qualitative research nursing study

Introduction to qualitative nursing research

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

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

Research 101: Descriptive statistics

Differentiating research, evidence-based practice, and quality improvement

How to appraise quantitative research articles

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

What is qualitative research?

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

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

Qualitative research designs

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

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

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

Sampling approaches

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

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

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

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

Data collection and analysis

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

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

Evaluating a qualitative study

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

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

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

Application to nursing practice

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

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

Successful implementation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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• Correspondence to Kate Seers RCN Research Institute, School of Health & Social Studies, University of Warwick, Coventry, CV4 7AL, Warwick, UK; kate.seers{at}warwick.ac.uk

https://doi.org/10.1136/ebnurs.2011.100352

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Good qualitative research uses a systematic and rigorous approach that aims to answer questions concerned with what something is like (such as a patient experience), what people think or feel about something that has happened, and it may address why something has happened as it has. Qualitative data often takes the form of words or text and can include images.

Qualitative research covers a very broad range of philosophical underpinnings and methodological approaches. Each has its own particular way of approaching all stages of the research process, including analysis, and has its own terms and techniques, but there are some common threads that run across most of these approaches. This Research Made Simple piece will focus on some of these common threads in the analysis of qualitative research.

So you have collected all your qualitative data – you may have a pile of interview transcripts, field-notes, documents and notes from observation. The process of analysis is described by Richards and Morse 1 as one of transformation and interpretation.

It is easy to be overwhelmed by the volume of data – novice qualitative researchers are sometimes told not to worry and the themes will emerge from the data. This suggests some sort of epiphany, (which is how it happens sometimes!) but generally it comes from detailed work and reflection on the data and what it is telling you. There is sometimes a fine line between being immersed in the data and drowning in it!

A first step is to sort and organise the data, by coding it in some way. For example, you could read through a transcript, and identify that in one paragraph a patient is talking about two things; first is fear of surgery and second is fear of unrelieved pain. The codes for this paragraph could be ‘fear of surgery’ and ‘fear of pain’. In other areas of the transcript fear may arise again, and perhaps these codes will be merged into a category titled ‘fear’. Other concerns may emerge in this and other transcripts and perhaps best be represented by the theme ‘lack of control’. Themes are thus more abstract concepts, reflecting your interpretation of patterns across your data. So from codes, categories can be formed, and from categories, more encompassing themes are developed to describe the data in a form which summarises it, yet retains the richness, depth and context of the original data. Using quotations to illustrate categories and themes helps keep the analysis firmly grounded in the data. You need to constantly ask yourself ‘what is happening here?’ as you code and move from codes, to categories and themes, making sure you have data to support your decisions. Analysis inevitably involves subjective choices, and it is important to document what you have done and why, so a clear audit trail is provided. The coding example above describes codes inductively coming from the data. Some researchers may use a coding framework derived from, for example, the literature, their research questions or interview prompts, (Ritchie and Spencer 2 ) or a combination of both approaches.

Qualitative data, such as transcripts from an interview, are often routed in the interaction between the participant and the researcher. Reflecting on how you, as a researcher, may have influenced both the data collected and the analysis is an important part of the analysis.

As well as keeping your brain very much in gear, you need to be really organised. You may use highlighting pens and paper to keep track of your analysis, or use qualitative software to manage your data (such as NVivio or Atlas Ti). These programmes help you organise your data – you still have to do all the hard work to analyse it! Whatever you choose, it is important that you can trace your data back from themes to categories to codes. There is nothing more frustrating than looking for that illustrative patient quote, and not being able to find it.

If your qualitative data are part of a mixed methods study, (has both quantitative and qualitative data) careful thought has to be given to how you will analyse and present findings. Refer to O’Caithain et al 3 for more details.

There are many books and papers on qualitative analysis, a very few of which are listed below. 4 , – , 6 Working with someone with qualitative expertise is also invaluable, as you can read about it, but doing it really brings it alive.

• Richards L ,
• Ritchie J ,
• O'Cathain ,
• Bradley EH ,
• Huberman AM

Competing interests None.

Read the full text or download the PDF:

Nursing Research Guide

• General Search Strategies
• Searching by Author & Theory
• Searching for Qualitative Studies
• Searching for Systematic Reviews & Controlled Trials
• Health Data & Statistics
• Tutorials & Help
• SoN and APA (7th Ed.)
• NSC 890: PICOT Searches

What is qualitative research?

Qualitative research  in Nursing approaches a clinical question from a place of unknowing in an attempt to understand the complexity, depth, and richness of a particular situation from the perspective of the person or persons impacted by the situation (i.e., the subjects of the study).

Study subjects may include the patient(s), the patient's caregivers, the patient's family members, etc. Qualitative research may also include information gleaned from the investigator's or researcher's observations.

While typically more subjective than quantitative research (which focuses on measurements and numbers), qualitative research still employs a systematic approach.

Qualitative research  is generally preferred over quantitative research (which on measurements and numbers) when the clinical question centers around life experiences or meaning.

Adapted from:

• Wilson, B., Austria, M.J., & Casucci, T. (2021 March 21).  Understanding Quantitative and Qualitative Approaches  
• Chicca, J. (2020 June 5).  Introduction to qualitative nursing research.   American Nurse Journal.

Where can I find qualitative research?

Qualitative research can be found in numerous databases. Some good starting options are:

• CINAHL Ultimate Journal articles and eBooks in nursing and allied health.
• MEDLINE (EBSCOhost Web) Journal articles in medicine, life sciences, health care, and biomedical research.
• APA PsycINFO Articles from journals, newspapers, and magazines, along with eBooks in nearly every social science subject area.
• PubMed Citation search of journal articles and books in health and life sciences.

How can I find qualitative research?

Cinahl and/or  medline.

• Start at the Advanced Search  screen.
• Add a search term that represents the topic you are interested in into one (or more) of the search boxes.
• Scroll down until you see the Limit your results  section.
• Qualitative - High Sensitivity (broadest category/broad search)
• Qualitative - High Specificity (narrowest category/specific search)
• Qualitative - Best Balance (somewhere in between)
• Select or click the search button.

APA PsycINFO

• Start at the Advanced Search  screen.
• Use the  Methodology menu to select  Qualitative .

• Use the drop-down menu next the Enter search term  box to set the search to MeSH Terms
• Qualitative Research
• Nursing Methodology Research

How can I use keywords to search for qualitative research?

Try adding adding a keyword that might specifically identify qualitative research. You could add the term qualitative  to your search and/or your could add different types of qualitative research according to your specific needs and/or research assignment.

For example, consider the following types of qualitative research in light of the types of questions a researcher might be trying to answer with each qualitative research type: 

•   Clinical question: What happens to the quality of nursing practice when we implement a peer-mentoring system?
• Clinical question: How is patient autonomy promoted by a unit?
• Clinical question: What is the nursing role in end-of-life decisions?
• Clinical question: What discourses are used in nursing practice and how do they shape practice?
• Clinical question: How does Filipino culture influence childbirth experiences?
• Clinical question: What are the immediate underlying psychological and environmental causes of incivility in nursing?
• Clinical question: How does the basic social process of role transition happen within the context of advanced practice nursing transitions?
• Clinical question: When and why did nurses become researchers?
• Clinical question: How does one live with a diagnosis of scleroderma?
• Clinical question:  What is the lived experience of nurses who were admitted as patients on their home practice units?

Adapted from: Chicca, J. (2020 June 5).  Introduction to qualitative nursing research . American Nurse Journal.

Need more help?

Finding relevant qualitative research can be both difficult and time consuming. Once you conduct a search, you will need to review your search results and look at individual articles, their subject terms, and abstracts to determine if they are truly qualitative research articles. And that's a determination that only you can make.

If you still need help after trying the search strategies and tips suggested on this research guide, we encourage you to schedule an in-person or Zoom research appointment . Health Services librarian Rachel Riffe-Albright is a great bet, but any librarian would be happy to help!

Additonal resources on qualitative research

The following are research guides created by other academic libraries. While you likely will not have access to any of their linked resources, the tips and tricks shared may be useful to you as you search for qualitative research:

• What is Qualitative Research? from UTA Libraries at University of Texas Arlington
• Finding Qualitative Research Articles from Ashland University Library
• Finding Qualitative Research Articles from the Health Sciences Library at University of Washington
• Advanced Search Guide: Qualitative and Quantitative Studies from Southern Connecticut State University Library
• Finding Qualitative and Quantitative Studies in CINAHL from Southern Connecticut State University Library
• << Previous: Searching by Author & Theory
• Next: Searching for Systematic Reviews & Controlled Trials >>
• Last Updated: Mar 29, 2024 11:04 AM
• URL: https://libguides.eku.edu/nursing

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Qualitative case study methodology in nursing research: an integrative review

Affiliation.

• 1 School of Nursing, McMaster University, Hamilton, Ontario, Canada. [email protected]
• PMID: 19374670
• DOI: 10.1111/j.1365-2648.2009.04998.x

Aim: This paper is a report of an integrative review conducted to critically analyse the contemporary use of qualitative case study methodology in nursing research.

Background: Increasing complexity in health care and increasing use of case study in nursing research support the need for current examination of this methodology.

Data sources: In 2007, a search for case study research (published 2005-2007) indexed in the CINAHL, MEDLINE, EMBASE, PsychINFO, Sociological Abstracts and SCOPUS databases was conducted. A sample of 42 case study research papers met the inclusion criteria.

Methods: Whittemore and Knafl's integrative review method guided the analysis.

Results: Confusion exists about the name, nature and use of case study. This methodology, including terminology and concepts, is often invisible in qualitative study titles and abstracts. Case study is an exclusive methodology and an adjunct to exploring particular aspects of phenomena under investigation in larger or mixed-methods studies. A high quality of case study exists in nursing research.

Conclusion: Judicious selection and diligent application of literature review methods promote the development of nursing science. Case study is becoming entrenched in the nursing research lexicon as a well-accepted methodology for studying phenomena in health and social care, and its growing use warrants continued appraisal to promote nursing knowledge development. Attention to all case study elements, process and publication is important in promoting authenticity, methodological quality and visibility.

Publication types

• Research Support, Non-U.S. Gov't
• Nursing Methodology Research / methods
• Nursing Research / methods*
• Qualitative Research*
• Research Design / trends*
• Terminology as Topic

• Open access
• Published: 09 April 2024

A qualitative study of leaders’ experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services

• Malin Knutsen Glette 1 , 2 ,
• Tone Kringeland 2 ,
• Lipika Samal 3 , 4 ,
• David W. Bates 3 , 4 &
• Siri Wiig 1  

BMC Health Services Research volume  24 , Article number:  442 ( 2024 ) Cite this article

Metrics details

The COVID-19 pandemic had a major impact on healthcare services globally. In care settings such as small rural nursing homes and homes care services leaders were forced to confront, and adapt to, both new and ongoing challenges to protect their employees and patients and maintain their organization's operation. The aim of this study was to assess how healthcare leaders, working in rural primary healthcare services, led nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study sought to explore how adaptations to changes and challenges induced by the pandemic were handled by leaders in rural nursing homes and homecare services.

The study employed a qualitative explorative design with individual interviews. Nine leaders at different levels, working in small, rural nursing homes and homecare services in western Norway were included.

Three main themes emerged from the thematic analysis: “Navigating the role of a leader during the pandemic,” “The aftermath – management of COVID-19 in rural primary healthcare services”, and “The benefits and drawbacks of being small and rural during the pandemic.”

Conclusions

Leaders in rural nursing homes and homecare services handled a multitude of immediate challenges and used a variety of adaptive strategies during the COVID-19 pandemic. While handling their own uncertainty and rapidly changing roles, they also coped with organizational challenges and adopted strategies to maintain good working conditions for their employees, as well as maintain sound healthcare management. The study results establish the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements, and how the rural context may affect these aspects.

Peer Review reports

In 2021, essential healthcare services in 90% of the world’s countries were disrupted by the COVID-19 pandemic [ 1 ]. Healthcare services were heavily stressed and had to address unexpected issues and sudden changes, whilst still providing high quality care over a prolonged period [ 2 , 3 ]. Despite the intense focus on hospitals during this period, other parts of the healthcare system such as nursing homes and homecare services also faced extreme challenges. These included issues such as having to introduce and constantly adapt new infection control routines, as well as being given increased responsibility in caring for infected and seriously ill patients in facilities that were not built for such circumstances [ 4 , 5 , 6 , 7 ]. Mortality rates in nursing homes were especially high [ 8 ].

Resilience in healthcare is about a system’s ability to adapt to challenges and changes at different levels (e.g., organization, leaders, health personnel) to maintain high quality care [ 9 , 10 ]. During the COVID-19 pandemic, leaders and the front line were forced to rapidly adjust to keep healthcare services afloat. It has been demonstrated in previous research that effective leadership is crucial in navigating crises and building resilience within health systems [ 11 , 12 , 13 ]. Furthermore, leaders play key roles in facilitating health personnel resilience, for example, through promoting a positive outlook on change and by developing health personnels’ competencies and strengths [ 12 , 14 , 15 ]. During the COVID-19 pandemic, this role became intensified [ 16 , 17 , 18 ], and leaders’ roles in promoting resilient healthcare services were central, for example safeguarding resources, providing emotional support and organizing systems to cope with extreme stresses [ 3 , 19 ].

Smaller, rural nursing homes and home care services are geographically dispersed and typically remote from specialized healthcare services or other nursing home and homecare services. They also tend to have reduced access to personnel due to low population density, frequently leading to the need to make independent decisions, often in complex situations [ 20 ]. Overall, rural healthcare services face different challenges than their urban counterparts [ 21 , 22 , 23 ]. The COVID-19 pandemic intensified some of these issues and created new ones which needed to be managed [ 21 , 24 , 25 ].

The research base on COVID-19 has expanded extensively the past years [ 26 ], covering areas such as clinical risks and outcomes for healthcare workers [ 27 ] and patients [ 28 ], hospital admissions [ 29 ] and healthcare utilization during the pandemic [ 30 ]. Moreover, areas like healthcare leaders' [ 16 , 17 , 31 ] and healthcare professionals’ [ 2 , 32 ] strategies to handle the pandemic challenges, and COVID related strategies’ effect on quality of care [ 33 , 34 ]. And lastly, but not exhaustively, the COVID-19 pandemic in different healthcare settings such as hospitals [ 35 ], primary healthcare services and [ 36 ] mental healthcare services [ 37 ]. However, research on rural healthcare settings, particularly leaders in rural nursing homes and homecare services, have received less attention [ 38 , 39 , 40 ]. Despite the anticipated importance of primary healthcare services in future healthcare and the prevalence of rural healthcare options [ 41 , 42 ]. Overall, there are still lessons to be learned from the COVID-19 pandemic, specifically identifying resilience promoting and inhibiting factors in different health care settings during crisis, how leaders deal with crisis management, and furthermore, to understand and draw lessons from challenges that were overcome during the pandemic[ 43 , 44 ].

Aim and research question

The aim of this study was to assess how healthcare leaders in rural primary healthcare services managed nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study aimed to explore how adaptations to changes and challenges induced by the pandemic were handled by these leaders.

The research question guiding the study was: How did primary healthcare leaders in rural areas experience their leadership during the COVID-19 pandemic, and how did they adapt to the rapid onset changes demanded by the COVID-19 outbreak?

The study employed a qualitative explorative design to study in-depth, how nursing home and homecare leaders in Norwegian rural primary healthcare services experienced and addressed the extreme challenges and needs for change induced by the COVID-19 pandemic [ 45 , 46 ]. Four rural municipalities of different sizes were included in the study. Nursing home and homecare leaders at different organizational levels participated in individual interviews (See Table  1 ).

Norway is divided into 356 municipalities. These municipalities have the autonomy to administer and manage their primary healthcare services, subject to certain laws and regulations (e.g., Act on municipal health and care services [ 47 ], Act on patient and user rights [ 48 ] and Regulation on quality in nursing and care services for service provision [ 49 ]). All municipalities are obligated to offer specified healthcare services independent of their size and inhabitant number (Se Fig.  1 for a brief overview of healthcare services provided by the Norwegian municipalities, comprising nursing homes and home care services, and included municipalities).

Brief overview of healthcare services provided by the Norwegian municipalities, comprising nursing homes and home care services, and the included municipalities

Recruitment and participants

Recruitment was anchored in the municipal management. The municipal manager of health and care in 11 municipalities across the Norwegian west coast were first contacted via email, then by telephone (se Fig.  1 ). Most managers who responded to our contact were positive, but many had to decline due to time constraints related to pandemic management. Four managers agreed to data collection in their municipality with the stipulation that the nursing home- and homecare leaders wanted to participate. All levels of leaders were eligible for inclusion due to the small size of the healthcare services. We contacted the leaders of nursing homes and home care services in the four municipalities, first by email, then by telephone. Nine leaders agreed to participate. One leader declined. All included leaders were female, registered nurses (RNs), and had long and broad experiences with working as RNs either in the healthcare service they now were leaders in, or in other healthcare settings. Some leaders stated that they had continued education or Master’s degrees, but more leader specific qualifications such as leader education, training or courses were not disclosed (Table  1 . Overview of participants and setting).

Data collection

Individual interviews were conducted from November 2021 to November 2022 by the first author (MKG). Leaders in one of the municipalities (municipality B) wished to do the interview in a group interview (three leaders), which we arranged. All but one interview was conducted at the leaders’ work premises (in their offices or in meeting rooms). One leader was interviewed via Zoom due to a temporary need for increased infection precautions. All interviews were guided by a predeveloped interview guide which was based on resilience in healthcare theory [ 50 , 51 ] and contained subject such as: Success factors and challenges with handling the COVID-19 pandemic; New solutions and how new knowledge and information was handled; and Lessons learned from the pandemic.

Data analysis

The interviews were audio recorded and transcribed. The analysis followed the steps in Braun and Clarkes thematic approach [ 52 ]. This involved reading through the transcripts multiple times to find meanings related to the overall research question. Text with meaning was inserted into a Word table which provided initial codes. After the coding process, which involved creating and continuously revising codes, there were 47 codes. The codes were then organized into categories and categories were sorted into initial main themes. Themes and categories were assessed to determine whether any of them should be merged, refined, split or eliminated [ 52 ] (see Table  2 for example of the analysis process). The author team reviewed and approved categories and themes to ensure that each theme illuminated its essence [ 52 ].

We analyzed the interviews and identified three main themes and eight categories (Table  3 ). The results are presented according to identified main themes.

Navigating the role of a leader during the pandemic

Overall, the leaders seemed to have two primary focuses when they talked about how they had experienced the COVID-19 pandemic. These were their personal coping, and how they managed the organizational challenges arising throughout the pandemic period. Particularly in the beginning, they reported feelings of fear and insecurity. Leaders dreaded the consequences which could result from mistakes, such as providing wrong, or missing essential information.

“Having such a responsibility is a burden, and even though you’re not alone, you still feel like you’re the one responsible for the safety of the employees and the patients. Ensuring the safety of everyone was the priority, which is why it was critical to make sure that the protocols we were distributing were the correct ones…” (L1 nursing home municipality C)

Additionally, several leaders stated that they were concerned about personnel who had contracted COVID-19 (some of whom had serious symptoms), and even felt responsible for their situation. Leaders of two of the municipalities reported feelings of frustration, and despair, and all leaders reported long working hours. Leaders expressed that they felt that they had been “on call” for the last two years, and described long working days, with limited consideration for evenings, nights, weekends, or vacations.

A range of organizational challenges was described (e.g., dealing with a stressed economy, experiencing task overload, working within an unprepared organization and the struggle to get a hold on enough personal protective equipment. One of the most prominent challenges in the data set, was the acquisition, interpretation, and distribution of information issued by the authorities. The leaders described that new information was issued frequently along with constantly changing routines. New routines where developed, distributed, and discarded nonstop in the attempt to “get the organization in line with the state authorities”.

“There was new information issued [from the Norwegian directorate of health] almost hourly… we had more than enough to, in a way, keep up with all these procedures that came, or all the new messages that came, and these [information and routines] had to be issued out to the employees and to the next of kin…” (L1 nursing home municipality A)

Despite the difficulties related to information flow, or lack thereof, the leaders devised a range of solutions to make information more accessible to their staff (e.g., informational e-mails, developing short information sheets, making information binders, and meeting up physically to go through new routines with their employees). The data indicated that it was hard to gauge how much information to make available to their staff, who were eager for knowledge, yet still found it hard to process everything. On occasion, the leaders desired assistance or someone to assume authority, or as one leader articulated: “someone to push the red button” (L1 homecare municipality C), due to their struggles to keep up with information, regulations, and routines in the face of rapid changes.

Not surprisingly, leaders felt a heightened need to take the lead during the COVID-19 pandemic. This was a long-running crisis, and they had to be present, approachable and a source of support for their staff, while also striving to gain the employees’ understanding. For example, in one healthcare service the employees wanted more strict rules than necessary and had strong opinions on how things should be done in “in their healthcare service”, while the leader was stringent with sticking to national regulations which were less strict. Another aspect was handling disagreement with measures among employees. Often measures were not in line with the employees’ wishes, which created friction.

The pandemic highlighted the importance of leaders taking on the task of creating a secure working environment for their employees. The leaders noted considerable anxiety among the staff, particularly in facilities that had not experienced any COVID-19 cases. Leaders came to understand the importance of tending to all wards, regardless of whether they had been affected by the infection, even though it was perceived as taxing. Overall, the leaders worked actively to make the situation in wards with infection outbreaks as best as possible. A leader from a healthcare service which had a major COVID-19 outbreak stated:

“We constantly tried to create new procedures to make it as easy as possible for them [So] that they didn’t have to think about anything. That they [didn’t have to think about] bringing food to work, that they had to [remember] this or that. That they were provided with everything they needed…” (L2 nursing home municipality C)

Another recurring topic in the dataset, was the constant challenges and changes the leaders had to overcome and adapt to during the COVID-19 pandemic. For example, there was a need to plan for all possible scenarios, particularly if they were to have a major infection outbreak among the staff (e.g., how to limit the infection outbreak, how to deal with staffing, how to arrange the wards in case of an outbreak). One healthcare service experienced such a scenario, which demanded a rapid response, when they had a major COVID-19 outbreak with over twenty infected employees almost overnight. The leaders were left with the impossible task of covering a range of shifts, and they were forced to adopt a strategy of reaching out to other healthcare services within their municipality (other wards, nursing homes, the home care services and psychiatric services) asking if they had any nurses “to spare.” Eventually, they managed to cover their staffing needs without using a temp agency.

The leaders of this nursing home also had to deal with numerous small, but important challenges such as how to deal with dirty laundry, what to do with food scraps, where to put decorations and knick-knacks, how to provide wardrobes and lunchrooms, and generally, how to handle an infection outbreak in facilities not designed for this purpose.

Leaders in all primary healthcare services implemented strategies to prevent infection or spread of infection. They introduced longer shifts, split up the personnel in teams, made cleaning routines for lunchrooms and on-call rooms, set up a temporary visiting room for next of kin, developed routines for patient visits, regularly debriefed personnel of infection routines, made temporary wardrobes, and removed unnecessary tasks from the work schedule. New digital tools were introduced, particularly for distributing instructional videos and information among employees, and to keep contact with other leaders.

Although many leaders described the situation as challenging, particularly in the beginning, many found themselves gaining increased control over the situation as time went by.

“Little by little, in some way, the routine of everyday life has become more settled… you can’t completely relax yet, but you can certainly feel a bit more organized, and more confident in your decisions, since we have been doing it for a while [ca 1 year]. (L1 nursing home municipality C)

The aftermath—management of covid-19 in rural primary healthcare services

Despite organizational as well as personal challenges, leaders’ overall impression of the COVID-19 management was positive. The leaders firmly believed that the quality of healthcare services had been preserved, and all the physical healthcare needs of the patients had been properly cared for. According to leaders, there was not a rise in adverse events (e.g., falls, wounds) and patients and next of kin were positive in their feedback. The one main concern regarding quality of care was, however, the aspect of the patients’ sociopsychological state. Patients became isolated and lonely when they could not receive visitors or had to be isolated in their rooms or their homes during COVID. Nevertheless, the leaders expressed admiration for the healthcare personnel's work in addressing psychosocial needs to the best of their capacity. Overall, the leaders were proud of how the front-line healthcare personnel had handled the pandemic, and the extraordinary effort they put in to keeping the healthcare services running.

Several leaders stated that they now felt better prepared for “a next pandemic”, but they also had multiple suggestions for organizational improvements. These suggestions included: set up a visit coordinator, develop a better pandemic plan, be better prepared nationally, develop local PPE storage sites, introduce digital supervision for isolation rooms (for example RoomMate [ 53 ]), provide more psychological help for employees who struggled in the aftermath of an infection outbreak, have designated staff on standby for emergency situations, establish clear communication channels for obtaining information and, when constructing new nursing homes and healthcare facilities, consider infection control measures.

The leaders also discussed the knowledge they had acquired during this period. Many talked about learning how to use digital tools, but mostly they talked about the experience they had gained in handling crisis:

“I believe we are equipped in a whole different way now. There’s no doubt about that. Both employees and leaders and the healthcare service in general, I think… I have no doubt about that… so… there have been lessons learned, no doubt about it….” (L1 nursing home municipality C)

Leaders also talked about what they experienced as success factors in handling the pandemic: Long shifts (11,5 h), with the same shift going 4 days in a row to avoid contacts between different shift, the use of Microsoft Teams and other communication tools to increased and ease intermunicipal cooperation, and the possibility to share experiences, making quick decisions and take action quickly, developing close cooperation with the municipality chief medical officer and the nursing home physician, the involvement of the occupational healthcare service (take the employees’ work situation seriously) and the conduct of “Risk, Vulnerability and Preparedness” analysis (a tool to identify possible threats in order to implement preventive measures and necessary emergency response). The leaders also talked about the advantages of getting input from employees (e.g., through close cooperation with the employee representatives).

The benefits and drawbacks of being small and rural during a pandemic

Aspects of being a small healthcare service within a small municipality were highlighted by several of the leaders. For example, the leader of one the smaller healthcare service included in the study, addressed the challenge of acquiring enough competent staff. To be able to fulfill their requirements for competent staff, the municipality needed to buy healthcare services from neighboring municipalities. Another drawback was that employees who had competence or healthcare education often lacked experience in infection control and infection control routines, because they had rarely or never had infectious outbreaks of any kind. This made it particularly challenging to implement infection control measures. In one of the larger municipalities in this study, they had worked targeted for years to increase the competence in their municipality by focusing on full time positions to all and educating assistants to become Licensed practical nurses (LPN). They benefited from these measures during the pandemic.

Another aspect which was emphasized as essential to survive a pandemic in a small municipality, was intermunicipal cooperation. Leaders of all four healthcare services stated that they built increased cooperation with nearby municipalities during the pandemic. Leaders from the different municipalities met often, sometimes several times a week, and helped each other, shared routines, and methods, asked each other questions, coordinated covid-19 testing and developed intermunicipal corona wards, kept each other updated on infection status locally, and relied on each other’s strengths.

“We established a very good intermunicipal cooperation within the health and care services. We helped each other. Shared both routines and procedures, and actually had Teams meetings twice a week, where I could ask questions…and… we all had different strengths in the roles we held, not all of them [group members] were healthcare personnel either, and they had a lot of questions regarding the practical [handling of the pandemic]. At the same time, they [people who were not healthcare personnel] were good at developing routines and procedures, which they shared with the rest. In other words, the cooperation between the municipalities was very good, and for a small municipality, it was worth its weight in gold”. (L1, nursing home/homecare Municipality D)

The same leader stated that they could not have managed the pandemic without support from other larger municipalities and advised closer cooperation following the pandemic as well. An advantage of being small was the ability to easily track and monitor the virus spread within the municipality. Moreover, it was easy to have close cooperation with the infectious disease physician, the municipal chief medical officer, and the nursing home physician, as one person often held several of these roles. Some leaders also had several roles themselves such as a combination of nursing home leader and homecare leader or a combination of nursing home leader and health and care manager (overseeing all health and care services in the municipality). This was perceived as both an advantage and a disadvantage. This was an advantage because they gained a full overview of the situation due to their multiple areas of responsibility, but a disadvantage because it was demanding for one person to handle everything alone, making the system vulnerable. Another challenging aspect was a lack of people to fill all the necessary roles. For example, in one municipality they did not have a public health officer (a physician in charge of the healthcare services in a municipality, and the municipal management’s medical adviser), and had to hire a private practicing physician, who was not resident in the municipality to take on this role.

The economy was also a continuous source of worry. Running a small healthcare service within a small municipality was stated as expensive because the municipalities were obligated to provide the same healthcare services as the larger municipalities, but with less income (e.g., tax payment per inhabitant). The pandemic led to new expenses such as overtime payment, and wage supplement for changed work hours. Leader had to continuously balance a sound use of resources, and responsible operation.

Table 4 provides and overview of the challenges leaders encountered, how they were handled, and leaders’ suggestions for further improvement.

We assessed how leaders in rural primary healthcare services coped with unprecedented challenges during the COVID-19 pandemic. On one hand, they had to manage personal struggles such as insecurity, guilt, and excessive workload. At the same time, they had to confront major organizational issues such as financial instability, lack of resources, and information overload. Moreover, their roles changed, and the need to lead, make more decisions and be more supportive was heightened. While adapting to these changing roles, the leaders continuously introduced new measures to handle pandemic induced challenges including development of new routines, distilled and distributed information, reorganized staffing plans and rearranged wards. Although patients’ safety and quality of care was perceived as safeguarded throughout the COVID-19 pandemic period, leaders had several suggestions for improvements in case of future crises.

Previous research on primary healthcare services during COVID-19 support several of the findings identified here. Similar challenges requiring leaders to adapt their ways of working such as insufficient contingency plans and infection control, lack of staffing, changing guidelines and routines and challenges related to information flow were found [ 17 , 31 , 54 , 55 , 56 ]. Leader strategies to handle these challenges included reallocation of staff, providing support, provide training and distill and distribute information [ 16 , 31 , 55 , 57 ]. Some findings in this study, particularly related to the rural context, has not been found elsewhere. We found that 1) the leaders’ and healthcare services’ increased their dependency on neighboring municipalities during the pandemic and 2) we identified both the advantages and drawbacks of leaders having to function in multiple roles during the pandemic. The heightened importance of cooperation within municipalities and healthcare services in rural areas as opposed to urban areas, has however, been highlighted both before and during the pandemic [ 17 , 23 ].

The pandemic prompted organizations like the World Health Organization (WHO), International Council of Nurses (ICN), and Organization for Economic Co-operation and Development (OECD) to advocate for the advancement of more resilient healthcare services to be able to overcome current and future health system challenges [ 3 , 58 , 59 ]. To achieve the goal of resilient healthcare services, a multi-focal perspective incorporating both individual, teams and systems, is needed. This is because health system organization and leadership on all levels will impact how resilience can be built on team and individual level and thereby reinforce resilience in organizations [ 12 , 51 , 60 , 61 , 62 ].

The multiple aspects of resilient leadership

Leadership style, leaders’ facilitation for flexibility and leaders’ management of resources, competence, and equipment, will affect the resilience of health personnel and thereby the organizational resilience [ 12 , 15 , 63 ]. However, resilient leadership is affected by multiple aspects. For one, leaders inherent individual resilience will influence how and if, they lead resiliently [ 64 ]. Individual resilience is a multifaceted concept consisting of the person’s determination, persistence, adaptability and recuperative capacity, and is impacted by their personal qualities, conduct and cultural outlook [ 12 ]. Similar to previous literature [ 65 , 66 ], the current study found that leaders had to cope with personal challenges such as fear, guilt, adapting to changed roles and increased workload, while performing their everyday tasks. Literature have shown that leaders' responses to challenges can be influenced by their unique personality traits, ultimately shaping their resilience and leadership style [ 67 , 68 ]. Personal qualities needed to “lead well” have also shown to vary between rural and urban healthcare services. For example, Doshi [ 69 ] found that being social, passionate and extrovert was more important in urban areas than in rural areas. This indicate that leaders’ personality traits affect resilience in healthcare, and that resilience promoting personality traits may vary across urban and rural areas. More research is needed to study these relationships.

Although measures to increase personal resilience can be effective (e.g., mindfulness, workshops/training, therapy) [ 70 , 71 , 72 , 73 ] it is not sufficient to base resilience building on these aspects alone [ 74 ]. There is a need to consider how leaders are influenced and supported by the system they are working within to become, and act more resiliently. This includes the support leaders have in their community (e.g., peer support, leader support and proper guidance), their access to resources and their freedom to make decisions [ 60 , 75 , 76 ]. In the current study, it appeared to be a connection between leaders’ coping and the amount of support they had from colleagues. In our interpretation, leaders who talked about their cooperation with others, also talked more positively of their COVID-19 experiences (e.g., how much they had learned or what they had accomplished, rather than how pressured and anxious they were). Similar results have previously been found. For example, leaders in Marshall and colleagues’ study [ 65 ] felt isolated and struggled to make sense of the situation (COVID-19 induced challenges), while leaders in Seljemo and colleagues’ study stated that support from other managers made it easier to cope with high workloads [ 31 ]. In smaller rural healthcare settings, obtaining support can be challenging due to the limited presence of leader colleagues in close proximity [ 77 ]. Additionally, Gray & Jones [ 78 ] suggests that resilient leaders are leaders who ask for help when needed. This indicates that leaders in more isolated areas may require more effort to form connections beyond their organization, and rural healthcare systems must afford greater attention to enabling peer networking (e.g., by providing time and resources).

Through recurrent intermunicipal, online meetings, leaders in the current study attained to initiate, and preserve contact with other leaders in other healthcare settings, much more than before the COVID-19 pandemic. This was particularly important for the smallest, most rural municipalities, where one leader held many roles, and was by one leader, stated as the main reason they were able to manage the COVID-19 pandemic in their primary healthcare service. The tendency to increase intermunicipal cooperation during this period, and the overall need for smaller, rural healthcare services to cooperate with others is found in other literature [ 23 , 79 ]. However, mostly as collaboration within primary healthcare services, and not across organizations. Although recommended by leaders, it is not clear if this close contact has been maintained after the pandemic.

The governance leaders are working under will affect leaders’ possibility to lead resiliently. The governance allows for effective coordination of financing, resource generation, and service delivery activities, ensuring optimal system performance [ 80 ]. Yet, governing for resilience has proven to be a major challenge, because it requires systems to be both flexible and stable at the same time [ 76 ]. Flexibility presupposes systems’, health personnel’, and leaders’ ability to adapt to current conditions, and is essential for systems to cope with unpredictable, non-linear, and ever-changing social and environmental conditions. Conversely, stability must also be implemented to ensure that new policies are sustained and effective, and to stabilize expectations and promote coordination over time [ 76 ]. This means that leaders need flexibility to make their own decisions, as well as the stability that proper guidelines and direction provides [ 81 ]. In this study, some leaders reported experiencing chaos and loss of control when routines and guidelines lacked in the beginning of the pandemic. Similar results have been found among other healthcare leaders, as well as healthcare personnel [ 32 , 66 ]. In contrast, the leaders’ need for flexibility to be able to adapt to the everchanging work environment brought on by the pandemic (examples in Table  3 ) was demonstrated in this, and other studies [ 16 , 17 ]. It can, however, be argued that the balance between flexibility and stability is often skewed more towards flexibility in rural regions. Rural leaders must make unsupported decisions more often than urban leaders as they face higher demands and fewer available resources (such as competence, staff, and funding) [ 77 ]. This requires rural leaders to be more innovative and adaptable to current circumstances [ 23 , 69 , 77 , 79 ]. That said, the availability of resources have shown to impact a system's flexibility, often by influencing the quality of its adaptations [ 2 ].

In low-resource healthcare settings across the globe, certain adaptations made to combat pandemic challenges ended up causing damage (e.g., reuse or misuse of PPE, overexploitation of healthcare personnel and the use of unconventional treatment methods) [ 2 , 82 ]. In high resource healthcare services, as included in this study, adaptations were often described as beneficial, and potential long-lasting solutions (Table  3 ) [ 16 , 17 , 31 ]. Although not comparable to low resource healthcare services, variation in resource availability and economy between the included healthcare services was also expressed in this study. Norwegian municipalities’ income is closely tied to their tax revenue and population size [ 83 ], and regardless of income, the municipalities are required to provide specific healthcare services to their inhabitants. Thus, the financial foundation of smaller more rural municipalities is not as strong as that of larger municipalities. These inequalities were expressed as notable by both leaders and by healthcare personnel in a preceding study exploring the same primary rural healthcare services as included here [ 32 ]. Since resilience in healthcare is also highly dependent on the competence and experience of employees and leaders, the combination of resource and financial deficiencies, more often experienced in rural healthcare services than in urban healthcare services, may pose particular challenges in resilience building in rural areas [ 23 , 84 ]. This is worth exploring further, along with the rural healthcare services’ particular need to be flexible versus the potential difficulty they may have in making beneficial adaptations because of a weaker financial foundation.

Resilience and leadership style

Providing support to employees was an important leader task during the pandemic [ 55 , 66 ] and have further, been found to be particularly vital in rural areas, where employees have a smaller network of colleagues to turn to [ 84 ]. Other vital leadership tasks, recognizable from crisis leadership literature and also found in this study, were the importance of organizing, directing and implementing actions, forging cooperation, enabling work- arounds or adaptation, direct and guide and the importance of communication and dissemination of information [ 85 , 86 ]. Although charismatic leadership Footnote 1 has been found to be most valuable during crisis [ 87 ], there is an ongoing discussion of what leadership style is best suited to promote resilience in healthcare [ 11 , 14 , 66 , 88 ]. For example, both transformational and transactional leadership 1 [ 89 ] have been stated as resilience promoting leadership styles [ 15 ]. However, as found in other literature [ 66 , 88 ], the results of this study indicated that leaders oscillated between different styles during the COVID-19 pandemic period. For example, in the beginning of the pandemic when uncertainty characterized the healthcare system, leaders became stricter with rules and regulations, demonstrating an authoritative leadership style 1 . Further, stepping in, lecturing about infection control procedures and use of PPE, indicated a coaching leadership 1 style and lastly, when the leaders went against employees wishes to ensure safe maintenance of operation, it showed similarities to a transformational leadership style 1 [ 90 ]. Interestingly, leaders did not speak directly about how their leadership styles changed, and seemed unaware of their leadership style adaptation. Similarly, in Sihvola et al. [ 66 ] leaders found it surprising how novel conditions could influence their leadership style.

On one side, these results, suggest that an adaptive leadership style can be necessary during crisis. On the other side, this and other studies [ 31 , 54 ] indicate that leaders need more knowledge on crisis leadership, for example, to be made aware of the potential need to oscillate between different leadership styles during a crisis, and the possible subsequent challenges. For example, a study conducted by Boyle og Mervin [ 91 ] found that being a “nurse leader” (all leaders in this study were nurses), showed challenging because the leaders were judged as a peer rather than a leader. This can cause challenges, particularly when stepping into an authoritative leadership style. Such conflicts were not reported in this study, however, these are all aspects which should be given more attention when investigating resilience in healthcare and leadership styles [ 88 ]. Furthermore, it is crucial to acquire further understanding on the distinctions between leading in rural and urban areas, and how various leadership approaches may be impacted by managing tight-knit employee teams, which is often the case in small rural nursing home and homecare services. And finally, there is a need to provide a deeper understanding of the factors that promote or impede resilience in rural primary healthcare services, and the influence of the contextual aspects on resilience in healthcare.

Limitations

This study has limitations which need to be addressed. A larger number of included primary healthcare leaders over a wider geographical area and across boarders would have provided a broader view of leader experiences during the COVID-19 pandemic. However, it was very difficult to get leaders to take time to reflect during this crisis. This study does provide insight into a variety of different municipalities of different sizes, organization and locations in the Norwegian context, providing a variety of rural primary healthcare leaders experiences during the pandemic. Interviews were conducted in different ways (focus group, digital and individually) this could have influenced leaders description of their experiences. Furthermore, interviews were held at different points throughout the pandemic phases, leading to a mix of leaders with both current and reflective experiences of navigating the pandemic. This should be taken into consideration when reading the results.

By exploring nursing home and home care leaders’ experiences with the COVID-19 pandemic in rural areas, we found that the leaders met a range of rapid onset challenges of different nature, many of which demanded fast decisions and solutions. Leaders handled these challenges and changes in a variety of ways in their different contexts. In addition to health system challenges, leaders also had to cope with rapidly changing roles, while managing their own and employees’ insecurities. This study’s results demonstrate the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements. In addition, there may be differences between how resilience in healthcare is built and progresses in rural healthcare services versus urban contexts. Further research to understand the interplay between these aspects is needed, and it is critical to consider context.

Availability of data and materials

Data are available from the corresponding author upon reasonable request.

Charismatic leadership : influence and persuasion of others to help the fulfill their mandate, also in face of adversity; Transformational leadership: pushing to work and think in new ways; Authoritative leadership : the leader in control, low autonomy; Coaching leadership : the leader support employee’s skill advancement; Transactional leadership : exchange of rewards for fulfilling expectations.

Abbreviations

International Council of Nurses

Licensed practical nurse

Organization for Economic Co-operation and Development

Personal protective equipment

Registered Nurse

The World Health Organization

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Acknowledgements

The authors would like to thank participating leaders for their contribution to the study. We would also like to acknowledge Ole-Jørn Borum for graphical design on fig. 1 .

Open access funding provided by University of Stavanger & Stavanger University Hospital The publication processing charge was covered by the University of Stavanger.

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MKG, SW, TK, and DWB was involved in discussions regarding the project’s development. MKG conducted interviews and led the analysis of the transcribed data. The manuscript was a collaborative effort between MKG, SW, TK, DWB and LS, where all authors provided feedback. The author team approved the manuscript before submission.

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The study was approved by the Norwegian Agency for Shared Services in Education and Research (SIKT) in 2022 and provides the ethical approval, information security and privacy services as a part of the HK-dir (Norwegian Directorate for Higher Education and Skills). An informed consent form was signed by all leaders prior to the interviews, and information about the aim of the study and their right to redraw was repeated immediately before the interviews started.

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Dr. Bates reports grants and personal fees from EarlySense, personal fees from CDI Negev, equity from ValeraHealth, equity from Clew, equity from MDClone, personal fees and equity from AESOP, personal fees and equity from Feelbet-ter, equity from Guided Clinical Solutions, and grants from IBM Watson Health, outside the submitted work. Dr. Bates has a patent pending (PHC-028564 US PCT), on intraoperative clinical decision support. The other authors report no competing interests.

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Glette, M.K., Kringeland, T., Samal, L. et al. A qualitative study of leaders’ experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services. BMC Health Serv Res 24 , 442 (2024). https://doi.org/10.1186/s12913-024-10935-y

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The environmental awareness of nurses as environmentally sustainable health care leaders: a mixed method analysis

• Olga María Luque-Alcaraz   ORCID: orcid.org/0000-0003-1598-1422 1 , 2 , 3 , 5 ,
• Pilar Aparicio-Martínez   ORCID: orcid.org/0000-0002-2940-8697 3 , 4 ,
• Antonio Gomera   ORCID: orcid.org/0000-0003-0603-3017 2 &
• Manuel Vaquero-Abellán   ORCID: orcid.org/0000-0002-0602-317X 2 , 3 , 4  

BMC Nursing volume  23 , Article number:  229 ( 2024 ) Cite this article

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People worldwide are concerned with the possibility of climate change, microplastics, air pollution, and extreme weather affecting human health. Countries are implementing measures to reduce environmental impacts. Nurses play a vital role, primarily through Green Teams, in the process of promoting sustainable practices and minimizing the environmental footprint of health care facilities. Despite existing knowledge on this topic, assessing nurses’ environmental awareness and behavior, including the barriers they face, is crucial with regard to improving sustainable health care practices.

To analyze the environmental awareness and behavior of nurses, especially nurse leaders, as members of the Green Team and to identify areas for improvement with regard to the creation of a sustainable environment.

A sequential mixed-method study was conducted to investigate Spanish nurses. The study utilized an online survey and interviews, including participant observation. An online survey was administered to collect quantitative data regarding environmental awareness and behavior. Qualitative interviews were conducted with environmental nurses in specific regions, with a focus on Andalusia, Spain.

Most of the surveyed nurses ( N  = 314) exhibited moderate environmental awareness (70.4%), but their environmental behavior and activities in the workplace were limited (52.23% of participants rarely performed relevant actions, and 35.03% indicated that doing so was difficult). Nurses who exhibited higher levels of environmental awareness were more likely to engage in sustainable behaviors such as waste reduction, energy conservation, and environmentally conscious purchasing decisions ( p  < 0.05). Additionally, the adjusted model indicated that nurses’ environmental behavior and activities in the workplace depend on the frequency of their environmental behaviors outside work as well as their sustainable knowledge ( p  < 0.01). The results of the qualitative study ( N  = 10) highlighted certain limitations in their daily practices related to environmental sustainability, including a lack of time, a lack of bins and the pandemic. Additionally, sustainable environmental behavior on the part of nursing leadership and the Green Team must be improved.

Conclusions

This study revealed that most nurses have adequate knowledge, attitudes, and behaviors related to environmental sustainability both inside and outside the workplace. Limitations were associated with their knowledge and behaviors outside of work. This study also highlighted the barriers and difficulties that nurses face in their attempts to engage in adequate environmental behaviors in the workplace. Based on these findings, interventions led by nurses and the Green Team should be developed to promote sustainable behaviors among nurses and address the barriers and limitations identified in this research.

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Introduction

The impact of climate change on human society is a global concern, especially with regard to microplastics, resource shortages, air pollution, droughts, and extreme weather. Such consequences affect human health both directly and indirectly, resulting in an increase in pathologies and a deterioration in medical attention [ 1 , 2 ]. In this context, diverse measures aimed at reducing the environmental impact of daily activities and minimizing the ecological footprint thereof [ 3 ] have been implemented by multiple countries [ 4 , 5 , 6 , 7 ]; these activities have been framed as environmental regulations in line with the Sustainable Development Goals (SDGs) [ 8 ].

The SDGs are being integrated into governments and a variety of other contexts, including the health care system. Spain is dedicated to such a goal, i.e., that of promoting a greener and more democratic health care transition. To achieve this goal, strategic plans have been developed to mitigate the effects of climate change [ 9 , 10 ]. One specific such program is the Strategic Health and Environment Plan (PESMA) [ 11 ], whose aim is to enhance the synergy between health and the environment innovatively by assessing the impact of the population in terms of 14 environmental indicators [ 12 ].

One such indicator focuses on the resources and support needed for sustainable practices, especially for nurses, due to the impact of the environment on their work [ 13 , 14 ]. The PESMA highlights the fact that health care providers should be included in strategies to reduce carbon footprints, build resilience to address the challenges associated with climate change and embrace a leadership role in the task of promoting sustainable health care practices [ 13 , 14 , 15 , 16 ]. Another critical aspect of PESMA focuses on education, training, and incentives that can promote sustainable behavior among health care workers, especially nurses [ 17 , 18 ]. As frontline health care workers, nurses have a unique opportunity to advocate for sustainable practices and reduce the environmental impact of the health care system. Nurses’ knowledge and behavior are limited despite the fact that nurses have positive attitudes toward environmental sustainability [ 19 ].

This situation stands in contrast to the role of nurses in the creation of more sustainable hospitals via the “Green Team” [ 20 ]. The Green Team, which originated in the United States of America a decade ago, is a committee that is responsible for finding and implementing sustainability projects to decrease the environmental impacts of daily operations. Members of various departments collaborate with sustainability staff to detect opportunities, spread awareness, and promote staff involvement in line with the Committee’s mission [ 21 ]. The team, which typically consists of and is led by nurses, aims to increase awareness of the health care industry’s effect on the environment and to develop tactics to mitigate the adverse environmental effects of hospitals.

In Spain, Green Teams, which span multiple disciplines and usually led by nursing professionals, are committed to sustainable change in health care [ 22 ]. Environmental nursing leaders on Green Teams control environmental sustainability in health care settings and provide education, resources, and support to other professionals with regard to the implementation of sustainable practices [ 23 ]. Accordingly, all nurses can contribute to the tasks of mitigating the impact of climate change on public health outcomes and promoting sustainable health for all [ 24 ]. These actions improve nurses’ knowledge, attitudes, and behavior in terms of sustainability and promote sustainable practices in health care settings, thus leading to a better understanding of the barriers faced by nurses in this context [ 24 , 25 , 26 ].

However, measuring and identifying nurses’ environmental awareness is essential for the promotion of sustainable hospitals [ 27 , 28 ]. Multidimensional indicators have been proposed for this purpose [ 16 ], the responsibility for which lies with nurse leaders on Green Teams. Nurses are responsible for promoting sustainability in health care organizations, as discussed by Kallio et al. (2018) [ 29 ], as well as for promoting nursing competencies related to environmental sustainability [ 30 ]. Several studies, including Harris et al. (2009) and Phiri et al. (2022), have examined nurses’ roles in environmental health and the effects of their leadership on the promotion of sustainability, especially during the COVID-19 pandemic, thereby emphasizing the importance of leadership [ 31 , 32 ].

As Ojemeni et al. (2019) discussed, leadership effectiveness in Green Teams, nursing teams and health care organizations must prioritize quality control and health care improvement to ensure sustainable development [ 33 ].

The topic of environmental management in health care organizations has been studied extensively, and an environmental or ecological model of care for promoting sustainability has been proposed [ 34 ]. As environmental creators and leaders on Green Teams, nurses are vital for minimizing hazardous waste in health care settings and improving awareness [ 35 ].

Although nurses have some degree of existing knowledge and awareness of sustainability, it is crucial to assess their proficiency in environmental matters and to gauge their environmental awareness. Such an evaluation can help identify areas for improvement within clinical management units [ 20 , 33 , 36 ]. Education and training programs can effectively promote sustainable behavior among nurses, but interventions should also address the barriers they face in their attempts to implement sustainable practices [ 37 ]. Therefore, it is imperative to examine the factors that foster sustainable behavior among nurses and to identify effective interventions that can promote sustainable health care practices and minimize the environmental footprint of health care facilities. Accordingly, this study aimed to analyze the environmental awareness and behavior of nurses, especially nurse leaders, as members of the Green Team and to identify areas for improvement with regard to creating a sustainable environment.

Study design

A sequential mixed-method study was conducted based on an online survey and interviews with a representative sample of Spanish nurses, including participant observation.

The study was divided into two phases. In the first phase, a cross-sectional, descriptive exploratory analysis was performed; this analysis relied on the results revealed using the Nurse’s Environmental Awareness Tool in Spanish (NEAT-es) [ 38 ], which was divided into three subscales: nursing awareness scale (NAS), environmental behaviors outside the workplace (PEB) and sustainable behaviors in the workplace (NPEB). In the second phase, qualitative interviews with environmental nurses (see Supplementary file 1 ) were conducted in regions featuring specific environmental units that were available in person (Andalusia).

Participants

The participants were recruited from public and private institutions associated with the National Health System, particularly from the nursing staff. The scope of the study focused on Spain, and the sample included all the nursing staff who completed the questionnaire and met the inclusion criteria.

The sampling process focused on the population of nurses in Spain in 2020, which was estimated to consist of 388,153 nurses. Therefore, a random sample of 314 participating individuals was sufficient to estimate the population with 95% confidence and an accuracy of +/- 2% units, which was expected to account for approximately 90% of the overall population. The inclusion and exclusion criteria used for the sample focused on nursing staff, nursing care auxiliary technicians, and students with relevant degrees, as this members of this group have the most significant presence in the health system and engage in direct and daily contact with environmental management in health centers (hospitals, primary care centers, sociosanitary centers and others). The remaining health and nonhealth personnel were excluded.

Additionally, the person from each unit who served as the environmental coordinator and other nurses from the ward who were members of the Green Team were asked to participate in the interviews and observations. The environmental coordinators, most of who were nursing supervisors, were determined based on the number of members of the Green Team and the sampling calculation used for the observational study. The interviews took place after various sessions, talks, or courses pertaining to environmental sustainability at the clinical management units.

Data collection

An intentional sampling process was implemented, and the data collection period spanned from November 2019 to March 2021. The observational data were collected in Spain via messages and posts on social media with the goal of quantifying nurses’ environmental awareness.

The initial sample of qualitative study included five environmental nursing leaders (NLs), 14 registered nurses (RNs), and ten nursing undergraduates. The final sample was reduced when the interviews reached data saturation ( N  = 10, five NLs, and five RNs). Before the interviews, a focal group composed of one nurse, one physician, two engineers and a psychologist was tested using the questions included in this research as part of a pilot study ( Supplementary file 1 ). These interviews were conducted at the beginning of the participant’s shift, usually in the morning, and they featured a median time of 30 min, a minimum of 20 min and a maximum of one hour per participant.

One researcher (O.A.L.) also observed nurses during their daily work after the interview from a position within the ward as an added team member or staff member. Nevertheless, the observer did not highlight mistakes or sustainability issues during the observation process. No other researcher was involved in this step of the ethnographic analysis to avoid bias with regard to observing a variety of tasks ranging from preparing medication to implementing treatments.

The data collected through the interviews were recorded on a Samsung Galaxy 31 A, and observations were collected in a field notebook based on the Google Keep and Evernote mobile applications from November 2019 to mid-March 2021. This study was conducted at a regional level 1 hospital in southern Spain, particularly in various clinical management units (neurosurgery, internal medicine, cardiology, traumatology, and COVID-19 units, among others), and it focused on nursing supervisors, who are the leaders who bear responsibility for environmental awareness (NLs), and registered nurses (RNs) who were members of the Green Team.

Data analysis

The quantitative data were analyzed by reference to descriptive statistics, including the mean, standard deviation (SD), and 95% confidence interval (CI); the relative frequencies of the variables were also analyzed. Normalization tests, Kolmogorov‒Smirnov tests with Lilliefors correction, and Q‒Q tests were used to compare the goodness-of-fit to an average data distribution with regard to continuous or discrete quantitative variables. The comparison of two or three independent means was performed using Student’s t test and analyses of variance for each variable. The Χ 2 test with Yates’ correction was used to compare percentages and Pearson’s correlation (r) coefficients across the quantitative variables. Finally, associations among the NPEB and the other variables were studied through multiple linear regression. Participant observation was used to support the qualitative study of the reflective ethnographic type [ 39 , 40 ], and this process ended when the data reached saturation. Two researchers developed transcripts for the interviews based on the recorded interviews and added descriptions based on the notes from the field notebook. The identification of themes and patrons was based on a process of triangulation among the researchers and by cross-checking the results. The interviews with nurses were analyzed to summarize the content analysis and identify keywords and concurrency among the terms. The themes thus identified included Green Teams, sustainable environmental behaviors, environment awareness, leadership barriers and limitations and areas for improvement.

EPIDAT (version 4.2) and SPSS (version 25) software were used to support the quantitative analysis. The computer program ATLAS.ti (version 22) and the Office Package with Microsoft Word Excel (version 2019) were used for the interviews and the visualization of the keywords based on the themes identified based on the records, observations and field notebooks.

Nurses’ awareness, knowledge, attitudes and skills.

The ages of the Spanish staff, mainly nurses, included in this study ( N  = 314) ranged from 19 to 68, with a mean age of 37.02 ± 12.7, CI = 95%, 35.6–38.4 years); in addition, 76.4% of these participants were women with more than 20 years of working experience (35.1%), and the majority were registered nurses (70.4%). Moreover, 113 (36%) participants worked at a local or regional hospital (30%) and were employees of a public institution (85.3%). Half of the nurses (157) worked only a morning shift (Table  1 ) in Andalusia, Madrid, or Catalonia (62.4%). The diverse autonomous regions on which this research focused were homogenously distributed and structured in line with the population. The analysis of these areas was also based on the specific inclusion of environmental units led by nurses (Andalusia, Madrid, and Catalonia), in contrast with regions featuring undetermined units or leaders related to this topic (such as Valencia) (37.5%).

Regarding nursing awareness, nurses scored higher on the PEB (31.83 ± 8.02 CI 95% 30.94–32.72 with regard to frequency vs. 32.36 ± 7.15 CI 95% 31.57–33.15 with respect to difficulty) than on the NAS (26.13 ± 9.91 CI 95% 25.03–27.23 with regard to knowledge vs. 47.39 ± 5.97 CI 95% 46.73–48.05 with respect to impact) and the NPEB (23.82 ± 6.45 CI 95% 23.10-24.53 with regard to frequency vs. 25.71 ± 6.31 CI 95% 25.01–26.41 with respect to difficulty). These results indicated that environmental knowledge among the Spanish population was limited (55.7%), although the nurses included in this research were aware of their potential impact on the environment (70.4%). The PEB subscale focused mostly on following environmental guidelines in their homes (57.3%) because these sustainable domestic tasks are easier for them (63.1%) than tasks in the professional field. The second subscale, NPEB, indicated that sustainable activities such as recycling were easy for the participants (57.6%), but sometimes they engaged in such activities less frequently than they would like (52.2%) (Fig.  1 and Fig.  2 ).

Representation of the frequency of nursing environmental behavior

Difficulty of engaging in adequate environmental behaviors

The sociodemographic variables indicated differences among the NEAT subscales (Table  2 ). Gender, working experience (with a median value of 10 years), and the position held in the institution and region were relevant with regard to environmental knowledge ( p  < 0.01), environmental behavior outside the workplace ( p  < 0.01), and environmental behavior in the workplace ( p  < 0.01).

The NPEB was associated with the worst scores, thereby reflecting the nurses’ environmental behavior and activities in the workplace (52.23% rarely performed relevant activities, and 35.03% indicated that doing so was difficult) (Fig.  1 and Fig.  2 ). The NPEB values pertaining to environmental behavior were positively linked to age ( r  = 0.412; p  < 0.001), NAS knowledge ( r  = 0.526; p  < 0.001), PEB frequency ( r  = 0. 57; p  < 0.001), PEB difficulty ( r  = 0.329; p  < 0.001), and finally, difficulty performing adequate environmental behaviors ( r  = 0.499; p  < 0.001). Additionally, the value of the NPEB with regard to the difficulty of performing adequate environmental behaviors was positively associated with age ( r  = 0.149; p  = 0.008), NAS knowledge ( r  = 0.249; p  < 0.001), PEB frequency ( r  = 0. 244; p  < 0.001) and PEB difficulty ( r  = 0.442; p  < 0.001).

Based on the relevance of certain sociodemographic variables, the nurses’ environmental awareness (NAS) and their behavior outside the workplace (PEB), linear multiple regression was performed to investigate nursing behavior in the workplace (NPEB). The initial model (square sum = 488.655; p  < 0.0001) indicated that age, the impact of nursing awareness (NAS), and the frequency of sustainable behaviors outside the workplace (PEB) were not relevant to nursing behavior in the workplace (NPEB) in terms of the frequency of performing adequate behavior or the difficulties experienced ( p  > 0.05). Based on these results, the adjusted model was calculated (Table  3 ), indicating that NPEB depends on PEB frequency and NAS knowledge ( p  < 0.01).

Nursing environmental behavior in the context of Green Teams: Barriers and areas for improvement.

The participants in the qualitative study ( N  = 10) included nine women and one man; their median age was 49 years; they exhibited an interval quartile range of 35–60; they had levels of working experience ranging between 20 and 30 years, and they worked only in the mornings (7/10). Furthermore, the group including nurses and nursing supervisors (5/10) exhibited higher levels of education (see Supplementary file 2 ). The themes identified via repetition and associations during the interviews and observations indicated links among nurses’ responsibilities on the Green Team since they conformed to the nature of such teams (i). This team and nursing leaders identified sustainable environmental behavior (ii) that could improve environmental awareness (iii), knowledge, aptitude, and skills. The nurses who are responsible for sustainable changes should be the leaders (iv), and the relevant barriers and limitations (v) and areas for improvement (vi) in diverse areas should be identified simultaneously.

Green teams were linked to nursing responsibilities in the context of environmental sustainability.

In the interviews, the Green Teams, led by environmental leader nurses and comprising various staff members, were identified as crucial committees dedicated to enhancing environmental awareness and knowledge among hospital staff. Participants indicated that these teams facilitated regular meetings to discuss sustainable practices and played a pivotal role in testing behaviors and knowledge related to environmental sustainability. The Green Teams were highlighted as platforms for fostering collaboration and discussion surrounding sustainable practices. Participants noted that these teams facilitated the main purpose of the team and its members to improve the hospital staff’s knowledge and attitudes via meetings (RN 2,3 and NL 1,3). Subsequently, the NL also indicated a key role of the team in the testing of behaviors and knowledge. The behavior of registered nurses should be tested using questions according to the NLs. Also, the NLs are included in disponibility of of proper disposal methods for medical waste:

“So, where is the rubbish bin for medicines, that white one that you showed in the session that is used for the remains of medicines that we do not give to patients?” [(NL5)]

By such comments, it can be inferred that the Green Team not only disseminates information, manages the training and measures knowledge but also ensures that staff members understand and adhere to best practices in waste management. These tasks of the NLs and other RNs in the Green Team contribute to the overall efficiency and effectiveness of environmental sustainability efforts within the hospital.

Sustainable environmental behaviors were emerged by Green Teams.

The results of the analysis indicated some degree of resistance among the nurses working at the clinical management units with regard to their lack of competencies, especially those pertaining to knowledge, skills and attitudes. The comments from the interviews highlighted potential factors contributing to this resistance, including age-related differences, varying levels of awareness, and challenges in applying the principles of reduce, reuse, and recycle (the three Rs). For instance, one repetitive comment expressed a sentiment of uncertainty, stating “It is what is, but we don’t know it or what to do with it” (RN 3,4,5, and NL 2,3).

“We know what the light packing is, and they (maintenance people) installed it to reduce the lights and reduce the expense and cost, but we don’t know what to do with the rubbish bins” [(NL 4)]

This comment highlights a disconnect between awareness of specific sustainable initiatives and the practical knowledge to implement them effectively. All comments reflect the importance of addressing knowledge gaps and providing practical guidance to support nurses in adopting sustainable environmental behaviours. By acknowledging and addressing these challenges, healthcare facilities can enhance their environmental stewardship efforts and promote a culture of sustainability among staff members.

Environmental awareness were drawn from the nursing responsibilities that led to the creation of the Green Team.

The comments indicated that environmental awareness among nurses was influenced by training sessions and courses on environmental sustainability. After receiving training featuring lectures and courses on environmental sustainability, the leaders also reflected on the ways in which nurses put the recommendations made during the environmental sustainability courses into practice. Moreover, the leaders indicated that education should be beyond formal training sessions. The environmental leaders were interested in supplementing these courses with environmental education practices for the general population, as noted, for example, in reports of discharge from patient care or cycling on the ward. These activities indicated the ideal of including a holistic approach to sustainability within the healthcare setting.

Relevant statements included, “We have to separate residues according to the material… light plastic goes to… it is important for the unit and all of us” (NL 2,5). One key point that the referees and registered nurses highlighted pertained to the climate, particularly the lack of water (NL 1–5 and RN 1,2).

“The drought is getting worse; I don’t know how we are going to keep up… we hope it rains soon” [(RN1)]

Overall, the interviews shed light on the efforts to foster environmental awareness among nurses through formal training and practical integration into everyday practices. These observations emphasize the importance of ongoing education and action in addressing environmental concerns within healthcare settings.

Leadership, which was linked by comments to the Green Teams.

The interviews revealed that leadership, particularly within the context of Green Teams, is crucial in promoting environmental awareness and fostering a culture of sustainability among nursing staff. All the participants ( n  = 10) indicated that the presence of adequate knowledge, meetings and awareness among nursing staff were the most important factors. These factors were identified as key drivers in promoting sustainable practices within the healthcare environment. NLs indicated the importance of creating a supportive working environment where nurses feel comfortable asking questions and seeking clarification without fear of negative feedback. Relevant statements included, “It is key to receive feedback from the nurses and provide a good working environment so that they can ask questions and reflect without negative comments” (NL 1,2,4, and RN 1,2). This working environment allowed the registered nurses to ask for help regarding the three Rs:

“Could you remind me (referring to the environmental coordinator) how the sustainable guidelines were included in the discharge report for the continuity of care; I remember some things from the course you gave us, but I want to convey it completely to my patient” [(RN2)]

Barriers and limitations, were drawn from nurses’ responsibilities.

Several nurses indicated that the difficulties they encountered with regard to performing environmental behaviors pertained to the lack of time, adequate bins, and space as well as the limited number of nurses per patient in the wards. Despite these challenges, participants noted a positive outcome in the form of increased awareness of sustainability issues among nurses, indicating a growing recognition of the importance of environmental stewardship within the healthcare setting. One factor that increased the barriers to environmental adequacy was the pandemic, which increased waste and rubbish. Despite these challenges, participants noted a positive outcome in the form of increased awareness of sustainability issues among nurses, indicating a growing recognition of the importance of environmental stewardship within the healthcare setting. Relevant statements included “There are not enough green rubbish bins for COVID waste” (EL 1,4,5 and RN1,2) and “How are we going to recycle if we don’t even have time to care for patients?” (RN 1,2 and NL 3).

All these comments indicated the barriers the nurses faced, but they also suggested possibilities for improvement. The pandemic, despite overloading nurses, also improved their awareness.

Areas subject to improvement emerged from nursing responsibilities, limitations and leadership.

Nurses indicated that despite their general levels of environmental awareness and the courses they had received, participants performed better regarding their recycling behaviors at home than at the hospital. Participants acknowledged performing better in recycling practices within their personal spaces, suggesting a potential gap in translating theoretical knowledge into practical action within the healthcare environment. Relevant statements included “It’s just that I recycle almost everything in my house, especially glass…, but here, there is no time…” (RN 1,4,5).

Moreover, time constraints emerged as a significant barrier impeding nurses’ ability to engage fully in environmental sustainability efforts. Participants cited the demanding nature of their work, particularly in the context of patient care responsibilities, as limiting their capacity to prioritize sustainability initiatives. This highlights the need for strategies to streamline environmental practices and integrate them seamlessly into nurses’ daily routines without adding undue burden.

Some statements also highlighted nurses’ willingness to improve paperwork and records. Nurses recognized the importance of incorporating environmental considerations into patient discharge reports and other documentation processes but sought further guidance on how to effectively implement these practices. Relevant statements included “Can you tell me how the patient’s continuity care report upon discharge was included in the recommendations for environmental sustainability… I want to do the report well with what you gave us in the clinical session the other day…” [(NL4)]

These comments indicated the opportunities for improvement in fostering a culture of environmental sustainability within the hospital setting. By addressing the identified challenges and providing targeted support and guidance, especially the lack of time, nurses can contribute to environmental stewardship efforts more effectively.

The current research highlights the relevance of nurses as promoters of environmentally sustainable behaviors in their roles as members of Green Teams and important leaders. The findings suggest that nurses exhibit acceptable knowledge, attitudes, and behaviors with regard to environmental sustainability both inside and outside the workplace. These results are complemented by a qualitative analysis indicating that such behaviors originate from nursing responsibility, Green Teams, leadership identification of barriers and areas of improvement. Both analyses highlight the fact that environmental nursing behavior in the workplace depends on sustainable behaviors outside the workplace. The qualitative analysis also identifies diverse barriers to the task of promoting sustainable behavior within the workplace, such as the COVID-19 pandemic and the need for more time to be allocated to this process. One key point identified by both analyses is that nurses have acceptable levels of knowledge; however, their attitudes, although as yet imperfect, are improving.

Several studies of nurses’ awareness of environmental sustainability have revealed that nurses exhibit moderate levels of awareness and a considerable degree of concern regarding the health impacts of climate change [ 37 , 42 , 43 ], as reflected in the NEAT-es results.

Interestingly, the participants exhibited a tendency to perform environmentally sustainable behaviors more consistently in their personal lives than in professional settings. These results are consistent with previous research on registered nurse and nursing students [ 36 , 41 , 42 ]. According to Swedish research, nurses generally recognize environmental issues but may lack awareness of the environmental impact of health care [ 43 ]. Polivka Barbara J. et al. (2012) highlighted the gap between nurses’ knowledge of sustainability and workplace behaviors, thereby emphasizing the need for education and training programs to promote sustainable practices [ 44 ]. These issues were also observed in a study conducted in Taiwan, which revealed that while nursing students exhibit positive attitudes toward sustainability, their knowledge and behaviors are inadequate [ 45 ].

By conducting qualitative analysis, this research also identified multiple barriers to the adoption of sustainable practices among nurses, including time constraints, disruptions caused by the COVID-19 pandemic, a lack of bins, and a lack of health care personnel. These findings are in line with those reported in other research, but certain barriers (in terms of resources, time, and support) to the implementation of sustainable practices in the workplace remain [ 29 ]. This study suggests that interventions should be designed to address these barriers and promote sustainable behavior among nurses, a suggestion which is consistent with the current research. These findings highlight the importance of comprehending nurses’ perspectives on environmental sustainability in health care contexts as well as the necessity for targeted interventions and support mechanisms [ 46 ]. The tasks assigned to nursing leaders and the Green Team involved addressing these barriers and promoting sustainable practices among nurses in the context of their professional roles. Environmental nursing leaders seem to be crucial with regard to establishing a more environmentally conscious health care environment, which is in line with recommendations to create a greener health care system [ 21 , 31 ]. Despite the results of the interviews, some global qualitative studies of nurses’ views on environmental issues have exhibited variations across countries [ 47 , 48 ]. In Sweden, nurses already exhibit pro-sustainability attitudes before the introduction of the 2030 SDGs [ 16 ]. However, the integration of environmental sustainability education into nursing programs can prepare future nurses more effectively to address the challenges associated with climate change and promote sustainable health outcomes [ 49 ].

Limitations

Although this investigation provides valuable insights, it is important to acknowledge its limitations. First, the study was conducted during the COVID-19 pandemic in Spain, which may have influenced the results due to the unique circumstances and stressors faced by health care workers during this period. Additionally, the assessment of nurses’ environmental awareness was performed on a larger scale, i.e., across multiple regions, and therefore may not accurately reflect individual attitudes and behaviors since the qualitative investigations focused on a specific region. However, this approach was adopted to minimize the risk of the ecological fallacy. Future studies could explore individual perspectives and experiences by reference to more diverse and representative samples.

Despite these limitations, this research is highly relevant because it sheds light on the role of nurses in the task of promoting environmental sustainability in health care settings. The research also emphasized the role of nursing leadership in the tasks of promoting environmental sustainability and providing nurses with the necessary resources and support to implement sustainable practices.

In conclusion, while nurses generally exhibit acceptable levels of knowledge, attitudes, and behaviors regarding environmental sustainability, a notable gap persists in terms of the frequency of sustainable actions within the professional settings in which they operate. This finding highlights the importance of closely aligning nurses’ personal and professional sustainability practices.

The qualitative analysis conducted as part of this study identified several barriers to the adoption of sustainable practices among nurses, including time constraints, disruptions resulting from the COVID-19 pandemic, issues with waste disposal, and challenges related to health care personnel. Despite the fact that these findings are in line with those reported in previous research, persistent barriers such as limited resources, time, and support hinder the implementation of sustainable practices in the workplace. Therefore, interventions aimed at addressing these barriers and promoting sustainable behavior among nurses are essential, as highlighted by both current research and the corresponding qualitative insights. Therefore, nursing leaders and Green Teams are pivotal with regard to overcoming these barriers and fostering sustainable practices within health care environments. Environmental nursing leaders in particular are instrumental to the cultivation of a more environmentally conscious health care system, thereby aligning with recommendations for greener health care practices.

Data availability

The datasets used and/or analyzed as part of the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors would like to thank the Excellent Official Nursing School and all the professionals who participated in this research for their support.

This research received no external funding; however, the project did receive an award from the Excellent Official Nursing School in Cordoba, Spain, in 2020.

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A.G. and M. V-A. conceived and designed the study, and O.M. L. and P.A-M. acquired the data, analyzed and interpreted the data, and drafted the article. The publication and supervision of the article were the responsibility of A.G. and M. V-A. All authors contributed equally to the writing and preparation of the final manuscript.

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Luque-Alcaraz, O.M., Aparicio-Martínez, P., Gomera, A. et al. The environmental awareness of nurses as environmentally sustainable health care leaders: a mixed method analysis. BMC Nurs 23 , 229 (2024). https://doi.org/10.1186/s12912-024-01895-z

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1 Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

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

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

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

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

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

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

The main take-away points of this paper are summarised in Table ​ Table1. 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

Take-away-points

Acknowledgements

Abbreviations, authors’ contributions.

LB drafted the manuscript; WW and CG revised the manuscript; all authors approved the final versions.

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ORIGINAL RESEARCH article

Challenges and support needs in psychological and physical health among pilots: a qualitative study.

• 1 School of Medicine, Shanghai Jiao Tong University, Shanghai, China
• 2 Other, Shanghai, China
• 3 National Center For Global Health and Medicine, Shinjuku, Tokyo, Japan
• 4 School of Public Health, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
• 5 School of Nursing, Shanghai Jiao Tong University, Shanghai, Shanghai, China
• 6 International Peace Maternity and Child Health Hospital, Shanghai, Shanghai Municipality, China

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Abstract Introduction Physical and mental health problems among pilots affect their working state and impact flight safety. Although pilots’ physical and mental health problems have become increasingly prominent, their health has not been taken seriously. This study aimed to clarify challenges and support needs related to psychological and physical health among pilots to inform development of a more scientific and comprehensive physical and mental health system for civil aviation pilots. Methods This qualitative study recruited pilots from nine civil aviation companies. Focus group interviews via an online conference platform were conducted in August 2022. Colaizzi analysis was used to derive themes from the data and explore pilots’ experiences, challenges, and support needs. Results The main sub-themes capturing pilots’ psychological and physical health challenges were: 1) imbalance between family life and work; 2) pressure from assessment and physical examination eligibility requirements; 3) pressure from worries about being infected with COVID-19; 4) nutrition deficiency during working hours; 5) changes in eating habits because of the COVID-19 pandemic; 6) sleep deprivation; 7) occupational diseases; 8) lack of support from the company in coping with stress; 9) pilots’ yearly examination standards; 10) support with sports equipment; 11) respecting planned rest time; and 12) isolation periods. Discussion The interviewed pilots experienced major psychological pressure from various sources, and their physical health condition was concerning. We offer several suggestions that could be addressed to improve pilots’ physical and mental health. However, more research is needed to compare standard health measures for pilots around the world in order to improve their physical and mental health and contribute to overall aviation safety.

Keywords: Occupational Health, Mental Health, physical health, qualitative study, Pilots and cabin crew, COVID-19

Received: 06 Dec 2023; Accepted: 05 Apr 2024.

Copyright: © 2024 Xu, Bao, Zhang, Li, Zhang, Li, Jin, Chen, Duan, Shi, Wang, Lu, Chen, Gao, Han, Ren, Su and Xiang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Yuyan Bao, School of Medicine, Shanghai Jiao Tong University, Shanghai, China Lin Zhang, Other, Shanghai, China Qingqing Jin, Other, Shanghai, China Yan Chen, Other, Shanghai, China Qingqing Duan, Other, Shanghai, China Feng Shi, Other, Shanghai, China Linlin Wang, Other, Shanghai, China Ziyang Lu, School of Medicine, Shanghai Jiao Tong University, Shanghai, China Xuhua Chen, School of Medicine, Shanghai Jiao Tong University, Shanghai, China Qijing Gao, School of Medicine, Shanghai Jiao Tong University, Shanghai, China Bin Ren, Other, Shanghai, China Ya Su, School of Nursing, Shanghai Jiao Tong University, Shanghai, Shanghai, China Mi Xiang, School of Public Health, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200240, China

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