findings effectively as you move forward.

Creating a Preliminary Codebook

Creating a preliminary codebook is an essential step in textual data analysis. This document acts as your guide, detailing the codes or themes you intend to use throughout your qualitative content analysis. Start by reviewing your data thoroughly and identifying initial categories that emerge. These categories should be broad enough to encompass various responses yet specific enough to provide meaningful insights.

Next, organize these codes into a structured format within the codebook. This may include definitions, examples from the data, and inclusion/exclusion criteria for each code. Creating a codebook not only helps establish consistency in coding but also serves as a reference point for your analysis team. Refining the codebook is an ongoing process; as you delve deeper into the data, new themes may arise, necessitating revisions. Remember, the quality of your textual data analysis hinges on a well-constructed preliminary codebook.

Advanced Coding Techniques for Textual Data Analysis

Advanced coding techniques for textual data analysis empower researchers to derive meaningful insights from qualitative data. Effective coding strategies can significantly enhance the analysis process, allowing for the identification of themes, patterns, and trends within large volumes of text. Researchers can adopt several advanced techniques to improve their engagement with textual data, enabling a more comprehensive interpretation of qualitative content.

Theme-Based Coding : This involves identifying broad themes within the data to categorize lighter nuances and variations.

In Vivo Coding : This technique uses the exact phrases and terms from participants, ensuring authenticity and grounding the analysis in the original context.

Deductive Coding : In this approach, pre-defined categories based on existing theories or literature guide the coding process, helping to confirm or challenge prior understanding.

Digital Text Analysis : Utilizing software tools to automate the identification of prominent themes can streamline the process, making data analysis faster and less prone to human error.

By mastering these techniques, researchers can enhance their qualitative content analysis, transforming raw textual data into actionable insights that inform decision-making and strategy development.

Applying Codes to Textual Data

To apply codes to textual data, begin by carefully reading through the content to identify key themes and patterns. This initial stage involves highlighting significant phrases or statements that resonate with your research questions. Understanding the context and the intent behind these phrases helps in coding them accurately.

Next, assign specific codes to these highlighted texts. Codes serve as labels that categorize chunks of data, simplifying the subsequent analysis. You might consider using a mix of deductive and inductive coding strategies. Deductive coding applies existing theories or frameworks to guide your analysis, while inductive coding allows themes to emerge naturally from the data itself.

Lastly, refine your codes through continuous comparison and adjustment. This iterative process ensures that the coding framework evolves alongside your understanding of the data, ultimately promoting a thorough analysis. By being systematic in applying codes, your textual data analysis becomes more meaningful and insightful.

Reviewing and Refining Codes

Reviewing and refining codes is a critical step in the process of qualitative content analysis coding. After initial coding, it is essential to revisit your codes systematically to ensure they accurately represent the underlying data. This review helps you identify any duplicates or gaps in your coding scheme. As you assess your codes, consider whether they adequately capture the themes and patterns that emerge from your textual data analysis.

Next, refining codes involves adjusting them based on insights gained during the review. You might merge similar codes or split complex ones into more specific categories. Continuous iteration enhances the depth and clarity of your analysis. The objective is to create a nuanced coding framework that reflects the richness of your data. By consistently reviewing and refining your codes, you enhance the reliability and validity of your findings, ultimately leading to more actionable insights in your research.

Conclusion: Refining Your Skills in Textual Data Analysis

Refining your skills in textual data analysis is an ongoing journey that can lead to profound insights. As you engage with qualitative content analysis, practice becomes essential. Each coded document offers an opportunity to enhance your understanding, enabling you to draw clearer conclusions from complex data sets.

To further develop your capabilities, consider collaborating with peers and sharing your findings. This exchange of ideas not only enriches your perspective but also fosters a deeper comprehension of analyzable content. Ultimately, refining these skills will empower you to extract valuable insights that drive informed decisions in your field. Embrace the learning process as a pathway to success in textual data analysis.

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Socio-technical Grounded Theory for Qualitative Data Analysis

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• Rashina Hoda   ORCID: orcid.org/0000-0001-5147-8096 2  

Qualitative data analysis forms the heart of socio-technical grounded theory (STGT). In this chapter, we will start by learning about the basics of qualitative data analysis and preparing for qualitative data analysis as it applies in STGT, including the mindset, approach, and worldview applied to analysis. This is followed by a visual notes-taking analogy to help explain the general idea of qualitative data analysis using STGT procedures. Then we will learn about the STGT procedure of open coding using hashtags, the zoom out–zoom in technique, and how to draw out analytical and socio-technical codes as well as considering options and revising codes. Next, we will learn about the procedure of constant comparison through which data is condensed and raised in levels of abstraction and the procedure of memoing to draw insights and relationships. This is followed by tips for data analysis , including tips for creating codes, coding for richness, context filling, role of research paradigm, and improving theoretical sensitivity. Next, we will consider team-based coding , including guidelines for achieving alignment in a coding team. Finally, the chapter ends with explaining the expected outcomes of applying STGT for data analysis.

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Hoda, R. (2024). Socio-technical Grounded Theory for Qualitative Data Analysis. In: Qualitative Research with Socio-Technical Grounded Theory. Springer, Cham. https://doi.org/10.1007/978-3-031-60533-8_10

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Physicians and nurses experiences of providing care to patients within a mobile care unit – a qualitative interview study

• Christofer Teske 1 , 2 ,
• Ghassan Mourad 1 &
• Micha Milovanovic 1 , 3  

BMC Health Services Research volume  24 , Article number:  1065 ( 2024 ) Cite this article

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Introduction

There is a growing need for alternative forms of care to address citizen demands and ensure a competent healthcare workforce across municipalities and regions. One of these forms of care is the use of mobile care units. The aim of the current study was to describe physicians and nurses experiences of providing care to patients within a mobile care unit in Sweden.

Data were collected between March 2022 and January 2023 through qualitative interviews with 14 physicians and nurses employed in various mobile care units in different regions in Sweden. These interviews were transcribed verbatim and subjected to content analysis, with the study adhering to the Standards for Reporting Qualitative Research (SRQR).

The analysis resulted in two main categories: “Unlocking the potential of mobile care”, and “The challenges of moving hospitals to patients’ homes”; and seven subcategories. The respondents viewed mobile care at home as highly advantageous, positively impacting both patients and caregivers. They believed their contributions enhanced patients’ well-being, fostering a welcoming atmosphere. They also noted receiving more quality time for each patient, enabling thorough assessments, and promoting a person-centered approach, which resulted in more gratifying mutual relationships. However, they experienced that mobile care also had challenges such as geographical limitations, limited opening hours and logistical complexity, which can lead to less equitable and efficient care.

Conclusions

Physicians and nurses in mobile care units emphasized positive outcomes, contributing to patient well-being through a person-centered approach. They highlighted increased quality time, comprehensive assessments, and overall satisfaction, praising the mobile care unit’s unique continuity for enhancing safety and fostering meaningful relationships in the patient’s home environment. In order for mobile care to develop and become a natural part of healthcare, challenges such as geographical limitations and logistics need to be addressed.

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Shifts in population demographics and the present structure of the healthcare system prompt inquiries about the optimal care for frail older people [ 1 , 2 , 3 , 4 ]. The multifaceted health conditions and diverse requirements of these individuals result in increased healthcare appointments and recurrent hospital stays, putting pressure on the current health infrastructure [ 5 , 6 ]. In Sweden, the state oversees general healthcare policy, with the Inspectorate for Health and Care supervising. While regions ensure that all citizens have access to quality care, municipalities look after long-term health and social care for the frail older people,. Primary care serves as the initial point of contact in the healthcare system, providing basic services either at facilities or at homes. They also guide patients to the appropriate level of care as required [ 7 ].

The transition towards accessible and qualitative healthcare is underway in municipalities and regions [ 8 ]. This transition is important because some individuals may experience problems accessing healthcare due to of distance, severe illness and immobility [ 9 , 10 , 11 ]. This change, however, demands long-term commitment and perseverance, not only from the regions and municipalities, but also from the government [ 12 ]. The goal is to develop person-centered, efficient, and purposeful methods that cater to patient needs. This also means that different healthcare stakeholders, specialties, and professions need to collaborate more effectively [ 6 ]. To respond to citizens’ demands for accessible care, there’s a need for alternative forms of care, for example, mobile care, that can offer prompt and appropriate care within the available resources [ 12 ].

The terminology, i.e. the meaning of mobile care varies from country to country, but the care provided is the same, as is its purpose, to provide highly specialized care, mainly by physicians and nurses, for conditions that normally require hospital admission [ 13 , 14 ]. Examples of mobile care are geriatric “Hospital at home” programs that offer treatments typically exclusive to hospitals right in the patient’s homes, including monitoring, drug administration, nursing, and rehabilitation processes [ 13 , 15 ]. Hospital at home is defined as “a service that provides active treatment, by health care professionals, in the patient’s home for a condition that otherwise would require acute hospital in-patient care, always for a limited time period” unlike home nursing care [ 13 , 16 ]. Patients are evaluated in various settings, including by their general practitioners or in emergency rooms, before being directed to these services. This model can also support those discharged early from hospital [ 17 , 18 ]. The target group for mobile care varies, but the mobile units in the current study focus on the frail older people. The National Board of Health and Welfare defines frail frail older people as people over 65 years of age with several chronic diseases and extensive needs for both outpatient and inpatient medical care [ 17 ].

Transitioning the care of patients from hospitals to their homes poses a formidable challenge, primarily due to concerns regarding patient safety and the constraints inherent to a patient’s home environment. Previous studies show that many patients are sent to hospitals instead of being assessed for mobile care due to various circumstances, e.g., for reasons of convenience [ 14 , 19 ]. In cases where the assessment is performed, the mobile care team often rejects the patient due to lack of time, logistical reasons or that the patient is unsuitable [ 13 , 14 , 20 ]. More knowledge is needed about physicians and nurses experiences of mobile care to provide an improved and developed perspective on how it can be incorporated into the healthcare system. The aim of the current study was to describe physicians and nurses experiences of providing care to patients within a mobile care unit in Sweden.

We employed a qualitative, inductive approach and used a content analysis methodology as outlined by Hsieh & Shannon [ 21 ]. In this approach, coding and theme development were driven by the shared meaning found within the data. The design’s primary objective was to discern, analyze, and interpret patterns within the qualitative data. The study adhered to the Standards for Reporting Qualitative Research (SRQR) [ 22 ]. The study was accepted by the Ethics Review Authority, Uppsala, Sweden (reg. number: 2020–06986).

Sampling and setting

The interviews were conducted between March 2022 and January 2023 in four Swedish cities in four different regions with populations varying between 61,000 and 160,000 inhabitants. All cities were equipped with mobile care units. Five units were found through an internet search, after which contact was made with the region management. Of these, four teams agreed to participate. These units specialize in mobile care as their primary field, delivering direct care to patients and offering indirect support to other physicians and nurses involved in providing such care. Mobile care units primarily offer home-based and inpatient care, with the number of patients receiving home care varying from 5 to 15. To be eligible for inclusion, participants had to meet the following criteria: active employment in a specialized field related to internal medicine or geriatric care, a minimum of 2 years of professional experience in the domain of the mobile care unit, and master the Swedish language. Invitation to participate in the study was issued by either the department head or a senior supervising physician within the healthcare facility. All physicians and nurses working in the included mobile care units who fulfilled the inclusion criteria were invited to participate, and all agreed to participate (Table  1 ).

Data collection

Due to the COVID-19 pandemic, interviews were performed using telephone ( n  = 11) and Microsoft Teams© (Microsoft Corporation, California, U.S.A) ( n  = 3). Participants were given the opportunity to propose a suitable time for the interview. The interview began with the participant introducing themselves and describing their experience with mobile care. The semi-structured interview guide was created by the authors with open-ended questions and was followed up by probing questions (See supplementary file). One pilot interview was conducted and did not result in any changes to the interview guide and was therefore included in the analysis. All interviews were performed by the first author (CT). CT is a registered nurse working within the field of emergency care and with previous experience in qualitative interviewing. CT had no prior care relationship with the study participants. Participants were encouraged to engage in open discussion, with occasional probing queries aimed at enhancing clarity, such as requests for further elaboration, explanations, and exploration of the how and why aspects. The interviews lasted between 25 and 55 min, were audio-recorded and then transcribed verbatim by CT. Before the study commenced, physicians and nurses were briefed on the study through both verbal and written communication. The participants were assured of confidentiality, and solely the researchers associated with the project could access the data, in line with The Swedish Research Council’s protocols [ 23 ].

Data analysis

The analysis of the transcribed interviews was conducted according to conventional content analysis based on Hsieh & Shannon [ 21 ]. All authors individually read four transcripts to gain both depth and breadth in understanding the material. Then, units of meaning in the text that were perceived to capture key thoughts or concepts were marked directly in the text. After this, notes were made in the margins describing the first impression, thereby conducting an initial analysis. To increase the trustworthiness of the study, all authors individually coded four transcripts and then mutually discussed the findings to employ a consistent coding scheme. Based on this coding scheme, CT coded the rest of the transcripts. The codes were then sorted into subcategories based on how the different codes were related and linked to each other. These subcategories were thereafter used to organize and group codes into meaningful clusters, which formed the basis for the emerging subcategories. Depending on how the subcategories were related to each other, they were afterwards divided into a smaller number of categories. These steps were mutually discussed by all authors. The findings of the research were strengthened and clarified by using specific quotations. These selected pieces, derived directly from the initial dataset, were eventually translated into English. Table  2 provides examples representing different stages of the analysis.

The results are derived from interviews with physicians and nurses, who were actively employed in specialized fields related to internal medicine or geriatric care. Each participant had at least two years of professional experience in the mobile care unit and was proficient in the Swedish language. Analysis of the interviews resulted in two main categories and seven subcategories according to Table  3 . The main categories were: Unlocking the potential of mobile care and The challenges of moving hospitals to patients’ homes.

Unlocking the potential of mobile care

Physicians and nurses described that mobile care promotes person-centered care based on mutual equality. Caring for the patient in their home increases transparency and safety for patients. Cooperation with different treatment units ensures comprehensive and safe care. It is a healthy work environment that gives professional pride.

Person-centered: the right way to care

Physicians and nurses described that it was rewarding to observe the patient in their natural environment. Physicians and nurses who had previously worked in a hospital setting experienced a shift in the balance of power when care had taken place in the patient’s home. The healthcare staff described that they felt that they were not in a position of power and called it “mutual equality”, and that this led to patients being more inclined to open up and share their opinions. This contributed to a more accurate assessment that aligned with a person-centered care approach. In an assessment of the patient in their living environment, physicians and nurses had been able to identify potential obstacles and complications more effectively. Such obstacles might have been, for example, thresholds in the dwelling that could potentially have been a fall risk. A significant distance between the toilet and bedroom might have resulted in the patient avoiding diuretics due to concerns about incontinence. Physicians and nursesdescribed that it is of central importance to not only identify existing shortcomings but also to anticipate potential vulnerabilities that might have arisen during the period when the patient was enrolled in the mobile care unit. Proactively working on prevention had been essential to ensure the patient’s overall well-being.

“I find it very rewarding to enter their home environment. You sort of get on the same wavelength , and it feels , what should I say , more human to sit with them at home. You get a sense of how this patient operates in their home environment , and it’s important information that we lack when the patient is in their hospital room” [ 7 ].

Safer care through increased patient activity

Physicians and nurses described that patients are satisfied with being cared for at home. The care can be planned collaboratively to a greater extent, ensuring continuous patient involvement. It facilitates conducting examinations and treatments at home rather than needing transportation. Physicians and nurses shared their experiences of safety of care and that a factor for increased safety of care was to enable a care plan with the patients. They expressed that this form of care offers a different type of continuity compared to hospital care where there is variability in the staff. Knowing the patient and their history increased the safety of care. According to physicians and nurses, communication was a key factor. It was essential to inform patients about the reason for the unit’s visit and the necessary treatments Additionally, informing relatives was highlighted as a aspect of care. Physicians and nurses described that relative need to be involved and aware of the plan for the patients, especially since this form of care might be new to some. Furthermore, it was important for physicians and nurses that they provide information to both relatives and the patient on how to contact healthcare if required as this leads to increased security for them.

“Sometimes , they may need an injection to reduce fluid retention for a week , and then the nurse will work together with the patient to develop a plan so that they feel confident in saying , ‘Yes , now we’re going to do it like this” [ 10 ].

Good care requires good collaboration

To ensure high-quality care, collaboration within different healthcare organizations was essential according to physicians and nurses. They conveyed that frequent interaction between various healthcare entities and professions enhanced the sense of security for physicians and nurses, which in turn positively affected the patients. When the mobile unit was aware that home care services assisted or that home healthcare was responsible for the patient at night, the unit felt an increased sense of security in providing care in the patient’s home.

“But the idea and the goal are that patients who do not require inpatient care should be able to stay with our assistance and in collaboration with home healthcare , as well as with , for example , occupational therapists and physiotherapists” [ 11 ].

The perceived benefit of collaborating with hospital specialists, who are not directly part of the mobile unit, was perceived to facilitate the unit’s care delivery. A contributing factor to effective collaboration was that the facility was a smaller hospital, and the mobile unit was stationed close to the hospital’s departments.

“We are a very small hospital , so we have the advantage of being close at hand. We have cooperation among all in.” [ 9 ].

Making a difference gives a sense of professional pride

Physicians and nurses experienced that they were doing something good for the frail older people. They provided good healthcare in a place where the patient wanted to be. Physicians and nurses believed that care in a patient’s home environment surpassed the care that was provided in hospitals. They felt that they had a meaningful profession and that they had a impact on the patients’ lives, but they also perceived that they contributed to the patient’s well-being. Physicians and nurses perceived that they contributed to the patient’s well-being. Physicians and nurses described that they had more time for each patient and did not have to move between patients as they did in the hospital. This led to less stress. It also allowed for a thorough assessment and promoted the establishment of a more rewarding mutual relationship.

“I believe that it’s necessary for us to fulfill a role and make a contribution for the elderly. I see that the unit is needed and that we serve a purpose” [ 3 ].

The challenges of moving hospitals to patients’ homes

Physicians and nurses describe that geographical differences and the limited operating hours of mobile care teams lead to unequal care. They face logistical challenges, such as transporting equipment and navigating different administrative systems, which need improvement. Additionally, maintaining good hygiene in less clean home environments can be difficult.

Mobile care availability varies among different populations

Physicians and nurses emphasized the limitations of a mobile care unit compared to traditional hospital care. They often used expressions such as: “compared to the hospital or the emergency room”.

Some of the physicians and nurses highlighted that this type of care is limited to geographical boundaries. Within a municipality, there is often a higher concentration of resources and opportunities compared to areas outside the central parts of the municipality. Physicians and nurses described that if the patients live within the area of the unit, they will be offered this type of care, otherwise not, leading to inequality in care. Furthermore, mobile care was perceived as insufficient as the number of scheduled visits must be reduced if the travel time becomes too long. At most, physicians and nurses need to travel up to 60 minutes for a visit.

“There are still quite significant differences in the care one receives when living inside the city as opposed to living outside the municipality.” [ 1 ]. “The furthest locations. It’s travel time and such. Considering that , we are not very efficient.” [ 3 ].

Limitations due to the unit size and working hours

According to physicians and nurses, the mobile unit usually consists of a fixed number of employees who are not replaced when illness occurs, making the unit fragile. The units’ operations include both scheduled and emergency visits, and emergency visits can be limited due to lack of necessary resources, e.g. due to illness in the unit members. In such situations, the common alternative is to call for ambulance transportation that brings the patient to nearest hospital for an emergency assessment.

Another aspect is that the mobile unit is only available during office hours. If the patient experiences an emergency with their health outside the office hours, they could speak to a healthcare professional who works in a hospital. Physicians and nurses perceived this opportunity as positive, that it provided an extra security for patients connected to mobile care, while others were more negative to the limited opening hours compared to the hospital.

“We work regular office hours , Monday to Friday. Then during other times , they can call us , and we leave a brochure. And if we don’t answer the phone , they are redirected to the department , so they can get in touch with the doctor. It has never really become a problem.” [ 8 ].

The importance of equipment and logistics

Physicians and nurses described that conducting home visits required extensive preparation, especially concerning the equipment that needed to be brought along. Technical complications can arise, which may be difficult to address in the patient’s home, underscoring the importance of reliable equipment. Another challenge highlighted by physicians and nurses was the incompatibility in record-keeping systems across different forms of care. Standardizing these systems could optimize the workflow. Moreover, physicians and nurses emphasized that some medical equipment cannot be easily implemented in the home environment. These were for example monitoring equipment, including the tracking of vital functions, and infusion systems that administer intravenous drugs safely.

“It requires quite a bit of logistics. You have to bring things with you. I realized it now when I was about to leave. It demands logistics , and you have to be organized.” [ 9 ].

Som physicians and nurses made it clear that not all patients are suitable for a specific treatment at home. In situations where the patient’s condition requires intravenous treatment, but the patient lacks supervision or municipal interventions, the unit need to make an assessment. If the unit can be present during the entire treatment period, then it is safe for the patient to receive the treatment at home, otherwise the alternative is to go to hospital.

Another issue was hygiene problems experienced by physicians and nurses. For example, in wound dressings, it is difficult to maintain cleanliness if the home is already dirty, which normally is not a problem in the hospital environment.

“First , it’s about how the home looks and what possibilities there are. If the home is in disarray , it’s impossible to keep it clean. I know , I was sewing today , and when I compare it to the healthcare center , it’s quite sterile in comparison to a bedroom” [ 2 ].

To our knowledge, this is the first study describing physicians and nurses’ experiences with providing care to patients within a mobile care unit in Sweden. The study contributes valuable knowledge and insights into how Physicians and nurses experience this type of highly specialized care in the patients’ homes, which differs from home care nursing which mainly offers basic medical treatment such as health monitoring, medication administration, wound dressing, and overall patient health support. Physicians and nurses considered that mobile care in the home environment offers advantages that have a positive impact on both the patient and physicians and nurses themselves. However, they also expressed some challenges connected with mobile care.

Physicians and nurses described mobile care as a person-centered approach, where caring for patients in their own home has several positive aspects that benefit not only the patient but also physicians and nurses. They perceived it as gratifying to witness patients in their natural surroundings and noted a power shift during home care, fostering mutual equality, which they felt was difficult to achieve when they worked in hospitals. Physicians and nurses described that patients experience satisfaction when they receive care at home. They emphasized that mobile care is characterized by collaborative planning, which ensures continuous patient participation. Although person-centered care emphasizes the importance of patient involvement in decision-making [ 24 ], earlier research has shown that not all patients prefer active participation. [ 25 , 26 ]. This is mainly due to health-related limitations, lack of support from physicians and nurses, or unfamiliarity with the possibility of participate actively. However, in cases where patients want to participate actively, they feel opposed by physicians and nurses. In those moments, they might feel like they don’t have much say or control, and it can make them feel less powerful and independent [ 27 , 28 ]. This suggests that physicians and nurses should pay attention to patients’ needs and wishes for participation in their care. It is also valuable to address non-active participation through targeted efforts such as patient education and empowerment initiatives to facilitate a smooth transition to acceptance of person-centered care in the home environment [ 26 ]. Through these efforts, we believe that it is possible to further promote and implement a person-centered approach in mobile care.

Physicians and nurses described that they received more quality time for each patient, enabling a more comprehensive assessment and fostering a more satisfying person-centered care. Specifically, they believed that their contributions had a substantial impact on the patient’s overall well-being and perceived a consistent sense of welcome, receiving affirmative responses regarding their endeavors. Physicians and nurses experience that the mobile care unit provides a unique continuity compared to hospital care, where staff turnover can introduce variability. Getting to know the patient and their medical history contributes to enhanced safety in care delivery. Previous research [ 11 , 12 , 13 ] has shown that building and maintaining relationships with the frail older people with physicians and nurses can be challenging due to the specialized and fragmented healthcare system. A limited number of staff meeting patients in their home environment usually means consistent contact that promotes the quality of care, affecting patients’ feelings of safety and comfort. However, other studies show that patients receiving medical care at home tend to report higher levels of satisfaction with their treating physician compared to patients receiving care in a traditional acute hospital environment [ 12 , 13 , 14 ]. Physicians and nurses in this study advocate for the mobile care unit, citing its unique continuity compared to hospitals. We therefore assume that consistent contact with a limited number of staff promotes relational continuity, positively impacting patient satisfaction.

Healthcare professional described that they provided good healthcare in a place where the patient wanted to be. They believed that care in a patients’ home environment surpassed the care that was provided in hospitals and had an impact on the patients’ lives. Physicians and nursesalso described having more time for each individual patient. This allowed for a thorough assessment and promoted the establishment of a more rewarding mutual relationship. This suggests that physicians and nurses appreciated the work environment in the mobile care team. Previous studies have shown a positive correlation between a healthy work environment and better patient experiences [ 29 , 30 ]. This implicates that a positive work environment in mobile care has far-reaching implications that extend beyond just the well-being of physicians and nurses. It also positively influences patient satisfaction, quality of care, staff engagement, and the overall efficiency of healthcare delivery in the mobile setting.

Physicians and nurses also described challenges in the work environment including unsanitary living conditions that can worsen a patient’s medical condition and make infection control more difficult. Previous studies confirm that there is an increased risk associated with certain types of treatment at home and that it is important to make a careful assessment of whether the patient and the environment are suitable for care [ 14 ]. On the other hand, being hospitalized, increases the risk ofnosocomial infections [ 31 , 32 , 33 ].

Physicians and nurses described that the mobile care units have limitations in terms of accessibility. This mostly concerns geographic accessibility, where patients in rural areas do not have the same opportunity for mobile care as in the cities. They also described that the units’ working hours and travelling distances was a limiting factor. The availability of mobile care, both geographically and in terms of restricted opening hours, is not in line with the Healthcare Act in Sweden [ 17 ], which stipulates that healthcare should be provided on equal terms for the entire population. Geographical accessibility can however be challenging to fulfill as Sweden is sparsely populated compared to many other European countries [ 34 ]. Proximity to patients in rural areas is a crucial factor affecting access to primary care [ 19 , 20 ]. To address this issue, the Ministry of Social Affairs has been tasked by the government to investigate and propose changes to increase access to healthcare in rural areas [ 21 ]. Global observations indicate a variety of essential approaches for enhancing accessibility to primary healthcare services in rural areas. These encompass reinforcing the healthcare financing system, enhancing the availability of medicines and supplies, collaborating with diverse partners and communities, implementing a robust evaluation system, and fostering dedicated leadership [ 35 , 36 , 37 ]. This indicates that follow-up healthcare appointments, digital solutions may become more relevant in the future to minimize transportation for the mobile care units.

Strengths and limitations

Mobile care is not yet widely adopted as a working method in Sweden. Consequently, a geographic spread could not be achieved, and the number of participants was limited. Nevertheless, the findings in this study are based on data collected from a relatively high number of physicians and nurses in Sweden with experiences of working in different mobile care units. According to Malterud [ 38 ], this indicates that the study has achieved sufficient information power, as all physicians and nurses working in the mobile care units participated in this study. They contributed with their unique experience and provided valuable knowledge to answer the aim of the study. Furthermore, the interviews yielded consistent data since no new information appeared in the last interviews, and this data was analyzed using an established analysis strategy by Hsieh & Shannon [ 21 ].

Eleven of the interviews were carried out via telephone and three via video using Microsoft Teams©. This might be considered as a limitation as telephone interviews may have impacted the richness of interview content compared with video interviews. However, research shows that the difference between telephone and video interviews is modest [ 39 , 40 ]. One strength is that the first author (CT) conducted all interviews, which may have influenced the quality of the interviews positively as the interviewer’s interview technique improved with each interview. Another strength is that all authors individually coded four transcripts and mutually discussed the findings to employ a consistent coding scheme, that CT used to code the rest of the transcripts afterwards. Furthermore, all authors participated in forming subcategories and categories to ensure credibility. Dependability was established by maintaining a comprehensive audit trail, ensuring consistent coding procedures, and involving multiple analysts to verify the stability and reliability of the findings, with every step of the research process thoroughly documented in the methods section.Variations were discussed among the authors during the meetings for the data analysis to enhance the confirmability of the study. The authors have different backgrounds and expertise, i.e. nursing, medicine and biomedicine and this can be seen as an “investigator triangulation” and thus a strength [ 41 ].

Although other mobile care units may work differently and have other experiences, our findings may demonstrate transferability to this context as care is delivered to patients in their homes, even though this could differ in content and delivery mode.

Physicians and nurses experience mobile care as a person-centered approach, promoting holistic care and collaborative planning. It emphasizes ongoing patient participation and eliminated transportation needs. On the other hand, mobile care poses challenges such as inequality of care if patients live outside the units’ areas, incompatible record-keeping, and difficulty implementing the use of certain medical devices. Despite this, mobile care is considered a a good alternative to traditional hospital care, where physicians and nurses felt they had a meaningful profession that positively affects the lives and well-being of the patients, and thus fostering rewarding mutual relationships. The challenge for the future is to engage at a national level with physicians, managers, and politicians to achieve improvements. Failing to come together to develop care pathways relevant to rural communities, for example, could be missing an opportunity to improve the nation’s health.

Data availability

The datasets used and/or analysed during the current study cannot be shared openly but are available on request from authors.

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Acknowledgements

We thank all the physicians and nurses for sharing their experiences in the interviews for this study.

No funding was received for conducting this study.

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Christofer Teske, Ghassan Mourad & Micha Milovanovic

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Christofer Teske

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CT collected and analyzed all data. Also contributed to writing - review and editing of the manuscript. GM contributed to study design, analysis of data via triangulation, reviewing and editing of the manuscript. MM contributed to discussion regarding all data of the study. Also contributed to writing - review and editing of the manuscript. All authors read and approved the final manuscript.

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Teske, C., Mourad, G. & Milovanovic, M. Physicians and nurses experiences of providing care to patients within a mobile care unit – a qualitative interview study. BMC Health Serv Res 24 , 1065 (2024). https://doi.org/10.1186/s12913-024-11517-8

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Background: Emergency departments are a last resort for some socially vulnerable patients without an acute medical illness (colloquially known as “socially admitted” patients), resulting in their occupation of hospital beds typically designated for patients requiring acute medical care. In this study, we aimed to explore the perceptions of health care providers regarding patients admitted as “social admissions.”

Methods: This qualitative study was informed by grounded theory and involved semistructured interviews at a Nova Scotia tertiary care centre. From October 2022 to July 2023, we interviewed eligible participants, including any health care clinician or administrator who worked directly with “socially admitted” patients. Virtual or in-person individual interviews were audio-recorded and transcribed, then independently and iteratively coded. We mapped themes on the 5 domains of the Quintuple Aim conceptual framework.

Results: We interviewed 20 nurses, physicians, administrators, and social workers. Most identified as female ( n = 11) and White ( n = 13), and were in their mid to late career ( n = 13). We categorized 9 themes into 5 domains: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes). Participants described experiences caring for “socially admitted” patients, perceptions and assumptions underlying “social” presentations, system barriers to care delivery, and suggestions of potential solutions.

Interpretation: Health care providers viewed “socially admitted” patients as needing enhanced care but identified individual, institutional, and system challenges that impeded its realization. Examining perceptions of the people who care for “socially admitted” patients offers insights to guide clinicians and policy-makers in caring for socially vulnerable patients.

See related editorial at www.cmaj.ca/lookup/doi/10.1503/cmaj.240577

Emergency departments have become a destination of last resort for some patients who are made vulnerable by social circumstances, resulting in their occupying hospital beds typically designated for people with acute medical issues. 1 “Social admission” is a colloquial, nondiagnostic label used to describe a person for whom no acute medical issues are recognized to be contributing to their seeking health care. However, many health care providers understand that patients who are admitted for social reasons face challenges such as a breakdown of care supports or an inability of the patient or family to cope with the demands of living at home. 2 These patients often have lengthy stays in emergency departments or hospital wards, and frequently encounter barriers (e.g., housing or home support) delaying safe discharge from hospital. The colloquial terms “failure to cope,” “acopia,” “orphan patient,” or “home care impossible,” among others, are sometimes used to refer to these patients. 3 – 5 Such terminology can be stigmatizing because it indicates a value judgment that patients require admission solely on “social” grounds, sometimes failing to account for underlying medical complexity. 6

The “social admission” phenomenon is an under-researched area in health care. These patients, often categorized by health care providers as not being acutely ill, experience in-hospital death rates as high as 22.2%–34.9%. 7 , 8 Explanations may include under-triaging in the emergency department owing to poor recognition of atypical clinical presentations and delays in timely assessments. 5 Patients may be misdiagnosed or develop acute illness during their hospital stay. In 2 international studies, by the end of hospitalization, an admission diagnosis of “acopia” was no longer the discharge diagnosis in 88%–92.5% of cases. 7 , 9 Diagnoses of falls, delirium, and mobility problems were common, but sepsis was initially undiagnosed in almost one-third of these patients. 7 This raises questions about health care providers’ awareness of atypical presentations and decision-making for “social” presentations, which often require a nuanced understanding of both medical and social care needs.

Health care providers face challenges providing high-quality care to this patient population across Canada 1 , 10 and internationally. 1 , 4 , 10 – 13 “Social admissions” may account for as many as 1 in 10 patients (0.57%–9.3%) presenting to the emergency department and 1 in 25 admissions to hospital, with increasing prevalence with age. 14 A survey from Wales showed that 51.8% of hospital physicians consider that they frequently care for these patients, encountering them several times per week. 15

Since “social admission” is a nondiagnostic label, its definition varies across regions and health care systems, meaning no guidelines exist to standardize approaches to meet medical or social care needs. Qualitative data evaluating how health care providers perceive and care for these patients are lacking. Therefore, we aimed to explore the perceptions of health care providers regarding patients admitted as “social admissions.”

Study design

This qualitative study was informed by constructivist grounded theory, which uses inductive analysis of data collected from participants to generate new theories. 16 , 17 We conducted semistructured interviews with clinicians and health care administrators between October 2022 and July 2023. Given that little is known about “social admissions,” grounded theory was best suited to our objective to generate an explanatory theory about this phenomenon. 17

The research team included qualitative methods experts, geriatric medicine specialists, clinician scientists, primary care and emergency department clinicians, and members with administrative leadership roles. We also included nursing students, medical students, and internal medicine residents of diverse backgrounds.

We reported this study using the Consolidated Criteria for Reporting Qualitative Research Checklist (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content ). 18

Setting and participants

Studying “social admissions” can be challenging because of the variability in terminology and admission policies across different jurisdictions. 19 The Orphan Patient Policy is a standardized “social admission” pathway used at the Queen Elizabeth II Health Sciences Centre, a tertiary care centre in Halifax, Nova Scotia. Halifax is the provincial capital and the largest city in the Atlantic region of Canada. In Nova Scotia, health care is provided through a publicly funded health care system.

Since March 2012, any patient, regardless of age or living situation, can be admitted to the Queen Elizabeth II Health Sciences Centre under the Orphan Patient Policy if they have undergone a medical assessment by a physician in the emergency department, are determined to have no acute or new medical conditions, and have been seen by a social worker or discharge planning nurse to exhaust all home care options. Inability to return home includes situations of homelessness, unavailable community supports, or waiting for transitions to long-term care. These patients are admitted to the first available inpatient bed, based on a rotating roster of all hospital admission services (e.g., medicine, psychiatry, surgery, subspecialty medicine or surgery, and hospitalist). The admitting service and its allied health care team become responsible for the patient’s care and disposition, with the expectation that discharge planning is the primary issue. Although these patients are locally called “orphan patients,” we use the terminology “social admission” throughout this paper.

Eligible participants included any clinical provider or administrator who worked directly with “socially admitted” patients. To identify potential participants for our study, we held initial interviews with hospital nursing bed flow managers who are responsible for administering the Orphan Patient Policy.

To recruit participants, we used snowball sampling: we emailed each health care provider or department that had been recommended by the initial interviewees (i.e., the nursing bed flow managers), and those suggested by study participants during their interviews or by key knowledge users with whom we shared preliminary findings (see Data analysis). Preliminary analyses also informed recruitment, and we used purposive and theoretical sampling 20 , 21 to ensure that the perspectives of multiple health care professionals within the “social admission” care pathway were included, with the aim of data saturation. We approached several departments and individuals who declined to participate or did not respond to our requests for interviews. These included recreation therapy, physiotherapy, occupational therapy, some administrative positions, and several subspecialty medicine divisions.

Data collection

The interview guide (Appendix 2a, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content ) was based on our literature review of “social admissions” 14 and informed by our chart reviews of more than 350 “social admissions” in Nova Scotia (unpublished data, 2021). The entire research team gave input on the interview guide through several iterative processes: multiple meetings to develop the guide, a pilot test with non-author colleagues, and a meeting after all interviewers had conducted at least 1 interview to discuss whether the guide was robust enough to elicit the information we were seeking. We revised the interview guide wording for clarity and understanding, and we added 2 major questions (interview guide questions 7 and 8) and several prompting questions.

Experienced qualitative researchers (C.S. and E.G.M.) provided training. We held 2 group and 1 individual interactive training and practice sessions, which provided methodological context, and practical approaches and techniques in qualitative interviewing. One research team member (J.C.M., L.E., G.A., or M.K.) administered individual interviews. Interviews occurred virtually (via Microsoft Teams) or in person in quiet rooms on hospital wards or participants’ offices. After interviews were completed, we contacted participants by email to provide self-identified demographic data. The survey was voluntary and anonymous, and participants selected from predefined categories or supplied free text for sex, gender, ethnicity, role, and profession (Appendix 2b).

Interviews were audio-recorded and transcribed verbatim. For additional rigour and contextualization during analysis, interviewers kept detailed field notes of their reflections during the interviews.

Data analysis

Data collection and analysis occurred simultaneously. All participants were invited to review their transcripts before analysis (1 participant opted to). We used Dedoose software for data coding and organization.

Two team members independently coded interview transcripts using an inductive approach. 16 , 17 Throughout the initial coding process, the coders (J.C.M., C.S., G.A., and M.K.) met regularly to refine, merge and expand codes, come to consensus about any disagreements and interpretations, add context to certain transcripts with their field notes from the interviews, and identify additional participants suggested by the participants. Using constant comparative and selective coding processes, 16 , 17 we generated categories and subcategories to form themes to reflect participants’ perspectives on “social admissions.”

We used several strategies to ensure rigour and trustworthiness throughout the research process. As per the grounded theory approach, we incorporated reflexivity into our analytic process and acknowledged our dual roles as researchers and health care providers delivering care. Most members of the research team were affiliated with the research site and possessed an in-depth understanding of the local context and providers involved in “social admission” care. This intimate understanding enabled us to add context to the findings. However, we also challenged our preconceptions and biases by recruiting participants with diverse experiences and perspectives, and scheduling regular meetings among research team members to triangulate findings with our internal chart review, knowledge user feedback, and data analysis. 22

We put participant narratives at the forefront by presenting the data (from preliminary interviews and after completion of interviews) to engaged key knowledge users within our hospital and university network (e.g., experienced researchers, clinicians, social workers, and administrators) in a variety of settings (e.g., individual communications, small group sessions, or internal department presentations). The knowledge users provided feedback and suggested further participants. The data were also triangulated with findings from our recent literature review. 14

After data saturation was achieved, we mapped our findings on the Quintuple Aim conceptual framework at the suggestion of a knowledge user and as per consensus with the research group. 23 , 24 This framework adequately organized and contextualized our findings and is a well-known approach to optimizing health system performance and defines 5 fundamental domains (definitions in Appendix 1) for transforming health care: enhance patient experience, better population health, optimize cost of care, improve care team well-being, and advance health equity. 23 , 24

Ethics approval

Nova Scotia Health granted institutional research ethics approval (REB no. 1027628).

We conducted 20 interviews (9 in person and 11 virtual) among hospital administrators and clinicians ( Table 1 ). Clinicians were nurses (charge, discharge planning, and inpatient), physicians (residents and staff physicians), and social workers, representing the following services: emergency department, internal medicine, medical subspecialties (cardiology, neurology, and geriatric medicine), psychiatry, hospitalist, and surgical specialties (orthopedics, general surgery, cardiovascular surgery, and vascular surgery). Administrators included nursing bed managers and directors of hospital divisions and long-term care. The mean interview length was 38 (range 16–76) minutes.

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Demographic information of hospital administrators and clinicians who were interviewed

We categorized 9 themes into each of the 5 domains of the Quintuple Aim framework as shown in Figure 1 : patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes for addressing “social admissions”). Additional illustrative quotations are presented in Appendix 3, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content .

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Domains (in the circle) and themes (outside the circle) using the Quintuple Aim framework. 23 , 24

Patient experience

Participants’ description of patients.

Participants provided diverse descriptions of these patients ( Table 2 ). One cited financial precarity as a key problem faced by these patients. Another highlighted recurrent health care system interactions as being important. Some mentioned these patients had a mix of medical, mental health, and social problems. Most equated “social admissions” with older patients or those who were cognitively impaired. Some deemed them the most frail, vulnerable, or complex cases. Few considered that “socially admitted” patients had no medical conditions involved (Appendix 3) or that the medical conditions could wholly be managed at a primary care level.

Descriptions and illustrative quotations of the patient description and provision of care themes in the patient experience domain

Provision of care

Participants described “socially admitted” patients as receiving passive and hands-off care, contrasting this with active approaches for medical and surgical cases. Participants reported that patients, especially those who were older or confused, often received limited attention and workup, leaving their needs unaddressed ( Table 2 ). The approach to care was characterized by patients being left in their beds, being the last person rounded on by the care team, and not being chosen to participate in rehabilitative programs or exercises. In short, these patients’ care needs were the last in the queue of nursing and physician priorities. Beyond direct provision of care, participants identified that hospital programs (e.g., recreation therapy) benefitting these patients had been discontinued or under-resourced (Appendix 3). Almost all clinical participants considered their ward was not the place to care for these patients.

Care team well-being

Moral distress.

Health care providers described their roles as acute care or sub-specialized experts but said they felt helpless when they were unable to provide care for “socially admitted” patients, who often had complex, unrecognized, or chronic health issues. They often stated that better care should be offered yet described challenges when caring for “socially admitted” patients. These included a lack of appropriate training, struggles to arrange suitable care, and resistance when attempting to involve other services, allied health care, or social work, leading to delays in appropriate management ( Table 3 ). As articulated by 1 participant (HC605): “I think that’s a lot to ask of different providers who may not have that skill set. So, sometimes I think it does cause, you know, moral distress and challenge for people sometimes, which then gets perhaps articulated as being ‘they shouldn’t be here.’” Many reported feeling negative toward the policy and labelling of these patients, and acknowledged it was used primarily to communicate with other health care providers. One participant suggested the policy prevented blame on clinicians for “admitting this [patient]” (HC840).

Descriptions and illustrative quotations of the moral distress and hierarchy of care themes in the care team well-being domain

Hierarchy of care

Participants highlighted a hierarchy in health care, prioritizing acute care patients over “social admissions.” One participant reflected on how hospitals rely on pathways with these patients not fitting into a clear “slot,” representing individuals not well differentiated, individuals with complexity, or individuals with issues that are not specialty specific. Consequently, “social admissions” were passed down the hierarchy, from physicians to residents, and sometimes to nursing assistants, implying they were less worthy of routine medical attention ( Table 3 ).

Health equity

Stigma and missed opportunities.

The term “social admission” led to incorrect assumptions about medical needs and cognitive abilities. Beliefs about behaviours were noted by several participants. These assumptions were propagated as early as handovers from paramedics to emergency nursing teams ( Table 4 ). Participants highlighted instances where these patients were not medically stable and emphasized that social stressors did not exempt patients from becoming medically ill during the admission. The label was reported to be an impediment to opportunities to look for underlying treatable medical issues, compounded by the need to make timely decisions because of pressures to free up beds.

Descriptions and illustrative quotations of the stigma and missed opportunities, and prejudices themes in the health equity domain

Ageist beliefs underpinned assumptions about capacity, especially for older “socially admitted” patients. Some participants recognized that these patients could not effectively advocate for themselves, and others pointed out that older patients were often assumed to be cognitively or functionally impaired, and decisions were made without them. Participants provided examples of premature capacity determinations made without proper medical evaluation or consultation ( Table 4 ). One participant described the invisibility of these patients, especially for women and minorities, and another noted how the care of “socially admitted” patients is undermined by negative attitudes similar to those encountered by individuals with substance use disorders (Appendix 3).

Cost of care

Wait-lists and scarcity of alternatives.

Inadequate community support often resulted in emergency department visits and hospital admissions, with the perception that hospitals are the safest place. Participants noted lengthy wait-lists for community services like home care, physiotherapy, or occupational therapy, which led to deconditioning ( Table 5 ). The transition to long-term care was described as “abysmal,” leaving patients in challenging situations for extended periods. Admissions were a “last resort” after all other options were exhausted, with patients and families struggling to access necessary care. The lack of alternatives contributed to participants’ distress when caring for “socially admitted” patients (Appendix 3).

Description and illustrative quotations of the wait-list and scarcity of alternatives theme in the cost of care domain

Population health

Factors leading to vulnerability.

Participants identified many issues that were associated with the “social admission” label, particularly for patients with cognitive impairment ( Table 6 ). These included physical barriers (e.g., inaccessible homes), homelessness, and financial challenges. Social isolation left individuals unsupported, managing alone until emergencies, such as falls, catalyzed hospital admission. The inability to advocate for oneself was also a common observation.

Descriptions and illustrative quotations of factors leading to vulnerability and system changes for addressing “social admission” themes in the population health domain

System changes for addressing “social admissions”

Participants identified systemic barriers that they considered disadvantaged “socially admitted” patients. Participants were concerned that the health care system is currently in crisis (e.g., with a lack of primary care and home support), and emergency departments cannot function as intended, causing the acute care system to become the community system or “the [inter]mediate pathway between community and long-term care” ( Table 6 ). Some called for specialized seniors’ care teams to address the unique needs of older adults. Participants emphasized the importance of understanding these patients’ situations holistically, with a multidisciplinary approach to assess medical history, social factors, and available resources; several examples of ideal approaches were shared. The system’s focus on individuals with higher functioning left “socially admitted” patients underserved, with emphases on services that are “organized from a provider lens, not from a patient-need lens” (HC605).

• Interpretation

We sought to understand how health care providers perceive patients labelled as “socially admitted” in hospital, and we identified 9 key themes across the Quintuple Aim framework. 23 , 24 The themes in the patient experience domain highlighted inconsistent definitions and passive care approaches for these patients, who are often seen as low priority in hospital. Under the care team well-being domain, themes of moral distress and hierarchy of care showed the challenges and dilemmas faced by health care providers. Issues of stigma (e.g., “they have dementia”), prejudices (e.g., ageism), wait-lists, and scarcity of alternatives underscored systemic challenges under the health equity and cost of care domains. Finally, factors leading to vulnerability and potential system changes were described by participants as ways to better the health of this population.

Our findings highlight the potential adverse effects on care when patients are labelled as “socially admitted” (or as “orphan patients” in the study hospital), such as incorrect assumptions about medical needs and cognitive abilities, which impedes opportunities to look for treatable medical issues. Despite a “social admission” pathway ostensibly designed to ensure there are no acute or new medical issues, patients were still perceived as having “multiple comorbidities” or being “the most frail … the most complex” ( Table 2 ). This finding is in keeping with the results of a case–control study (in London, Ontario), in which medical comorbidity played a minimal role in the label of a “failure to cope” admission among adults aged 70 years or older. Instead, recent failed discharge from hospital was significantly associated with a “social admission” label, leading the authors to suggest blame was an important part of the use of this label in a system that prizes efficiency. 3 This supports the viewpoint that it is more a system’s failure to cope than the patient’s. 10

Our findings also demonstrate possible negative impacts on health care providers not addressed in previous research. Although similar patient populations (“failure to thrive” or “failure to cope”) in British Columbia 25 and Ontario, 3 and “acopia” admissions in the United Kingdom and Australia, 7 , 9 have been researched, these studies did not consider the insights of providers directly caring for these patients. We highlight some structures (e.g., propagation of the label early in care) or cultures (e.g., ageism) in our health care systems, leading to system and individual tensions caring for “socially admitted” patients, especially in the context of few readily available alternatives. We observed that participants frequently reported feeling conflicted defining, prioritizing, and managing this patient population, yet unequivocally considered these patients deserved care — albeit care delivered by someone else. This latter finding contrasts with a survey of physicians in Wales in which two-thirds (62.7%) considered patients labelled as “social admissions/acopia” were a burden on national health resources, with 44.8% of physicians admitted to feeling that these patients were a burden on their time. 15

Despite considering that “socially admitted” patients were deserving of care, our participants recounted how care was passed down to less-senior members of the health care team. This pattern of downgrading care can lead to situations in which “socially admitted” patients are looked after by team members who possess minimal experience recognizing evolving medical presentations or lack the authority to advocate strongly for clinical reassessments when needed. The implication that the care of “social admissions” should be delegated to others reflects an implicit attitude of hierarchy and detachment from the needs associated with this patient population. Not being able to provide the care that is warranted while at the same time believing that the needed care is beneath the care they provide is in keeping with cognitive dissonance literature in medicine (i.e., holding 2 or more inconsistent beliefs or behaving in a way that is inconsistent with core beliefs). 26 Cognitive dissonance can trigger negative emotions and subsequent defensive reactions resulting in fault finding in others (e.g., blaming “social admissions”), reinforced commitment to wrong actions (e.g., propagating labels), and overlooked medical errors, 26 , 27 offering some explanations for understanding how stigma and hierarchies of care can lead to missed acute medical illnesses (e.g., sepsis, malignancy, and strokes) in previous “social admission” populations. 5 , 7 , 9

Existing literature indicates that “social admission” labelling may harm patients. 14 Our findings suggest that the use of this label appears to have little benefit for the health care providers who care for this patient population. Moreover, no evidence exists to date that “social admissions” labelling or pathways help the health care system. Therefore, re-evaluating an approach to caring for “socially admitted” patients is imperative, and this may include abandoning the nondiagnostic label.

Better support for this patient population may be achieved through enhanced policies that propose feasible solutions to support these patients. To achieve this, further steps are required to define “social admissions,” and to highlight the importance and scope of the issues surrounding the patient population captured under this label. 28 However, we found inconsistencies in how “social admissions” are described, which adds to the challenge in developing effective policies for these patients, and in comparing similar presentations across Canada. 29 Developing a consistent definition for “social admissions” may also prompt clinical specialties to claim responsibility for this population, as champions are key to raising issues for prioritization in health care. 30

“Social admissions” can be considered a “wicked problem” with no single easy solution. 31 A previously proposed ecological approach can guide clinicians in managing “social” presentations. 2 , 32 Participants in our study made suggestions about community- and institutional-level solutions such as home care and primary care teams that support social integration, more multidisciplinary care teams in and out of the hospital, and “geriatrizing” acute care. These suggestions reflect many of the same calls for action made by previous scholars and advocates, 33 , 34 and are similar to solutions proposed by the National Institute on Ageing’s “Ageing in the Right Place” report. 35 Scholars in France have proposed a societal-level solution involving the procedural and financial restructuring of ultraspecialized medicine, coupled with a revival of historic values combining medicine and social work to address the needs of an increasingly frail and socially complex population. 36

Limitations

Our study was conducted in a single tertiary health centre in Nova Scotia, where “socially admitted” patients are admitted under an institution-specific Orphan Patient Policy, which likely limits the generalizability of our findings. Our participants were mainly White and female, which also limits the generalizability to other settings across the country and internationally. Furthermore, the participant sample did not include recreational therapists, volunteers, physiotherapists, or occupational therapists. In the study centre, recreation and volunteer programs had been discontinued or reduced following the COVID-19 pandemic, and there were no occupational or physiotherapists specifically assigned to this patient population. Another limitation of our study is that some interviewers had prior acquaintance with the participants they interviewed. This familiarity may introduce bias in the data collection and interpretation, although this should be balanced with constructivist grounded theory’s emphasis on researchers as co-participants in the research process.

Our research draws attention to health care providers’ challenges in managing care for “socially admitted” patients, and to perceptions regarding “social” presentations, perceived system barriers and resource shortages, and some potential solutions for better patient care. Overall, no consensus emerged as to what constitutes a “social admission” (who are the patients labelled as “socially admitted”?) or ownership for “social admissions” (who cares for these patients?), and participants reported inconsistencies in care delivered for such patients (how to care for “socially admitted” patients). To improve the patient experience and alleviate the moral distress of staff who care for “socially admitted” patients in hospital, the inherent structures of our health care system, such as hierarchies and stigmatization, should be reformed to better address the needs of patients with increasingly complex social problems who present to hospitals.

Competing interests: Jasmine Mah receives scholarships supporting her PhD research from the Department of Medicine at Dalhousie University, Dalhousie Medical Research Foundation, Dr. Patrick Madore Traineeship, and the Pierre Elliott Trudeau Foundation. Kenneth Rockwood has asserted copyright of the Clinical Frailty Scale through Dalhousie University’s Industry, Liaison, and Innovation Office. In addition to academic and hospital appointments, Kenneth Rockwood is cofounder of Ardea Outcomes, which (as DGI Clinical) in the last 3 years has contracts with pharmaceutical and device manufacturers (Danone, Hollister, INmune, Novartis, Takeda) on individualized outcome measurement. In 2020, he attended an advisory board meeting with Nutricia on dementia and chaired a Scientific Workshop & Technical Review Panel on frailty for the Singapore National Research Foundation. He is associate director of the Canadian Consortium on Neurodegeneration in Aging, itself funded by the Canadian Institutes for Health Research, the Alzheimer Society of Canada, and several other charities. He holds the Kathryn Allen Weldon Chair in Alzheimer Research, funded by the Dalhousie Medical Research Foundation. Kenneth Rockwood also reports personal fees from Ardea Outcomes, the Chinese Medical Association, Wake Forest University Medical School Centre, the University of Nebraska Omaha, the Australia and New Zealand Society for Geriatric Medicine, Atria Institute, Fraser Health Authority, McMaster University, and EpiPharma. In addition, Dr. Rockwood has licensed the Clinical Frailty Scale to Enanta Pharmaceuticals, Synairgen Research, Faraday Pharmaceuticals, KCR S.A., Icosavax, BioAge Labs, Biotest AG, Qu Biologics, AstraZeneca UK, Cellcolabs AB, Pfizer, W.L. Gore & Associates, pending to Cook Research Incorporated, Renibus Therapeutics, and, as part of Ardea Outcomes, has a pending patent for Electronic Goal Attainment Scaling. He also reports permission for the Pictorial Fit-Frail Scale licensed to Congenica. Use of both the Clinical Frailty Scale and Pictorial Fit-Frail Scale is free for education, research, and nonprofit health care with completion of a permission agreement stipulating users will not change, charge for, or commercialize the scales. For-profit entities pay a licensing fee, 15% of which is is retained by the Dalhousie University Office of Commercialization and Industry Engagement. The remainder of the licence fees are donated to the Dalhousie Medical Research Foundation. Melissa Andrew reports grants from Sanofi, grants and support to attend meetings from GSK, grants from Pfizer, grants from Canadian Frailty Network, personal fees from Sanofi, personal fees from Pfizer, personal fees from Seqirus, grants from Merck, grants from Public Health Agency of Canada, and grants from Canadian Institutes of Health Research, outside the submitted work. Dr. Andrew is a volunteer board member for the Alzheimer Society of Nova Scotia and the National Advisory Committee on Immunization. Sheliza Khan declares leadership in the patient flow department at Queen Elizabeth II Hospital. No other competing interests were declared.

This article has been peer reviewed.

Contributors: Jasmine Mah and Christie Stilwell contributed equally as co–first authors. Jasmine Mah contributed to the conceptualization and design, procurement of data, analysis of data, drafting of the original manuscript, and review of the manuscript. Christie Stilwell and Emily Marshall contributed to the conceptualization and design, analysis of data, drafting of the original manuscript, and review of the manuscript. Madeline Kubiseski and Gaurav Arora contributed to the conceptualization and design, procurement of data, analysis of data, and review of the manuscript. Karen Nicholls, Sheliza Khan, Jonathan Veinot, Lucy Eum, Susan Freter, Katalin Koller, Maia von Maltzahn, Kenneth Rockwood, Samuel Searle, and Melissa Andrew contributed to the conceptualization and design, analysis of data, and drafting of the original manuscript or review of manuscript drafts. All authors approved the final version to be published and agreed to be accountable for its accuracy and integrity.

Data sharing: Anonymized data from our study may be available on request. Interested parties are encouraged to contact the lead author via email to access these data or to obtain a copy of the Orphan Patient Policy. The data will be shared under terms that ensure the protection of participant privacy and compliance with relevant data protection regulations.

Funding: This study is supported by Nova Scotia Health, through a grant from the Nova Scotia Health Research Fund. Nova Scotia Health is the provincial health authority.

• Accepted March 5, 2024.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

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• Published: 12 September 2024

Exploring sexual life enrichment: a journey into strengthening well-being for women post- menopause through qualitative study

• Elnaz Haji Rafiei 1 ,
• Hedyeh Riazi 2 ,
• Jamal Shams 3 &
• Hamid Alavi Majd 4  

BMC Women's Health volume  24 , Article number:  506 ( 2024 ) Cite this article

Metrics details

women post-menopause, are faced with various physical, emotional, and relational challenges. One such aspect that tends to be overlooked is the impact of menopause on sexual well-being. This study aimed to elucidate the concept of enriching the sexual life of women post-menopause.

A qualitative research strategy was adopted using a conventional content analysis approach. Data collection was conducted through semi-structured interviews with 24 participants (17 women post-menopause and 7 experts), using purposive sampling.

The data analysis resulted in the extraction of 341 codes, 24 subcategories, and 8 categories. Ultimately, the following three themes emerged: “maintaining and enhancing the position of sexual relationships,” “deepening sexual relationships and expanding intimacy,” and “improving communication skills with the spouse “.

Enriching the sexual life of women post-menopause, as suggested by the themes, involves nurturing their relationships, keeping these connections strong and valued, deepening intimacy, and promoting effective communication to ensure a fulfilling and enjoyable experience during this phase of life. This leads to a sense of security, health, and tranquility, ultimately manifesting positive repercussions on the couple’s and family’s health.

Peer Review reports

The sexual aspect of life constitutes one of the important physiological needs of humans, providing a framework for the attainment of individual and social well-being [ 1 ]. Dissatisfaction in sexual life stands as a primary contributor to relational conflicts, capable of instigating doubt regarding love and affection, and increasing concerns among couples regarding the stability of their relationships [ 2 ]. Numerous factors exert an influential impact on sexual life, with menopause being one of the foremost among them [ 3 ].

The term postmenopause refers to the period of time after the final menstrual period and includes early stage (first 5 years) and late stage (after five years until death) based on the Stages of Reproductive Aging Workshop (STRAW) guidelines [ 4 ]. Continuation of sexual activities in women post-menopause enhances the quality of life and leads to increased satisfaction with life [ 5 , 6 ]. Women post menopause, due to the complex interplay of individual, interpersonal, and societal factors influencing health, are more susceptible to sexual disorders compared to women in the reproductive phase [ 5 ]. Additionally, the postmenopausal period is typically accompanied by physiological and psychological changes that impact sexual issues [ 7 ]. The reduction in estrogen levels, coupled with alterations in vascular, muscular, and urinary systems, as well as changes in mood, sleep pattern, and cognitive function, gives rise to sexual problems directly and indirectly affecting sexual performance [ 5 , 6 ]. Sexual dysfunction prevents the experience of satisfying sexual activity and results in decreased overall life satisfaction [ 8 , 9 ]. The prevalence of this disorder in women post-menopause is reported to be 85.2% globally [ 10 ] and more than 80% in Iran [ 11 ]. The significant prevalence and adverse consequences of sexual problems in women post-menopause have prompted an increasing focus on providing scientifically sound solutions, particularly in preventive care, with a specific emphasis on sexual health [ 1 , 12 ].

Enrichment programs are proposed as one of the solutions to improve the quality of life. These programs are comprehensive counseling or education designed to enhance the lives of individuals, by providing them with new knowledge, skills, or experiences [ 13 , 14 ]. Various studies indicate the positive effects of enrichment interventions in some fields, including enhancing marital relationships [ 15 ]. Aspects such as improving the sexual knowledge of couples, strengthening relationship skills, and applying conflict resolution strategies, have been highlighted in enrichment programs [ 13 , 14 , 16 ]. These aspects involve a movement toward the growth of the marital relationship, aiming to enhance the relationship by establishing goals and direction for achieving the desired objectives [ 17 ]. Based on our knowledge, existing studies in the field of the sexual life of menopausal women have primarily focused on variables such as sexual function and interventions like education, symptom recognition, health promotion, attention to the sexual partner, and individualized therapeutic approaches [ 7 , 18 , 19 , 20 , 21 ]. None of these studies have comprehensively evaluated the sexual life of women in the context of enrichment, and it appears that the lack of a well-defined concept of sexual life enrichment in the existing literature may contribute to this limitation. Given the absence of documentation to clarify this issue, it seems necessary to first define this concept for planning effective and comprehensive interventions based on it. Therefore, the present study was conducted to explore the concept of sexual life enrichment among women post-menopause.

Materials & methods

Study design and participants.

This was a qualitative study employing the conventional content analysis approach. The study setting comprised comprehensive health centers in Qazvin, Iran. The purposive sampling was the sampling strategy. Participants included women post-menopause and experts (sexologists, sex-therapists, and psychologists) who expressed willingness to participate in the study. The inclusion criteria for women post-menopause were as follows: being Iranian, having at least basic literacy skills, being married (having a male spouse), being sexually active, not experiencing a stressful event (such as accidents, serious illness, or death of close relatives) in the past six months, women and their spouses not suffering from recognized mental illnesses, women and their spouses not having a severe physical illness that impedes sexual relationships (such as uncontrolled diabetes or mobility restrictions), being in the first ten years of postmenopause, and not experiencing severe marital conflicts (such as conflicts leading to separation/divorce) in the past six months. Furthermore, inclusion criteria for experts included having more than 2 years of work experience and a history of providing services in the field of sexual health to women-post menopause. Unwillingness to continue participation in the study was the sole criterion for exclusion.

Data collection

Data were collected through semi-structured interviews. The main researcher conducted all interviews. Sampling took place from July 2022 to December of the same year, ensuring maximum diversity in terms of age, education level, socio-economic status, duration of menopause, occupation, and work experience. Informed consent for participation in the study was obtained from all participants. All interviews were conducted in a calm, private environment, providing the necessary psychological security for the participants. Interviews with women-post menopause began with general questions such as “What is your perspective on sexual relationships?” If the interviewees’ discussions moved away from the topic under investigation, the researcher redirected their attention to the desired subject, with a question extracted from their statements. The interview process involved probing questions such as “Can you elaborate more on this? Can you clarify this further? What experiences have you had in this regard?” to facilitate a clearer understanding of the concept for both the researcher and the participants. Some eexamples of questions for interview with women post-menopause and experts are shown in Table  1 . All interviews were recorded, thoroughly transcribed, and then subjected to analysis. The duration of interviews ranged from 35 to 65 min. Richness of data was achieved after interviewing 24 participants [ 22 ].

Data analysis

The data analysis process followed the recommended stages by Lundman and Graneheim [ 23 ]. Initially, the researcher transcribed the interview text verbatim into Microsoft Word 2018 software and conducted the data analysis concurrently. To understand the interview content, the text was read multiple times, and coding units considered the most significant part of content analysis were determined. The entire text was regarded as the unit of analysis, and smaller segments, including a word, phrase, sentence, or paragraph with relevant meaning or concept related to the study question, were considered meaningful units. While preserving the original concept, the meaningful units were condensed into compact expressions and then coded. The codes were placed into subcategories based on their similarities and differences. Similar subcategories were grouped together to form categories. Finally, considering the hidden meanings within the categories, themes emerged, and the main concepts revealed [ 23 , 24 ].

Rigor of the data

In this research, Lincoln and Guba’s criteria, including data credibility, confirmability, dependability, and transferability were considered to ensure the accuracy and reliability of the data. Methods such as reviewing the data for prolonged engagement, obtaining participants’ feedback, and the experts revising codes and categorization based on their input were employed to confirm credibility. For confirmability, several interview transcripts, the coding process, and the extraction of themes were made available to other expert researchers in qualitative research for review. Furthermore, maintaining documentation related to the study in a way that allows others to follow the process, contributed to the confirmability of this research. To ensure the dependability of the data, code-recode, and external checking were applied. To enhance the transferability of the data, attempts were made to clarify the complete description of the participants and the research process [ 23 ].

Ethical considerations

At the beginning of each interview, the researcher introduced herself to the participants and explained the research objectives. Subsequently, written informed consent was obtained from the participants. Participants were assured that their audio files would be kept confidential. Sufficient information was provided regarding the voluntary nature of participation in the research and the option to withdraw from the study at any stage. Throughout the study, participants’ names were kept confidential, and they were mentioned by specific codes.

This study received ethical approval with the code IR.SBMU.PHARMACY.REC.1402.187 from the Ethics Committee of Shahid Beheshti University of Medical Sciences.

Seventeen women post-menopause and 7 experts participated in the study. The mean age was 52.29 and 45.42 respectively. Further characteristics of the participants are shown in Table  2 , and Table  3 .

The data analysis resulted in the extraction of 341 codes, 24 subcategories, and 8 categories. Ultimately, 3 themes were identified as follows: “maintaining and enhancing the position of sexual relationships”, “deepening sexual relationships and expanding intimacy”, and “improving communication skills with the spouse” (Table  4 ).

Theme 1- maintaining and enhancing the position of sexual relationships

Women post-menopause and experts paid particular attention to maintaining and continuing sexual relationships during postmenopausal period. This aspect emphasizes the importance of prioritizing and valuing sexual relationships during this phase of life. It highlights the need to ensure that these connections remain an essential part of their lives and contribute to their overall well-being. It appears that the continuation of sexual relationships during this period is one of the suitable approaches for strengthening and promoting couple’s romantic relationships. This theme encompasses categories such as the importance and necessity of sexual relationships, a sense of health and tranquility, and the positive repercussions of sexual relationships on the health of the couple and the family. A participant with a 6-year postmenopausal history expressed:

“I don’t think we should equate the cessation of sexual relations with the end of menstruation. It is something that has ended , but sexual relations must continue” (p15).

Some acknowledged the positive outcomes of continuing and maintaining sexual relationships during postmenopause, including peace of mind and well-being. In this regard, a participant who was 4 years postmenopause expressed:

“ Although I am a stressful person , I can concentrate after sex , and I think that sex reduces my stress and makes me feel relaxed " (p1).

One of the experts also stated:

“The sexual activity of a post-menopausal woman , aside from being a component of her sexual and reproductive rights , plays a fundamental role in her physical and mental well-being” (p21).

One additional positive outcome of the continuation or maintenance of sexual relationships between spouses during the postmenopausal period is the health and well-being of the couple, contributing to the overall health of their family. A participant with a 6-year postmenopausal history believed:

“Intimate relations are highly beneficial , fostering an increase in affection and love between spouses.” (p16).

Theme 2- deepening sexual relationships and expanding intimacy

Based on the study results, it seems that attention to the deepening of sexual relationships and expanding intimacy is one of the effective measures for improving the sexual relationships of couples during postmenopausal period. This theme highlights the significance of fostering emotional and physical closeness, which can lead to a more fulfilling and satisfying relationship. Women post-menopause can experience a more profound level of intimacy by deepening the connection which can lead to increased satisfaction and happiness in their relationships. By promoting intimate sexual relationships, focusing on love-making and foreplay, diversifying sexual experiences, and infusing excitement into sexual relationships, a high-quality sexual life can be achieved for women post-menopause. The interviews suggest that promoting intimate sexual relationships, including sexual awareness of the couple, attention to each other’s sexual characteristics, and mutual participation, serves as a foundation for enhancing intimate sexual relationships. One of the experts stated:

“The intimacy in sexual relations should persist , and individuals should not perceive the aging process , graying hair , wrinkles on the face , or the altered self-image due to aging as reasons to refrain from intimacy in sexual relations with their spouse. It is very important to pay attention to the fact that sexual intimacy between couples should not be interrupted with age and menopause” (p23).

A participant with a history of 6 years of postmenopausal period acknowledged:

“My spouse and I try to repeat positive experiences; for instance , when a good incident occurs , we share it with laughter and humor. In fact , we try to maintain our close relationship , and I think it has positive effects on our sexual relationships” (p15).

In this regard, one of the experts stated:

“Spouses ought to discuss their sexual desires and needs openly , addressing what brings them joy or discomfort. In fact , they should familiarize themselves with each other’s sexual needs in a constructive manner” (p21).

According to participants, the necessity of preparation for engaging in sexual relations, the importance of identifying and enhancing stimuli for entering into sexual relationships, focusing, and sexual fantasies are considered effective approaches in improving the sexual life of women post-menopause.

A participant with 6 years of postmenopausal experience emphasized the importance of focusing during sexual relationships to derive pleasure:

“It is crucial to focus during sexual relationships and concentrate our thoughts so that we can derive sufficient pleasure from the established relationship” (p16).

An expert stated:

“It is better for spouses to initiate by preparing each other and engaging in pleasant activities , such as kissing the neck and exploring other parts of the body. Overall , engaging in activities that are enjoyable for both individuals is recommended” (p18).

Another expert stated:

“The physical contact between partners inherently constitutes sex , and this contact can be elevated , particularly in private settings , progressing to intimate engagement involving sexual organs. And it may , or may not , lead to orgasm. This period necessitates the utilization of various other stimuli , such as subjects , fantasies , games , and effective use of touch , smell , etc., to induce arousal. A deliberate plan and preparation in advance are required for a more special expression of affection from the spouse to induce arousal” (p21).

In terms of diversification and infusing excitement into sexual relationships, the role of sexual enthusiasm, such as playful humor in the conversations of the couples was discussed. Matters related to the significance of motivational actions and creating a positive atmosphere for the enhancement of sexual life were addressed. A participant with 8 years of postmenopause experience expressed:

“Now that we have aged , we should seek diversity. I believe one should wear very good clothes , be stylish , and consider variety in her attire , all of which have a significant impact on sexual relationships. For example , if you wear the same outfit at home all the time , your husband will ask , ‘What kind of clothes is this that you’re wearing? Dress up!’ Because he knows that wearing stylish clothes means you are livelier , more attractive , and will even have better sexual relationships” (p8).

One of the experts stated:

“Considering that women in this period likely have experienced a minimum of 20 to 30 years of married life , it is essential for them to preserve vitality in their relationships. Typically , the initial steps individuals in middle age take to enhance their marital relationships involve motivational interventions. It is necessary to instill motivation in the individual to encourage a willingness to make changes in their sexual behaviors and relationship with their spouse” (p22).

Theme 3- improving communication skills with the spouse

This theme is derived from the categories of: expressing desires and needs and conversation with the language of love. Effective communication plays a crucial role in addressing concerns, expectations, and desires between partners. By fostering open and honest dialogue, women post-menopause and their spouses can better understand each other’s needs, leading to a stronger bond and more enjoyable experiences. The articulation of needs in sexual relationships can lead to an enhancement in the quality of sexual relationships. Additionally, it appears that disrupted interactions between spouses may have an adverse effect on sexual relationships.

From the participants’ perspective, expressing sexual desires leads to a deeper understanding between spouses and fosters a better sense of satisfaction in sexual life. One participant stated:

“ I think that I get sexual pleasure when I express my desire and need” (p11).

“Primarily , couples need to engage in a conversation about their sexual relationships , expressing their desires and needs” (p22).

It appears that discussions about sexual matters and emotional relationships among spouses, or in other words, conversation with the language of love, contribute to the enhancement of overall marital relations, ultimately leading to an improvement in their sexual relationships. In this regard, an expert expressed:

“It is beneficial for couples to create opportunities for discussing sexual matters openly to improve their sexual relations. For instance , suggesting certain attire or behaviors is a positive approach” (p21).

A participant with a 6-year history of postmenopause stated:

“In my opinion , sexual relations constitute a dyadic relationship , wherein each party must communicate their love emotions to the other” (p16).

While the existing literature has covered various aspects of menopausal women’s quality of life, our study provided a new concept that can help enrich women’s sexual lives, which in turn could lead to the improvement of the quality of women’s sexual lives. Three significant themes emerged from the study: “maintaining and enhancing the position of sexual relationships”, “deepening sexual relationships and expanding intimacy”, and “improving communication skills with the spouse”. These themes highlight the importance of prioritizing sexual relationships, fostering emotional and physical closeness, and promoting open communication in maintaining and enhancing intimacy in the post-menopausal period.

The results of the current research emphasize the significance of continuing sexual relationships during post-menopause, as it contributes to the overall well-being of both spouses and the family. By maintaining these connections, women post-menopause can experience a sense of peace and mental tranquility, which in turn benefits their partners and the family unit. The findings of the study by Nappi et al. (2014) demonstrated that a healthy sexual relationship during post-menopause is a fundamental component of women’s life. The care for women post-menopause should encompass attention to sexual changes associated with menopause, counseling to overcome potential sexual issues during this period, general education, awareness of menopausal symptoms, promoting health, paying attention to partner, and individual treatment to preserve the sexual relationships of women post-menopause [ 7 ]. Sexual health for women is a priority for the World Health Organization, as unfavorable sexual function can cause concerns for couples about their married life [ 25 ]. The findings also highlighted the need to recognize the positive outcomes of continuing sexual relationships, such as increased affection and love between spouses, and the importance of sexual relationships as part of postmenopausal women’s sexual and reproductive rights. Sexual relationships are an important factor in marital happiness, and if unsatisfactory, they can contribute to feelings of dissatisfaction and insecurity [ 26 ]. Sexual disorders result in the deterioration of mental health in families, creating or exacerbating mutual psychological problems. Many conflicts, controversies, and marital disputes can be attributed to these disorders [ 26 , 27 ]. Additionally, it has been demonstrated that the sexual relationships of couples contribute to the improvement of physical health and the quality of marital life [ 28 ], aligning with the results of our study.

According to the present research, deepening sexual relationships and expanding intimate sexual relationships between couples, fostering lovemaking, and diversifying sexual experiences are appropriate approaches to improving individuals’ sexual lives and leading to a more fulfilling and satisfying relationship during post-menopausal period. By promoting intimate sexual relationships, focusing on foreplay, and infusing excitement into sexual relationships, women post-menopause can experience a higher quality of sexual life. The participants and experts suggest that fostering emotional and physical closeness, open communication of needs and desires, and engaging in activities that bring joy to both partners can contribute to enhancing intimate sexual relationships. Sexual intimacy is a complex matter that requires special attention, involving sharing romantic experiences, the need for physical contact, sexual intercourse, and relationships that are designed to arouse, stimulate, and satisfy sexual desires. If couples are aware of their differences in terms of demands and preferences in sexual intercourse, they can address them properly before their relationship encounters difficulties. Conversely, if couples are not aware of their sexual intimacy, often becomes a source of problems and conflict [ 29 ]. Happy and intimate couples tend to derive more pleasure from sexual intimacy and, as a result, become even happier and more satisfied [ 30 , 31 ]. Intimacy, expressing love, and receiving love are essential components of marital life, often acquired through sexual interactions [ 32 ]. It is shown that couples with excellent relationships are less likely to experience sexual disorders. Conversely, as the relationship quality deteriorates the incidence of sexual dysfunctions increase [ 32 ]. Additionally, it has been shown that for many elderly individuals, physical closeness and intimacy may be more important than sexual activity [ 33 ].

The results demonstrate the importance of the role of effective communication in addressing concerns, expectations, and desires between partners. By fostering open and honest dialogue, women post-menopause and their spouses can better understand each other’s needs, leading to a stronger bond and more enjoyable experiences. Improving interpersonal communication skills between spouses constitute one of the influential factors in sexual relationships. In addition to the quality of the relationship between spouses, women’s sexual inclination towards interactions experienced with their partners is contingent upon such dynamics. In fact, women’s sexual inclination is intricately linked to the communication and dynamics of the relationship with their partners [ 34 ]. The articulation of needs and conversation with the language of love in sexual relationships can lead to an enhancement in the quality of sexual relationships. Disrupted interactions between spouses may have an adverse effect on sexual relationships, highlighting the importance of open communication in maintaining intimacy. Participants believed that marital relationships play a role in the quality of individuals’ sexual lives, a finding congruent with other studies [ 35 , 36 , 37 ]. It appears that desirable interpersonal relationships between spouses contribute more to the satisfaction of marital life than the frequency of sexual relations [ 36 ]. According to the results of Morad’s study (2022), provided that women achieve emotional readiness before entering the menopausal stage, including being seen by their spouses, being respected, and understanding each other both physically and mentally, their sexual function does not undergo significant changes in postmenopausal period. It may be argued that commitment and love are highly crucial for sexual relationships during this stage [ 38 ]. After many years of marital life, what becomes significant in a sexual relationship is being seen and accepted by the partner. This aspect propels couples towards experiencing the pleasure of being together and cultivating a desirable sexual relationship with one another. In such a context, the acceptance of menopause as a natural stage of life is fostered, and couples come to believe that every moment of togetherness is valuable. The focus shifts from merely achieving orgasm to unifying as a couple and deriving pleasure from one another [ 38 ].

The findings demonstrate that sexual life enrichment in postmenopausal period is a multifaceted issue that requires attention to various aspects, such as maintaining sexual relationships, deepening intimacy, and enhancing communication skills.

Strengths and limitations

The present study represents the first attempt to elucidate the concept of enriching the sexual life of women post-menopause which is crucial for improving their sexual well-being. Applying a qualitative approach allowed a deep exploration of participants’ experiences, perspectives, and insights into the complexities of this concept. This approach enabled a rich understanding of the themes and categories identified. We included participants with varying menopausal histories, ranging from 2 to 10 years. This diverse representation provided a more comprehensive understanding of the experiences and challenges faced by women post-menopause across different timeframes and it could increase transferability of our study. Furthermore, incorporating the views of experts in the field added credibility to the study and provided valuable insights from professionals who have extensive knowledge about the topic. As with any qualitative research, the researcher’s influence on the participants and the interpretation of the data cannot be entirely ruled out. To minimize this potential limitation, the researcher maintained reflexivity and transparency in the data analysis process. Moreover, the age of the experts may have limited their understanding of the lived reality of post-menopause, as they may not have had personal experience with the condition themselves. The experts’ experience was not specifically focused on working with women post-menopause, which could impact the findings. Another limitation is that this was a heteronormative demographic, and it is unclear how the findings could be extrapolated to same-sex couples.

In conclusion, this study offers valuable insights into women’s post-menopause sexual life enrichment by focusing on maintaining and enhancing sexual relationships, deepening sexual relationship and expanding intimacy, and improving communication skills with the spouse. Such efforts result in feelings of security, health, and tranquility, ultimately yielding positive repercussions on the health of the couple and the family. The present study serves as a foundation for further research in this under-researched area, ultimately aiming to improve the sexual well-being and overall quality of life for postmenopausal women and their partners. By focusing on enriching their sexual lives, women post-menopause can experience greater satisfaction, improved communication, and stronger bonds with their partners, ultimately contributing to their overall health and happiness. These insights can contribute to the development of interventions and support systems that cater to the unique needs of women post-menopause.

Data availability

All data generated during this study are included in this published article.

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The authors would like to extend their gratitude to all the participants of this study.

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Hedyeh Riazi

Behavioral Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

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EHR collected the data. HR designed the study, supervised it, and provided the final draft. JS was involved in data interpretation. HAM participated in data interpretation. All authors reviewed the manuscript.

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Rafiei, E.H., Riazi, H., Shams, J. et al. Exploring sexual life enrichment: a journey into strengthening well-being for women post- menopause through qualitative study. BMC Women's Health 24 , 506 (2024). https://doi.org/10.1186/s12905-024-03350-2

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DOI : https://doi.org/10.1186/s12905-024-03350-2

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