examples of qualitative research proposals in nursing

How to Write a Nursing Research Proposal Topics | Guide & Examples [Updated]

• Dr. Rachel Andel
• July 24, 2023
• Nursing Writing Guides

Nursing research proposal topics can vary greatly, depending on the type of research you’re looking to conduct.

Whether you are interested in studying public health issues or improving patient care through innovative research methods, something on this list likely appeals to you.

Here’s a guide on writing a nursing research proposal and nursing research proposal topics , DNP research proposal topics, current nursing research proposal topics, and nursing research examples.

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How to Write a Nursing Research Proposal

A nursing research proposal serves as a blueprint for conducting studies that address important clinical questions, explore innovative interventions, and contribute to the overall body of nursing knowledge. 

To create a strong nursing research proposal, there are several key considerations that nursing students must take into account, which include;

• Defining a clear and concise research question addresses an important nursing knowledge gap.
• Selecting an appropriate research design and methodology that aligns with the research question and objectives.
• Ensuring ethical considerations are addressed and appropriate measures are in place to protect the rights and welfare of participants.
• Determining an appropriate sample size and recruitment strategy to ensure adequate statistical power and generalizability of findings.
• Developing a detailed data analysis plan that aligns with the research design and objectives.
• Consider dissemination and knowledge translation strategies to ensure research findings reach the intended audience and positively impact nursing practice.

Key components of a Nursing Research Proposa l

When creating a nursing research proposal, including all the components contributing to a comprehensive and well-structured document is crucial.

Understanding these components will ensure that your proposal is clear and organized and addresses the necessary aspects of your research endeavor. 

Problem Statement

• It should provide a clear description of a problem that will be solved.
• It shows the gap between the current situation and the future goal to improve it.

Research Question

• The research question forms the foundation of your nursing research proposal. It is a concise and focused statement that outlines the main objective of your research.
• Your research question should be specific, measurable, attainable, relevant, and time-bound (SMART), enabling you to address a particular problem or gap in the existing literature.

Study Design

• The study design section outlines the methodology and approach you will employ to conduct your research.
• It includes details on the type of study, such as quantitative, qualitative, or mixed methods, and explains how data will be collected, analyzed, and interpreted.
• The study design should align with your research question and ensure the validity and reliability of your findings.

Methodology

• The methodology component of your nursing research proposal describes the specific techniques and procedures you will use to gather data.
• This may include surveys, interviews, observations, or systematic reviews.
• Clearly outlining your methodology ensures transparency and allows others to reproduce your study if needed.

Sample Size Determination

• Determining an appropriate sample size is crucial in nursing research to ensure your findings’ statistical power and representativeness.
• This section will explain how you calculated the required sample size based on the research question, study design, and expected effect size.
• It is essential to consider factors such as the population size, confidence level, and desired margin of error.

Ethical Considerations

• Ethical considerations play a vital role in nursing research.
• This component addresses the protection and well-being of participants, safeguarding their privacy and confidentiality, and the potential risks and benefits associated with the study.
• Ethical considerations also involve obtaining informed consent from participants and ensuring compliance with institutional review boards or ethical committees.

Nursing Research Proposal Outline

List of nursing research proposal topics.

• Racial and ethnic disparities in nursing care
• The impact of technology on nursing care
• Prevalence and determinants of burnout in nurses
• Quality of life for people with chronic illnesses served by nurses
• Effectiveness of nurse-led interventions for short-term weight loss in adults
• Nursing home adjusted Living Experience Surveys: measuring resident satisfaction and quality of life
• Identification and characterization of health disparities among LGBT elders in long-term care facilities
• Role of nurses in the early detection and management of cancer diagnosis
• Effects of delegation on nurse burnout, patient safety, and coordination of care
• The use of technology in home health care: a study of patient and nurse perspectives11. The impact of nurse staffing on patient safety
• Effectiveness of Nurse-led interventions for promoting healthy physical Activity in hospitalized patients.
• The role of nurses in the development and implementation of evidence-based pain management guidelines
• Effectiveness of patient-centred communication interventions to reduce bed sores in nursing home residents
• Identification and characterization of best practices for providing hospice care
• Nurse-led stress reduction interventions for long-term care staff
• Nurses’ perceptions of work-life balance: a qualitative study
• Development and  evaluation of a web-based tool to support caregiver adherence to oral health care  guidelines among long-term care residents
• Effects of sleep deprivation on nurses’ cognitive performance, satisfaction with work, and daytime sleepiness
• A study exploring the  association between nurse  staffing levels and rates of infection in a university hospital setting
• A qualitative study exploring how  nurses manage  transitions from inpatient to outpatient settings
• The use of  social media by nurses in an acute hospital  setting
• Nurses’ experiences with burnout: a cross-sectional study
• Nurse preparedness for pandemic influenza: an examination of the role of  professional development
• The use of telehealth in long-term  care settings:  a study of nurses’ experiences
• Nurses’ experiences with  chronic pain:  a qualitative study
• The impact of the Affordable Care Act on the workforce and nursing
• Nursing care plans  for patients with dementia: a systematic review
• Implementation of evidence-based interventions for preventing  falls in older adults  living in long-term care facilities
• Nurse staffing and  quality of patient care:  a cross-sectional study
• Use of  social media  by nurses during preoperative assessment
• Nurses’ perceptions of resident safety in an acute hospital setting: a qualitative study
• The effects of nurse staffing on patient satisfaction and outcomes in an acute hospital setting
• A comparative study investigating the use of videoconferencing  among nurses  in different specialties
• A qualitative study exploring how  nurse educators use technology to engage students in online learning  environments
• Examining the effect on patient safety when using electronic health records to order medications on off-hours
• Nurse staffing, work demands, and burnout in neonatal intensive care units 38. Factors that predict nurses’ decision to leave their jobs
• Effects of nurse-led interventions to improve care for  veterans with chronic pain
• The use of wearable technology in hospitals: a systematic review
• Review and assessment of technologies used to support nurses during surgery
• Nursing care plans  for patients with cancer: a systematic review
• Nurse-led interventions to prevent falls in older adults living in  long-term care facilities:  a systematic review
• The use of electronic health records to  inform clinical  decision making: a systematic review
• Implementation of evidence-based interventions to  improve patient  safety in hospitals
• A qualitative study exploring how nurses use technology in the workplace
• Factors influencing  nurse satisfaction  with their work and workplace culture
• Identification and assessment of best practices for preoperative  patient communication in the surgical setting
• Effectiveness of nurse-led stress reduction interventions on nurses’ burnout
• Nurse staffing, workload, and burnout in intensive care units: a cross-sectional study
• There are many other nursing research proposal  topics that can be explored in order to improve patient care .

Some additional potential nursing research proposal topics include:

• Assessing the effectiveness of nurse-led interventions for reducing readmissions among hospitalized patients
• Evaluating the impact of nurse call patterns on patient safety
• Analyzing the influence of nurse staffing levels on patient outcomes
• Determining the best methods for measuring patient satisfaction with nurse care
• Studying the  factors influencing  nurse decision making
• Investigating the feasibility and  effectiveness of using remote patient monitoring technology to improve patient care

DNP Research proposal topics

There are countless  nursing research  proposal topics that could be explored in a doctoral or post-doctoral program. Below is a list of some DNP Research proposal topics consider:

• Investigating the feasibility and effectiveness of using remote patient monitoring technology to improve patient care
• The effect of sleep deprivation on nurses
• The use of technology in nursing care
• Investigating the relationship between patient satisfaction and nurse retention
• Studying nutrition-related issues in the context of nursing
• Assessing the impact  of patient satisfaction on nurse recruitment and retention
• The relationship between patient satisfaction and nurse retention
• Investigating the feasibility of using remote patient monitoring technology in healthcare settings
• Evaluating the impact of patient satisfaction on nurse retention
• Research the best methods for measuring patient satisfaction with nurse care
• Studying the feasibility of using remote patient monitoring technology in healthcare settings

Check out the additional DNP Research proposal topics as suggested by a Nursing Instructor

• Nursing research  on dementia care
• Nursing research on neonatal intensive care unit (NICU) management
• Nursing research on palliative care
• Nursing research on wound healing and reconstruction 5.  Nursing research on pediatric health  nursing
• Nursing research on geriatric care
• Nursing research on pharmacology for nursing
• Nursing research on infection control in the acute care setting
• Nursing research on nutrition for nursing
• The  Effect of Health Education on Patient Outcomes
• Development and Evaluation of Nursing Intervention  Programs
• Assessment of Patient Satisfaction with  Nursing Services
• Advocating for  Improved Patient-Nurse Communication
• Assessing the Effectiveness of Interventions to Address Nurses’ Burnout
• Investigating the Relationship between Nurse workload and Patient outcomes7. Evaluating the Impact of Technology on Nursing Care
• Investigating the Relationship between Professionalism and Patient Outcomes
• Studying Nutrition-Related Issues in the Context of Nursing
• Evaluating Patient-Nurse Interactions in the Context of Home Health Services

The list of DNP Research proposal topics above should guide you in creating a Research proposal.

Current Nursing research proposal topics

Nursing research proposal topics  can vary greatly, depending on the type of research you’re looking to conduct. Some common topics include:

• The effects of sleep deprivation on nurses
• The effect of patient communication skills on nurses’ outcomes
• How to improve patient safety in nursing care
• How to reduce readmissions among hospitalized patients
• Study the feasibility of using remote patient monitoring technology in healthcare settings
• Evaluate the impact of patient satisfaction on nurse recruitment and retention
• Evaluate the impact of nurse staffing levels on patient outcomes
• Research the feasibility of using remote patient monitoring technology in healthcare  settings
• Research the impact of patient satisfaction on nurse recruitment and retention
• Opioid use in the elderly
• Preterm birth and neonatal care
• Mobile health technology in nursing
• Nursing home  quality improvement
• The impact of social media on nursing

Nursing research proposal topics can vary greatly, so it’s important to select a  topic that is of interest to you and that will help you to improve patient care .

Nursing research proposal writing tips

When  preparing your nursing  research proposal, it’s important to keep the following tips in mind:

• Be organized

Planning and organizing your data will make your research proposal more concise and easier to read. Start by identifying the specific question you want to answer, and then list all the relevant sources that you consulted in order to reach your conclusions. Use headings and subheadings to help organize your information , and be sure to include detailed citations for all sources used.

• Use effective writing techniques

To produce a well-written research proposal, use effective writing techniques such as strong thesis statements , clear language, and well-organized data. You should also make use of persuasive arguments, vivid descriptions, and concrete  examples in order to make your case for the proposed study .

• Include references

In order for your nursing research proposal to be accepted, it  must include references  from reliable sources that support your findings. Always cite the source where you obtained the data presented in your proposal, as well as any other sourcesthat you used in order to support your arguments.

• Make sure your proposal is properly formatted

Your nursing research proposal should be properly formatted and error-free in order to be accepted for review. Always use the correct style and grammar when writing, and make sure all data is properly referenced. avoid using excessive jargon or acronyms, and try to keep your presentation as concise as possible.

• Submit your proposal well in advance of the deadline

The sooner you submit your proposal, the better chance you have of being accepted for review. Make sure to follow the submission guidelines outlined by the journal you are submitting to, as well as the submission system specific to that journal .

Nursing Research Proposal Examples

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In this article, we will provide you with some  ideas for nursing research proposal topics  that can be used in any discipline. Whether you are interested in studying public  health issues or improving patient care  through innovative research methods, there is likely something on this list that appeals to you. So get started on your Nursing Research Proposal now by  placing an order  with us.

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Designing a Research Proposal in Qualitative Research

• First Online: 27 October 2022

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• Md. Ismail Hossain 4 ,
• Nafiul Mehedi 4 &
• Iftakhar Ahmad 4  

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The chapter discusses designing a research proposal in qualitative research. The main objective is to outline the major components of a qualitative research proposal with example(s) so that the students and novice scholars easily get an understanding of a qualitative proposal. The chapter highlights the major components of a qualitative research proposal and discusses the steps involved in designing a proposal. In each step, an example is given with some essential tips. Following these steps and tips, a novice researcher can easily prepare a qualitative research proposal. Readers, especially undergraduate and master’s students, might use this as a guideline while preparing a thesis proposal. After reading this chapter, they can easily prepare a qualitative proposal.

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Hossain, M.I., Mehedi, N., Ahmad, I. (2022). Designing a Research Proposal in Qualitative Research. In: Islam, M.R., Khan, N.A., Baikady, R. (eds) Principles of Social Research Methodology. Springer, Singapore. https://doi.org/10.1007/978-981-19-5441-2_18

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Introduction to qualitative nursing research

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

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

Research 101: Descriptive statistics

Differentiating research, evidence-based practice, and quality improvement

How to appraise quantitative research articles

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

What is qualitative research?

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

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

Qualitative research designs

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

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

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

Sampling approaches

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

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

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

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

Data collection and analysis

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

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

Evaluating a qualitative study

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

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

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

Application to nursing practice

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

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

Successful implementation

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

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

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

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The qualitative research proposal

Affiliation.

• 1 School of Nursing Science, North-West University, South Africa. [email protected]
• PMID: 19653539
• DOI: 10.4102/curationis.v31i4.1062

Qualitative research in the health sciences has had to overcome many prejudices and a number of misunderstandings, but today qualitative research is as acceptable as quantitative research designs and is widely funded and published. Writing the proposal of a qualitative study, however, can be a challenging feat, due to the emergent nature of the qualitative research design and the description of the methodology as a process. Even today, many sub-standard proposals at post-graduate evaluation committees and application proposals to be considered for funding are still seen. This problem has led the researcher to develop a framework to guide the qualitative researcher in writing the proposal of a qualitative study based on the following research questions: (i) What is the process of writing a qualitative research proposal? and (ii) What does the structure and layout of a qualitative proposal look like? The purpose of this article is to discuss the process of writing the qualitative research proposal, as well as describe the structure and layout of a qualitative research proposal. The process of writing a qualitative research proposal is discussed with regards to the most important questions that need to be answered in your research proposal with consideration of the guidelines of being practical, being persuasive, making broader links, aiming for crystal clarity and planning before you write. While the structure of the qualitative research proposal is discussed with regards to the key sections of the proposal, namely the cover page, abstract, introduction, review of the literature, research problem and research questions, research purpose and objectives, research paradigm, research design, research method, ethical considerations, dissemination plan, budget and appendices.

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Getting started with qualitative research: developing a research proposal, cristina g vivar lecturer, department of community nursing and maternal & child health care, school of nursing, university of navarra, spain, and a doctoral student, nursing studies, school of health in social science, university of edinburgh, uk, anne mcqueen senior lecturer, nursing studies, school of health in social science, university of edinburgh, uk, dorothy a whyte honorary fellow, nursing studies, school of health in social science, university of edinburgh, uk, navidad canga armayor lecturer, head of department of community nursing and maternal & child health care, school of nursing, university of navarra, spain.

The aim of this article is to illustrate in detail important issues that research beginners may have to deal with during the design of a qualitative research proposal in nursing and health care. Cristina Vivar has developed a 17-step process to describe the development of a qualitative research project. This process can serve as an easy way to start research and to ensure a comprehensive and thorough proposal.

Nurse Researcher . 14, 3, 60-73. doi: 10.7748/nr2007.04.14.3.60.c6033

qualitative research - research proposal - research process - proposal design

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• Research article
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• Published: 14 June 2021

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice

• Jannine van Schothorst–van Roekel 1 ,
• Anne Marie J.W.M. Weggelaar-Jansen 1 ,
• Carina C.G.J.M. Hilders 1 ,
• Antoinette A. De Bont 1 &
• Iris Wallenburg 1  

BMC Nursing volume  20 , Article number:  97 ( 2021 ) Cite this article

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Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.

A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.

Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.

Conclusions

Conducting small-change experiments, anchored by action and appraisal rather than by design , clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

Peer Review reports

The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [ 1 , 2 ]. Nurses play an important role in facing these contemporary challenges [ 3 , 4 ]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [ 5 , 6 ]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [ 7 , 8 ]. This issue has sparked renewed interest in nursing role development [ 9 , 10 , 11 ]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [ 12 , 9 ].

New nursing roles usually arise through task specialization [ 13 , 14 ] and the development of advanced nursing roles [ 15 , 16 ]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [ 17 , 18 ]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [ 19 , 20 ]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [ 21 , 22 , 23 ].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [ 24 , 25 ] but also in Australia [ 26 , 27 ], Singapore [ 20 ] and the United States of America [ 28 , 29 ]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [ 30 ]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [ 31 ].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [ 32 ]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [ 33 , 34 , 35 , 36 ], based on nurses’ thorough knowledge of professional practices [ 37 ] and leadership role [ 38 , 39 , 40 ].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [ 41 ]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [ 42 , 43 , 44 ]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [ 31 ]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.

The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.

We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [ 45 , 46 ]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [ 47 , 48 ]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table  1 . The project team, comprising nursing policy staff, coaches and HR staff ( N  = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers ( N  = 4), and the CEO ( N  = 1) in the meetings.

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [ 45 ] (see Table  2 ).

Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [ 49 , 50 ], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [ 46 ].

Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams ( n  = 2); (2) bi-monthly meetings ( n  = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed ( n  = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice ( n  = 15). Minutes and detailed notes also produced thick descriptions [ 51 ]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [ 52 ]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO ( n  = 1), middle managers ( n  = 4), VNs ( n  = 6), BNs ( n  = 9, including four senior nurses), paramedics ( n  = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards ( N  = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Data analysis

Data collection and inductive thematic analysis took place iteratively [ 45 , 53 ]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file ). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [ 54 ]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.

Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [ 48 ]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [ 55 ]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [ 56 , 57 ]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [ 54 ]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [ 48 ]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.

Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [ 32 ]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is , is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [ 58 ] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [ 59 ]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [ 49 ]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [ 1 , 60 ]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [ 61 ]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [ 62 ] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [ 63 ], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [ 64 ]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [ 65 ]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [ 1 ], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [ 66 ] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.

This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [ 49 ]. Usually, invisible work gets no formal recognition, for example in policy documents [ 55 ], whereas it is crucial in daily routines and organizational structures [ 49 , 60 ]. Second, experimenting triggers an accumulation of small changes [ 33 , 35 ] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [ 37 ]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [ 43 ] resulting in a subordinate position, power inequity and lack of autonomy [ 44 ]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [ 12 ] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [ 9 , 10 , 11 ] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [ 41 ] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [ 42 ] and Abbott [ 67 ] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [ 37 , 39 , 40 ]. Adding to Mannix et al. [ 38 ], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [ 64 , 65 ]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [ 34 , 68 ] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.

Limitations

Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.

This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design , the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

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The authors would like to thank all participants for their contribution to this study.

The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

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A.W. and I.W. developed the study design. J.S. and A.W. were responsible for data collection, enhanced by I.W. for data analysis and drafting the manuscript. C.H. and A.B. critically revised the paper. All authors have read and approved the manuscript.

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van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20 , 97 (2021). https://doi.org/10.1186/s12912-021-00613-3

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A Practical Guide to Writing Quantitative and Qualitative Research Questions and Hypotheses in Scholarly Articles

Edward barroga.

1 Department of General Education, Graduate School of Nursing Science, St. Luke’s International University, Tokyo, Japan.

Glafera Janet Matanguihan

2 Department of Biological Sciences, Messiah University, Mechanicsburg, PA, USA.

The development of research questions and the subsequent hypotheses are prerequisites to defining the main research purpose and specific objectives of a study. Consequently, these objectives determine the study design and research outcome. The development of research questions is a process based on knowledge of current trends, cutting-edge studies, and technological advances in the research field. Excellent research questions are focused and require a comprehensive literature search and in-depth understanding of the problem being investigated. Initially, research questions may be written as descriptive questions which could be developed into inferential questions. These questions must be specific and concise to provide a clear foundation for developing hypotheses. Hypotheses are more formal predictions about the research outcomes. These specify the possible results that may or may not be expected regarding the relationship between groups. Thus, research questions and hypotheses clarify the main purpose and specific objectives of the study, which in turn dictate the design of the study, its direction, and outcome. Studies developed from good research questions and hypotheses will have trustworthy outcomes with wide-ranging social and health implications.

INTRODUCTION

Scientific research is usually initiated by posing evidenced-based research questions which are then explicitly restated as hypotheses. 1 , 2 The hypotheses provide directions to guide the study, solutions, explanations, and expected results. 3 , 4 Both research questions and hypotheses are essentially formulated based on conventional theories and real-world processes, which allow the inception of novel studies and the ethical testing of ideas. 5 , 6

It is crucial to have knowledge of both quantitative and qualitative research 2 as both types of research involve writing research questions and hypotheses. 7 However, these crucial elements of research are sometimes overlooked; if not overlooked, then framed without the forethought and meticulous attention it needs. Planning and careful consideration are needed when developing quantitative or qualitative research, particularly when conceptualizing research questions and hypotheses. 4

There is a continuing need to support researchers in the creation of innovative research questions and hypotheses, as well as for journal articles that carefully review these elements. 1 When research questions and hypotheses are not carefully thought of, unethical studies and poor outcomes usually ensue. Carefully formulated research questions and hypotheses define well-founded objectives, which in turn determine the appropriate design, course, and outcome of the study. This article then aims to discuss in detail the various aspects of crafting research questions and hypotheses, with the goal of guiding researchers as they develop their own. Examples from the authors and peer-reviewed scientific articles in the healthcare field are provided to illustrate key points.

DEFINITIONS AND RELATIONSHIP OF RESEARCH QUESTIONS AND HYPOTHESES

A research question is what a study aims to answer after data analysis and interpretation. The answer is written in length in the discussion section of the paper. Thus, the research question gives a preview of the different parts and variables of the study meant to address the problem posed in the research question. 1 An excellent research question clarifies the research writing while facilitating understanding of the research topic, objective, scope, and limitations of the study. 5

On the other hand, a research hypothesis is an educated statement of an expected outcome. This statement is based on background research and current knowledge. 8 , 9 The research hypothesis makes a specific prediction about a new phenomenon 10 or a formal statement on the expected relationship between an independent variable and a dependent variable. 3 , 11 It provides a tentative answer to the research question to be tested or explored. 4

Hypotheses employ reasoning to predict a theory-based outcome. 10 These can also be developed from theories by focusing on components of theories that have not yet been observed. 10 The validity of hypotheses is often based on the testability of the prediction made in a reproducible experiment. 8

Conversely, hypotheses can also be rephrased as research questions. Several hypotheses based on existing theories and knowledge may be needed to answer a research question. Developing ethical research questions and hypotheses creates a research design that has logical relationships among variables. These relationships serve as a solid foundation for the conduct of the study. 4 , 11 Haphazardly constructed research questions can result in poorly formulated hypotheses and improper study designs, leading to unreliable results. Thus, the formulations of relevant research questions and verifiable hypotheses are crucial when beginning research. 12

CHARACTERISTICS OF GOOD RESEARCH QUESTIONS AND HYPOTHESES

Excellent research questions are specific and focused. These integrate collective data and observations to confirm or refute the subsequent hypotheses. Well-constructed hypotheses are based on previous reports and verify the research context. These are realistic, in-depth, sufficiently complex, and reproducible. More importantly, these hypotheses can be addressed and tested. 13

There are several characteristics of well-developed hypotheses. Good hypotheses are 1) empirically testable 7 , 10 , 11 , 13 ; 2) backed by preliminary evidence 9 ; 3) testable by ethical research 7 , 9 ; 4) based on original ideas 9 ; 5) have evidenced-based logical reasoning 10 ; and 6) can be predicted. 11 Good hypotheses can infer ethical and positive implications, indicating the presence of a relationship or effect relevant to the research theme. 7 , 11 These are initially developed from a general theory and branch into specific hypotheses by deductive reasoning. In the absence of a theory to base the hypotheses, inductive reasoning based on specific observations or findings form more general hypotheses. 10

TYPES OF RESEARCH QUESTIONS AND HYPOTHESES

Research questions and hypotheses are developed according to the type of research, which can be broadly classified into quantitative and qualitative research. We provide a summary of the types of research questions and hypotheses under quantitative and qualitative research categories in Table 1 .

Research questions in quantitative research

In quantitative research, research questions inquire about the relationships among variables being investigated and are usually framed at the start of the study. These are precise and typically linked to the subject population, dependent and independent variables, and research design. 1 Research questions may also attempt to describe the behavior of a population in relation to one or more variables, or describe the characteristics of variables to be measured ( descriptive research questions ). 1 , 5 , 14 These questions may also aim to discover differences between groups within the context of an outcome variable ( comparative research questions ), 1 , 5 , 14 or elucidate trends and interactions among variables ( relationship research questions ). 1 , 5 We provide examples of descriptive, comparative, and relationship research questions in quantitative research in Table 2 .

Hypotheses in quantitative research

In quantitative research, hypotheses predict the expected relationships among variables. 15 Relationships among variables that can be predicted include 1) between a single dependent variable and a single independent variable ( simple hypothesis ) or 2) between two or more independent and dependent variables ( complex hypothesis ). 4 , 11 Hypotheses may also specify the expected direction to be followed and imply an intellectual commitment to a particular outcome ( directional hypothesis ) 4 . On the other hand, hypotheses may not predict the exact direction and are used in the absence of a theory, or when findings contradict previous studies ( non-directional hypothesis ). 4 In addition, hypotheses can 1) define interdependency between variables ( associative hypothesis ), 4 2) propose an effect on the dependent variable from manipulation of the independent variable ( causal hypothesis ), 4 3) state a negative relationship between two variables ( null hypothesis ), 4 , 11 , 15 4) replace the working hypothesis if rejected ( alternative hypothesis ), 15 explain the relationship of phenomena to possibly generate a theory ( working hypothesis ), 11 5) involve quantifiable variables that can be tested statistically ( statistical hypothesis ), 11 6) or express a relationship whose interlinks can be verified logically ( logical hypothesis ). 11 We provide examples of simple, complex, directional, non-directional, associative, causal, null, alternative, working, statistical, and logical hypotheses in quantitative research, as well as the definition of quantitative hypothesis-testing research in Table 3 .

Research questions in qualitative research

Unlike research questions in quantitative research, research questions in qualitative research are usually continuously reviewed and reformulated. The central question and associated subquestions are stated more than the hypotheses. 15 The central question broadly explores a complex set of factors surrounding the central phenomenon, aiming to present the varied perspectives of participants. 15

There are varied goals for which qualitative research questions are developed. These questions can function in several ways, such as to 1) identify and describe existing conditions ( contextual research question s); 2) describe a phenomenon ( descriptive research questions ); 3) assess the effectiveness of existing methods, protocols, theories, or procedures ( evaluation research questions ); 4) examine a phenomenon or analyze the reasons or relationships between subjects or phenomena ( explanatory research questions ); or 5) focus on unknown aspects of a particular topic ( exploratory research questions ). 5 In addition, some qualitative research questions provide new ideas for the development of theories and actions ( generative research questions ) or advance specific ideologies of a position ( ideological research questions ). 1 Other qualitative research questions may build on a body of existing literature and become working guidelines ( ethnographic research questions ). Research questions may also be broadly stated without specific reference to the existing literature or a typology of questions ( phenomenological research questions ), may be directed towards generating a theory of some process ( grounded theory questions ), or may address a description of the case and the emerging themes ( qualitative case study questions ). 15 We provide examples of contextual, descriptive, evaluation, explanatory, exploratory, generative, ideological, ethnographic, phenomenological, grounded theory, and qualitative case study research questions in qualitative research in Table 4 , and the definition of qualitative hypothesis-generating research in Table 5 .

Qualitative studies usually pose at least one central research question and several subquestions starting with How or What . These research questions use exploratory verbs such as explore or describe . These also focus on one central phenomenon of interest, and may mention the participants and research site. 15

Hypotheses in qualitative research

Hypotheses in qualitative research are stated in the form of a clear statement concerning the problem to be investigated. Unlike in quantitative research where hypotheses are usually developed to be tested, qualitative research can lead to both hypothesis-testing and hypothesis-generating outcomes. 2 When studies require both quantitative and qualitative research questions, this suggests an integrative process between both research methods wherein a single mixed-methods research question can be developed. 1

FRAMEWORKS FOR DEVELOPING RESEARCH QUESTIONS AND HYPOTHESES

Research questions followed by hypotheses should be developed before the start of the study. 1 , 12 , 14 It is crucial to develop feasible research questions on a topic that is interesting to both the researcher and the scientific community. This can be achieved by a meticulous review of previous and current studies to establish a novel topic. Specific areas are subsequently focused on to generate ethical research questions. The relevance of the research questions is evaluated in terms of clarity of the resulting data, specificity of the methodology, objectivity of the outcome, depth of the research, and impact of the study. 1 , 5 These aspects constitute the FINER criteria (i.e., Feasible, Interesting, Novel, Ethical, and Relevant). 1 Clarity and effectiveness are achieved if research questions meet the FINER criteria. In addition to the FINER criteria, Ratan et al. described focus, complexity, novelty, feasibility, and measurability for evaluating the effectiveness of research questions. 14

The PICOT and PEO frameworks are also used when developing research questions. 1 The following elements are addressed in these frameworks, PICOT: P-population/patients/problem, I-intervention or indicator being studied, C-comparison group, O-outcome of interest, and T-timeframe of the study; PEO: P-population being studied, E-exposure to preexisting conditions, and O-outcome of interest. 1 Research questions are also considered good if these meet the “FINERMAPS” framework: Feasible, Interesting, Novel, Ethical, Relevant, Manageable, Appropriate, Potential value/publishable, and Systematic. 14

As we indicated earlier, research questions and hypotheses that are not carefully formulated result in unethical studies or poor outcomes. To illustrate this, we provide some examples of ambiguous research question and hypotheses that result in unclear and weak research objectives in quantitative research ( Table 6 ) 16 and qualitative research ( Table 7 ) 17 , and how to transform these ambiguous research question(s) and hypothesis(es) into clear and good statements.

a These statements were composed for comparison and illustrative purposes only.

b These statements are direct quotes from Higashihara and Horiuchi. 16

a This statement is a direct quote from Shimoda et al. 17

The other statements were composed for comparison and illustrative purposes only.

CONSTRUCTING RESEARCH QUESTIONS AND HYPOTHESES

To construct effective research questions and hypotheses, it is very important to 1) clarify the background and 2) identify the research problem at the outset of the research, within a specific timeframe. 9 Then, 3) review or conduct preliminary research to collect all available knowledge about the possible research questions by studying theories and previous studies. 18 Afterwards, 4) construct research questions to investigate the research problem. Identify variables to be accessed from the research questions 4 and make operational definitions of constructs from the research problem and questions. Thereafter, 5) construct specific deductive or inductive predictions in the form of hypotheses. 4 Finally, 6) state the study aims . This general flow for constructing effective research questions and hypotheses prior to conducting research is shown in Fig. 1 .

Research questions are used more frequently in qualitative research than objectives or hypotheses. 3 These questions seek to discover, understand, explore or describe experiences by asking “What” or “How.” The questions are open-ended to elicit a description rather than to relate variables or compare groups. The questions are continually reviewed, reformulated, and changed during the qualitative study. 3 Research questions are also used more frequently in survey projects than hypotheses in experiments in quantitative research to compare variables and their relationships.

Hypotheses are constructed based on the variables identified and as an if-then statement, following the template, ‘If a specific action is taken, then a certain outcome is expected.’ At this stage, some ideas regarding expectations from the research to be conducted must be drawn. 18 Then, the variables to be manipulated (independent) and influenced (dependent) are defined. 4 Thereafter, the hypothesis is stated and refined, and reproducible data tailored to the hypothesis are identified, collected, and analyzed. 4 The hypotheses must be testable and specific, 18 and should describe the variables and their relationships, the specific group being studied, and the predicted research outcome. 18 Hypotheses construction involves a testable proposition to be deduced from theory, and independent and dependent variables to be separated and measured separately. 3 Therefore, good hypotheses must be based on good research questions constructed at the start of a study or trial. 12

In summary, research questions are constructed after establishing the background of the study. Hypotheses are then developed based on the research questions. Thus, it is crucial to have excellent research questions to generate superior hypotheses. In turn, these would determine the research objectives and the design of the study, and ultimately, the outcome of the research. 12 Algorithms for building research questions and hypotheses are shown in Fig. 2 for quantitative research and in Fig. 3 for qualitative research.

EXAMPLES OF RESEARCH QUESTIONS FROM PUBLISHED ARTICLES

• EXAMPLE 1. Descriptive research question (quantitative research)
• - Presents research variables to be assessed (distinct phenotypes and subphenotypes)
• “BACKGROUND: Since COVID-19 was identified, its clinical and biological heterogeneity has been recognized. Identifying COVID-19 phenotypes might help guide basic, clinical, and translational research efforts.
• RESEARCH QUESTION: Does the clinical spectrum of patients with COVID-19 contain distinct phenotypes and subphenotypes? ” 19
• EXAMPLE 2. Relationship research question (quantitative research)
• - Shows interactions between dependent variable (static postural control) and independent variable (peripheral visual field loss)
• “Background: Integration of visual, vestibular, and proprioceptive sensations contributes to postural control. People with peripheral visual field loss have serious postural instability. However, the directional specificity of postural stability and sensory reweighting caused by gradual peripheral visual field loss remain unclear.
• Research question: What are the effects of peripheral visual field loss on static postural control ?” 20
• EXAMPLE 3. Comparative research question (quantitative research)
• - Clarifies the difference among groups with an outcome variable (patients enrolled in COMPERA with moderate PH or severe PH in COPD) and another group without the outcome variable (patients with idiopathic pulmonary arterial hypertension (IPAH))
• “BACKGROUND: Pulmonary hypertension (PH) in COPD is a poorly investigated clinical condition.
• RESEARCH QUESTION: Which factors determine the outcome of PH in COPD?
• STUDY DESIGN AND METHODS: We analyzed the characteristics and outcome of patients enrolled in the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) with moderate or severe PH in COPD as defined during the 6th PH World Symposium who received medical therapy for PH and compared them with patients with idiopathic pulmonary arterial hypertension (IPAH) .” 21
• EXAMPLE 4. Exploratory research question (qualitative research)
• - Explores areas that have not been fully investigated (perspectives of families and children who receive care in clinic-based child obesity treatment) to have a deeper understanding of the research problem
• “Problem: Interventions for children with obesity lead to only modest improvements in BMI and long-term outcomes, and data are limited on the perspectives of families of children with obesity in clinic-based treatment. This scoping review seeks to answer the question: What is known about the perspectives of families and children who receive care in clinic-based child obesity treatment? This review aims to explore the scope of perspectives reported by families of children with obesity who have received individualized outpatient clinic-based obesity treatment.” 22
• EXAMPLE 5. Relationship research question (quantitative research)
• - Defines interactions between dependent variable (use of ankle strategies) and independent variable (changes in muscle tone)
• “Background: To maintain an upright standing posture against external disturbances, the human body mainly employs two types of postural control strategies: “ankle strategy” and “hip strategy.” While it has been reported that the magnitude of the disturbance alters the use of postural control strategies, it has not been elucidated how the level of muscle tone, one of the crucial parameters of bodily function, determines the use of each strategy. We have previously confirmed using forward dynamics simulations of human musculoskeletal models that an increased muscle tone promotes the use of ankle strategies. The objective of the present study was to experimentally evaluate a hypothesis: an increased muscle tone promotes the use of ankle strategies. Research question: Do changes in the muscle tone affect the use of ankle strategies ?” 23

EXAMPLES OF HYPOTHESES IN PUBLISHED ARTICLES

• EXAMPLE 1. Working hypothesis (quantitative research)
• - A hypothesis that is initially accepted for further research to produce a feasible theory
• “As fever may have benefit in shortening the duration of viral illness, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response when taken during the early stages of COVID-19 illness .” 24
• “In conclusion, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response . The difference in perceived safety of these agents in COVID-19 illness could be related to the more potent efficacy to reduce fever with ibuprofen compared to acetaminophen. Compelling data on the benefit of fever warrant further research and review to determine when to treat or withhold ibuprofen for early stage fever for COVID-19 and other related viral illnesses .” 24
• EXAMPLE 2. Exploratory hypothesis (qualitative research)
• - Explores particular areas deeper to clarify subjective experience and develop a formal hypothesis potentially testable in a future quantitative approach
• “We hypothesized that when thinking about a past experience of help-seeking, a self distancing prompt would cause increased help-seeking intentions and more favorable help-seeking outcome expectations .” 25
• “Conclusion
• Although a priori hypotheses were not supported, further research is warranted as results indicate the potential for using self-distancing approaches to increasing help-seeking among some people with depressive symptomatology.” 25
• EXAMPLE 3. Hypothesis-generating research to establish a framework for hypothesis testing (qualitative research)
• “We hypothesize that compassionate care is beneficial for patients (better outcomes), healthcare systems and payers (lower costs), and healthcare providers (lower burnout). ” 26
• Compassionomics is the branch of knowledge and scientific study of the effects of compassionate healthcare. Our main hypotheses are that compassionate healthcare is beneficial for (1) patients, by improving clinical outcomes, (2) healthcare systems and payers, by supporting financial sustainability, and (3) HCPs, by lowering burnout and promoting resilience and well-being. The purpose of this paper is to establish a scientific framework for testing the hypotheses above . If these hypotheses are confirmed through rigorous research, compassionomics will belong in the science of evidence-based medicine, with major implications for all healthcare domains.” 26
• EXAMPLE 4. Statistical hypothesis (quantitative research)
• - An assumption is made about the relationship among several population characteristics ( gender differences in sociodemographic and clinical characteristics of adults with ADHD ). Validity is tested by statistical experiment or analysis ( chi-square test, Students t-test, and logistic regression analysis)
• “Our research investigated gender differences in sociodemographic and clinical characteristics of adults with ADHD in a Japanese clinical sample. Due to unique Japanese cultural ideals and expectations of women's behavior that are in opposition to ADHD symptoms, we hypothesized that women with ADHD experience more difficulties and present more dysfunctions than men . We tested the following hypotheses: first, women with ADHD have more comorbidities than men with ADHD; second, women with ADHD experience more social hardships than men, such as having less full-time employment and being more likely to be divorced.” 27
• “Statistical Analysis
• ( text omitted ) Between-gender comparisons were made using the chi-squared test for categorical variables and Students t-test for continuous variables…( text omitted ). A logistic regression analysis was performed for employment status, marital status, and comorbidity to evaluate the independent effects of gender on these dependent variables.” 27

EXAMPLES OF HYPOTHESIS AS WRITTEN IN PUBLISHED ARTICLES IN RELATION TO OTHER PARTS

• EXAMPLE 1. Background, hypotheses, and aims are provided
• “Pregnant women need skilled care during pregnancy and childbirth, but that skilled care is often delayed in some countries …( text omitted ). The focused antenatal care (FANC) model of WHO recommends that nurses provide information or counseling to all pregnant women …( text omitted ). Job aids are visual support materials that provide the right kind of information using graphics and words in a simple and yet effective manner. When nurses are not highly trained or have many work details to attend to, these job aids can serve as a content reminder for the nurses and can be used for educating their patients (Jennings, Yebadokpo, Affo, & Agbogbe, 2010) ( text omitted ). Importantly, additional evidence is needed to confirm how job aids can further improve the quality of ANC counseling by health workers in maternal care …( text omitted )” 28
• “ This has led us to hypothesize that the quality of ANC counseling would be better if supported by job aids. Consequently, a better quality of ANC counseling is expected to produce higher levels of awareness concerning the danger signs of pregnancy and a more favorable impression of the caring behavior of nurses .” 28
• “This study aimed to examine the differences in the responses of pregnant women to a job aid-supported intervention during ANC visit in terms of 1) their understanding of the danger signs of pregnancy and 2) their impression of the caring behaviors of nurses to pregnant women in rural Tanzania.” 28
• EXAMPLE 2. Background, hypotheses, and aims are provided
• “We conducted a two-arm randomized controlled trial (RCT) to evaluate and compare changes in salivary cortisol and oxytocin levels of first-time pregnant women between experimental and control groups. The women in the experimental group touched and held an infant for 30 min (experimental intervention protocol), whereas those in the control group watched a DVD movie of an infant (control intervention protocol). The primary outcome was salivary cortisol level and the secondary outcome was salivary oxytocin level.” 29
• “ We hypothesize that at 30 min after touching and holding an infant, the salivary cortisol level will significantly decrease and the salivary oxytocin level will increase in the experimental group compared with the control group .” 29
• EXAMPLE 3. Background, aim, and hypothesis are provided
• “In countries where the maternal mortality ratio remains high, antenatal education to increase Birth Preparedness and Complication Readiness (BPCR) is considered one of the top priorities [1]. BPCR includes birth plans during the antenatal period, such as the birthplace, birth attendant, transportation, health facility for complications, expenses, and birth materials, as well as family coordination to achieve such birth plans. In Tanzania, although increasing, only about half of all pregnant women attend an antenatal clinic more than four times [4]. Moreover, the information provided during antenatal care (ANC) is insufficient. In the resource-poor settings, antenatal group education is a potential approach because of the limited time for individual counseling at antenatal clinics.” 30
• “This study aimed to evaluate an antenatal group education program among pregnant women and their families with respect to birth-preparedness and maternal and infant outcomes in rural villages of Tanzania.” 30
• “ The study hypothesis was if Tanzanian pregnant women and their families received a family-oriented antenatal group education, they would (1) have a higher level of BPCR, (2) attend antenatal clinic four or more times, (3) give birth in a health facility, (4) have less complications of women at birth, and (5) have less complications and deaths of infants than those who did not receive the education .” 30

Research questions and hypotheses are crucial components to any type of research, whether quantitative or qualitative. These questions should be developed at the very beginning of the study. Excellent research questions lead to superior hypotheses, which, like a compass, set the direction of research, and can often determine the successful conduct of the study. Many research studies have floundered because the development of research questions and subsequent hypotheses was not given the thought and meticulous attention needed. The development of research questions and hypotheses is an iterative process based on extensive knowledge of the literature and insightful grasp of the knowledge gap. Focused, concise, and specific research questions provide a strong foundation for constructing hypotheses which serve as formal predictions about the research outcomes. Research questions and hypotheses are crucial elements of research that should not be overlooked. They should be carefully thought of and constructed when planning research. This avoids unethical studies and poor outcomes by defining well-founded objectives that determine the design, course, and outcome of the study.

Disclosure: The authors have no potential conflicts of interest to disclose.

Author Contributions:

• Conceptualization: Barroga E, Matanguihan GJ.
• Methodology: Barroga E, Matanguihan GJ.
• Writing - original draft: Barroga E, Matanguihan GJ.
• Writing - review & editing: Barroga E, Matanguihan GJ.

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Original research article, exploring cambodian adolescents' perceptions on sex: a qualitative investigation.

• 1 School of Nursing, Research Institute of Nursing Science, Sustainable Development Center, Jeonbuk National University, Jeonju, Republic of Korea
• 2 Seoul Samsung Medical Center, Seoul, Republic of Korea
• 3 St. David’s School of Nursing, Texas State University, Round Rock, TX, United States
• 4 Jersey City Medical Center, Jersey City, NJ, United States

Introduction: Involvement in sexual activities increases during adolescence in many countries, including Cambodia. The objective of this study is to explore the perspectives and interpretations of sex held by Cambodian adolescents within the context of their social norms and culture.

Methods: A qualitative research design was used to conduct in-depth interviews with a purposive sample of 91 Cambodian adolescents aged between 15 and 19 years. Participants were recruited from rural areas, and data was collected through face-to-face interviews using semi-structured interview guides. Thematic analysis was used to analyze the data.

Results: Four themes as perspectives of sex were identified: (1) Desire: Releasing sexual desire and stress; (2) relationship: an emotional connection and demonstration of love; (3) roles: responsibilities within a woman's marital duties; and (4) values: the value of virginity and future engagement. Cambodian adolescents' perspectives and interpretations of sex were deeply influenced by their social norms and cultural values. Men typically perceived sex through the lens of instinct and pleasure, while women often emphasized a deep sense of familial duty and held premarital sex to be morally unacceptable.

Discussion: The findings suggest that interventions aimed at improving the sexual health of Cambodian adolescents should be designed with an understanding of the social norms and cultural values that shape their perspectives and interpretations of sex. Such interventions should focus on promoting safe sex practices and providing accurate and comprehensive sexual education.

1 Introduction

Adolescence is the period between 10 and 19 years of age that marks the transition from childhood to adulthood ( 1 ). Adolescents experience rapid changes not only in their physical growth but also in cognitive, emotional, and psychosocial development while pursuing sex and intimate relationships ( 1 ). Adolescence is considered a healthy period of life; however, negative sexual and reproductive health (SRH) outcomes can threaten the well-being of adolescents, especially in low- and middle-income countries ( 2 ). Young people typically engage in sexual activities as they reach adolescence, with limited knowledge about SRH, leading to the highest rates of sexually transmitted infections (STIs) and HIV infections ( 2 ).

The global adolescent population has increased, with the majority of adolescents living in Southeast Asia ( 3 ). Cambodia has the largest adolescent and young adult population in Southeast Asia, with two-thirds of its 14.7 million people under the age of 30 ( 4 ). However, Cambodia lags behind its neighboring countries in implementing effective strategies to improve SRH. Cambodian youth face numerous obstacles to sustainable SRH, including lack of SRH literacy and limited access to modern contraceptives ( 4 ). Only 6.7% of Cambodian youth reported having visited a local health center, hospital, or clinic to seek reproductive health care ( 3 ). Furthermore, the rate of condom use among young Cambodian men decreased from 26% in 2010 to 18% in 2014 ( 5 ). This means that challenges, such as unexpected pregnancies and STIs, are on the rise.

However, essential health services are expensive, particularly in rural areas, due to user fees and transportation, as well as food and accommodation costs. Geographical factors, including the time required to travel to facilities and transportation availability, are barriers to health care access ( 6 ). Therefore, eliminating financial and geographical barriers is critical to increasing health care utilization. In addition, sex education must be taught among adolescents, particularly on how to practice safe sex. Since mid-1997, the Reproductive Health Association of Cambodia has used peer educators, group discussions, one-on-one discussions, local theaters or quiz shows, various educational materials, and youth centers to convey reproductive health messages and information to young people. In 2007, the project distributed condoms and offered STI services to youth under the age of 25 ( 7 ). However, condom use declined over the following four years ( 5 ). This implies that the program must be revised the program to boost its effectivity.

Sex is often linked to the concept of marriage, with some regarding it as conditional on marriage, especially in rural areas. Young, unmarried individuals in urban Cambodia are 60% more likely to engage in pre-marital sexual intercourse compared with those who live in rural areas ( 5 ). Our study also supports this finding, stating that many of the respondents from rural Cambodia oppose premarital sex. After marriage, the purposive act of having a child has emerged as another primary reason for sex. Most rural households depend on agriculture and related subsectors to survive. Since launching its official rice export policy in 2010, Cambodia has emerged as a major player in the international rice commodity trade ( 8 ). Therefore, agricultural human resources are necessary for survival, and children are a form of accessible and inexpensive labor.

Cambodia's traditional wedding culture welcomes forced marriages and teenage pregnancies. For many Cambodians, marriage enhances their social and economic status ( 9 ). In addition to robbing a girl of her childhood, education, and future independence, child marriage also exposes her to the risk of fatal health complications associated with early childbearing. Additionally, forced child marriage exposes girls to repeated sexual and physical violence, which can have devastating effects on their mental and physical health and undermine gender equality ( 10 ). This practice deprives Cambodian women of sexual agency after marriage.

Most of the social norms underpinning this marriage system are patriarchal. For young girls, early marriage signifies an early transition to adulthood, socially imposed sexual norms, mandatory obedience, filial piety, and lack of economic freedom ( 11 ). In Cambodia, women are constantly exposed to sexual violence as a result of their subordinate status in a patriarchal society. This system renders women vulnerable to exploitation at the hands of their husbands, fathers, neighbors, authorities, and other male figures ( 12 ). Furthermore, social and cultural practices prevent women from exercising their rights to self-determination. These social norms are linked to Cambodia's early and forced marriage systems ( 5 ), as well as the Khmer cultural principle known as Chbab Srey ( 13 ). Cambodian culture encourages marriage at a young age, when women are typically unable to decide for themselves. Chbab Srey is considered crucial in Khmer culture and is taught in schools and Khmer literature. It codifies women's status at home and conveys the idea that married women should be respectful and submissive toward their husbands ( 13 ). Failure to comply with Chbab Srey results in social sanctions and exclusions ( 14 ). Moreover, most women are dependent (financially or otherwise) on their husbands, especially if they have children. In this social system, women have no option but to obey men ( 12 ).

Essentially, having children means preparing for old age. In Cambodia, filial piety means that most residents believe their children should devote themselves to their parents' welfare.

Many Asian cultures view sexuality as taboo and forbid sexual activities outside of marriage. However, increased access to media access has strengthened permissive attitudes toward dating and premarital sex among adolescents ( 2 ). In Cambodia, men enjoy more freedom than women. Women in Cambodia often repress their potential, whereas men enjoy the innate privileges afforded by their gender ( 5 ). A famous Cambodian Khmer proverb, “fruits should not ripen before they change color,” advises young women to maintain their virginity until marriage ( 15 ). In Cambodia, a woman's virginity is considered a sacred virtue reserved for their future spouses. Furthermore, a girl who loses virginity is a disgrace to her family, regardless of whether it was caused by sexual abuse, and will remain a loss of “virtue” ( 9 ). Cambodian society also disapproves of children born outside of wedlock, compelling young pregnant girls to marry ( 12 ). The 1975–1979 Cambodian Civil War disrupted social and family norms and precipitated rapid lifestyle changes. This period saw a decline in traditional monogamy and increased sexual promiscuity, often resulting from increased access to sex workers, who are individuals receiving monetary compensation in exchange for consensual sexual services ( 16 ). Almost half of the participants (45.0%) had their first sexual experience with a sex worker, and over half (58.3%) had engaged in sexual intercourse with multiple sex partners, including their wives ( 16 ). In Phnom Penh, Cambodia, the prevalence of HIV among sex workers ranged from 9.2% to 23% ( 17 ). Alarming statistics revealed that over 40% of new HIV infections are identified among adolescents ( 18 ). Furthermore, most Cambodian men engage in unprotected sex, such as not wearing a condom, with their wives, despite being uncertain about their HIV status ( 19 ). Some reasons for not practicing safe sex were poor sexual sensitivity, lack of prophylactic knowledge, and the belief that condom use indicates a lack of spousal trust ( 19 ). A recent study in Cambodia revealed that 68% of young males aged 16–24 years old were sexually active, and 27% of them had sexual contact with sex workers within the previous year, placing them at a high risk of contracting HIV ( 20 ).

In a qualitative study among Cambodian adults, sex was perceived as a woman's obligation but a man's personal pleasure ( 21 ). However, the sexual behaviors and perceptions of Cambodian adolescents are gradually changing and are influenced by cultural perceptions and subjective factors. As such, the patriarchal culture practiced in Cambodia may have substantially influenced these perceptions and behaviors. The purpose and meaning of sex in adolescents may be associated with early sexual initiation and practice of unprotected sex. This may also be related to efforts to maintain virginity, all of which can help develop programs to prevent STIs and improve reproductive health. This study was conducted to explore the perceptions of Cambodian adolescents toward sex to understand the cultural influence on sexual behaviors.

2 Materials and methods

2.1 study design, participants, and setting.

A descriptive qualitative approach was used to investigate the significance of sex to Cambodian adolescents. Three rural provinces in Cambodia, Kandal, Kompong Speu, and Kampong Chhnang, were selected through convenience sampling. This study was conducted between July and August 2017 in the high schools of these provinces. To be included in this study, participants must be (a) Cambodian residents, (b) third-year high school students, (c) aged 17–19 years, and (d) unmarried. The study aims, research processes, and interview questions were approved by the Cambodian Ministry of Education, Youth, and Sports. Furthermore, the respective high school principals approved the study after they were informed of its purpose, eligibility criteria, participation process, and student recruitment. The schools provided a private room to ensure confidentiality. The interviews were digitally audio recorded with participants' permission. Ethical permission for the study was obtained from the Jeonbuk National University Institutional Human Subjects Review Committee (2017-06-014-002) and Cambodia National Ethics Committee for Health Research of the Ministry of Health.

2.2 Data collection

The study team included two non-Cambodian (two females) and two Cambodian (one male and one female) researchers. Third-year students were briefly introduced to the study and its purpose. The participants were informed of their right to information privacy, confidentiality, and withdrawal at any time. Only those who agreed to participate were given a date and time for the interview. Informed consent was obtained from the participants, and interviews were conducted in Khmer using an in-depth interview guide and open-ended questions, such as “Can you explain your understanding of the concept of sex?” to explore the general perception of ex among adolescents. Additional probing questions were used to elicit rich and detailed perspectives from the participant, such as (1) “Tell me more about that …”, (2) “Tell me what you meant by…”, and (3) “How did that make you feel?” Two non-Cambodian investigators completed the data collection, while the Cambodian investigator assisted as a bilingual Khmer/English interpreter throughout the process. A male interpreter assisted the male participants, whereas a female interpreter assisted the female participants. So as to reduce bias between the researchers, the primary investigator participated in the male and female interviews. The gender identity of the primary investigator (PI) was female, and she participated in interviews while maintaining a neutral stance. To mitigate potential gender-related biases in the interviews, the PI adhered to the principles of qualitative research and research ethics, ensuring transparency throughout the process. These deliberate efforts were undertaken to uphold rigorous and unbiased research practices. Given that the research team conducted the interviews while traveling together, after each daily interview, the research team gathered to share the interview progress and monitor the follow-up. Each interview lasted between 40 and 80 min, and data were collected until data saturation. As a token of appreciation, each participant was given 20,000 Cambodian riels (equivalent to US$5) in a sealed envelope upon completing the interview. A total of 48 male and 43 female students participated in the interviews.

2.3 Data analysis

Each participant was assigned a pseudonym to ensure their privacy and confidentiality. The digitally recorded interviews were transcribed by a native Khmer speaker and translated into English. The interviews were then analyzed using thematic qualitative analysis ( 22 ). First, data familiarity was achieved by repeatedly reading the English transcripts. The initial concepts that represented the most critical features of the data were then coded to produce themes. The codes relevant to each theme were classified into subthemes. Next, a thematic “map” was created on the basis of whether the potential themes worked with the extracted codes and entire dataset. Themes were then assigned definitions and names to refine their characteristics. Finally, a written analysis was conducted after reviewing themes related to the literature and interview questions. Thereafter, the transcripts were read and reviewed to ensure that the codes adequately represented the aims of the study in the Cambodian context. The ATlas.ti software (version 6.0) was used to mark the code.

2.4 Ensuring research rigor

In order to enhance the rigor of our qualitative research, we maintained a high degree of transparency and reflexivity throughout the study. Transparency was achieved by meticulously documenting and reporting our research process, allowing for the scrutiny of our methods and decision-making. This documentation included detailed notes on data collection, coding processes, and analytical decisions. Reflexivity was a critical component of our study, as we recognized the potential impact of our own perspectives and experiences on the research process. To address this, we consistently engaged in self-reflection and acknowledged our positionalities, which were used to inform our interpretation of the data. This reflexive approach helped ensure that our findings were as objective as possible.

The average age of the participants was 17.9 and 18.7 years for females and males, respectively. Most participants identified as Buddhists. Their average monthly spending money was US$89 for females, whereas US$113 for males. Most participants lived with their parents ( Table 1 ). Regarding what sex meant to them, the following themes emerged from the data analysis: (1) desire: Releasing sexual desire and stress; (2) relationship: an emotional connection and demonstration of love; (3) roles: responsibilities within a woman's marital duties; and (4) values: the value of virginity and future engagement. Table 2 displays the themes, sub-themes, and corresponding codes.

Table 1 . Characteristics of the participants.

Table 2 . The results of the analysis: theme, sub-themes, codes.

3.1.1 Releasing sexual desire and stress

Many participants, including females, agreed that they found sex enjoyable. One male student mentioned that humans, similar to animals, naturally desire fulfilling their sexual needs. Sex is also regarded as a form of stress relief or evening entertainment.

“And maybe it is our desire. It is normal for men and women to desire sex.” (Soren, female, aged 18)

“For general people, some just want to have fun for a while, and they need to fulfill their desire.” (Nita, female, aged 19)

“The purpose of sex is to fulfill our sexual desires, and humans have similar feelings as animals. We want to have fun, so we do it to satisfy our desires.” (Kosal, male, aged 19)

3.2 Relationships

Male and female participants expressed that sex was a way to strengthen relationships and that the act of sex became a medium for expressing love toward one another. This theme was used to examine the romantic responses of students to sexual encounters.

3.2.1 A way to connect with one another

One female student believes that sex is a ritual in which two people accepted each other as life partners. She noted that sex serves as a physical promise to their partners, signifying their romantic bond that would endure for the rest of their lives. One male student provided a similar answer, stating that sex evokes feelings of love and happiness. He added that he felt at ease after engaging in sexual activity with his significant other.

“The meaning of sex is the accepting of a person into my life and us becoming one.” (Chanthavy, female, aged 18)

“We need sex to feel happy, in love, and connected with a partner, and able to sleep.” (Khemera, male, aged 18)

3.2.2 A way to show love

Many female students claimed that they express their affection through sex. To them, the act represents love, trust, honesty, faith, and the commitment to never betray their partners. Furthermore, many were willing to have sex with someone they genuinely loved.

“I am aware that sometimes it is the display of love. If we are just friends, I will not allow touching or having intimate relationships. However, for the person I love, I will allow it. I will be willing to sacrifice my body to fulfill his desires. This is the meaning of the love that I have shown him. Love is shown through sexual intercourse.” (Bopha, female, aged 18)

“I want to show him my faithfulness and sincerity that I will never betray him.” (Chenda, female, aged 17)

3.3.1 Conditional acts: after marriage

As provisions of sexual intercourse have been frequently discussed, this theme focuses specifically on marital sex. Some female participants believe that marriage authorizes them to give their husbands something they had previously protected and treasured. Despite the fact that modern norms indicate an increase in the prevalence of premarital sex, many still regard sex as an act of love between husband and wife, such that they should not hesitate to give themselves in such a physical manner in a marital context.

“It’s meaningful when both of them decide to get married and they can wait till the last night.” (Kiry, male, aged 18)

“[Sex is] to show the love and at that time we should not be afraid of anything because we are already husband and wife. So, what I have kept I will give to my husband.” (Deavy, female, aged 16)

3.3.2 Purposive acts: reproductive means

Many participants mentioned children on this theme. They believe that the purpose of marriage is to have children, which requires sexual intercourse. For these participants, children are the result of their love and an investment in their old age. Some participants claimed that children unite a couple and serve as a means to continue their lineage. One participant felt that he needed someone to care for him as he aged. He regarded the child as a resource to support him during old age.

“The meaning of sex… is the desire of a man who wants to be with a woman and to have a baby.” (Kunthea, female, aged 18)

“I think after marriage we have sex because we want to have children to protect our lineage and receive the result of our love.” (Chantou, female, aged 18)

“I think, [the purpose of sex is] to have kids for the next generation. When I get older, they can take care of me.” (Mony, female, aged 18)

3.3.3 Dutiful acts: wifely responsibilities

Some female students felt that sex would be their duty, as husbands took their wives for that purpose. Some women claimed that marriage was the act of giving life to their husbands. These participants believe that they are willing to sacrifice everything for their husbands after marriage because these men would provide for them for the rest of their lives. As part of this sacrifice, their husbands' sexual desires must be fulfilled.

“Because it is his desire, I will fulfill it, as we mentioned earlier, whatever he likes and we serve him, something like that.” (Bopha, female, aged 18)

“The wife should fulfill her duty as a wife because the husband gets a wife to fulfill his needs.” (Kanya, female, aged 18)

Additional questions were posed to the female participants. They were asked what they would do if their husbands asked for sex several times a day. While many female participants regarded sex as their duty, they generally responded negatively to the prospect of excessive demand for sex. They felt that excessive sexual intercourse would lead health problems in their reproductive system. Others thought that this would hinder their ability to complete daytime tasks. Many female respondents claimed that unlike previous generations, most modern women participated in economic activities. These obligations, in conjunction with familial duties, meant that they cannot comply with the frequent demands for sex.

“It is because I cannot have sex with him more than once a day. Sometimes, it exhausts me, and my health deteriorates. My health is more important, so I have to think of it.” (Maly, female, aged 18)

“The woman in this present day is not like before, [and] most women now also work outside to earn money. In the olden times she was just a housewife, and had to stay at home, but now it is different.” (Neary, female, aged 19)

This theme explains the different perceptions of sexual relationships, as they pertain to sex with a wife, sex worker, or girlfriend. A few male students were pleased with the prospect of sexual intimacy with pure and virgin wives. However, they felt psychologically burdened by engaging in premarital sex with a girlfriend due to unclear responsibilities and uncertain future. Furthermore, they were not sufficiently satisfied when engaging in sexual activities with workers.

3.4.1 Wife vs. sex worker: the value of virginity

Several male students clearly distinguished between potential wives and sex workers. However, they focused on virginity as the key factor. According to them, being a virgin is synonymous with having a clean body, which makes sex more pleasurable. These male participants claimed that while their wives would be pure, sex workers would not. Thus, sexual experiences with sex workers are less gratifying. One participant said:

“Having sex with the sex worker is not romantic because all of them have already lost their virginity and have less sexual pleasure, which is unlike wives or girlfriends who have a clean body because they allow sex only with the person they love. I can say it is more romantic.” (Dara, male, aged 19)

A few female students mentioned virginity. They believe that they had to offer pure bodies to their future husbands as a bond to unite them.

“I think he believes in me, [that] I have never done bad things before. And my virginity will be given to him so that he knows his baby is really his and understands that the baby that comes from his blood that belongs to him.” (Sothy, female, aged 18)

3.4.2 Girlfriend or wife: the burden of future engagement

While discussing their girlfriends, a few of the male students focused on the possibility of marriage. They expressed anxiety about having premarital sex due to the uncertainty of the relationship in the future. These male participants explained that engaging in sexual activities with a girlfriend may lead to unexpected pregnancies or STIs. Furthermore, they described it as being out of wedlock; thus, less meaningful to them.

“Having sex with a girlfriend, we are not sure if we can be responsible or marry her. Unlike having sex with a wife, which is to have children and create a family together.” (Manndy, male, aged 19)

4 Discussion

This study investigated the social and cultural perspectives on sex among adolescents in Cambodia. The influence of Cambodian culture on adolescents' sexual concepts and behaviors is a key outcome of this research. This study demonstrated differences and similarities in attitudes and perspectives of young men and women regarding sex.

Our study found males and females agreed that sexual intercourse grants them happiness and satisfaction, whereas for women, it is a marital obligation. Most of the respondents who focused on sex for physical pleasure were male. Men often focus on the physical aspects of sex, whereas women focus on the emotional aspects. Some male students acknowledged the emotional exchanges involved in sexual intercourse. These participants agreed that sex strengthened their relationship with their partners, allowing them to express their love for one another and feel connected.

Previous study reported that sex was considered a women's obligation ( 21 ). Our study result also revealed some female adolescents expressed that wives were obligated to have sex with their husbands. Others felt a strong sense of duty toward their role as wives, particularly concerning sexual matters. These beliefs are driven by societal and cultural norms that encourage acquiescence toward a husband's sexual desires ( 23 ).Some male participants ascribed different values to sex, depending on their sexual partner (wife, girlfriend, or sex worker). In Cambodian culture, a girl's values vary on the basis of her purity ( 24 ), and women are taught that a wife should retain her vaginal purity until marriage. Our study found many believed that a “pure” woman is dedicated entirely to her husband, which increases sexual gratification. Male adolescents expressed that they would feel more comfortable having sex with a future wife than with their girlfriends. Among the various sexual services, paid services for sex workers were the only ones available to experience sexual release. Interestingly, not all women view sex workers negatively. Previous literature reported that some wives believe they are incapable of sexually pleasing their husbands; thus, they encourage their husbands to have sexual relations with other women to avoid divorce ( 23 ). Additionally, men often perceive sex as innate and vital for personal happiness. In Cambodia, engaging with sex workers is a prevalent cultural norm, and Cambodian society does not view it negatively ( 19 ). However, sex workers, of which there are an estimated 40,000 nationwide, are considered a high-risk group for STIs ( 25 ). Recently, the prevalence of STIs in Cambodia has significantly decreased as a result of the government's national efforts to protect sex workers from STIs ( 26 ). However, despite those efforts, men often spread STIs to their wives when they do not use condoms during sexual intercourse ( 19 ).

To prevent STI transmission in Cambodia, the perception of sexual labor must be altered. The fulfillment of masculine needs is often used to justify engaging with sex workers; however, these men must be made aware of the dangers of STIs. Furthermore, those at risk of spreading STIs should be educated on the essential use of condoms during intercourse, even with their wives, to prevent transmission. Thus, rather than demonizing sex workers, STI cross-infection must be minimized.

Cambodia has a unique culture that includes sexual behavior among adolescents and young adults. Although Cambodian society has changed under the influence of Western culture, this study revealed that some Cambodian adolescents retain traditional attitudes toward sexual behavior. Furthermore, Cambodian men have more sexual and general freedom, whereas women are expected to retain their “purity” for their future husbands. Additionally, male sex before marriage is widely accepted by male and female adolescents.

The level of sexual concept varies depending on the meaning and purpose of sex, and in some cases, the risk of exposure to early sexual experience, lack of condom use, and maintenance of multiple sex partners may increase. Indiscriminate sex, caused by low-level sexual concepts, can be a shortcut to facing uncomfortable situations (e.g., STIs, unexpected pregnancies, and so on.) Adolescents and young adults should be taught that seeking sexual health care is necessary and normal to protect their health and that of their loved ones. Systems should also be established wherein adolescents can access regular check-ups. As in many developing countries, access to health care in Cambodia is constrained by poverty. By understanding Cambodian youth's perspective on sex, we can better understand the prevalence of STIs and the causes of unexpected pregnancies among adolescents in Cambodia. Several educational programs and resources are available to inform Cambodian citizens about safe sex practices and encourage the use of health services. However, STIs continue to spread from husbands to wives. Therefore, revised and culturally accepted sex education and intervention programs must be implemented to prevent the spread of STIs. Ultimately, adolescents in Cambodia must be taught appropriate SRH education.

5 Strengths and limitation of the study

A notable strength of this study is its adherence to rigorous qualitative research methodology, conducted across three regions capturing the perspectives of approximately 100 high school seniors. They eloquently expressed their thoughts and viewpoints, allowing for a comprehensive understanding of perspectives within Cambodia's unique culture and societal context. This can be considered a pioneering study in this regard. However, this study interviewed adolescents in rural areas only. Therefore, future study should include adolescents in urban areas to capture any changes in perception on sex among Cambodian adolescents nowadays. While language limitations may arise due to the principal investigator being a non-Cambodian researcher, over five years of residence in Cambodia and extensive research conducted within the country contribute to overcoming this challenge, supported by knowledgeable and skillful local scholars.

6 Conclusion

This study was conducted to comprehend the perspectives on sexuality among Cambodian adolescents. The research findings revealed differences between the viewpoints of males and females, but they were not significantly different from those of adults. To prevent HIV, STIs, and teenage pregnancy, there is a need for comprehensive sexual education promoting healthy attitudes towards sexuality and practicing protected sex. As the internet and social media continue to advance, contemporary adolescents exposed to these mediums require ICT-based educational resources and content. To support this, various research initiatives and policies should be in place.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Jeonbuk National University Institutional Human Subjects Review Committee (2017-06-014-002) and Cambodia National Ethics Committee for Health Research of the Ministry of Health. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

Author contributions

YY: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. JK: Writing – original draft, Writing – review & editing. GP: Writing – original draft, Writing – review & editing. RT: Writing – original draft, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article.

This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (2016S1A2A2912566).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: adolescents, cambodia, HIV, sexual health, STIs

Citation: Yang Y, Kim J, Park G and Thapa R (2024) Exploring Cambodian adolescents' perceptions on sex: a qualitative investigation. Front. Reprod. Health 6:1275941. doi: 10.3389/frph.2024.1275941

Received: 10 August 2023; Accepted: 8 May 2024; Published: 16 May 2024.

Reviewed by:

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

*Correspondence: Gloria Park, [email protected]

This article is part of the Research Topic

Reproductive Health and Mental Health in LMICs: Adolescent Health