qualitative research quality criteria

Criteria for Good Qualitative Research: A Comprehensive Review

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• Published: 18 September 2021
• Volume 31 , pages 679–689, ( 2022 )

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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Yadav, D. Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Edu Res 31 , 679–689 (2022). https://doi.org/10.1007/s40299-021-00619-0

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11 Considerations of Quality in Qualitative Research

• Published: February 2023
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This chapter describes how excellence and quality can be demonstrated in qualitative research and provides criteria for discerning these qualities as a consumer of qualitative reports. Researchers are advised to make carefully considered choices about the terms they adopt, such as “validation,” “verification,” “credibility,” and “trustworthiness,” for describing qualitative inquiry. The chapter discusses design elements and validation strategies that researchers can use to enhance the credibility of their research, as well as ways that research participants and external reviewers can be involved in these processes. Strategic actions that researchers can take include pursuing triangulation or crystallization, presenting negative case analysis, engaging in reflexive practices, and taking steps to recognize and manage their own subjectivity. Participants can be actively engaged in validation through member reflections, by interacting with the researcher in the field over a prolonged period of time, or through more intense collaboration with researchers in various phases of the research. Additional validation strategies call for external reviewers to audit the research process and products and for readers to assess the potential transferability of research findings based on thick description provided by the researcher. We conclude the chapter with guiding questions readers can use to discern quality in the research reports they consume.

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Dr Karen Lumsden

trainer / coach / consultant / researcher

Assessing the ‘Quality’ of Qualitative Research

One of the questions that comes up regularly in training courses on qualitative methods is how we should assess the quality of a qualitative study. At some point in their research career, qualitative researchers will inevitably experience the ‘apples versus oranges’ phenomenon, whereby our qualitative research is evaluated based on quantitative principles and criteria, instead of qualitative principles. The quality standards used in quantitative research do not directly translate to qualitative studies.

Should We Use Standardized Criteria to Evaluate Qualitative Research?

Over the years, many qualitative scholars have proposed frameworks and criteria for assessing qualitative research (see Guba and Lincoln 1989; Lather 1993; Schwandt 1996; Bochner 2000; Ritchie et al. 2003; Tracy 2010; Altheide and Johnson 2011). Some have also argued that standardized criteria in are unhelpful in qualitative inquiry (i.e. see Schwandt 1996; Altheide and Johnson 2011). For example, Bochner (2000) argues that ‘traditional empiricist criteria’ are ‘unhelpful’ when applied to new ethnographic approaches (cited in Tracy 2010: 838). As Altheide and Johnson (2011: 582) argue:

“There are many ways to use, practice, promote, and claim qualitative research, and in each there is a proposed or claimed relationship between some field of human experience, a form of representation, and an audience. Researchers and scholars in each of these areas have been grappling with issues of truth, validity, verisimilitude, credibility, trustworthiness, dependability, confirmability, and so on. What is valid for clinical studies or policy studies may not be adequate or relevant for ethnography or autoethnography or performance ethnography.”

Qualitative research is conducted within different research paradigms, which complicates the assessment of the quality of a particular study.

As Tracy (2010) notes, many of these critiques result in the development of new quality standards and criteria for evaluating qualitative inquiry which are seen as more flexible than quantitative standard and of more sensitive to the context bound nature of qualitative research. Below, we explore the main criteria proposed for assessing qualitative research:

Criteria for Assessing Qualitative Research

• Trustworthiness

In the 1980s, Guba and Lincoln (1989 see also Krefting 1991) developed criteria which can be used to determine rigor in a qualitative inquiry. Instead of ‘rigor’, they focus on the development of trustworthiness in qualitative inquiry through determining: credibility, transferability, reliability and confirmability .

• Credibility

Credibility asks us to consider if the research findings are plausible and convincing. Questions to consider include:

• How well does the study capture and portray the world it is trying to describe?
• How well backed up are the claims made by the research?
• What is the evidential base for the research?
• How plausible are the findings?

As Stenfors et al. (2020) point out, there should be alignment between ‘theory, research question, data collection, analysis and results’ while the ‘sampling strategy, the depth and volume of data, and the analytical steps taken’ must be appropriate within that framework.

• Transferability

Here, we are interested in how clear the basis is for drawing wider inference (Ritchie et al. 2003) from our study. Can the findings of our study be transferred to another group, context or setting?

As Ritchie et al. (2003) argue, the findings of qualitative research can be generalized but the framework within which this can occur needs greater clarification. Instead, we refer to the transferability of findings in a qualitative study. For example, in an empirical sense: can findings from qualitative research studies be applied to populations or settings beyond the particular sample of the study? We can also explore the generation of theoretical concepts or propositions which are deemed to be of wider, or universal, application from a qualitative study.

When attempting to extrapolate from a qualitative study we should be conscious that meanings and behaviours are context bound. Therefore extrapolation may be possible if offered as a working hypothesis to help us to make sense of findings in other contexts.

Questions to consider include:

• Sample coverage: did the sample frame contain any known bias; were the criteria used for selection inclusive of the constituencies thought to be of importance?
• Capture of the phenomena: was the environment, quality of questioning effective for participants to fully express their views?
• Identification or labelling: have the phenomena been identified, categorised and named in ways that reflect the meanings assigned by participants?
• Interpretation: is there sufficient internal evidence for the explanatory accounts that have been developed?
• Display: have the findings been portrayed in a way that remains true to the original data and allows others to see the analytic constructions which have occurred? (see Ritchie et al. 2003)
• Dependability

Dependability is ‘the extent to which the research could be replicated in similar conditions’ (Stenfors et al. 2020). The researcher should have provided enough information on the design and conduct of their study that another researcher could follow these and take the same steps in their study. Given the context specific nature of qualitative research, it can be difficult to demonstrate which features of the qualitative data should be expected to be consistent, dependable or reliable.

Questions to consider for reliability include:

• Was the sample design/selection without bias, ‘symbolically’ representative of the target population, comprehensive of all known constituencies; was there any known feature of non-response or attrition within the sample?
• Was the fieldwork carried out consistently, did it allow respondents sufficient opportunities to cover relevant ground, to portray their experiences?
• Was the analysis carried out systematically and comprehensively, were classifications, typologies confirmed by multiple assessment?
• Is the interpretation well supported by the evidence?
• Did the design/conduct allow equal opportunity for all perspectives to be identified or were there features that led to selective, or missing, coverage? (see Ritchie et al. 2003).
• Confirmability

Here, we are looking for a clear link between the data and the findings. For example, researchers should evidence their claims with the use of quotes/excerpts of data. Qualitative researchers should avoid the temptation to quantify findings with claims such as ‘70% of participants felt that xxx…’ It is also important in the Discussion to demonstrate how the research findings relate to the wider body of literature and to answer the research question. Any limitations of the study should also be flagged up.

• Reflexivity

Stenfors et al. (2020) draw attention to reflexivity as another important criteria in assessing qualitative inquiry. For Guba and Lincoln (1989) the reflexive journal is a further means of helping to assess qualitative inquiry. A reflexive approach helps us to be aware of the social, ethical and political impact of our research, the central, fluid and changing nature/s of power relations (with participants, gatekeepers, research funders, etc.) and our relationships with the researched (Lumsden 2019).

We can ask whether the researcher has stepped back and critically reflected on their role in the research process, their relationships with the researched, and their social position? It should be clear how reflexivity has been embedded in the research process (Stenfors et al. 2020). As Altheide and Johnson (2011: 581) write:

‘Good qualitative research—and particularly ethnographies—shows the hand of the ethnographer. The effort may not always be successful, but there should be clear “tracks” that the attempt has been made.’

Additional Criteria: Ethics

Tracy (2010) also provides a useful overview of 8 key criteria for excellent qualitative research: worthy topic, rich rigor, sincerity, credibility, resonance, significant contribution, ethical, meaningful coherence (p.840). There is overlap with the above criteria and some elements could be said to be already subsumed in the above discussion, therefore I will not delve into them all here. However, it is important to draw attention to ethical considerations in qualitative studies. As Tracy notes, the research should consider:

• Procedural ethics (such as human subjects);
• Situational and culturally specific ethics;
• Relational ethics;
• Exiting ethics (leaving the scene and sharing the research) (see Tracy 2010: 840).

Strategies for Determining Trustworthiness (Rigor)

The strategies adopted in order to determine the trustworthiness of a qualitative study depend on a variety of factors including: research paradigm, the specifics of each research design, the research methods utilised (i.e. interviews, ethnography, observation, focus groups, creative methods, visual methods, secondary data analysis, narratives etc.) and the type of qualitative analysis being conducted.

Moore (2015) provides a useful evaluation of the use of various strategies for ensuring rigor in qualitative studies. Strategies which she evaluates as typically used in attempts to ensure validity and reliability include:

• Prolonged engagement in ethnographic research via time spent in the field to reduce researcher effect;
• Prolonged observation in ethnographic research reduces researcher effect;
• Thick description;
• Triangulation;
• Development of a coding system and inter-rater reliability in semi-structured interviews;
• Researcher bias;
• Negative case analysis;
• Peer review debriefing (in team research);
• Member checks;
• External audits (viewed as problematic and not routinely used) (see pages 1217-1220).

She provides a useful evaluation of the appropriateness and success of these strategies for ensuring rigor, for those who wish to explore this further. Interestingly, through her critique of these strategies, Moore also suggests that ‘qualitative researchers return to the terminology of social sciences, using rigor, reliability, validity, and generalizability’ (p.1212) instead of those proposed in the 1980s by Guba and Lincoln (1989).

Awareness of the criteria used when assessing the quality of qualitative research is key for anyone conducting qualitative research. As we have seen these criteria typically include: trustworthiness, credibility, transferability, dependability, confirmability, reflexivity and ethics.

However the strategies which each researcher adopts in order to ensure the trustworthiness (rigor) of their study, will depend on a variety of factors specific to each qualitative research project including the research method they adopt and the research paradigm. As Moore (2019: 1219) writes: ‘…rigor, comprising both validity and reliability, is achieved primarily by researchers in the process of data collection and analysis’. In addition, the assessment criteria which are valid when assessing fields such as clinical studies may not be relevant for those working in areas such as ethnography or narrative studies (see Altheide and Johnson 2011). There is no easy route or ‘one size fits all’ approach for assessing the quality of qualitative research, but the above criteria give us a good starting point which we can refer to when designing and conducting our qualitative inquiries.

References and further reading

Altheide, D.L. and Johnson, J.M. (2011) ‘Reflections on Interpretive Adequacy in Qualitative Research.’ In N.K. Denzin and Y.S. Lincoln (eds) Handbook of Qualitative Research, Fifth Edition (pp. 581-594). London: Sage.

Bochner, A. (2000) ‘Criteria Against Ourselves.’ Qualitative Inquiry , 6: 266-272.

Braun, V. and Clarke, V. (2013) Successful Qualitative Research . London: Sage.

Guba, E. and Lincoln, Y. (1989) Fourth Generation Evaluation . Newbury Park, CA: Sage.

Krefting, L. (1991) ‘Rigor in Qualitative Research: The Assessment of Trustworthiness.’ American Journal of Occupational Therapy , 45: 214–222.

Lather, P. (1993) ‘Fertile Obsession: Validity after Poststructuralism.’ Sociological Quarterly , 34: 673-693.

Lingard L. (2015) ‘Joining a Conversation: The Problem/Gap/Hook Heuristic.’ Perspectives on Medical Education , 4(5): 252–253.

Lumsden, K. (2019) Reflexivity: Theory, Method and Practice . London: Routledge.

Morse, J.M. (2015) ‘Critical Analysis of Strategies for Determining Rigor in Qualitative Inquiry.’ Qualitative Health Research , 25(9): 1212-1222.

Schwandt, T.A. (1996) ‘Farewell to Criteriology.’ Qualitative Inquiry , 2: 58-72.

Spencer, L., Ritchie, J., Lewis, J., and Dillon, L. (2003) Quality in Qualitative Evaluation: A Framework for Assessing Research Evidence , GCSRO.  Available at: www.policyhub.gov.uk/publications

Stenfors, T., Kajamaa, A. and Bennett, D. (2020) ‘How to… Assess the Quality of Qualitative Research.’ The Clinical Teacher , https://doi.org/10.1111/tct.13242

Tracy, S.J. (2010) ‘Qualitative Quality: Eight “Big-Tent” Criteria for Excellent Qualitative Research.’ Qualitative Inquiry , 16: 837–851.

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Published by Dr Karen Lumsden

trainer / coach / consultant / researcher I am a social scientist with expertise in qualitative research methods. I have a passion for delivering qualitative methods training and coaching to clients. I am also Assistant Professor in Criminology at the University of Nottingham, UK and have experience of delivering qualitative methods training via the Social Research Association and to various universities and organisations. View all posts by Dr Karen Lumsden

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• Open access
• Published: 13 May 2024

What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review

• Olivia R. Phillips 1 , 2   na1 ,
• Cerian Harries 2 , 3   na1 ,
• Jo Leonardi-Bee 1 , 2 , 4   na1 ,
• Holly Knight 1 , 2 ,
• Lauren B. Sherar 2 , 3 ,
• Veronica Varela-Mato 2 , 3 &
• Joanne R. Morling 1 , 2 , 5  

Research Involvement and Engagement volume  10 , Article number:  48 ( 2024 ) Cite this article

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There is increasing interest in using patient and public involvement (PPI) in research to improve the quality of healthcare. Ordinarily, traditional methods have been used such as interviews or focus groups. However, these methods tend to engage a similar demographic of people. Thus, creative methods are being developed to involve patients for whom traditional methods are inaccessible or non-engaging.

To determine the strengths and limitations to using creative PPI methods in health and social care research.

Electronic searches were conducted over five databases on 14th April 2023 (Web of Science, PubMed, ASSIA, CINAHL, Cochrane Library). Studies that involved traditional, non-creative PPI methods were excluded. Creative PPI methods were used to engage with people as research advisors, rather than study participants. Only primary data published in English from 2009 were accepted. Title, abstract and full text screening was undertaken by two independent reviewers before inductive thematic analysis was used to generate themes.

Twelve papers met the inclusion criteria. The creative methods used included songs, poems, drawings, photograph elicitation, drama performance, visualisations, social media, photography, prototype development, cultural animation, card sorting and persona development. Analysis identified four limitations and five strengths to the creative approaches. Limitations included the time and resource intensive nature of creative PPI, the lack of generalisation to wider populations and ethical issues. External factors, such as the lack of infrastructure to support creative PPI, also affected their implementation. Strengths included the disruption of power hierarchies and the creation of a safe space for people to express mundane or “taboo” topics. Creative methods are also engaging, inclusive of people who struggle to participate in traditional PPI and can also be cost and time efficient.

‘Creative PPI’ is an umbrella term encapsulating many different methods of engagement and there are strengths and limitations to each. The choice of which should be determined by the aims and requirements of the research, as well as the characteristics of the PPI group and practical limitations. Creative PPI can be advantageous over more traditional methods, however a hybrid approach could be considered to reap the benefits of both. Creative PPI methods are not widely used; however, this could change over time as PPI becomes embedded even more into research.

Plain English Summary

It is important that patients and public are included in the research process from initial brainstorming, through design to delivery. This is known as public and patient involvement (PPI). Their input means that research closely aligns with their wants and needs. Traditionally to get this input, interviews and group discussions are held, but this can exclude people who find these activities non-engaging or inaccessible, for example those with language challenges, learning disabilities or memory issues. Creative methods of PPI can overcome this. This is a broad term describing different (non-traditional) ways of engaging patients and public in research, such as through the use or art, animation or performance. This review investigated the reasons why creative approaches to PPI could be difficult (limitations) or helpful (strengths) in health and social care research. After searching 5 online databases, 12 studies were included in the review. PPI groups included adults, children and people with language and memory impairments. Creative methods included songs, poems, drawings, the use of photos and drama, visualisations, Facebook, creating prototypes, personas and card sorting. Limitations included the time, cost and effort associated with creative methods, the lack of application to other populations, ethical issues and buy-in from the wider research community. Strengths included the feeling of equality between academics and the public, creation of a safe space for people to express themselves, inclusivity, and that creative PPI can be cost and time efficient. Overall, this review suggests that creative PPI is worthwhile, however each method has its own strengths and limitations and the choice of which will depend on the research project, PPI group characteristics and other practical limitations, such as time and financial constraints.

Peer Review reports

Introduction

Patient and public involvement (PPI) is the term used to describe the partnership between patients (including caregivers, potential patients, healthcare users etc.) or the public (a community member with no known interest in the topic) with researchers. It describes research that is done “‘with’ or ‘by’ the public, rather than ‘to,’ ‘about’ or ‘for’ them” [ 1 ]. In 2009, it became a legislative requirement for certain health and social care organisations to include patients, families, carers and communities in not only the planning of health and social care services, but the commissioning, delivery and evaluation of them too [ 2 ]. For example, funding applications for the National Institute of Health and Care Research (NIHR), a UK funding body, mandates a demonstration of how researchers plan to include patients/service users, the public and carers at each stage of the project [ 3 ]. However, this should not simply be a tokenistic, tick-box exercise. PPI should help formulate initial ideas and should be an instrumental, continuous part of the research process. Input from PPI can provide unique insights not yet considered and can ensure that research and health services are closely aligned to the needs and requirements of service users PPI also generally makes research more relevant with clearer outcomes and impacts [ 4 ]. Although this review refers to both patients and the public using the umbrella term ‘PPI’, it is important to acknowledge that these are two different groups with different motivations, needs and interests when it comes to health research and service delivery [ 5 ].

Despite continuing recognition of the need of PPI to improve quality of healthcare, researchers have also recognised that there is no ‘one size fits all’ method for involving patients [ 4 ]. Traditionally, PPI methods invite people to take part in interviews or focus groups to facilitate discussion, or surveys and questionnaires. However, these can sometimes be inaccessible or non-engaging for certain populations. For example, someone with communication difficulties may find it difficult to engage in focus groups or interviews. If individuals lack the appropriate skills to interact in these types of scenarios, they cannot take advantage of the participation opportunities it can provide [ 6 ]. Creative methods, however, aim to resolve these issues. These are a relatively new concept whereby researchers use creative methods (e.g., artwork, animations, Lego), to make PPI more accessible and engaging for those whose voices would otherwise go unheard. They ensure that all populations can engage in research, regardless of their background or skills. Seminal work has previously been conducted in this area, which brought to light the use of creative methodologies in research. Leavy (2008) [ 7 ] discussed how traditional interviews had limits on what could be expressed due to their sterile, jargon-filled and formulaic structure, read by only a few specialised academics. It was this that called for more creative approaches, which included narrative enquiry, fiction-based research, poetry, music, dance, art, theatre, film and visual art. These practices, which can be used in any stage of the research cycle, supported greater empathy, self-reflection and longer-lasting learning experiences compared to interviews [ 7 ]. They also pushed traditional academic boundaries, which made the research accessible not only to researchers, but the public too. Leavy explains that there are similarities between arts-based approaches and scientific approaches: both attempts to investigate what it means to be human through exploration, and used together, these complimentary approaches can progress our understanding of the human experience [ 7 ]. Further, it is important to acknowledge the parallels and nuances between creative and inclusive methods of PPI. Although creative methods aim to be inclusive (this should underlie any PPI activity, whether creative or not), they do not incorporate all types of accessible, inclusive methodologies e.g., using sign language for people with hearing impairments or audio recordings for people who cannot read. Given that there was not enough scope to include an evaluation of all possible inclusive methodologies, this review will focus on creative methods of PPI only.

We aimed to conduct a qualitative systematic review to highlight the strengths of creative PPI in health and social care research, as well as the limitations, which might act as a barrier to their implementation. A qualitative systematic review “brings together research on a topic, systematically searching for research evidence from primary qualitative studies and drawing the findings together” [ 8 ]. This review can then advise researchers of the best practices when designing PPI.

Public involvement

The PHIRST-LIGHT Public Advisory Group (PAG) consists of a team of experienced public contributors with a diverse range of characteristics from across the UK. The PAG was involved in the initial question setting and study design for this review.

Search strategy

For the purpose of this review, the JBI approach for conducting qualitative systematic reviews was followed [ 9 ]. The search terms were (“creativ*” OR “innovat*” OR “authentic” OR “original” OR “inclu*”) AND (“public and patient involvement” OR “patient and public involvement” OR “public and patient involvement and engagement” OR “patient and public involvement and engagement” OR “PPI” OR “PPIE” OR “co-produc*” OR “co-creat*” OR “co-design*” OR “cooperat*” OR “co-operat*”). This search string was modified according to the requirements of each database. Papers were filtered by title, abstract and keywords (see Additional file 1 for search strings). The databases searched included Web of Science (WoS), PubMed, ASSIA and CINAHL. The Cochrane Library was also searched to identify relevant reviews which could lead to the identification of primary research. The search was conducted on 14/04/23. As our aim was to report on the use of creative PPI in research, rather than more generic public engagement, we used electronic databases of scholarly peer-reviewed literature, which represent a wide range of recognised databases. These identified studies published in general international journals (WoS, PubMed), those in social sciences journals (ASSIA), those in nursing and allied health journals (CINAHL), and trials of interventions (Cochrane Library).

Inclusion criteria

Only full-text, English language, primary research papers from 2009 to 2023 were included. This was the chosen timeframe as in 2009 the Health and Social Reform Act made it mandatory for certain Health and Social Care organisations to involve the public and patients in planning, delivering, and evaluating services [ 2 ]. Only creative methods of PPI were accepted, rather than traditional methods, such as interviews or focus groups. For the purposes of this paper, creative PPI included creative art or arts-based approaches (e.g., e.g. stories, songs, drama, drawing, painting, poetry, photography) to enhance engagement. Titles were related to health and social care and the creative PPI was used to engage with people as research advisors, not as study participants. Meta-analyses, conference abstracts, book chapters, commentaries and reviews were excluded. There were no limits concerning study location or the demographic characteristics of the PPI groups. Only qualitative data were accepted.

Quality appraisal

Quality appraisal using the Critical Appraisal Skills Programme (CASP) checklist [ 10 ] was conducted by the primary authors (ORP and CH). This was done independently, and discrepancies were discussed and resolved. If a consensus could not be reached, a third independent reviewer was consulted (JRM). The full list of quality appraisal questions can be found in Additional file 2 .

Data extraction

ORP extracted the study characteristics and a subset of these were checked by CH. Discrepancies were discussed and amendments made. Extracted data included author, title, location, year of publication, year study was carried out, research question/aim, creative methods used, number of participants, mean age, gender, ethnicity of participants, setting, limitations and strengths of creative PPI and main findings.

Data analysis

The included studies were analysed using inductive thematic analysis [ 11 ], where themes were determined by the data. The familiarisation stage took place during full-text reading of the included articles. Anything identified as a strength or limitation to creative PPI methods was extracted verbatim as an initial code and inputted into the data extraction Excel sheet. Similar codes were sorted into broader themes, either under ‘strengths’ or ‘limitations’ and reviewed. Themes were then assigned a name according to the codes.

The search yielded 9978 titles across the 5 databases: Web of Science (1480 results), PubMed (94 results), ASSIA (2454 results), CINAHL (5948 results) and Cochrane Library (2 results), resulting in 8553 different studies after deduplication. ORP and CH independently screened their titles and abstracts, excluding those that did not meet the criteria. After assessment, 12 studies were included (see Fig.  1 ).

PRISMA flowchart of the study selection process

Study characteristics

The included studies were published between 2018 and 2022. Seven were conducted in the UK [ 12 , 14 , 15 , 17 , 18 , 19 , 23 ], two in Canada [ 21 , 22 ], one in Australia [ 13 ], one in Norway [ 16 ] and one in Ireland [ 20 ]. The PPI activities occurred across various settings, including a school [ 12 ], social club [ 12 ], hospital [ 17 ], university [ 22 ], theatre [ 19 ], hotel [ 20 ], or online [ 15 , 21 ], however this information was omitted in 5 studies [ 13 , 14 , 16 , 18 , 23 ]. The number of people attending the PPI sessions varied, ranging from 6 to 289, however the majority (ten studies) had less than 70 participants [ 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Seven studies did not provide information on the age or gender of the PPI groups. Of those that did, ages ranged from 8 to 76 and were mostly female. The ethnicities of the PPI group members were also rarely recorded (see Additional file 3 for data extraction table).

Types of creative methods

The type of creative methods used to engage the PPI groups were varied. These included songs, poems, drawings, photograph elicitation, drama performance, visualisations, Facebook, photography, prototype development, cultural animation, card sorting and creating personas (see Table  1 ). These were sometimes accompanied by traditional methods of PPI such as interviews and focus group discussions.

The 12 included studies were all deemed to be of good methodological quality, with scores ranging from 6/10 to 10/10 with the CASP critical appraisal tool [ 10 ] (Table  2 ).

Thematic analysis

Analysis identified four limitations and five strengths to creative PPI (see Fig.  2 ). Limitations included the time and resource intensity of creative PPI methods, its lack of generalisation, ethical issues and external factors. Strengths included the disruption of power hierarchies, the engaging and inclusive nature of the methods and their long-term cost and time efficiency. Creative PPI methods also allowed mundane and “taboo” topics to be discussed within a safe space.

Theme map of strengths and limitations

Limitations of creative PPI

Creative ppi methods are time and resource intensive.

The time and resource intensive nature of creative PPI methods is a limitation, most notably for the persona-scenario methodology. Valaitis et al. [ 22 ] used 14 persona-scenario workshops with 70 participants to co-design a healthcare intervention, which aimed to promote optimal aging in Canada. Using the persona method, pairs composed of patients, healthcare providers, community service providers and volunteers developed a fictional character which they believed represented an ‘end-user’ of the healthcare intervention. Due to the depth and richness of the data produced the authors reported that it was time consuming to analyse. Further, they commented that the amount of information was difficult to disseminate to scientific leads and present at team meetings. Additionally, to ensure the production of high-quality data, to probe for details and lead group discussion there was a need for highly skilled facilitators. The resource intensive nature of the creative co-production was also noted in a study using the persona scenario and creative worksheets to develop a prototype decision support tool for individuals with malignant pleural effusion [ 17 ]. With approximately 50 people, this was also likely to yield a high volume of data to consider.

To prepare materials for populations who cannot engage in traditional methods of PPI was also timely. Kearns et al. [ 18 ] developed a feedback questionnaire for people with aphasia to evaluate ICT-delivered rehabilitation. To ensure people could participate effectively, the resources used during the workshops, such as PowerPoints, online images and photographs, had to be aphasia-accessible, which was labour and time intensive. The author warned that this time commitment should not be underestimated.

There are further practical limitations to implementing creative PPI, such as the costs of materials for activities as well as hiring a space for workshops. For example, the included studies in this review utilised pens, paper, worksheets, laptops, arts and craft supplies and magazines and took place in venues such as universities, a social club, and a hotel. Further, although not limited to creative PPI methods exclusively but rather most studies involving the public, a financial incentive was often offered for participation, as well as food, parking, transport and accommodation [ 21 , 22 ].

Creative PPI lacks generalisation

Another barrier to the use of creative PPI methods in health and social care research was the individual nature of its output. Those who participate, usually small in number, produce unique creative outputs specific to their own experiences, opinions and location. Craven et al. [ 13 ], used arts-based visualisations to develop a toolbox for adults with mental health difficulties. They commented, “such an approach might still not be worthwhile”, as the visualisations were individualised and highly personal. This indicates that the output may fail to meet the needs of its end-users. Further, these creative PPI groups were based in certain geographical regions such as Stoke-on-Trent [ 19 ] Sheffield [ 23 ], South Wales [ 12 ] or Ireland [ 20 ], which limits the extent the findings can be applied to wider populations, even within the same area due to individual nuances. Further, the study by Galler et al. [ 16 ], is specific to the Norwegian context and even then, maybe only a sub-group of the Norwegian population as the sample used was of higher socioeconomic status.

However, Grindell et al. [ 17 ], who used persona scenarios, creative worksheets and prototype development, pointed out that the purpose of this type of research is to improve a certain place, rather than apply findings across other populations and locations. Individualised output may, therefore, only be a limitation to research wanting to conduct PPI on a large scale.

If, however, greater generalisation within PPI is deemed necessary, then social media may offer a resolution. Fedorowicz et al. [ 15 ], used Facebook to gain feedback from the public on the use of video-recording methodology for an upcoming project. This had the benefit of including a more diverse range of people (289 people joined the closed group), who were spread geographically around the UK, as well as seven people from overseas.

Creative PPI has ethical issues

As with other research, ethical issues must be taken into consideration. Due to the nature of creative approaches, as well as the personal effort put into them, people often want to be recognised for their work. However, this compromises principles so heavily instilled in research such as anonymity and confidentiality. With the aim of exploring issues related to health and well-being in a town in South Wales, Byrne et al. [ 12 ], asked year 4/5 and year 10 pupils to create poems, songs, drawings and photographs. Community members also created a performance, mainly of monologues, to explore how poverty and inequalities are dealt with. Byrne noted the risks of these arts-based approaches, that being the possibility of over-disclosure and consequent emotional distress, as well as people’s desire to be named for their work. On one hand, the anonymity reduces the sense of ownership of the output as it does not portray a particular individual’s lived experience anymore. On the other hand, however, it could promote a more honest account of lived experience. Supporting this, Webber et al. [ 23 ], who used the persona method to co-design a back pain educational resource prototype, claimed that the anonymity provided by this creative technique allowed individuals to externalise and anonymise their own personal experience, thus creating a more authentic and genuine resource for future users. This implies that anonymity can be both a limitation and strength here.

The use of creative PPI methods is impeded by external factors

Despite the above limitations influencing the implementation of creative PPI techniques, perhaps the most influential is that creative methodologies are simply not mainstream [ 19 ]. This could be linked to the issues above, like time and resource intensity, generalisation and ethical issues but it is also likely to involve more systemic factors within the research community. Micsinszki et al. [ 21 ], who co-designed a hub for the health and well-being of vulnerable populations, commented that there is insufficient infrastructure to conduct meaningful co-design as well as a dominant medical model. Through a more holistic lens, there are “sociopolitical environments that privilege individualism over collectivism, self-sufficiency over collaboration, and scientific expertise over other ways of knowing based on lived experience” [ 21 ]. This, it could be suggested, renders creative co-design methodologies, which are based on the foundations of collectivism, collaboration and imagination an invalid technique in the research field, which is heavily dominated by more scientific methods offering reproducibility, objectivity and reliability.

Although we acknowledge that creative PPI techniques are not always appropriate, it may be that their main limitation is the lack of awareness of these methods or lack of willingness to use them. Further, there is always the risk that PPI, despite being a mandatory part of research, is used in a tokenistic or tick-box fashion [ 20 ], without considering the contribution that meaningful PPI could make to enhancing the research. It may be that PPI, let alone creative PPI, is not at the forefront of researchers’ minds when planning research.

Strengths of creative PPI

Creative ppi disrupts power hierarchies.

One of the main strengths of creative PPI techniques, cited most frequently in the included literature, was that they disrupt traditional power hierarchies [ 12 , 13 , 17 , 19 , 23 ]. For example, the use of theatre performance blurred the lines between professional and lay roles between the community and policy makers [ 12 ]. Individuals created a monologue to portray how poverty and inequality impact daily life and presented this to representatives of the National Assembly of Wales, Welsh Government, the Local Authority, Arts Council and Westminster. Byrne et al. [ 12 ], states how this medium allowed the community to engage with the people who make decisions about their lives in an environment of respect and understanding, where the hierarchies are not as visible as in other settings, e.g., political surgeries. Creative PPI methods have also removed traditional power hierarchies between researchers and adolescents. Cook et al. [ 13 ], used arts-based approaches to explore adolescents’ ideas about the “perfect” condom. They utilised the “Life Happens” resource, where adolescents drew and then decorated a person with their thoughts about sexual relationships, not too dissimilar from the persona-scenario method. This was then combined with hypothetical scenarios about sexuality. A condom-mapping exercise was then implemented, where groups shared the characteristics that make a condom “perfect” on large pieces of paper. Cook et al. [ 13 ], noted that usually power imbalances make it difficult to elicit information from adolescents, however these power imbalances were reduced due to the use of creative co-design techniques.

The same reduction in power hierarchies was noted by Grindell et al. [ 17 ], who used the person-scenario method and creative worksheets with individuals with malignant pleural effusion. This was with the aim of developing a prototype of a decision support tool for patients to help with treatment options. Although this process involved a variety of stakeholders, such as patients, carers and healthcare professionals, creative co-design was cited as a mechanism that worked to reduce power imbalances – a limitation of more traditional methods of research. Creative co-design blurred boundaries between end-users and clinical staff and enabled the sharing of ideas from multiple, valuable perspectives, meaning the prototype was able to suit user needs whilst addressing clinical problems.

Similarly, a specific creative method named cultural animation was also cited to dissolve hierarchies and encourage equal contributions from participants. Within this arts-based approach, Keleman et al. [ 19 ], explored the concept of “good health” with individuals from Stoke-on Trent. Members of the group created art installations using ribbons, buttons, cardboard and straws to depict their idea of a “healthy community”, which was accompanied by a poem. They also created a 3D Facebook page and produced another poem or song addressing the government to communicate their version of a “picture of health”. Public participants said that they found the process empowering, honest, democratic, valuable and practical.

This dissolving of hierarchies and levelling of power is beneficial as it increases the sense of ownership experienced by the creators/producers of the output [ 12 , 17 , 23 ]. This is advantageous as it has been suggested to improve its quality [ 23 ].

Creative PPI allows the unsayable to be said

Creative PPI fosters a safe space for mundane or taboo topics to be shared, which may be difficult to communicate using traditional methods of PPI. For example, the hypothetical nature of condom mapping and persona-scenarios meant that adolescents could discuss a personal topic without fear of discrimination, judgement or personal disclosure [ 13 ]. The safe space allowed a greater volume of ideas to be generated amongst peers where they might not have otherwise. Similarly, Webber et al. [ 23 ], , who used the persona method to co-design the prototype back pain educational resource, also noted how this method creates anonymity whilst allowing people the opportunity to externalise personal experiences, thoughts and feelings. Other creative methods were also used, such as drawing, collaging, role play and creating mood boards. A cardboard cube (labelled a “magic box”) was used to symbolise a physical representation of their final prototype. These creative methods levelled the playing field and made personal experiences accessible in a safe, open environment that fostered trust, as well as understanding from the researchers.

It is not only sensitive subjects that were made easier to articulate through creative PPI. The communication of mundane everyday experiences were also facilitated, which were deemed typically ‘unsayable’. This was specifically given in the context of describing intangible aspects of everyday health and wellbeing [ 11 ]. Graphic designers can also be used to visually represent the outputs of creative PPI. These captured the movement and fluidity of people and well as the relationships between them - things that cannot be spoken but can be depicted [ 21 ].

Creative PPI methods are inclusive

Another strength of creative PPI was that it is inclusive and accessible [ 17 , 19 , 21 ]. The safe space it fosters, as well as the dismantling of hierarchies, welcomed people from a diverse range of backgrounds and provided equal opportunities [ 21 ], especially for those with communication and memory difficulties who might be otherwise excluded from PPI. Kelemen et al. [ 19 ], who used creative methods to explore health and well-being in Stoke-on-Trent, discussed how people from different backgrounds came together and connected, discussed and reached a consensus over a topic which evoked strong emotions, that they all have in common. Individuals said that the techniques used “sets people to open up as they are not overwhelmed by words”. Similarly, creative activities, such as the persona method, have been stated to allow people to express themselves in an inclusive environment using a common language. Kearns et al. [ 18 ], who used aphasia-accessible material to develop a questionnaire with aphasic individuals, described how they felt comfortable in contributing to workshops (although this material was time-consuming to make, see ‘Limitations of creative PPI’ ).

Despite the general inclusivity of creative PPI, it can also be exclusive, particularly if online mediums are used. Fedorowicz et al. [ 15 ], used Facebook to create a PPI group, and although this may rectify previous drawbacks about lack of generalisation of creative methods (as Facebook can reach a greater number of people, globally), it excluded those who are not digitally active or have limited internet access or knowledge of technology. Online methods have other issues too. Maintaining the online group was cited as challenging and the volume of responses required researchers to interact outside of their working hours. Despite this, online methods like Facebook are very accessible for people who are physically disabled.

Creative PPI methods are engaging

The process of creative PPI is typically more engaging and produces more colourful data than traditional methods [ 13 ]. Individuals are permitted and encouraged to explore a creative self [ 19 ], which can lead to the exploration of new ideas and an overall increased enjoyment of the process. This increased engagement is particularly beneficial for younger PPI groups. For example, to involve children in the development of health food products, Galler et al. [ 16 ] asked 9-12-year-olds to take photos of their food and present it to other children in a “show and tell” fashion. They then created a newspaper article describing a new healthy snack. In this creative focus group, children were given lab coats to further their identity as inventors. Galler et al. [ 16 ], notes that the methods were highly engaging and facilitated teamwork and group learning. This collaborative nature of problem-solving was also observed in adults who used personas and creative worksheets to develop the resource for lower back pain [ 23 ]. Dementia patients too have been reported to enjoy the creative and informal approach to idea generation [ 20 ].

The use of cultural animation allowed people to connect with each other in a way that traditional methods do not [ 19 , 21 ]. These connections were held in place by boundary objects, such as ribbons, buttons, fabric and picture frames, which symbolised a shared meaning between people and an exchange of knowledge and emotion. Asking groups to create an art installation using these objects further fostered teamwork and collaboration, both at an individual and collective level. The exploration of a creative self increased energy levels and encouraged productive discussions and problem-solving [ 19 ]. Objects also encouraged a solution-focused approach and permitted people to think beyond their usual everyday scope [ 17 ]. They also allowed facilitators to probe deeper about the greater meanings carried by the object, which acted as a metaphor [ 21 ].

From the researcher’s point of view, co-creative methods gave rise to ideas they might not have initially considered. Valaitis et al. [ 22 ], found that over 40% of the creative outputs were novel ideas brought to light by patients, healthcare providers/community care providers, community service providers and volunteers. One researcher commented, “It [the creative methods] took me on a journey, in a way that when we do other pieces of research it can feel disconnected” [ 23 ]. Another researcher also stated they could not return to the way they used to do research, as they have learnt so much about their own health and community and how they are perceived [ 19 ]. This demonstrates that creative processes not only benefit the project outcomes and the PPI group, but also facilitators and researchers. However, although engaging, creative methods have been criticised for not demonstrating academic rigour [ 17 ]. Moreover, creative PPI may also be exclusive to people who do not like or enjoy creative activities.

Creative PPI methods are cost and time efficient

Creative PPI workshops can often produce output that is visible and tangible. This can save time and money in the long run as the output is either ready to be implemented in a healthcare setting or a first iteration has already been developed. This may also offset the time and costs it takes to implement creative PPI. For example, the prototype of the decision support tool for people with malignant pleural effusion was developed using personas and creative worksheets. The end result was two tangible prototypes to drive the initial idea forward as something to be used in practice [ 17 ]. The use of creative co-design in this case saved clinician time as well as the time it would take to develop this product without the help of its end-users. In the development of this particular prototype, analysis was iterative and informed the next stage of development, which again saved time. The same applies for the feedback questionnaire for the assessment of ICT delivered aphasia rehabilitation. The co-created questionnaire, designed with people with aphasia, was ready to be used in practice [ 18 ]. This suggests that to overcome time and resource barriers to creative PPI, researchers should aim for it to be engaging whilst also producing output.

That useable products are generated during creative workshops signals to participating patients and public members that they have been listened to and their thoughts and opinions acted upon [ 23 ]. For example, the development of the back pain resource based on patient experiences implies that their suggestions were valid and valuable. Further, those who participated in the cultural animation workshop reported that the process visualises change, and that it already feels as though the process of change has started [ 19 ].

The most cost and time efficient method of creative PPI in this review is most likely the use of Facebook to gather feedback on project methodology [ 15 ]. Although there were drawbacks to this, researchers could involve more people from a range of geographical areas at little to no cost. Feedback was instantaneous and no training was required. From the perspective of the PPI group, they could interact however much or little they wish with no time commitment.

This systematic review identified four limitations and five strengths to the use of creative PPI in health and social care research. Creative PPI is time and resource intensive, can raise ethical issues and lacks generalisability. It is also not accepted by the mainstream. These factors may act as barriers to the implementation of creative PPI. However, creative PPI disrupts traditional power hierarchies and creates a safe space for taboo or mundane topics. It is also engaging, inclusive and can be time and cost efficient in the long term.

Something that became apparent during data analysis was that these are not blanket strengths and limitations of creative PPI as a whole. The umbrella term ‘creative PPI’ is broad and encapsulates a wide range of activities, ranging from music and poems to prototype development and persona-scenarios, to more simplistic things like the use of sticky notes and ordering cards. Many different activities can be deemed ‘creative’ and the strengths and limitations of one does not necessarily apply to another. For example, cultural animation takes greater effort to prepare than the use of sticky notes and sorting cards, and the use of Facebook is cheaper and wider reaching than persona development. Researchers should use their discretion and weigh up the benefits and drawbacks of each method to decide on a technique which suits the project. What might be a limitation to creative PPI in one project may not be in another. In some cases, creative PPI may not be suitable at all.

Furthermore, the choice of creative PPI method also depends on the needs and characteristics of the PPI group. Children, adults and people living with dementia or language difficulties all have different engagement needs and capabilities. This indicates that creative PPI is not one size fits all and that the most appropriate method will change depending on the composition of the group. The choice of method will also be determined by the constraints of the research project, namely time, money and the research aim. For example, if there are time constraints, then a method which yields a lot of data and requires a lot of preparation may not be appropriate. If generalisation is important, then an online method is more suitable. Together this indicates that the choice of creative PPI method is highly individualised and dependent on multiple factors.

Although the limitations discussed in this review apply to creative PPI, they are not exclusive to creative PPI. Ethical issues are a consideration within general PPI research, especially when working with more vulnerable populations, such as children or adults living with a disability. It can also be the case that traditional PPI methods lack generalisability, as people who volunteer to be part of such a group are more likely be older, middle class and retired [ 24 ]. Most research is vulnerable to this type of bias, however, it is worth noting that generalisation is not always a goal and research remains valid and meaningful in its absence. Although online methods may somewhat combat issues related to generalisability, these methods still exclude people who do not have access to the internet/technology or who choose not to use it, implying that online PPI methods may not be wholly representative of the general population. Saying this, however, the accessibility of creative PPI techniques differs from person to person, and for some, online mediums may be more accessible (for example for those with a physical disability), and for others, this might be face-to-face. To combat this, a range of methods should be implemented. Planning multiple focus group and interviews for traditional PPI is also time and resource intensive, however the extra resources required to make this creative may be even greater. Although, the rich data provided may be worth the preparation and analysis time, which is also likely to depend on the number of participants and workshop sessions required. PPI, not just creative PPI, often requires the provision of a financial incentive, refreshments, parking and accommodation, which increase costs. These, however, are imperative and non-negotiable, as they increase the accessibility of research, especially to minority and lower-income groups less likely to participate. Adequate funding is also important for co-design studies where repeated engagement is required. One barrier to implementation, which appears to be exclusive to creative methods, however, is that creative methods are not mainstream. This cannot be said for traditional PPI as this is often a mandatory part of research applications.

Regarding the strengths of creative PPI, it could be argued that most appear to be exclusive to creative methodologies. These are inclusive by nature as multiple approaches can be taken to evoke ideas from different populations - approaches that do not necessarily rely on verbal or written communication like interviews and focus groups do. Given the anonymity provided by some creative methods, such as personas, people may be more likely to discuss their personal experiences under the guise of a general end-user, which might be more difficult to maintain when an interviewer is asking an individual questions directly. Additionally, creative methods are by nature more engaging and interactive than traditional methods, although this is a blanket statement and there may be people who find the question-and-answer/group discussion format more engaging. Creative methods have also been cited to eliminate power imbalances which exist in traditional research [ 12 , 13 , 17 , 19 , 23 ]. These imbalances exist between researchers and policy makers and adolescents, adults and the community. Lastly, although this may occur to a greater extent in creative methods like prototype development, it could be suggested that PPI in general – regardless of whether it is creative - is more time and cost efficient in the long-term than not using any PPI to guide or refine the research process. It must be noted that these are observations based on the literature. To be certain these differences exist between creative and traditional methods of PPI, direct empirical evaluation of both should be conducted.

To the best of our knowledge, this is the first review to identify the strengths and limitations to creative PPI, however, similar literature has identified barriers and facilitators to PPI in general. In the context of clinical trials, recruitment difficulties were cited as a barrier, as well as finding public contributors who were free during work/school hours. Trial managers reported finding group dynamics difficult to manage and the academic environment also made some public contributors feel nervous and lacking confidence to speak. Facilitators, however, included the shared ownership of the research – something that has been identified in the current review too. In addition, planning and the provision of knowledge, information and communication were also identified as facilitators [ 25 ]. Other research on the barriers to meaningful PPI in trial oversight committees included trialist confusion or scepticism over the PPI role and the difficulties in finding PPI members who had a basic understanding of research [ 26 ]. However, it could be argued that this is not representative of the average patient or public member. The formality of oversight meetings and the technical language used also acted as a barrier, which may imply that the informal nature of creative methods and its lack of dependency on literacy skills could overcome this. Further, a review of 42 reviews on PPI in health and social care identified financial compensation, resources, training and general support as necessary to conduct PPI, much like in the current review where the resource intensiveness of creative PPI was identified as a limitation. However, others were identified too, such as recruitment and representativeness of public contributors [ 27 ]. Like in the current review, power imbalances were also noted, however this was included as both a barrier and facilitator. Collaboration seemed to diminish hierarchies but not always, as sometimes these imbalances remained between public contributors and healthcare staff, described as a ‘them and us’ culture [ 27 ]. Although these studies compliment the findings of the current review, a direct comparison cannot be made as they do not concern creative methods. However, it does suggest that some strengths and weaknesses are shared between creative and traditional methods of PPI.

Strengths and limitations of this review

Although a general definition of creative PPI exists, it was up to our discretion to decide exactly which activities were deemed as such for this review. For example, we included sorting cards, the use of interactive whiteboards and sticky notes. Other researchers may have a more or less stringent criteria. However, two reviewers were involved in this decision which aids the reliability of the included articles. Further, it may be that some of the strengths and limitations cannot fully be attributed to the creative nature of the PPI process, but rather their co-created nature, however this is hard to disentangle as the included papers involved both these aspects.

During screening, it was difficult to decide whether the article was utilising creative qualitative methodology or creative PPI , as it was often not explicitly labelled as such. Regardless, both approaches involved the public/patients refining a healthcare product/service. This implies that if this review were to be replicated, others may do it differently. This may call for greater standardisation in the reporting of the public’s involvement in research. For example, the NIHR outlines different approaches to PPI, namely “consultation”, “collaboration”, “co-production” and “user-controlled”, which each signify an increased level of public power and influence [ 28 ]. Papers with elements of PPI could use these labels to clarify the extent of public involvement, or even explicitly state that there was no PPI. Further, given our decision to include only scholarly peer-reviewed literature, it is possible that data were missed within the grey literature. Similarly, the literature search will not have identified all papers relating to different types of accessible inclusion. However, the intent of the review was to focus solely on those within the definition of creative.

This review fills a gap in the literature and helps circulate and promote the concept of creative PPI. Each stage of this review, namely screening and quality appraisal, was conducted by two independent reviewers. However, four full texts could not be accessed during the full text reading stage, meaning there are missing data that could have altered or contributed to the findings of this review.

Research recommendations

Given that creative PPI can require effort to prepare, perform and analyse, sufficient time and funding should be allocated in the research protocol to enable meaningful and continuous PPI. This is worthwhile as PPI can significantly change the research output so that it aligns closely with the needs of the group it is to benefit. Researchers should also consider prototype development as a creative PPI activity as this might reduce future time/resource constraints. Shifting from a top-down approach within research to a bottom-up can be advantageous to all stakeholders and can help move creative PPI towards the mainstream. This, however, is the collective responsibility of funding bodies, universities and researchers, as well as committees who approve research bids.

A few of the included studies used creative techniques alongside traditional methods, such as interviews, which could also be used as a hybrid method of PPI, perhaps by researchers who are unfamiliar with creative techniques or to those who wish to reap the benefits of both. Often the characteristics of the PPI group were not included, including age, gender and ethnicity. It would be useful to include such information to assess how representative the PPI group is of the population of interest.

Creative PPI is a relatively novel approach of engaging the public and patients in research and it has both advantages and disadvantages compared to more traditional methods. There are many approaches to implementing creative PPI and the choice of technique will be unique to each piece of research and is reliant on several factors. These include the age and ability of the PPI group as well as the resource limitations of the project. Each method has benefits and drawbacks, which should be considered at the protocol-writing stage. However, given adequate funding, time and planning, creative PPI is a worthwhile and engaging method of generating ideas with end-users of research – ideas which may not be otherwise generated using traditional methods.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Critical Appraisal Skills Programme

The Joanna Briggs Institute

National Institute of Health and Care Research

Public Advisory Group

Public and Patient Involvement

Web of Science

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Acknowledgements

With thanks to the PHIRST-LIGHT public advisory group and consortium for their thoughts and contributions to the design of this work.

The research team is supported by a National Institute for Health and Care Research grant (PHIRST-LIGHT Reference NIHR 135190).

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Olivia R. Phillips and Cerian Harries share joint first authorship.

Authors and Affiliations

Nottingham Centre for Public Health and Epidemiology, Lifespan and Population Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK

Olivia R. Phillips, Jo Leonardi-Bee, Holly Knight & Joanne R. Morling

National Institute for Health and Care Research (NIHR) PHIRST-LIGHT, Nottingham, UK

Olivia R. Phillips, Cerian Harries, Jo Leonardi-Bee, Holly Knight, Lauren B. Sherar, Veronica Varela-Mato & Joanne R. Morling

School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK

Cerian Harries, Lauren B. Sherar & Veronica Varela-Mato

Nottingham Centre for Evidence Based Healthcare, School of Medicine, University of Nottingham, Nottingham, UK

Jo Leonardi-Bee

NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, NG7 2UH, UK

Joanne R. Morling

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Author contributions: study design: ORP, CH, JRM, JLB, HK, LBS, VVM, literature searching and screening: ORP, CH, JRM, data curation: ORP, CH, analysis: ORP, CH, JRM, manuscript draft: ORP, CH, JRM, Plain English Summary: ORP, manuscript critical review and editing: ORP, CH, JRM, JLB, HK, LBS, VVM.

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Additional file 3: Table 1: Description of data: elements of the data extraction table that are not in the main manuscript

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Phillips, O.R., Harries, C., Leonardi-Bee, J. et al. What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review. Res Involv Engagem 10 , 48 (2024). https://doi.org/10.1186/s40900-024-00580-4

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Qualitative research in health care

Assessing quality in qualitative research, nicholas mays.

a Social Policy Branch, The Treasury, PO Box 3724, Wellington, New Zealand, b Department of Social Medicine, University of Bristol, Bristol BS8 2PR

Catherine Pope

The views expressed in this paper are those of the authors and do not necessarily reflect the views of the New Zealand Treasury, in the case of NM. The Treasury takes no responsibility for any errors or omissions in, or for the correctness of the information contained in this article.

In the past decade, qualitative methods have become more commonplace in areas such as health services research and health technology assessment, and there has been a corresponding rise in the reporting of qualitative research studies in medical and related journals. 1 Interest in these methods and their wider exposure in health research has led to necessary scrutiny of qualitative research. Researchers from other traditions are increasingly concerned to understand qualitative methods and, most importantly, to examine the claims researchers make about the findings obtained from these methods.

The status of all forms of research depends on the quality of the methods used. In qualitative research, concern about assessing quality has manifested itself recently in the proliferation of guidelines for doing and judging qualitative work. 2 – 5 Users and funders of research have had an important role in developing these guidelines as they become increasingly familiar with qualitative methods, but require some means of assessing their quality and of distinguishing “good” and “poor” quality research. However, the issue of “quality” in qualitative research is part of a much larger and contested debate about the nature of the knowledge produced by qualitative research, whether its quality can legitimately be judged, and, if so, how. This paper cannot do full justice to this wider epistemological debate. Rather it outlines two views of how qualitative methods might be judged and argues that qualitative research can be assessed according to two broad criteria: validity and relevance.

Summary points

• Qualitative methods are now widely used and increasingly accepted in health research, but quality in qualitative research is a mystery to many health services researchers
• There is considerable debate over the nature of the knowledge produced by such methods and how such research should be judged
• Antirealists argue that qualitative and quantitative research are very different and that it is not possible to judge qualitative research by using conventional criteria such as reliability, validity, and generalisability
• Quality in qualitative research can be assessed with the same broad concepts of validity and relevance used for quantitative research, but these need to be operationalised differently to take into account the distinctive goals of qualitative research

Two opposing views

There has been considerable debate over whether qualitative and quantitative methods can and should be assessed according to the same quality criteria. Extreme relativists hold that all research perspectives are unique and each is equally valid in its own terms, but this position means that research cannot derive any unequivocal insights relevant to action, and it would therefore command little support among applied health researchers. 6 Other than this total rejection of any quality criteria, it is possible to identify two broad, competing positions, for and against using the same criteria. 7 Within each position there is a range of views.

Separate and different: the antirealist position

Advocates of the antirealist position argue that qualitative research represents a distinctive paradigm and as such it cannot and should not be judged by conventional measures of validity, generalisability, and reliability. At its core, this position rejects naive realism—a belief that there is a single, unequivocal social reality or truth which is entirely independent of the researcher and of the research process; instead there are multiple perspectives of the world that are created and constructed in the research process. 8

Relativist criteria for quality 7

• Degree to which substantive and formal theory is produced and the degree of development of such theory
• Novelty of the claims made from the theory
• Consistency of the theoretical claims with the empirical data collected
• Credibility of the account to those studied and to readers
• Extent to which the description of the culture of the setting provides a basis for competent performance in the culture studied
• Extent to which the findings are transferable to other settings
• Reflexivity of the account—that is, the degree to which the effects of the research strategies on the findings are assessed or the amount of information about the research process that is provided to readers

Those relativists who maintain that assessment criteria are feasible but that distinctive ones are required to evaluate qualitative research have put forward a range of different assessment schemes. In part, this is because the choice and relative importance of different criteria of quality depend on the topic and the purpose of the research. Hammersley has attempted to pull together these quality criteria (box). 7 These criteria are open to challenge (for example, it is arguable whether all research should be concerned to develop theory). At the same time, many of the criteria listed are not exclusive to qualitative research.

Using criteria from quantitative research: subtle realism

Other authors agree that all research involves subjective perception and that different methods produce different perspectives, but, unlike the anti-realists, they argue that there is an underlying reality which can be studied. 9 , 10 The philosophy of qualitative and quantitative researchers should be one of “subtle realism”—an attempt to represent that reality rather than to attain “the truth.” From this position it is possible to assess the different perspectives offered by different research processes against each other and against criteria of quality common to both qualitative and quantitative research, particularly those of validity and relevance. However, the meansof assessment may be modified to take account of the distinctive goals of qualitative research. This is our position.

Assessing the validity of qualitative research

There are no mechanical or “easy” solutions to limit the likelihood that there will be errors in qualitative research. However, there are various ways of improving validity, each of which requires the exercise of judgment on the part of researcher and reader.

Triangulation

Triangulation compares the results from either two or more different methods of data collection (for example, interviews and observation) or, more simply, two or more data sources (for example, interviews with members of different interest groups). The researcher looks for patterns of convergence to develop or corroborate an overall interpretation. This is controversial as a genuine test of validity because it assumes that any weaknesses in one method will be compensated by strengths in another, and that it is always possible to adjudicate between different accounts (say, from interviews with clinicians and patients). Triangulation may therefore be better seen as a way of ensuring comprehensiveness and encouraging a more reflexive analysis of the data (see below) than as a pure test of validity.

Respondent validation

Respondent validation, or “member checking,” includes techniques in which the investigator's account is compared with those of the research subjects to establish the level of correspondence between the two sets. Study participants' reactions to the analyses are then incorporated into the study findings. Although some researchers view this as the strongest available check on the credibility of a research project, 8 it has its limitations. For example, the account produced by the researcher is designed for a wide audience and will, inevitably, be different from the account of an individual informant simply because of their different roles in the research process. As a result, it is better to think of respondent validation as part of a process of error reduction which also generates further original data, which in turn requires interpretation. 11

Clear exposition of methods of data collection and analysis

Since the methods used in research unavoidably influence the objects of inquiry (and qualitative researchers are particularly aware of this), a clear account of the process of data collection and analysis is important. By the end of the study, it should be possible to provide a clear account of how early, simpler systems of classification evolved into more sophisticated coding structures and thence into clearly defined concepts and explanations for the data collected. Although it adds to the length of research reports, the written account should include sufficient data to allow the reader to judge whether the interpretation proffered is adequately supported by the data.

Reflexivity

Reflexivity means sensitivity to the ways in which the researcher and the research process have shaped the collected data, including the role of prior assumptions and experience, which can influence even the most avowedly inductive inquiries. Personal and intellectual biases need to be made plain at the outset of any research reports to enhance the credibility of the findings. The effects of personal characteristics such as age, sex, social class, and professional status (doctor, nurse, physiotherapist, sociologist, etc) on the data collected and on the “distance” between the researcher and those researched also needs to be discussed.

Attention to negative cases

As well as exploration of alternative explanations for the data collected, a long established tactic for improving the quality of explanations in qualitative research is to search for, and discuss, elements in the data that contradict, or seem to contradict, the emerging explanation of the phenomena under study. Such “deviant case analysis” helps refine the analysis until it can explain all or the vast majority of the cases under scrutiny.

Fair dealing

The final technique is to ensure that the research design explicitly incorporates a wide range of different perspectives so that the viewpoint of one group is never presented as if it represents the sole truth about any situation.

Research can be relevant when it either adds to knowledge or increases the confidence with which existing knowledge is regarded. Another important dimension of relevance is the extent to which findings can be generalised beyond the setting in which they were generated. One way of achieving this is to ensure that the research report is sufficiently detailed for the reader to be able to judge whether or not the findings apply in similar settings. Another tactic is to use probability sampling (to ensure that the range of settings chosen is representative of a wider population, for example by using a stratified sample). Probability sampling is often ignored by qualitative researchers, but it can have its place. Alternatively, and more commonly, theoretical sampling ensures that an initial sample is drawn to include as many as possible of the factors that might affect variability of behaviour, and then this is extended, as required, in the light of early findings and emergent theory. 2 The full sample, therefore, attempts to include the full range of settings relevant to the conceptualisation of the subject.

Some questions about quality that might be asked of a qualitative study

• Worth or relevance—Was this piece of work worth doing at all? Has it contributed usefully to knowledge?
• Clarity of research question — If not at the outset of the study, by the end of the research process was the research question clear? Was the researcher able to set aside his or her research preconceptions?
• Appropriateness of the design to the question—Would a different method have been more appropriate? For example, if a causal hypothesis was being tested, was a qualitative approach really appropriate?
• Context—Is the context or setting adequately described so that the reader could relate the findings to other settings?
• Sampling—Did the sample include the full range of possible cases or settings so that conceptual rather than statistical generalisations could be made (that is, more than convenience sampling)? If appropriate, were efforts made to obtain data that might contradict or modify the analysis by extending the sample (for example, to a different type of area)?
• Data collection and analysis—Were the data collection and analysis procedures systematic? Was an “audit trail” provided such that someone else could repeat each stage, including the analysis? How well did the analysis succeed in incorporating all the observations? To what extent did the analysis develop concepts and categories capable of explaining key processes or respondents' accounts or observations? Was it possible to follow the iteration between data and the explanations for the data (theory)? Did the researcher search for disconfirming cases?
• Reflexivity of the account—Did the researcher self consciously assess the likely impact of the methods used on the data obtained? Were sufficient data included in the reports of the study to provide sufficient evidence for readers to assess whether analytical criteria had been met?

Is there any place for quality guidelines?

Whether quality criteria should be applied to qualitative research, which criteria are appropriate, and how they should be assessed is hotly debated. It would be unwise to consider any single set of guidelines as definitive. We list some questions to ask of any piece of qualitative research (box); the questions emphasise criteria of relevance and validity. They could also be used by researchers at different times during the life of a particular research project to improve its quality.

Although the issue of quality in qualitative health and health services research has received considerable attention, a recent paper was able to argue, legitimately, that “quality in qualitative research is a mystery to many health services researchers.” 12 However, qualitative researchers can address the issue of quality in their research. As in quantitative research, the basic strategy to ensure rigour, and thus quality, in qualitative research is systematic, self conscious research design, data collection, interpretation, and communication. Qualitative research has much to offer. Its methods can, and do, enrich our knowledge of health and health care. It is not, however, an easy option or the route to a quick answer. As Dingwall et al conclude, “qualitative research requires real skill, a combination of thought and practice and not a little patience.” 12

Further reading

Murphy E, Dingwall R, Greatbatch D, Parker S, Watson P. Qualitative research methods in health technology assessment: a review of the literature . Health Technology Assessment 1998;2.

Dingwall R, Murphy E, Watson P, Greatbatch D, Parker S. Catching goldfish: quality in qualitative research. Journal of Health Services Research and Policy 1998;3:167-72.

Acknowledgments

We acknowledge the contribution of the HTA report on qualitative research methods by Elizabeth Murphy, Robert Dingwall, David Greatbatch, Susan Parker, and Pamela Watson to this paper. We thank these authors for their careful exposition of a tangled series of debates, and their timely publication of this literature review.

This is the first in a series of three articles

Series editors: Catherine Pope and Nicholas Mays

Competing interests: None declared.

This article is taken from the second edition of Qualitative Research in Health Care , edited by Catherine Pope and Nicholas Mays, published by BMJ Books

• Open access
• Published: 16 May 2024

Factors associated with clinical nurse’s mental health: a qualitative study applying the social ecological model

• Qiang Yu 1   na1 ,
• Chongmei Huang 2 , 3   na1 ,
• Yusheng Tian 1 ,
• Jiaxin Yang 1 ,
• Xuting Li 1 ,
• Meng Ning 4 ,
• Zengyu Chen 4 ,
• Jiaqing He 1 &
• Yamin Li 1  

BMC Nursing volume  23 , Article number:  330 ( 2024 ) Cite this article

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Metrics details

The prevalence of burnout, depression, and anxiety among Chinese nurses was 34%, 55.5%, and 41.8% respectively. Mental health problems have significant impacts on their personal well-being, work performance, patient care quality, and the overall healthcare system. Mental health is influenced by factors at multiple levels and their interactions.

This was a descriptive qualitative study using phenomenological approach. We recruited a total of 48 nurses from a tertiary hospital in Changsha, Hunan Province, China. Data were collected through focus group interviews. Audio-recorded data were transcribed and inductively analysed.

Four major themes with 13 subthemes were identified according to the social ecological model: (1) individual-level factors, including personality traits, sleep quality, workplace adaptability, and years of work experience; (2) interpersonal-level factors, encompassing interpersonal support and role conflict; (3) organization-level factors, such as organizational climate, organizational support, career plateau, and job control; and (4) social-level factors, which included compensation packages, social status, and legislative provision and policy.

Conclusions

Our study provides a nuanced understanding of the multifaceted factors influencing nurses’ mental health. Recognizing the interconnectedness of individual, interpersonal, organizational, and social elements is essential for developing targeted interventions and comprehensive strategies to promote and safeguard the mental well-being of nurses in clinical settings.

Trial and protocol registration

The larger study was registered with Chinese Clinical Trial Registry: ChiCTR2300072142 (05/06/2023) https://www.chictr.org.cn/showproj.html?proj=192676 .

Reporting method

This study is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Peer Review reports

The prevalence of mental health problem among clinical nurses is high. As the largest group of health systems, clinical nurses play a crucial role in promoting health and preventing disease [ 1 ]. Although they are trained to provide care for their patients, they rarely cared about themselves [ 1 ]. Clinical nurses are suffering from mental health problems, including stress, anxiety, depression, and burnout. A meta-analysis involving 45,539 nurses from 49 countries revealed that a global prevalence of burnout symptoms was 11.23% across various specialties [ 2 ]. In Australia, the prevalence of depression, anxiety and stress among nurses was 32.4%, 41.2% and 41.2%, respectively [ 1 ]. In Italy, the prevalence of generalized anxiety disorder among nurses is 50% [ 3 ].In Spain, 68% of nurses had depression, anxiety, insomnia and distress to some degree, and 38% of them had moderate or severe symptoms [ 4 ]. A survey of clinical nurses from 30 Chinese provinces indicated that the rates of burnout, depression, and anxiety was 34%, 55.5%, and 41.8%, respectively [ 5 ]. Mental health problems may compromise physical, mental, and social health and even increase suicide risk [ 6 ].

The mental health problems among clinical nurses affects their personal well-being, work performance, patient care quality, and the healthcare system. Remarkably, their mental health problems not only heighten the risk of physical conditions such as heart disease, chronic pain, gastrointestinal distress, and even mortality [ 7 ], but also correlate with absenteeism, intention to leave, and elevated turnover rates [ 8 , 9 ]. These increased turnover rates exacerbate the financial challenges faced by healthcare institutions [ 10 ]. The presence of one or more of these mental health problems can contribute to occupational mishaps, including medical errors [ 1 , 11 ], compromised work performance, and a pessimistic workplace demeanor [ 12 ]. Nurses with mental health problems are at 26–71% more likely to make medical errors [ 13 ]. Furthermore, their mental health may imperil the well-being of patients and the quality of health services [ 14 ]. Moreover, these challenges can contribute to reputation harm, diminished productivity, and decreased clinical efficacy of the hospital [ 15 ]. Therefore, it is necessary to identify factors associated with their mental health for developing and implementing targeted intervention.

Previous studies have identified several factors associated with clinical nurses’ mental health, with some limitations [ 16 ]. According to the social ecological model, mental health is affected by factors at multiple levels and interaction between factors. However, most studies explored factors at a single level or a single type of factors. For instance, studies focused on factors either at individual (psychological characteristics) [ 17 , 18 ], or interpersonal (e.g., social support) [ 19 , 20 , 21 ], organizational (e.g., workplace violence) [ 22 ], or societal level (e.g., social status) [ 23 , 24 ]. Therefore, these studies fail to offer a complete picture of factors at multiple levels and examine interactions between factors. Additionally, the majority of extant studies adopt quantitative design with standardized measurements, which may neglect the intricacies of personal experiences and the significance of context.

To fill aforementioned gap, our study is aimed to explore associated factors for mental health at all four socio-ecological levels and to understand the interactions between factors from the perspective of clinical nurses.

Study design

This study adopted a qualitative descriptive design with focus group interviews. Qualitative description design is widely used to gather insight from key informants about poorly understood healthcare questions [ 25 , 26 ]. The design was considered appropriate because this study aimed to obtain a detailed description of participants’ perceived influencing factors of mental health. Focus group interviews were used for data collection to encourage the free exchange of information and to yield richer data and deeper insights into the topic.

This study was conducted in a tertiary hospital in Changsha, Hunan Province, China. The hospital has 3000 nurses and 137 head nurses.

Participants

This study included clinical nurses and head nurses who were employed by the hospital for one year or over. They were recruited, using both convenience and purposive sampling between April to May 2023. The study was advertised through the existing network of the authors. Potential participants were approached by the authors via WeChat with an explanatory statement. The explanatory statement included a brief introduction of the study and invited potential participants to contact the first author directly to arrange the interview time and venue. Purposive sampling was used to obtain maximum variation, within participants’ characteristics including gender, years of work experience, clinical work area, and having an administrative position or not.

Data collection

We conducted seven focus groups (seven- eight participants in each group) in the meeting room of the hospital between April to May 2023. We introduced the purpose of the research and topics before conducting the group interview. The interview guide were developed based on the literature review, including following questions: (1) How about your mental health in daily work? (2) What are the factors influencing your mental health? (3) How does mental health affect your daily life? (4) When you felt down, what kind of coping strategies do you adopted? (5) What external factors (e.g., individual, interpersonal and environmental factors) are conducive to promoting your mental health? The interviews were conducted in Mandarin. The second author acted as a facilitator for focus groups, and she participated workshop in qualitative research as part of master course. The fourth author acted as a note taker who took field notes and observed the interaction within the groups. The duration of the focus group interviews ranged from 65 to 94 min (mean 81.5 min).

Data analysis

Preliminary data collection and data analysis were conducted simultaneously, which enabled collection to cease on reaching data saturation. All audio recordings were transcribed in Mandarin using Xunfei software, and the accuracy was verified by the first, third, and fifth authors. Then, all the data were input entered into excel for analysis. Three authors (the second, eighth, and ninth authors) independently coded the transcripts line by line and then deliberated to form a preliminary coding framework. Constant comparative analysis ensured consistent coding across transcripts. They developed a preliminary coding framework after coding the first three transcripts, refining it iteratively with subsequent transcripts. This was repeated with further transcripts, and the subthemes were refined and reduced in number by grouping codes together. Following the development of the final coding framework, the remaining transcripts remained open to new additions if needed.

Final themes were constructed using an inductive process. The social ecological model was used to group themes. This model was used to connect the findings with the literature and conceptual framework. The social ecological model [ 27 ] is used to describe multiple factors affecting mental health and explore healthcare behaviors [ 28 , 29 ], these factors grouped into four levels: intrapersonal, interpersonal, organizational and societal level. This model includes four levels: individual, interpersonal, organizational and societal. Individual level identifies biological, character traits and psychological factors. Interpersonal level examines communication and interaction with individuals in social networks. Organizational level contains resources obtained from organizations and through social interactions. Societal level focuses on factors that help create an atmosphere conducive to maintaining mental health.

The study’s rigor was established through meticulous attention to credibility, transferability, dependability, and confirmability [ 30 ]. Credibility was achieved by rigorously analyzing the data by the research team. Transferability was ensured by providing a comprehensive description of the study setting and detailed narratives of participant experiences. Additionally, dependability and confirmability were upheld through a meticulous audit of methodological decisions made by the research team throughout the study process.

Participant’s characteristics

Fifty nurses were invited to participate in this study, and two declined the invitation; the remaining 48 nurses completed the interview. More female nurse participated in the study ( n  = 37) rather than male ( n  = 5). The participants’ social demographic characteristics are presented in Table  1 .

Main findings

As shown shown in Fig. 1, factors associated with clinical nurses’ mental health were categorized four themes and 13 subthemes: (1) individual-level factors, (2) interpersonal-level factors, (3) organization-level factors, and (4) social-level factors.

Factors associated with clinical nurse’s mental health

Individual-level factors

Participants reported that their mental health could be impacted by personality traits (i.e., optimistic/negative life outlook), quality of sleep, workplace adaptability, and years of work experience. Some participants mentioned that adaptability was important for them to manage emotional and practical daily challenges in the face of rapidly changing and unpredictable circumstances.

When novice nurses take care of patients by themselves, they may experience increased stress, especially when patients’ condition changes suddenly during the night shift (F1P4).

Interpersonal-level factors

Participants perceived that interpersonal support and role conflict were associated with their mental health.

Interpersonal support

Our participants identified that interpersonal support was playing an important role in maintaining their mental health. They explained that talking to their families, friends, colleagues and supervisor were an effective way to relieve work stress.

I sought to the person I trust the most (my family) and talked all the unpleasant things with them when I felt very stressed (F3P3).

Role conflict

Participants mentioned that it was inevitable for them to experience role conflict (i.e., work-family conflict and work-school conflict) because of the demanding and challenging conditions of the job. They felt guilty when work pressures interfered with family responsibilities. Some participants identified that their emotional stress increased when their work interfered with their ability to meet the demands of their kids’ school. The demands of long study hours and early clinical hours caused stress among them and kept them from household responsibilities of cooking, cleaning, and spending time with children. Participants also felt that family support of their career choices helped their job performance.

. my father was diagnosed with lung cancer two years ago. He was resuscitated many times during his treatment. However, I was always busy working at the fever outpatient department and couldn’t spend much time with him. I still feel sad…(F7P4) .

Organization-level factors

Participants perceived that their mental health was influenced by the following four organizational-level factors, including (1) organization climate, (2) organization support, (3) career plateau, and (4) job control.

Organization climate

In this study, organization climate included emotional climate and workplace incivility. Participants perceived the importance of the emotional climate due to the transmissive nature of emotional states. It was easy to be infected by the negative emotions of colleagues, so that the entire department can generate or maintain a negative emotional climate, vice versa.

Some colleagues are always complaining, which affects others’ the mood (F3P4).

Most participates identified it was common for them to experience workplace incivility which came from their nurses, physicians, supervisors and patients. They felt disrespected, threatened reprimanded, and emotionally abused, which evoke negative emotions, such as anxiety, depression, exhaustion.

Organization support

Participants perceived that organization support (i.e., instrumental and emotional support) were related to job satisfaction and mental health. Participants identified various forms of instrumental support, including physical environment, sufficient human resource, task assistance, training opportunities and flexibility in work schedule. The support helped them to perform job roles, which also carried emotional meanings. Emotional support included listening to work concerns, allowing to vent emotions, and providing words of encouragement. The support provided socioemotional resources, involving affection, sympathy, understanding, acceptance, and recognition.

. we definitely don’t want our supervisor to scold us without getting the full picture (of the whole thing), and we really hope that supervisor investigate what really happened…(F7P2) .

Career plateau

Our participants, especially seniors frequently mentioned the challenge of double career plateau which includes hierarchical plateau and content plateau. They felt frustrated and even hopeless when they were experiencing a permanent end in career advancement. Some participants perceived little opportunity for vertical improvement because of the flattened pyramid shape within the hospital. Some participants expressed the concern about future professional recession because they have limited opportunities to master new skills.

Everyone think that our nurses don’t seem to have a future, especially the male nurses… only one or two nurses can really be head nurses (F2P1).

Job control

Many participates complained that they lack of control over work time and tasks. They had to extend their work time without compensation, leading to work-family conflicts. They felt exhausted and disgusted when they were asked to attend training and meetings immediately after night shifts. Additionally, some participants got annoyed by research tasks because they were not interested in it, and some participants felt incompetent at it because they did not receive relevant training.

we were asked to attend meetings and participate training and other activities after we finish our night shift. It’s really annoying (F7P5).

Social-level factors

Participants identified three social-level factors associated with the mental health, including (1) compensation package, (2) social status, and (3) legislative provision and policy.

Compensation package

Many participants were not satisfied with their compensation package. They indicated feelings of inadequate reward for their efforts and the level of responsibility, and unfairness of salary compared with doctors. Some participants felt unsafe because the institute did not buy pension insurance for them.

I did not have pension insurance, I feel stressed (laughing)… I reckon that as long as our profession enjoys good welfare and incentives…People will regard nursing as a valuable profession…(F2P8) .

Social status

Some participants perceived their social status as low, and it is common for them to receive discrimination from patients, relatives and doctors. Participants shared their experience of being viewed as servants by patients in the ward, which made them feel humiliated. They frankly voiced that their low social status, low salary and unsatisfactory professional image made them reluctant to recommend this career to others.

…In the eyes of most people, our status, ,are indeed low, they (patients) look down on us as if we were just waiters (F7P7)… .

Legislative provision and policy

Participants believe that legislative provision and supportive policy was an effective approach to improve social status and professional image.

How do you advocate for the rights of nurses? I believe the legal aspect is more important…(F5P4) .

To our knowledge, this is the first qualitative study which explored factors associated with mental health of clinical nurses by using socio-ecological model. The study advances the literature by emphasizing (1) the mental health is influenced by multi-level factors which include intrapersonal - (i.e., personality traits, quality of sleep, workplace adaptability, and years of work experience), interpersonal (i.e., interpersonal support and role conflict), organizational (i.e., organization climate, organization support, career plateau, and job control), and social-level factors (i.e., including compensation package, social status, and legislative provision and policy), (2) the interaction between factors, and (3) the reciprocal relationship between individuals’ mental health and their environments.

Consistent with the findings of previous research [ 31 , 32 , 33 , 34 , 35 ], our study found that nurses experience more work-to-family conflict than family-to-work conflict, leading to a feeling of stress and guilt. This may be because work and family life are mutually incompatible to some extent. Nurses experience high levels of physical, cognitive, and emotional demands due to the nature of the nursing profession. Meanwhile, most nurses are women, indicating a substantial number of dual-career or single-woman-headed households. They always are expected to take the primary responsibility for childcare and housework by themselves and society [ 36 ]. Therefore, they feel guilty when their work interferes with household duties and family responsibilities, or work detracts from quality time with their families. Notably, our study also found that organizational support (i.e., supportive working environment and flexibility in work schedule) and family support systems could help to mitigate work-family conflict. Consistently, organizational support has been identified as a valuable resource for fostering positive work attitudes and alleviating depressive symptoms [ 37 , 38 ].

Our study recognized the occurrence of double career plateau in nursing. This is because hierarchical and content plateau are closely connected. For example, the hierarchical plateau could lead to the content plateau. Nurse staff are more like to decrease their effort and consciously avoid holding more responsibilities due to the absence of promotion opportunities. Vice versa, nurse staff who are unable to expand their job expertise have limited opportunity for promotion. Notable, our study found that some nursing staff have initiated strategies to manage career plateau by improving academic qualifications. This finding was supported by previous evidence showing that more and more nurses are pursuing master’s and doctorates degrees [ 39 ]. Therefore, those nurses are more likely to experience role conflict and have compromised mental health [ 40 ]. Because they must navigate the added role of a student in addition to their professional career and family responsibilities within limited time and energy [ 41 ]. The career plateau not only leads to mental health problems (e.g.,depression, psychological stress, and burnout) but also exerts adverse effects on physical health. These effects manifest as irritability, outbursts, deteriorating service attitudes, confrontations with managers [ 42 ]. Nursing organizations and managers can address career plateau by providing more opportunities for advancement in nursing positions and titles and by establishing multi-dimensional career advancement pathways. For instance, implementing hierarchical management for nurses [ 43 ] can diversify career opportunities, motivate them, and ease the sense of professional stagnation, thereby alleviating mental health issues linked to career plateaus.

Our study found that nurses experience workplace uncivil acts from various sources, involving other nurses, physicians, supervisors, patients, and visitors. Consistently, evidence indicated that 65.7 − 90.4% of nurses were exposed to some degree of incivility. Previous studies have examined how this destructive behaviour affects organizational and individual outcomes, and which factors influence it [ 44 , 45 , 46 , 47 , 48 ]. Workplace incivility could cause emotional distress and productivity losses in nurses. This situation may be detrimental to patient safety and satisfaction. These negative outcomes could leads to financial strain on healthcare organizations [ 49 ]. Uncivil interactions within the healthcare team could be triggered by organizational and interpersonal factors, such as lack of support, heavy workload, inadequate personnel, and long working shifts. Particularly, these interactions negatively affect nurses who are the backbone of the team. Similarly, these factors were identified as risk factors of mental health of nurses in our study. We also found that support from other supervisors and coworkers could create healthy work environment, which is associated with improved mental health of nurses.

Strengths and limitations

A strength of this study was the use of the social ecological model as a theoretical framework. Contributory factors identified within each level of the framework were discussed by participants. This highlights that interventions developed around these contributory factors have the potential to improve clinical nurses’ mental health.

This study only recruited clinical nurses in one tertiary hospital, which may limits its generalizability. Our participants were recruited through the existing network of the author team, which may lead to selection bias.

This groundbreaking study has utilized the socio-ecological model to illuminate the intricate web of factors influencing the mental health of clinical nurses. The findings underscore the need for holistic interventions that address not only intrapersonal and interpersonal factors but also organizational and social-level factors to promote nurses’ well-being. By acknowledging the complexities of the nursing profession, healthcare organizations, managers, and policymakers can take proactive steps to create supportive environments, foster career development, and mitigate the adverse effects of workplace incivility. Ultimately, these efforts hold the promise of enhancing the mental health and overall job satisfaction of clinical nurses, which in turn contributes to improved patient care and healthcare system performance.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors extend their sincere thanks to the research participants.

This study was supported by the grant of the 2023 Scientific Research Projects of the Chinese Nursing Association (Nurses’ mental health study, ID: ZHKY202306).

Author information

Qiang Yu and Chongmei Huang should be considered the joint first authors. Qiang Yu and Chongmei Huang made equal contributions to this manuscript.

Authors and Affiliations

Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China

Qiang Yu, Yusheng Tian, Jiaxin Yang, Xuting Li, Jie Du, Jiaqing He & Yamin Li

School of Nursing, Ningxia Medical University, Yinchuan, China

Chongmei Huang

School of Nursing, Changsha Medical University, Changsha, China

Xiangya School of Nursing, Central South University, Changsha, China

Meng Ning & Zengyu Chen

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Contributions

YQ, HCM, TYS, YJX and LYM designed the study. HCM and YJX performed the interview. YQ, HCM, TYS, LXT, CZY, DJ and HJQ analyzed data. YQ, HCM, TYS, LXT, NM, CZY, DJ and HJQ did background researches, helped data transcriptions using software. YQ have drafted the manuscript. LYM supervised the research and revised the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Yamin Li .

Ethics declarations

Ethics approval and consent to participate.

The Ethics Committee of National Clinical Medical Research Center, Second Xiangya Hospital, Central South University approved this study (No.2023 − 0267). Formal written informed consent was obtained from each participant. Apart from the aim and pro-cedure of this study, nurses were also told that the participation wouldn’t affect them or their career, the whole interview would be audio-recorded and the anonymous records would only be used for this study. Besides, they were told about their rights to refuse to answer any question or withdraw at any time as well. With agreement to participant, they would sign an informed consent, after which they would be officially included in the study and interviewed. All methods were performed in accordance with the guidelines and regulations of the Declaration of Helsinki.

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Not applicable.

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The author(s) declare that they have no conflict of interests.

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Yu, Q., Huang, C., Tian, Y. et al. Factors associated with clinical nurse’s mental health: a qualitative study applying the social ecological model. BMC Nurs 23 , 330 (2024). https://doi.org/10.1186/s12912-024-02005-9

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Received : 28 December 2023

Accepted : 09 May 2024

Published : 16 May 2024

DOI : https://doi.org/10.1186/s12912-024-02005-9

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