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  • How to Do Thematic Analysis | Step-by-Step Guide & Examples

How to Do Thematic Analysis | Step-by-Step Guide & Examples

Published on September 6, 2019 by Jack Caulfield . Revised on June 22, 2023.

Thematic analysis is a method of analyzing qualitative data . It is usually applied to a set of texts, such as an interview or transcripts . The researcher closely examines the data to identify common themes – topics, ideas and patterns of meaning that come up repeatedly.

There are various approaches to conducting thematic analysis, but the most common form follows a six-step process: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing up. Following this process can also help you avoid confirmation bias when formulating your analysis.

This process was originally developed for psychology research by Virginia Braun and Victoria Clarke . However, thematic analysis is a flexible method that can be adapted to many different kinds of research.

Table of contents

When to use thematic analysis, different approaches to thematic analysis, step 1: familiarization, step 2: coding, step 3: generating themes, step 4: reviewing themes, step 5: defining and naming themes, step 6: writing up, other interesting articles.

Thematic analysis is a good approach to research where you’re trying to find out something about people’s views, opinions, knowledge, experiences or values from a set of qualitative data – for example, interview transcripts , social media profiles, or survey responses .

Some types of research questions you might use thematic analysis to answer:

  • How do patients perceive doctors in a hospital setting?
  • What are young women’s experiences on dating sites?
  • What are non-experts’ ideas and opinions about climate change?
  • How is gender constructed in high school history teaching?

To answer any of these questions, you would collect data from a group of relevant participants and then analyze it. Thematic analysis allows you a lot of flexibility in interpreting the data, and allows you to approach large data sets more easily by sorting them into broad themes.

However, it also involves the risk of missing nuances in the data. Thematic analysis is often quite subjective and relies on the researcher’s judgement, so you have to reflect carefully on your own choices and interpretations.

Pay close attention to the data to ensure that you’re not picking up on things that are not there – or obscuring things that are.

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Once you’ve decided to use thematic analysis, there are different approaches to consider.

There’s the distinction between inductive and deductive approaches:

  • An inductive approach involves allowing the data to determine your themes.
  • A deductive approach involves coming to the data with some preconceived themes you expect to find reflected there, based on theory or existing knowledge.

Ask yourself: Does my theoretical framework give me a strong idea of what kind of themes I expect to find in the data (deductive), or am I planning to develop my own framework based on what I find (inductive)?

There’s also the distinction between a semantic and a latent approach:

  • A semantic approach involves analyzing the explicit content of the data.
  • A latent approach involves reading into the subtext and assumptions underlying the data.

Ask yourself: Am I interested in people’s stated opinions (semantic) or in what their statements reveal about their assumptions and social context (latent)?

After you’ve decided thematic analysis is the right method for analyzing your data, and you’ve thought about the approach you’re going to take, you can follow the six steps developed by Braun and Clarke .

The first step is to get to know our data. It’s important to get a thorough overview of all the data we collected before we start analyzing individual items.

This might involve transcribing audio , reading through the text and taking initial notes, and generally looking through the data to get familiar with it.

Next up, we need to code the data. Coding means highlighting sections of our text – usually phrases or sentences – and coming up with shorthand labels or “codes” to describe their content.

Let’s take a short example text. Say we’re researching perceptions of climate change among conservative voters aged 50 and up, and we have collected data through a series of interviews. An extract from one interview looks like this:

In this extract, we’ve highlighted various phrases in different colors corresponding to different codes. Each code describes the idea or feeling expressed in that part of the text.

At this stage, we want to be thorough: we go through the transcript of every interview and highlight everything that jumps out as relevant or potentially interesting. As well as highlighting all the phrases and sentences that match these codes, we can keep adding new codes as we go through the text.

After we’ve been through the text, we collate together all the data into groups identified by code. These codes allow us to gain a a condensed overview of the main points and common meanings that recur throughout the data.

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thematic analysis research paper themes

Next, we look over the codes we’ve created, identify patterns among them, and start coming up with themes.

Themes are generally broader than codes. Most of the time, you’ll combine several codes into a single theme. In our example, we might start combining codes into themes like this:

At this stage, we might decide that some of our codes are too vague or not relevant enough (for example, because they don’t appear very often in the data), so they can be discarded.

Other codes might become themes in their own right. In our example, we decided that the code “uncertainty” made sense as a theme, with some other codes incorporated into it.

Again, what we decide will vary according to what we’re trying to find out. We want to create potential themes that tell us something helpful about the data for our purposes.

Now we have to make sure that our themes are useful and accurate representations of the data. Here, we return to the data set and compare our themes against it. Are we missing anything? Are these themes really present in the data? What can we change to make our themes work better?

If we encounter problems with our themes, we might split them up, combine them, discard them or create new ones: whatever makes them more useful and accurate.

For example, we might decide upon looking through the data that “changing terminology” fits better under the “uncertainty” theme than under “distrust of experts,” since the data labelled with this code involves confusion, not necessarily distrust.

Now that you have a final list of themes, it’s time to name and define each of them.

Defining themes involves formulating exactly what we mean by each theme and figuring out how it helps us understand the data.

Naming themes involves coming up with a succinct and easily understandable name for each theme.

For example, we might look at “distrust of experts” and determine exactly who we mean by “experts” in this theme. We might decide that a better name for the theme is “distrust of authority” or “conspiracy thinking”.

Finally, we’ll write up our analysis of the data. Like all academic texts, writing up a thematic analysis requires an introduction to establish our research question, aims and approach.

We should also include a methodology section, describing how we collected the data (e.g. through semi-structured interviews or open-ended survey questions ) and explaining how we conducted the thematic analysis itself.

The results or findings section usually addresses each theme in turn. We describe how often the themes come up and what they mean, including examples from the data as evidence. Finally, our conclusion explains the main takeaways and shows how the analysis has answered our research question.

In our example, we might argue that conspiracy thinking about climate change is widespread among older conservative voters, point out the uncertainty with which many voters view the issue, and discuss the role of misinformation in respondents’ perceptions.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

  • Normal distribution
  • Measures of central tendency
  • Chi square tests
  • Confidence interval
  • Quartiles & Quantiles
  • Cluster sampling
  • Stratified sampling
  • Discourse analysis
  • Cohort study
  • Peer review
  • Ethnography

Research bias

  • Implicit bias
  • Cognitive bias
  • Conformity bias
  • Hawthorne effect
  • Availability heuristic
  • Attrition bias
  • Social desirability bias

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What (Exactly) Is Thematic Analysis?

Plain-Language Explanation & Definition (With Examples)

By: Jenna Crosley (PhD). Expert Reviewed By: Dr Eunice Rautenbach | April 2021

Thematic analysis is one of the most popular qualitative analysis techniques we see students opting for at Grad Coach – and for good reason. Despite its relative simplicity, thematic analysis can be a very powerful analysis technique when used correctly. In this post, we’ll unpack thematic analysis using plain language (and loads of examples) so that you can conquer your analysis with confidence.

Thematic Analysis 101

  • Basic terminology relating to thematic analysis
  • What is thematic analysis
  • When to use thematic analysis
  • The main approaches to thematic analysis
  • The three types of thematic analysis
  • How to “do” thematic analysis (the process)
  • Tips and suggestions

First, the lingo…

Before we begin, let’s first lay down some terminology. When undertaking thematic analysis, you’ll make use of codes . A code is a label assigned to a piece of text, and the aim of using a code is to identify and summarise important concepts within a set of data, such as an interview transcript.

For example, if you had the sentence, “My rabbit ate my shoes”, you could use the codes “rabbit” or “shoes” to highlight these two concepts. The process of assigning codes is called coding. If this is a new concept to you, be sure to check out our detailed post about qualitative coding .

Codes are vital as they lay a foundation for themes . But what exactly is a theme? Simply put, a theme is a pattern that can be identified within a data set. In other words, it’s a topic or concept that pops up repeatedly throughout your data. Grouping your codes into themes serves as a way of summarising sections of your data in a useful way that helps you answer your research question(s) and achieve your research aim(s).

Alright – with that out of the way, let’s jump into the wonderful world of thematic analysis…

Thematic analysis 101

What is thematic analysis?

Thematic analysis is the study of patterns to uncover meaning . In other words, it’s about analysing the patterns and themes within your data set to identify the underlying meaning. Importantly, this process is driven by your research aims and questions , so it’s not necessary to identify every possible theme in the data, but rather to focus on the key aspects that relate to your research questions .

Although the research questions are a driving force in thematic analysis (and pretty much all analysis methods), it’s important to remember that these questions are not necessarily fixed . As thematic analysis tends to be a bit of an exploratory process, research questions can evolve as you progress with your coding and theme identification.

Thematic analysis is about analysing the themes within your data set to identify meaning, based on your research questions.

When should you use thematic analysis?

There are many potential qualitative analysis methods that you can use to analyse a dataset. For example, content analysis , discourse analysis , and narrative analysis are popular choices. So why use thematic analysis?

Thematic analysis is highly beneficial when working with large bodies of data ,  as it allows you to divide and categorise large amounts of data in a way that makes it easier to digest. Thematic analysis is particularly useful when looking for subjective information , such as a participant’s experiences, views, and opinions. For this reason, thematic analysis is often conducted on data derived from interviews , conversations, open-ended survey responses , and social media posts.

Your research questions can also give you an idea of whether you should use thematic analysis or not. For example, if your research questions were to be along the lines of:

  • How do dog walkers perceive rules and regulations on dog-friendly beaches?
  • What are students’ experiences with the shift to online learning?
  • What opinions do health professionals hold about the Hippocratic code?
  • How is gender constructed in a high school classroom setting?

These examples are all research questions centering on the subjective experiences of participants and aim to assess experiences, views, and opinions. Therefore, thematic analysis presents a possible approach.

In short, thematic analysis is a good choice when you are wanting to categorise large bodies of data (although the data doesn’t necessarily have to be large), particularly when you are interested in subjective experiences .

Thematic analysis allows you to divide and categorise large amounts of data in a way that makes it far easier to digest.

What are the main approaches?

Broadly speaking, there are two overarching approaches to thematic analysis: inductive and deductive . The approach you take will depend on what is most suitable in light of your research aims and questions. Let’s have a look at the options.

The inductive approach

The inductive approach involves deriving meaning and creating themes from data without any preconceptions . In other words, you’d dive into your analysis without any idea of what codes and themes will emerge, and thus allow these to emerge from the data.

For example, if you’re investigating typical lunchtime conversational topics in a university faculty, you’d enter the research without any preconceived codes, themes or expected outcomes. Of course, you may have thoughts about what might be discussed (e.g., academic matters because it’s an academic setting), but the objective is to not let these preconceptions inform your analysis.

The inductive approach is best suited to research aims and questions that are exploratory in nature , and cases where there is little existing research on the topic of interest.

The deductive approach

In contrast to the inductive approach, a deductive approach involves jumping into your analysis with a pre-determined set of codes . Usually, this approach is informed by prior knowledge and/or existing theory or empirical research (which you’d cover in your literature review ).

For example, a researcher examining the impact of a specific psychological intervention on mental health outcomes may draw on an existing theoretical framework that includes concepts such as coping strategies, social support, and self-efficacy, using these as a basis for a set of pre-determined codes.

The deductive approach is best suited to research aims and questions that are confirmatory in nature , and cases where there is a lot of existing research on the topic of interest.

Regardless of whether you take the inductive or deductive approach, you’ll also need to decide what level of content your analysis will focus on – specifically, the semantic level or the latent level.

A semantic-level focus ignores the underlying meaning of data , and identifies themes based only on what is explicitly or overtly stated or written – in other words, things are taken at face value.

In contrast, a latent-level focus concentrates on the underlying meanings and looks at the reasons for semantic content. Furthermore, in contrast to the semantic approach, a latent approach involves an element of interpretation , where data is not just taken at face value, but meanings are also theorised.

“But how do I know when to use what approach?”, I hear you ask.

Well, this all depends on the type of data you’re analysing and what you’re trying to achieve with your analysis. For example, if you’re aiming to analyse explicit opinions expressed in interviews and you know what you’re looking for ahead of time (based on a collection of prior studies), you may choose to take a deductive approach with a semantic-level focus.

On the other hand, if you’re looking to explore the underlying meaning expressed by participants in a focus group, and you don’t have any preconceptions about what to expect, you’ll likely opt for an inductive approach with a latent-level focus.

Simply put, the nature and focus of your research, especially your research aims , objectives and questions will  inform the approach you take to thematic analysis.

The four main approaches to thematic analysis are inductive, deductive, semantic and latent. The choice of approach depends on the type of data and what you're trying to achieve

What are the types of thematic analysis?

Now that you’ve got an understanding of the overarching approaches to thematic analysis, it’s time to have a look at the different types of thematic analysis you can conduct. Broadly speaking, there are three “types” of thematic analysis:

  • Reflexive thematic analysis
  • Codebook thematic analysis
  • Coding reliability thematic analysis

Let’s have a look at each of these:

Reflexive thematic analysis takes an inductive approach, letting the codes and themes emerge from that data. This type of thematic analysis is very flexible, as it allows researchers to change, remove, and add codes as they work through the data. As the name suggests, reflexive thematic analysis emphasizes the active engagement of the researcher in critically reflecting on their assumptions, biases, and interpretations, and how these may shape the analysis.

Reflexive thematic analysis typically involves iterative and reflexive cycles of coding, interpreting, and reflecting on data, with the aim of producing nuanced and contextually sensitive insights into the research topic, while at the same time recognising and addressing the subjective nature of the research process.

Codebook thematic analysis , on the other hand, lays on the opposite end of the spectrum. Taking a deductive approach, this type of thematic analysis makes use of structured codebooks containing clearly defined, predetermined codes. These codes are typically drawn from a combination of existing theoretical theories, empirical studies and prior knowledge of the situation.

Codebook thematic analysis aims to produce reliable and consistent findings. Therefore, it’s often used in studies where a clear and predefined coding framework is desired to ensure rigour and consistency in data analysis.

Coding reliability thematic analysis necessitates the work of multiple coders, and the design is specifically intended for research teams. With this type of analysis, codebooks are typically fixed and are rarely altered.

The benefit of this form of analysis is that it brings an element of intercoder reliability where coders need to agree upon the codes used, which means that the outcome is more rigorous as the element of subjectivity is reduced. In other words, multiple coders discuss which codes should be used and which shouldn’t, and this consensus reduces the bias of having one individual coder decide upon themes.

Quick Recap: Thematic analysis approaches and types

To recap, the two main approaches to thematic analysis are inductive , and deductive . Then we have the three types of thematic analysis: reflexive, codebook and coding reliability . Which type of thematic analysis you opt for will need to be informed by factors such as:

  • The approach you are taking. For example, if you opt for an inductive approach, you’ll likely utilise reflexive thematic analysis.
  • Whether you’re working alone or in a group . It’s likely that, if you’re doing research as part of your postgraduate studies, you’ll be working alone. This means that you’ll need to choose between reflexive and codebook thematic analysis.

Now that we’ve covered the “what” in terms of thematic analysis approaches and types, it’s time to look at the “how” of thematic analysis.

Need a helping hand?

thematic analysis research paper themes

How to “do” thematic analysis

At this point, you’re ready to get going with your analysis, so let’s dive right into the thematic analysis process. Keep in mind that what we’ll cover here is a generic process, and the relevant steps will vary depending on the approach and type of thematic analysis you opt for.

Step 1: Get familiar with the data

The first step in your thematic analysis involves getting a feel for your data and seeing what general themes pop up. If you’re working with audio data, this is where you’ll do the transcription , converting audio to text.

At this stage, you’ll want to come up with preliminary thoughts about what you’ll code , what codes you’ll use for them, and what codes will accurately describe your content. It’s a good idea to revisit your research topic , and your aims and objectives at this stage. For example, if you’re looking at what people feel about different types of dogs, you can code according to when different breeds are mentioned (e.g., border collie, Labrador, corgi) and when certain feelings/emotions are brought up.

As a general tip, it’s a good idea to keep a reflexivity journal . This is where you’ll write down how you coded your data, why you coded your data in that particular way, and what the outcomes of this data coding are. Using a reflexive journal from the start will benefit you greatly in the final stages of your analysis because you can reflect on the coding process and assess whether you have coded in a manner that is reliable and whether your codes and themes support your findings.

As you can imagine, a reflexivity journal helps to increase reliability as it allows you to analyse your data systematically and consistently. If you choose to make use of a reflexivity journal, this is the stage where you’ll want to take notes about your initial codes and list them in your journal so that you’ll have an idea of what exactly is being reflected in your data. At a later stage in the analysis, this data can be more thoroughly coded, or the identified codes can be divided into more specific ones.

Keep a research journal for thematic analysis

Step 2: Search for patterns or themes in the codes

Step 2! You’re going strong. In this step, you’ll want to look out for patterns or themes in your codes. Moving from codes to themes is not necessarily a smooth or linear process. As you become more and more familiar with the data, you may find that you need to assign different codes or themes according to new elements you find. For example, if you were analysing a text talking about wildlife, you may come across the codes, “pigeon”, “canary” and “budgerigar” which can fall under the theme of birds.

As you work through the data, you may start to identify subthemes , which are subdivisions of themes that focus specifically on an aspect within the theme that is significant or relevant to your research question. For example, if your theme is a university, your subthemes could be faculties or departments at that university.

In this stage of the analysis, your reflexivity journal entries need to reflect how codes were interpreted and combined to form themes.

Step 3: Review themes

By now you’ll have a good idea of your codes, themes, and potentially subthemes. Now it’s time to review all the themes you’ve identified . In this step, you’ll want to check that everything you’ve categorised as a theme actually fits the data, whether the themes do indeed exist in the data, whether there are any themes missing , and whether you can move on to the next step knowing that you’ve coded all your themes accurately and comprehensively . If you find that your themes have become too broad and there is far too much information under one theme, it may be useful to split this into more themes so that you’re able to be more specific with your analysis.

In your reflexivity journal, you’ll want to write about how you understood the themes and how they are supported by evidence, as well as how the themes fit in with your codes. At this point, you’ll also want to revisit your research questions and make sure that the data and themes you’ve identified are directly relevant to these questions .

If you find that your themes have become too broad and there is too much information under one theme, you can split them up into more themes, so that you can be more specific with your analysis.

Step 4: Finalise Themes

By this point, your analysis will really start to take shape. In the previous step, you reviewed and refined your themes, and now it’s time to label and finalise them . It’s important to note here that, just because you’ve moved onto the next step, it doesn’t mean that you can’t go back and revise or rework your themes. In contrast to the previous step, finalising your themes means spelling out what exactly the themes consist of, and describe them in detail . If you struggle with this, you may want to return to your data to make sure that your data and coding do represent the themes, and if you need to divide your themes into more themes (i.e., return to step 3).

When you name your themes, make sure that you select labels that accurately encapsulate the properties of the theme . For example, a theme name such as “enthusiasm in professionals” leaves the question of “who are the professionals?”, so you’d want to be more specific and label the theme as something along the lines of “enthusiasm in healthcare professionals”.

It is very important at this stage that you make sure that your themes align with your research aims and questions . When you’re finalising your themes, you’re also nearing the end of your analysis and need to keep in mind that your final report (discussed in the next step) will need to fit in with the aims and objectives of your research.

In your reflexivity journal, you’ll want to write down a few sentences describing your themes and how you decided on these. Here, you’ll also want to mention how the theme will contribute to the outcomes of your research, and also what it means in relation to your research questions and focus of your research.

By the end of this stage, you’ll be done with your themes – meaning it’s time to write up your findings and produce a report.

It is very important at the theme finalisation stage to make sure that your themes align with your research questions.

Step 5: Produce your report

You’re nearly done! Now that you’ve analysed your data, it’s time to report on your findings. A typical thematic analysis report consists of:

  • An introduction
  • A methodology section
  • Your results and findings
  • A conclusion

When writing your report, make sure that you provide enough information for a reader to be able to evaluate the rigour of your analysis. In other words, the reader needs to know the exact process you followed when analysing your data and why. The questions of “what”, “how”, “why”, “who”, and “when” may be useful in this section.

So, what did you investigate? How did you investigate it? Why did you choose this particular method? Who does your research focus on, and who are your participants? When did you conduct your research, when did you collect your data, and when was the data produced? Your reflexivity journal will come in handy here as within it you’ve already labelled, described, and supported your themes.

If you’re undertaking a thematic analysis as part of a dissertation or thesis, this discussion will be split across your methodology, results and discussion chapters . For more information about those chapters, check out our detailed post about dissertation structure .

It’s absolutely vital that, when writing up your results, you back up every single one of your findings with quotations . The reader needs to be able to see that what you’re reporting actually exists within the results. Also make sure that, when reporting your findings, you tie them back to your research questions . You don’t want your reader to be looking through your findings and asking, “So what?”, so make sure that every finding you represent is relevant to your research topic and questions.

Quick Recap: How to “do” thematic analysis

Getting familiar with your data: Here you’ll read through your data and get a general overview of what you’re working with. At this stage, you may identify a few general codes and themes that you’ll make use of in the next step.

Search for patterns or themes in your codes : Here you’ll dive into your data and pick out the themes and codes relevant to your research question(s).

Review themes : In this step, you’ll revisit your codes and themes to make sure that they are all truly representative of the data, and that you can use them in your final report.

Finalise themes : Here’s where you “solidify” your analysis and make it report-ready by describing and defining your themes.

Produce your report : This is the final step of your thematic analysis process, where you put everything you’ve found together and report on your findings.

Tips & Suggestions

In the video below, we share 6 time-saving tips and tricks to help you approach your thematic analysis as effectively and efficiently as possible.

Wrapping Up

In this article, we’ve covered the basics of thematic analysis – what it is, when to use it, the different approaches and types of thematic analysis, and how to perform a thematic analysis.

If you have any questions about thematic analysis, drop a comment below and we’ll do our best to assist. If you’d like 1-on-1 support with your thematic analysis, be sure to check out our research coaching services here .

thematic analysis research paper themes

Psst… there’s more (for free)

This post is part of our dissertation mini-course, which covers everything you need to get started with your dissertation, thesis or research project. 

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Thematic analysis explainer

21 Comments

Ollie

I really appreciate the help

Oliv

Hello Sir, how many levels of coding can be done in thematic analysis? We generate codes from the transcripts, then subthemes from the codes and themes from subthemes, isn’t it? Should these themes be again grouped together? how many themes can be derived?can you please share an example of coding through thematic analysis in a tabular format?

Abdullahi Maude

I’ve found the article very educative and useful

TOMMY BIN SEMBEH

Excellent. Very helpful and easy to understand.

SK

This article so far has been most helpful in understanding how to write an analysis chapter. Thank you.

Ruwini

My research topic is the challenges face by the school principal on the process of procurement . Thematic analysis is it sutable fir data analysis ?

M. Anwar

It is a great help. Thanks.

Pari

Best advice. Worth reading. Thank you.

Yvonne Worrell

Where can I find an example of a template analysis table ?

aishch

Finally I got the best article . I wish they also have every psychology topics.

Rosa Ophelia Velarde

Hello, Sir/Maam

I am actually finding difficulty in doing qualitative analysis of my data and how to triangulate this with quantitative data. I encountered your web by accident in the process of searching for a much simplified way of explaining about thematic analysis such as coding, thematic analysis, write up. When your query if I need help popped up, I was hesitant to answer. Because I think this is for fee and I cannot afford. So May I just ask permission to copy for me to read and guide me to study so I can apply it myself for my gathered qualitative data for my graduate study.

Thank you very much! this is very helpful to me in my Graduate research qualitative data analysis.

SAMSON ROTTICH

Thank you very much. I find your guidance here helpful. Kindly let help me understand how to write findings and discussions.

arshad ahmad

i am having troubles with the concept of framework analysis which i did not find here and i have been an assignment on framework analysis

tayron gee

I was discouraged and felt insecure because after more than a year of writing my thesis, my work seemed lost its direction after being checked. But, I am truly grateful because through the comments, corrections, and guidance of the wisdom of my director, I can already see the bright light because of thematic analysis. I am working with Biblical Texts. And thematic analysis will be my method. Thank you.

OLADIPO TOSIN KABIR

lovely and helpful. thanks

Imdad Hussain

very informative information.

Ricky Fordan

thank you very much!, this is very helpful in my report, God bless……..

Akosua Andrews

Thank you for the insight. I am really relieved as you have provided a super guide for my thesis.

Christelle M.

Thanks a lot, really enlightening

fariya shahzadi

excellent! very helpful thank a lot for your great efforts

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  • 5 Highland Park, NJ, USA
  • 6 Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
  • Correspondence to: C H Saunders catherine.hylas.saunders{at}dartmouth.edu
  • Accepted 26 April 2023

Qualitative research methods explore and provide deep contextual understanding of real world issues, including people’s beliefs, perspectives, and experiences. Whether through analysis of interviews, focus groups, structured observation, or multimedia data, qualitative methods offer unique insights in applied health services research that other approaches cannot deliver. However, many clinicians and researchers hesitate to use these methods, or might not use them effectively, which can leave relevant areas of inquiry inadequately explored. Thematic analysis is one of the most common and flexible methods to examine qualitative data collected in health services research. This article offers practical thematic analysis as a step-by-step approach to qualitative analysis for health services researchers, with a focus on accessibility for patients, care partners, clinicians, and others new to thematic analysis. Along with detailed instructions covering three steps of reading, coding, and theming, the article includes additional novel and practical guidance on how to draft effective codes, conduct a thematic analysis session, and develop meaningful themes. This approach aims to improve consistency and rigor in thematic analysis, while also making this method more accessible for multidisciplinary research teams.

Through qualitative methods, researchers can provide deep contextual understanding of real world issues, and generate new knowledge to inform hypotheses, theories, research, and clinical care. Approaches to data collection are varied, including interviews, focus groups, structured observation, and analysis of multimedia data, with qualitative research questions aimed at understanding the how and why of human experience. 1 2 Qualitative methods produce unique insights in applied health services research that other approaches cannot deliver. In particular, researchers acknowledge that thematic analysis is a flexible and powerful method of systematically generating robust qualitative research findings by identifying, analysing, and reporting patterns (themes) within data. 3 4 5 6 Although qualitative methods are increasingly valued for answering clinical research questions, many researchers are unsure how to apply them or consider them too time consuming to be useful in responding to practical challenges 7 or pressing situations such as public health emergencies. 8 Consequently, researchers might hesitate to use them, or use them improperly. 9 10 11

Although much has been written about how to perform thematic analysis, practical guidance for non-specialists is sparse. 3 5 6 12 13 In the multidisciplinary field of health services research, qualitative data analysis can confound experienced researchers and novices alike, which can stoke concerns about rigor, particularly for those more familiar with quantitative approaches. 14 Since qualitative methods are an area of specialisation, support from experts is beneficial. However, because non-specialist perspectives can enhance data interpretation and enrich findings, there is a case for making thematic analysis easier, more rapid, and more efficient, 8 particularly for patients, care partners, clinicians, and other stakeholders. A practical guide to thematic analysis might encourage those on the ground to use these methods in their work, unearthing insights that would otherwise remain undiscovered.

Given the need for more accessible qualitative analysis approaches, we present a simple, rigorous, and efficient three step guide for practical thematic analysis. We include new guidance on the mechanics of thematic analysis, including developing codes, constructing meaningful themes, and hosting a thematic analysis session. We also discuss common pitfalls in thematic analysis and how to avoid them.

Summary points

Qualitative methods are increasingly valued in applied health services research, but multidisciplinary research teams often lack accessible step-by-step guidance and might struggle to use these approaches

A newly developed approach, practical thematic analysis, uses three simple steps: reading, coding, and theming

Based on Braun and Clarke’s reflexive thematic analysis, our streamlined yet rigorous approach is designed for multidisciplinary health services research teams, including patients, care partners, and clinicians

This article also provides companion materials including a slide presentation for teaching practical thematic analysis to research teams, a sample thematic analysis session agenda, a theme coproduction template for use during the session, and guidance on using standardised reporting criteria for qualitative research

In their seminal work, Braun and Clarke developed a six phase approach to reflexive thematic analysis. 4 12 We built on their method to develop practical thematic analysis ( box 1 , fig 1 ), which is a simplified and instructive approach that retains the substantive elements of their six phases. Braun and Clarke’s phase 1 (familiarising yourself with the dataset) is represented in our first step of reading. Phase 2 (coding) remains as our second step of coding. Phases 3 (generating initial themes), 4 (developing and reviewing themes), and 5 (refining, defining, and naming themes) are represented in our third step of theming. Phase 6 (writing up) also occurs during this third step of theming, but after a thematic analysis session. 4 12

Key features and applications of practical thematic analysis

Step 1: reading.

All manuscript authors read the data

All manuscript authors write summary memos

Step 2: Coding

Coders perform both data management and early data analysis

Codes are complete thoughts or sentences, not categories

Step 3: Theming

Researchers host a thematic analysis session and share different perspectives

Themes are complete thoughts or sentences, not categories

Applications

For use by practicing clinicians, patients and care partners, students, interdisciplinary teams, and those new to qualitative research

When important insights from healthcare professionals are inaccessible because they do not have qualitative methods training

When time and resources are limited

Fig 1

Steps in practical thematic analysis

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We present linear steps, but as qualitative research is usually iterative, so too is thematic analysis. 15 Qualitative researchers circle back to earlier work to check whether their interpretations still make sense in the light of additional insights, adapting as necessary. While we focus here on the practical application of thematic analysis in health services research, we recognise our approach exists in the context of the broader literature on thematic analysis and the theoretical underpinnings of qualitative methods as a whole. For a more detailed discussion of these theoretical points, as well as other methods widely used in health services research, we recommend reviewing the sources outlined in supplemental material 1. A strong and nuanced understanding of the context and underlying principles of thematic analysis will allow for higher quality research. 16

Practical thematic analysis is a highly flexible approach that can draw out valuable findings and generate new hypotheses, including in cases with a lack of previous research to build on. The approach can also be used with a variety of data, such as transcripts from interviews or focus groups, patient encounter transcripts, professional publications, observational field notes, and online activity logs. Importantly, successful practical thematic analysis is predicated on having high quality data collected with rigorous methods. We do not describe qualitative research design or data collection here. 11 17

In supplemental material 1, we summarise the foundational methods, concepts, and terminology in qualitative research. Along with our guide below, we include a companion slide presentation for teaching practical thematic analysis to research teams in supplemental material 2. We provide a theme coproduction template for teams to use during thematic analysis sessions in supplemental material 3. Our method aligns with the major qualitative reporting frameworks, including the Consolidated Criteria for Reporting Qualitative Research (COREQ). 18 We indicate the corresponding step in practical thematic analysis for each COREQ item in supplemental material 4.

Familiarisation and memoing

We encourage all manuscript authors to review the full dataset (eg, interview transcripts) to familiarise themselves with it. This task is most critical for those who will later be engaged in the coding and theming steps. Although time consuming, it is the best way to involve team members in the intellectual work of data interpretation, so that they can contribute to the analysis and contextualise the results. If this task is not feasible given time limitations or large quantities of data, the data can be divided across team members. In this case, each piece of data should be read by at least two individuals who ideally represent different professional roles or perspectives.

We recommend that researchers reflect on the data and independently write memos, defined as brief notes on thoughts and questions that arise during reading, and a summary of their impressions of the dataset. 2 19 Memoing is an opportunity to gain insights from varying perspectives, particularly from patients, care partners, clinicians, and others. It also gives researchers the opportunity to begin to scope which elements of and concepts in the dataset are relevant to the research question.

Data saturation

The concept of data saturation ( box 2 ) is a foundation of qualitative research. It is defined as the point in analysis at which new data tend to be redundant of data already collected. 21 Qualitative researchers are expected to report their approach to data saturation. 18 Because thematic analysis is iterative, the team should discuss saturation throughout the entire process, beginning with data collection and continuing through all steps of the analysis. 22 During step 1 (reading), team members might discuss data saturation in the context of summary memos. Conversations about saturation continue during step 2 (coding), with confirmation that saturation has been achieved during step 3 (theming). As a rule of thumb, researchers can often achieve saturation in 9-17 interviews or 4-8 focus groups, but this will vary depending on the specific characteristics of the study. 23

Data saturation in context

Braun and Clarke discourage the use of data saturation to determine sample size (eg, number of interviews), because it assumes that there is an objective truth to be captured in the data (sometimes known as a positivist perspective). 20 Qualitative researchers often try to avoid positivist approaches, arguing that there is no one true way of seeing the world, and will instead aim to gather multiple perspectives. 5 Although this theoretical debate with qualitative methods is important, we recognise that a priori estimates of saturation are often needed, particularly for investigators newer to qualitative research who might want a more pragmatic and applied approach. In addition, saturation based, sample size estimation can be particularly helpful in grant proposals. However, researchers should still follow a priori sample size estimation with a discussion to confirm saturation has been achieved.

Definition of coding

We describe codes as labels for concepts in the data that are directly relevant to the study objective. Historically, the purpose of coding was to distil the large amount of data collected into conceptually similar buckets so that researchers could review it in aggregate and identify key themes. 5 24 We advocate for a more analytical approach than is typical with thematic analysis. With our method, coding is both the foundation for and the beginning of thematic analysis—that is, early data analysis, management, and reduction occur simultaneously rather than as different steps. This approach moves the team more efficiently towards being able to describe themes.

Building the coding team

Coders are the research team members who directly assign codes to the data, reading all material and systematically labelling relevant data with appropriate codes. Ideally, at least two researchers would code every discrete data document, such as one interview transcript. 25 If this task is not possible, individual coders can each code a subset of the data that is carefully selected for key characteristics (sometimes known as purposive selection). 26 When using this approach, we recommend that at least 10% of data be coded by two or more coders to ensure consistency in codebook application. We also recommend coding teams of no more than four to five people, for practical reasons concerning maintaining consistency.

Clinicians, patients, and care partners bring unique perspectives to coding and enrich the analytical process. 27 Therefore, we recommend choosing coders with a mix of relevant experiences so that they can challenge and contextualise each other’s interpretations based on their own perspectives and opinions ( box 3 ). We recommend including both coders who collected the data and those who are naive to it, if possible, given their different perspectives. We also recommend all coders review the summary memos from the reading step so that key concepts identified by those not involved in coding can be integrated into the analytical process. In practice, this review means coding the memos themselves and discussing them during the code development process. This approach ensures that the team considers a diversity of perspectives.

Coding teams in context

The recommendation to use multiple coders is a departure from Braun and Clarke. 28 29 When the views, experiences, and training of each coder (sometimes known as positionality) 30 are carefully considered, having multiple coders can enhance interpretation and enrich findings. When these perspectives are combined in a team setting, researchers can create shared meaning from the data. Along with the practical consideration of distributing the workload, 31 inclusion of these multiple perspectives increases the overall quality of the analysis by mitigating the impact of any one coder’s perspective. 30

Coding tools

Qualitative analysis software facilitates coding and managing large datasets but does not perform the analytical work. The researchers must perform the analysis themselves. Most programs support queries and collaborative coding by multiple users. 32 Important factors to consider when choosing software can include accessibility, cost, interoperability, the look and feel of code reports, and the ease of colour coding and merging codes. Coders can also use low tech solutions, including highlighters, word processors, or spreadsheets.

Drafting effective codes

To draft effective codes, we recommend that the coders review each document line by line. 33 As they progress, they can assign codes to segments of data representing passages of interest. 34 Coders can also assign multiple codes to the same passage. Consensus among coders on what constitutes a minimum or maximum amount of text for assigning a code is helpful. As a general rule, meaningful segments of text for coding are shorter than one paragraph, but longer than a few words. Coders should keep the study objective in mind when determining which data are relevant ( box 4 ).

Code types in context

Similar to Braun and Clarke’s approach, practical thematic analysis does not specify whether codes are based on what is evident from the data (sometimes known as semantic) or whether they are based on what can be inferred at a deeper level from the data (sometimes known as latent). 4 12 35 It also does not specify whether they are derived from the data (sometimes known as inductive) or determined ahead of time (sometimes known as deductive). 11 35 Instead, it should be noted that health services researchers conducting qualitative studies often adopt all these approaches to coding (sometimes known as hybrid analysis). 3

In practical thematic analysis, codes should be more descriptive than general categorical labels that simply group data with shared characteristics. At a minimum, codes should form a complete (or full) thought. An easy way to conceptualise full thought codes is as complete sentences with subjects and verbs ( table 1 ), although full sentence coding is not always necessary. With full thought codes, researchers think about the data more deeply and capture this insight in the codes. This coding facilitates the entire analytical process and is especially valuable when moving from codes to broader themes. Experienced qualitative researchers often intuitively use full thought or sentence codes, but this practice has not been explicitly articulated as a path to higher quality coding elsewhere in the literature. 6

Example transcript with codes used in practical thematic analysis 36

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Depending on the nature of the data, codes might either fall into flat categories or be arranged hierarchically. Flat categories are most common when the data deal with topics on the same conceptual level. In other words, one topic is not a subset of another topic. By contrast, hierarchical codes are more appropriate for concepts that naturally fall above or below each other. Hierarchical coding can also be a useful form of data management and might be necessary when working with a large or complex dataset. 5 Codes grouped into these categories can also make it easier to naturally transition into generating themes from the initial codes. 5 These decisions between flat versus hierarchical coding are part of the work of the coding team. In both cases, coders should ensure that their code structures are guided by their research questions.

Developing the codebook

A codebook is a shared document that lists code labels and comprehensive descriptions for each code, as well as examples observed within the data. Good code descriptions are precise and specific so that coders can consistently assign the same codes to relevant data or articulate why another coder would do so. Codebook development is iterative and involves input from the entire coding team. However, as those closest to the data, coders must resist undue influence, real or perceived, from other team members with conflicting opinions—it is important to mitigate the risk that more senior researchers, like principal investigators, exert undue influence on the coders’ perspectives.

In practical thematic analysis, coders begin codebook development by independently coding a small portion of the data, such as two to three transcripts or other units of analysis. Coders then individually produce their initial codebooks. This task will require them to reflect on, organise, and clarify codes. The coders then meet to reconcile the draft codebooks, which can often be difficult, as some coders tend to lump several concepts together while others will split them into more specific codes. Discussing disagreements and negotiating consensus are necessary parts of early data analysis. Once the codebook is relatively stable, we recommend soliciting input on the codes from all manuscript authors. Yet, coders must ultimately be empowered to finalise the details so that they are comfortable working with the codebook across a large quantity of data.

Assigning codes to the data

After developing the codebook, coders will use it to assign codes to the remaining data. While the codebook’s overall structure should remain constant, coders might continue to add codes corresponding to any new concepts observed in the data. If new codes are added, coders should review the data they have already coded and determine whether the new codes apply. Qualitative data analysis software can be useful for editing or merging codes.

We recommend that coders periodically compare their code occurrences ( box 5 ), with more frequent check-ins if substantial disagreements occur. In the event of large discrepancies in the codes assigned, coders should revise the codebook to ensure that code descriptions are sufficiently clear and comprehensive to support coding alignment going forward. Because coding is an iterative process, the team can adjust the codebook as needed. 5 28 29

Quantitative coding in context

Researchers should generally avoid reporting code counts in thematic analysis. However, counts can be a useful proxy in maintaining alignment between coders on key concepts. 26 In practice, therefore, researchers should make sure that all coders working on the same piece of data assign the same codes with a similar pattern and that their memoing and overall assessment of the data are aligned. 37 However, the frequency of a code alone is not an indicator of its importance. It is more important that coders agree on the most salient points in the data; reviewing and discussing summary memos can be helpful here. 5

Researchers might disagree on whether or not to calculate and report inter-rater reliability. We note that quantitative tests for agreement, such as kappa statistics or intraclass correlation coefficients, can be distracting and might not provide meaningful results in qualitative analyses. Similarly, Braun and Clarke argue that expecting perfect alignment on coding is inconsistent with the goal of co-constructing meaning. 28 29 Overall consensus on codes’ salience and contributions to themes is the most important factor.

Definition of themes

Themes are meta-constructs that rise above codes and unite the dataset ( box 6 , fig 2 ). They should be clearly evident, repeated throughout the dataset, and relevant to the research questions. 38 While codes are often explicit descriptions of the content in the dataset, themes are usually more conceptual and knit the codes together. 39 Some researchers hypothesise that theme development is loosely described in the literature because qualitative researchers simply intuit themes during the analytical process. 39 In practical thematic analysis, we offer a concrete process that should make developing meaningful themes straightforward.

Themes in context

According to Braun and Clarke, a theme “captures something important about the data in relation to the research question and represents some level of patterned response or meaning within the data set.” 4 Similarly, Braun and Clarke advise against themes as domain summaries. While different approaches can draw out themes from codes, the process begins by identifying patterns. 28 35 Like Braun and Clarke and others, we recommend that researchers consider the salience of certain themes, their prevalence in the dataset, and their keyness (ie, how relevant the themes are to the overarching research questions). 4 12 34

Fig 2

Use of themes in practical thematic analysis

Constructing meaningful themes

After coding all the data, each coder should independently reflect on the team’s summary memos (step 1), the codebook (step 2), and the coded data itself to develop draft themes (step 3). It can be illuminating for coders to review all excerpts associated with each code, so that they derive themes directly from the data. Researchers should remain focused on the research question during this step, so that themes have a clear relation with the overall project aim. Use of qualitative analysis software will make it easy to view each segment of data tagged with each code. Themes might neatly correspond to groups of codes. Or—more likely—they will unite codes and data in unexpected ways. A whiteboard or presentation slides might be helpful to organise, craft, and revise themes. We also provide a template for coproducing themes (supplemental material 3). As with codebook justification, team members will ideally produce individual drafts of the themes that they have identified in the data. They can then discuss these with the group and reach alignment or consensus on the final themes.

The team should ensure that all themes are salient, meaning that they are: supported by the data, relevant to the study objectives, and important. Similar to codes, themes are framed as complete thoughts or sentences, not categories. While codes and themes might appear to be similar to each other, the key distinction is that the themes represent a broader concept. Table 2 shows examples of codes and their corresponding themes from a previously published project that used practical thematic analysis. 36 Identifying three to four key themes that comprise a broader overarching theme is a useful approach. Themes can also have subthemes, if appropriate. 40 41 42 43 44

Example codes with themes in practical thematic analysis 36

Thematic analysis session

After each coder has independently produced draft themes, a carefully selected subset of the manuscript team meets for a thematic analysis session ( table 3 ). The purpose of this session is to discuss and reach alignment or consensus on the final themes. We recommend a session of three to five hours, either in-person or virtually.

Example agenda of thematic analysis session

The composition of the thematic analysis session team is important, as each person’s perspectives will shape the results. This group is usually a small subset of the broader research team, with three to seven individuals. We recommend that primary and senior authors work together to include people with diverse experiences related to the research topic. They should aim for a range of personalities and professional identities, particularly those of clinicians, trainees, patients, and care partners. At a minimum, all coders and primary and senior authors should participate in the thematic analysis session.

The session begins with each coder presenting their draft themes with supporting quotes from the data. 5 Through respectful and collaborative deliberation, the group will develop a shared set of final themes.

One team member facilitates the session. A firm, confident, and consistent facilitation style with good listening skills is critical. For practical reasons, this person is not usually one of the primary coders. Hierarchies in teams cannot be entirely flattened, but acknowledging them and appointing an external facilitator can reduce their impact. The facilitator can ensure that all voices are heard. For example, they might ask for perspectives from patient partners or more junior researchers, and follow up on comments from senior researchers to say, “We have heard your perspective and it is important; we want to make sure all perspectives in the room are equally considered.” Or, “I hear [senior person] is offering [x] idea, I’d like to hear other perspectives in the room.” The role of the facilitator is critical in the thematic analysis session. The facilitator might also privately discuss with more senior researchers, such as principal investigators and senior authors, the importance of being aware of their influence over others and respecting and eliciting the perspectives of more junior researchers, such as patients, care partners, and students.

To our knowledge, this discrete thematic analysis session is a novel contribution of practical thematic analysis. It helps efficiently incorporate diverse perspectives using the session agenda and theme coproduction template (supplemental material 3) and makes the process of constructing themes transparent to the entire research team.

Writing the report

We recommend beginning the results narrative with a summary of all relevant themes emerging from the analysis, followed by a subheading for each theme. Each subsection begins with a brief description of the theme and is illustrated with relevant quotes, which are contextualised and explained. The write-up should not simply be a list, but should contain meaningful analysis and insight from the researchers, including descriptions of how different stakeholders might have experienced a particular situation differently or unexpectedly.

In addition to weaving quotes into the results narrative, quotes can be presented in a table. This strategy is a particularly helpful when submitting to clinical journals with tight word count limitations. Quote tables might also be effective in illustrating areas of agreement and disagreement across stakeholder groups, with columns representing different groups and rows representing each theme or subtheme. Quotes should include an anonymous label for each participant and any relevant characteristics, such as role or gender. The aim is to produce rich descriptions. 5 We recommend against repeating quotations across multiple themes in the report, so as to avoid confusion. The template for coproducing themes (supplemental material 3) allows documentation of quotes supporting each theme, which might also be useful during report writing.

Visual illustrations such as a thematic map or figure of the findings can help communicate themes efficiently. 4 36 42 44 If a figure is not possible, a simple list can suffice. 36 Both must clearly present the main themes with subthemes. Thematic figures can facilitate confirmation that the researchers’ interpretations reflect the study populations’ perspectives (sometimes known as member checking), because authors can invite discussions about the figure and descriptions of findings and supporting quotes. 46 This process can enhance the validity of the results. 46

In supplemental material 4, we provide additional guidance on reporting thematic analysis consistent with COREQ. 18 Commonly used in health services research, COREQ outlines a standardised list of items to be included in qualitative research reports ( box 7 ).

Reporting in context

We note that use of COREQ or any other reporting guidelines does not in itself produce high quality work and should not be used as a substitute for general methodological rigor. Rather, researchers must consider rigor throughout the entire research process. As the issue of how to conceptualise and achieve rigorous qualitative research continues to be debated, 47 48 we encourage researchers to explicitly discuss how they have looked at methodological rigor in their reports. Specifically, we point researchers to Braun and Clarke’s 2021 tool for evaluating thematic analysis manuscripts for publication (“Twenty questions to guide assessment of TA [thematic analysis] research quality”). 16

Avoiding common pitfalls

Awareness of common mistakes can help researchers avoid improper use of qualitative methods. Improper use can, for example, prevent researchers from developing meaningful themes and can risk drawing inappropriate conclusions from the data. Braun and Clarke also warn of poor quality in qualitative research, noting that “coherence and integrity of published research does not always hold.” 16

Weak themes

An important distinction between high and low quality themes is that high quality themes are descriptive and complete thoughts. As such, they often contain subjects and verbs, and can be expressed as full sentences ( table 2 ). Themes that are simply descriptive categories or topics could fail to impart meaningful knowledge beyond categorisation. 16 49 50

Researchers will often move from coding directly to writing up themes, without performing the work of theming or hosting a thematic analysis session. Skipping concerted theming often results in themes that look more like categories than unifying threads across the data.

Unfocused analysis

Because data collection for qualitative research is often semi-structured (eg, interviews, focus groups), not all data will be directly relevant to the research question at hand. To avoid unfocused analysis and a correspondingly unfocused manuscript, we recommend that all team members keep the research objective in front of them at every stage, from reading to coding to theming. During the thematic analysis session, we recommend that the research question be written on a whiteboard so that all team members can refer back to it, and so that the facilitator can ensure that conversations about themes occur in the context of this question. Consistently focusing on the research question can help to ensure that the final report directly answers it, as opposed to the many other interesting insights that might emerge during the qualitative research process. Such insights can be picked up in a secondary analysis if desired.

Inappropriate quantification

Presenting findings quantitatively (eg, “We found 18 instances of participants mentioning safety concerns about the vaccines”) is generally undesirable in practical thematic analysis reporting. 51 Descriptive terms are more appropriate (eg, “participants had substantial concerns about the vaccines,” or “several participants were concerned about this”). This descriptive presentation is critical because qualitative data might not be consistently elicited across participants, meaning that some individuals might share certain information while others do not, simply based on how conversations evolve. Additionally, qualitative research does not aim to draw inferences outside its specific sample. Emphasising numbers in thematic analysis can lead to readers incorrectly generalising the findings. Although peer reviewers unfamiliar with thematic analysis often request this type of quantification, practitioners of practical thematic analysis can confidently defend their decision to avoid it. If quantification is methodologically important, we recommend simultaneously conducting a survey or incorporating standardised interview techniques into the interview guide. 11

Neglecting group dynamics

Researchers should concertedly consider group dynamics in the research team. Particular attention should be paid to power relations and the personality of team members, which can include aspects such as who most often speaks, who defines concepts, and who resolves disagreements that might arise within the group. 52

The perspectives of patient and care partners are particularly important to cultivate. Ideally, patient partners are meaningfully embedded in studies from start to finish, not just for practical thematic analysis. 53 Meaningful engagement can build trust, which makes it easier for patient partners to ask questions, request clarification, and share their perspectives. Professional team members should actively encourage patient partners by emphasising that their expertise is critically important and valued. Noting when a patient partner might be best positioned to offer their perspective can be particularly powerful.

Insufficient time allocation

Researchers must allocate enough time to complete thematic analysis. Working with qualitative data takes time, especially because it is often not a linear process. As the strength of thematic analysis lies in its ability to make use of the rich details and complexities of the data, we recommend careful planning for the time required to read and code each document.

Estimating the necessary time can be challenging. For step 1 (reading), researchers can roughly calculate the time required based on the time needed to read and reflect on one piece of data. For step 2 (coding), the total amount of time needed can be extrapolated from the time needed to code one document during codebook development. We also recommend three to five hours for the thematic analysis session itself, although coders will need to independently develop their draft themes beforehand. Although the time required for practical thematic analysis is variable, teams should be able to estimate their own required effort with these guidelines.

Practical thematic analysis builds on the foundational work of Braun and Clarke. 4 16 We have reframed their six phase process into three condensed steps of reading, coding, and theming. While we have maintained important elements of Braun and Clarke’s reflexive thematic analysis, we believe that practical thematic analysis is conceptually simpler and easier to teach to less experienced researchers and non-researcher stakeholders. For teams with different levels of familiarity with qualitative methods, this approach presents a clear roadmap to the reading, coding, and theming of qualitative data. Our practical thematic analysis approach promotes efficient learning by doing—experiential learning. 12 29 Practical thematic analysis avoids the risk of relying on complex descriptions of methods and theory and places more emphasis on obtaining meaningful insights from those close to real world clinical environments. Although practical thematic analysis can be used to perform intensive theory based analyses, it lends itself more readily to accelerated, pragmatic approaches.

Strengths and limitations

Our approach is designed to smooth the qualitative analysis process and yield high quality themes. Yet, researchers should note that poorly performed analyses will still produce low quality results. Practical thematic analysis is a qualitative analytical approach; it does not look at study design, data collection, or other important elements of qualitative research. It also might not be the right choice for every qualitative research project. We recommend it for applied health services research questions, where diverse perspectives and simplicity might be valuable.

We also urge researchers to improve internal validity through triangulation methods, such as member checking (supplemental material 1). 46 Member checking could include soliciting input on high level themes, theme definitions, and quotations from participants. This approach might increase rigor.

Implications

We hope that by providing clear and simple instructions for practical thematic analysis, a broader range of researchers will be more inclined to use these methods. Increased transparency and familiarity with qualitative approaches can enhance researchers’ ability to both interpret qualitative studies and offer up new findings themselves. In addition, it can have usefulness in training and reporting. A major strength of this approach is to facilitate meaningful inclusion of patient and care partner perspectives, because their lived experiences can be particularly valuable in data interpretation and the resulting findings. 11 30 As clinicians are especially pressed for time, they might also appreciate a practical set of instructions that can be immediately used to leverage their insights and access to patients and clinical settings, and increase the impact of qualitative research through timely results. 8

Practical thematic analysis is a simplified approach to performing thematic analysis in health services research, a field where the experiences of patients, care partners, and clinicians are of inherent interest. We hope that it will be accessible to those individuals new to qualitative methods, including patients, care partners, clinicians, and other health services researchers. We intend to empower multidisciplinary research teams to explore unanswered questions and make new, important, and rigorous contributions to our understanding of important clinical and health systems research.

Acknowledgments

All members of the Coproduction Laboratory provided input that shaped this manuscript during laboratory meetings. We acknowledge advice from Elizabeth Carpenter-Song, an expert in qualitative methods.

Coproduction Laboratory group contributors: Stephanie C Acquilano ( http://orcid.org/0000-0002-1215-5531 ), Julie Doherty ( http://orcid.org/0000-0002-5279-6536 ), Rachel C Forcino ( http://orcid.org/0000-0001-9938-4830 ), Tina Foster ( http://orcid.org/0000-0001-6239-4031 ), Megan Holthoff, Christopher R Jacobs ( http://orcid.org/0000-0001-5324-8657 ), Lisa C Johnson ( http://orcid.org/0000-0001-7448-4931 ), Elaine T Kiriakopoulos, Kathryn Kirkland ( http://orcid.org/0000-0002-9851-926X ), Meredith A MacMartin ( http://orcid.org/0000-0002-6614-6091 ), Emily A Morgan, Eugene Nelson, Elizabeth O’Donnell, Brant Oliver ( http://orcid.org/0000-0002-7399-622X ), Danielle Schubbe ( http://orcid.org/0000-0002-9858-1805 ), Gabrielle Stevens ( http://orcid.org/0000-0001-9001-178X ), Rachael P Thomeer ( http://orcid.org/0000-0002-5974-3840 ).

Contributors: Practical thematic analysis, an approach designed for multidisciplinary health services teams new to qualitative research, was based on CHS’s experiences teaching thematic analysis to clinical teams and students. We have drawn heavily from qualitative methods literature. CHS is the guarantor of the article. CHS, AS, CvP, AMK, JRK, and JAP contributed to drafting the manuscript. AS, JG, CMM, JAP, and RWY provided feedback on their experiences using practical thematic analysis. CvP, LCL, SLB, AVC, GE, and JKL advised on qualitative methods in health services research, given extensive experience. All authors meaningfully edited the manuscript content, including AVC and RKS. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding: This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Provenance and peer review: Not commissioned; externally peer reviewed.

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thematic analysis research paper themes

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How to do a thematic analysis

thematic analysis research paper themes

What is a thematic analysis?

When is thematic analysis used, braun and clarke’s reflexive thematic analysis, the six steps of thematic analysis, 1. familiarizing, 2. generating initial codes, 3. generating themes, 4. reviewing themes, 5. defining and naming themes, 6. creating the report, the advantages and disadvantages of thematic analysis, disadvantages, frequently asked questions about thematic analysis, related articles.

Thematic analysis is a broad term that describes an approach to analyzing qualitative data . This approach can encompass diverse methods and is usually applied to a collection of texts, such as survey responses and transcriptions of interviews or focus group discussions. Learn more about different research methods.

A researcher performing a thematic analysis will study a set of data to pinpoint repeating patterns, or themes, in the topics and ideas that are expressed in the texts.

In analyzing qualitative data, thematic analysis focuses on concepts, opinions, and experiences, as opposed to pure statistics. This requires an approach to data that is complex and exploratory and can be anchored by different philosophical and conceptual foundations.

A six-step system was developed to help establish clarity and rigor around this process, and it is this system that is most commonly used when conducting a thematic analysis. The six steps are:

  • Familiarization
  • Generating codes
  • Generating themes
  • Reviewing themes
  • Defining and naming themes
  • Creating the report

It is important to note that even though the six steps are listed in sequence, thematic analysis is not necessarily a linear process that advances forward in a one-way, predictable fashion from step one through step six. Rather, it involves a more fluid shifting back and forth between the phases, adjusting to accommodate new insights when they arise.

And arriving at insight is a key goal of this approach. A good thematic analysis doesn’t just seek to present or summarize data. It interprets and makes a statement about it; it extracts meaning from the data.

Since thematic analysis is used to study qualitative data, it works best in cases where you’re looking to gather information about people’s views, values, opinions, experiences, and knowledge.

Some examples of research questions that thematic analysis can be used to answer are:

  • What are senior citizens’ experiences of long-term care homes?
  • How do women view social media sites as a tool for professional networking?
  • How do non-religious people perceive the role of the church in a society?
  • What are financial analysts’ ideas and opinions about cryptocurrency?

To begin answering these questions, you would need to gather data from participants who can provide relevant responses. Once you have the data, you would then analyze and interpret it.

Because you’re dealing with personal views and opinions, there is a lot of room for flexibility in terms of how you interpret the data. In this way, thematic analysis is systematic but not purely scientific.

A landmark 2006 paper by Victoria Braun and Victoria Clarke (“ Using thematic analysis in psychology ”) established parameters around thematic analysis—what it is and how to go about it in a systematic way—which had until then been widely used but poorly defined.

Since then, their work has been updated, with the name being revised, notably, to “reflexive thematic analysis.”

One common misconception that Braun and Clarke have taken pains to clarify about their work is that they do not believe that themes “emerge” from the data. To think otherwise is problematic since this suggests that meaning is somehow inherent to the data and that a researcher is merely an objective medium who identifies that meaning.

Conversely, Braun and Clarke view analysis as an interactive process in which the researcher is an active participant in constructing meaning, rather than simply identifying it.

The six stages they presented in their paper are still the benchmark for conducting a thematic analysis. They are presented below.

This step is where you take a broad, high-level view of your data, looking at it as a whole and taking note of your first impressions.

This typically involves reading through written survey responses and other texts, transcribing audio, and recording any patterns that you notice. It’s important to read through and revisit the data in its entirety several times during this stage so that you develop a thorough grasp of all your data.

After familiarizing yourself with your data, the next step is coding notable features of the data in a methodical way. This often means highlighting portions of the text and applying labels, aka codes, to them that describe the nature of their content.

In our example scenario, we’re researching the experiences of women over the age of 50 on professional networking social media sites. Interviews were conducted to gather data, with the following excerpt from one interview.

In the example interview snippet, portions have been highlighted and coded. The codes describe the idea or perception described in the text.

It pays to be exhaustive and thorough at this stage. Good practice involves scrutinizing the data several times, since new information and insight may become apparent upon further review that didn’t jump out at first glance. Multiple rounds of analysis also allow for the generation of more new codes.

Once the text is thoroughly reviewed, it’s time to collate the data into groups according to their code.

Now that we’ve created our codes, we can examine them, identify patterns within them, and begin generating themes.

Keep in mind that themes are more encompassing than codes. In general, you’ll be bundling multiple codes into a single theme.

To draw on the example we used above about women and networking through social media, codes could be combined into themes in the following way:

You’ll also be curating your codes and may elect to discard some on the basis that they are too broad or not directly relevant. You may also choose to redefine some of your codes as themes and integrate other codes into them. It all depends on the purpose and goal of your research.

This is the stage where we check that the themes we’ve generated accurately and relevantly represent the data they are based on. Once again, it’s beneficial to take a thorough, back-and-forth approach that includes review, assessment, comparison, and inquiry. The following questions can support the review:

  • Has anything been overlooked?
  • Are the themes definitively supported by the data?
  • Is there any room for improvement?

With your final list of themes in hand, the next step is to name and define them.

In defining them, we want to nail down the meaning of each theme and, importantly, how it allows us to make sense of the data.

Once you have your themes defined, you’ll need to apply a concise and straightforward name to each one.

In our example, our “perceived lack of skills” may be adjusted to reflect that the texts expressed uncertainty about skills rather than the definitive absence of them. In this case, a more apt name for the theme might be “questions about competence.”

To finish the process, we put our findings down in writing. As with all scholarly writing, a thematic analysis should open with an introduction section that explains the research question and approach.

This is followed by a statement about the methodology that includes how data was collected and how the thematic analysis was performed.

Each theme is addressed in detail in the results section, with attention paid to the frequency and presence of the themes in the data, as well as what they mean, and with examples from the data included as supporting evidence.

The conclusion section describes how the analysis answers the research question and summarizes the key points.

In our example, the conclusion may assert that it is common for women over the age of 50 to have negative experiences on professional networking sites, and that these are often tied to interactions with other users and a sense that using these sites requires specialized skills.

Thematic analysis is useful for analyzing large data sets, and it allows a lot of flexibility in terms of designing theoretical and research frameworks. Moreover, it supports the generation and interpretation of themes that are backed by data.

There are times when thematic analysis is not the best approach to take because it can be highly subjective, and, in seeking to identify broad patterns, it can overlook nuance in the data.

What’s more, researchers must be judicious about reflecting on how their own position and perspective bears on their interpretations of the data and if they are imposing meaning that is not there or failing to pick up on meaning that is.

Thematic analysis offers a flexible and recursive way to approach qualitative data that has the potential to yield valuable insights about people’s opinions, views, and lived experience. It must be applied, however, in a conscientious fashion so as not to allow subjectivity to taint or obscure the results.

The purpose of thematic analysis is to find repeating patterns, or themes, in qualitative data. Thematic analysis can encompass diverse methods and is usually applied to a collection of texts, such as survey responses and transcriptions of interviews or focus group discussions. In analyzing qualitative data, thematic analysis focuses on concepts, opinions, and experiences, as opposed to pure statistics.

A big advantage of thematic analysis is that it allows a lot of flexibility in terms of designing theoretical and research frameworks. It also supports the generation and interpretation of themes that are backed by data.

A disadvantage of thematic analysis is that it can be highly subjective and can overlook nuance in the data. Also, researchers must be aware of how their own position and perspective influences their interpretations of the data and if they are imposing meaning that is not there or failing to pick up on meaning that is.

How many themes make sense in your thematic analysis of course depends on your topic and the material you are working with. In general, it makes sense to have no more than 6-10 broader themes, instead of having many really detailed ones. You can then identify further nuances and differences under each theme when you are diving deeper into the topic.

Since thematic analysis is used to study qualitative data, it works best in cases where you’re looking to gather information about people’s views, values, opinions, experiences, and knowledge. Therefore, it makes sense to use thematic analysis for interviews.

After familiarizing yourself with your data, the first step of a thematic analysis is coding notable features of the data in a methodical way. This often means highlighting portions of the text and applying labels, aka codes, to them that describe the nature of their content.

thematic analysis research paper themes

  • How it works

Thematic Analysis – A Guide with Examples

Published by Alvin Nicolas at August 16th, 2021 , Revised On August 29, 2023

Thematic analysis is one of the most important types of analysis used for qualitative data . When researchers have to analyse audio or video transcripts, they give preference to thematic analysis. A researcher needs to look keenly at the content to identify the context and the message conveyed by the speaker.

Moreover, with the help of this analysis, data can be simplified.  

Importance of Thematic Analysis

Thematic analysis has so many unique and dynamic features, some of which are given below:

Thematic analysis is used because:

  • It is flexible.
  • It is best for complex data sets.
  • It is applied to qualitative data sets.
  • It takes less complexity compared to other theories of analysis.

Intellectuals and researchers give preference to thematic analysis due to its effectiveness in the research.

How to Conduct a Thematic Analysis?

While doing any research , if your data and procedure are clear, it will be easier for your reader to understand how you concluded the results . This will add much clarity to your research.

Understand the Data

This is the first step of your thematic analysis. At this stage, you have to understand the data set. You need to read the entire data instead of reading the small portion. If you do not have the data in the textual form, you have to transcribe it.

Example: If you are visiting an adult dating website, you have to make a data corpus. You should read and re-read the data and consider several profiles. It will give you an idea of how adults represent themselves on dating sites. You may get the following results:

I am a tall, single(widowed), easy-going, honest, good listener with a good sense of humor. Being a handyperson, I keep busy working around the house, and I also like to follow my favourite hockey team on TV or spoil my two granddaughters when I get the chance!! Enjoy most music except Rap! I keep fit by jogging, walking, and bicycling (at least three times a week). I have travelled to many places and RVD the South-West U.S., but I would now like to find that special travel partner to do more travel to warm and interesting countries. I now feel it’s time to meet a nice, kind, honest woman who has some of the same interests as I do; to share the happy times, quiet times, and adventures together

I enjoy photography, lapidary & seeking collectibles in the form of classic movies & 33 1/3, 45 & 78 RPM recordings from the 1920s, ’30s & ’40s. I am retired & looking forward to travelling to Canada, the USA, the UK & Europe, China. I am unique since I do not judge a book by its cover. I accept people for who they are. I will not demand or request perfection from anyone until I am perfect, so I guess that means everyone is safe. My musical tastes range from Classical, big band era, early jazz, classic ’50s & 60’s rock & roll & country since its inception.

Development of Initial Coding:

At this stage, you have to do coding. It’s the essential step of your research . Here you have two options for coding. Either you can do the coding manually or take the help of any tool. A software named the NOVIC is considered the best tool for doing automatic coding.

For manual coding, you can follow the steps given below:

  • Please write down the data in a proper format so that it can be easier to proceed.
  • Use a highlighter to highlight all the essential points from data.
  • Make as many points as possible.
  • Take notes very carefully at this stage.
  • Apply themes as much possible.
  • Now check out the themes of the same pattern or concept.
  • Turn all the same themes into the single one.

Example: For better understanding, the previously explained example of Step 1 is continued here. You can observe the coded profiles below:

Make Themes

At this stage, you have to make the themes. These themes should be categorised based on the codes. All the codes which have previously been generated should be turned into themes. Moreover, with the help of the codes, some themes and sub-themes can also be created. This process is usually done with the help of visuals so that a reader can take an in-depth look at first glance itself.

Extracted Data Review

Now you have to take an in-depth look at all the awarded themes again. You have to check whether all the given themes are organised properly or not. It would help if you were careful and focused because you have to note down the symmetry here. If you find that all the themes are not coherent, you can revise them. You can also reshape the data so that there will be symmetry between the themes and dataset here.

For better understanding, a mind-mapping example is given here:

Extracted Data

Reviewing all the Themes Again

You need to review the themes after coding them. At this stage, you are allowed to play with your themes in a more detailed manner. You have to convert the bigger themes into smaller themes here. If you want to combine some similar themes into a single theme, then you can do it. This step involves two steps for better fragmentation. 

You need to observe the coded data separately so that you can have a precise view. If you find that the themes which are given are following the dataset, it’s okay. Otherwise, you may have to rearrange the data again to coherence in the coded data.

Corpus Data

Here you have to take into consideration all the corpus data again. It would help if you found how themes are arranged here. It would help if you used the visuals to check out the relationship between them. Suppose all the things are not done accordingly, so you should check out the previous steps for a refined process. Otherwise, you can move to the next step. However, make sure that all the themes are satisfactory and you are not confused.

When all the two steps are completed, you need to make a more précised mind map. An example following the previous cases has been given below:

Corpus Data

Define all the Themes here

Now you have to define all the themes which you have given to your data set. You can recheck them carefully if you feel that some of them can fit into one concept, you can keep them, and eliminate the other irrelevant themes. Because it should be precise and clear, there should not be any ambiguity. Now you have to think about the main idea and check out that all the given themes are parallel to your main idea or not. This can change the concept for you.

The given names should be so that it can give any reader a clear idea about your findings. However, it should not oppose your thematic analysis; rather, everything should be organised accurately.

Steps of Writing a dissertation

Does your Research Methodology Have the Following?

  • Great Research/Sources
  • Perfect Language
  • Accurate Sources

If not, we can help. Our panel of experts makes sure to keep the 3 pillars of Research Methodology strong.

Does your Research Methodology Have the Following?

Also, read about discourse analysis , content analysis and survey conducting . we have provided comprehensive guides.

Make a Report

You need to make the final report of all the findings you have done at this stage. You should include the dataset, findings, and every aspect of your analysis in it.

While making the final report , do not forget to consider your audience. For instance, you are writing for the Newsletter, Journal, Public awareness, etc., your report should be according to your audience. It should be concise and have some logic; it should not be repetitive. You can use the references of other relevant sources as evidence to support your discussion.  

Frequently Asked Questions

What is meant by thematic analysis.

Thematic Analysis is a qualitative research method that involves identifying, analyzing, and interpreting recurring themes or patterns in data. It aims to uncover underlying meanings, ideas, and concepts within the dataset, providing insights into participants’ perspectives and experiences.

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  • How It Works

A worked example of Braun and Clarke’s approach to reflexive thematic analysis

  • Open access
  • Published: 26 June 2021
  • Volume 56 , pages 1391–1412, ( 2022 )

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  • David Byrne   ORCID: orcid.org/0000-0002-0587-4677 1  

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Since the publication of their inaugural paper on the topic in 2006, Braun and Clarke’s approach has arguably become one of the most thoroughly delineated methods of conducting thematic analysis (TA). However, confusion persists as to how to implement this specific approach to TA appropriately. The authors themselves have identified that many researchers who purport to adhere to this approach—and who reference their work as such—fail to adhere fully to the principles of ‘reflexive thematic analysis’ (RTA). Over the course of numerous publications, Braun and Clarke have elaborated significantly upon the constitution of RTA and attempted to clarify numerous misconceptions that they have found in the literature. This paper will offer a worked example of Braun and Clarke’s contemporary approach to reflexive thematic analysis with the aim of helping to dispel some of the confusion regarding the position of RTA among the numerous existing typologies of TA. While the data used in the worked example has been garnered from health and wellbeing education research and was examined to ascertain educators’ attitudes regarding such, the example offered of how to implement the RTA would be easily transferable to many other contexts and research topics.

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1 Introduction

Although the lineage of thematic analysis (TA) can be traced back as far as the early twentieth century (Joffe 2012 ), it has up until recently been a relatively poorly demarcated and poorly understood method of qualitative analysis. Much of the credit for the recent enlightenment and subsequent increase in interest in TA can arguably be afforded to Braun and Clarke’s ( 2006 ) inaugural publication on the topic of thematic analysis in the field of psychology. These authors have since published several articles and book chapters, as well as their own book, all of which make considerable contributions to further delineating their approach to TA (see, for example, Braun and Clarke 2012 , 2013 , 2014 , 2019 , 2020 ; Braun et al. 2016 ; Terry et al. 2017 ). However, on numerous occasions Braun and Clarke have identified a tendency for scholars to cite their 2006 article, but fail to fully adhere to their contemporary approach to RTA (see Braun and Clarke 2013 , 2019 , 2020 ). Commendably, they have acknowledged that their 2006 paper left several aspect of their approach incompletely defined and open to interpretation. Indeed, the term ‘reflexive thematic analysis’ only recently came about in response to these misconceptions (Braun and Clarke 2019 ). Much of their subsequent body of literature in this area addresses these issues and attempts to correct some of the misconceptions in the wider literature regarding their approach. Braun and Clarke have repeatedly iterated that researchers who chose to adopt their approach should interrogate their relevant publications beyond their 2006 article and adhere to their contemporary approach (Braun and Clarke 2019 , 2020 ). The purpose of this paper is to contribute to dispelling some of the confusion and misconceptions regarding Braun and Clarke’s approach by providing a worked example of their contemporary approach to reflexive thematic analysis. The worked example will be presented in relation to the author’s own research, which examined the attitudes of post-primary educators’ regarding the promotion of student wellbeing. This paper is intended to be a supplementary resource for any prospective proponents of RTA, but may be of particular interest to scholars conducting attitudinal studies in an educational context. While this paper is aimed at all scholars regardless of research experience, it may be most useful to research students and their supervisors. Ultimately, the provided example of how to implement the six-phase analysis is easily transferable to many contexts and research topics.

2 What is reflexive thematic analysis?

Reflexive thematic analysis is an easily accessible and theoretically flexible interpretative approach to qualitative data analysis that facilitates the identification and analysis of patterns or themes in a given data set (Braun and Clarke 2012 ). RTA sits among a number of varied approaches to conducting thematic analysis. Braun and Clarke have noted that very often, researchers who purport to have adopted RTA have failed to fully delineate their implementation of RTA, of have confused RTA with other approaches to thematic analysis. The over-riding tendency in this regard is for scholars to mislabel their analysis as RTA, or to draw from a number of different approaches to TA, some of which may not be compatible with each other (Braun and Clarke 2012 , 2013 , 2019 ; Terry et al. 2017 ). In an attempt to resolve this confusion, Braun and Clarke have demarcated the position of RTA among the other forms of thematic analysis by differentiating between three principal approaches to TA: (1) coding reliability TA; (2) codebook approaches to TA, and; (3) the reflexive approach to TA (Braun et al. 2019 ).

Coding reliability approaches, such as those espoused by Boyatzis ( 1998 ) and Joffe ( 2012 ), accentuate the measurement of accuracy or reliability when coding data, often involving the use of a structured codebook. The researcher would also seek a degree of consensus among multiple coders, which can be measured using Cohen’s Kappa (Braun and Clarke 2013 ). When adopting a coding reliability approach, themes tend to be developed very early in the analytical process. Themes can be hypothesised based on theory prior to data collection, with evidence to support these hypotheses then gathered from the data in the form of codes. Alternatively, themes can be hypothesised following a degree of familiarisation with the data (Terry et al. 2017 ). Themes are typically understood to constitute ‘domain summaries’, or “summaries of what participants said in relation to a particular topic or data collection question” (Braun et al. 2019 , p. 5), and are likely to be discussed as residing within the data in a positivistic sense.

Codebook approaches, such as framework analysis (Smith and Firth 2011 ) or template analysis (King and Brooks 2017 ), can be understood to be something of a mid-point between coding reliability approaches and the reflexive approach. Like coding reliability approaches, codebook approaches adopt the use of a structured codebook and share the conceptualisation of themes as domain summaries. However, codebook approaches are more akin to the reflexive approach in terms of the prioritisation of a qualitative philosophy with regard to coding. Proponents of codebook approaches would typically forgo positivistic conceptions of coding reliability, instead recognising the interpretive nature of data coding (Braun et al. 2019 ).

The reflexive approach to TA highlights the researcher’s active role in knowledge production (Braun and Clarke 2019 ). Codes are understood to represent the researcher’s interpretations of patterns of meaning across the dataset. Reflexive thematic analysis is considered a reflection of the researcher’s interpretive analysis of the data conducted at the intersection of: (1) the dataset; (2) the theoretical assumptions of the analysis, and; (3) the analytical skills/resources of the researcher (Braun and Clarke 2019 ). It is fully appreciated—even expected—that no two researchers will intersect this tripartite of criteria in the same way. As such, there should be no expectation that codes or themes interpreted by one researcher may be reproduced by another (although, this is of course possible). Prospective proponents of RTA are discouraged from attempting to provide accounts of ‘accurate’ or ‘reliable’ coding, or pursuing consensus among multiple coders or using Cohen’s Kappa values. Rather, RTA is about “the researcher’s reflective and thoughtful engagement with their data and their reflexive and thoughtful engagement with the analytic process” (Braun and Clarke 2019 , p. 594). Multiple coders may, however, be beneficial in a reflexive manner (e.g. to sense-check ideas, or to explore multiple assumptions or interpretations of the data). If analysis does involve more than one researcher, the approach should be collaborative and reflexive, aiming to achieve richer interpretations of meaning, rather than attempting to achieve consensus of meaning. Indeed, in this sense it would be beneficial for proponents of RTA to remain cognisant that qualitative analysis as a whole does not contend to provide a single or ‘correct’ answer (Braun and Clarke 2013 ).

The process of coding (and theme development) is flexible and organic, and very often will evolve throughout the analytical process (Braun et al. 2019 ). Progression through the analysis will tend to facilitate further familiarity with the data, which may in turn result in the interpretation of new patterns of meaning. This is converse to the use of codebooks, which can often predefine themes before coding. Through the reflexive approach, themes are not predefined in order to ‘find’ codes. Rather, themes are produced by organising codes around a relative core commonality, or ‘central organising concept’, that the researcher interprets from the data (Braun and Clarke 2019 ).

In their 2006 paper, Braun and Clarke ( 2006 ) originally conceptualised RTA as a paradigmatically flexible analytical method, suitable for use within a wide range of ontological and epistemological considerations. In recent publications, the authors have moved away from this view, instead defining RTA as a purely qualitative approach. This pushes the use RTA into exclusivity under appropriate qualitative paradigms (e.g. constructionism) (Braun and Clarke 2019 , 2020 ). As opposed to other forms of qualitative analysis such as content analysis (Vaismoradi et al. 2013 ), and even other forms of TA such as Boyatzis’ ( 1998 ) approach, RTA eschews any positivistic notions of data interpretation. Braun and Clarke ( 2019 ) encourage the researcher to embrace reflexivity, subjectivity and creativity as assets in knowledge production, where they argue some scholars, such as Boyatzis ( 1998 ), may otherwise construe these assets as threats.

3 A worked example of reflexive thematic analysis

The data used in the following example is taken from the qualitative phase of a mixed methods study I conducted, which examined mental health in an educational context. This study set out to understand the attitudes and opinions of Irish post-primary educators with regard to the promotion of students’ social and emotional wellbeing, with the intention to feed this information back to key governmental and non-governmental stakeholders such as the National Council for Curriculum and Assessment and the Department of Education. The research questions for this study aimed to examine educators’ general attitudes toward the promotion of student wellbeing and towards a set of ‘wellbeing guidelines’ that had recently been introduced in Irish post-primary schools. I also wanted to identify any potential barriers to wellbeing promotion and to solicit educators’ opinions as to what might constitute apposite remedial measures in this regard.

The qualitative phase of this study, from which the data for this example is garnered, involved eleven semi-structured interviews, which lasted approximately 25–30 min each. Participants consisted of core-curriculum teachers, wellbeing curriculum teachers, pastoral care team-members and senior management members. Participants were questioned on their attitudes regarding the promotion of student wellbeing, the wellbeing curriculum, the wellbeing guidelines and their perceptions of their own wellbeing. When conducting these interviews, I loosely adhered to an interview agenda to ensure each of these four key topics were addressed. However, discussions were typically guided by what I interpreted to be meaningful to the interviewee, and would often weave in and out of these different topics.

The research questions for this study were addressed within a paradigmatic framework of interpretivism and constructivism. A key principle I adopted for this study was to reflect educators’ own accounts of their attitudes, opinions and experiences as faithfully as was possible, while also accounting for the reflexive influence of my own interpretations as the researcher. I felt RTA was highly appropriate in the context of the underlying theoretical and paradigmatic assumptions of my study and would allow me to ensure qualitative data was collected and analysed in a manner that respected and expressed the subjectivity of participants’ accounts of their attitudes, while also acknowledging and embracing the reflexive influence of my interpretations as the researcher.

In the next section, I will outline the theoretical assumptions of the RTA conducted in my original study in more detail. It should be noted that outlining these theoretical assumptions is not a task specific to reflexive thematic analysis. Rather, these assumptions should be addressed prior to implementing any form of thematic analysis (Braun and Clarke 2012 , 2019 , 2020 ; Braun et al. 2016 ). The six-phase process for conducting reflexive thematic analysis will then be appropriately detailed and punctuated with examples from my study.

3.1 Addressing underlying theoretical assumptions

Across several publications, Braun and Clarke ( 2012 , 2014 , 2020 ) have identified a number of theoretical assumptions that should be addressed when conducting RTA, or indeed any form of thematic analysis. These assumptions are conceptualised as a series of continua as follows: essentialist versus constructionist epistemologies; experiential versus critical orientation to data; inductive versus deductive analyses, and; semantic versus latent coding of data. The aim is not just for the researcher to identify where their analysis is situated on each of these continua, but why the analysis is situated as it is and why this conceptualisation is appropriate to answering the research question(s).

3.1.1 Essentialist versus constructionist epistemologies

Ontological and epistemological considerations would usually be determined when a study is first being conceptualised. However, these considerations may become salient again when data analysis becomes the research focus, particularly with regard to mixed methods. The purpose of addressing this continuum is to conceptualise theoretically how the researcher understands their data and the way in which the reader should interpret the findings (Braun and Clarke 2013 , 2014 ). By adhering to essentialism, the researcher adopts a unidirectional understanding of the relationship between language and communicated experience, in that it is assumed that language is a simple reflection of our articulated meanings and experiences (Widdicombe and Wooffiitt 1995 ). The meanings and systems inherent in constructing these meanings are largely uninterrogated, with the interpretive potential of TA largely unutilised (Braun et al. 2016 ).

Conversely, researchers of a constructionist persuasion would tend to adopt a bidirectional understanding of the language/experience relationship, viewing language as implicit in the social production and reproduction of both meaning and experience (Burr 1995 ; Schwandt 1998 ). A constructionist epistemology has particular implications with regard to thematic analysis, namely that in addition to the recurrence of perceptibly important information, meaningfulness is highly influential in the development and interpretation of codes and themes. The criteria for a theme to be considered noteworthy via recurrence is simply that the theme should present repeatedly within the data. However, what is common is not necessarily meaningful or important to the analysis. Braun and Clarke ( 2012 , p. 37) offer this example:

…in researching white-collar workers’ experiences of sociality at work, a researcher might interview people about their work environment and start with questions about their typical workday. If most or all reported that they started work at around 9:00 a.m., this would be a pattern in the data, but it would not necessarily be a meaningful or important one.

Furthermore, there may be varying degrees of conviction in respondents’ expression when addressing different issues that may facilitate in identifying the salience of a prospective theme. Therefore, meaningfulness can be conceptualised, firstly on the part of the researcher, with regard to the necessity to identify themes that are relevant to answering the research questions, and secondly on the part of the respondent, as the expression of varying degrees of importance with regard to the issues being addressed. By adopting a constructionist epistemology, the researcher acknowledges the importance of recurrence, but appreciates meaning and meaningfulness as the central criteria in the coding process.

In keeping with the qualitative philosophy of RTA, epistemological consideration regarding the example data were constructionist. As such, meaning and experience was interpreted to be socially produced and reproduced via an interplay of subjective and inter-subjective construction. Footnote 1

3.1.2 Experiential versus critical orientation

An experiential orientation to understanding data typically prioritises the examination of how a given phenomenon may be experienced by the participant. This involves investigating the meaning ascribed to the phenomenon by the respondent, as well as the meaningfulness of the phenomenon to the respondent. However, although these thoughts, feelings and experiences are subjectively and inter-subjectively (re)produced, the researcher would cede to the meaning and meaningfulness ascribed by the participant (Braun and Clarke 2014 ). Adopting an experiential orientation requires an appreciation that the thoughts, feelings and experiences of participants are a reflection of personal states held internally by the participant. Conversely, a critical orientation appreciates and analyses discourse as if it were constitutive, rather than reflective, of respondents’ personal states (Braun and Clarke 2014 ). As such, a critical perspective seeks to interrogate patterns and themes of meaning with a theoretical understanding that language can create, rather than merely reflect, a given social reality (Terry et al. 2017 ). A critical perspective can examine the mechanisms that inform the construction of systems of meaning, and therefore offer interpretations of meaning further to those explicitly communicated by participants. It is then also possible to examine how the wider social context may facilitate or impugn these systems of meaning (Braun and Clarke 2012 ). In short, the researcher uses this continuum to clarify their intention to reflect the experience of a social reality (experiential orientation) or examine the constitution of a social reality (critical orientation).

In the present example, an experiential orientation to data interpretation was adopted in order to emphasise meaning and meaningfulness as ascribed by participants. Adopting this approach meant that this analysis did not seek to make claims about the social construction of the research topic (which would more so necessitate a critical perspective), but rather acknowledged the socially constructed nature of the research topic when examining the subjective ‘personal states’ of participants. An experiential orientation was most appropriate as the aim of the study was to prioritise educators’ own accounts of their attitudes, opinions. More importantly, the research questions aimed to examine educators’ attitudes regarding their experience of promoting student wellbeing—or the ‘meanings made’—and not, for example, the socio-cultural factors that may underlie the development of these attitudes—or the ‘meaning making’.

3.1.3 Inductive versus deductive analysis

A researcher who adopts a deductive or ‘theory-driven’ approach may wish to produce codes relative to a pre-specified conceptual framework or codebook. In this case, the analysis would tend to be ‘analyst-driven’, predicated on the theoretically informed interpretation of the researcher. Conversely, a researcher who adopts an inductive or ‘data-driven’ approach may wish to produce codes that are solely reflective of the content of the data, free from any pre-conceived theory or conceptual framework. In this case, data are not coded to fit a pre-existing coding frame, but instead ‘open-coded’ in order to best represent meaning as communicated by the participants (Braun and Clarke 2013 ). Data analysed and coded deductively can often provide a less rich description of the overall dataset, instead focusing on providing a detailed analysis of a particular aspect of the dataset interpreted through a particular theoretical lens (Braun and Clarke 2020 ). Deductive analysis has typically been associated with positivistic/essentialist approaches (e.g. Boyatzis 1998 ), while inductive analysis tends to be aligned with constructivist approaches (e.g. Frith and Gleeson 2004 ). That being said, inductive/deductive approaches to analysis are by no means exclusively or intrinsically linked to a particular epistemology.

Coding and analysis rarely fall cleanly into one of these approaches and, more often than not, use a combination of both (Braun and Clarke 2013 , 2019 , 2020 ). It is arguably not possible to conduct an exclusively deductive analysis, as an appreciation for the relationship between different items of information in the data set is necessary in order to identify recurring commonalities with regard to a pre-specified theory or conceptual framework. Equally, it is arguably not possible to conduct an exclusively inductive analysis, as the researcher would require some form of criteria to identify whether or not a piece of information may be conducive to addressing the research question(s), and therefore worth coding. When addressing this issue, Braun and Clarke ( 2012 ) clarify that one approach does tend to predominate over the other, and that the predominance of the deductive or inductive approach can indicate an overall orientation towards prioritising either researcher/theory-based meaning or respondent/data-based meaning, respectively.

A predominantly inductive approach was adopted in this example, meaning data was open-coded and respondent/data-based meanings were emphasised. A degree of deductive analysis was, however, employed to ensure that the open-coding contributed to producing themes that were meaningful to the research questions, and to ensure that the respondent/data-based meanings that were emphasised were relevant to the research questions.

3.1.4 Semantic versus latent coding

Semantic codes are identified through the explicit or surface meanings of the data. The researcher does not examine beyond what a respondent has said or written. The production of semantic codes can be described as a descriptive analysis of the data, aimed solely at presenting the content of the data as communicated by the respondent. Latent coding goes beyond the descriptive level of the data and attempts to identify hidden meanings or underlying assumptions, ideas, or ideologies that may shape or inform the descriptive or semantic content of the data. When coding is latent, the analysis becomes much more interpretive, requiring a more creative and active role on the part of the researcher. Indeed, Braun and Clarke ( 2012 , 2013 , 2020 ) have repeatedly presented the argument that codes and themes do not ‘emerge’ from the data or that they may be residing in the data, waiting to be found. Rather, the researcher plays an active role in interpreting codes and themes, and identifying which are relevant to the research question(s). Analyses that use latent coding can often overlap with aspects of thematic discourse analysis in that the language used by the respondent can be used to interpret deeper levels of meaning and meaningfulness (Braun and Clarke 2006 ).

In this example, both semantic and latent coding were utilised. No attempt was made to prioritise semantic coding over latent coding or vice-versa. Rather, semantic codes were produced when meaningful semantic information was interpreted, and latent codes were produced when meaningful latent information was interpreted. As such, any item of information could be double-coded in accordance with the semantic meaning communicated by the respondent, and the latent meaning interpreted by the researcher (Patton 1990 ). This was reflective of the underlying theoretical assumptions of the analysis, as the constructive and interpretive epistemology and ontology were addressed by affording due consideration to both the meaning constructed and communicated by the participant and my interpretation of this meaning as the researcher.

3.2 The six-phase analytical process

Braun and Clarke ( 2012 , 2013 , 2014 , 2020 ) have proposed a six-phase process, which can facilitate the analysis and help the researcher identify and attend to the important aspects of a thematic analysis. In this sense, Braun and Clarke ( 2012 ) have identified the six-phase process as an approach to doing TA, as well as learning how to do TA. While the six phases are organised in a logical sequential order, the researcher should be cognisant that the analysis is not a linear process of moving forward through the phases. Rather, the analysis is recursive and iterative, requiring the researcher to move back and forth through the phases as necessary (Braun and Clarke 2020 ). TA is a time consuming process that evolves as the researcher navigates the different phases. This can lead to new interpretations of the data, which may in turn require further iterations of earlier phases. As such, it is important to appreciate the six-phase process as a set of guidelines, rather than rules, that should be applied in a flexible manner to fit the data and the research question(s) (Braun and Clarke 2013 , 2020 ).

3.2.1 Phase one: familiarisation with the data

The ‘familiarisation’ phase is prevalent in many forms of qualitative analysis. Familiarisation entails the reading and re-reading of the entire dataset in order to become intimately familiar with the data. This is necessary to be able to identify appropriate information that may be relevant to the research question(s). Manual transcription of data can be a very useful activity for the researcher in this regard, and can greatly facilitate a deep immersion into the data. Data should be transcribed orthographically, noting inflections, breaks, pauses, tones, etc. on the part of both the interviewer and the participant (Braun and Clarke 2013 ). Often times, data may not have been gathered or transcribed by the researcher, in which case, it would be beneficial for the researcher to watch/listen to video or audio recordings to achieve a greater contextual understanding of the data. This phase can be quite time consuming and requires a degree of patience. However, it is important to afford equal consideration across the entire depth and breadth of the dataset, and to avoid the temptation of being selective of what to read, or even ‘skipping over’ this phase completely (Braun and Clarke 2006 ).

At this phase, I set about familiarising myself with the data by firstly listening to each interview recording once before transcribing that particular recording. This first playback of each interview recording required ‘active listening’ and, as such, I did not take any notes at this point. I performed this active-listen in order to develop an understanding of the primary areas addressed in each interview prior to transcription. This also provided me an opportunity, unburdened by tasks such as note taking, to recall gestures and mannerisms that may or may not have been documented in interview notes. I manually transcribed each interview immediately after the active-listen playback. When transcription of all interviews was complete, I read each transcripts numerous times. At this point, I took note of casual observations of initial trends in the data and potentially interesting passages in the transcripts. I also documented my thoughts and feelings regarding both the data and the analytical process (in terms of transparency, it would be beneficial to adhere to this practice throughout the entire analysis). Some preliminary notes made during the early iterations of familiarisation with the data can be seen in Box 1. It will be seen later that some of these notes would go on to inform the interpretation of the finalised thematic framework.

figure a

Example of preliminary notes taken during phase one

3.2.2 Phase two: generating initial codes

Codes are the fundamental building blocks of what will later become themes. The process of coding is undertaken to produce succinct, shorthand descriptive or interpretive labels for pieces of information that may be of relevance to the research question(s). It is recommended that the researcher work systematically through the entire dataset, attending to each data item with equal consideration, and identifying aspects of data items that are interesting and may be informative in developing themes. Codes should be brief, but offer sufficient detail to be able to stand alone and inform of the underlying commonality among constituent data items in relation to the subject of the research (Braun and Clarke 2012 ; Braun et al. 2016 ).

A brief excerpt of the preliminary coding process of one participant’s interview transcript is presented in Box 2. The preliminary iteration of coding was conducted using the ‘comments’ function in Microsoft Word (2016). This allowed codes to be noted in the side margin, while also highlighting the area of text assigned to each respective code. This is a relatively straightforward example with no double-codes or overlap in data informing different codes, as new codes begin where previous codes end. The code C5 offers an exemplar of the provision of sufficient detail to explain what I interpreted from the related data item. A poor example of this code would be to say “the wellbeing guidelines are not relatable” or “not relatable for students”. Each of these examples lack context. Understanding codes written in this way would be contingent upon knowledge of the underlying data extract. The code C8 exemplifies this issue. It is unclear if the positivity mentioned relates to the particular participant, their colleagues, or their students. This code was subsequently redefined in later iterations of coding. It can also be seen in this short example that the same code has been produced for both C4 and C9. This code was prevalent throughout the entire dataset and would subsequently be informative in the development of a theme.

figure b

Extract of preliminary coding

Any item of data that might be useful in addressing the research question(s) should be coded. Through repeated iterations of coding and further familiarisation, the researcher can identify which codes are conducive to interpreting themes and which can be discarded. I would recommend that the researcher document their progression through iterations of coding to track the evolution of codes and indeed prospective themes. RTA is a recursive process and it is rare that a researcher would follow a linear path through the six phases (Braun and Clarke 2014 ). It is very common for the researcher to follow a particular train of thought when coding, only to encounter an impasse where several different interpretations of the data come to light. It may be necessary to explore each of these prospective options to identify the most appropriate path to follow. Tracking the evolution of codes will not only aid transparency, but will afford the researcher signposts and waypoints to which they may return should a particular approach to coding prove unfruitful. I tracked the evolution of my coding process in a spreadsheet, with data items documented in the first column and iterations of codes in each successive column. I found it useful to highlight which codes were changed in each successive iteration. Table 1 provides an excerpt of a Microsoft Excel (2016) spreadsheet that was established to track iterations of coding and document the overall analytical process. All codes developed during the first iteration of coding were transferred into this spreadsheet along with a label identifying the respective participant. Subsequent iterations of coding were documented in this spreadsheet. The original transcripts were still regularly consulted to assess existing codes and examine for the interpretation of new codes as further familiarity with the data developed. Column one presents a reference number for the data item that was coded, while column two indicates the participant who provided each data item. Column three presents the data item that was coded. Columns four and five indicate the iteration of the coding process to be the third and fourth iteration, respectively. Codes revised between iterations three and four are highlighted.

With regard to data item one, I initially considered that a narrative might develop exploring a potential discrepancy in levels of training received by wellbeing educators and non-wellbeing educators. In early iterations of coding, I adopted a convention of coding training-related information with reference to the wellbeing or non-wellbeing status of the participant. While this discrepancy in levels of training remained evident throughout the dataset, I eventually deemed it unnecessary to pursue interpretation of the data in this way. This coding convention was abandoned at iteration four in favour of the pre-existing generalised code “insufficient training in wellbeing curriculum”. With data item three, I realised that the code was descriptive at a semantic level, but not very informative. Upon re-evaluating this data item, I found the pre-existing code “lack of clarity in assessing student wellbeing” to be much more appropriate and representative of what the participant seemed to be communicating. Finally, I realised that the code for data item five was too specific to this particular data item. No other data item shared this code, which would preclude this code (and data item) from consideration when construction themes. I decided that this item would be subsumed under the pre-existing code “more training is needed for wellbeing promotion”.

The process of generating codes is non-prescriptive regarding how data is segmented and itemised for coding, and how many codes or what type of codes (semantic or latent) are interpreted from an item of data. The same data item can be coded both semantically and latently if deemed necessary. For example, when discussing how able they felt to attend to their students’ wellbeing needs, one participant stated “…if someone’s struggling a bit with their schoolwork and it’s getting them down a bit, it’s common sense that determines what we say to them or how we approach them. And it might help to talk, but I don’t know that it has a lasting effect” [2B]. Here, I understood that the participant was explicitly sharing the way in which they address their students’ wellbeing concerns, but also that the participant was implying that this commonsense approach might not be sufficient. As such, this data item was coded both semantically as “educators rely on common sense when attending to wellbeing issues”, and latently as “common sense inadequate for wellbeing promotion”. Both codes were revised later in the analysis. However, this example illustrates the way in which any data item can be coded in multiple ways and for multiple meanings. There is also no upper or lower limit regarding how many codes should be interpreted. What is important is that, when the dataset is fully coded and codes are collated, sufficient depth exists to examine the patterns within the data and the diversity of the positions held by participants. It is, however, necessary to ensure that codes pertain to more than one data item (Braun and Clarke 2012 ).

3.2.3 Phase three: generating themes

This phase begins when all relevant data items have been coded. The focus shifts from the interpretation of individual data items within the dataset, to the interpretation of aggregated meaning and meaningfulness across the dataset. The coded data is reviewed and analysed as to how different codes may be combined according to shared meanings so that they may form themes or sub-themes. This will often involve collapsing multiple codes that share a similar underlying concept or feature of the data into one single code. Equally, one particular code may turn out to be representative of an over-arching narrative within the data and be promoted as a sub-theme or even a theme (Braun and Clarke 2012 ). It is important to re-emphasise that themes do not reside in the data waiting to be found. Rather, the researcher must actively construe the relationship among the different codes and examine how this relationship may inform the narrative of a given theme. Construing the importance or salience of a theme is not contingent upon the number of codes or data items that inform a particular theme. What is important is that the pattern of codes and data items communicates something meaningful that helps answer the research question(s) (Braun and Clarke 2013 ).

Themes should be distinctive and may even be contradictory to other themes, but should tie together to produce a coherent and lucid picture of the dataset. The researcher must be able and willing to let go of codes or prospective themes that may not fit within the overall analysis. It may be beneficial to construct a miscellaneous theme (or category) to contain all the codes that do not appear to fit in among any prospective themes. This miscellaneous theme may end up becoming a theme in its own right, or may simple be removed from the analysis during a later phase (Braun and Clarke 2012 ). Much the same as with codes, there is no correct amount of themes. However, with too many themes the analysis may become unwieldy and incoherent, whereas too few themes can result in the analysis failing to explore fully the depth and breadth of the data. At the end of this stage, the researcher should be able to produce a thematic map (e.g. a mind map or affinity map) or table that collates codes and data items relative to their respective themes (Braun and Clarke 2012 , 2020 ).

At this point in the analysis, I assembled codes into initial candidate themes. A thematic map of the initial candidate themes can be seen in Fig.  1 . The theme “best practice in wellbeing promotion” was clearly definable, with constituent coded data presenting two concurrent narratives. These narratives were constructed as two separate sub-themes, which emphasised the involvement of the entire school staff and the active pursuit of practical measures in promoting student wellbeing, respectively. The theme “recognising student wellbeing” was similarly clear. Again, I interpreted a dichotomy of narratives. However, in this case, the two narratives seemed to be even more synergetic. The two sub-themes for “best practice…” highlighted two independently informative factors in best practice. Here, the sub-themes are much more closely related, with one sub-theme identifying factors that may inhibit the development of student wellbeing, while the second sub-theme discusses factors that may improve student wellbeing. At this early stage in the analysis, I was considering that this sub-theme structure might also be used to delineate the theme “recognising educator wellbeing”. Finally, the theme “factors influencing wellbeing promotion” collated coded data items that addressed inhibitive factors with regard to wellbeing promotion. These factors were conceptualised as four separate sub-themes reflecting a lack of training, a lack of time, a lack of appropriate value for wellbeing promotion, and a lack of knowledge of supporting wellbeing-related documents. While it was useful to bring all of this information together under one theme, even at this early stage it was evident that this particular theme was very dense and unwieldy, and would likely require further revision.

figure 1

Initial thematic map indicating four candidate themes

3.2.4 Phase four: reviewing potential themes

This phase requires the researcher to conduct a recursive review of the candidate themes in relation to the coded data items and the entire dataset (Braun and Clarke 2012 , 2020 ). At this phase, it is not uncommon to find that some candidate themes may not function well as meaningful interpretations of the data, or may not provide information that addresses the research question(s). It may also come to light that some of the constituent codes and/or data items that inform these themes may be incongruent and require revision. Braun and Clarke ( 2012 , p. 65) proposed a series of key questions that the researcher should address when reviewing potential themes. They are:

Is this a theme (it could be just a code)?

If it is a theme, what is the quality of this theme (does it tell me something useful about the data set and my research question)?

What are the boundaries of this theme (what does it include and exclude)?

Are there enough (meaningful) data to support this theme (is the theme thin or thick)?

Are the data too diverse and wide ranging (does the theme lack coherence)?

The analysis conducted at this phase involves two levels of review. Level one is a review of the relationships among the data items and codes that inform each theme and sub-theme. If the items/codes form a coherent pattern, it can be assumed that the candidate theme/sub-theme makes a logical argument and may contribute to the overall narrative of the data. At level two, the candidate themes are reviewed in relation to the data set. Themes are assessed as to how well they provide the most apt interpretation of the data in relation to the research question(s). Braun and Clarke have proposed that, when addressing these key questions, it may be useful to observe Patton’s ( 1990 ) ‘dual criteria for judging categories’ (i.e. internal homogeneity and external heterogeneity). The aim of Patton’s dual criteria would be to observe internal homogeneity within themes at the level one review, while observing external heterogeneity among themes at the level two review. Essentially, these two levels of review function to demonstrate that items and codes are appropriate to inform a theme, and that a theme is appropriate to inform the interpretation of the dataset (Braun and Clarke 2006 ). The outcome of this dual-level review is often that some sub-themes or themes may need to be restructured by adding or removing codes, or indeed adding or removing themes/sub-themes. The finalised thematic framework that resulted from the review of the candidate themes can be seen in Fig.  2 .

figure 2

Finalised thematic map demonstrating five themes

During the level one review, inspection of the prospective sub-theme “sources of negative affect” in relation to the theme “recognising educator wellbeing” resulted in a new interpretation of the constituent coded data items. Participants communicated numerous pre-existing work-related factors that they felt had a negative impact upon their wellbeing. However, it was also evident that participants felt the introduction of the new wellbeing curriculum and the newly mandated task of formally attending to student wellbeing had compounded these pre-existing issues. While pre-existing issues and wellbeing-related issues were both informative of educators’ negative affect, the new interpretation of this data informed the realisation of two concurrent narratives, with wellbeing-related issues being a compounding factor in relation to pre-existing issues. This resulted in the “sources of negative affect” sub-theme being split into two new sub-themes; “work-related negative affect” and “the influence of wellbeing promotion”. The “actions to improve educator wellbeing” sub-theme was folded into these sub-themes, with remedial measures for each issue being discussed in respective sub-themes.

During the level two review, my concerns regarding the theme “factors inhibiting wellbeing promotion” were addressed. With regard to Braun and Clarke’s key questions, it was quite difficult to identify the boundaries of this theme. It was also particularly dense (or too thick) and somewhat incoherent. At this point, I concluded that this theme did not constitute an appropriate representation of the data. Earlier phases of the analysis were reiterated and new interpretations of the data were developed. This candidate theme was subsequently broken down into three separate themes. While the sub-themes of this candidate theme were, to a degree, informative in the development of the new themes, the way in which the constituent data was understood was fundamentally reconceptualised. The new theme, entitled “the influence of time”, moves past merely describing time constraints as an inhibitive factor in wellbeing promotion. A more thorough account of the bi-directional nature of time constraints was realised, which acknowledged that previously existing time constraints affected wellbeing promotion, while wellbeing promotion compounded previously existing time constraints. This added an analysis of the way in which the introduction of wellbeing promotion also produced time constraints in relation to core curricular activities.

The candidate sub-themes “lack of training” and “knowledge of necessary documents” were re-evaluated and considered to be topical rather than thematic aspects of the data. Upon further inspection, I felt that the constituent coded data items of these two sub-themes were informative of a single narrative of participants attending to their students’ wellbeing in an atheoretical manner. As such, these two candidate sub-themes were folded into each other to produce the theme “incompletely theorised agreements”. Finally, the level two review led me to the conclusion that the full potential of the data that informed the candidate sub-theme “lack of value of wellbeing promotion” was not realised. I found that a much richer understanding of this data was possible, which was obscured by the initial, relatively simplistic, descriptive account offered. An important distinction was made, in that participants held differing perceptions of the value attributed to wellbeing promotion by educators and by students. Further, I realised that educators’ perceptions of wellbeing promotion were not necessarily negative and should not be exclusively presented as an inhibitive factor in wellbeing promotion. A new theme, named “the axiology of wellbeing” and informed by the sub-themes “students’ valuation of wellbeing promotion” and “educators’ valuation of wellbeing promotion”, was developed to delineate this multifaceted understanding of participants’ accounts of the value of wellbeing promotion.

It is quite typical at this phase that codes, as well as themes, may be revised or removed to facilitate the most meaningful interpretation of the data. As such, it may be necessary to reiterate some of the activities undertaken during phases two and three of the analysis. It may be necessary to recode some data items, collapse some codes into one, remove some codes, or promote some codes as sub-themes or themes. For example, when re-examining the data items that informed the narrative of the value ascribed to wellbeing promotion, I observed that participants offered very different perceptions of the value ascribed by educators and by students. To pursue this line of analysis, numerous codes were reconceptualised to reflect the two different perspectives. Codes such as “positivity regarding the wellbeing curriculum” were split into the more specified codes “student positivity regarding the wellbeing curriculum” and “educator positivity regarding the wellbeing curriculum”. Amending codes in this way ultimately contributed to the reinterpretation of the data and the development of the finalised thematic map.

As with all other phases, it is very important to track and document all of these changes. With regard to some of the more significant changes (removing a theme, for example), I would recommend making notes on why it might be necessary to take this action. The aim of this phase is to produce a revised thematic map or table that captures the most important elements of the data in relation to the research question(s).

3.2.5 Phase five: defining and naming theme

At this phase, the researcher is tasked with presenting a detailed analysis of the thematic framework. Each individual theme and sub-theme is to be expressed in relation to both the dataset and the research question(s). As per Patton’s ( 1990 ) dual criteria, each theme should provide a coherent and internally consistent account of the data that cannot be told by the other themes. However, all themes should come together to create a lucid narrative that is consistent with the content of the dataset and informative in relation to the research question(s). The names of the themes are also subject to a final revision (if necessary) at this point.

Defining themes requires a deep analysis of the underlying data items. There will likely be many data items underlying each theme. It is at this point that the researcher is required to identify which data items to use as extracts when writing up the results of the analysis. The chosen extracts should provide a vivid and compelling account of the arguments being made by a respective theme. Multiple extracts should be used from the entire pool of data items that inform a theme in order to convey the diversity of expressions of meaning across these data items, and to demonstrate the cohesion of the theme’s constituent data items. Furthermore, each of the reported data extracts should be subject to a deep analysis, going beyond merely reporting what a participant may have said. Each extract should be interpreted in relation to its constitutive theme, as well as the broader context of the research question(s), creating an analytic narrative that informs the reader what is interesting about this extract and why (Braun and Clarke 2012 ).

Data extracts can be presented either illustratively, providing a surface-level description of what participants said, or analytically, interrogating what has been interpreted to be important about what participants said and contextualising this interpretation in relation to the available literature. If the researcher were aiming to produce a more illustrative write-up of the analysis, relating the results to the available literature would tend to be held until the ‘discussion’ section of the report. If the researcher were aiming to produce an analytical write-up, extracts would tend to be contextualised in relation to the literature as and when they are reported in the ‘results’ section (Braun and Clarke 2013 ; Terry et al. 2017 ). While an illustrative write-up of RTA results is completely acceptable, the researcher should remain cognisant that the narrative of the write-up should communicate the complexities of the data, while remaining “embedded in the scholarly field” (Braun and Clarke 2012 , p. 69). RTA is an interpretive approach to analysis and, as such, the overall report should go beyond describing the data, providing theoretically informed arguments as to how the data addresses the research question(s). To this end, a relatively straightforward test can reveal a researcher’s potential proclivity towards one particular reporting convention: If an extract can be removed and the write-up still makes sense, the reporting style is illustrative; if an extract is removed and the write-up no longer makes sense, the reporting style is analytical (Terry et al. 2017 ).

The example in Box 3 contains a brief excerpt from the sub-theme “the whole-school approach”, which demonstrates the way in which a data extract may be reported in an illustrative manner. Here, the narrative discussed the necessity of having an ‘appropriate educator’ deliver the different aspects of the wellbeing curriculum. One participant provided a particularly useful real-world example of the potential negative implications of having ‘the wrong person’ for this job in relation to physical education (one of the aspects of the wellbeing curriculum). This data extract very much informed the narrative and illustrated participants’ arguments regarding the importance of choosing an appropriate educator for the job.

figure c

Example of data extract reported illustratively

In Box 4, an example is offered of how a data extract may be reported in an analytical manner. This excerpt is also taken from the sub-theme “the whole-school approach”, and also informs the ‘appropriate educator for the job’ narrative. Here, however, sufficient evidence has already been established to illustrate the perspectives of the participants. The report turns to a deeper analysis of what has been said and how it has been said. Specifically, the way in which participants seemed to construe an ‘appropriate educator’ was examined and related to existing literature. The analytical interpretation of this data extract (and others) proposes interesting implications regarding the way in which participants constructed their schema of an ‘appropriate educator’.

figure d

Example of data extract reported analytically

The names of themes are also subject to a final review (if necessary) at this point. Naming themes may seem trivial and might subsequently receive less attention than it actually requires. However, naming themes is a very important task. Theme names are the first indication to the reader of what has been captured from the data. Names should be concise, informative, and memorable. The overriding tendency may be to create names that are descriptors of the theme. Braun and Clarke ( 2013 , 2014 , 2020 ) encourage creativity and advocate the use of catchy names that may more immediately capture the attention of the reader, while also communicating an important aspect of the theme. To this end, they suggest that it may be useful to examine data items for a short extract that could be used to punctuate the theme name.

3.2.6 Phase six: producing the report

The separation between phases five and six can often be blurry. Further, this ‘final’ phase would rarely only occur at the end of the analysis. As opposed to practices typical of quantitative research that would see the researcher conduct and then write up the analysis, the write-up of qualitative research is very much interwoven into the entire process of the analysis (Braun and Clarke 2012 ). Again, as with previous phases, this will likely require a recursive approach to report writing. As codes and themes change and evolve over the course of the analysis, so too can the write-up. Changes should be well documented by this phase and reflected in informal notes and memos, as well as a research journal that should be kept over the entire course of the research. Phase six then, can be seen as the completion and final inspection of the report that the researcher would most likely have begun writing before even undertaking their thematic analysis (e.g. a journal article or thesis/dissertation).

A useful task to address at this point would be to establish the order in which themes are reported. Themes should connect in a logical and meaningful manner, building a cogent narrative of the data. Where relevant, themes should build upon previously reported themes, while remaining internally consistent and capable of communicating their own individual narrative if isolated from other themes (Braun and Clarke 2012 ). I reported the theme “best practice in wellbeing promotion” first, as I felt it established the positivity that seemed to underlie the accounts provided by all of my participants. This theme was also strongly influence by semantic codes, with participants being very capable of describing what they felt would constitute ‘best practice’. I saw this as an easily digestible first theme to ease the reader into the wider analysis. It made sense to report “the axiology of wellbeing promotion” next. This theme introduced the reality that, despite an underlying degree of positivity, participants did indeed have numerous concerns regarding wellbeing promotion, and that participants’ attitudes were generally positive with a significant ‘but’. This theme provided good sign-posting for the next two themes that would be reported, which were “the influence of time” and “incompletely theorised agreements”, respectively. I reported “the influence of time” first, as this theme established how time constraints could negatively affect educator training, contributing to a context in which educators were inadvertently pushed towards adopting incompletely theorised agreements when promoting student wellbeing. The last theme to be reported was “recognising educator wellbeing”. As the purpose of the analysis was to ascertain the attitudes of educators regarding wellbeing promotion, it felt appropriate to offer the closing commentary of the analysis to educators’ accounts of their own wellbeing. This became particularly pertinent when the sub-themes were revised to reflect the influence of pre-existing work-related issues and the subsequent influence of wellbeing promotion.

An issue proponents of RTA may realise when writing up their analysis is the potential for incongruence between traditional conventions for report writing and the appropriate style for reporting RTA—particularly when adopting an analytical approach to reporting on data. The document structure for academic journal articles and Masters or PhD theses typically subscribe to the convention of reporting results of analyses in a ‘results’ section and then synthesising and contextualising the results of analyses in a ‘discussion’ section. Conversely, Braun and Clarke recommend synthesising and contextualising data as and when they are reported in the ‘results’ section (Braun and Clarke 2013 ; Terry et al. 2017 ). This is a significant departure from the traditional reporting convention, which researchers—particularly post-graduate students—may find difficult to reconcile. While Braun and Clarke do not explicitly address this potential issue, it is implicitly evident that they would advocate that researchers prioritise the appropriate reporting style for RTA and not cede to the traditional reporting convention.

4 Conclusion

Although Braun and Clarke are widely published on the topic of reflexive thematic analysis, confusion persists in the wider literature regarding the appropriate implementation of this approach. The aim of this paper has been to contribute to dispelling some of this confusion by provide a worked example of Braun and Clarke’s contemporary approach to reflexive thematic analysis. To this end, this paper provided instruction in how to address the theoretical underpinnings of RTA by operationalising the theoretical assumptions of the example data in relation to the study from which the data was taken. Clear instruction was also provided in how to conduct a reflexive thematic analysis. This was achieved by providing a detailed step-by-step guide to Braun and Clarke’s six-phase process, and by providing numerous examples of the implementation of each phase based on my own research. Braun and Clarke have made (and continue to make) an extremely valuable contribution to the discourse regarding qualitative analysis. I strongly recommended that any prospective proponents of RTA who may read this paper thoroughly examine Braun and Clarke’s full body of literature in this area, and aim to achieve an understanding of RTA’s nuanced position among the numerous different approaches to thematic analysis.

While the reconceptualisation of RTA as falling within the remit of a purely qualitative paradigm precipitates that the research fall on the constructionist end of this continuum, it is nevertheless good practice to explicate this theoretical position.

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Byrne, D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant 56 , 1391–1412 (2022). https://doi.org/10.1007/s11135-021-01182-y

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Children's understandings’ of obesity, a thematic analysis

Childhood obesity is a major concern in today's society. Research suggests the inclusion of the views and understandings of a target group facilitates strategies that have better efficacy. The objective of this study was to explore the concepts and themes that make up children's understandings of the causes and consequences of obesity. Participants were selected from Reception (4–5 years old) and Year 6 (10–11 years old), and attended a school in an area of Sunderland, in North East England. Participants were separated according to age and gender, resulting in four focus groups, run across two sessions. A thematic analysis (Braun & Clarke, 2006) identified overarching themes evident across all groups, suggesting the key concepts that contribute to children's understandings of obesity are “Knowledge through Education,” “Role Models,” “Fat is Bad,” and “Mixed Messages.” The implications of these findings and considerations of the methodology are discussed in full.

The Health Survey for England 2009 illustrated that 65.9% of men and 56.9% of women have a body mass index (BMI) higher than 25 kg/m 2 , classing them as overweight, obese (>30 kg/m 2 ), or morbidly obese (>40 kg/m 2 ). Obesity is linked to many chronic illnesses, including type II diabetes, heart disease, and some cancers—specifically bowel and others within the digestive system (Renehan, Tyson, Egger, Heller, & Zwahlen, 2008 ). As a result, the direct cost to the National Health Service (NHS) of treating obesity was estimated to be between £991 and £1,124 million, for the 2001/2002 financial year (McCormick & Stone, 2007 ).

Childhood obesity is of particular concern because obese children are far more likely than children of a normal weight to become obese adults (Alexander & Sherman, 1991 ). The Health Survey for England 2009 showed that between 1995 and 2008, the percentage of overweight and obese girls rose from 25.5 to 29.2% and from 24.5 to 31.4% for boys. This is despite the fact that during the same period reported total energy intake in the United Kingdom (UK) fell by around 20% (Statistics on Obesity, Physical Activity and Diet England, 2006 ). These contradictory figures highlight the complexity of factors contributing to obesity, pointing to issues such as levels of physical activity, which have significantly fallen over the past two decades (Prentice & Jebb, 1995 ).

Many other factors influence incidences of obesity. The negative impact of childhood obesity causes the greatest concern and needs to be further understood. Obese children are more likely to become obese adults and experience increased health problems. Knowler, Pettitt, and Saad ( 1991 ), highlighted the links between childhood obesity and a poor immune system, risk of raised blood pressure, and cardiovascular problems. Studies have also identified that overweight and obese children are more likely to suffer psychological problems associated with low self-esteem, bullying, and social exclusion (Breat, Mervielde, & Vandereycken, 1997 ).

On an international scale, obesity can be seen as a problem of the developed world, a result of economic wealth, high food availability, and low levels of manual labour leading to lower levels of physical activity. This is in conjunction with high levels of car ownership and wide ranging public transport systems adding to the problem. In short, at the heart of obesity lies a homeostatic biological system that works constantly to maintain energy balance to keep the body at a constant weight. This system has not yet adapted to the world in which we currently live because the pace of technological progress has surpassed evolution resulting in a more sedentary lifestyle (Department of Innovation Universities and Skills, 2007). One surprising feature of the geographical distribution of obesity is its increased prevalence in economically and socially deprived areas in the western world, including the focus of this current piece of research, the United Kingdom. This phenomenon is very much a recent development, because historically deprived areas tended to see higher levels of under-nutrition. Brunt, Lester, Davies, and Williams ( 2008 ) illustrate how this situation has now reversed. They found between 1995 and 2005 the gap between obesity levels in the most deprived areas compared to the least (the latter typically having the higher levels) was steadily closing, and that by 2005 obesity levels in the most deprived areas had overtaken those in the least deprived areas, a phenomena that persists today.

The Childhood Measurement Programme (Department of Health and Department for Children, Schools and Families, 2008 ) demonstrated Sunderland in the north-east of England has some of the highest levels of overweight and obese children in the United Kingdom. This same publication also points out the strong positive correlation between areas considered as deprived and levels of obesity in children in Reception (4–5 year olds) and Year 6 (10–11 year olds). Areas of Sunderland are considered to be economically and socially deprived meaning the children who live there can be considered high risk. The statistics relating to Sunderland, where this study took place, demonstrate that 27.8% of Reception-aged children are either overweight or obese and for Year 6 pupils this rises to 38.4%.

The Foresight Report (Department of Innovation Universities and Skills, 2007), tackling obesity, points out that current policies are failing because they do not provide the depth and range of interventions needed. This might lead to positive interventions being ineffective if they are undermined by other areas in society such as social factors and the power of media advertising. The government launched its Healthy Schools Initiative in 2005; however, there has been no substantial reduction in obesity levels since 2005 (Department of Health and Department for Children, Schools and Families, 2008). With this in mind it would seem timely to approach the problem from a different perspective. Effective policies to tackle obesity need to consider all parties involved. However, current policies have been formed using a top down approach i.e., from government, health and education professionals, and even celebrity chefs! Even though these groups are likely to have a broad understanding of the problem from its roots to the long-term consequences, there has been a notable failure to take into consideration the understandings of the individuals at highest risk of obesity, the children themselves. There is growing evidence that interventions incorporating the views of the target population have a greater level of success (Hesketh, Water, Green, Salmon, & Williams, 2005). In the United Kingdom there has been a strong movement to ensure the inclusion of children in decision making particularly in relation to issues that directly affect them such as education, social care, and health (Department of Health, 2002 ; Department of Health and Department for Education and Skills, 2004 ). The collection and dissemination of the understandings of children relating to obesity could provide an insight into why so many strategies are failing. This in turn could lead to the development of policies that can be delivered to provide more successful outcomes.

There is a clear shortage of research examining children's understandings’ of obesity, the studies that have attempted to explore this domain have focused on exploring parent and care giver perceptions (Young-Hyman, Herman, Scott, & Schlundt, 1999), and the understandings of health professionals (Chamberlin, Sherman, Jain, Powers, & Whitaker, 2002 ). More recently studies have considered the understandings of care givers, health professionals, and teachers alongside those of the children themselves (Borra, Kelly, Shirreffs, Neville, & Geiger, 2003; Hesketh et al., 2005). Studies that have examined children's understanding have been focused on body image, overweight versus underweight (Hill & Silver, 1995 ), and peer perceptions of overweight and eating behaviour (Bell & Morgan, 2000 ; Oliver & Thelen, 1996 ), but not on the understandings’ of the children themselves with regards to the causes and consequences of obesity.

Focus groups have proved to be a particularly useful method for collecting data from children, they are most effective with groups of three children and in situations where the children know and like each other. Groups must be carefully selected to ensure the children are comfortable with each other. Talking together in small groups is familiar territory for children because it simulates class work. This method allows the researcher to structure the discussion around themes or topics rather than direct questions. This in turn enables the children to take control of the discussion (Mauthner, 1997 ) with the researcher present to keep things on track. Conducting group discussions in single sex groups can also prove to be more successful because boys are often louder and more willing to talk and this can mean they direct the topic of conversation. It has also been noted the use of some sort of structured activity such as drawing, reading, or sorting cards, can help focus discussion in particular with young children. When discussing diet with children, nutritionists and dieticians regularly use replica food items to help visualise the topic under discussion and photos depicting scenes of physical activity have proved effective in qualitative studies (Hesketh et al., 2005 ).

In summary the objective of this research is to investigate the understandings of a high risk group of children (high risk because of their socio-economic status so determined by their locality), of some of the causes and consequences of obesity, and its links to diet and physical activity. The concepts and themes generated by this research should be used to provide an insight that may inform local policies and interventions that need to be developed to provide a broader and deeper range of options to address this multi-faceted issue.

In order to address the gaps in current literature it was decided this research should focus on identifying themes within the participants understanding. This would provide the researcher with scope for further investigation of the subject in question. It was therefore decided that the most appropriate method of analysis would be a thematic analysis. However, there have been criticisms of this approach in the past due to the lack of clear guidelines for researchers employing such methods. This has subsequently contributed to some researchers omitting “how” they actually analysed their results (Attride-Stirling, 2001 ). It was of upmost importance to the authors in this current study to employ a clear, replicable, and transparent methodology.

Braun and Clarke ( 2006 ) outline a series of phases through which researchers must pass in order to produce a thematic analysis. This procedure allows a clear demarcation of thematic analysis, providing researchers with a well-defined explanation of what it is and how it is carried out whilst maintaining the “flexibility” tied to its epistemological position. The authors in this paper take a position that acknowledges our desire to incorporate the individual experiences of the participants and the meanings they attach to them. However, we also wish to consider the impact of the wider social context on these meanings. Braun and Clarke describe such a position as “contextualist,” sitting firmly between essentialism or realism and constuctionism. Not all theorists describe these two poles of epistemological outlook in the same way; Madill et al. ( 2000 ) refers to them as “naive realist” and “radical relativist.” Methodologies that go hand in hand with this mid-ground position are typically phenomenological in nature, but the flexibility of thematic analysis means that it can also be underpinned by an “in-between” epistemological position. Willig ( 2008 , p. 13) summarises this by explaining a position that argues “while experience is always the product of interpretation and, therefore, constructed (and flexible) … it is nevertheless ‘real’ to the person who is having the experience.” We wish to consider the reality of obesity to the participants, through an exploration of their experiences and the meanings they attach to them, whilst incorporating the broader role society plays in contributing to and shaping the participants meaning making and subsequent understandings.

Participants

Twelve participants were selected through liaising with the school and class teachers, this was particularly important considering the sensitive nature of the research topic and the fact that the participants taking part in this study were children—a vulnerable group. Measures were taken to prevent any of the participants feeling stigmatised. Therefore, under the guidance of the class teachers, the participants approached to take part in the study were carefully selected to ensure no children who may have been made to feel uncomfortable by the discussion were included, and to make sure that the children selected to be in the same focus groups were comfortable with each other. Six (three boys and three girls) were selected from two school years; Reception, aged between 4 and 5 years and Year 6 aged between 10 and 11. The motivation for selecting these age groups was that government statistics relating to childhood obesity are published for these two age brackets. These age groups are viewed as critical points in measuring children's BMI and in monitoring their changing health status. Through looking at these age groups, it may help us to gain an insight into what understandings children arrive at school with (primarily shaped by their experiences set within a home environment) and those that they have later on in their school life when further social influence (school and peers) may play a role in shaping their understandings. Efforts were made to make the sample representative of ethnicities attending the school so a proportionate number of children of Bangladeshi and Afro-Caribbean heritage took part. Participants were not recruited on account of their BMI or weight status. The parents of the children were provided with a study information letter and, in addition, received a phone call from the school's community liaison officer to ensure that parents fully understood the nature of the study because the researcher was aware that for some parents English was not their first language. The phone calls were made in their mother tongue thus allowing the parents to sign the parental assent form with all their queries being answered. Participants were also asked for their verbal consent on the day prior to the study taking place.

The study had received ethical approval from Northumbria University's School of Psychology and Sports Science Ethics Board prior to commencing. The researcher had also been approved by means of an enhanced criminal records background check clearing her to work with children; this approval was required by both the school and the university.

The focus groups all took place in the same quiet room at the school and were conducted by the principal investigator (referred to herein as the researcher). On arrival, the researcher introduced herself and provided name badges for the participants. The researcher briefly explained to the participants that she was there to talk to them about food and exercise. The researcher also explained to the participants that she wanted them to assume that she knew nothing, they were not being tested, and she was only interested in hearing what they had to say—not whether they were right or wrong. Verbal instructions were provided to the participants and they provided verbal assent prior to the recording commencing. A series of questions were developed by the research team, these were designed to keep the focus group sessions on track whilst exploring issues relevant to the research question. The sessions started initially with a discussion centred on the replica food items laid out on the table. Participants were asked to use the replica food and pick out healthy foods and make what they thought would be a healthy lunch. They were asked to explain why it was healthy and what made it healthy. Participants were then asked about foods they liked and why they liked them. In addition, they were asked about the sorts of things they normally ate at home and in school and things they liked to eat. Once conversation had dwindled concerning the replica food the researcher introduced the laminated picture cards, and the discussion moved to physical activity with the researcher encouraging the participants to explore the relationship between diet and exercise. Questions focussed on what activities they thought were healthy (as the images depicted activities that were both physical and sedentary; that is, one image of somebody running another of somebody playing computer games). The participants were asked about what sorts of activities they liked doing and what made those activities good for them. They were asked what activities they regularly engaged with, the sorts of sports their parents and siblings took part in, and the activities they did as families. The themes of discussion were encouraged around the two elements pertinent to any strategy looking to reduce obesity: healthy eating and physical activity. Furthermore, questions also probed at what the participants thought the benefits were of following a healthy lifestyle and what the consequences were of not following one. They were also asked what advice they would give somebody who wanted to be healthier and how important it was to them to be healthy. The focus group guide was intended to provide a structure but not rigidly dictate the line of questioning. The researcher included prompts and encouraged participants to expand on their initial responses and followed up on notions that the participants raised themselves. The sessions on the first day lasted between 20 and 30 min, ending when the participants input was insufficient to continue. At the end of each session the researcher read out the participant debrief and provided each participant with a parental debrief information sheet to take home.

In order to strengthen the analysis process and gather the most appropriate data, the researchers reviewed the recording made on the first day and reflected on the procedures employed in the focus groups. Similar approaches of reviewing data to informing further data collection are used in methods such as grounded theory and it was felt that doing so would strengthen the current study. The decision was made not to use the props (replica food and cards) used on the first day in the second round of focus groups, as at times they had proved to be a distraction to the participants. As an alternative, Reception children were given colouring pens and paper to focus their attention. Year 6 focus groups were run again allowing for free discussion, following on from issues and understandings they had raised in the initial session. The second round of focus groups, other than the changes already detailed above, followed the same sequence as they had on day one and lasted around 30 min. The recordings were transcribed combining the recordings from both days creating four transcripts, one for each group.

Data analysis

The data collected from all the focus groups was transcribed by the principal investigator, during this process the initial thoughts and ideas were noted down as this is considered an essential stage in analysis (Riessman, 1993 ). The transcribed data was then read and re-read several times and, in addition, the recordings were listened to several times to ensure the accuracy of the transcription. This process of “repeated reading” (Braun & Clarke, 2006 ) and the use of the recordings to listen to the data, results in data immersion and refers to the researcher's closeness with the data. Following on from this initial stage and building on the notes and ideas generated through transcription and data immersion is the coding phase. These codes identified features of the data that the researcher considered pertinent to the research question. Furthermore, as is intrinsic to the method, the whole data set was given equal attention so that full consideration could be given to repeated patterns within the data. The third stage involved searching for themes; these explained larger sections of the data by combining different codes that may have been very similar or may have been considered the same aspect within the data. All initial codes relevant to the research question were incorporated into a theme. Braun and Clarke (2006) also suggest the development of thematic maps to aid the generation of themes. These helped the researchers to visualise and consider the links and relationships between themes. At this point any themes that did not have enough data to support them or were too diverse were discarded. This refinement of the themes took place on two levels, primarily with the coded data ensuring they formed a coherent pattern, secondly once a coherent pattern was formed the themes were considered in relation to the data set as a whole. This ensured the themes accurately reflected what was evident in the data set as a whole (Braun & Clarke, 2006 ). Further coding also took place at this stage to ensure no codes had been missed in the earlier stages. Once a clear idea of the various themes and how they fitted together emerged, analysis moved to phase five. This involves defining and naming the themes, each theme needs to be clearly defined and accompanied by a detailed analysis. Considerations were made not only of the story told within individual themes but how these related to the overall story that was evident within the data. In addition, it was highly important to develop short but punchy names that conveyed an immediate indication of the essence of the theme. The final stage or the report production involved choosing examples of transcript to illustrate elements of the themes. These extracts clearly identified issues within the theme and presented a lucid example of the point being made.

The thematic analysis process that was applied to the transcripts elicited key concepts that were evident in the data. These themes are viewed as essential in determining the understandings of all the participants. These categories have been labelled as “Knowledge through Education,” “Role Models,” “Fat is Bad,” and “Mixed Messages.” There are of course aspects of the participants’ understandings that overlap across these categories. This, however, should be viewed as a good interpretation of understandings and attitudes in general, which are never made up of isolated concepts but are all relative to each other.

Knowledge through education

This theme is defined by the ability of all the participants to understand the roles of diet and physical activity. This is, in part, likely to be defined by different levels of education that the two age groups represented have, but nothing conclusive can be drawn given the relatively small sample size. The impact of their education on their knowledge will be demonstrated through evidence from the transcript.

All participants in the reception age group expressed the ability to name and identify different food items from the replica food. When they were asked to prepare a healthy lunch from the food items, they were able to point out food that would typically be classified as healthy.

I: No none of it is real! So what have you put in your healthy lunches girls? You tell me what you have got. *: Apple, I've got pasta, egg, cracker, grapes, bun and cheese. Girls reception Open in a separate window

However, despite displaying that they “know” what healthy means there is evidence of confusion, and it would seem the concept of something being “good” for them is interpreted to be things they like to eat. This suggests that they don't yet fully understand the concept of “healthy” food.

I: And why's rice healthy? *: Because it's nice. I: What healthy food do you eat? *: Chips Boys reception Open in a separate window

Their definition of healthy is centred on food they believe will make them grow for which fruit is highlighted as being particularly important. However, they also attribute this property to the food that makes up their personal diets. This understanding might result from being told to eat so they grow up to be big and strong. It is important to consider younger children's understandings are likely to be primarily shaped by their home environment, where the emphasis is often on how much children are eating as opposed to what they are eating.

I: Why is a banana important? *: Because it makes you strong so you can grow you have to have fruit so you can grow. I: Can you tell me then girls, we have found all these things that are good, as an example can you tell me, sausage, why is sausage good? *: Because it makes you feel strong. Girls reception Open in a separate window

This understanding of the reception-aged girls represented in this study of eating so they can grow up to be strong is also evident with the boys in the same age group. However, the reception boys also place great importance on the necessity of exercise to develop strength, this demonstrates another aspect in their knowledge.

I: What about this one here, swimming, who likes swimming? *: Me *: Me *: Me I: And why is swimming good for you? *: Cos it makes you strong. Boys reception Open in a separate window

It is fair to say Year 6 groups relished the opportunity to express their knowledge. They were able to identify and name different food groups and discuss different types of physical activity; what's more they understand the link between the two in relation to obesity. It seems other influences have impacted on the children's understandings’ such as school and extracurricular groups.

*: This is a banana. I: Ok why's a banana healthy? *: Because it's got seeds inside, because it's a fruit. Girls year 6 Open in a separate window

The ability to identify a particular fruit by one of its universal characteristics shows a deeper level of understanding and suggests that a higher degree of learning. In fact it is explicitly stated that this nutritional knowledge has been gained at school.

I: So do you know the different groups of food like carbohydrates, I heard you say protein and dairy before? *: Done it in science. Girls year 6 Open in a separate window

Moreover, it isn't just a nutritional knowledge they have developed through education. They appear well versed in the concept of a balanced diet and also understand the importance of a balanced lifestyle in relation to physical activity. They are able to articulate the notion of a balanced, healthy lifestyle through a consideration of the consequences of over eating and not exercising.

I: So what happens to you if all you do is you do watch TV and play the computer, eat the food that you told me was the bad food, what would happen to you? *: You would have a miserable life. *: Get fat, teeth will fall out. Girls year 6 Open in a separate window

In the case of the Year 6 boys who took part in this study, it is apparent that although a great deal of their knowledge has come through education at school, other avenues have helped them develop different aspects of their understandings. In this case it seems to be through taking part in activities, typically sport outside of school, or and more uniquely to this group through the influence of their fathers.

*: I would say my dad likes fish so I eat fish loads. *: My dad likes chicken, so he gives me chicken cos after school I do sport, like boxing, he gives me a sandwich with loads of different toppings in cos meats a muscle maker and vegetables is like an energy maker, so if you eat those you will get fitter and healthier. Boys year 6 Open in a separate window

It is evident where the ability exists, or is encouraged, to apply knowledge they have in a context relevant to their own lives, the knowledge becomes embedded in their understandings; it is applicable to them and, therefore, moves from being written on the board in school to being important to their own existence. This is exhibited by those participants, in particular the boys who participated, who have an involvement in sport. Having a motivation to understand nutrition and exercise leads to a desire to apply it because they comprehend the potential benefits. This aspect within the initial theme of knowledge through education leads directly on to the next theme of role models. The key difference between these two themes is the first relates to information that is directly and intentionally meant to inform the children about healthy lifestyles in an institutional setting, while the second theme is typified by understandings that are formed through interactions with other people.

Role models

The application of knowledge gained through education is often facilitated by role models such as family members who reiterate this information through example. Role models play an important role in the concepts described by all the groups, for example, the older boys reported that their fathers helped encourage healthy behaviours, above and beyond the nutritional knowledge in the previous theme.

*: Like sometimes on an afternoon my dad goes to the gym, then there is these tracks outside, and I practice every day on my 100 meter sprint and I can do it in 12 seconds, and when I started doing it I was 21 second, so I keep practicing. Boys year 6 Open in a separate window

This demonstrates some of the participants’ understandings have developed by examples set for them by significant individuals in their lives. This is evident in the younger children's understandings in a less explicit manner; the example below demonstrates good health behaviours can be established through everyday behaviour exhibited by role models.

I: What about this one, walking to school? … Why is it good for you? *: Because me and my mam walk to school and its good. Girls reception Open in a separate window

There is some evidence that examples set to the girls who took part in this study, at home and by other role models, can encourage behaviours or ideals that are not beneficial to the girls health. Girls appear to look up to older female family members who aspire to be skinny.

*: I like to be skinny, my nana does as well, and she wants to be skinny because she's fat now but I still love her. Girls reception Open in a separate window

They also appear to have developed unrealistic ideas about weight loss and the consequences in terms of treatment. Viewing hospital treatment as a solution to obesity, demonstrates a lack of understanding about the role of lifestyle behaviours in the condition. This may also suggest that these participants don't appreciate the importance of lifestyle behaviours in the onset of obesity.

*: Guess what, I seen this film right the boy was fat right, his legs was right down to the bottom, he had a fat tummy, I was hiding cos I hated him, he was horrible, he will have to go to hospital, he was fat. Girls reception I: So what would you tell somebody if you pretend that I was really, really fat, what would you tell me to do. *: Go to the doctors … hospital, operation. Girls reception Open in a separate window

There was some evidence that the older girls in this study had a more balanced outlook on what sort of body shape was healthiest, because they were aware of the negative health consequences associated with being underweight. It is interesting, however, that they are aware that maintaining a healthy lifestyle may be a challenge and this may result in a barrier to adopting healthier practices.

I: What about the other end of the scale, you know if you've got overweight being fat on this side what about being underweight at this end? *: It's bad cos you're all bony and you can't do anything cos you're not strong enough, you're weak. *: So you need to be in the middle. I: Is it easy to stay in the middle? *: No, because sometimes you can't be bothered to eat well and exercise. Girls year 6 Open in a separate window

Within the theme of role models, there was some evidence of a difference between the genders in terms of available role models. The participating boys often cited football heroes as people whom they looked up to and aspired to be like. This highlights the role of the celebrity in providing a role model for today's children; the evidence from the participants in this study may suggest that typically boys look to footballers and other sporting heroes. It can be argued that such individuals do not always provide a strong moral code; they are seen as following a healthy lifestyle in terms of diet and exercise. It would seem that the female participants in this study often looked up to celebrities who weren't so explicitly seen to be following healthy lifestyles, or a sense of caution was attached to following healthier behaviours.

*: Yeah like Wayne Rooney. I: And why is he fit? *: Cos he's good at footballing. I: Do you think that they have to eat special food? *: Yes I: And what special food do they have to eat? *: Bananas and apples. Boys reception *: Actually you can put weight on running cos muscle weighs more than fat so you can put weight on—like Katie Price she put on 10 pounds cos she started running. Girls year 6 Open in a separate window

Another interesting aspect of the notion of role models’ is that the girls were more concerned with how they appeared in a physical sense; it was particularly striking that the Year 6 boys identified unhealthy behaviour in their female peers attributing this to a desire to be like models.

*: Yes, she wants to be a model so she starves herself, her mam gives her a big packed lunch and she puts most of it in the bin, she's like that skinny then she walks out of the dinner hall. Boys year 6 Open in a separate window

There were many aspects of the transcript that highlighted participants were aware that being underweight was as worrying as being overweight. However, across the board they were far more critical of individuals who were overweight and discussed wide ranging consequences for these individuals, this leads on to the next theme evident in the analysis.

There was a united consensus that being fat was something to avoid, that it was a bad thing, and had typically negative consequences. Elements of this theme have been demonstrated throughout the discussion of the previous two themes; however, this illustrates how their understanding impacts on their attitudes toward obesity.

*: Like all the fat goes through your blood and stuff. *: Like sugar, like all the sugar goes through your blood if you eat too much of it would clog up your arteries and you might die. Boys year 6 I: Like how? What would happen to you? Is something going to happen straight away or is it something that's going to happen to. *: You would get rotten teeth and you would not be as strong as you would be if you ate healthy and stuff. *: You could die. Girls year 6 *: Because fat would be horrible. *: Because it's bad for you, because it looks bad. *: Because people call you big fat. Girls reception Open in a separate window

In addition to the health issues and those relating to physical attractiveness were the issues of bullying and social exclusion, which seemed to play a big role in the children's understandings of what it would be like to be overweight. The stigma attached to being overweight is evident as participants often started giggling when talking about people being overweight.

I: Is it important to eat things that are good for you? *: Laughter I: What do you think happens to you if you eat lots of these biscuits? *: Fat I: And what good would stop you from getting fat, or would help you not be fat? *: Giggling Boys reception Open in a separate window

Inability to have a successful career and even death were understood to be the results of obesity. Participants felt people who were overweight were in some way bad or an embarrassment. There was even a sense of fear toward people who they considered overweight, indicating that they would avoid being seen with somebody who was obese.

I: So … so what do you think about being fat, like if you see somebody in the street who looks like they are not very healthy do you think? *: They can't do much, like most of the things you want to do in life, like swimming, jogging. *: Jobs when you grow older. Girls year 6 *: Like if my parents were proper massive and I went to the town with them I would just say they took me to the town and I don't know them. Boys year 6 Open in a separate window

It is clear that the participants’ understanding is that obesity is a very negative issue. However, there is also evidence that they understand the complexity of the condition and are also aware being underweight maybe as much of a problem. The older children in this study seemed to understand that it is a complex issue and fully grasped the concept of moderation. They often refer to the fact that you can have a small amount of things that maybe classified as unhealthy, as long as you don't eat them all the time or balance them out with exercise.

I: And what sort of things for eating well? *: Like fruit and vegetables. *: Some Sugar. *: If you eat vegetables and fruit and you might get back to underweight. *: And you want to be in the middle. *: You need a bit of fat on you. Girls year 6 Open in a separate window

This category of Fat is Bad highlights an issue that clouds all the children's understandings of issues surrounding obesity and that is of conflicting messages. This notion of mixed messages forms the final theme evident in the data.

Mixed messages

The evidence presented here would suggest the information intended to educate and inform children is often met with equal amounts of contradictory or confusing messages and behaviours. The result of this is easily demonstrated by comparing what the children know they should be doing with what they actually talk about doing. For the majority of the participants their knowledge did not always match with their described behaviour, their food preferences often overriding their knowledge. This was perhaps not so surprising; knowledge does not by any means dictate behaviour.

I: Do you have breakfast most mornings? Do you normally have some breakfast, what do you normally have for breakfast? *: Miss I have chocolate cookies. I: What did you have for your tea last night? *: I just had for my supper. I: What did you have last night for your supper? *: Err sandwiches, cake and I: What about what did you have last night for your tea? *: Pizza Girls reception I: You eat two, two pieces of fruit? *: Yes, cos my mam chops it into two halves. Boys reception Open in a separate window

Conflict existed in a number of forms in the understandings expressed by the participants. It is worth reiterating that the younger girls who participated believed treatment for obesity was to go to the hospital and have an operation—something they have picked up from a TV documentary—this conflicts with diet and exercise education they receive at school. Other participants gave more specific and direct examples of receiving contradictory information. This ranged from conflicts in direct health messages to conflicting information and action between school and home. They felt that at times it was difficult to know which information was the right information, not only was it conflicting but it was forever changing.

*: And people say if you make fruit smoothies its healthy for you but it said in the news something about being obese again it said that if you drink a smoothie one a day you'll put on 13 pounds, that's nearly a stone in a year. Boys year 6 I: What about at home? You know if you're taught all this stuff at school what happens when you go home? Do Mum and Dad teach you the same things or is it different? *: Different I: And why is it different? *: I eat more sweets. Girls year 6 Open in a separate window

In addition to this, older children also pointed out they felt that healthy lifestyle information wasn't always delivered in the correct manner, there was a belief that stigmatising people who were overweight was negative. There was an awareness that there is a psychological aspect to overeating, and in some individuals it is this that needs to be addressed. Moreover, there was a feeling again demonstrated solely by the older participants that being overweight/obese could be difficult to rectify and maintaining a healthy weight could be a challenge.

*: So you need to be in the middle. I: Is it easy to stay in the middle? *: No, because sometimes you can't be bothered to eat well and exercise. Girls year 6 I: Do you think it's quite easy to lose weight? *: Yes *: Well for some people. *: If you put your mind to it, it is. I: No go on cos everyone's got different ideas. *: You can't just lose weight quickly. *: Cos my dad when he was young he was obese so he told me, but he's sort of addicted really. *: Addicted to what. *: Addicted he cannot stop but he's trying. *: He cannot stop what. *: Eating when he was young, he like learnt now he's saying to me about being fit cos he tells me about what happened when he was young so I try it. Boys year 6 Open in a separate window

This understanding of the complex nature of the obesity problem, coupled with the confusion and conflict in both the information and behaviours the participants are exposed to, can help explain some of the barriers to individuals adopting a healthier lifestyle.

Comprehensive understanding

The results detailed above highlight some important findings as to how children understand obesity in terms of some of its causes and consequences. It was particularly clear that knowledge, often imparted in a school setting, is getting through to the children who participated in this study. However, it appears equally evident that this knowledge in many cases does not transfer to behaviour. Further examination of the results allows us to explore the potential reasons behind the knowledge-behaviour gap.

Role models by their nature provide examples for both the children's beliefs and their behaviour. There are a wide variety of potential role models for children from parents, teachers, peers, and celebrities. What seems particularly important, in terms of being a positive role model with regards to healthy lifestyles, is that children have an opportunity to view the process of being healthy. In this study, this was typified by the examples of the Year 6 boys who participated in sport with their fathers. It appears this close and active relationship allows the knowledge that has been started at school to grow. Allowing children the opportunity to apply their knowledge and see the steps taken by a role model to get or stay fit help translate this knowledge into behaviour. What is interesting, however, is that it seems passive behaviours by role models can have the same impact. It was the case with these participants that the effect of passive knowledge transfer seemed to be more negative, but that is by no means to say that passive behaviours by role models will not also encourage positive lifestyle behaviours in other cases. The most obvious example of this within this data set was the seemingly implicit messages that the girls received about being skinny. There was not an overtly explicit attempt on the behalf of the role models described here to encourage a “skinny” ideal; however, messages seemed to reach the participants that would indicate this is the case. The key difference between these active and passive role models appears to come from whether the role models place focus on the process; taking part in sport (in the example of the older boys) or outcome being skinny (in the example of the girls). Focus on the action of being physically active or enjoying a healthy diet in the case of these participants produces a healthier outlook on maintaining a healthy body weight. When that focus is on the outcome—the weight loss or the weight gain—there seems to be less concern for actually “being healthy” in terms of body weight and lifestyle. This notion about process and outcome is intrinsically linked to the theme of Fat is Bad.

It is interesting to note that whilst the children expressed an understanding of fat as a component of diet and were able to identify high fat foods and their link to obesity, the focus was on fat as an outcome and not so much about it as input. It is a well-documented fact that fat is a requirement of a balanced diet. The participants were able to recite in great detail the consequences of becoming fat but were not so forthright about the processes involved in becoming fat. It can be suggested that by focussing on the process of becoming fat and understanding the need for fat in moderation and being physically active it may help to discourage fat becoming the output. This may also help to draw away the focus from physical appearance that is so closely tied to the stigma attached to being overweight and place it on living a healthy lifestyle and being healthy.

The key finding of this study is that it is evident that children receive contradictory messages when it comes to following a healthy diet and taking part in exercise. The research presented here highlights children's understandings of some of the causes of obesity and the consequences of becoming overweight. However, it is equally evident that this information has reached them on a knowledge level but has not or cannot be fully translated into behaviour. It appears that central to this problem are the multiple discourses that exist around diet and exercise. Whilst government campaigns may impart facts and figures and provide advice on changes that can be made, there are a whole host of other sources to contend with. There is an undoubted role played by the media both in terms of active advertising campaigns for junk food or sedentary games and the passive portrayal of unattainable body shapes and sizes in magazines and by celebrity culture. However, more than this, health messages are competing against a variety of cultural values, social, and personal norms that may well go against messages that encourage certain behaviours. What is more is that ultimately individuals have the power and autonomy to make their own choices about diet and exercise. Stakeholders need to ensure that people are in a position to make an informed decision and not one where their judgement is clouded by an array of contradicting messages. There is also a responsibility to ensure that individuals are able to act on advice given and to provide advice that is relevant and tailored to individual circumstances. It is easy to understand why parents on a low income may struggle to incorporate “5 a day” into their families diets when they perhaps don't have access to a car and the nearest shop selling fresh fruit and vegetables is several miles away. Ensuring people know that frozen fruits and vegetables are just as good and, in some cases better, is a far more useful and usable message.

Comparisons with past research

The objective of this study was to explore children's understandings of obesity in terms of diet and physical activity; the children included were considered high risk because of their socio-economic status. To meet this objective, focus group data was analysed using thematic analysis. This analysis produced key themes pertaining to the understandings of the participants. There is not a wealth of prior research in this domain and it was for this reason thematic analysis was chosen to analyse the data. The method proved to be particularly useful in generating these exploratory data that are discussed here in relation to previous findings.

The theme of knowledge has previously been identified by Hesketh et al. ( 2005 ) in terms of information and awareness that is pertinent to children's perceptions of healthy eating, activity, and preventing obesity. Increasing knowledge relating to diet and physical activity cannot prevent obesity but it can encourage children to make informed choices.

This study, as have others (Hesketh et al., 2005 ; Borra et al., 2003 ; Musaiger, Mater, Alekri, & Mahdi, 1991 ), identified misunderstandings in children's knowledge as barriers to healthful behaviour. It might be useful to address this issue, particularly with younger children who are developing their knowledge. Previous literature has identified young children often consume their recommended daily intake of fruit but fall well short when it comes to vegetables (Dennison, Rockwell, & Baker, 1998 ). Government campaigns encourage people to eat five portions of fruit and vegetables a day ( www.5aday.nhs.co.uk ); however, nutritionists would encourage three portions of vegetables and two of fruit—fruit having high sugar content. There was no evidence in the transcripts that any of the children were aware of or understood this distinction. This needs further investigation; however, education should encourage an understanding of fruit and vegetables as separate entities to help increase the consumption of vegetables (Gibson, Wardle, & Watts, 1998 ).

The evidence in this study suggests children grasp the causes of obesity, overeating, and low levels of physical activity; however, there was a general lack of understanding of the underlying physiological processes. There was a limited understanding of the concept of energy balance or that there might also be medical reasons for the obesity. Bell and Morgan ( 2000 ) demonstrated providing medical explanations for obesity can have a positive effect on children's attitudes to obese individuals. Overweight individuals were generally stigmatised by the participants in this study, so providing better medical information could help to alleviate these negative attitudes. It is fair to say those children who did have more in-depth knowledge of obesity were more sympathetic in their considerations of overweight individuals acknowledging the difficulty in making lifestyle changes.

The influence of parents concerning diet and exercise behaviours is well documented (Prout, 1996 ). Hesketh et al. (2005), Borra et al. (2003), and Young-Hyman et al. ( 2000 ) consider parental influence to be a determining factor in children's attitudes and understandings of obesity. It is clear this influence can be as detrimental as it can be beneficial. Previous research (Borra et al., 2003 ) argues interventions need to be developed that consider the role of the parent. Children cannot be expected to apply the information they receive at school to themselves if it is not reiterated at home. Nutritional education and physical education have not formed a core or extensive part of school curriculums in the United Kingdom in previous years, and there is now a generation of young parents who do not have the skills to attractively present appropriate foods (Tuttle & Truswell, 2002 ) or who regularly take part in sport themselves. The impact of this on their children's behaviour is that they don't always have examples of healthy behaviour to model their own on.

Of particular importance was the finding that children feel that they often receive mixed and contradicting messages. This is of great relevance when considering the development of policies and strategies that can be more effective. More over this backs up the findings of Dorey and McCool ( 2009 ) who conclude that nutritional messages evident in health promotion and advertising were often perceived by child audiences to be ambiguous. The authors warn that these contradictory messages could potentially serve to weaken the trustworthiness viewers have in health promotion initiatives. This really points to a key area in which health professionals can target efforts to tackle obesity. Clarity and consistency in healthy messages and recommendations are central to helping people take on board and act on the information they receive. Contradiction allows room for people to question the advice given and when effort is required to make a change in behaviour that change is less likely to be made if there is reason to doubt the accuracy of information. Furthermore, coherent messages need to consider person specific factors that may inhibit behaviour change; when individuals are encouraged to behave in a certain way but the constraints of day-to-day life lead to another, the results are confusion and hostility to the initial message (Owens & Driffill, 2008 ).

Procedural issues

The main methodological issue arising was participants from Reception struggled to engage fully in conversation, and the sessions followed a structure more a kin to an interview (i.e., question and answer). It was difficult to encourage responses that were longer than a few words; often one word responses were given. There is the potential to gain some very useful information from children in this age group; however, it can be a long and time-consuming process to elicit enough information to make the analysis process worthwhile. The length of the sessions also must be kept relatively short because attention spans are not long lasting; this was a finding similar to that of Miller ( 2000 ). The replica food items selected to help provide structure to the focus groups were useful and did provide a catalyst for discussion; however, for very young children (i.e., those in Reception) they resemble toys too closely, this then leads to them becoming more of a distraction, hindering the discussion. The use of the picture cards and pens and paper as suggested by Backett and Alexander ( 1991 ) provided a more a suitable means of structuring focus groups for young children.

There were at times issues with certain members of the groups making themselves heard more than others, thus the researcher had to encourage those happier to sit back and let others take the lead (Kirk, 2007 ). However, through a little encouragement all participants appeared comfortable talking with each other and participated equally, a result of the careful selection process. It also appeared to be beneficial speaking to boys and girls separately, with the boys often more excitable in their discussion style in comparison to the girls. It also facilitated the identification of some important issues, for example, the Year 6 boys identified eating behaviours present in the Year 6 girls that the girls themselves did not discuss.

Implications for the future

The Foresight Report (Department of Innovation Universities and Skills, 2007 ), in tackling obesity, points out that current policies are failing because they do not provide the depth and range of interventions needed. This present study has determined that central to children's understandings of the causes and consequences of obesity are the concepts of knowledge, the opportunity to apply this knowledge to their own lives, and the existence of role models to set an example. There exist certain myths and misconceptions that need to be addressed and children need to believe they can trust the health messages they receive because they are aware some messages are misleading or forever changing.

The key to this issue seems to be children learn by example, they can have all the knowledge in the world provided to them through an institution such as a school but this information needs to be supported by life at home. This provides evidence that campaigns need to target parents to tackle childhood obesity; this is an issue that policy makers are already aware of ( National Institute for Health and Clinical Excellence, 2006 ). However, this means health messages delivered to the general public need to be clearer and avoid ambiguity. There needs to be careful considerations of the context in which health messages are received, taking into account the understandings of the target population (Hesketh et al., 2005).

There were some issues raised in the focus group that were beyond the scope of this particular study. There was a representation of different ethnic minorities in the groups, and slight differences in the understandings of these different groups were identified. Further research should investigate the understandings of different minority groups to see if ethnicity influences or results in divergent concepts. Future study also needs to look at strategies that enable children to apply healthy lifestyle information to their own lives.

Children spend, on average, a quarter of their waking lives in schools; therefore, schools can be seen as an effective environment and source to help encourage healthy lifestyles. However, that leaves three quarters of a child's time in which they are out of the control of the school environment. Strategies must be developed to unite the teaching at school with practices in the home. This supports the conclusions of Hughes, Sherman, and Whitaker ( 2010 ) who write that strategies need to be framed in a manner that makes low income mothers feel more supported in addressing issues their children may have with their weight. Ensuring that approaches to encourage healthy lives take on a holistic format will also help to provide consistent and realistic role models. There needs to be a concerted effort from within society to develop role models who have a healthy relationship with food and exercise. These seem to already exist for young boys in the form of sporting heroes but seem in short supply for young girls who already consider that being healthy is the ideal but then look to surgery as a form of weight loss. Lieberman, Gauvin, Bukowski, and White ( 2001 ) highlight the importance of role models and peer influence in the onset of disordered eating in young girls and this needs to be seriously taken into account when sending out messages that being overweight is bad, girls need to be aware that being underweight also has severe health consequences.

In conclusion, the time children spend eating and taking part in physical activity out of school is likely to be the biggest challenge to preventing the continuing obesity problems in the United Kingdom, and this is where current strategies appear to be failing. Children understand obesity and its contributing factors in terms set out to them by those people they consider role models. It is only by helping these role models to provide consistent and reliable information by setting suitable active examples and by being aware of the impact of their passive actions that we can begin to address the problem of obesity.

Acknowledgements

The authors would like to thank Sunderland Children's Centres and Back on the Map for their support in facilitating this research.

Conflict of interest and funding

The author have not received any funding or benefits from industry or elsewhere to conduct this study

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  • How to Do Thematic Analysis | Guide & Examples

How to Do Thematic Analysis | Guide & Examples

Published on 5 May 2022 by Jack Caulfield .

Thematic analysis is a method of analysing qualitative data . It is usually applied to a set of texts, such as an interview or transcripts . The researcher closely examines the data to identify common themes, topics, ideas and patterns of meaning that come up repeatedly.

There are various approaches to conducting thematic analysis, but the most common form follows a six-step process:

  • Familiarisation
  • Generating themes
  • Reviewing themes
  • Defining and naming themes

This process was originally developed for psychology research by Virginia Braun and Victoria Clarke . However, thematic analysis is a flexible method that can be adapted to many different kinds of research.

Table of contents

When to use thematic analysis, different approaches to thematic analysis, step 1: familiarisation, step 2: coding, step 3: generating themes, step 4: reviewing themes, step 5: defining and naming themes, step 6: writing up.

Thematic analysis is a good approach to research where you’re trying to find out something about people’s views, opinions, knowledge, experiences, or values from a set of qualitative data – for example, interview transcripts , social media profiles, or survey responses .

Some types of research questions you might use thematic analysis to answer:

  • How do patients perceive doctors in a hospital setting?
  • What are young women’s experiences on dating sites?
  • What are non-experts’ ideas and opinions about climate change?
  • How is gender constructed in secondary school history teaching?

To answer any of these questions, you would collect data from a group of relevant participants and then analyse it. Thematic analysis allows you a lot of flexibility in interpreting the data, and allows you to approach large datasets more easily by sorting them into broad themes.

However, it also involves the risk of missing nuances in the data. Thematic analysis is often quite subjective and relies on the researcher’s judgement, so you have to reflect carefully on your own choices and interpretations.

Pay close attention to the data to ensure that you’re not picking up on things that are not there – or obscuring things that are.

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Once you’ve decided to use thematic analysis, there are different approaches to consider.

There’s the distinction between inductive and deductive approaches:

  • An inductive approach involves allowing the data to determine your themes.
  • A deductive approach involves coming to the data with some preconceived themes you expect to find reflected there, based on theory or existing knowledge.

There’s also the distinction between a semantic and a latent approach:

  • A semantic approach involves analysing the explicit content of the data.
  • A latent approach involves reading into the subtext and assumptions underlying the data.

After you’ve decided thematic analysis is the right method for analysing your data, and you’ve thought about the approach you’re going to take, you can follow the six steps developed by Braun and Clarke .

The first step is to get to know our data. It’s important to get a thorough overview of all the data we collected before we start analysing individual items.

This might involve transcribing audio , reading through the text and taking initial notes, and generally looking through the data to get familiar with it.

Next up, we need to code the data. Coding means highlighting sections of our text – usually phrases or sentences – and coming up with shorthand labels or ‘codes’ to describe their content.

Let’s take a short example text. Say we’re researching perceptions of climate change among conservative voters aged 50 and up, and we have collected data through a series of interviews. An extract from one interview looks like this:

In this extract, we’ve highlighted various phrases in different colours corresponding to different codes. Each code describes the idea or feeling expressed in that part of the text.

At this stage, we want to be thorough: we go through the transcript of every interview and highlight everything that jumps out as relevant or potentially interesting. As well as highlighting all the phrases and sentences that match these codes, we can keep adding new codes as we go through the text.

After we’ve been through the text, we collate together all the data into groups identified by code. These codes allow us to gain a condensed overview of the main points and common meanings that recur throughout the data.

Next, we look over the codes we’ve created, identify patterns among them, and start coming up with themes.

Themes are generally broader than codes. Most of the time, you’ll combine several codes into a single theme. In our example, we might start combining codes into themes like this:

At this stage, we might decide that some of our codes are too vague or not relevant enough (for example, because they don’t appear very often in the data), so they can be discarded.

Other codes might become themes in their own right. In our example, we decided that the code ‘uncertainty’ made sense as a theme, with some other codes incorporated into it.

Again, what we decide will vary according to what we’re trying to find out. We want to create potential themes that tell us something helpful about the data for our purposes.

Now we have to make sure that our themes are useful and accurate representations of the data. Here, we return to the dataset and compare our themes against it. Are we missing anything? Are these themes really present in the data? What can we change to make our themes work better?

If we encounter problems with our themes, we might split them up, combine them, discard them, or create new ones: whatever makes them more useful and accurate.

For example, we might decide upon looking through the data that ‘changing terminology’ fits better under the ‘uncertainty’ theme than under ‘distrust of experts’, since the data labelled with this code involves confusion, not necessarily distrust.

Now that you have a final list of themes, it’s time to name and define each of them.

Defining themes involves formulating exactly what we mean by each theme and figuring out how it helps us understand the data.

Naming themes involves coming up with a succinct and easily understandable name for each theme.

For example, we might look at ‘distrust of experts’ and determine exactly who we mean by ‘experts’ in this theme. We might decide that a better name for the theme is ‘distrust of authority’ or ‘conspiracy thinking’.

Finally, we’ll write up our analysis of the data. Like all academic texts, writing up a thematic analysis requires an introduction to establish our research question, aims, and approach.

We should also include a methodology section, describing how we collected the data (e.g., through semi-structured interviews or open-ended survey questions ) and explaining how we conducted the thematic analysis itself.

The results or findings section usually addresses each theme in turn. We describe how often the themes come up and what they mean, including examples from the data as evidence. Finally, our conclusion explains the main takeaways and shows how the analysis has answered our research question.

In our example, we might argue that conspiracy thinking about climate change is widespread among older conservative voters, point out the uncertainty with which many voters view the issue, and discuss the role of misinformation in respondents’ perceptions.

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A Comprehensive Guide to Thematic Analysis in Qualitative Research

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What is Qualitative Data?

What do all the methods above have in common? They result in loads of qualitative data. If you're not new here, you've heard us mention qualitative data many times already. Qualitative data is non-numeric data that is collected in the form of words, images, or sound bites. Qual data is often used to understand people's experiences, perspectives, and motivations, and is often collected and sorted by UX Researchers to better understand the company's users. Qualitative data is subjective and often in response to open-ended questions, and is typically analyzed through methods such as thematic analysis, content analysis, and discourse analysis. In this resource we'll be focusing specifically on how to conduct an effective thematic analysis from scratch! Qualitative data is the sister of quantitative data, which is data that is collected in the form of numbers and can be analyzed using statistical methods. Qualitative and quantitative data are often used together in mixed methods research, which combines both types of data to gain a more comprehensive understanding of a research question.

UX Research Methods

There are many different types of UX research methods that can be used to gather insights about user behavior and attitudes. Some common UX research methods include:

  • Interviews: One-on-one conversations with users to gather detailed information about their experiences, needs, and preferences.
  • Surveys: Online or paper-based questionnaires that can be used to gather large amounts of data from a broad group of users.
  • Focus groups: Group discussions with a moderated discussion to explore user attitudes and behaviors.
  • User testing: Observing users as they interact with a product or service to identify problems and gather feedback.
  • Ethnographic research: Observing and interacting with users in their natural environments to gain a deep understanding of their behaviors and motivations.
  • Card sorting: A technique used to understand how users categorize and organize information.
  • Tree testing: A method used to evaluate the effectiveness of a website's navigation structure.
  • Heuristic evaluation: A method used to identify usability issues by having experts review a product and identify potential problems.
  • Expert review: Gathering feedback from industry experts on a product or service to identify potential issues and areas for improvement.

Introduction to Thematic Analysis of Qualitative Data

Thematic analysis is a popular way of analyzing qualitative data, like transcripts or interview responses, by identifying and analyzing recurring themes (hence the name!). This method often follows a six-step process, which includes getting familiar with the data, sorting and coding the data, generating your various themes, reviewing and editing these themes, defining and naming the themes, and writing up the results to present. This process can help researchers avoid confirmation bias in their analysis. Thematic analysis was developed for psychology research, but it can be used in many different types of research and is especially prevalent in the UX research profession.

When to Use Thematic Analysis

Thematic analysis is a useful method for analyzing qualitative data when you are interested in understanding the underlying themes and patterns in the data. Some situations in which thematic analysis might be appropriate include:

  • When you have a large amount of qualitative data, such as transcripts from interviews or focus groups.
  • When you want to understand people's experiences, perspectives, or motivations in depth.
  • When you want to identify patterns or themes that emerge from the data.
  • When you want to explore complex and open-ended research questions.
  • When you are interested in understanding how people make sense of their experiences and the world around them.

Some UX research specific questions that could be a good fit for thematic analysis are:

  • How do users think about their experiences with a particular product, service or company?
  • What are the common challenges that a user might encounter when using a product or service, and how do they overcome them?
  • How do users make sense of the navigation of a website or app?
  • What are the key drivers of user satisfaction or dissatisfaction with a product or service?
  • How do users' experiences with a product or service compare with their expectations?

It is important to keep in mind that thematic analysis is just one of many methods for analyzing qualitative data, and it may not be the most appropriate method for every research question or situation. A key part of a UX researcher's role is being aware of the most appropriate research method to use based on the problem the company is trying to solve and the constraints of the company's research practice.

Types of Thematic Analysis

There are two primary types of thematic analysis, called inductive and deductive approaches. An inductive approach involves going into the study blind, and allowing the results of the data-capture to guide and shape the analysis and theming. Think of it like induction heating-- the data heats your results! (OK, we get it, that was a bad joke. But you won't forget now!) An example of an inductive approach would be parachuting onto a client without knowing much about their website, and discovering the checkout was difficult to use by the amount of people who brought it up. An easy theme! On the flip-side, a deductive approach involves attacking the data with some preconceived notions you expect to find in the qualitative data, based on a theory. For example, if you think your company's website navigation is hard to use because the text is too small, you may find yourself looking for themes like "small text" or "difficult navigation." We don't have a joke for this one, but we tried. To get even more nitty-gritty, there are two additional types of thematic analysis called semantic and latent thematic analysis. These are more advanced, but we'll throw them here for good measure. Semantic thematic analysis involves identifying themes in the data by analyzing the exact wording of the comments made used by participants. Latent thematic analysis involves identifying themes in the data by analyzing the underlying meanings and actions that were taken, but perhaps not necessarily stated by study participants. Both of these methods can be used in user research, though latent analysis is more popular because users often say different things than what they actually do.

Steps in Conducting a Thematic Analysis

Let's jump in! As mentioned before, there are 6 steps to completing a thematic analysis.

Step One: get familiar with your data!

This might seem obvious, but sometimes it's hard to know when to start. This might take the form of listening to the audio interviews or unmoderated studies, or reading the notes taken during a moderated interview. It's important to know the overall ideas of what you're dealing with to effectively theme your study. While you're doing this, pay attention to some big picture themes you can use in step two when you code your data. Break out key ideas from each participant. This might take the form of summarized answers for each question response, or a written review of actions taken for each task given. Just make sure to standardize it across participants.

Step Two: sort & code the data.

Now that you have your standardized notes across your participants, it's time to sort and code the collected qualitative data! Think of the themes from before when you were taking your notes. Think of these codes like metaphorical buckets, and start sorting! Every comment that fits a theme in a box, put it there. Back to our navigation example: some codes could be "small text" or "hard to use." We could put a participant action of "squinting" into the bucket for "small text," or a comment from another mentioning they had trouble finding "tents" in "hard to use."

Step Three: break the codes into themes!

Try to think of each theme as a makeup of three or more codes. For the navigation example, we could put both "small text," and "hard to use" into a theme of "Difficult Navigation."

Step Four: review and name your themes.

Now is the time to clean up the data. Are all your themes relevant to the problem you're trying to solve? Are all the themes coherent and straightforward? Are you comfortable defending your theme choices to teammates? These are all great questions to ask yourself in this stage.

Step Five: Present!!

To have a cohesive presentation of your thematic analysis, you'll need to include an introduction that explains the user problem you were trying to identify and the method you took to study it. Use the terminology from beginning of this resource to identify your research method. Usually for something like this, it will be a user survey or interview. ‍ You also need to include how you analyzed your participant data (inductive, deductive, latent or semantic) to identify your codes and themes. In the meaty section of your presentation, describe each theme and give quotations and user actions from the data to support your points.

Step Six: Insights and Recommendations

Your conclusion should not stop at your presentation of your findings. The best user researchers are valuable for both their insights and recommendations. Since UX researchers spend so much time with participants, they have indispensable knowledge about the best way to do things that make life easy for the company's users. Don't keep this information to yourself! On the final 1-3 slides of your presentation, state the "Next Steps & Recommendations" that you'd like your team and leadership to follow up on. These recommendations could include things like additional qualitative or quantitative studies, UX changes to make or test, or a copy change to make the experience clearer for readers. Your ultimate job is to create the best user experience, and you made it this far-- you got this!

And there you have it! That's everything you need to complete a thematic analysis of qualitative data to identify potential solutions or key concepts for a particular user problem. But don't stop there! We recommend using these principles in the wild to conduct research of your own. Identify a question or potential problem you'd like to analyze on one of your favorite sites. Use a service like Sprig to come up with non-bias questions to ask friends and family to try and gather your own qualitative data. Next, complete and document yourself completing the 6-step analysis process. What do you discover? Be prepared to share on interviews-- hiring managers love to see initiative! Good luck.

View the UX Research Job Guide Here

Our Sources: 

Caulfield, J. (2022, November 25). How to Do Thematic Analysis | Step-by-Step Guide & Examples . Scribbr. https://www.scribbr.com/methodology/thematic-analysis/

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  • Open access
  • Published: 02 March 2024

“She was finally mine”: the moral experience of families in the context of trisomy 13 and 18– a scoping review with thematic analysis

  • Zoe Ritchie 1 ,
  • Gail Teachman 2 ,
  • Randi Zlotnik Shaul 3 , 4 &
  • Maxwell J. Smith 1  

BMC Medical Ethics volume  25 , Article number:  24 ( 2024 ) Cite this article

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Introduction

The value of a short life characterized by disability has been hotly debated in the literature on fetal and neonatal outcomes.

We conducted a scoping review to summarize the available empirical literature on the experiences of families in the context of trisomy 13 and 18 (T13/18) with subsequent thematic analysis of the 17 included articles.

Themes constructed include (1) Pride as Resistance, (2) Negotiating Normalcy and (3) The Significance of Time.

Interpretation

Our thematic analysis was guided by the moral experience framework conceived by Hunt and Carnevale (2011) in association with the VOICE (Views On Interdisciplinary Childhood Ethics) collaborative research group.

This article will be of interest and value to healthcare professionals and bioethicists who support families navigating the medically and ethically complex landscape of T13/18.

Peer Review reports

This paper adds to knowledge on the complexities of contemporary neonatal ethics discourse through a review and analysis of empirical literature concerning families’ moral experiences in the context of Trisomy 13 and 18 (T13/18). The value of a short life characterized by severe disability has been hotly debated in the literature on fetal and neonatal outcomes. Furthermore, in neonatal care, where decisions are made on behalf of a child, a challenge arises when we consider whose knowledge and values are considered authoritative in establishing goals of care and interventions in the best interest of a medically fragile infant. In some neonatal conditions, treatment options and anticipated outcomes are reasonably well known with a strong evidence basis in the medical literature. On the contrary, other conditions feature prognostic uncertainty that can make determining goals of care and appropriate medical intervention more uncertain and complex. Medical ethicist and physician John Lantos describes this as a distinct zone in neonatal ethics, which he refers to as the “stable grey zone” [ 1 ]. He describes three factors that would influence a condition and its associated treatment decision(s) to remain in this state of ambiguity: (a) if survival rates associated with a condition are critically low, (b) if survival rates are high but associated with severe neurocognitive deficiencies, and (c) if the treatment is long, complex, painful, and/or expensive [ 1 ]. In cases where the general public, the medical community and/or a patient group (or their substitute decision-makers) are divided on their confidence in either of these three factors, the condition is likely to remain in a state of persistent ethical ambiguity . Lantos offers trisomy 13 (Patau syndrome) and trisomy 18 (Edwards syndrome) as salient examples of conditions that exist in a state of persistent ethical ambiguity [ 1 ].

Ethical analysis in a state of persistent ethical ambiguity requires different evidence bases to evaluate how a divide in the perception of a condition has grown and persists between a broader public consensus, medical convention, and the experiences of a patient group. Footnote 1 Our literature review is concerned with the evidence base of the latter– exploring the moral experiences of families Footnote 2 in the context of T13/18. We do not contend understanding the moral experiences of families will bring the condition and its various treatment decisions out of a state of persistent ethical ambiguity. Rather, such understandings have the potential to illuminate the ‘invasiveness’ of this state. By invasiveness, we refer to how ethical ambiguity may coexist, influence, or be a barrier to decision-makers’ ability to realize the values they deem as critically important to making medical decisions. To our knowledge, no synthesis of the health-related literature on families’ experiences in the context of T13/18 has been performed to date. Our scoping review and subsequent thematic analysis seek: (a) to synthesize and analyze existing literature in terms of nature, features, volume, and (b) identify gaps in the existing pool of research.

Trisomy 13 and 18

T13 and T18 belong to a class of chromosomal genetic disorders caused by an extra copy of the associated chromosome. After trisomy 21 (Down syndrome), these conditions are the second and third most commonly diagnosed autosomal trisomies in liveborn infants [ 2 ]. While T13 and T18 are distinct conditions, we have elected to include both in this review due to their similarities. This decision aligns with the broader health-related literature in the T13/18 area, where qualitative [ 3 ] and quantitative studies [ 4 ] often discuss the conditions in tandem.

A decade ago, T13/18 were largely considered conditions incompatible with life [ 5 ]. Research published within the last decade has demonstrated that 5–10% of infants with these conditions survive beyond their first year of life [ 2 ]. Children born with T13/18 have a combination of serious congenital disabilities. T13/18 are frequently (up to 80%) associated with multiple anomalies, including congenital heart defects, such as atrial or ventricular septal defect, patent ductus arteriosus, atrioventricular septal defect, tetralogy of Fallot, and intellectual disability [ 4 ]. Shifting perceptions of futility in cases of T13/18 have begun to change healthcare providers’ unwillingness to recommend life-prolonging measures, precipitating a recent upward trend in healthcare utilization among parents whose children have T13/18. A retrospective cohort study conducted in 2016 in Missouri found that between 1990 and 2014, major procedures on T13 patients increased from period 1 (1990–1997) to period 3 (2006–2013) from 0.11 to 0.78 procedures per patient [ 6 ]. For T18, the increase between the periods was from 0.14 to 1.33 procedures per patient [ 6 ]. The marked increases in these study results correspond with those reported in studies using national administrative data sets conducted outside of North America, including a 2015 study in Japan that measured medical procedures and outcomes of Japanese patients with T13/T18 [ 7 ]. These studies suggest changing perceptions on the futile nature of T13/18 may have significantly contributed to a substantial rise in the provision of major life-sustaining procedures on infants with T13/18.

Moral experience

Our review adopts a moral experience framework developed for empirical and theoretical inquiry in bioethics by scholars Matthew Hunt and Franco Carnevale [ 8 ]. They define moral experience as “[e]ncompassing a person’s sense that values that they deem important are being realized and thwarted in everyday life. This includes a person’s interpretations of a lived encounter, or a set of lived encounters, that fall on spectrums of right-wrong, good-bad, just-unjust”  ([ 8 ] p. 659). The framework focuses on five key elements: (a) sense and interpretation – specifying moral experience encompasses the ‘sense’ and ‘interpretation’ of particular encounters by individuals and the meanings they ascribe to particular experiences; (b) the person – specifying a focus on subjective experience with regard for the collective histories or contexts that constrain or shape an individual’s interpretation; (c) values thwarted or realized in everyday life – an individual’s sense that meaningful values are being enacted or impeded, highlighting the process of enacting or impeding values can occur simultaneously and in tension with one another; (d) lived encounter or a set of lived encounters – the sense that values are being realized or thwarted may or may not be linked to an identifiable person, object or circumstance and may include background orientations like a particular outlook on life; (e) spectrums of right-wrong, good-bad, just-unjust – describing spectrums, as opposed to categories, seeks to make visible variations and degrees of moral experience that can play out in both seemingly mundane and high pressure settings [ 8 ]. The framework was utilized in the development of the scope of our literature review and in the subsequent thematic analysis we pursued.

Identifying the research question and scope of the review

We used Arksey and O’Malley’s [ 9 ] methodological framework for conducting scoping reviews and heeded the enhanced recommendations of scholars Heather Colquhoun [ 10 ] and Danielle Levac [ 11 ]. We employed the MIP model for empirical literature reviews in bioethics to establish the scope of the review [ 12 ]. The question we produced to guide our review was, “What is known in the literature about the moral experience of families navigating decision-making in the context of trisomy 13 or 18?” Adopting a contextual framing in the review question is congruent with the method of analysis, a moral experience framework [ 8 ], which we subsequently employed in our thematic analysis, interpreting the idea of ‘context’ to include a wide range of phenomena, moral spectrums, and diverse circumstances.

Identifying relevant studies

The literature we reviewed was retrieved through searches of the MEDLINE, EMBASE, CINHAL, and SCOPUS databases using a combination of search terms and keywords related to methodology (e.g., qualitative, interview, thematic), experiences (e.g., ethics, lived experience, decision-making), and participants (e.g., parents, pregnancy, trisomy 13, trisomy 18). We chose these databases to cover the broad range of disciplines scholars interested in the topic have published in (e.g., nursing, medicine, genetics, bioethics, social sciences). A general list of search terms was created and tested in each database. We further reviewed the reference list of included articles and conducted a grey literature review to enhance the rigour of the process and ensure no relevant articles were missed. We consulted with a research librarian at Western University, Meagan Stanley, throughout the design and execution of our search strategy. See Table  1 for terms used in the search strategy.

Study selection

Our study selection process began with developing inclusion and exclusion criteria (see Table  2 ). Our database search garnered 297 articles. We identified and removed 83 duplicates. The primary author performed the title and abstract screening of 214 articles, excluding 182 articles. A secondary reviewer from the authorship team (MS) worked with the primary author to review the remaining 32 full-text articles, excluding 19 articles. At this point, the two authors also searched grey literature and screened the reference lists of preliminarily included articles. After adding 4 articles from the grey literature search, this led to a total of 17 articles being selected for our review (see PRISMA diagram in Fig.  1 ).

figure 1

PRISMA Flow Diagram

Charting the data

We extracted descriptive data (See Table  3 ) from articles, including the geographical study location, disciplinary location of the primary author (if more than two authors were listed the first was considered primary), research question/topic, type(s) of qualitative methods used, data analysis of the qualitative component, makeup of participants, and the key findings of the qualitative component.

Descriptive features of included articles

The majority of studies we included in the review were conducted in the United States [ 13 ], with the remainder having diverse disciplinary locations, including Japan [ 1 ], England/Scotland [ 1 ], Canada [ 1 ] and Germany [ 1 ]. The disciplinary backgrounds of the primary authors were also diverse, including Medicine, Bioethics, Nursing, Genetics, Psychology, Law, and Health Humanities. All articles were published in the last 13 years, with the oldest published in 2008 [ 24 ] and the most recent in 2021 [ 15 , 19 ]. Studies examined different experiences in the context of T13/18, including screening in the prenatal phase, experiences during the pregnancy after diagnosis, and experiences of families after birth. Interviews and focus groups were the most popular data collection method (58%), followed by surveys with open-ended questions (41%). A significant number of studies that reported a method of analysis for the qualitative component of their study used a form of thematic analysis (58%) or content analysis (23%). Other methods of qualitative analysis included interpretive description and grounded theory. A significant number of studies (41%) did not report a specific method for the analysis of their qualitative component, though most did organize the findings into ‘themes’. Four articles [ 5 , 15 , 16 , 17 ] are associated with a larger study [ 16 ]. Despite similarities in data reported, we included all four articles as they produced distinct analyses. No studies included in the review used the term moral experience or applied it as a framework [ 8 ].

Data analysis

We employed reflexive thematic analysis proposed by scholars Braun and Clarke [ 28 ] to analyze themes across articles in our review. The first step involved close reading and note-taking to begin to think about codes. We moved between articles to begin to appreciate patterns among them. We coded textual excerpts of quotes from participants in the studies reviewed and interpretations from the authors of the studies. Quirkos [ 29 ], a qualitative data management software, was used to organize the data, and all coding was performed manually. A deductive coding scheme (See Table  4 ) was then used as the analytic interests in the review were informed by Hunt and Carnevale’s moral experience framework [ 8 ]. As none of the studies explicitly used childhood ethics language, we focused on producing codes that would seek to broadly interpret the features of the moral experience of families as expressed across the studies included in this review. Several codes (e.g., choices, moral beliefs, life, family) are purposively broad. These codes were further developed into sub-themes and often a code was applied to multiple sub-themes. Our analysis resulted in three distinct themes: (a) Pride as Resistance, (b) Negotiating Normalcy, and (c) The Significance of Time. Themes are described below, with accompanying excerpts from the studies included in this review. See Fig.  2 for a thematic map reflecting the relationship between codes, sub-themes, and central themes.

figure 2

Thematic Map

Pride as resistance

Across multiple studies, parents of infants with T13/18 who chose to continue their pregnancy to term reported facing significant opposition from healthcare professionals who questioned whether their choices were in the best interest of their child or were primarily concerned with self-interests. Several scholars suggested it was common for parents who chose to continue their pregnancy after a T13/18 diagnosis to face significant, strong opposition from healthcare professionals.

“The doctor blurted out she was going to die before everyone left the room, even my 4-year-old son.” (study participant, Janvier et al., [ 15 ] , p. 282).
“When I heard a nurse say to another one “She must be so uncaring and unloving making that baby suffer!” A nurse told us “We want what is in her best interests. Why would you want that done to your child?” (study participant, Janvier et al., [ 17 ] , p. 266).

This sentiment was expressed by several study participants, like those above, across articles in our review. Further, researchers in multiple studies underscored the prominence of this sentiment.

“Following the diagnosis, parents report being told by a HCP that their baby would likely die before or at the time of birth (94%), that their baby would not live for more than a few months (88%), that the condition of their baby was lethal or incompatible with life (93%), that their child would be a vegetable (55%), that their baby would destroy their family or their marriage (28%), and that if their baby survived, he would live a meaningless life (55%) or a life of suffering (68%).” (Guon et al., [ 5 ] , p. 312).
“Most parents had been told their child was “incompatible with life” and would live a meaningless life of suffering (Guon et al., [ 5 ] ) but perhaps experienced the opposite; their baby grew, smiled, and progressed and the family coped and was enriched. A quarter of parents regretted not doing enough interventions.” (Janvier et al., [ 15 ], p. 285).

Although many parents reported finding this opposition distressing, multiple studies in our review suggested it may have contributed to the development of resiliency that became significant to their ability to navigate the psychosocial challenges of their clinical and personal environments. Both study participants in the description of their experiences, and researchers in the presentation of findings, expressed this resistance through fighting metaphors.

“Several families described having to fight on behalf of their fetus.” (Walker et al. , [ 24 ] , p. 17).
“I think that healthcare providers are so negative about the baby they force families on the defensive […] If we feel providers want our babies dead, we will fight for them. This is what parents do.” (study participant, Janvier et al., [ 17 ] , p. 267).
“My understanding of prognosis is that the odds are stacked against my daughter. She has got a lot of uphill battles to fight.” (study participant, Weaver et al., [ 27 ] , p. 2).

In comparison, other studies presented the experiences of parents who expressed that developing and maintaining this resiliency within clinician environments often led to severe exhaustion and frustration.

“We did not know what to do. Then I got pressure to terminate my pregnancy. They told me she would ruin my life and there was no hope. This was too much. My baby was worth it and I would get what she needed. We went somewhere else.” (study participant, Janvier et al., [ 17 ] , p. 267).
“The narrative impulse (of participants) seemed to be a response to their feelings of powerlessness as they struggled to grasp their child’s diagnosis. They described feeling at odds with the medical staff.” (Arthur and Gupta, [ 3 ] , p. 235).
“We were unsure of what to do about surgery, this was our child’s life […] they (medical team) were sure it would be better if he died quickly. It seemed very simple to them. When they told us there was nothing they could do, and all the things he would not get, we decided this was enough and that we would get something, everything for our baby.” (study participant, Janvier et al., [ 17 ], p. 267) .

In multiple studies, researchers presented the experience of parents who advocated for their child’s agency, personhood, and unique attributes to be recognized by individuals around them.

“She had a peaceful character, a sense of humor, a toughness that always made her try hard and never give up, and friendliness.” (study participant, Kosho et al., [ 18 ] , p. 1538).
“She loves to ride her horse with her special saddle and support, pet her cats, and pet her dogs. She loves to play in the water or float and splash. She is the light of our lives. She is almost always happy and she’s full of sass. She is the strongest person I know and I’m so proud to be her mom.” (study participant, Weaver et al., [ 26 ] , p. 234).
“All of the parents interviewed described unique and distinctive qualities for their child. They often characterized their child as energetic and opinionated, using words like “bossy” and “magnetic” (#10), “feisty,” and “proud of herself” (#17), “spunky” and “sassy” (#28), and a “princess warrior” that ran her household (#10).” (Arthur and Gupta, [ 3 ] , p. 228).
“Some parents saw their child as an autonomous entity with his or her own agency and plan. One family felt encouraged by their doctor telling them that their daughter would “tell her own story.” (Arthur & Gupta, [ 3 ] , p. 228).

Studies also reported the parents they interviewed found value in like-minded communities who had lived experience in advocating for their infant with T13/18 and navigating the medical system. Storytelling within these communities emerged as a meaningful interest for families.

“All of the families expressed a particular interest in supporting other families who had children with T 13/18. One mother described her daughter as a 1-year-old with a desire to “impact so many people,” a “purpose” that her mother perceived her daughter passing to her in her final hours: “Mom, I am tired, you can carry the torch now.” (Arthur & Gupta, [ 3 ] , p. 233).
“If there is something that we can say from our experience that will help support somebody else, that’s really important because we want her life to have purpose and we want her life to have meaning. And anything that we can do to make sure that stays forever I’ll do (#12).” (study participant, Arthur & Gupta, [ 3 ] , p. 233).

Negotiating normalcy

A subset of articles in this review focused on family screening and pregnancy experiences in the context of T13/18. Several researchers found that while the screening process for T13/18 commonly involves noninvasive medical testing (did not require surgical intervention), this testing had intrusive implications for parents’ lives in another way, as highly socially invasive.

“One prenatal diagnostician made a powerful claim concerning the social implications of NIPT when she said that “I know it calls itself a noninvasive test, but basically, it is a highly invasive test. For me, this is an invasive test, though not with a needle, yet it is highly intrusive.” In line with this claim, we argue that despite its clinical non-invasiveness, NIPT affects decision-making and is in this sense socially invasive. It can introduce disturbances into, and interferences with, social relationships.” (Reinsch et al., [ 22 ] , p. 210).

Researchers found that some parents interviewed pursued screening for the perceived feelings of reassurance they believed a negative test could offer the rest of their pregnancy experience.

“NIPT, in contrast was frequently described as reassuring […] for the majority of women NIPT enabled them to have reassurance that the baby was not affected by one of the three main trisomies and reduced anxiety for the remainder of the pregnancy.” (Lewis et al., [ 20 ] , 877).

Conversely, other researchers found some parents expressed the anticipated distress and burden to their psychological health, in the event of a positive test, outweighed possible benefits the knowledge of the test might have offered them.

“In our study, we found that some women chose the strategy of non-testing in order to avoid the psychological distress and burden they expected to be caused by NIPT. For these women, the experience of an unburdened pregnancy outweighed the knowledge that the test provides.” (Reinsch et al., [ 22 ] , p. 211).

One researcher [ 22 ] described how prenatal testing influenced how parents morally positioned themselves toward their fetus and other people in their lives with disabilities.

“not only [did she] position herself towards the fetus that she was carrying at the time of the interview. Rather considerations of an abortion established an important link to her firstborn. The mere potentiality of an abortion challenged the relationship with this first child who had down syndrome and, thus the notion of unconditional love towards him.” (Reinsch et al., [ 22 ] , p. 209).
“I think, for me, in particular, my husband has multiple sclerosis and I’ve got two children already and I’m a bit older and so it was very important for me… I was quite clear about the fact that I couldn’t take on caring for something knowing I might have to care for my husband in the future.” (study participant, Lewis et al., [ 20 ] , p. 877).

Several researchers found the parents they spoke with profoundly mourned the loss of meaningful social experiences or personal feelings they had an expectation they would experience during pregnancy or as parents before they received a T13/18 diagnosis.

“These feelings contrast poignantly with a normal pregnancy experience, where social acknowledgment of the expected baby, even from strangers, adds to the joy of the pregnancy. The deep divide between the parents’ personal experience and the social experience was a source of pain beyond their feelings of grief and loss.” (Cote-Arsenault & Denney-Koelsch., [ 14 ] , p. 1307).
“The ultrasound technician had a poker face like you would not believe. I had no clue that anything was wrong. I think that I would have preferred for her to have found a doctor and talked to me right there because we learned the sex of our baby and I had practically redecorated the nursery the night I found out, and we had called the whole family.” (study participant, Walker et al. , [ 24 ] , p. 15).

Significance of time

The studies reviewed discuss time in diverse and meaningful ways. In this theme, we express our understanding that time was discussed as both indicative of states of being and a thing to be hoped for and cherished. The first way we understood time to be meaningful to the moral experiences of families within the context of T13/18 was the way in which many researchers, explicitly through participant testimony, described the isolation and disempowerment parents felt navigating the medical system.

“We were in limbo.” (study participant, Cote-Arsenault & Denney-Koelsch., [ 14 ] , p. 1305).
“Parents heard bad news over time, in disconnected, uncomfortable interactions from different providers. Diagnoses often took many weeks, leaving the mother and father anxious and worried, but still hoping for the best.” (Cote-Arsenault & Denney-Koelsch., [ 14 ] , p. 1306).

Findings and participant testimony presented by researchers also reflected discontinuity in care was a significant factor leading families to experience distress, confusion, frustration, and uncertainty over the future choices they would have to make on behalf of their infant.

“Discontinuity of care was a common complaint among our study population. Families were often referred to a large medical centre or a high-risk obstetric clinic for further care.” (Walker et al., [ 24 ] , p. 14).
“I lost contact with my regular health care provider, so we got shuttled into a little subsystem. It’s like ‘something’s wrong, so you don’t go to us anymore, you go to these new people.’ It would’ve been nice if my doctor would’ve called and said ‘you know I understand that there’s a problem, let me know if there’s anything I can help you with’.” (study participant, Walker et al., [ 24 ] , p.14).

Clinical spaces were not the only setting where researchers reported parents experienced feelings of powerlessness. Some parents also had a similar experience in online support groups.

““A mother who chose hospice for her child described online resources as often being characterized by judgment from parents with surviving children towards those who didn’t choose aggressive interventions (followed by an excerpt from interview transcript)– “What you are going to see is all the parents that still have living trisomy kids are the ones that are out there saying, do this, do this, do this. It’s the rest of us, the 90%... we basically keep our mouth shut about it because that’s not what our story was.”” (Arthur and Gupta, [ 3 ] , p. 233).
“I looked on the Internet and found some support groups. They get people posting who have a spiritual view or whose babies live a long time. There is the tendency to think that that is the typical experience, which is a shortcoming of leaving the patient to find information on their own.” (study participant, Walker et al. , [ 24 ] , p. 16).

Parents were also highly future-oriented, some studies reported, keenly invested in thinking about how their choices in pregnancy would impact their ability to fulfill the interests of themselves, and their family in the future.

“I believe continuing my pregnancy was beneficial to my long-term emotional health because it allowed a more natural grieving process (vs. termination).” (study participant, Guon et al., [ 5 ] , p. 311).
“Participants also reflected on their ‘future lives’, for example, one participant with a high-risk reflected on what the long-term future of parenting a child affected by down syndrome [the study looked at a variety of trisomies] would look like and the implications for her own children” (Lewis et al., [ 20 ] , p. 876).

Time was not simply described by studies in terms of a state of being, it was also something parents hoped for deeply– time with their child.

“My biggest hope was that he would not suffer in any way. Naturally I hoped that he would be with us for a long time and have a good life. I wanted to give him a chance.” (study participant, Janvier et al., [ 15 ] , p. 281).

Researchers across studies found a hope for time was often accompanied by some common desires of parents including: to be together as a family, to have their infant be born alive, and to bring them to their home.

“I hoped that we would be able to bring her home and raise her and care for her in our family.” (study participant, Janvier et al., [ 15 ], p. 281).
“I would like to be able to bring her home and have a family experience having her home. I am hoping to let her have quality time with us as a family once we are able to get her to that point. I hope one day she will be well enough to go home with us to be a family for as long as she is able.” (study participant, Weaver et al., [ 27 ] , p. 2).

In cases where time with the fetus or newborn was likely to be critically short, multiple studies found parents were comforted by healthcare professionals who encouraged parents to reconsider the time they deemed as part of their child’s life.

“They suggested that we treat Tessa’s time in the womb as part of her life. It made her life more meaningful to our younger children and us.” (study participant, Janvier et al., [ 17 ] , p. 266).

Some studies suggested parents experienced significant distress in cases where healthcare professionals did not encourage this outlook on life, time, and togetherness. This quote stood out as quite a visceral emotional description of a mother feeling able to bond with her child, and craft memories, only after the child had died, and no one cared what she did.

“One mother struggled to recall a fond memory of the 14 weeks she spent with her child in the ‘sterile’ NICU because, “I didn’t feel like she was mine […] all of my pictures I’m in a hospital gown and no wedding ring… that’s not me.” After her daughter passed away, she finally had a chance to craft the memories that she wanted, “I wanted my picture taken because she wasn’t attached to anything […] and then I wouldn’t put her down for some hours […] because she was finally mine […] because she wasn’t connected and nobody cared what I did.” (study participant, Arthur and Gupta, [ 3 ] , p. 232).

The persistence of the ethically ambiguous state of T13/18 in medical, social, and cultural communities, as demonstrated by our analysis of the literature we reviewed, has a profound influence on many families’ interpretation and sense of how their values may be both thwarted and actualized in their lived experiences of T13/18. In this discussion, we present a constructive reflection on how our inquiry into the moral experience of families captured in the current body of literature on their lived experiences contributes to a strengthened understanding of how we might view and navigate the invasiveness of these conditional states of persistent ethical ambiguity.

An inquiry into the agency of a particular group, as our theoretical lens understands it, involves the discernment of phenomena in terms of their broader meaningfulness [ 30 ]. From a moral experience lens, this process involves seeking to understand how the experience of this phenomenon (which may be conceived of events, interactions, interpretations, situations, circumstances) matters to the agent, which is in part shaped by the systems of meaning the agent is socially embedded within [ 8 ]. Our review collected a small but rich body of literature which explored the lived experiences of families in the context of T13/18. Our analysis demonstrated how (a) pride as resistance, (b) negotiating normalcy, and (c) the significance of time can be regarded as meaningful concepts to further our understanding of how agency is perceived and exercised by families experiencing T13/18 as expressed by the body of literature we reviewed.

Our theme, ‘pride as resistance,’ acknowledged the myriad of different ways that experiences and normative evaluation interrelate in the context of T13/18 and suggests some families who chose to continue their pregnancy found deep meaning in resisting the historically dominant discourse in medicine that T13/18 are conditions incompatible with life. In our analysis, we discussed the agentic nature of this resistance, reflected in the fighting metaphors both authors and their participants used [ 3 ]. Resistance, especially of a nature that families in the literature expressed, presupposes the existence of a strong ‘force’ one interprets as working against them. This lens allows us to unpack why families who wish to continue their pregnancy might feel the need to be zealous in their advocacy publicly and in online support forums for other parents. One could also argue studies that pointed out the use of fighting metaphors are reflective of families’ cultural beliefs about engaging in parenthood. This resistance may support the ability of parents to express how meaningful it is for their child’s agency, personhood, unique attributes, and life story to be recognized by individuals and communities they are or seek to be embedded within. Equally, taking on that advocacy role can be exhausting, isolating, and increase perceptions of injustice. There is a distinct richness to the moral nature of the experiences captured in the literature we reviewed, which describes families experiencing many emotions and expressions of identity like pride, grief, surprise, play, anger, resistance, sass, acceptance, spunk, magnetism, peace, and toughness, in complex and intertwined ways.

Our theme, ‘negotiating normalcy,’ discussed families’ experiences of desiring and, in some cases, sensing they were denied access to culturally valuable ‘goods’ within their social communities— expressed in terms of beliefs and values— like the loss of a ‘normal’ pregnancy experience. Families in the studies we reviewed experienced the ethical ambiguity associated with T13/18 as invasive in their social interactions [ 3 , 15 , 24 ]. This invasiveness challenged their access to social acknowledgments that mattered to their sense of social belonging and to the formation of their identity as parents ‘in becoming’. We also discuss critical ideas in the literature we reviewed about the underappreciation of how morally and existentially challenging prenatal screening can be for families. Parents after a T13/18 diagnosis may be vulnerable to pressures regarding what identity they must take up to be a ‘good parent’ considering the new knowledge they have acquired through the diagnosis. In the current available research this is mainly explored through studies that looked at parents’ involvement in social networks [ 16 ], or studies that discuss how parents navigated the interpretation of trustworthy informational sources [ 24 ]. As research about ‘good parent beliefs’ evolves and grows in the pediatric ethics space [ 31 , 32 ] this could be a powerful avenue into future research on the moral experiences of families in the T13/18 context. In the context of what we know about persistent ethical states of ambiguity, we might consider the lack of acknowledgment of how challenging the screening process can be for families, which could contribute to the moral distress they face in the decision-making process that follows their screening.

Our theme, the ‘significance of time,’ analyzed how time, both temporally and spatially, was morally significant to how parents/families conceptualized their agency and ability to make normative evaluations about decisions on behalf of their pregnancy/child. Looking at both the temporal and spatial expression of time offered unique ways to think about how parents assess information and express their hopes and desires for their child in the context of T13/18. Several philosophical scholarly contributions on the ethical challenges surrounding the provision of life-sustaining measures in cases of T13/18 motivate a central tension in these cases concerns how a family and clinical team conceive of choices in the best interest of an infant considering their predicted present and future quality of life. In healthcare, quality and quantity of life can often be positioned as dichotomous concepts in goals of care discussions [ 33 ]. Across multiple studies included in this review [ 5 , 17 , 27 ], families expressed the prominence of this dichotomy (that their choices in effect would either attend to quality or quantity of life concerns, not both at the same time) in medical cultures constrained their ability to feel heard and understood by clinicians in establishing goals of care for their child. Families often felt their motivations to push for life-sustaining treatment were mischaracterized by clinicians as efforts to simply prolong their child’s life or a failure to appreciate the severity of their infant’s condition.

Several studies we reviewed [ 15 , 18 ] provided rich insight that a crucial part of families’ moral experience was a deep desire for engagement and connection with their infant, to make memories and bonds outside of clinical environments many parents felt alienated within. This might necessitate more attention in the clinical setting be given to supporting a family to consider how they integrate their infant with T13/18 into the quality of being a member of their family in a way that feels real and meaningful considering their unique moral, cultural and/or spiritual context. The current body of research positions quality of life, quantity of life, and the value of ‘togetherness’ or the ‘adoption’ of the child into the existing family of parents as significant values that are often held by parents simultaneously. In exploring the significance of these values to the moral experience of families, one might consider how a parent’s motivation to pursue ‘togetherness’ as an interest could influence prioritization of this value ahead of other values perceived to be more constitutive to the best interest of the child. However, the social and cultural complexities of familial interests demonstrated within this body of literature illustrate separating the interests of a critically ill infant from those of their parents is ethically and practically challenging in a condition like T13/18. This insight is also reflective of growing ethical discourse [ 34 , 35 , 36 ] in associated bodies of literature on the utility of the best interest of the child standard in establishing goals of care for children across pediatric medical specialties.

Of critical importance to this discussion is the recognition that societal, cultural, religious, political, and legal factors influence the way different families consider the morality of their healthcare decisions and sometimes the authority and choices they can make on behalf of their child. In the context of this literature review, as the majority of articles included reported on studies conducted in America, a North American context bears relevance to the experiences of those research participants, the authors who reported on them, and our secondary analysis of that reporting. One study included in our review, which was conducted in Japan [ 18 ], points out in their clinical experience it appeared more natural for Japanese healthcare professionals in treating children with severe disabilities to consider their existence to be precious and valuable. Moral matters are rooted in a person’s moral ontology, that is, the underlying commonly implicit beliefs held by a person or a group of persons. The moral experience lens we adopted in this review recognizes these forces as ‘horizons of significance’ [ 8 ]. If we consider how families as moral agents stand against a background of ‘horizons of significance,’ we can start to distinguish how their agency is constructed by the context that they reside within and the sociohistorical-based moral order within which the meaning of their identity and experiences of having a pregnancy/child with a diagnosis of T13/18 is rooted [ 8 ]. The literature we analyzed in this review demonstrates having a pregnancy/child with a T13/18 diagnosis requires families to be in a complex process of continual appraisal of how their concerns stand in relation to their local moral context; this moral experience is compounded by the ethically ambiguous nature of their local moral context in relation to the conditions.

Empirical bioethical inquiry centring on how an individual or group exercises, or ‘ought’ to exercise, agency, can often presuppose a normative ethical lens seeking to understand how ethical principles or standards stand in relation to culturally accepted moral values we deem relevant to decision-making [ 8 ]. In this way, these lines of inquiry value the perceived benefit of exploring subjective and collective endorsements of moral systems constructed of coherent, systematic, and reasonable principles, rules, ideals, and values to produce ethically justified decision-making [ 8 ]. We would suggest conditions that find themselves in persistent states of ethical ambiguity (like T13/18) are uniquely suited to challenge the value of this presupposition. As such, researchers should consider the utility of alternative approaches to studying the contours of agency and, consequently, the nature of decision-making in these states.

In our review, we used a moral experience lens to analyze literature that explored the lived experience of families navigating a condition (T13/18) in a state of persistent ethical ambiguity. This approach allowed us to shift our focus from considering normative questions like, “what does the literature say we should do to support parents to make ethical decisions in the context of T13/18?” to “what does the literature say about how parents’ interpretation of their experiences in the context of T13/18 inform what matters or is at stake for them in their decisions?” and “how are parents’/families’ experience of evaluating morality in their decisions shaped by the systems of meaning they are embedded in?– furthermore, do families have the power to resist or transform those systems of meaning?” Normative questions ask what we should or ought to do. In states of persistent ethical ambiguity, while, of course, actions still need to be taken, just by the nature of these states themselves, we can presuppose that the “should” is highly resistant to an objective answer. We found in our review of the literature that a focus on moral experience and the systems of meaning that influence those subjective experiences was a rich lens to contribute applied and theoretical insight into why T13/18 remains in a state of persistent ethical ambiguity, and how families live and make decisions within that state.

Strengths and limitations

It should be acknowledged this review only considered the inclusion of articles written or available in the English language. Regional legal regulations, cultural values, and healthcare policies in different regions bear significant context to our analysis. As the majority of articles in this review were conducted in the United States, it should be recognized our analysis may be more relevant to healthcare systems and bioethics traditions that bear similarities to a North American context. This review excluded normative literature on the subject, despite its valuable contributions to the ethical discourses we explore in our review. We made this decision to forefront empirical work which examined the experiences of families in the context of trisomy 13/18. Our review and analysis does not contend to speak to, or for, the moral experiences of all families in the context of T13/18. Consistent with our theoretical outlook our inquiry acknowledges this would be an impossible feat considering the subjective and culturally embedded nature of moral experience.

This review suggests there is great value in applying a moral experience lens to research the experiences of families’ in the context of T13/18. Decision-making in the context of T13/18 engages with questions of the morality of prolonging life, suffering and the effects of illness and disability on a family. Our review demonstrates a myriad of other ethically relevant concerns deserve consideration in these discussions, including notions of a ‘normal’ pregnancy and child, the psychological price of continued resistance against a medical system one perceives themselves to be at odds with, how pride and resistance interrelate, how the decision-makers in families forecast their future needs, and how both quality and quantity of life can be complementary desires, among several others. The richness of these ethically relevant concerns demonstrates more research into the experience of families’ in the context of T13/18 could produce valuable insight into supportive actions to alleviate some of the moral distress these families, and their healthcare providers face.

Availability of data and materials

The articles reviewed in this scoping review are available in the associated journals in which they were originally published. Full citation details of these articles are included in the reference section.

In the case of T13/18 the patient group can include the individual carrying the pregnancy with a diagnosis of T13/18 and the infant born with T13/18. This paper reviews several articles, wherein many parents also recognized the fetus involved in the pregnancy as their child. In this paper we do not engage in philosophical, or political discussion, on the personhood status of a fetus. The articles we review in this paper also do not explore these nuances.

We choose the term family (or families) to refer comprehensively to a group of individuals which may (or may not include) the individual carrying a pregnancy with a T13/18 diagnosis, their partner or support system, the parents associated with the pregnancy/child, the pregnancy itself, or the child/infant itself after birth. Since we review studies which involve individuals who are navigating the context of T13/18 in different phases (pregnancy, after birth or after the death of their child), and therefore might constitute the members of their families in different ways, there is no clear linguistic convention to refer to all these individuals and states.

Abbreviations

Trisomy 13 and/or 18

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Acknowledgements

Meagan Stanley, a Teaching and Learning Librarian with Western Libraries at Western University assisted in developing and testing our review strategy.

This review was conducted for degree completion requirements for the Health and Rehabilitation Sciences doctoral program within the Faculty of Health Sciences at Western University. The doctoral work of the primary author is supported by a graduate student stipend provided by the VOICE (Views on Interdisciplinary Childhood Ethics) group at McGill University and an Ontario Graduate Scholarship awarded by the Government of Ontario.

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Ritchie, Z., Teachman, G., Shaul, R.Z. et al. “She was finally mine”: the moral experience of families in the context of trisomy 13 and 18– a scoping review with thematic analysis. BMC Med Ethics 25 , 24 (2024). https://doi.org/10.1186/s12910-023-00994-x

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External context in individual placement and support implementation: a scoping review with abductive thematic analysis

  • Jaakko Harkko   ORCID: orcid.org/0000-0001-8682-1544 1 ,
  • Noora Sipilä 2 ,
  • Hilla Nordquist 3 , 4 ,
  • Tea Lallukka 4 ,
  • Kaija Appelqvist-Schmidlechner 2 ,
  • Michael Donnelly 5 &
  • Anne Kouvonen 1 , 5  

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Context including the external context may considerably affect the adoption, implementation, sustainment, and scale-up of evidence-based practices. We investigated external contextual features by conducting a scoping review of empirical research regarding the implementation of an evidence-based psychiatric or mental health vocational rehabilitation service called Individual Placement and Support (IPS).

The protocol for the scoping review was registered with the Open Science Framework. We used the methodology by Joanna Briggs Institute for conducting the scoping review and reported it according to the PRISMA-ScR checklist. We searched 12 databases for research regarding ‘Individual Placement and Support’ or ‘Evidence-Based Supported Employment’. We retained peer-reviewed empirical studies investigating external contextual factors and their impact on IPS implementation outcomes. We extracted data from the eligible articles and conducted descriptive and thematic analyses.

Fifty-nine original research papers met our eligibility requirements and were retained after reviewing 1124 titles and abstracts and 119 full texts. The analysis generated two main themes: (1) external contextual determinants of service delivery and (2) external systems influencing the evidence-to-practice process. The first main theme encompassed policies and laws, financing, and administratively instituted support resources, and organizational arrangements associated with external stakeholders that may facilitate or hinder the local implementation. The second main theme comprised strategies and actions used by different stakeholders to facilitate implementation locally or scale-up efforts at a system level.

Our scoping review illustrates the important role that external contextual factors play and how they may facilitate or hinder the implementation and scale-up of the IPS model across mental health services in different countries. Consideration of these factors by decision-makers in mental health and welfare services, planners, providers, and practitioners is likely to facilitate the development of effective strategies for bridging the evidence-practice gap in implementing the EBPs. Finally, the scoping review identified gaps in knowledge and offered suggestions for future research.

Trial registration

Open Science Framework

Peer Review reports

Contributions to the literature

The scoping review of 59 studies provides a summary of results from empirical implementation studies covering the implementation, sustainment, and scale-up of the Individual Placement and Support (IPS) model, evidence-based practice in mental health services to obtain employment for persons with mental disorders.

The study identifies external contextual factors occurring consistently across the reviewed literature.

The study highlights the strategies and actions that different key stakeholders (namely researchers, political and administrative decision-makers, support organizations, and agency leaders) undertake to facilitate or hinder the local implementation and scale-up efforts at the system level.

The institutions and structures outside a service organization can significantly impact the implementation of evidence-based practices (EBPs). These contextual factors can affect both the implementation strategies [ 1 ] and outcomes [ 2 ], including the sustained use of EBPs [ 3 ]. Factors such as scientific support, funding, legislation, social policy, supportive educational and training structures, variables related to communities, the service environment, leadership, and networks have been identified as crucial for translating evidence into practice [ 4 , 5 , 6 , 7 ]. These external context factors have also been recognized as important targets for systematic study [ 4 , 7 ], and the lack of emphasis on the system and policy levels of implementation has been considered to contribute to suboptimal results in translating evidence to practice [ 8 ]. However, the concept ‘external context’, which largely overlaps in meaning with other concepts such as ‘outer setting’ or ‘external environment’, is defined ambiguously and inconsistently across various studies [ 9 , 10 ]. It also is less frequently the focus of empirical observation in implementation and dissemination research [ 2 , 11 , 12 ]. For these reasons, there is a need to increase the efforts to organize and systematize the findings from existing research literature in a structured way.

In this scoping review, we examined the processes, mechanisms, and social systems traditionally considered as ‘external context’ in relation to the implementation of the Individual Placement and Support (IPS) model. IPS is an EBP in mental health care that integrates vocational rehabilitation and mental health treatment through a multidisciplinary team approach [ 13 ]. Meta-analyses have shown that the IPS model effectively supports people with mental disorders to paid employment [ 14 , 15 ]. The model’s feasibility for different patient groups and the predictive validity of the fidelity model has also been demonstrated [ 16 , 17 ]. The model was developed in the USA in the 1990s and is now used in many countries, including the USA, Canada, Australia, and several European countries. In addition to building up the evidence base, the model’s creators’ have engaged in several ways to increase the model’s penetration and reach. These efforts include the IPS Learning Collaborative, a two-tier dissemination model for administration representatives and regional support organizations [ 18 , 19 ]. The model’s originators also have produced standardized guidelines and training materials, published standards for monitoring the implementation quality, participated in training state trainers, and provided summaries of the evaluation and monitoring reports [ 18 , 19 ]. Despite these efforts, the IPS model has achieved relatively low penetration in service systems across countries [ 20 , 21 , 22 ].

The motivation to study the external context, specifically with respect to the IPS model, is driven by several converging reasons. First, there is a noticeable overlap in time between the maturing evidence base and reports of challenges in innovation dissemination. Second, since the late 2000s, there has been a growing body of individual studies that identify external contextual factors as barriers affecting the implementation and penetration of IPS. This review attempts to identify potentially consistent trends across existing research findings. Third, the IPS model promotes the ‘recovery approach’. This approach values community inclusion as a pivotal aim of the care process [ 23 , 24 ]. The recovery approach signifies a society-driven shift in the care paradigm, a shift that is inherently connected to the evolution of the service system which is part of the ‘external context’. Finally, studying a relatively consistent and homogenous intervention may reduce the variability that may occur when summarizing and comparing results from interventions with different foundational principles or methodologies, i.e., differences between interventions may act as confounding variables.

Previously, only one study has attempted to systematically review empirical research on external context constructs that affect the implementation of complex evidence-based health interventions [ 2 ]. We searched the Cochrane Database of Systematic Reviews and Joanna Briggs Institute (JBI) Evidence Synthesis but identified no current or underway systematic or scoping reviews on our topic. We chose a scoping review and not systematic review methodology as the scope of our review is the context rather than the properties of the intervention, and as the concept ‘external context’ is not unambiguously defined or measured in literature, and the purpose of this study is to discuss the implementation science concepts [ 23 , 24 , 25 ].

We conducted a scoping review to systematically map the empirical research covering the external contextual factors in implementing and scaling up the IPS model and identify existing gaps in knowledge. Our research question was ‘How does external context affect the adoption, implementation, sustainment, and scale-up of the Individual Placement and Support (IPS) Model?’.

Protocol and registration

We followed the JBI methodology [ 23 , 26 ] to produce the protocol. We prospectively registered the protocol with the Open Science Framework [ 27 ].

Eligibility criteria

We followed the ‘Population/Concept/Context’ framework (PCC) recommended by JBI [ 23 ] for scoping reviews. We defined our study population to encompass all pertinent stakeholders, including practitioners, researchers, policymakers, state bureaucrats, and leaders of mental health agencies. The concept examined by this scoping review was ‘external context’ which we define as any condition or circumstance external to the agency where the IPS model is executed, as outlined in the model guidelines [ 28 ]. We define context along this distinction as ‘local service context’ and ‘external context’.We accepted studies with no country restrictions. We included only peer-reviewed journal articles covering IPS services targeted at persons with any mental disorder written in English. Quantitative, qualitative, and mixed-method studies were included. We excluded studies not meeting the eligibility criteria, e.g., non-English studies, gray literature, theses and conference abstracts, and theoretical studies.

Information sources

We searched the following bibliographic databases: PROSPERO, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports, and APA PsycInfo, Pubmed, Science Direct, ProQuest Social Science Premium Collection (Sociology Collection, Social Science Database, Politics Collection), and Ebsco Psychology/Sociology Databases (CINAHL, SocINDEX, Academic Search Complete). We used assistance from university librarians in choosing the databases.

We conducted database searches using the search terms ["Individual Placement and Support"] and ["Evidence-based supported employment"] individually in all databases. We limited our search to study titles and abstracts and, when possible, selected the option to include only peer-reviewed articles. We conducted the searches first in April 2022, and the searches were updated in January 2023. Our search was restricted to articles published up to December 2022, with no restrictions for the earliest publication dates. We further employed the snowballing technique by reviewing the reference lists of all the studies included after the screening. The number of screened studies was 1 124 in total. The review of additional articles from the reference list search did not lead to any changes in the established theme structure, and no further searches were conducted.

Selection of sources of evidence

The titles and abstracts were uploaded into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia). The screening was undertaken independently by two reviewers. The first author and one of the second reviewers (NS, HN, TL, KA-S, AK) assessed the titles and abstracts against the eligibility criteria. Full texts were reviewed when screening produced indecisive results. We solved potential disagreements about study selection with a consensus method with three reviewers. We applied a similar procedure for full-text screening.

Data charting process

The first author created the list of data-charting items and initial code structure to determine the units of analysis to be extracted. The list was updated during the analysis iteratively to produce the best obtainable data description. The process was conducted in collaboration with the co-authors.

The first author undertook data extraction. The extracted data on article characteristics included year of publication, geographical area, aims, population, methods, and main results. For further thematic analysis, we extracted all text in the results sections of the articles that referred to ‘external context’ and could be associated with those ‘implementation outcomes’ referring to the extent to which the innovation has been implemented or is being delivered [ 29 , 30 ]. They include adoption, implementation, and sustainment, which refer to local ‘actual implementation outcomes’ [ 30 ], as well as penetration and reach, which pertains to corresponding ‘actual’ system-level implementation outcomes. Only sections covering the IPS model were extracted if the articles included observations from multiple EBPs. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [ 25 ], we did not conduct quality assessments for the articles.

Synthesis of results

The first author charted, extracted, and classified the data using Atlas.ti (version 9.1.7) software. The extracted data was subjected to abductive thematic analysis. Abductive thematic analysis is a research approach that combines inductive and deductive reasoning to iteratively explore and interpret data, aiming to generate the most plausible explanations for observed phenomena by aligning empirical findings with existing theoretical frameworks or creating new ones [ 31 , 32 ]. We used an existing and widely used theoretical framework (Consolidated Framework for Implementation Research, CFIR) as the starting point of the data coding. However, we used an inductive approach for categorization and thematization when the empirical data was considered relevant, but the framework did not provide a straightforward way to classify the items or patterns observed in the data. This approach led us to use a two-stage approach to presenting the results. First, we report the results describing the ‘outer setting domain’ [ 4 , 33 ] determinants of the ‘actual implementation outcomes’ [ 30 ], i.e., the results congruent with the CFIR framework. This section is labeled ‘ External contextual determinants ’ and describes the data in which each text excerpt representing a determinant and implementation outcome association was coded as either ‘Facilitators’ or ‘Barriers’. In this section, we also present those ‘inner setting’ items that may be evaluated as subject to external societal and professional influences or were reported as targets of interventions by the external stakeholder. Second, we describe results associated with the strategies and actions of the different external stakeholders under the label ‘ Systems of evidence-to-practice ’. These ‘resource systems’ [ 34 ] encompass organizations and individuals that shape the external determinants of local implementation or aim at system-level implementation outcomes. Informed by the socio-ecological [ 7 , 35 , 36 ] and complex adaptive [ 37 ] systems approaches these ‘resource systems’ were perceived as multi-layered, self-organizing, interacting with each other, with outcomes that are contingent and intrinsically uncertain. We organized the results by stakeholder groups and presented the associations of these items with other external contextual determinants.

We convey the findings narratively, highlighting the key aspects and findings of each category. As the thematic categories utilized in our study were mutually non-exclusive and the same data excerpts could be coded with several codes, we avoid double reporting of the items when possible. We present results according to PRISMA-ScR [ 25 ], and the completed checklist is in Additional file 1 . Descriptive tables were compiled with Stata Statistical Software (Version 17). We used Grammarly ( www.grammarly.com ) and OpenAI’s Chat-GPT 3 ( https://chat.openai.com/chat , version 13) for proofreading purposes.

The search and screening results at each stage are shown as a PRISMA flow chart in Fig.  1 . We screened unique 1124 titles and abstracts and 113 full-text documents. Of those, 59 original research papers met the eligibility criteria. The full list of included studies can be found in Additional file 2 , and the record of excluded full-text studies can be found in Additional file 3 .

figure 1

PRISMA flow diagram

Characteristics of sources of evidence

Eight out of 59 included studies used quantitative methodologies, 33 qualitative, and 18 mixed methods. Twenty-four were conducted in the USA, 7 in the Netherlands, 6 in Sweden, and 4 in Canada, Australia, and England. The remaining 10 studies were conducted in other countries. The year of publication ranged from 1998 to 2022 (median = 2017). The study aims reflected high variability in the scope of investigations, ranging from those interested in implementation processes and evaluation, through stakeholder perspectives and experiences, to comparative and regional analysis. Descriptive data about the included studies are presented in Table 1 .

Table 2 displays the characteristics of evidence sources, presenting the frequency of observations and the sources by thematic categories. Table 2 also shows the frequencies of observations for each determinant cross-tabulated by each implementation outcome. Implementation stood out as the dominant outcome, covered in 46 articles, while adoption and penetration/reach were discussed in 29 and 26 of the articles, respectively. Sustainment found the least attention ( n  = 16). The data prominently showcased local determinants, including work infrastructure ( n  = 34), mission alignment ( n  = 33), and culture ( n  = 29), emphasizing their significance in the adoption and implementation phases. Of these, mission alignment was highly prevalent in sustainment articles. The concept of agency leaders was discussed in 38 articles, and their role was highly present in adoption, implementation, and sustainment articles. Researchers ( n  = 11) and political/administrative decision-makers ( n  = 25) were most frequently cited in articles concerning sustainment and penetration/reach. They had in common their frequent association with national strategies ( n  = 25), while the former was more often associated with evaluation, monitoring, and feedback ( n  = 25) and the latter with financing ( n  = 41). Discussion on sustainment and penetration/reach also frequently associated with national strategies, legislative context ( n  = 31), and financing. External support professionals ( n  = 20) were relatively highly represented in the articles on sustainment. Figure  2 is a diagram that depicts the relative positions of categories and directions of influence between them in a conceptual model.

figure 2

Associations between the systems of evidence-to-practice, external contextual determinants, and implementation outcomes: a conceptual model

External contextual determinants

Policies and laws: national strategies and systemic integration.

National or regional strategies were described as promoting the uptake and implementation of IPS [ 38 ] and appeared to be backed by administrative decisions about responsibility-sharing or funding. These policies included national mental health strategies [ 39 ], guidelines [ 40 ], and agreements on implementation support issues [ 18 , 19 ]. The IPS model was perceived as a contributor to the strategic goal of implementing the recovery approach and serving as a vehicle for producing system reform at national and regional levels [ 18 ]. Congruence with other national policy goals and frameworks, such as social inclusion [ 39 ] and participation [ 41 ], was found to facilitate the incorporation of IPS principles into national mental health care policies. Systematic approaches in providing implementation support could support national strategies [ 42 ] whereas a mismatch between overarching national strategies and a lack of programs to implement IPS to achieve the goals of these strategies was reported to lead to lower penetration or adaptation of the IPS model [ 39 , 43 , 44 ].

One feature of the national strategies was the aim of expanding the clientele from persons with severe mental disorders such as psychotic disorders to those with any mental disorder, leading to implementing IPS in various care settings, e.g., forensic or psychiatric housing programs [ 45 , 46 ]. The implications of different work infrastructures on implementation are discussed in a separate section below (work infrastructure).

Policies and laws: legislative context

Legislative contexts concerning mental health and employment were reported to impact the implementation of the IPS model. Laws that mandate employment services for individuals with severe mental illness [ 47 ] or policies redirecting services from activities not following the IPS model [ 48 ] increased the adoption of IPS programs. On the other hand, the availability of competing practices [ 49 , 50 , 51 ], procedures mandated by policies but not supported by research, such as work capacity assessments [ 52 , 53 , 54 ] or mandated lengthy referral processes [ 54 ], were reportedly at odds with the implementation of IPS with adherence to model guidelines. Social insurance criteria that excluded clients based on expected employment outcomes [ 55 ] or received benefit types [ 56 ] were also reported as barriers. The policy of allocating decision-making and management of services to local authorities was reported to hinder adoption due to low prioritization at the local level [ 41 ]. Laws and regulations related to sharing client information and access to data and mandated use of multiple information systems were reported to complicate the implementation of IPS [ 44 , 57 , 58 ]. Legally mandated limitations on using data could be circumvented by strategic actions by the administrative authorities or local leaders [ 18 , 44 ].

The availability of funding was critical for adopting and implementing IPS across the settings. National or regional development projects were often used in the adoption phase [ 59 , 60 ]. Sustained direct funding schemes through health ministries or other governmental organizations were used to increase the use or adoption within the service system or provide the necessary flexibility to implement the model as intended at the local level [ 38 , 48 , 60 ]. A state-level funding mechanism was associated with statewide uptake of the model [ 49 ]. Payments based on achieved results were reported to facilitate sustained implementation [ 49 , 61 ]. Many studies reported that a well-managed transition from projects to sustained programs was a critical period.

Specific funding mechanisms were reported as barriers to the successful implementation of IPS. Payment models that were based on specific medical diagnoses rather than outcomes [ 62 , 63 ] and separate or divided sources of funding [ 18 , 41 , 42 , 51 ] hindered the implementation. Set or predefined funding duration to funding [ 41 , 46 , 57 , 59 , 64 ], restrictions on financing employment services as health services [ 51 , 65 ], and rules that penalize short employment contracts [ 51 ] were also perceived to impact the quality of implementation negatively. Funding contracts covering a broader set of programs could include criteria conflicting with the IPS fidelity criteria [ 50 , 63 ].

Training and technical assistance

Training and technical assistance were reported to facilitate the implementation of IPS. Sources for training and assistance included support from national, state, and regional organizations [ 66 , 67 ] and IPS/EBP development projects [ 42 , 68 ], as well as openly available guidelines and training material provided by the program’s developers [ 55 ]. These supports reportedly helped those putting the model into practice with goal setting and providing a sense of purpose [ 44 , 50 ], helped providers to work systematically according to protocols and improved their knowledge of evidence-based practices [ 44 , 68 ], and provided opportunities to share knowledge and experiences with other sites [ 55 ]. Agency leaders [ 44 ] and staff [ 62 , 69 ] were reported to benefit from initial training and assistance [ 65 ].

Evaluation, monitoring, and feedback

National, state, and regional organizations [ 19 , 42 , 67 ] and outside experts were used to conduct evaluations and monitoring of the implementation of IPS that were often reported in conjunction with training and technical assistance. Routinely assessing implementation was perceived to help ensure that the model is implemented as intended over time [ 62 ], and imposing continuous evaluation by agency leaders may increase the probability of the sustainment of the program [ 70 ]. In some cases, fidelity above a certain threshold was used as a prerequisite for funding by national or regional decision-making organizations [ 71 ]. Disseminating the results on the effectiveness of IPS reportedly increased the model's adoption [ 18 ], and evaluations and monitoring were used to motivate leaders to maintain or reinstate high-fidelity services [ 40 ]. In contrast, the lack of results from monitoring or evaluations could discourage agency leaders from following national guidelines that promoted the use of IPS [ 46 ].

Local factors affected by external context

Mission alignment.

Both the recovery approach [ 41 , 59 , 63 , 72 ] and evidence-based policy commitment [ 69 , 73 ] were reported to facilitate the reorienting of organizational goals to be consistent with IPS implementation and sustainment. The shift in organizational goals was associated with the de-implementation of vocational services that lacked evidence-based support and were supported by structural changes and financial arrangements through administrative decisions [ 74 ].

The non-alignment with organizational goals was reported to hinder the model’s implementation. The model could be at odds with existing organizational goals based on traditional medical or vocational services [ 75 , 76 ]. These goals could be mandated by existing rules and regulations [ 53 ]. Challenges were reported when collaborating partners from different organizations had different goals in their respective organizations [ 52 , 53 , 60 , 77 ], which could lead to giving lower priority to collaborating with the IPS team [ 52 , 70 ].

Acceptance of the model by the professionals, professional norms, and local attitudes was reported as important for the uptake and implementation of the model. Understanding the program logic [ 60 , 73 ] and recognizing unmet user needs [ 72 , 78 ] were associated with the changes in acceptance of the model and professional norms. Several studies found that influencing practitioners’ professional norms and attitudes was an important goal during the adoption period. During this time, practitioners could learn about the rights and needs of users, the benefits of IPS, and community resources; changes in these attitudes would lead to better implementation results [ 55 , 58 , 72 , 79 ]. Receiving training and support from site managers and national organizations [ 65 ], experiencing bringing together service functions as intended, and sharing success stories [ 58 ] were perceived to facilitate the implementation and sustainment of the model.

In several studies, the practitioners were reported to view IPS as conflicting with the core beliefs or principles of care. The practitioners may see employment or financial self-sufficiency as a not crucial outcome for health services [ 49 , 70 , 77 ], or they may see IPS as an inferior or unnecessary service [ 46 , 63 , 77 ]. Negative attitudes about the capabilities of the target group could lead to lower referrals to IPS [ 41 , 44 , 57 , 65 , 80 ], referrals to employment services not supported by research [ 48 , 55 , 57 ], exclusion from the service [ 55 , 80 ], inadequately bringing together service functions [ 48 , 65 ], and poor collaboration with external partners [ 53 , 63 ].

Work infrastructure

IPS was implemented within mental health services, outside of mental health services, or as a collaboration between different organizations. Programs in community mental health settings rated higher fidelity than those in rehabilitation centers, housing units, or independent programs [ 45 , 81 , 82 ]. Providing the service in a mental health care setting was reported to lead to higher and shorter referral processes. Transforming a work setting to a high-fidelity IPS service was reported to require creating or protecting designated or reserved staff roles, adjusting the number of clients assigned to a single professional, or renegotiating the existing job descriptions [ 62 , 69 , 74 ]. The infrastructure related to continuous support was reported to promote the model’s sustainment [ 70 ].

In the situations where multiple organizations implemented the model together, strategies and agreements on financial matters [ 54 , 83 ], identifying shared clients [ 83 ], and practical arrangements such as office space [ 83 ] and designated contact persons [ 64 ] were reported to facilitate implementation. The willingness to share expertise and the complementary experiences of different stakeholders [ 46 ] can also help with implementation. On the other hand, organizations that are expected to collaborate may resort to conflicting service processes [ 52 , 53 , 56 , 60 ]. In situations where multiple organizations worked together, the absence of formal agreements led to poor referrals [ 54 ] and hindered effective implementation [ 41 ].

Systems of evidence-to-practice

Researchers.

Researchers’ active involvement in developing and implementing strategies for disseminating the IPS model included collaborating directly with political and administrative decision-making, national and regional support organizations, and the implementing agencies. In the USA, the promotion of the decision-makers’ participation in the learning community was found to encourage interagency collaboration at the state level [ 47 ], including arrangements for state-level funding [ 66 , 84 ] and evaluation and training support [ 47 , 84 ], resulting in a higher number of IPS programs per state population and faster growth in penetration [ 84 ]. In Australia, national-level advocacy included a group of researchers promoting the IPS model to state and federal politicians and government department administrators, leading to decisions related to funding and development projects [ 40 ].

The US Learning Collaborative, a researcher-led initiative for disseminating the IPS model, has also produced numerous research collaborations supporting the model’s spread across the settings [ 19 ]. These collaborations were found in the form of partnering with the developers of the model to produce new evidence or support implementation [ 18 , 40 , 51 , 59 ], training experts at the national level [ 40 ], or collaborating with those putting the model into practice directly [ 48 , 51 ].

Political/administrative decision-makers

The model’s penetration was facilitated by decisions by the state politicians and administration [ 18 , 40 , 48 , 55 ] or local political decision-makers [ 77 , 85 ]. The dedication and enthusiasm of actors at the administration level were reported to facilitate the necessary collaborations [ 41 , 48 , 49 , 62 ]. Enthusiastic state IPS coordinators and administrative authorities were reported to foster a culture shift in agencies, leading to high-fidelity implementation and sustained model use [ 49 , 71 ].

Political/administrative decision-making was reported to induce changes in national policies. Recurrent funding decisions [ 48 ] and funding designated for IPS were reported as a facilitator of local implementation and service system penetration [ 49 ]. Also, decisions to change policy regulations and protocols, rules for referring to services, and providing support resources for implementing the model were reported to support the system-level adoption of the model [ 18 , 49 ]. Enforcing national strategies and guidelines was reported to stipulate political or administrative decision-making at the local level [ 38 ]. Administrative collaboration, including coordination, consensus-building, or formal agreements between responsible agencies [ 18 , 51 , 54 ] or professional networks [ 83 ], reportedly facilitated coordinated referral processes and joint data collection efforts, resulting in higher penetration [ 49 , 50 ] and quality of services at the aggregate level [ 18 ].

Administrators’ commitment to models not supported by research [ 49 ] and the lack of state-level collaboration between administrators in different agencies were associated with non-aligned strategies for employment services for the target group [ 47 ]. Studies also reported the ambiguity that decision-makers face when facing different potential service models [ 41 , 70 ] and when considering increasing the penetration outside the specialized mental health care system [ 41 ]. One study reported ambiguity in that the strategies might recognize the significance of enhancing employment rates for individuals with mental disorders but consistent implementation plans were lacking [ 39 ]. In addition, administrative hesitancy was linked to the lack of power in decision-making [ 70 , 83 ].

External support professionals

National or regional supporting organizations were reported to promote collaboration, funding, training, and evaluation. Their form varied from organizations created to support individual IPS projects [ 18 , 19 , 46 , 67 ] to quality improvement collaborations involving several EBPs [ 42 , 68 ] and contracting support services from other sites that implement the service [ 18 ]. These collaborations often included partnerships with and resources from university researchers [ 18 , 66 ]. Implementing these supports could be a feature of a dissemination plan [ 49 ], and the number of active IPS programs was associated with the number of national trainers [ 19 ].

Support organizations could help the implementing sites to create implementation strategies [ 65 , 83 ], budget plans involving one or more agencies [ 62 ], and encourage agency leaders to proceed with the implementation in problematic situations [ 83 ]. Training, technical assistance, fidelity, and outcome monitoring were often reported as critical aspects of implementation support [ 18 , 46 , 49 , 83 , 86 ]. Evaluation and monitoring data were reported to have been used to increase accountability and motivate decision-makers to increase funding [ 18 , 49 ]. Centralized enforcement of adherence to model guidelines and outcome monitoring was found to improve the quality of implementation over time across sites [ 49 ]. Fidelity and outcome monitoring also reportedly facilitated both national consensus-building and supervision based on achieved results at the local level [ 18 ].

Poor or lack of national implementation support was reported to lead to fewer links and communications between academics and implementing agencies and low leadership involvement [ 44 ]. Removal of regional leadership and a decline in national/regional training and evaluation supports were found to lead to lower quality implementation of once-sustained programs [ 40 ]. Short timeframes for national development projects that provided external support for local sites were associated with challenges in achieving organizational structural changes in the service-producing organizations [ 46 , 68 ].

Agency leaders

Senior leaders, often motivated by the recovery approach and the evidence base [ 48 , 59 , 63 ], were the actors who promoted ‘systemic transformation’ [ 51 ] and placed the IPS within a broader area of strategy for psychosocial services provided by the care organization [ 72 ]. Committed senior leaders communicated the importance of the recovery approach and services tailored to each person’s specific needs, which was reported to lead to higher quality services [ 62 , 71 , 87 ]. Prioritizing and enforcing strategies and actions, often using the steering group, was decisive as it affected several aspects of the effort, including the affecting organizational policy, promoting the program’s credibility among the professionals, the methods for cooperation, and the financing decisions [ 51 , 55 , 62 , 63 , 70 , 71 , 83 ]. Senior leaders’ commitment to the guidelines to ensure the IPS program is being implemented as intended [ 40 , 54 ] and enforcing fidelity monitoring [ 40 , 70 ] were reported to facilitate sustained implementation. In the situations where multiple organizations worked together, combining leadership outside the provider organization was perceived beneficial for implementation [ 59 ].

Agency senior leaders’ failure to align the IPS model principles with organizational goals and inadequate agency prioritization [ 44 , 65 , 71 , 77 ] led to poorer implementation or non-sustainment. Lack of enthusiasm and promotion of the model [ 70 , 71 ], not being able to channel funding [ 65 , 77 ], and not using performance-related indicators [ 46 ] can also hinder its implementation or sustainment. Failure of steering groups to commit or their dissolution after the project period was reported to cause a cessation of funding or poor coordination with external partners [ 56 , 77 ].

Summary of evidence

We investigated and identified the external contextual factors that can influence the adoption, implementation, sustainment, and scale-up of the Individual Placement and Support (IPS) model, an evidence-based practice (EBP) for acquiring employment for persons with mental disorders. In this scoping review, we found that policies and laws, financing, and administratively instituted support resources were consistently conceived as facilitators or barriers to implementation across diverse settings in Western countries. Organizational mission alignment, culture, and work infrastructure were also identified as externally influenced factors that facilitated or hindered the implementation. Furthermore, we found these determinants of local implementation to be affected by strategies and actions of researchers, political and administrative decision-makers, external support professionals, and the implementing organization’s leaders support. Collectively, these actors formed and participated in complex nationally or regionally varying constellations facilitating or hindering the local implementation effort and model’s penetration into service systems.

To study how external contextual factors can affect implementation processes at the local level [ 4 , 5 , 88 ], we used CFIR framework [ 4 , 33 ] categories as the starting point of our data analysis. It allowed us to classify the data coherently to a variable degree depending on the variables, and the framework-to-data fit may be considered moderate. Our results indicate several areas where the CFIR framework did not give the best attainable framework-to-data match. First, we introduced ‘evaluation and monitoring’ and ‘training and technical assistance’ as external context categories. These items could have been coded as enactments of ‘national strategies’ or omitted from this analysis by categorizing them under CFIR’s implementation process domain. Given the high prevalence of these items in the data and their relative position to other concepts, including these items as external contextual provided an improved framework-to-data match. We also considered including these items feasible, as facilitation of implementation is considered a central or important feature in other implementation frameworks [ 36 , 89 ]. Second, we refined the CFIR categorization by distinguishing between ‘national strategies and systemic integration’ and ‘legislative context’ as separate subcategories within the ‘policies and laws’ category. This decision does not represent a deviation from CFIR but acknowledges the qualitative difference between the items, supported by the prevalence in data and distinctiveness of the items. A comparable distinction has been made in other frameworks [ 5 , 89 ]. The legislative context category included observations on many broader structural policy arrangements outside the healthcare administration’s decision-making power, which may be important when considering strategies for the model expansion in real-world settings.

The most significant deviation from CFIR was how external stakeholders were considered. The analytical choice in this study was to perceive their role through the lens of socio-ecological systems [ 7 , 35 , 36 ], which allows the incorporation of the agency of different stakeholders. The most significant difference to CFIR was to include observations describing the stakeholders’ strategies and actions that were directed not solely towards local implementation efforts but also towards affecting the other external contextual determinants and scaling up efforts [ 29 , 30 ]. The proposed ‘systems of evidence-to-practice’ category holds findings that could be considered in CFIR’s ‘partnerships and connections’ category, ‘implementation process domain’, or be excluded from the analysis to the extent they did not directly refer to the external influences on the local organization. Implementation science theorists have called after studies incorporated observations on multi-level strategies [ 10 ] or accountability mechanisms reflecting both the organizational and systemic levels [ 90 , 91 , 92 ]. With this regard, our classification resulted in improved framework-to-data match and narrowed the gap in knowledge with regard to the real-world processes through which different key stakeholders, namely researchers, political and administrative decision-makers, and support organizations, actively promote the translation of the evidence to actual implementation outcomes.

Our results support considering certain ‘inner setting’ items such as ‘mission alignment’, ‘culture’, and ‘work infrastructure’ as factors influenced by the broader structure of societal norms and arrangements. They were present in data describing the external and organizational contextual features’ interaction and often targets of interventions by the external facilitators. These items represent one facet of the non-distinctiveness of the line between the outer and inner contexts [ 4 ]. Similar items were also included in the taxonomy of external context items affecting the implementation of complex evidence-based health interventions by Watson et al. [ 2 ]. To conclude, our analysis led to a slightly modified list of CFIR’s ‘outer setting domain’ categories which we labeled as ‘enabling structures’, denoting the core components affecting the implementation and scale-up efforts.

Our analysis suggests several areas for further studies. First, our study confirms a knowledge gap: the external context factors were a systematically under-emphasized area of empirical research [ 2 , 10 , 11 ] and mainly described in an exploratory fashion [ 2 ] also within empirical IPS research. Second, the heterogeneity and perceived variability in the quality of the data suggest that deliberate efforts should be directed to establish more stringent operational definitions of external context. Our conceptual model represents a plausible way to organize the complexity of ‘external contextual’ items and stakeholder relationships needed for such research. Future studies would also benefit from the use of clearly defined and operationalized implementation outcomes. Differentiating between outcomes could prompt researchers to concentrate on under-researched areas. The most significant knowledge gap highlighted by our data is the studies dedicated specifically to sustainment outcomes, followed by system-level outcomes. Third, future studies should move the non-systematic approach to socio-ecological systems that partake in translating evidence to practice. Extending the study of the implementation strategies and their implementation [ 1 ] to external stakeholders with their respective organizational contextual underpinnings, potentially with the help of organizational theories [ 10 , 93 ], could improve the findings’ completeness and real-world relevance. Finally, our results highlight leadership’s moderating role in context-implementation relationships not only when considering local organizational contexts [ 94 , 95 ] but also when accounting for external contextual influences, marking it as a crucial topic for future studies.

Strengths and limitations

Our study has several strengths, including being strictly based on studies reporting empirical insights concerning the actual implementation and excluding theoretical or descriptive accounts, the large number of reviewed articles, the focus on a single well-defined intervention, and the heterogeneity of the organizational and societal settings from which our results were derived. However, there are several limitations to consider. First, the generalizability of our findings outside IPS implementation may be limited. This is because different health sectors, organizational settings, and EBPs each have unique characteristics that may require distinct implementation frameworks and models [ 96 ]. Second, the generalizability is bounded by all included studies being conducted in rich developed countries. Third, our results may be subject to author bias as a considerable portion of the reviewed literature was written by researchers associated with the model’s creation and early expansion. As an abductive thematic analysis, the results of this study may be biased by the authors’ judgments. Also, coding for thematic analysis was solely conducted by the first author, potentially impacting the reliability and validity of the results. Fourth, in line with our protocol and PRISMA-ScR guidelines, we did not systematically assess the quality of the included studies. We acknowledge, however, that such an assessment would have enhanced the reliability of our results, given the perceived variance in the quality of the data analyzed. In this study, we have aimed to reduce these biases by following a standardized reporting protocol for scoping reviews [ 25 ] and being explicit about the analytical choices.

Conclusions

Our scoping review provides an empirically based perspective for discussing the role of the external contextual factors affecting EBP implementation and scale-up. Our study summarises empirical research that reports structural, policy, and legal levels and support systems as facilitators or barriers to the implementation effort. Our findings highlight the importance of different stakeholders’ unique characteristics and collaboration at different socio-ecological system levels. The results indicate gaps in knowledge in implementation science and offer suggestions for future research.

Availability of data and materials

The dataset used to generate the tables in the current study is available in the Open Science Framework repository [ 97 ].

Abbreviations

Consolidated Framework for Implementation Research

Evidence-based practice

Individual Placement and Support

Joanna Briggs Institute

Population/Concept/Context framework

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews

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Acknowledgements

Open Access funding provided by University of Helsinki (including Helsinki University Central Hospital). The study was supported by the Social Insurance Institution of Finland (grant: 18/26/2021). The funder had no role in the design, execution, or analysis of this study and was not involved in the decision to publish the manuscript.

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Conceptualization: JH, NS, HN, TL, KA, MD, and AK. Methodology: JH. Software: JH. Validation: JH. Formal analysis: JH. Investigation: JH, NS, HN, TL, KA, and AK. Resources: AK and JH. Data curation: JH. Writing—original draft preparation; JH. Writing—review and editing: JH, NS, HN, TL, KA, MD, and AK. Visualization: JH. Supervision, AK. Project administration: AK. Funding acquisition: JH and AK.

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Harkko, J., Sipilä, N., Nordquist, H. et al. External context in individual placement and support implementation: a scoping review with abductive thematic analysis. Implementation Sci 18 , 61 (2023). https://doi.org/10.1186/s13012-023-01316-w

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ORIGINAL RESEARCH article

Research trends on the gut microbiota in endocrine metabolism: a thematic and bibliometric analysis provisionally accepted.

  • 1 Department of Pediatric Endocrinology, Faculty of Medicine, Çanakkale Onsekiz Mart University, Türkiye
  • 2 Department of Pediatric Infectious Disease, Faculty of Medicine, Çanakkale Onsekiz Mart University, Türkiye

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Background: Gut microbiota studies in the field of endocrinology metabolism have attracted increasing attention in recent years. To comprehensively assess the evolving landscape of this research field, we conducted a thorough bibliometric analysis of gut microbiota studies in endocrinology metabolism indexed in the Web of Science database. Methods: We collected and analyzed 3,339 original research articles and reviews published from 1972 to 2023. Using various bibliometric indicators, we investigated publication trends, country contributions, international collaborations, prolific authors, top journals, and influential articles. Results: Our analysis revealed a significant upsurge in publications after 2010, indicating a growing scientific interest in microbiota and endocrinology metabolism. Keyword and thematic analyses have identified gut microbiota, obesity, diabetes, and inflammation as core research themes. Additionally, the roles of probiotics and prebiotics are increasingly researched for their therapeutic effects in shaping the microbiota. Conclusion: This study reveals that research in endocrinology metabolism is increasingly decoding the connection between gut microbiota and diseases. There's also a growing focus on microbiota manipulation, which points to a shift towards personalized medicine. Future research should focus on integrating these findings into clinical practice, moving from lab-based studies to real-world patient care.

Keywords: Gut Microbiota, bibliometric analysis, Endocrinology, Probiotics, short-chain fatty acid

Received: 16 Jan 2024; Accepted: 11 Mar 2024.

Copyright: © 2024 Doğan and Çelik. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Durmus Doğan, Faculty of Medicine, Çanakkale Onsekiz Mart University, Department of Pediatric Endocrinology, Çanakkale, Türkiye

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Swiss medical schools’ experiences with online teaching during the COVID-19 pandemic in light of international experiences

  • Artemisa Gogollari 1 , 2 ,
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  • Sissel Guttormsen 1  

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During the pandemic, all universities had to switch to digital learning and teaching (DLT), the experiences were diverse. The advantages and obstacles of DLT are well reported in research. To ensure a sustainable DLT implementation, the requirements of institutions, educators and students should be aligned.

This paper aims at identifying and describing the experiences made at the Swiss medical schools after having to switch from on-site to on-line teaching; in particular, the experienced issues, requirements, and solutions were investigated and compared to international literature.

We conducted a literature review to derive themes and subthemes regarding the central aspects of the transition from on-site to on-line teaching. Also, we conducted semi-structured interviews with people responsible for the medical curricula at the Swiss Medical Schools. We used a purposive sampling method and invited eleven curriculum managers at the seven Swiss Medical Schools. The interviews were conducted in English, audio-recorded and transcribed. Subsequently the data was analysed with the software NVivo. We used a qualitative, deductive, content analysis to explore faculty experiences.

Twenty-four articles met the eligibility criteria and were included for full text screening. Of the included articles, 15 reported on DLT in general and nine articles reported on DLT during the Pandemic. The thematic analysis of the interviews resulted in four overall themes, requirements, obstacles, facilitators and advantages. Curriculum managers reported that institutions were relatively unprepared for the quick transition from onsite to online at the onset of the pandemic.

Conclusions

Our research reports a lack of institutional structures, communication, digital competences and literacy, teaching strategies, as well as a theoretical foundation for DLT implementation. A conceptual framework for DLT adapted to the Swiss universities beyond the current situation is needed.

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Introduction

The Covid-19 pandemic (hereafter pandemic) had significant implications on education systems as it forced all universities worldwide to switch to online teaching. This shift towards ‘digital Learning and teaching’ (DLT), as a response to the crisis, seems to meet students’ preferences for flexible learning opportunities. Before the pandemic, students’ presence in onsite events was decreasing across all educational systems [ 1 ], still, the rate of implementation of DLT by Universities worldwide, and in Switzerland, remained slow [ 2 , 3 , 4 , 5 ]. In the context of this article, DLT refers to the utilization of electronic technologies and resources to facilitate the acquisition, development, and application of knowledge, skills, and attitudes within educational settings. Within this term we encompass both the broader, established approach of "online teaching and learning" and also "Emergency remote teaching" a rapid instructional mode implemented in response to sudden disruptions like the Corona Pandemic [ 6 ]. If implemented well, DLT has the potential to increase student engagement, support active learning and interaction with the learning material [ 7 , 8 ] and enable students to personalize their learning [ 9 ]. Furthermore, DLT fosters peer learning and self-directed learning skills [ 10 , 11 ]. In medical education, advantages of DLT include improved information accessibility, facilitation of standardised content, cost-effectiveness and accountability [ 12 , 13 , 14 ]. Obstacles for DLT implementation are also widely reported including a lack of institutional DLT structures, low awareness of benefits, and missing strategies for DLT implementation [ 5 , 15 ]. Teachers acknowledge the values of DLT [ 16 ], but due to lack of institutional support [ 5 ], technical knowledge and time constraints [ 17 ], implementation of interactive online learning is lagging [ 18 ]. Presented solutions to these challenges are not always optimal [ 19 ]. For successful DLT implementation the requirements of all the key-players, students, teachers and institutions, must be addressed specifically.

Students were among the first to notice the consequences of the rapid change to online teaching. Their perceptions about online learning during the pandemic show a high degree of dissatisfaction [ 20 , 21 , 22 , 23 ]. While students report higher ‘learner control’ [ 24 ], they also report lack of additional instructional support and difficulty in adjusting their learning approach to DLT [ 25 ]. Reduced interaction and feedback with peers and educators are noted disadvantages of online learning [ 20 , 21 , 25 ]. The European Medical Student Association (EMSA) surveyed 11 countries on experiences during the pandemic [ 21 ], highlighting a low level of student involvement in decision-making, absence of a feedback mechanism and lack of quality resources. Similar data is reported in many Asian countries [ 20 , 22 , 23 ] and, in two comprehensive global reviews [ 26 , 27 ].

Teachers need a new set of skills in order to support a digital teaching programme, such as communicating online, time management, technical literacy, and adapting to a new role as a facilitator [ 20 , 28 ]. Effective DLT is not restricted to telling students what is known, but rather to scaffold learning. Published studies report that teachers are not aware of this role [ 29 , 30 , 31 ].

Also, educational institutions, particularly curriculum managers play a key-role in facilitating the requirements of teachers and students. Institutions have the decision power to implement a pedagogical framework, to provide an educational setting supporting DLT [ 32 ], to allocate resources [ 32 , 33 ], and ensure effective implementation of DLT. A lack of guidance on the institutional level is often among the biggest obstacles to meaningful change [ 34 ]. While the pandemic resulted in an incredible effort to succeed in the delivery of effective online teaching, there is a risk that this spirit will fade away when the pandemic crisis is resolved [ 35 ]. To ensure that institutions and educators continue to maximise teaching and learning using both online and onsite, fitting to education needs of students, the current innovation momentum is essential to work towards optimal and sustainable DLT implementation, both didactically and organizationally [ 36 ]. The following research questions address crucial insights needed in this process:

RQ 1: Which factors, known from research before the pandemic, are particularly relevant for DLT implementation in higher medical education?

RQ 2 What is known from the literature about DLT experiences in medical education during the pandemic?

RQ 3: Which DLT experiences do Swiss medical curriculum manager report from the pandemic and how do these experiences relate to the literature?

We applied two methodological approaches, a literature review and structured interviews, converging to an integrated analysis. We identified a set of themes and sub-themes to illustrate the transition from onsite to online teaching, which will be addressed below.

Literature review

To address the first two research questions, we conducted a ‘literature review’ following Booth and Grant, 2009 [ 37 ], which is inherently semi-structured. We applied the following approach: 1) search for relevant studies (before and after the pandemic); 2) select appropriate studies based on pre-defined inclusion criteria; 3) extract and code data using NVivo; and 4) summarise the results using descriptive themes. The search code and the PRISMA flow diagram are shown in Supplementary Material 1 : Appendix I.

In the first step, we reviewed evidence to contextualise knowledge in terms of existing DLT themes such as requirements, obstacles, facilitators and advantages without looking for a special topic of implementation. We also searched literature describing the transition from onsite to online teaching, before and after the pandemic. We performed the search in the electronic databases PubMed, EBSCOHOST (CINHAL plus; Education research Complete); Google (Google Scholar); EMBASE (Ovid). For RQ1, we included studies evaluating the transition from onsite to online either blended or a full transition. For RQ2 studies describing medical faculties’ experiences with DLT during the pandemic was the primary focus. We included quantitative, qualitative, and mixed methods studies.

In the second step, the search results were downloaded to EndNote® desktop software and screened according to relevance for RQ1 and RQ2. Empirical studies published in peer-review journals meeting review-specific eligibility criteria were included. Studies that did not include medical faculty experiences were excluded.

In the third step, one of the authors extracted the data. The full text of included papers was uploaded to NVivo 12 computer software [ 38 ]. Thematic analysis was used to organize data in a structured evidence-based approach [ 39 , 40 ]. The upper level deductive themes, identified from the initial literature review were applied for initial extraction: requirements, obstacles facilitators and advantages.

In the fourth step, we identified subthemes from the selected articles. Following the logical order of the thematic analysis framework, codes were identified and decided with multiple researchers.

To investigate the RQ3, semi-structured interviews with curriculum managers were implemented. The steps to collect data and to analyse the interviews are described below.

The development of the question route based on the thematic synthesis of the reviewed studies published before the pandemic, the question route was developed according to the procedure suggested by Gideon [ 41 ], and high-level themes of relevance to the study were identified. For each of the identified main themes the authors wrote two questions each. Four questions per theme were validated by two authors and the two best fitting were selected by consensus. The resulting questions were revised in two steps, first, through a critically semantic review of ambiguous wording or meanings. Second, 2 pilot interviews were conducted to assess the level of understanding of the presented questions. The pilot offered the possibility to discuss with targeted participants and to refine the question route according to the collated feedback. The resulting question route is shown in the Supplementary Material 1 : Appendix II.

Participants

A purposive sampling method was applied and key persons from 7 Swiss Medical Schools (Basel, Bern, Freiburg, Geneva, Lausanne, Zürich, and the Swiss Federal Institute of Technology in Zürich) were invited. At two institutions, more than one person participated in the interview, resulting in a total of eleven interviewees (10 Male; 1 female, 10 physicians and 1 natural scientist, 5 Vice Deans; 6 heads of curriculum management). ‘Curriculum mangers’ hold crucial stakeholder positions within the Swiss educational system and are typically entrusted to one or two individuals per school. Their tasks involve deep insights into operative issues at each University. Using interviews, we could capture each participants’ unique experiences. At Swiss Universities, undergraduate medical education is a six-year programme and is based on the Bologna reform, with a Bachelor and a Master programme, each covering 3 years of study. Students acquire knowledge in medical basic sciences during the bachelor study, combined with early clinical experiences. The master-degree includes clinical teaching and experiences in all the main medical disciplines. All the medical schools apply the same national learning objectives framework [ 42 ].

Procedure and setting

The interviewees were recruited by e-mail and received information on the purpose and procedure of the interviews. Full anonymity for data analysis and results were guaranteed. Interviewees participated by Zoom ( N  = 6) and in person ( N  = 4), between 18 May and 16 July 2020. All interviews were conducted by the same interviewer in English, following the question route shown in Table  1 .

Interviews lasted between 50 and 70 min and were audio-recorded. The structure of the question route was followed but spontaneous information and associations evoked by the questions were explicitly encouraged. The data were transcribed verbatim. After transcription, the interviewees approved the transcript and confirmed that their responses could be included in the analysis.

We analysed the interview data using NVivo. The question route provided a first draft of deductive themes. In addition, we identified inductive themes through a thorough review of repeated concepts. To address RQ 3, we performed a comparative analysis between the results from the literature addressing pandemic experiences and the interviews.

We followed the method for comparative thematic analysis, purposed by Riggs [ 43 ] to gain a better understanding of the institutions’ experiences during the pandemic in relation to emerged themes from the literature. This comparative analysis was performed using NVivo. Categories were formulated based on the themes analysed in NVivo. Two reviewers decided on the categories with 100% interrater reliability.

A total of 1643 potentially relevant titles and abstracts were screened. 24 articles met the eligibility criteria and were included for full text screening. Of the included articles, 15 reported on DLT more general and nine articles reported on DLT during the Pandemic. Four of the included papers were comprehensive reviews which offered an overview of enablers and barriers to DLT in health education [ 5 , 15 , 44 , 45 ].

Synthesis of DLT literature on DLT experience before the pandemic (RQ1)

The thematic analysis of the literature confirmed four overall themes, requirements, obstacles, facilitators and advantages (Table  2 ).

Synthesis of the DLT literature addressing the situation during the early pandemic-phase (RQ2)

The second part of the literature review was used to add to and support the analysis of the interviews. The same primary themes were identified (Table  3 ).

Synthesis of the interviews (RQ3)

Curriculum managers shared their perspectives during interviews that institutions were relatively un-prepared for the quick transition from onsite to online at the onset of the pandemic (Table  4 ). Given that interviewees consisted of curriculum managers only, the presented themes of teachers’ and student’s are presented from the perspective of curriculum managers and from their own experiences as teachers.

Comparative analysis between literature and interviews: Common aspects.

Figure  1 illustrates the results from the integrated thematic analysis and highlights commonalities (dark) and differences (light) between literature and interview findings addressing DLT experience.

figure 1

Common (dark) and different elements (light) between literature and interview findings addressing DLT experience

Requirements

We noticed a lack of standards regarding the quality of the online teaching is apparent. Interviewees suggested that it is not necessary to focus on the quality of teaching in times of crisis, although a need for best practice guidelines for DLT was stated. ‘Structure’ and ‘Strategy’ were selected as relevant themes particularly for students, as they can reduce stress and anxiety to manage assigned tasks. (Abbreviation for quotes below: L = from literature; I = from the interviews).

L: “Providing structure was a key element of effective support for managing stress and anxiety. (p 292 [ 55 ])” (Structure).
I: “…that was for students maybe the hardest point, that a structure was crushed” …. The teaching strategy was called into question, exposing that the reluctance towards transition to online teaching my not be the relevant issue, instead there is a need that educators rethink teaching and clarify the purpose of teaching. (Structure).
L: “Given the limited time available for transition to remote/online delivery, the authors experiences demonstrated an almost consistent strategy of repurposing existing material (page 294 [ 55 ])”. (Strategy).
I: “…we should think about the teaching strategy in general and not only the online teaching strategy”. (Strategy).

The need for teacher ‘training’ is a recurring issue. Due to the immediate transition from onsite to online training, no support could be offered to the teachers at the rate required. From our findings, we present unique means of training support.

L: “When tasks are beyond their training, additional training must be provided… (page 13 [ 42 ])” (Training).
I: “Teachers had personal coaching, they were able to make a date with us to come to our house and get supported to record and upload their lecturers online.” (Training).

One of the most frequent obstacles was a lack of ‘technical’ knowledge, particularly for the teachers, which was a direct consequence of the reluctance to adapt, combined with minimal institutional support and lacking institutional structures.

L: “A common challenge reflected on was that of information technology (IT) skills, and the lack of prior training or knowledge for effective online education delivery practices. (p 289 [ 55 ]). (Technical).
I: “We had to choose the right tool for keeping up the pedagogical concepts as much as we could.” (Technical).

DLT offers ‘flexibility’ of temporal teaching-delivery, as indicated in Fig.  1 . Another advantage and effect of the pandemic was gained DLT experience, which indeed can facilitate DLT implementation. When users overcome resistance due to unknown or unfamiliar territory, ‘new experiences’ on a learning platform could be further encouraged.

L: “The experience respondents have had during the first few weeks of COVID-19 has increased their confidence in the effectiveness of online medical education. (page 9 [ 56 ])” (new experience).
I: “So, the students could take this class and then that class in the order they wanted, and in the rhythm wanted, or could stop and look for more material.” (Flexibility).

Facilitators

Both the literature and interviewees stress that a positive attitude towards implementing and using DLT possibilities is a prerequisite for success (See Fig.  1 ). ‘Collaboration’ was one of the most mentioned elements to assure a higher acceptance of DLT. In the interviews, the importance of communication was stressed between teachers and between universities.

L: “Collaboration or interaction between learners and facilitators would influence an attitude of sharing knowledge, which is one of the crucial elements of e-learning’s shared enterprise.” (p 8 [ 15 ]] (Collaboration).
I: “I also experience that there is a good sense of teamwork with the whole faculty in an extreme situation.” (Collaboration).

Comparative analysis between literature and interviews: Deviating aspects

Most differences between the literature review and interviews were found related to ‘Requirements’ of stakeholders (students and teachers). No deviating insights between the literature and interviews on requirements at the institutional level were noted. Also, we found relevant differences between the literature and interviews under characteristics of ‘Obstacles’.

Requirements of teachers and students

The literature reports requirements for implementation of DLT including student guidance, time and training. The interviews, however, offered a richer picture of requirements. In the process of course delivery and digital uploads, participants noted a positive experience of interacting with their ‘institution’. At some institutions, however, this process required more time than planned, due to a lack of prior experience and ‘strategy’ with DLT. Delivery of online ‘exams’ were challenging due to the possibility of cheating.

I: “I would say that it was good to see that in this modern crisis, our system was able to adapt very quickly and very effectively.” (Pedagogy, exams).
I: “So here it took maybe double that time < as planned > .” (Lecture distribution).
I: “There was no strategic plan for online teaching before.” (Pedagogy, exams).
I: “We reduced the time of the exam to minimize the possibilities for collaboration.” (Pedagogy, exams).
I: “It's a wonderful opportunity to increase the part of blended learning in our curriculum.” (Lecture distribution).

In published research, ‘inequality’, in terms of access to resources, persist as a recurrent theme. This did not emerge from the interviews, which is likely to be an effect of high socioeconomic standards in the Swiss educational system among all stakeholders. However, the interviewees mentioned a variety of other Swiss obstacles influencing students’ learning and teachers’ coping (theme ‘general’). More specifically, students were overwhelmed with the amount of available information. A lack of interaction between teachers and the students was reported in the interviews in many different ways.

I: “The students prefer to have as few different sources as possible.” (General).
I: “Students would have preferred to stay in presence at the university.” (General).
I: “There was less discussion between the students and less interaction with teachers and students.” (General).
I: “Of course, interactivity was an issue. And so, we learned to use the chat room for asking questions, and to break the zoom call into smaller groups for student presentations.” (General).

As shown in Fig.  1 , also for the theme ‘facilitators’, the insights gained from the interviews were richer than the literature. The subtheme ‘cost-effectiveness’ was only mentioned in the literature.

L: “…the studies included addressed the cost-effectiveness of eLearning versus traditional learning. (page 11 [ 25 ])” (Cost-effectiveness).

In the interviews, ‘competence’ emerged as a new theme. The presence of highly skilled persons at the university facilitated the DLT transition.

I: “What I learned is that we have wonderful people around us and they have competence that sometimes they don't need to use that much. And all of a sudden, because of the crisis, you see how competent they are in some fields, how willing and involved they are to help and make things happen.” (Competence).

In the literature the theme Increased ‘confidence’ in new technologies due to the pandemic was unique (28). In the interview a similar but not identical subtheme emerged: discovery of ‘new tools’, meaning that the forced online teaching brought teachers a chance to try new tools.

L: “…COVID-19 has boosted their < teachers > confidence in the effectiveness of online education…(page 1 [ 56 ])”. (Confidence).
I: “So personally, I found it was a very big opportunity to discover some of those tools.” (New tools).

In this study, we capture the experiences of the rapid transition to online teaching in the pandemic from literature and Swiss curriculum developers. The comparison between views of curriculum managers across Switzerland with findings from international literature brought important insights and served to view the Swiss experience in a broader context. In the following we reflect how the findings provide answers to our three research questions.

The first research question investigated salient factors that influence the success of DLT activities. Through the thematic analysis of the relevant literature, we could identify four main themes: ‘requirements’, ‘obstacles’, ‘advantages’, and ‘facilitators’, which showed to be applicable also for the interviews. We developed the question route for the interviews based on this literature and were thereby able to identify further salient deductive themes. Through analysis of the selected studies, a structure of related subthemes was extracted providing a framework for further analysis (Fig.  1 ). Although a need for more DLT was already known prior to the pandemic, our findings suggest that the former reported lag in DLT implementation was most likely caused by ignorance related to the known obstacles at the institutional level.

The second research question relates to early international experiences of implementing DLT initiatives during the pandemic in medical education. The pandemic led to a landslide of DLT developments and ad hoc solutions to transition from onsite to online. A comparison of the new experiences with earlier literature clearly shows that obstacles had to be addressed through mandatory initiatives at an institutional level due to the crisis. The new focus changed from supporting an onsite teaching culture to active practical implemention of DLT.

Delivering of clinical training to learners was critically reduced and could only partially be delivered online. Innovative digital approaches further facilitated delivery of hands-on teaching by Incorporation virtual-reality applications or 3D anatomy software with a decrease in cadaver dissection [ 57 ]. This may be applied to other fields in the future.

Our results show a differentiated picture of requirements, obstacles and facilitators for DLT implementation. We note that several challenges that emerged from our interviewees are also reported in recent publications, indicating that early challenges are not a pandemic problem easily solved. These include economic repercussions of the pandemic; social distancing affecting the delivery of medical education, the surge of patients affecting redeployment of personnel and potential compromises in core training; and the overall impact on the wellness and mental health of trainees and educators [ 58 ]. Post pandemic, current literature continues to stress that early noted obstacles must be addressed in the future [ 59 ].

One recent review shows that readiness to respond to the situation by the institutions was a facilitator for success. The remaining barriers are the lack of planning, –resources, and –interactivity between teachers and students [ 59 ]. Other findings from the pandemic point to the same direction: attitude to e-learning, networking and interdisciplinary collaborations affected the implementation of DLT. Challenges like inadequate interactions, time constrictions, and administrative issues will continue to be obstacles in any situation demanding a quick move to online learning in the future [ 60 ]. Therefore, it continues to be important to develop the necessary infrastructure and assure the adequate resources [ 28 ]. Also, the need to be more specific about how we teach has been noted in recent literature [ 60 ].

The third research question address the Swiss experience. Our analysis shows commonalities and differences between published research and the perspective of curriculum managers. The interviews identified specific themes that are also relevant for the continued implementation and management of DLT. Within the theme of ‘requirements’ further differences were noted for obstacles, facilitators and advantages, which we will present in more detail.

The interviews revealed that the Swiss faculties were mostly unprepared for the complete shift to DLT in the first lock-down. The crisis management, as reported from the interviewees, exposed important requirements related to structures, strategy, standards and implementation, directly impacting administration and communication.

Another barrier revealed by the interviewees included quality assurance issues. This finding is consistent with an earlier study [ 61 ], in which the authors concluded that one of the most imperative means for implementing online modules is encouraging collaboration among all departments and stakeholders. An organized and clear institutional approach is required to formulate a well-regulated and efficient system which can facilitate the adoption of useful methodologies by faculty members for implementing an online learning [ 61 ]. Specifically, the interviewees raised concerns on how to sustain the high quality of Swiss exams when they are delivered online. Existing Swiss medical exams are normally not designed for open book solutions, and so in order to reduce fraud, exam time was reduced to a minimum, limiting students time to investigate answers from online sources. This concern was not noted in this way from our findings within the literature.

The provision of support delivered with access to ‘help desk’ or a mentor is essential to effective teaching online. Institutions were faced with the challenge to radically increase and rapidly scale up online support for DLT from the onset of the Covid-19 pandemic. This was a reported challenge from all Swiss faculties, independent of the former DLT progress. Consequently, both new literature and our interviews show that foci shifted from planning to doing. These insights are also emphasized in recent literature discussing DLT during the Pandemic [ 62 , 63 ]. Experiences related to DLT during the pandemic uncover new obstacles including a lack of institutional support for faculty training, a decrease in student engagement and challenges in implementing assessments online, insufficient communication between the stakeholders, and time management, as well as a host of additional challenges [ 19 , 20 , 29 , 30 , 31 , 50 , 56 , 64 , 65 , 66 , 67 ]. The delivery of most practical skills-based training was not possible. Some medical disciplines had to take extensive effort to adapt to the DLT setting (e.g. surgery, internal medicine), as teachers and students need opportunities for safe exercise opportunities or demonstrative learning, communication, and group dynamics [ 68 ]. However, online learning can serve as an efficient resource for clinical practice if the method is upgraded through the integration of modalities such as virtual simulation technologies and computer-based models of real-life processes [ 69 ]. Further, online learning for clinical skills can serve as an excellent preparation for onsite clinical training, e.g. for communication training [ 70 , 71 ]. Our findings in this research project are congruent with the literature that communication training online was feasible and surprisingly well accepted [ 72 ]. For the future, given that online training is well implemented, it can produce multiple benefits for clinical learners by providing controlled opportunities to practice rare and critical events in safe environments excluding the risk to patients [ 73 ].

According to the interviewees, many teachers show general enthusiasm for DLT. However, as the traditional teaching is their main source of experience—they simply lacked technical knowledge and DLT experience resulting in initial scepticism towards DLT. Initially, technical knowledge was a hinderance for learners, but this evolved into positive encounters through accumulated experience. At the start of the pandemic the teaching format remained unchanged as all the lectures were uploaded as podcasts. So, the issue was not so much to achieve quality, but only basic online teaching, without optimisations or innovations. Due to lack of experience, training and time, even this simple aim was a challenge, as teachers were not trained or prepared to deliver online content. One of the most common barriers was technical insufficiency, including deficits in educators’ basic computer skills. The themes identified in our study complement previous studies [ 74 ].

One of the main aspects discussed in the interviews was that teaching quality is not dependent on the mode of delivery; online or onsite. There is a relevant distinction to be made between the quality of teaching and teaching method: “ It’s actually quite depressing the quality of teaching sometimes, but it’s not about online but interactivity. It’s not that because you do online, you have to be more interactive. ” The most poignant reflection from our study is the consistently reported lack of good quality teaching. Does online teaching demand its own didactic, or does it make sense to focus on the holistic view of currently teaching? Newer studies also stress this question [ 42 ]. We could document that making the first step is important, a major success factor was that earlier resistances from the teachers had less impact, than expected. This enabled all stakeholders to gain new experiences and trust in their own digital competences.

The interviewees noted that students in general experienced a lack of guidance, deficits in interaction with their teachers, as well as lacking optimised solutions for clinical demonstrations, lack of direct contact, spontaneous interaction and clarifications of their questions. The known deficits of online learning, captured from the literature [ 20 , 21 , 25 ] about students’ feelings of isolation resulting in reduced mental health, were not explicitly noted by the interviewees. Reflecting on this point, our participants took part in interviews at the beginning of the Covid-19 pandemic, where students’ ‘isolation’ may not have yet had significant impact.

Critical reflections

This study reports on experiences of curriculum managers at the start of the pandemic, where the initial adaptation to DLT was still new. The relevance of this study would be reduced, if experiences changed during the pandemic and different issues became dominant at a later stage. Our impression from the newer literature, reported above, is that many challenges, as reported in the Tables  1 , 2 and 3 , remain. Long-term development of DLT is needed to address all requirements, obstacles, advantages and facilitators related to successful implementation.

The interviews were conducted in English, and consequently there may be a potential bias introduced here as subtle nuances might be lost when non-native speakers express complex ideas in another language. However, all interviewees were fluent in English, and approved the transcript. The use of English facilitated the use of quotations without misinterpretation from translation.

We interviewed 11 curriculum managers from 7 Swiss medical Schools, which may be considered a small sample raising questions of the representativeness information gathered. However, this sample represents important stakeholder roles within the Swiss educational system and are normally in the responsibility of one to two persons. In this sense, the sample is representable. We also investigate perspectives of students and teachers- as reported by the interviewees, which may not capture the true perspective from these groups at large. However, data from the interviews is validated as many of the emergent themes from the interviews are well aligned to the literature. Our findings illustrate a high degree of converging experiences, indicating saturation of data. Variations between the institutions were noted, some reporting smoother DLT integration than others.

In reflecting on our findings, it is evident that educators require a diverse skill set to effectively support digital teaching initiatives, encompassing online communication, time management, technical proficiency and a transition to a more facilitative role.

Since the onset of the pandemic, education systems have unexpectedly transitioned to a new era of education with more focus on DLT. This study underscores the essential role of strategic and operative support of DLT at an organisational level, taking the needs of students and teachers into consideration.

A strategic focus for DLT is needed including reflections on the future goals of teaching in medical education. Educators must be enabled to support students in effective and efficient learning, in multiple ways [ 73 ]. Medical schools and education institutions are advised to promote facilitating factors to effective online learning and address barriers hindering effective DLT implementation. For an optimal implementation of DLT, our findings support an alignment between key players’ requirements. The need for alignment is evident in the literature for all three central stakeholders, institutions, teachers, and students. With facilities and resources available to Swiss medical students, it might be expected that education institutions could offer and implement high quality DLT with relative ease. Our results show this was not the case during the pandemic. Sustained financial support for a continued DLT development together with a clear strategy based on didactic insights is needed.

Our research reports a lack of institutional structures, communication, digital literacy, teaching strategies, as well as a theoretical foundation for DLT implementation. A conceptual DLT framework adapted to the Swiss universities is needed to prepare for a period of transition to long-term sustainable solutions. Findings have the potential to advise medical institutions in how to implement DLT in a didactical sustainable way, to provide high quality online teaching post pandemic. Changing a system takes time. After all the experiences during the pandemic, for good and for bad, reaching the true potential of DLT will be a journey.

While our research focuses on the challenges and strategies within medical education's shift to DLT, the identified requirementfor institutional structures, clear communication, and a robust theoretical foundation for DLT is universally applicable across disciplines. The journey to fully realize the potential of DLT, underscored by our findings, offers valuable insights for all educational institutions striving for sustainable, high-quality online teaching in a post-pandemic world.

Availability of data and materials

The datasets generated and/or analyzed during the current study are currently not publicly available because these are interviews from well-known heads of curriculum management and vice deans. We have a written declaration that we will ensure their privacy. Availability of source data can be provided only on reasonable request and the interviews will be modified to ensure absolute anonymity. I this case please contact the first author.

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Acknowledgements

We thank you the curriculum managers of the Swiss medical faculties for taking part in the interviews.

The views expressed in the submitted article are the author`s independent findings and are not influenced from an official position of the hiring institutions or funder.

All support for the present manuscript (e.g.,provision of study materials, etc.) is from the Institute for medical Education, medical faculty, University of Bern, Switzerland. The study was funded with a grant from SNF (Swiss National Foundation) Grant No 100019_200811 / 1.

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Artemisa Gogollari did the literature review and conducted the interviews. Artemisa Gogollari and Sissel Guttormsen developed the questions and wrote the main manuscript text. Artemisa Gogollari did the transcription of the interviews and the analyses in NVivo. Artemisa Gogollari prepared figures and tables. Sharon Mitchell provided input and feedback on the presentation of the findings, as well as the design, methods and discussion of the paper. All authors reviewed the manuscript.

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Gogollari, A., Mitchell, S. & Guttormsen, S. Swiss medical schools’ experiences with online teaching during the COVID-19 pandemic in light of international experiences. BMC Med Educ 24 , 242 (2024). https://doi.org/10.1186/s12909-024-05218-3

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    Reflexive thematic analysis is widely used in qualitative research published in Palliative Medicine, and in the broader field of health research.However, this approach is often not used well. Common problems in published reflexive thematic analysis in general include assuming thematic analysis is a singular approach, rather than a family of methods, confusing themes and topics, and treating ...