qualitative research questions examples nursing

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Nursing: Forming Questions

• Getting Started
• Background Info
• 6S/Foreground Info
• Further Research
• Clinical Practice
• Nursing Theory

A Good Question...

• Focuses your information needs
• Identifies key seach concepts
• Points you in the direction of potential resources

Background Questions

These questions are general in nature and provide foundational information on a single concept.  Background questions cover:

• Terminology
• General Pathology
• Patient Education Resources
• General Drug Information
• Examination/Assessment Procedures

What is the pathology of asthma ?

What drugs are used to treat hypertension ?

How do I perform a psychological assessment ?

What education resources exist for patients with gestational diabetes ?

How is hepatitis b diagnosed?

What does a normal heartbeat sound like?

These questions are best answered using the resources found in the Background Info page of this guide.

Foreground Questions

These questions bring together multiple concepts related to a specific clinical situation or research topic.  They may be divided into two  broad categories:

• Qualitative Questions  aim to discover meaning or gain an understanding of a phenomena or experience.  They ask about an individual's or population's experience of certain situations or circumstances
• Quantitative Questions  aim to discover cause and effect relationships, often through comparison. Comparison may occur between two or more individuals or groups based on outcomes associated with differences in exposures or interventions. Comparison may also be made to 'no intervention', standard care or standard practice, 'no exposure'.

These questions are best answered using the resources found in the 6S/Foreground Info page of this guide.

Forming Foreground Questions

Building an effective foreground question can be challenging.  The following models will help:

Qualitative Questions: The PS Model

P - Patient/Population

S - Situation

How do/does ___ [P] ____ experience _____ [S] _____?

What is the experience of ____ [P] ___ [S] ____?

Ex. How do  caregiver- spouses of Alzheimer patients  experience  placing their spouse in a nursing home ?

___________________________________________________________________________

Quantitative Questions: The PICO(T) Model

A quantitative approach can answer many different types of questions, but all can be formatted by following the  PICO(T) Model  outlined below:     

PICO(T) Templates

In ___ [ P ]___,  do/does ___[ I ]___ result in ___[ O ]____ when compared with ___[ C ]___ over ___[ T ]____?

E.g.) In nursing home residents with osteoporosis , do hip protectors result in fewer injuries from slips, trips, and falls when compared with standard osteoporosis drug therapy over the course of their stay ?

Are ___[ P ]___  with  ___[ I ]___  over ____[ T ]____ more likely to ___[ O ]____ when compared with ___[ C ]___ ?

E.g.) Are   female non-smokers   with  daily exposure to second-hand smoke  over  a period of ten years or greater  more likely to  develop breast cancer  when compared with  female non-smokers without daily exposure to second-hand smoke ?

Is/are ___[ I ]___ performed on ___[ P ]___   more effective than ___[ C ]___  over ___[ T ]____in ___[ O ]____?

E.g.) Are   self-reporting interviews and parent reports  performed on   children aged 5-10   more effective than  parent reports alone  over a  four-week consultation process  in  diagnosing depression ?

In ___[ P ]___,  do/does ___[ I ]___ result in ___[ O ]____ when compared with ___[ C ]___ over ___[ T ]____?

E.g.) In  emergency room visitors , do   hand sanitizing stations  result in   fewer in-hospital infections  when compared  with no hand sanitizing stations  over  a year-long pilot period ?

Do/does ___[ I ]___ performed on ___[ P ]___   lead to  ___[ O ]___  over ___[ T ]____compared with ___[ C ]____?

E.g.) Do  regular text message reminders  performed on  patients recently diagnosed with diabetes  lead to  a lower occurrence of forgotten insulin doses  over  the first six months of treatment  compared with  no reminders ?

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Qualitative Research Questions: Gain Powerful Insights + 25 Examples

We review the basics of qualitative research questions, including their key components, how to craft them effectively, & 25 example questions.

Einstein was many things—a physicist, a philosopher, and, undoubtedly, a mastermind. He also had an incredible way with words. His quote, "Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted," is particularly poignant when it comes to research. 

Some inquiries call for a quantitative approach, for counting and measuring data in order to arrive at general conclusions. Other investigations, like qualitative research, rely on deep exploration and understanding of individual cases in order to develop a greater understanding of the whole. That’s what we’re going to focus on today.

Qualitative research questions focus on the "how" and "why" of things, rather than the "what". They ask about people's experiences and perceptions , and can be used to explore a wide range of topics.

The following article will discuss the basics of qualitative research questions, including their key components, and how to craft them effectively. You'll also find 25 examples of effective qualitative research questions you can use as inspiration for your own studies.

Let’s get started!

What are qualitative research questions, and when are they used?

When researchers set out to conduct a study on a certain topic, their research is chiefly directed by an overarching question . This question provides focus for the study and helps determine what kind of data will be collected.

By starting with a question, we gain parameters and objectives for our line of research. What are we studying? For what purpose? How will we know when we’ve achieved our goals?

Of course, some of these questions can be described as quantitative in nature. When a research question is quantitative, it usually seeks to measure or calculate something in a systematic way.

For example:

• How many people in our town use the library?
• What is the average income of families in our city?
• How much does the average person weigh?

Other research questions, however—and the ones we will be focusing on in this article—are qualitative in nature. Qualitative research questions are open-ended and seek to explore a given topic in-depth.

According to the Australian & New Zealand Journal of Psychiatry , “Qualitative research aims to address questions concerned with developing an understanding of the meaning and experience dimensions of humans’ lives and social worlds.”

This type of research can be used to gain a better understanding of people’s thoughts, feelings and experiences by “addressing questions beyond ‘what works’, towards ‘what works for whom when, how and why, and focusing on intervention improvement rather than accreditation,” states one paper in Neurological Research and Practice .

Qualitative questions often produce rich data that can help researchers develop hypotheses for further quantitative study.

• What are people’s thoughts on the new library?
• How does it feel to be a first-generation student at our school?
• How do people feel about the changes taking place in our town?

As stated by a paper in Human Reproduction , “...‘qualitative’ methods are used to answer questions about experience, meaning, and perspective, most often from the standpoint of the participant. These data are usually not amenable to counting or measuring.”

Both quantitative and qualitative questions have their uses; in fact, they often complement each other. A well-designed research study will include a mix of both types of questions in order to gain a fuller understanding of the topic at hand.

If you would like to recruit unlimited participants for qualitative research for free and only pay for the interview you conduct, try using Respondent  today. 

Crafting qualitative research questions for powerful insights

Now that we have a basic understanding of what qualitative research questions are and when they are used, let’s take a look at how you can begin crafting your own.

According to a study in the International Journal of Qualitative Studies in Education, there is a certain process researchers should follow when crafting their questions, which we’ll explore in more depth.

1. Beginning the process 

Start with a point of interest or curiosity, and pose a draft question or ‘self-question’. What do you want to know about the topic at hand? What is your specific curiosity? You may find it helpful to begin by writing several questions.

For example, if you’re interested in understanding how your customer base feels about a recent change to your product, you might ask: 

• What made you decide to try the new product?
• How do you feel about the change?
• What do you think of the new design/functionality?
• What benefits do you see in the change?

2. Create one overarching, guiding question 

At this point, narrow down the draft questions into one specific question. “Sometimes, these broader research questions are not stated as questions, but rather as goals for the study.”

As an example of this, you might narrow down these three questions: 

into the following question: 

• What are our customers’ thoughts on the recent change to our product?

3. Theoretical framing 

As you read the relevant literature and apply theory to your research, the question should be altered to achieve better outcomes. Experts agree that pursuing a qualitative line of inquiry should open up the possibility for questioning your original theories and altering the conceptual framework with which the research began.

If we continue with the current example, it’s possible you may uncover new data that informs your research and changes your question. For instance, you may discover that customers’ feelings about the change are not just a reaction to the change itself, but also to how it was implemented. In this case, your question would need to reflect this new information: 

• How did customers react to the process of the change, as well as the change itself?

4. Ethical considerations 

A study in the International Journal of Qualitative Studies in Education stresses that ethics are “a central issue when a researcher proposes to study the lives of others, especially marginalized populations.” Consider how your question or inquiry will affect the people it relates to—their lives and their safety. Shape your question to avoid physical, emotional, or mental upset for the focus group.

In analyzing your question from this perspective, if you feel that it may cause harm, you should consider changing the question or ending your research project. Perhaps you’ve discovered that your question encourages harmful or invasive questioning, in which case you should reformulate it.

5. Writing the question 

The actual process of writing the question comes only after considering the above points. The purpose of crafting your research questions is to delve into what your study is specifically about” Remember that qualitative research questions are not trying to find the cause of an effect, but rather to explore the effect itself.

Your questions should be clear, concise, and understandable to those outside of your field. In addition, they should generate rich data. The questions you choose will also depend on the type of research you are conducting: 

• If you’re doing a phenomenological study, your questions might be open-ended, in order to allow participants to share their experiences in their own words.
• If you’re doing a grounded-theory study, your questions might be focused on generating a list of categories or themes.
• If you’re doing ethnography, your questions might be about understanding the culture you’re studying.

Whenyou have well-written questions, it is much easier to develop your research design and collect data that accurately reflects your inquiry.

In writing your questions, it may help you to refer to this simple flowchart process for constructing questions:

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25 examples of expertly crafted qualitative research questions

It's easy enough to cover the theory of writing a qualitative research question, but sometimes it's best if you can see the process in practice. In this section, we'll list 25 examples of B2B and B2C-related qualitative questions.

Let's begin with five questions. We'll show you the question, explain why it's considered qualitative, and then give you an example of how it can be used in research.

1. What is the customer's perception of our company's brand?

Qualitative research questions are often open-ended and invite respondents to share their thoughts and feelings on a subject. This question is qualitative because it seeks customer feedback on the company's brand. 

This question can be used in research to understand how customers feel about the company's branding, what they like and don't like about it, and whether they would recommend it to others.

2. Why do customers buy our product?

This question is also qualitative because it seeks to understand the customer's motivations for purchasing a product. It can be used in research to identify the reasons  customers buy a certain product, what needs or desires the product fulfills for them, and how they feel about the purchase after using the product.

3. How do our customers interact with our products?

Again, this question is qualitative because it seeks to understand customer behavior. In this case, it can be used in research to see how customers use the product, how they interact with it, and what emotions or thoughts the product evokes in them.

4. What are our customers' biggest frustrations with our products?

By seeking to understand customer frustrations, this question is qualitative and can provide valuable insights. It can be used in research to help identify areas in which the company needs to make improvements with its products.

5. How do our customers feel about our customer service?

Rather than asking why customers like or dislike something, this question asks how they feel. This qualitative question can provide insights into customer satisfaction or dissatisfaction with a company. 

This type of question can be used in research to understand what customers think of the company's customer service and whether they feel it meets their needs.

20 more examples to refer to when writing your question

Now that you’re aware of what makes certain questions qualitative, let's move into 20 more examples of qualitative research questions:

• How do your customers react when updates are made to your app interface?
• How do customers feel when they complete their purchase through your ecommerce site?
• What are your customers' main frustrations with your service?
• How do people feel about the quality of your products compared to those of your competitors?
• What motivates customers to refer their friends and family members to your product or service?
• What are the main benefits your customers receive from using your product or service?
• How do people feel when they finish a purchase on your website?
• What are the main motivations behind customer loyalty to your brand?
• How does your app make people feel emotionally?
• For younger generations using your app, how does it make them feel about themselves?
• What reputation do people associate with your brand?
• How inclusive do people find your app?
• In what ways are your customers' experiences unique to them?
• What are the main areas of improvement your customers would like to see in your product or service?
• How do people feel about their interactions with your tech team?
• What are the top five reasons people use your online marketplace?
• How does using your app make people feel in terms of connectedness?
• What emotions do people experience when they're using your product or service?
• Aside from the features of your product, what else about it attracts customers?
• How does your company culture make people feel?

As you can see, these kinds of questions are completely open-ended. In a way, they allow the research and discoveries made along the way to direct the research. The questions are merely a starting point from which to explore.

This video offers tips on how to write good qualitative research questions, produced by Qualitative Research Expert, Kimberly Baker.

Wrap-up: crafting your own qualitative research questions.

Over the course of this article, we've explored what qualitative research questions are, why they matter, and how they should be written. Hopefully you now have a clear understanding of how to craft your own.

Remember, qualitative research questions should always be designed to explore a certain experience or phenomena in-depth, in order to generate powerful insights. As you write your questions, be sure to keep the following in mind:

• Are you being inclusive of all relevant perspectives?
• Are your questions specific enough to generate clear answers?
• Will your questions allow for an in-depth exploration of the topic at hand?
• Do the questions reflect your research goals and objectives?

If you can answer "yes" to all of the questions above, and you've followed the tips for writing qualitative research questions we shared in this article, then you're well on your way to crafting powerful queries that will yield valuable insights.

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Asking the right questions in the right way is the key to research success. That’s true for not just the discussion guide but for every step of a research project. Following are 100+ questions that will take you from defining your research objective through  screening and participant discussions.

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Qualitative Research

• What is Qualitative Research
• PEO for Qualitative Questions
• SPIDER for Mixed Methods Qualitative Research Questions
• Finding Qualitative Research Articles
• Critical Appraisal of Qualitative Research Articles
• Mixed Methods Research
• Qualitative Synthesis

PEO: Answering a Qualitative Question

PEO is an acronym that can help you create a search strategy for finding research to answer a qualitative research question.

• Patient, Population or Problem you are investigating
• Exposure to an illness, a risk factor, screening, rehabilitation service, etc.
• Outcome or themes include experiences, attitudes, feelings, improvement in condition, mobility, responsiveness to treatment, care, quality of life or daily living.

Example of PEO in Action

FINAL BOOLEAN SEARCH:

(Acute care OR acute setting OR hospital* OR inpatient* OR ward*) AND (Nurs* OR professional* OR practitioner* OR staff OR personnel) AND (Dementia OR alzheimer*) AND ( Attitude* OR opinion* OR perception* OR perspective* OR belief*)

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Examples of Research Questions

Phd in nursing science program, examples of broad clinical research questions include:.

• Does the administration of pain medication at time of surgical incision reduce the need for pain medication twenty-four hours after surgery?
• What maternal factors are associated with obesity in toddlers?
• What elements of a peer support intervention prevent suicide in high school females?
• What is the most accurate and comprehensive way to determine men’s experience of physical assault?
• Is yoga as effective as traditional physical therapy in reducing lymphedema in patients who have had head and neck cancer treatment?
• In the third stage of labor, what is the effect of cord cutting within the first three minutes on placenta separation?
• Do teenagers with Type 1 diabetes who receive phone tweet reminders maintain lower blood sugars than those who do not?
• Do the elderly diagnosed with dementia experience pain?
•  How can siblings’ risk of depression be predicted after the death of a child?
•  How can cachexia be prevented in cancer patients receiving aggressive protocols involving radiation and chemotherapy?

Examples of some general health services research questions are:

• Does the organization of renal transplant nurse coordinators’ responsibilities influence live donor rates?
• What activities of nurse managers are associated with nurse turnover?  30 day readmission rates?
• What effect does the Nurse Faculty Loan program have on the nurse researcher workforce?  What effect would a 20% decrease in funds have?
• How do psychiatric hospital unit designs influence the incidence of patients’ aggression?
• What are Native American patient preferences regarding the timing, location and costs for weight management counseling and how will meeting these preferences influence participation?
•  What predicts registered nurse retention in the US Army?
• How, if at all, are the timing and location of suicide prevention appointments linked to veterans‘ suicide rates?
• What predicts the sustainability of quality improvement programs in operating rooms?
• Do integrated computerized nursing records across points of care improve patient outcomes?
• How many nurse practitioners will the US need in 2020?

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DISTINCTIONS

• Research article
• Open access
• Published: 09 November 2005

A qualitative study of nursing student experiences of clinical practice

• Farkhondeh Sharif 1 &
• Sara Masoumi 2  

BMC Nursing volume  4 , Article number:  6 ( 2005 ) Cite this article

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Nursing student's experiences of their clinical practice provide greater insight to develop an effective clinical teaching strategy in nursing education. The main objective of this study was to investigate student nurses' experience about their clinical practice.

Focus groups were used to obtain students' opinion and experiences about their clinical practice. 90 baccalaureate nursing students at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery) were selected randomly from two hundred students and were arranged in 9 groups of ten students. To analyze the data the method used to code and categories focus group data were adapted from approaches to qualitative data analysis.

Four themes emerged from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap"," clinical supervision", professional role", were considered as important factors in clinical experience.

The result of this study showed that nursing students were not satisfied with the clinical component of their education. They experienced anxiety as a result of feeling incompetent and lack of professional nursing skills and knowledge to take care of various patients in the clinical setting.

Peer Review reports

Clinical experience has been always an integral part of nursing education. It prepares student nurses to be able of "doing" as well as "knowing" the clinical principles in practice. The clinical practice stimulates students to use their critical thinking skills for problem solving [ 1 ]

Awareness of the existence of stress in nursing students by nurse educators and responding to it will help to diminish student nurses experience of stress. [ 2 ]

Clinical experience is one of the most anxiety producing components of the nursing program which has been identified by nursing students. In a descriptive correlational study by Beck and Srivastava 94 second, third and fourth year nursing students reported that clinical experience was the most stressful part of the nursing program[ 3 ]. Lack of clinical experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. In study done by Hart and Rotem stressful events for nursing students during clinical practice have been studied. They found that the initial clinical experience was the most anxiety producing part of their clinical experience [ 4 ]. The sources of stress during clinical practice have been studied by many researchers [ 5 – 10 ] and [ 11 ].

The researcher came to realize that nursing students have a great deal of anxiety when they begin their clinical practice in the second year. It is hoped that an investigation of the student's view on their clinical experience can help to develop an effective clinical teaching strategy in nursing education.

A focus group design was used to investigate the nursing student's view about the clinical practice. Focus group involves organized discussion with a selected group of individuals to gain information about their views and experiences of a topic and is particularly suited for obtaining several perspectives about the same topic. Focus groups are widely used as a data collection technique. The purpose of using focus group is to obtain information of a qualitative nature from a predetermined and limited number of people [ 12 , 13 ].

Using focus group in qualitative research concentrates on words and observations to express reality and attempts to describe people in natural situations [ 14 ].

The group interview is essentially a qualitative data gathering technique [ 13 ]. It can be used at any point in a research program and one of the common uses of it is to obtain general background information about a topic of interest [ 14 ].

Focus groups interviews are essential in the evaluation process as part of a need assessment, during a program, at the end of the program or months after the completion of a program to gather perceptions on the outcome of that program [ 15 , 16 ]. Kruegger (1988) stated focus group data can be used before, during and after programs in order to provide valuable data for decision making [ 12 ].

The participants from which the sample was drawn consisted of 90 baccalaureate nursing students from two hundred nursing students (30 students from the second year and 30 from the third and 30 from the fourth year) at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery). The second year nursing students already started their clinical experience. They were arranged in nine groups of ten students. Initially, the topics developed included 9 open-ended questions that were related to their nursing clinical experience. The topics were used to stimulate discussion.

The following topics were used to stimulate discussion regarding clinical experience in the focus groups.

How do you feel about being a student in nursing education?

How do you feel about nursing in general?

Is there any thing about the clinical field that might cause you to feel anxious about it?

Would you like to talk about those clinical experiences which you found most anxiety producing?

Which clinical experiences did you find enjoyable?

What are the best and worst things do you think can happen during the clinical experience?

What do nursing students worry about regarding clinical experiences?

How do you think clinical experiences can be improved?

What is your expectation of clinical experiences?

The first two questions were general questions which were used as ice breakers to stimulate discussion and put participants at ease encouraging them to interact in a normal manner with the facilitator.

Data analysis

The following steps were undertaken in the focus group data analysis.

Immediate debriefing after each focus group with the observer and debriefing notes were made. Debriefing notes included comments about the focus group process and the significance of data

Listening to the tape and transcribing the content of the tape

Checking the content of the tape with the observer noting and considering any non-verbal behavior. The benefit of transcription and checking the contents with the observer was in picking up the following:

Parts of words

Non-verbal communication, gestures and behavior...

The researcher facilitated the groups. The observer was a public health graduate who attended all focus groups and helped the researcher by taking notes and observing students' on non-verbal behavior during the focus group sessions. Observer was not known to students and researcher

The methods used to code and categorise focus group data were adapted from approaches to qualitative content analysis discussed by Graneheim and Lundman [ 17 ] and focus group data analysis by Stewart and Shamdasani [ 14 ] For coding the transcript it was necessary to go through the transcripts line by line and paragraph by paragraph, looking for significant statements and codes according to the topics addressed. The researcher compared the various codes based on differences and similarities and sorted into categories and finally the categories was formulated into a 4 themes.

The researcher was guided to use and three levels of coding [ 17 , 18 ]. Three levels of coding selected as appropriate for coding the data.

Level 1 coding examined the data line by line and making codes which were taken from the language of the subjects who attended the focus groups.

Level 2 coding which is a comparing of coded data with other data and the creation of categories. Categories are simply coded data that seem to cluster together and may result from condensing of level 1 code [ 17 , 19 ].

Level 3 coding which describes the Basic Social Psychological Process which is the title given to the central themes that emerge from the categories.

Table 1 shows the three level codes for one of the theme

The documents were submitted to two assessors for validation. This action provides an opportunity to determine the reliability of the coding [ 14 , 15 ]. Following a review of the codes and categories there was agreement on the classification.

Ethical considerations

The study was conducted after approval has been obtained from Shiraz university vice-chancellor for research and in addition permission to conduct the study was obtained from Dean of the Faculty of Nursing and Midwifery. All participants were informed of the objective and design of the study and a written consent received from the participants for interviews and they were free to leave focus group if they wish.

Most of the students were females (%94) and single (% 86) with age between 18–25.

The qualitative analysis led to the emergence of the four themes from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap", clinical supervision"," professional role", was considered as important factors in clinical experience.

Initial clinical anxiety

This theme emerged from all focus group discussion where students described the difficulties experienced at the beginning of placement. Almost all of the students had identified feeling anxious in their initial clinical placement. Worrying about giving the wrong information to the patient was one of the issues brought up by students.

One of the students said:

On the first day I was so anxious about giving the wrong information to the patient. I remember one of the patients asked me what my diagnosis is. ' I said 'I do not know', she said 'you do not know? How can you look after me if you do not know what my diagnosis is?'

From all the focus group sessions, the students stated that the first month of their training in clinical placement was anxiety producing for them.

One of the students expressed:

The most stressful situation is when we make the next step. I mean ... clinical placement and we don't have enough clinical experience to accomplish the task, and do our nursing duties .

Almost all of the fourth year students in the focus group sessions felt that their stress reduced as their training and experience progressed.

Another cause of student's anxiety in initial clinical experience was the students' concern about the possibility of harming a patient through their lack of knowledge in the second year.

One of the students reported:

In the first day of clinical placement two patients were assigned to me. One of them had IV fluid. When I introduced myself to her, I noticed her IV was running out. I was really scared and I did not know what to do and I called my instructor .

Fear of failure and making mistakes concerning nursing procedures was expressed by another student. She said:

I was so anxious when I had to change the colostomy dressing of my 24 years old patient. It took me 45 minutes to change the dressing. I went ten times to the clinic to bring the stuff. My heart rate was increasing and my hand was shaking. I was very embarrassed in front of my patient and instructor. I will never forget that day .

Sellek researched anxiety-creating incidents for nursing students. He suggested that the ward is the best place to learn but very few of the learner's needs are met in this setting. Incidents such as evaluation by others on initial clinical experience and total patient care, as well as interpersonal relations with staff, quality of care and procedures are anxiety producing [ 11 ].

Theory-practice gap

The category theory-practice gap emerged from all focus discussion where almost every student in the focus group sessions described in some way the lack of integration of theory into clinical practice.

I have learnt so many things in the class, but there is not much more chance to do them in actual settings .

Another student mentioned:

When I just learned theory for example about a disease such as diabetic mellitus and then I go on the ward and see the real patient with diabetic mellitus, I relate it back to what I learned in class and that way it will remain in my mind. It is not happen sometimes .

The literature suggests that there is a gap between theory and practice. It has been identified by Allmark and Tolly [ 20 , 21 ]. The development of practice theory, theory which is developed from practice, for practice, is one way of reducing the theory-practice gap [ 21 ]. Rolfe suggests that by reconsidering the relationship between theory and practise the gap can be closed. He suggests facilitating reflection on the realities of clinical life by nursing theorists will reduce the theory-practice gap. The theory- practice gap is felt most acutely by student nurses. They find themselves torn between the demands of their tutor and practising nurses in real clinical situations. They were faced with different real clinical situations and are unable to generalise from what they learnt in theory [ 22 ].

Clinical supervision

Clinical supervision is recognised as a developmental opportunity to develop clinical leadership. Working with the practitioners through the milieu of clinical supervision is a powerful way of enabling them to realize desirable practice [ 23 ]. Clinical nursing supervision is an ongoing systematic process that encourages and supports improved professional practice. According to Berggren and Severinsson the clinical nurse supervisors' ethical value system is involved in her/his process of decision making. [ 24 , 25 ]

Clinical Supervision by Head Nurse (Nursing Unit Manager) and Staff Nurses was another issue discussed by the students in the focus group sessions. One of the students said:

Sometimes we are taught mostly by the Head Nurse or other Nursing staff. The ward staff are not concerned about what students learn, they are busy with their duties and they are unable to have both an educational and a service role

Another student added:

Some of the nursing staff have good interaction with nursing students and they are interested in helping students in the clinical placement but they are not aware of the skills and strategies which are necessary in clinical education and are not prepared for their role to act as an instructor in the clinical placement

The students mostly mentioned their instructor's role as an evaluative person. The majority of students had the perception that their instructors have a more evaluative role than a teaching role.

The literature suggests that the clinical nurse supervisors should expressed their existence as a role model for the supervisees [ 24 ]

Professional role

One view that was frequently expressed by student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

We just do basic nursing care, very basic . ... You know ... giving bed baths, keeping patients clean and making their beds. Anyone can do it. We spend four years studying nursing but we do not feel we are doing a professional job .

The role of the professional nurse and nursing auxiliaries was another issue discussed by one of the students:

The role of auxiliaries such as registered practical nurse and Nurses Aids are the same as the role of the professional nurse. We spend four years and we have learned that nursing is a professional job and it requires training and skills and knowledge, but when we see that Nurses Aids are doing the same things, it can not be considered a professional job .

The result of student's views toward clinical experience showed that they were not satisfied with the clinical component of their education. Four themes of concern for students were 'initial clinical anxiety', 'theory-practice gap', 'clinical supervision', and 'professional role'.

The nursing students clearly identified that the initial clinical experience is very stressful for them. Students in the second year experienced more anxiety compared with third and fourth year students. This was similar to the finding of Bell and Ruth who found that nursing students have a higher level of anxiety in second year [ 26 , 27 ]. Neary identified three main categories of concern for students which are the fear of doing harm to patients, the sense of not belonging to the nursing team and of not being fully competent on registration [ 28 ] which are similar to what our students mentioned in the focus group discussions. Jinks and Patmon also found that students felt they had an insufficiency in clinical skills upon completion of pre-registration program [ 29 ].

Initial clinical experience was the most anxiety producing part of student clinical experience. In this study fear of making mistake (fear of failure) and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. This finding is supported by Hart and Rotem [ 4 ] and Stephens [ 30 ]. Developing confidence is an important component of clinical nursing practice [ 31 ]. Development of confidence should be facilitated by the process of nursing education; as a result students become competent and confident. Differences between actual and expected behaviour in the clinical placement creates conflicts in nursing students. Nursing students receive instructions which are different to what they have been taught in the classroom. Students feel anxious and this anxiety has effect on their performance [ 32 ]. The existence of theory-practice gap in nursing has been an issue of concern for many years as it has been shown to delay student learning. All the students in this study clearly demonstrated that there is a gap between theory and practice. This finding is supported by other studies such as Ferguson and Jinks [ 33 ] and Hewison and Wildman [ 34 ] and Bjork [ 35 ]. Discrepancy between theory and practice has long been a source of concern to teachers, practitioners and learners. It deeply rooted in the history of nurse education. Theory-practice gap has been recognised for over 50 years in nursing. This issue is said to have caused the movement of nurse education into higher education sector [ 34 ].

Clinical supervision was one of the main themes in this study. According to participant, instructor role in assisting student nurses to reach professional excellence is very important. In this study, the majority of students had the perception that their instructors have a more evaluative role than a teaching role. About half of the students mentioned that some of the head Nurse (Nursing Unit Manager) and Staff Nurses are very good in supervising us in the clinical area. The clinical instructor or mentors can play an important role in student nurses' self-confidence, promote role socialization, and encourage independence which leads to clinical competency [ 36 ]. A supportive and socialising role was identified by the students as the mentor's function. This finding is similar to the finding of Earnshaw [ 37 ]. According to Begat and Severinsson supporting nurses by clinical nurse specialist reported that they may have a positive effect on their perceptions of well-being and less anxiety and physical symptoms [ 25 ].

The students identified factors that influence their professional socialisation. Professional role and hierarchy of occupation were factors which were frequently expressed by the students. Self-evaluation of professional knowledge, values and skills contribute to the professional's self-concept [ 38 ]. The professional role encompasses skills, knowledge and behaviour learned through professional socialisation [ 39 ]. The acquisition of career attitudes, values and motives which are held by society are important stages in the socialisation process [ 40 ]. According to Corwin autonomy, independence, decision-making and innovation are achieved through professional self-concept 41 . Lengacher (1994) discussed the importance of faculty staff in the socialisation process of students and in preparing them for reality in practice. Maintenance and/or nurturance of the student's self-esteem play an important role for facilitation of socialisation process 42 .

One view that was expressed by second and third year student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

The finding of this study and the literature support the need to rethink about the clinical skills training in nursing education. It is clear that all themes mentioned by the students play an important role in student learning and nursing education in general. There were some similarities between the results of this study with other reported studies and confirmed that some of the factors are universal in nursing education. Nursing students expressed their views and mentioned their worry about the initial clinical anxiety, theory-practice gap, professional role and clinical supervision. They mentioned that integration of both theory and practice with good clinical supervision enabling them to feel that they are enough competent to take care of the patients. The result of this study would help us as educators to design strategies for more effective clinical teaching. The results of this study should be considered by nursing education and nursing practice professionals. Faculties of nursing need to be concerned about solving student problems in education and clinical practice. The findings support the need for Faculty of Nursing to plan nursing curriculum in a way that nursing students be involved actively in their education.

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The author would like to thank the student nurses who participated in this study for their valuable contribution

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Sharif, F., Masoumi, S. A qualitative study of nursing student experiences of clinical practice. BMC Nurs 4 , 6 (2005). https://doi.org/10.1186/1472-6955-4-6

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Practice writing out PICO components and then forming a focused question about one of the case studies below. Choose one or several that interest you.

You have read that peer support interventions help individuals and families affected by cancer across the care continuum from prevention through survivorship and end-of-life care. You wonder about the characteristics of peer support programs and how peer support programs have been used to reduce disparities and barriers to care.

Open to check your PICO analysis of the scenario for cancer care.

Nurses in oncology units interact frequently with adults with cancer who do not speak English as their primary language. You are curious whether cultural awareness among nurses improves these patients’ care and participation in the decision-making process.

Open to check your PICO analysis of the scenario for nursing care.

You’re a new nurse on a labor and delivery unit. You’ve noticed that most women give birth in the lithotomy position at the encouragement of their doctors. However, you’re sure you heard in nursing school that other positions are less likely to lead to deliveries with forceps or a vacuum.. or did you? You want to find some literature to back up your claim.

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You work in the Big City Hospital ICU. Your mechanically ventilated patients sometimes contract nosocomial pneumonia, which leads to costly complications. You want to know if raising the head of the bed lowers the chance of the patient contracting pneumonia compared to letting the patient lie flat on their back.

Open to check your PICO analysis of the scenario for the ICU..

In the past few years, your hospital has installed antibacterial foam dispensers on all the nursing units. You’ve had nurses asking you if the foam is just as effective as washing their hands with water and soap.

Open to check your PICO analysis of the scenario for infection control.

Shift change on your busy med-surg unit can be frustrating for you and your coworkers. Report at the nursing station takes up to 30 minutes, by the end of which you’re anxious to see your patients. You read something in a recent ANA newsletter about other hospitals switching to a bedside shift report, and you want to find out if staff liked that style of shift change better.

Open to check your PICO analysis of the scenario in med-surg.

Open to check your pico analysis of the scenario in the nicu..

It’s the last semester of your BSN students’ time in school and they’re excited.. and anxious! They’ve been asking you if they should take the NCLEX right after they graduate or wait for a while after graduation so they can relax and study.

Open to check your PICO analysis of the scenario for nurse educators.

It’s winter at your family practice, and you have a lot of patients coming in with runny noses and general malaise. Brenda, a 35 year old working mother in for a checkup states, "I’m so busy between work and home that I definitely don’t have time to get sick! Can those vitamin C or zinc pills prevent colds?"

Open to check your PICO analysis of the scenario for nurse practitioners.

The main concern for most of your patients coming out of anesthesia in your PACU is pain. You want to explore nursing interventions you can use on top of medication administration to decrease pain. One coworker mentions trying to make the PACU feel less clinical by playing soft music to relax patients.

Open to check your PICO analysis of the scenario for PACU.

You work in a pediatrician’s office and give patients their routine vaccinations. The younger children are often fearful of needles, and some of the staff use toys to distract the patients. You want to know if this technique actually has an effect on the children's pain response.

Open to check your PICO analysis of the scenario for pediatrics.

You work on an inpatient psychiatric unit. One of your patients with chronic schizophrenia, Joe, normally mumbles to himself, but will occasionally speak to others when residents play games together. Noticing this, you say to a coworker that maybe social skills group training sessions would bring out Joe’s conversational skills. Your coworker shakes her head and says "I don’t think so. Joe is in and out of this hospital, he’s a lost cause."

Open to check your PICO analysis of the scenario for psychiatry.

You coordinate health education programs and have been holding seminars for teenagers about STI prevention. You’ve been found that they’re hesitant to open up to you during classes to ask you questions. You’re wondering if recruiting peer educators closer to their age will encourage them to actively participate and get more satisfaction out of the classes.

Open to check your PICO analysis of the scenario for public health.

On your pulmonary unit, many of your COPD patients receive injections of heparin to prevent pulmonary emboli, and patients find the bruises associated with heparin injections unsightly. You’ve had nursing students shadowing you lately, so you’ve been particularly concerned with injection technique. You want to find out if the duration of injection has any effect on the extent of bruising.

Open to check your PICO analysis of the scenario for pulmonary.

You’re a school nurse and one aspect of your job is counseling pregnant teens with the aim of enabling them to complete high school. You’ve even been conducting home visits on top of your normal in-school meetings as part of their preparation-for-motherhood counseling. You want sources to backup the effectiveness of these home visits.

Open to check your PICO analysis of the scenario for school nursing.

A diabetic patient from a nursing home has recently been admitted with a stage III pressure ulcers on his heels. The unit nurses have called you in for a wound consult. You have to choose between standard moist wound therapy and using a wound vac.

Open to check your PICO analysis of the scenario for wound care.

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Differences between Qualitative & Quantitative Research

" Quantitative research ," also called " empirical research ," refers to any research based on something that can be accurately and precisely measured.  For example, it is possible to discover exactly how many times per second a hummingbird's wings beat and measure the corresponding effects on its physiology (heart rate, temperature, etc.).

" Qualitative research " refers to any research based on something that is impossible to accurately and precisely measure.  For example, although you certainly can conduct a survey on job satisfaction and afterwards say that such-and-such percent of your respondents were very satisfied with their jobs, it is not possible to come up with an accurate, standard numerical scale to measure the level of job satisfaction precisely.

It is so easy to confuse the words "quantitative" and "qualitative," it's best to use "empirical" and "qualitative" instead.

Hint: An excellent clue that a scholarly journal article contains empirical research is the presence of some sort of statistical analysis

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Foreground Questions

A "foreground" question in health research is one that is relatively specific, and is usually best addressed by locating primary research evidence. 

Using a structured question framework can help you clearly define the concepts or variables that make up the specific research question. 

 Across most frameworks, you’ll often be considering:

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• a how ([how] did the [what] affect the [who] - an outcome, an effect). 

PICO is the most common framework for developing a clinical research question, but multiple question frameworks exist.

PICO (Problem/Population, Intervention, Comparison, Outcome)

Appropriate for : clinical questions, often addressing the effect of an intervention/therapy/treatment

Example : For adolescents with type II diabetes (P) does the use of telehealth consultations (I) compared to in-person consultations  (C) improve blood sugar control  (O)?

Framing Different Types of Clinical Questions with PICO

Different types of clinical questions are suited to different syntaxes and phrasings, but all will clearly define the PICO elements.  The definitions and frames below may be helpful for organizing your question:

Intervention/Therapy

Questions addressing how a clinical issue, illness, or disability is treated.

"In__________________(P), how does__________________(I) compared to_________________(C) affect______________(O)?"

Questions that address the causes or origin of disease, the factors which produce or predispose toward a certain disease or disorder.

"Are_________________(P), who have_________________(I) compared with those without_________________(C) at_________________risk for/of_________________(O) over_________________(T)?" 

Questions addressing the act or process of identifying or determining the nature and cause of a disease or injury through evaluation.

In_________________(P) are/is_________________(I) compared with_________________(C) more accurate in diagnosing_________________(O)?

Prognosis/Prediction:

Questions addressing the prediction of the course of a disease.

In_________________(P), how does_________________(I) compared to_________________ (C) influence_________________(O)?

Questions addressing how one experiences a phenomenon or why we need to approach practice differently.

"How do_________________(P) with_________________(I) perceive_________________(O)?" 

Adapted from: Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Beyond PICO: Other Types of Question Frameworks

PICO is a useful framework for clinical research questions, but may not be appropriate for all kinds of reviews.  Also consider:

PEO (Population, Exposure, Outcome)

Appropriate for : describing association between particular exposures/risk factors and outcomes

Example : How do  preparation programs (E) influence the development of teaching competence  (O) among novice nurse educators  (P)?

SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research Type)

Appropriate for : questions of experience or perspectives (questions that may be addressed by qualitative or mixed methods research)

Example : What are the experiences and perspectives (E) of  undergraduate nursing students  (S)  in clinical placements within prison healthcare settings (PI)?

SPICE (Setting, Perspective, Intervention/phenomenon of Interest, Comparison, Evaluation)

Appropriate for : evaluating the outcomes of a service, project, or intervention

Example : What are the impacts and best practices for workplace (S) transition support programs (I) for the retention (E) of newly-hired, new graduate nurses (P)?

PCC (Problem/population, Concept, Context)

Appropriate for : broader (scoping) questions

Example : How do nursing schools  (Context) teach, measure, and maintain nursing students ' (P)  technological literacy  (Concept))throughout their educational programs?

Background Questions

To craft a strong and reasonable foreground research question, it is important to have a firm understanding of the concepts of interest.  As such, it is often necessary to ask background questions, which ask for more general, foundational knowledge about a disorder, disease, patient population, policy issue, etc. 

For example, consider the PICO question outlined above:

"For adolescents with type II diabetes does the use of telehealth consultations compared to in-person consultations  improve blood sugar control ?

To best make sense of the literature that might address this PICO question, you would also need a deep understanding of background questions like:

• What are the unique barriers or challenges related to blood sugar management in adolescents with TII diabetes?
• What are the measures of effective blood sugar control?
• What kinds of interventions would fall under the umbrella of 'telehealth'?
• What are the qualitative differences in patient experience in telehealth versus in-person interactions with healthcare providers?
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PICO Templates

For an intervention/therapy:

In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)?

For etiology:

Are ____ (P) who have _______ (I) at ___ (increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)?

Diagnosis or diagnostic test:

Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)?

Prevention:

For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)?

Prognosis/Predictions

Does __________ (I) influence ________ (O) in patients who have _______ (P) over ______ (T)?

How do ________ (P) diagnosed with _______ (I) perceive ______ (O) during _____ (T)?

Based on Melnyk B., & Fineout-Overholt E. (2010). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins .

Using PICO to Formulate Clinical Questions

PICO  (alternately known as PICOT ) is a mnemonic used to describe the four elements of a good clinical question. It stands for:

P --Patient/Problem I --Intervention C --Comparison O --Outcome

Many people find that it helps them clarify their question, which in turn makes it easier to find an answer. 

Use PICO to generate terms - these you'll use in your literature search for the current best evidence.   Once you have your PICO terms, you can then use them to re-write your question.  (Note, you can do this in reverse order if that works for you.)

Often we start with a vague question such as, "How effective is CPR, really?"  But, what do we mean by CPR?  And how do we define effective?  PICO is a technique to help us - or force us - to answer these questions.   Note that you may not end up with a description for each element of PICO. 

P -  our question above doesn't address a specific problem other than the assumption of a person who is not breathing. So, ask yourself questions such as, am I interested in a specific age cohort? (Adults, children, aged); a specific population (hospitalized, community dwelling); health cohort (healthy, diabetic, etc.)   

I - our question above doesn't have a stated intervention, but we might have one in mind such as 'hands-only'

C - Is there another method of CPR that we want to compare the hands-only to?  Many research studies do not go head to head with a comparison.  In this example we might want to compare to the standard, hands plus breathing

O - Again, we need to ask, what do we mean by 'effective'?  Mortality is one option with the benefit that it's easily measured. 

Our PICO statement would look like:

From our PICO, we can write up a clearer and more specific question, such as:

 In community dwelling adults, how effective is hands-only CPR versus hands plus breathing CPR at preventing mortality?

More information on formulating PICO questions

Now that we've clarified what we want to know, it will be much easier to find an answer.

Breaking Down Your PICO into a Search Strategy

We can use our PICO statement to list terms to search on.  Under each letter, we'll list all the possible terms we might use in our search. 

P - Community Dwelling:  It is much easier to search on 'hospitalized' than non-hospitalized subjects.  So I would leave these terms for last. It might turn out that I don't need to use them as my other terms from the I, C, or O of PICO might be enough.

community dwelling  OR out-of-hospital

P - adults: I would use the limits in MEDLINE or CINAHL for All Adults.  Could also consider the following depending upon the population you need:

adult OR adults OR aged OR elderly OR young adult

CPR  -  cardiopulmonary resuscitation

I - Hands-only

 hands-only OR compression-only OR chest compression OR compression OR Heart Massage

C - Hands plus breathing Breathing is a tougher term to match.

breathing OR mouth to mouth OR conventional OR traditional

O - Mortality:  If your outcomes terms are general, they may not as useful in the literature search.  They will still be useful in your evaluation of the studies.

mortality OR death OR Survival

Putting it together - a search statement from the above might look like this:

cardiopulmonary resuscitation AND (hands-only OR compression-only OR chest compression OR compression OR Heart Massage) AND (breathing OR mouth to mouth OR conventional OR traditional)

Note that the above strategy is only using terms from the I and the C of PICO.  Depending upon the results, you may need to narrow your search by adding in terms from the P or the O.  

An easy way to keep track of your search strategy is to use a table. This keeps the different parts of your PICO question and their various keywords and subject terms together. This document shows you how to use the tables and provides a few options to organize your table. Use whichever works best for you!  Search Strategy Tables to Break your PICO into Concepts .

PICO and Qualitative Questions

A qualitative PICO question focuses on in-depth perspectives and experiences.  It does not try to solve a problem by analyzing numbers, but rather to enrich understanding through words.  Therefore, the emphasis in qualitative PICO questions is on fully representing the information gathered, rather than primarily emphasizing ways the information can be broken down and expressed through measurable units (though measurability can also play an important role). 

A strength of a qualitative PICO question is that it can investigate what patient satisfaction looks like, for example, instead of only reporting that 25% of patients who took a survey reported that they are satisfied. 

When working with qualitative questions, an alternative to using PICO in searching for sources is the SPIDER search tool.  SPIDER is an acronym that breaks down like this:

P=Phenomena of Interest

E=Evaluation

R=Research Type

Cooke, A., Smith, D., & Booth, A. (2012). Beyond PICO: The SPIDER tool for qualitative evidence synthesis . Qualitative Health Research, 22 (10), 1435-1443. doi:10.1177/1049732312452938

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• Volume 2, Issue 2
• Identifying the best research design to fit the question. Part 2: qualitative designs
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• Jenny Ploeg , RN, MScN
• School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada

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Qualitative research methods have become increasingly important as ways of developing nursing knowledge for evidence-based nursing practice. Qualitative research answers a wide variety of questions related to nursing's concern with human responses to actual or potential health problems. The purpose of qualitative research is to describe, explore, and explain phenomena being studied. 1 Qualitative research questions often take the form of what is this? or what is happening here? and are more concerned with the process rather than the outcome. 2 This editorial provides an overview of qualitative research, describes 3 common types of qualitative research, and gives examples of their use in nursing.

Sampling, data collection, and data analysis

Sampling refers to the process used to select a portion of the population for study. Qualitative research is generally based on non-probability and purposive sampling rather than probability or random approaches. 3 Sampling decisions are made for the explicit purpose of obtaining the richest possible source of information to answer the research questions. Purposive sampling decisions influence not only the selection of participants but also settings, incidents, events, and activities for data collection. Some of the sampling strategies used in qualitative research are maximum variation sampling, stratified purposeful sampling, and snowball sampling. 3 Qualitative research usually involves smaller sample sizes than quantitative research. 4 Sampling in qualitative research is flexible and often continues until no new themes emerge from the data, a point called data saturation .

Qualitative data analysis, unlike quantitative data analysis, is not concerned with statistical analysis, but with analysis of codes, themes, and patterns in the data. 6 Increasingly, qualitative researchers use computer software programs to assist with coding and analysis of data. 6 The product of qualitative research varies with the approach used. Qualitative research may produce a rich, deep description of the phenomenon being studied or a theory about the phenomenon. Qualitative research reports often contain direct quotes from participants that provide rich illustrations of the study themes. Qualitative research, unlike its quantitative counterpart, does not lend itself to empirical inference to a population as a whole; rather it allows the researcher to generalise to a theoretical understanding of the phenomenon being examined.

Types of qualitative research

There are many different types of qualitative research, such as ethnography, phenomenology, grounded theory, life history, and ethnomethodology. 6 As in quantitative research, it is important for the nurse researcher to select the qualitative research approach that would best answer the research question. Three of the most commonly used approaches to qualitative research in nursing are phenomenology, ethnography, and grounded theory. 5 The goals and methods associated with each approach will be described briefly in the following sections. Examples of research studies that use each approach and that have previously been abstracted in Evidence-Based Nursing are summarised to illustrate some of the similarities and differences among approaches. Other sources are available that provide a more complete description and comparison of these approaches and their use in nursing. 2 , 4 , 7

Phenomenology

The aim of a phenomenological approach to qualitative research is to describe accurately the lived experiences of people, and not to generate theories or models of the phenomenon being studied. 8 The origins of phenomenology are in philosophy, particularly the works of Husserl, Heidegger, and Merleau-Ponty. 8 Because the primary source of data is the life world of the individual being studied, in depth interviews are the most common means of data collection. Furthermore, emerging themes are frequently validated with participants because their meanings of that lived experience are central in phenomenological study.

Phenomenology was used to answer the research question what is the lived experience of adults who are integrating a hearing loss into their lives ? 9 (See Evidence-Based Nursing , 1998 October, p131). The convenience sample consisted of 32 adults with mild to profound degrees of hearing loss. Data were collected through semi-structured, audiotaped interviews with participants. Analysis involved identification of core and major themes in the data, and validation of the findings with selected participants. The core theme of dancing with eloquently captured the participants' perceptions of moving, gracefully or awkwardly, with the changes required by hearing loss, never sure of the next steps. The major themes of dancing with (a) loss and fear, (b) fluctuating feelings, (c) courage amidst change, and (d) an altered life perspective, provide the reader with a rich description of the participants' perceptions of what it was like to live with hearing loss. These findings offer nurses a deep understanding of the phenomenon that they can apply in their interactions with people living with hearing loss. The phenomenological approach was key to uncovering participants' meanings of the complex and dynamic process of integrating hearing loss into their lives.

Ethnography

The goal of ethnography is to learn about a culture from the people who actually live in that culture. 10 A culture can be defined not only as an ethnic population but also as a society, a community, an organisation, a spatial location, or a social world. 11 Ethnography has its roots in cultural anthropology, which aims to describe the values, beliefs, and practices of cultural groups. 10 The process of ethnography is characterised by intensive, ongoing, face to face involvement with participants of the culture being studied and by participating in their settings and social worlds during a period of fieldwork. The essential data collection methods of participant observation and indepth interviewing permit the researcher to learn about the meanings that informants attach to their knowledge, behaviours, and activities. 12 The context (social, political, and economic) of the culture assumes an important part of an ethnographic study, unlike a phenomenological study.

An ethnographic approach was used to answer the research question what is it like to be a young urban African-American who has at least one AIDS-afflicted family member ? 13 (See Evidence-Based Nursing , 1998 October, p130.) Stories of 6 young people are described in the article. There was an extensive 4 year period of in depth fieldwork that included telephone and in person interviews and participant observation. The stories powerfully illustrated how the culture in which the youths had to survive was so alienating that they deliberately sought exposure to HIV. The findings provide an important understanding for nurses working with adolescents in either preventive or acute care roles. The ethnographic approach was uniquely suited to bring attention to the important influence of the context of marginalisation, insensitive social policies, and demanding caretaking responsibilities, on the lives of these youths.

Grounded theory

The purpose of a grounded theory approach to qualitative research is to discover social-psychological processes. 14 Grounded theory was developed by Glaser and Strauss in the 1960s and is founded philosophically on symbolic interactionism. 15 Distinct features of grounded theory include theoretical sampling and the constant comparative method. Theoretical sampling refers to sampling decisions made throughout the entire research process in which participants are selected based on their knowledge of the topic and based on emerging study findings. In data analysis, the researcher constantly compares incidents, categories, and constructs to determine similarities and differences and to develop a theory that accounts for behavioural variation. Both observation and interviewing are commonly used for data collection.

Grounded theory was used to answer the research question what is the process of reimaging after an alteration in body appearance or function ? 16 (See Evidence-Based Nursing , 1998 October, p133.) The theoretical sample consisted of 28 participants who had experienced body image disruptions such as significant weight change; amputation or paralysis of body parts; and scars from burns, surgery, or trauma. Participants were interviewed at 3, 6, 12, and 18 months after the physical alteration. The constant comparative method of concurrent data collection and analysis was used to develop a 3 phase theory of the process of reimaging: (a) body image disruption, (b) wishing for restoration, and (c) reimaging the self. Nurses can use this vital understanding of the phases of reimaging to assist clients through the process by anticipating potential needs or problems, providing information and support, and exploring alternative problem solving strategies. The grounded theory approach was ideally suited to discovering the social-psychological process of reimaging.

The examples of nursing research studies using 3 different approaches exemplify the value of qualitative research in answering important nursing questions. The studies also provide rich illustration of the differences and similarities between the disparate approaches that are captured by the term “qualitative research.” The approaches differed in the type of research question asked, the philosophical underpinnings, the methods used, and to some extent, the final product. All studies, however, resulted in important new information about the phenomena studied. This new information facilitates a deeper understanding of participants' experiences by nurse readers and—as long as nurses remain aware of the theoretical rather than empirical basis for generalising from the qualitative findings—has the potential for influencing nursing practice in similar situations.

• ↵ Marshall C, Rossman GB. Designing qualitative research . Second edition. Thousand Oaks, California: Sage Publications, 1995.
• ↵ Munhall PL, Boyd CO. Nursing research: a qualitative perspective . Second edition. New York: National League for Nursing Press, 1993.
• ↵ Miles MB, Huberman AM. Qualitative data analysis . Second edition. Thousand Oaks, California: Sage Publications, 1994.
• ↵ Morse JM. Designing funded qualitative research. In: Denzin NK, Lincoln YS, editors. Qualitative research . Thousand Oaks, California: Sage Publications, 1994:220–35.
• ↵ Morse JM, Field PA. Qualitative research methods for health professionals. Second edition. Thousand Oaks, California: Sage Publications, 1995.
• ↵ Tesch R. Qualitative research: analysis types and software tools . New York: Falmer, 1990.
• ↵ Streubert HJ, Carpenter DR. Qualitative research in nursing: advancing the humanistic imperative . Philadelphia: Lippincott, 1995.
• ↵ Van Manen M. Researching lived experience: human science for an action sensitive pedagogy . London: Althouse Press, 1990.
• ↵ Herth K. Integrating hearing loss into one's life. Qual Health Res 1998 ; 8 : 207 –23. OpenUrl CrossRef PubMed Web of Science
• ↵ Spradley JP. The ethnographic interview . New York: Harcourt Brace Jovanovich College Publishers, 1979.
• ↵ Hammersley M. What's wrong with ethnography? Methodological explorations . New York: Routledge, 1992.
• ↵ Germain CP. Ethnography: the method. In: Munhall PL, Boyd CO, editors. Nursing research: a qualitative perspective. Second edition . New York: National League for Nurses Press, 1993:237–68.
• ↵ Tourigny SC. Some new dying trick: African American youths “choosing” HIV/AIDS. Qual Health Res 1998 ; 8 : 149 –67. OpenUrl CrossRef Web of Science
• ↵ Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, California: Sage Publications, 1990.
• ↵ Chenitz WC, Swanson JM. From practice to grounded theory: qualitative research in nursing . Menlo Park, California: Addison-Wesley, 1986.
• ↵ Norris J, Kunes-Connell M, Spelic SS. A grounded theory of reimaging. Adv Nurs Sci 1998 ; 20 : 1 –12.

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• v.4(4); 2017 Oct

Patient involvement for improved patient safety: A qualitative study of nurses’ perceptions and experiences

Janna skagerström.

1 Research and Development Unit in Region Östergötland and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden

Carin Ericsson

2 Centre of Heart and Medicine, Region Östergötland, Linköping, Sweden

3 Department of Medical and Health Sciences, Linköping University, Linköping, Sweden

Mirjam Ekstedt

4 Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden

5 Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden

Kristina Schildmeijer

To explore nurses’ perceptions and experiences of patient involvement relevant to patient safety.

Qualitative design using individual semi‐structured interviews.

Interviews with registered nurses ( n  =   11) and nurse assistants ( n  =   8) were conducted in 2015–2016. Nurses were recruited from five different healthcare units in Sweden. The material was analysed using conventional content analysis.

The analysis resulted in four categories: healthcare professionals’ ways of influencing patient involvement for safer care; patients’ ways of influencing patient involvement for safer care; barriers to patient involvement for safer care; and relevance of patient involvement for safer care. The nurses expressed that patient involvement is a shared responsibility. They also emphasized that healthcare provider has a responsibility to create opportunities for the patient to participate. According to the nurses, involvement can be hindered by factors related to the patient, the healthcare provider and the healthcare system. However, respondents expressed that patient involvement can lead to safer care and benefits for individual patients.

Why is this research needed?

• The patient has an overall perspective of their care and observes the whole care process.
• Most research on patient involvement concern the patient perspective and there is limited knowledge about the healthcare professionals’ views on patient participation for patient safety.

What are the key findings?

• The nurses believed that healthcare professionals and patients had a shared responsibility for patient participation to occur.
• The nurses emphasized the importance of their own initiatives to achieve patient involvement for enhanced patient safety by initiating dialogue and inviting the patients to ask questions.
• The nurses expressed that barriers to achieve patient participation for safer care were seen both within patients, healthcare professionals and the healthcare system.

How should the findings be used to influence policy/practice/research/education?

• The healthcare system should allocate time and supportive environments to facilitate open dialogue between healthcare professionals and patients.
• Healthcare professionals should be offered training in how to encourage the patients to be involved in their health care.

1. INTRODUCTION

Patient safety has progressed over the last 15 years from being a relatively insignificant issue to a position high on the agenda for healthcare professionals, managers and policy makers as well as the public. Sweden has seen increased patient safety efforts since 2009 when a national study on adverse events in Swedish hospital care was published (Soop, Fyksmark, Köster, & Haglund, 2009 ). The study estimated the percentage of preventable adverse events as high as 8.6% in hospital care, demonstrating that the magnitude of the patient safety problem was not smaller in Sweden than elsewhere. Efforts for improved patient safety in Sweden were further enhanced in 2011 with the introduction of a new law on patient safety and a financial incentive for county councils (responsible for providing health care in Sweden) that performed certain patient safety‐enhancing activities (Ridelberg, Roback, Nilsen, & Carlfjord, 2016 ).

There is increasing interest in involving patients in safety‐related initiatives, premised on the assumption that their interaction with healthcare professionals can improve the safety of health care in many ways (Berger, Flickinger, Pfoh, Martinez, & Dy, 2014 , World Health Organization, 2013a a). The importance of eliciting and acting on patients’ concerns has been emphasized. The patients are privileged witnesses of health care because they are at the centre of the process of care and observe the whole process (Schwappach & Wernli, 2010 ). Patients also carry out hidden work to compensate for inefficiencies of the healthcare system, such as relaying information between healthcare professionals (Vincent & Davis, 2012 ). Various policy initiatives have been undertaken aimed at encouraging patients in a range of safety‐relevant behaviours. The World Health Organization (WHO) promotes the program “Patients for Patient Safety” to bring together patients and various stakeholders to improve patient safety through advocacy, collaboration and partnership (WHO, 2013 ). In Sweden, the National Board of Health and Welfare and Swedish Association of Local Authorities and Region (SALAR), representing the county councils and municipalities, have emphasized the importance of a new perspective on the patient for improved quality and effectiveness of health care (National Board of Health and Welfare, 2015 , SALAR, 2011 ). Healthcare professionals are also obliged by the law to give patients an opportunity to take part in patient safety work (SFS, 2010 ).

1.1. Background

Research indicates that there is a potential for patients to improve safety (Davis, Jacklin, Sevdalis, & Vincent, 2007 ; Vincent & Coulter, 2002 ) and that patients are willing and able to be involved in safety‐related work (Waterman et al., 2006 Wright et al., 2016 ). However, several barriers to involving patients in improving patient safety has been identified and organized into three key barriers: (i) patients are not always willing or prepared to commit their time and energy to improve their care because they have enough to worry about being ill; (ii) healthcare professionals represent traditional medical authority and questioning or advising professionals about what they do is unacceptable for many patients; and (iii) patients may be apprehensive about reporting problems in their care when providers’ responses are unappreciative or when the patients believe that their feedback may jeopardize the providers’ goodwill towards the patient (Iedema, Allen, Britton, & Gallagher, 2012 ). Organizational factors such as a busy setting, lack of continuity of care and patients being unaware of incident reporting systems have also been identified as barriers to active patient participation (Doherty & Stavropoulou, 2012 ).

Nurses comprise the largest professional group in health care in Sweden. The main categories of nurses in Swedish health care are registered nurses and nurse assistants, who differ with regard to their level of education, work duties and responsibilities. Registered nurses are critically important to achieve patient safety since they often have a role as coordinator of multidisciplinary care and are involved with many aspects of patient care, from providing comfort and hygiene to administering injections, updating medical records, as well as handling some therapeutic and diagnostic procedures. Several studies have stressed the importance of nurses’ role for identifying, interrupting and correcting medical adverse events (Gaffney, Hatcher, & Milligan, 2016 ) and for reducing patients’ feelings of being unsafe and vulnerable in the health care setting (Kenward, Whiffin, & Spalek, 2017 ).

Thus far, very few studies have investigated nurses and other healthcare professionals’ attitudes, beliefs and behaviours concerning patient involvement for improved patient safety. Research conducted hitherto suggests that providers may be willing to support patient involvement in safety‐relevant behaviours, although the factors behind these preliminary findings remain largely unexplored (Davis, Briggs, Arora, Moss, & Schwappach, 2014 ; Hochreutener & Wernli, 2010 ; Schwappach, Frank, & Davis, 2012 ). A previous Swedish study assessing nurses’ perceptions of factors influencing patient safety found that patient‐nurse interaction was an important factor that could hinder or facilitate enhanced patient safety depending on the quality of the communication (Ridelberg, Roback, & Nilsen, 2014 ). This study provides an in‐depth investigation into nurses’ perspectives on patient involvement for safer care in meetings with healthcare professionals, being the first Nordic study on this topic. The aim was to explore nurses’ experiences and perceptions with regard to patient involvement of relevance for patient safety.

2. THE STUDY

2.1. study setting.

The study was set in Sweden. Health care in Sweden is mainly tax‐funded although private health care also exists. All residents are insured by the state, with equal access for the entire population. Out‐of‐pocket fees are low and regulated by law. The responsibility for health and medical care in Sweden is shared by the central government, county councils and municipalities throughout Sweden. The health care system is financed primarily through taxes levied by county councils and municipalities.

2.2. Study design

A qualitative study approach using standardized (also referred to as structured) open‐ended interviews was deemed appropriate regarding the explorative aim of the study. This qualitative descriptive study is grounded in the assumption that human beings construct the meaning of their experiences in social interaction with their environment. Qualitative descriptive studies comprise a valuable methodologic approach, by using open‐ended interviews where the phenomenon under study is explored in an interaction between the interviewer and the interviewee (Sandelowski, 2000 ).

2.3. Participants

We used a purposeful sampling strategy to achieve a heterogeneous sample of nurses working in different healthcare facilities, with patients who varied in terms of health status (from patients seen in primary health care to ill patients receiving hospital care and, for example, surgery patients), length of stay in health care (from patients visiting outpatient facilities to in‐hospital patients) and age. The aim was to achieve a sample of nurses that represented a broad spectrum of perceptions and experiences concerning patient involvement in relation to patient safety.

The nurses were recruited using an email that briefly described the study. The email request was sent to the manager of each work unit, explaining that we wanted a sample of three or four nurses. The manager in turn forwarded the request to all or a sample of registered nurses and nurse assistants at the unit. An information letter describing the study was sent to interested nurses and the interviews were scheduled. No respondents declined involvement after receiving the information letter.

2.4. Data collection

The interview guide used in the study was developed by the authors and concerned the nurses’ experiences and perceptions regarding patient involvement of relevance for patient safety. There were general questions on patient involvement of relevance for patient safety. There were also specific questions on the respondent's own experiences and examples of patients who have observed and highlighted something of importance for patient safety. The interview guide ended with questions on existing routines to account for patients’ views and experiences and on the nurses’ suggestions on how patient involvement for safer care can be achieved.

Patient safety was defined in accordance with the definition used in Swedish law (SFS, 2010 ), that is: “protection against adverse events” where adverse events is defined as “suffering, bodily or mental harm or illness and deaths that could have been avoided if adequate measures had been taken at the patient contact with the healthcare system”. The definition was read to the nurses at the beginning of the interview and a printed definition was placed on the table during the interview so that the respondents could read it.

The questions were pilot tested in one test interview, not analysed. The test interview indicated that the questions were generic enough to be used in different healthcare contexts and that the wording was clear. The interviews were conducted by KS, CE and JS and were digitally recorded using a Dictaphone. Interviews were held during regular working hours to facilitate involvement. Each interview lasted between 18–53 min. The interviews were transcribed verbally by a firm specialized in transcription. The researchers checked the transcripts and removed statements that could reveal the identity of the informant.

Before starting the interviews, the participants were asked to re‐read the information letter and give their written informed consent to participate. Each interview started with an open question asking the participants to describe their thoughts on how patients can influence patient safety. The questions were open ended to stimulate narratives of the participants’ own experiences. During the interviews, probing questions were asked, for example: “what do you mean?” and “can you explain this a little further?” to deepen or clarify the descriptions or drawing the attention back to the topic (Kvale & Brinkman, 2009 ).

2.5. Data analysis

Data were analysed using content analysis. We followed the analytical procedure for conventional content analysis as detailed by Hsieh and Shannon ( 2005 ). The analysis was data driven and based on the participants’ unique perspectives rather than guided by a pre‐defined theory or hypothesis. Investigator triangulation was used to validate the findings. All researchers read and re‐read the transcripts to gain a sense of the content and an overview of the whole material. With the aim of the study in mind, the researchers highlighted text and made notes and headings in the margins to include all aspects of the content. Initial thoughts and impressions regarding the material were written down. No pre‐defined structures were used as the codes were derived from the data to capture key concepts. Codes that were related to each other were grouped and organized into subcategories and categories. This process was iterative, going back and forth checking the codes against the whole material. The subcategories and categories were subsequently compared for differences and similarities, with the aim of being as internally homogeneous and as externally heterogeneous as possible.

2.6. Rigour

Credibility in the data analysis was strengthened by the fact that the initial coding of the data was performed by several researchers independently (JS, CE and KS). The classification of categories and subcategories was then discussed by two researchers (JS and CE). After they reached consensus, the classification was discussed by all the authors and adjustments were made until all were satisfied. The multidisciplinary research team allowed different perspectives on the issue of patient involvement in relation to patient safety. The team consisted of a nurse with experience in clinical patient work as well as work with miscellaneous patient safety issues (KS), a public health researcher (JS), a behavioural science practitioner working with organizational development and experience in developing and implementing patient involvement policies (CE), a nurse experienced in qualitative methods, patient involvement and system safety issues (ME) and an experienced implementation and patient safety researcher (PN).

2.7. Ethical considerations

The study was performed according to the World Medical Association Declaration of Helsinki ethical principles for medical research involving human subjects. All the participants gave their consent to participate in the interviews. The study did not require ethical approval because it did not involve sensitive personal information, as specified in Swedish law regulating ethical approval for research concerning humans (SFS, 2003 ).

3. FINDINGS

Interviews were conducted with 19 nurses, of which 11 were registered nurses and 8 were nurse assistants. They were employed in five different work units: (i) pulmonary medical unit in a university hospital (550 beds); (ii) surgery unit in a mid‐sized hospital (350 beds), (iii) ear, nose and throat unit in a mid‐sized hospital (500 beds); (iv) one maternity care unit (outpatient care); and (v) one nursing home (18 residents). Table  1 provides information on the participants. The interviews were carried out from May 2015 – February 2016 at the participants’ work units.

Participant characteristics

Analysis of the data yielded four categories related to patient involvement for enhanced patient safety: healthcare professionals’ ways of influencing patient involvement for safer care; patients’ ways of influencing patient involvement for safer care; barriers to patient involvement for safer care; and relevance of patient involvement for safer care (Table  2 ).

Categories and subcategories

3.1. Healthcare professionals’ initiatives to achieve patient involvement for safer care

The nurses expressed that there were a few ways they and other healthcare professionals can influence patient involvement of potential relevance for patient safety. They believed that they could facilitate patient involvement by ensuring favourable conditions for dialogue with the patients, making sure that information is received and understood by the patients and creating a trustful relationship with the patients.

3.1.1. Dialogue

The nurses described that they can facilitate patient involvement by providing conditions that are conducive to this involvement, including taking sufficient time to listen to patients and inviting them to ask questions and be active in the dialogue. Specific ways of achieving this included telling the patients that they are happy to answer any questions they might have, informing the patients that there will be time for their questions or concerns at the end of the consultation (after finishing medical examinations) and encouraging the patients to share their opinions regarding the health care:

Instead you have to be inviting and show a friendly response, encourage conversation and dialogue. You have to make sure it doesn't become a monologue, where you just sit and talk without… We, the staff, must encourage them to ask questions and to become involved. Participant 24

Some nurses mentioned that it is important to adapt to each individual patient they meet. It is especially important to be observant and take in facial expressions with patients who are unable to express themselves verbally.

3.1.2. Information

The nurses expressed that they can influence the patients’ potential to be involved in their care by making sure that the patients receive and understand information provided to them. The information should be given in a language that can be understood by the patients and without medical terms that may be unfamiliar to the patients. The nurses mentioned that the patients’ abilities to assimilate information vary considerably and it may be necessary to repeat information at several time points. Patients with new diagnoses or treatments, patients with fatigue and patients discharged after a longer stay in hospital were all mentioned as groups that could benefit from repeated information:

Sometimes I think you could ask…”Do you think you got the information you needed, did you understand it?” or something like that, so it's not too much [information]. Participant 23

3.1.3. Trustful relationship

The importance of a trustful relationship between the healthcare professional and patient to make the patients feel comfortable raising any concerns was made clear in the interviews. Although the nurses believed that the provider and patient have a shared concern for creating this relationship, the nurses argued that the ultimate responsibility to facilitate a trustful provider‐patient relationship rested with the providers of health care.

The importance of building a trustful relationship was primarily mentioned by nurses working in specialties which patients visit several times. Continuity of healthcare staff to ensure that the patient can meet the same professionals over time was mentioned as a factor that influenced the opportunity to establish a trusting relationship. The presence of a specific contact person to whom the patient could turn with their thoughts or questions was believed to enhance the patients’ confidence to engage in issues of potential relevance for patient safety.

Specific personal behaviours such as being empathic and humble as well as the ability to facilitate an open climate and allow sufficient time were seen as important to build a trustful relationship:

Yes, you have to be open, responsive in order for them [the patients] to open up. You can't just walk in and be really tough…that's not going to make it easy to open up if you have problems. Participant 16

3.2. Patients’ initiatives to achieve patient involvement for safer care

The nurses’ perceptions about what the patients can do differed somewhat depending on the healthcare context and what types of patients they typically meet. However, in general, nurses conveyed that the patients can assume responsibility for their health and treatment and be active in communication with healthcare professionals.

3.2.1. Assuming responsibility for one's treatment and care

The nurses expressed that the patients can participate in their care and enhance patient safety by taking an active interest in their health and treatment. The interest could be manifested as searching for information or actively reading information. Further, using and asking for medical aids such as rollators, reading user manuals for medical devices used in home care or watching out for complications or abnormalities when in treatment were provided as examples of responsible patient actions to increase patient safety:

They [the patients] could get more involved in… to make sure things aren't forgotten, because we have a lot of different hoses and drainage, venous catheters and things like that, where they could help and be observant to prevent infections. Participant 4

3.2.2. Being active in communication with healthcare professionals

Nurses stated that patients who are active in dialogue with healthcare professionals can improve patient safety. Writing down questions and thoughts or bringing a relative to appointments were tips for patients to prepare for communication with the professionals. Also, the nurses stated that the patients could be active by attending regular check‐ups, reminding staff about return visits or treatments and reporting any side effects:

They [the patients] have to tell us about, for example, side effects and things like that, that's nothing we can see ourselves. So, if I don't get that feedback, they might get medications that don't make them feel so good. Participant 3

Sharing detailed information about their medical conditions, heredity and side effects was viewed as important because this could help the healthcare professionals to understand the patients’ symptoms and healthcare needs and reduce the risk of important aspects being neglected:

Well, how it feels and… how they understand the situation, both physically and mentally, how they describe an ailment, how detailed they are… can actually make me reconsider and think otherwise. Participant 21

3.3. Interaction between healthcare professionals and patients to achieve patient involvement for safer care

The nurses were generally in favour of patient involvement and believed that it could lead to improved patient safety. However, they identified numerous potential problems and disadvantages associated with patient involvement, including problems relating to the patients’ lack of will and ability to participate, constraints related to the healthcare system and healthcare professionals’ ambivalent feelings concerning patient involvement.

3.3.1. Patients’ hesitancy to interact

The nurses described that there are many obstacles to patients being active and participating in their care. They argued that some patients are unwilling to question healthcare professionals because they view them as authorities and reason that they, the doctor in particular, know what is best for them. Nurses believed that some patients might refrain from offering criticisms for fear of receiving suboptimal treatment or care. Patients who perceive that the healthcare professionals are stressed are unwilling to ask questions or start a dialogue because they feel that they might disturb or interrupt more important tasks:

When we seem stressed, they [the patients] feel they should not ask that simple question. You often hear that “I won't bother you [the staff] about this”. Participant 1

For some patients, participating in their treatment or care is hindered by health problems, difficulties with understanding, language problems or feeling uncomfortable with disclosing sensitive issues.

3.3.2. Constraints related to the healthcare system

Several factors in the healthcare system were brought up by the nurses as hindering patient involvement to achieve safer care. Lack of privacy was a problem mentioned by nurses working in clinical wards where patients often share rooms. Shortage of the healthcare professionals’ time was another limitation for patient involvement. Appointments are sometimes just long enough for physical examinations but leave little time for dialogue or questions from the patients. The nurses thought that problems with availability and staff discontinuity can lead to disenchantment for the patients. Further, the possibility of building trustful relationships is decreased:

Temporary doctors mean that they [the patients] won't meet the same [doctor] next time and then they [the patients] say, “It's no use asking.” You often hear that. Participant 12

3.3.3. Healthcare professionals’ ambivalent feelings

The nurses described a range of feelings towards active patients who are informed and may ask more critical questions. By and large, the nurses were pleased to learn from the patients. If they made a mistake, they were grateful that someone pointed it out to them, although the mistake itself could make them ashamed. Some informed and active patients could make the nurses feel incompetent or question their profession. Some nurses expressed concern that patients who question a great deal or want detailed information can take too much time:

They [the patients] have too little knowledge. At the same time, they want to be involved, which requires a lot… a sort of pedagogical responsibility rests with me that demands a lot [of time and energy]. Participant 21

3.4. Relevance of patient involvement for safer care

This category concerns the nurses’ perceptions of the “results” of patient involvement. Some of the nurses could not think of any example where a patient had recognized or reported something relevant for patient safety. They described situations where the patients’ involvement had not directly affected patient safety but had led to positive effects for the patients. Others shared examples of varying relevance for patient safety, for example, how patients’ involvement had directly prevented a mistake or eliminated potential patient safety hazards.

3.4.1. Patients receiving personal benefits

The nurses believed that patients who were active and questioned aspects of their treatment or care, such as long waiting times or outdated medical aids, could gain advantages compared with patients who did not raise any complaints or concerns. Advantages such as getting help quicker, shorter waiting times for medical examinations or receiving a more modern type of medical aid were brought up in the interviews:

If you're active as a patient and ask when you can get an appointment that could definitely shorten the waiting time compared with if you remain quiet and wait. Participant 8

3.4.2. Safer care

Several nurses shared examples of situations when involvement by patients led to improvements in patient safety. The examples included patients reminding about allergies, asking for aids to avoid fall injuries, observing defects in medical devices and asking about referrals that their healthcare provider had forgotten about:

There was one [patient] with coeliac disease who almost ate food that she should certainly not have. And, of course it was [detected] because she asked, “Is this really gluten‐free?” Participant 9

Another example of indirect patient involvement was when the nurses themselves thought of some hazard, such as giving a patient a double dose of medication and asked the patient to verify whether the mistake had been made or not. Although the patients did not notice the error themselves, they could participate by confirming the nurses’ suspicions.

4. DISCUSSION

The aim of this study was to explore nurses’ perceptions and experiences with regard to patient involvement of potential relevance for patient safety. The study contributes to the research field by addressing the nurses’ perspective in contrast to much previous work that has concerned patient views. Further, the study provides insights into how patient involvement for safer care can be achieved in the provider‐patient interaction. In general, the nurses expressed positive attitudes to patient involvement and believed it could have a positive impact on patient safety. However, patient involvement does not occur by itself. Rather, both patients and healthcare professionals must take responsibility if patient involvement for safer care is going to be realized.

The nurses in our study emphasized the importance of their own initiatives to achieve patient involvement. They stated that healthcare professionals can facilitate this involvement by initiating dialogue and inviting the patients to ask questions. Our findings are consistent with previous research from the patient perspective, which has shown the importance of healthcare professionals encouraging patients to speak their opinion (Davis, Koutantji, & Vincent, 2008 ; Entwistle et al., 2010 ; Rainey, Ehrich, Mackintosh, & Sandall, 2015 ). It has been suggested that patients, due to imbalance of power and health literacy, are unwilling to speak their mind if they fear negative or judgemental reactions from the providers, or being ignored or not taken seriously (Davis, Sevdalis, Jacklin, & Vincent, 2012 ). This is supported by our findings from the nurses’ viewpoint, because the nurses highlighted the relevance of building a trustful relationship with the patient by actively listen to them and encourage them to express opinions and ask questions.

Further, the nurses pointed to the importance of providing individualized information to the patients. In a previous Swedish study examining facilitators and barriers to patient safety, nurses expressed that providing well‐structured information to patients is a facilitator for patient safety (Ridelberg et al., 2014 ). Further, research from the patient perspective has highlighted the value of patients understanding of information for them to participate in their care and to make informed decisions (Davis et al., 2012 ; Eldh, Ehnfors, & Ekman, 2006 ; Longtin et al., 2010 ). Patients who have been comprehensively informed are also more likely to feel confident and trust their own decisions (Forsyth, Maddock, Iedema, & Lessere, 2010 ; Longtin et al., 2010 ). Provision of appropriate and sufficient information in a supportive environment are key points in patient involvement (Larsson, Sahlsten, Sjostrom, Lindencrona, & Plos, 2007 ). Patients who have access to information on their health and care are more willing and able to be involved in safety issues (Forsyth et al., 2010 ; Iedema et al., 2012 ). It is likely that patients who receive adequate information become more knowledgeable about what to expect from nursing activities, treatment and care, which enables them to detect potential deviations of relevance for patient safety.

The hindering factors associated with patient involvement for safer care that we found in this study are largely consistent with the barriers identified in research on patient involvement from the patient perspective (Howe, 2006 ; Iedema et al., 2012 ; Larsson, Sahlsten, Segesten, & Plos, 2011 ). With regard to shared decision making in health care, Joseph‐Williams, Elwyn, and Edwards ( 2014 ) concluded in a systematic review that patients’ participation depends on their knowledge (about the condition, options for care, outcomes and personal preferences) and power, that is, perceived influence on decision making. The two factors, knowledge and power, are in turn influenced by interpersonal patient‐provider factors, patient characteristics, trust and time allocated for discussions. Assessing nurses’ opinions of factors influencing patient safety in general, Ridelberg et al. ( 2014 ) found factors relating to both patient interactions and healthcare providers skills and feelings to be potential barriers for patient safety.

It has been suggested that nurses believe patients lack sufficient medical knowledge, making it necessary for nurses to retain power and control (Henderson, 2003 ). Grimen ( 2009 ) has highlighted the interconnection between power and trust, arguing that many healthcare professionals fail to recognize the power associated with professional autonomy, which makes equal dialogue between patients and healthcare professionals unrealistic; patients are in an inferior position vis à vis healthcare professionals. Hence, being a patient is to trust that professionals know what they are doing and to temporary delegate power to them. On the other hand, knowledge and power is a two‐edged sword, which if used wisely in a patient‐provider encounter, can foster mutual respect for the knowledge possessed by both patients and healthcare professionals (Eldh, Ekman, & Ehnfors, 2010 ).

Ignorance of this provider‐patient power imbalance could make nurses resistant to patient involvement because they do not believe in and inform themselves about the patients’ opportunities to make informed contributions. This in turn contributes to creating a culture of professional defensiveness towards patient involvement (Henderson, 2003 ; Howe, 2006 ). Some nurses in this study mentioned that active patients can be time consuming and that too much time is wasted on explaining irrelevant matters to the patients. Communication with patients cannot always be prioritized, because nurses also need to focus on taking care of risk situations and complete tasks (Tobiano, Marshall, Bucknall, & Chaboyer, 2016 ). As pointed out by Ekdahl, Hellström, Andersson, and Friedrichsen ( 2012 ), the remuneration system used in Swedish health care favours treating a large number of patients, which leads to time restrictions and insufficient time for many patients. Time barriers exist not only in Sweden. In a study on patient involvement conducted in 15 European countries, time spent with patients and communications were perceived as the most important areas for improvement of patient involvement (European Commission, 2012 ). Organizational factors such as time constraints (Bolster & Manias, 2010 ; Entwistle et al., 2010 ) and lack of continuity in care (Unruh & Pratt, 2007 ) have previously been suggested to have a negative impact on patients’ active involvement in safety work. For individual healthcare professionals to be able to invite patients to be involved in their care, as suggested by the nurses in our study, requires a shift in the healthcare system to allow more time for conversations with each patient. Our study also pointed to the relevance of the nurses’ ambivalent feelings towards patient involvement. Perceiving that one's professionalism is questioned could hinder providers from actively involving patients in some situations.

4.1. Limitations

This study has several shortcomings that must be considered when interpreting the results. The recruitment strategy could have led to a bias towards participation by nurses who were more interested in patient involvement and/or patient safety issues. The importance of patient involvement has recently been highlighted in Sweden. This might have led to the participants providing more positive answers in the interviews because they want to provide responses that are somehow politically correct. On the other hand, the interview guide was constructed to give the responders the opportunity to answer in general terms rather than revealing their personal opinions.

Nineteen individual interviews with registered nurses and nurse assistants working in different types of healthcare settings were conducted. Various ages, work experience and types of patients contribute to a large variation in the sample. This heterogeneity increases the possibility of viewing patient involvement for improved patient safety from different angles, which can be considered a strength in the study. Inclusion of male nurses in the sample would have increased the heterogeneity further. However, the lack of male participants was deemed acceptable since 88% of registered nurses and 84% of nurse assistants working in Swedish health care are female (SALAR, 2015 ). Transparency was sought by describing the sampling procedure and data analyses in detail.

During the interviews and data analysis, it became evident that the nurses did not always share our definition of patient safety. Although the official definition of patient safety was read to the participants at the beginning of the interview, they tended to interpret the concept more broadly to encompass various aspects of health care in general. This was especially common among the nurse assistants; they provided examples that had more to do with regular health care provision than with patient safety as defined. We found this interesting and did not want to interrupt to impede the nurses’ willingness to tell stories they found important. However, our findings primarily relate to various aspects of patient safety, as defined in this study.

5. CONCLUSIONS

We found that nurses are in general positive to patient involvement and believe it can contribute to increased patient safety. The nurses believe that they can influence patient involvement and that they have a responsibility to do so, but that the patients are responsible for being active in meetings with healthcare professionals. Patient involvement also depends on a well‐functioning provider‐patient interaction. The finding also suggest that healthcare professionals need support from the healthcare system to achieve patient involvement of relevance for patient safety.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interests.

ACKNOWLEDGEMENTS

The authors thank all registered nurses and nurse assistants who participated in the interviews.

Skagerström J, Ericsson C, Nilsen P, Ekstedt M, Schildmeijer K. Patient involvement for improved patient safety: A qualitative study of nurses’ perceptions and experiences . Nursing Open . 2017; 4 :230–239. https://doi.org/10.1002/nop2.89 [ PMC free article ] [ PubMed ] [ Google Scholar ]

This study was funded by The Swedish Research Council for Health, Working Life and Welfare, FORTE, 2014‐4567

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