ethics in qualitative research issues and challenges

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Perspect Med Educ
v.7(2); 2018 Apr

Difficult but important questions about the ethics of qualitative research

Elise paradis.

1 University of Toronto, Toronto, Canada

Lara Varpio

2 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland USA

We are excited to write this commentary and commend Reid and colleagues for their reflexions on their personal challenges with the ethics of qualitative research. Recently, Baker et al. [ 1 ] educated our health professions education community about the difference between procedural and practical ethics. Procedural ethics refers to the formal process of ethical board review, and practical ethics refers to the ethical decision-making that arises during research practice [ 1 , p. 607]. These authors note the importance of authentically representing study participants, minimizing power differentials, and contributing meaningfully to knowledge. Baker et al. argue for reflexivity, which can help researchers ‘appreciate the importance of procedural ethics and respond thoughtfully to practical ethics’ (p. 607).

This is precisely what Reid and colleagues do in their piece titled ‘Ethical dilemmas and reflexivity in qualitative research’ [ 2 ]: through reflection, they make themselves and their research practices open to scrutiny. In so doing, the authors offer us glimpses into the power of reflexive research practices. Following Tracy [ 3 ], Reid et al. explore four domains of research processes and products: procedural ethics (or the ethics approval process, where the authors cover issues of integrity and altruism), situational ethics (or the research context, where they discuss access negotiations), ethical relationships between researchers and participants (where the authors explore power dynamics and role conflicts), as well as issues related to completing and disseminating findings.

Through their work, Reid and colleagues illustrate powerfully how the ethics of qualitative research involves much more than obtaining informed consent before an interview, ensuring that data are anonymized prior to analysis, or following our institutional review board’s prescriptions for how data will be stored securely. Indeed, the ethics of qualitative research are much more than “a ‘hurdle’ to be surmounted” [ 2 ]. The ethics of qualitative research live in the ‘specific and situated ethical tensions and dilemmas [that] arise during the practice of research’ [ 2 ]. Reid et al.’s piece is an important step towards making these tensions and dilemmas part of the research discourse in health professions education. Their work clearly identifies an under-explored area in health professions education research: research on practical ethics.

As qualitative researchers, we also have first-hand knowledge of the ethical challenges that are part of qualitative research. In fact, some research experiences haunted one of us (L.V.) for nearly 10 years. Only recently was L.V. able to articulate the lessons learned during a needs assessment study for global health education (GHE) as a lesson in practical ethics [ 4 ]. This 10-year delay between the experience and the sharing of that story is, at least in part, indicative of how daunting it can be for researchers to talk about ethical dilemmas. In the case of the GHE needs assessment, the research team stumbled upon stories of emotional and physical trauma experienced by learners while engaging in global health experiences. While no ethical lines were crossed during the research intervention or data collection, the interview data unveiled a problem of which the local institution was completely unaware. Close data monitoring allowed the research team to react quickly to these stories, but sharing how the situation was handled was difficult. It felt like a story that should be hidden rather than shared. It was uncomfortable. But it is those uncomfortable stories and situations that will enable all of us to be better qualitative researchers and better partners to our research participants. Instead of burying those stories, or waiting 10 years to tell them, we want to encourage readers to share their experiences of contending with the ethics of qualitative research.

Reid et al. [ 2 ] also challenge us to face the very hard question of whether research can ever be truly altruistic. As researchers, we always benefit directly from the research we conduct (through the prestige and rewards associated with grant capture and/or publishing), while our research participants rarely do: they seldom read our publications and generally are not the beneficiaries of the educational and policy changes that follow from our findings. Our community has not yet brought participatory approaches into the mainstream, but Reid et al. challenge us to consider more carefully the role of principal investigators in defining research agendas.

Finally, and unfortunately, health professions education research is still held to the ethical standards developed for clinical medicine. Qualitative research often needs to be contorted to fit ethical review forms that reflect clinical research. The kinds of phenomena that are qualitatively studied—people’s perceptions and practices—are often deemed to be without any risk to participants. Yet, as Reid et al.’s piece shows, this is simply not the case.

Qualitative researchers in our field need to take action. We must advocate for the transformation of the ethics approval process to address the ethics of qualitative research. Yes, this will likely require that we educate, and maybe even sit on, ethics review committees. We may need to get involved with the design of ethics-related educational modules that address the specificities of the ethics of qualitative research. But we contend that it is better to invest our time and energy in doing that work than wasting it on the charade that there are no ethical challenges in qualitative research.

Biographies

PhD, is assistant professor at the University of Toronto’s Leslie Dan Faculty of Pharmacy, and cross-appointed with the Department of Anesthesia and the Department of Sociology. She is also a scientist at the Wilson Centre, and a fellow of the Centre for Critical Qualitative Health Research.

PhD, is professor of Medicine and associate director of Research for the Health Professions Education graduate degree program at the Uniformed Services University of the Health Sciences (USU).

Conflict of interest

E. Paradis and L. Varpio declare that they have no competing interests.

The views expressed in this manuscript are solely those of the authors and do not necessarily reflect those of the Uniformed Services University of the Health Sciences or the US Department of Defense.

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Ethics in Qualitative Research Controversies and Contexts

Martyn Hammersley - The Open University, UK
Anna Traianou - Goldsmiths, University of London, UK
Description

All researchers need to think about research ethics, and for a variety of reasons it is an increasingly important part of research methods training. Ethics in Qualitative Research explores this field and presents a distinctive perspective; one that is at odds with the assumptions underpinning ethical regulation, but also with the views of many qualitative researchers today.

Martyn Hammersley and Anna Traianou emphasize the difficult and controversial character of ethical issues, and examine the philosophical assumptions involved, the social contexts in which key ethical principles arise, and their implications for research practice.

The authors argue that the starting point for any discussion of research ethics must be the values intrinsic to research, above all the commitment to knowledge-production. However, the pursuit of inquiry is rightly constrained by external values, and the book focuses on three of these: minimizing harm, respecting autonomy, and protecting privacy. These values are shown to be far from unequivocal in character, often in conflict with one another, or with the commitments of research, and always subject to situational interpretation and practical judgment.

It is argued that in the present challenging times it is essential that qualitative researchers think clearly about, and stand up for, their principles.

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As a former Masters student and novice qualitative researcher, had I had more insight into the complexities around ethics detailed in this book before entering the field I may well have been better equipped to deal with some of the more problematic issues I encountered. Chloe Roberts Action Learning: Research & Practice

What is ethical acting in qualitative research, what want to say it when you act ethical or unethical, and just imagine that how solid are questions at the heart of this book. The introduction is also immediately announced that answering these questions is not easy and that the answers given by the authors are controversial. Such a statement makes me curious and will read something very new in the hope you go with the book to get started. (Translation).

Very useful on the ethics course to encourage critique and reflection on ethical issues in qualitative research and to support the students in developing ethical awareness

Martyn Hammersley and Anna Traianou have set out to examine some important underlying assumptions and concepts in ethics in qualitative research. Starting with a historical context for the ever increasing ethical requirements in research since the mid 20thC, the authors then set the tone and tenor of the discussion by raising the debate around the perceived purpose of research ethics. They invoke the moral dimension of research aims and outcomes, differentiating between the ethical requirements of research within an institutional context together with the morality of differing research design in various populations and from a range of perspectives. This is an informative and thought-provoking text that will appeal to postgraduate students keen to use qualitative methods as well as experienced researchers, wanting to revisit and re-examine some important ethical debates.

Excellent and thought provoking text which challenges mainstream beliefs around ethics in qualitative research. Would cause you to challenge your core understanding on principles associated with certain aspects relating to qualitative research. Particularly liked the synopsis of chapters in the summary section too. Useful if you are re-visiting the text after a break away.

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Sociology of the Sacred - Ch.1 : Introduction

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ETHICS IN QUALITATIVE RESEARCH: ISSUES AND CHALLENGES

Published 2006
Education, Sociology

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Ethical challenges in qualitative research: examples from practice

Affiliation.

1 School of Nursing and Midwifery Studies, National University of Ireland, Galway.
PMID: 21138082
DOI: 10.7748/nr2010.10.18.1.15.c8044

This article examines the many ethical challenges that are specific to qualitative research. These challenges concern the issues of informed consent procedures, the researcher-participant relationship, risk-benefit ratio, confidentiality and the dual role of the nurse-researcher. Each challenge will be examined and practical examples of how it was dealt with, using examples from a multiple case study, will be described.

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Ethical challenges in the conduct of qualitative research. Hegney D, Chan TW. Hegney D, et al. Nurse Res. 2010;18(1):4-7. doi: 10.7748/nr2010.10.18.1.4.c8042. Nurse Res. 2010. PMID: 21138080 No abstract available.

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Open access
Published: 06 September 2024

“ Starting to think that way from the start” : approaching deprescribing decision-making for people accessing palliative care - a qualitative exploration of healthcare professionals views

Anna Robinson-Barella 1 , 2 ,
Charlotte Lucy Richardson 1 , 2 ,
Zana Bayley 1 ,
Andy Husband 1 , 2 ,
Andy Bojke 3 ,
Rona Bojke 3 ,
Catherine Exley 2 ,
Barbara Hanratty 2 ,
Joanna Elverson 4 ,
Jesse Jansen 5 &
Adam Todd ORCID: orcid.org/0000-0003-1496-9341 1 , 2

BMC Palliative Care volume 23 , Article number: 221 ( 2024 ) Cite this article

Metrics details

Deprescribing has been defined as the planned process of reducing or stopping medications that may no longer be beneficial or are causing harm, with the goal of reducing medication burden while improving patient quality of life. At present, little is known about the specific challenges of decision-making to support deprescribing for patients who are accessing palliative care. By exploring the perspectives of healthcare professionals, this qualitative study aimed to address this gap, and explore the challenges of, and potential solutions to, making decisions about deprescribing in a palliative care context.

Semi-structured interviews were conducted with healthcare professionals in-person or via video call, between August 2022 – January 2023. Perspectives on approaches to deprescribing in palliative care; when and how they might deprescribe; and the role of carers and family members within this process were discussed. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the NHS Health Research Authority (ref 305394).

Twenty healthcare professionals were interviewed, including: medical consultants, nurses, specialist pharmacists, and general practitioners (GPs). Participants described the importance of deprescribing decision-making, and that it should be a considered, proactive, and planned process. Three themes were developed from the data, which centred on: (1) professional attitudes, competency and responsibility towards deprescribing; (2) changing the culture of deprescribing; and (3) involving the patient and family/caregivers in deprescribing decision-making.

Conclusions

This study sought to explore the perspectives of healthcare professionals with responsibility for making deprescribing decisions with people accessing palliative care services. A range of healthcare professionals identified the importance of supporting decision-making in deprescribing, so it becomes a proactive process within a patient’s care journey, rather than a reactive consequence. Future work should explore how healthcare professionals, patients and their family can be supported in the shared decision-making processes of deprescribing.

Trial registration

Ethical approval was obtained from the NHS Health Research Authority (ref 305394).

Peer Review reports

Deprescribing has been defined as the planned process, under the supervision of healthcare professionals, of reducing or stopping medications that may no longer be beneficial or are causing harm, with the goal of reducing medication burden while improving patient quality of life [ 1 , 2 , 3 ]. On a global level, there is a growing recognition of the need for deprescribing [ 4 ], with the World Health Organisation (WHO) including it as a component of safe medication management, stating the process should be ‘as robust as that of prescribing’ [ 5 ]. In a palliative care context, where polypharmacy is common and medication burden is high [ 6 , 7 ], deprescribing is an increasingly important care consideration. Indeed, there is growing evidence that deprescribing can be a safe and effective way to improve outcomes for patients using potentially inappropriate medication [ 8 , 9 , 10 ]. For example, studies concerning the deprescribing of anti-hypertensives, diuretics, benzodiazepines, antipsychotics and statins have demonstrated physical and cognitive benefits, and no significant harm, when these medications are reduced or stopped [ 11 , 12 , 13 , 14 ]. Studies have also shown that deprescribing of medications for patients with life limiting illness can improve quality of life [ 15 ], as well as reducing the risk of developing adverse drug events [ 16 ]. Whilst evidence has demonstrated that some interventions can be used to support deprescribing, practical challenges still remain; these can influence a decision to stop or reduce medication - especially in a palliative care context. For example: how to involve a multi-disciplinary team of healthcare professionals, patients and their family members when making shared decisions about possible deprescribing [ 3 ]. A recent systematic review explored these challenges further and highlighted the importance of involving all stakeholders in the deprescribing decision-making process to ensure a joint decision is made between the patient and healthcare professional [ 17 ]. Whilst several studies have focused on the broader issues of taking steps towards deprescribing in a palliative care context [ 18 , 19 , 20 , 21 ], at present, little is known about the specific challenges of decision-making that support deprescribing to occur. By exploring the perspectives of healthcare professionals with responsibility for prescribing medication, this qualitative study aimed to address this gap, explore the challenges of, and potential solutions to, making decisions about deprescribing in a palliative care context.

Recruitment and sampling

The consolidated criteria for reporting qualitative research (COREQ) checklist was followed (see Item 1 , Supplementary File) [ 22 ]. Inclusion criteria comprised: healthcare professionals (such as nurses, pharmacists and medical doctors) with experience of prescribing or reviewing medication for patients in receipt of palliative care. To be included in the study, healthcare professionals had to practice in the UK. Recruitment was facilitated by (i) two hospital and two hospice research sites in the North East of England, United Kingdom (UK), (ii) professional palliative care networks of the research team and (iii) social media. All interested participants were emailed a participant information sheet and consent form detailing the purpose and aims of the research. Those who expressed an interest and gave their informed written consent, were enrolled in the study. There was no relationship established between the researcher and participants prior to study commencement or recruitment. Convenience sampling was used to recruit participants from a variety of job roles and responsibilities, as well as providing generalist or specialist palliative care. Practitioner age and time qualified were also considered within the sampling framework.

Semi-structured interviews

In-depth, semi-structured interviews were conducted by one researcher (ZB, a female postdoctoral researcher with experience of qualitative research) between August 2022 and January 2023. Interviews were conducted remotely ( via Zoom) or in-person (face-to-face) depending on participant preference. The semi-structured interview topic guide (see Item 2 , Supplementary File for the complete interview guide) was developed based on three pilot interviews (not included in the final participant numbers) and was informed by findings from previous studies conducted by the research team [ 23 , 24 ], as well as the lived-experiences of patient champions involved in this study (AB and RB). Areas explored included: participants’ perspectives on, and approaches to, deprescribing; when and how they might deprescribe; the role of carers and family members within this process; and exploration of gaps around deprescribing decision-making.

Data analysis

All semi-structured interviews were audio-recorded to enable data analysis. The audio files were encrypted and transcribed verbatim by an external transcription company; audio files were uploaded to an encrypted, password-protected site and immediately following confirmation of accurate transcription were deleted. All interview data were anonymised at the point of transcription and all transcripts were checked for accuracy and correctness by ZB and CLR (a researcher with expertise in qualitative research). Participants did not provide comment on the transcripts, nor feedback on results.

Following reflexive thematic analysis processes, as defined by Braun and Clarke [ 25 , 26 ], the principle of constant comparison guided an iterative process of data collection and analysis. Reflexive thematic analysis was performed by two researchers (CLR and AR-B, a researcher with expertise in conducting qualitative research) to analyse the interview data. Close and detailed reading of the transcripts allowed the researchers to familiarise themselves with the data. Initial descriptive codes were identified in a systematic manner across the data; these were then sorted into common coding patterns, which enabled the development of analytic themes from the data. The themes were reviewed, refined and named once coherent and distinctive. Two authors (AR-B and CLR) performed the data analysis through discussion and, if agreement was not reached, by consensus with the other members of the research team (AT, AH and CE, with expertise in palliative care and qualitative research). Post-interview field notes enhanced this reflective process. NVivo (version 12) software was used to facilitate data management. The research team were in agreement that data sufficiency and information power [ 27 , 28 ] occurred after 18 semi-structured interviews and thus, study recruitment stopped following interview number 20; recurring similarity within participant responses, with no new concepts discussed, guided this decision. To ensure confidentiality when using direct participant quotes, non-identifiable pseudonyms are used throughout the research (e.g., Participant 1 and Participant 2 etc.)

Ethical approval

This study was granted ethical approval by the UK National Health Service (NHS) Health Research Authority (reference 305394, date approved: 08.04.2022, South Birmingham REC). Research governance was followed in accordance with Newcastle University and NHS Trust research policies at study sites.

Participant demographics

Twenty participants were recruited and interviewed for this study (participant demographics are described in Table 1 ). Of the twenty participants interviewed; 7 described their job role as a medical consultant working within various settings in the UK (including palliative medicine and respiratory medicine), 6 participants were nurses providing palliative and end-of-life care to patients across primary or secondary care settings, 4 were specialist pharmacists working across a range of disciplines, including frailty and heart failure, and 3 participants were general practitioners (GPs). Nineteen participants self-reported their ethnicity as White British and one participant identified as British Asian. Twelve of the 20 participants were aged between 40 and 50 years and the mean time qualified in their respective roles was 17 years (SD ± 8.5 years). Five interviews were conducted using video software (Zoom ® , n = 5), while the rest were carried out in-person ( n = 15). Interviews ranged from 27 to 62 min. There were no refusals to partake, participant dropouts or repeat interviews.

From the interviews, many participants described the importance of deprescribing decision-making, and that it should be a considered, proactive, and planned process. To achieve this, three themes and subsequent sub-themes were developed from the data (Fig. 1 ); these focused on: (1) professional attitudes, competency and responsibility towards deprescribing; (2) changing the culture of deprescribing and (3) involving the patient and family/caregivers in deprescribing decision-making. Note the use of arrows in the figure to visually represent the interplay between the themes, and their sub-themes, as part of the bigger picture of achieving proactive deprescribing.

Themes developed to support the delivery of deprescribing as a proactive process, rather than a reactive consequence for patients in receipt of palliative care

Theme 1: Professional attitudes, competency and responsibility towards deprescribing

Taking ownership of the deprescribing decision.

Participants across all healthcare professional roles shared beliefs that deprescribing was potentially a positive process; however, a number of challenges and concerns were raised, which seemed to influence whether deprescribing was undertaken, or not. The first of these related to taking ownership of the process, and ultimately, the decision-making. A number of participants described a lack of clarity around “whose job is it to do deprescribing?” (Participant 15). In turn, participants discussed feeling “like I don’t want to be treading on other people’s toes” by making decisions about stopping medicines, particularly when patients are receiving care from “a big multidisciplinary team” (Participant 10).

“One of the big barriers I see is ownership… There’s a sense that “I don’t want to touch the rheumatology drugs” or “they’re under the heart failure team so I don’t want to touch any of that” … having some sense professionally , as a cohesive profession about who does it – I think we need to get to that place” (Participant 15 , Medical Consultant).

In efforts to take responsibility for deprescribing practices, participants acknowledged that certain healthcare settings may be better suited to make decisions about deprescribing. Two participants proposed making use of multidisciplinary team meetings as an approach to deprescribing decision-making in collaboration with members of the wider care team. One participant stated: “I would always do (deprescribing) in collaboration with , I guess what we’d call , the parent team” , indicating the connection that may be required between specialist palliative care services and other clinical specialities (Participant 12). While another participant highlighted “the beauty of palliative care specialities (for having) an easily accessible multidisciplinary team with a doctor , a specialist nurse , a physio , an OT (occupational therapist) … you can sit round the table and make those decisions and offer advice” (Participant 13). Several participants also emphasised general practice or “care offered by teams based in the community” as preferable settings to make decisions for deprescribing (Participant 1). For example, one participant working within secondary care shared a preference for community-based healthcare professionals to take ownership of deprescribing processes as they can “go into somebody’s home , where they (the patient) will feel more comfortable… in an environment where they feel safe so that open communication can be a bit easier” (Participant 1). The same participant indicated this preference for community-based ownership compared with conversations occurring “if they (the patient) were on a ward setting” (Participant 1). This was echoed by a Nurse Specialist who suggested deprescribing decision making “needs to be done in a calmer environment when you’ve got the time to have those discussions” (Participant 12).

Recognising the challenges associated with deprescribing decisions

Participants recognised the challenges that healthcare professionals face when making decisions around deprescribing medicines for patients in receipt of palliative care. One such challenge related to healthcare professionals’ fear and uncertainty about the repercussions of stopping medications. For example, the hesitancy “of stopping medications because it is not always clear what the outcome of that is going to be” for their patients (Participant 2).

“I think they’re scared of stopping an aspirin and then someone having a stroke… or stopping a NOAC (non-vitamin K oral anticoagulant) and their AF (atrial fibrillation) being uncontrolled and causing a stroke. I think they’re scared of the consequences” (Participant 13 , Specialist Pharmacist).

Several participants suggested that this fear may relate to a lack of formal education on deprescribing for healthcare professionals during their training years with one participant stating “F1 (foundation year 1) doctors are scared of doing deprescribing because it feels like a big responsibility , and that’s scary” (Participant 13). Other participants noted caution amongst medical healthcare professionals when it came to deprescribing, and postulated that causes of this could be due to a lack of exposure in training and the lack of normalisation of the process as part of their scope of practice. One participant stated that “if they (medics) learnt about it as undergraduates , like anything , the more you do it , the easier it becomes and the more confident you feel in doing it” (Participant 3) and another suggested “it will take a little time to become a normal thing for prescribers to do more confidently” (Participant 13).

Theme 2: changing the culture of deprescribing

Establishing the culture of deprescribing, by starting from the start.

Healthcare professionals shared views around better establishing the culture of deprescribing within clinical practice. They highlighted perspectives around the importance of “starting to think that way from the start” (Participant 11) at the point of prescribing a medication. Participants felt that this change to prescribing culture may also prompt patients to normalise “medicines aren’t always needed to be a forever thing” (Participant 14).

“When you prescribe something… historically people are just like , I’ve written it up and here you go and off you go. But I think maybe just having a real explanation of it… even saying there might come a point where you might want to think about stopping it” (Participant 14 , General Practitioner).

A key aspect within establishing a culture of deprescribing centred on participant’s views of the ‘best times’ to have conversations around stopping or reducing medication. One participant discussed a common trend seen in their clinical experience where conversations often happen too late in a patient’s clinical trajectory. They described feeling “ like it ends up being , if a patient is just really unwell… it’s probably then when [deprescribing] really starts being thought about” (Participant 14). Another participant working in palliative care, echoed these views and stated “by the time I’ve got involved as a palliative care nurse , it can be too late for some of these conversations. It would be nice if somebody would at least start them earlier on” (Participant 12). Despite recognising the importance of this, the ‘optimal’ timing of these conversations was not identified by participants; instead, they placed emphasis that having conversations around deprescribing should be guided according to a person’s individualised care needs. One proposed timeframe was at the point of “ an annual medication review for everyone in respect of what you’re diagnosing and treating” (Participant 12) and then “continually , as and when” thereafter (Participant 11).

Educating and empowering patients

Alongside the need for healthcare professionals to begin establishing the culture of deprescribing, it was also recognised that patient education and empowerment to make decisions around deprescribing was vital. Participants viewed deprescribing as a process ideally underpinned by shared decision-making, which should be “collaborative… we should say (to the patient) “look , in a medical opinion , we could do this , but what do you think?” I think should be a proper open discussion” (Participant 3). In order to achieve this collaboration, participants recognised the need to “give patients information in a way that they a) want and b) understand” so that they feel valued and “feel a true part of the conversation” (Participant 13). One palliative medicine consultant acknowledged the importance of patient empowerment when it came to changing the culture around deprescribing; they viewed medicines education and psychological support as vital tools to achieve supportive deprescribing and understood the worry that may accompany people having to think - and make decisions - about potentially stopping medications.

“It’s probably the first time they’ve been asked , “What does this drug really mean to you? Would it worry you if you had to stop it? What do you think it’s doing for you?” Those are quite big conversations.” (Participant 15 , Medical Consultant) .

Theme 3: involving patients (and others) in deprescribing decision-making

Acknowledging the priorities of patients, alongside others involved in their care.

Healthcare professionals recognised the need to involve patients closely in conversations and decisions around deprescribing, particularly taking into consideration their priorities when it comes to medication. A number of participants reflected on the importance of individualisation and tailoring deprescribing conversations to each specific person, rather than adopting a ‘one size fits all’ approach. One participant reflected on focusing on an individual’s preferences about taking medications, recognising that there may be discrepancies between their own clinical judgement about the necessity of a medication and the desire of a person to take it; they felt it important to voice both sides of the conversation and help the patient make an informed choice about deprescribing. From this, the importance of establishing the priorities of the patient was considered essential in deprescribing decision-making.

“Focusing on what we know what is important for that person… if somebody turned around to me and said , “I’m terrified of dying of a stroke , is it alright if I keep taking the statins?” the answer would be “absolutely yes” , and saying , “Well , what are your priorities in your remaining weeks , months , years of life , and what would you like us to focus on as healthcare professionals?” (Participant 4 , Medical Consultant).

Taking time to understand what influences a patient to take their medications was recognised by participants. It appeared important to appreciate that some patients may not want to make any changes with their medication at the point of an initial deprescribing conversation taking place; it was recognised that this may change over time, with fluctuations in their symptoms, disease trajectory, prognosis or even shifts in a person’s preferences or priorities around their care.

Whilst it was important to have a patient voice present in those discussions, healthcare professionals also recognised the importance of acknowledging priorities of others involved in their care, such as family, friends and caregivers. Healthcare professionals acknowledged the day-to-day input that family and carers have with their loved one’s medication, and reported it was vital to have their input into overall deprescribing decisions. One participant discussed the importance of “pre-planning” discussions about deprescribing with relatives, and having these conversations at an early enough stage “when there’s less tightened emotions to give them (relative) a chance to think and input into decisions about medicines , at a pace that is suitable for all parties” (Participant 3).

Participants reflected on the challenges that can sometimes present when making decisions about deprescribing if medication priorities differ between the patient and family member(s). One participant shared an example “where the patient wants to carry on with some medication but the family thought “I don’t think you need that – it’s making you too drowsy”” (Participant 14). They went on to further postulate the implications that continuation of a medication may have for the carer “or family member who feels like “well because you’re more drowsy , I’ve got to come and help you with this and that”” (Participant 14). Another participant discussed the commonality of conflicts between patients and family members when it concerns the trajectory of life-limiting illnesses. Specifically, if a carer or relative “hasn’t accepted that the person is dying , and me coming in and talking about stopping all these meds they’ve been on for years – that’s often the thing that really brings it home to them” (Participant 8).

Reflections on language used to establish shared conversations around deprescribing

Another participant reflected on the influence that language can have when establishing and shaping shared conversations with patients around deprescribing. They reflected on common phrasing used when prescribing and commencing new medicines, believing that often “the message we give as professionals is “once you’re on it , you’re on it forever”. I get why we do that for compliance , concordance … but maybe we need a bit of “this will be reviewed annually and we might change it” phrasing built in” (Participant 15). In doing so, it was deemed helpful to establish and share expectations between the prescriber and the patient relating to the intention and duration of each medication, whilst also involving patient perspectives in the ongoing review process.

Another participant shared an example where language used when starting a medication was a barrier to deprescribing in a specialist palliative care setting. They reflected on how often it is communicated by prescribers: ”never stop this medicine” or “this medicine is so important” that (when discussing deprescribing with one patient) … he just kind of thought as soon as he stopped it , he would die” (Participant 17). Reflections in language were also noted by other participants, specifically when describing successful deprescribing episodes as consultations that are framed in a way to minimise (or avoid) patient fear and/or concern. They recommended using shared language that aligned with “trialling without” a particular medication, as opposed to “stopping it” (Participant 5), so that the patient felt they could have input as an equal partner in the deprescribing decision-making process.

“It’s the framing of how you’re doing it – “we’ll put this to one side. I’m not stopping it , we’ll put it to one side. If you feel any different , you can put the medicine straight back up” (Participant 5 , Medical Consultant).

Another participant picked up on the influence of language when discussing deprescribing medication for patients with life-limiting illnesses. In particular, the importance of gently introducing deprescribing concepts that “explain we’re not giving up on them” and “emphasising that we’re on a journey together and they’re not being left high and dry” (Participant 9).

A further participant reflected on the importance of language and terms used to establish a relationship of trust between the healthcare professional and the patient, prior to making a deprescribing decision. For example, to help establish such a relationship they flatten the hierarchy between the patient and themselves, in a bid to “ feel that they (patients) can ask things to me that maybe they otherwise won’t” (Participant 10). In doing so, the participant felt the dynamic of the consultation was one of shared decision-making, rather than a “traditional consultation” with a paternalistic approach. Other participants alluded to the power and value of forming relationships between the patient and the prescriber where “trust needs to be at the centre … if they don’t know they can trust you , they might not be comfortable (with deprescribing decisions) … until you’ve built up that rapport” (Participant 1).

By exploring the perspectives of healthcare professionals, this study builds on previous evidence by exploring the challenges of, and potential solutions to, making decisions about deprescribing in a palliative care context. This study collated the perspectives from a range of healthcare professional groups working with responsibility for prescribing medication in a palliative care context – a specialist patient cohort, which has previously been under-reported in the deprescribing literature, as well as healthcare research more broadly. A consistent finding across all interviews was that the decision-making to underpin deprescribing approaches should be considered, planned, and done proactively as part of ongoing clinical care, rather than as a separate reactive process as a consequence of a patient’s illness or development of an adverse drug reaction. This was a unique finding from this work, which encompassed elements of professional responsibility and attitudes, alongside a need to change the culture in which prescribing and deprescribing are recognised as similar entities when it comes to safe and effective medicines use. Another unique learning point centres on the use of shared language within deprescribing conversations; framing decision-making consultations with terminology that reflects shared, equal conversations may prove more inclusive and balanced. As well, patient empowerment and person-centred approaches were deemed essential components of deprescribing decision-making; whereby the priorities of patients and others (such as family members or carers) are recognised and included as part of the deprescribing process.

Echoing previous studies in the wider deprescribing literature [ 29 , 30 , 31 ], healthcare professionals interviewed as part of this study acknowledged the value of forming and establishing trust with patients prior to deprescribing conversations taking place. Indeed, given the emotions that accompany a life-limiting illness, once a positive patient-healthcare professional relationship was formed, participants perceived it was easier to broach the subject of deprescribing. It is not clear from this research if patients perceive all healthcare professionals as the same, but findings in the wider literature suggest that older adults have greater trust in certain healthcare professionals, such as medical doctors, compared to others, like pharmacists [ 30 , 32 , 33 , 34 ]. Further building on elements of trust within deprescribing practices, participants discussed the underpinning uncertainty or fear that is experienced from a healthcare professional standpoint when a decision is made whether to deprescribe. Specifically, participants reported a lack of education built within their professional undergraduate and/or postgraduate training about how to approach deprescribing. In keeping with this study, these findings have been reported by prescribers working in a range of healthcare specialities including mental health [ 35 ], geriatric medicine [ 36 , 37 , 38 ] and wider primary care services [ 39 , 40 ]. In recognition of the inconsistent and non-standardised implementation of deprescribing within undergraduate education, a curricular framework for approaches to deprescribing has been proposed [ 41 ]. In this, recommendations were made aiming to improve the previously reported low prescriber self-efficacy and self-confidence when it comes to deprescribing [ 42 , 43 , 44 , 45 , 46 , 47 ] – something which future research may seek to evaluate, specifically within specialist patient cohorts like people accessing palliative care services.

Findings in this study echoed the value of building and maintaining interdisciplinary relationships between healthcare professional groups when approaching deprescribing as part of a multi-disciplinary team [ 38 , 48 , 49 ]. As well as this, the significance of shared collaborative conversations between clinicians, patients, and family members or carers was also echoed [ 17 ]. Much focus within previous studies has rightly placed patient preferences of deprescribing at the centre [ 50 , 51 , 52 ], however, future research may wish to further explore the dynamics and interplay between the preferences of others involved in a person’s care. Considering the role that carers and family members play in supporting people in receipt of palliative care [ 53 , 54 , 55 , 56 ], a greater understanding of shared patient-relative-clinician triad discussions about deprescribing would be useful to explore.

Another important study finding was the importance of the language used to have shared deprescribing conversations and the language used by healthcare professionals. Studies in wider healthcare literature have previously alluded to the complexity of conversations about end-of-life care and life-limiting illness [ 57 ], as well as the challenges of initiating discussions about medicines during periods of clinical deterioration or changes in disease trajectory [ 58 ]. Findings from this work show the importance of aligning language with shared expectations and shared decisions between the prescriber and the patient, specifically relating to the intended duration and rationale for each prescribed medication. A recent study by Green et al. [ 59 ] recommended suggestions for patient-preferred language that clinicians could use when communicating deprescribing decisions amongst older adults; findings from this and other studies [ 60 , 61 ] could be transferable to this work, in particular recognition of framing deprescribing decisions around an individual’s priorities and goals [ 59 ].

Whilst we believe our results are robust and have important implications for the way in which healthcare professionals approach deprescribing decision-making, we do acknowledge that the majority of our sample was limited to practice within the North East of England thus, the experience of our participants was that of, predominantly, White British females. Including the voices of healthcare professionals from other ethnic groups may have brought previously unheard considerations to the forefront, which may impact or influence deprescribing processes in minoritised groups – given the growing diversity of the patient population within the UK, this warrants further investigation in a bid to ensure cultural competence is embedded within deprescribing decision-making.

There remains a need to develop interventions to promote deprescribing decision-making for patients accessing palliative care services. In particular, there are still gaps in knowledge concerning the needs and challenges of patients and their family members or carers in this context, especially when it comes to the prescribing and deprescribing of medications as an overall component of care. Future research approaches should seek to further explore the steps within shared decision-making of deprescribing to understand how future interventions could best support this process. To achieve this, co-design methodology could be used to collectively combine the views of all people involved in the deprescribing process, including people with lived experience of receiving palliative care, their family members or carers, as well as healthcare professionals. By exploring the perspectives of healthcare professionals with responsibility for prescribing medication, this qualitative study addressed the first steps of this process and could be used to support future co-design work in this area.

This study sought to further explore the perspectives of healthcare professionals with responsibility for making deprescribing decisions with people accessing palliative care services. A diverse range of healthcare professionals identified the importance of supporting deprescribing decision-making so it becomes a proactive process, using shared language, rather than a reactive consequence, within a person’s care journey. The identified themes included professional attitudes, competency and responsibility towards deprescribing decision-making; changing the culture of deprescribing; and, the importance of involving patients and their family/caregivers in deprescribing decision-making. Future work should explore how healthcare professionals, patients and their family can best be supported in the shared decision-making processes of deprescribing.

Data availability

Data is provided within the manuscript or supplementary information files.

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Acknowledgements

Acknowledgement is given to the healthcare professionals who were participants in this study – without their support, the study would not have been possible. Also, thanks are given to the wider PONDER team - Dr. Lisa Baker, Dr. Ellie Bond, and Dr. Rachel Quibell.

This project is funded by the National Institute for Health and Care Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number Award ID: NIHR202283). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. In addition, authors AT, AH and BH are part-funded by the NIHR Newcastle Patient Safety Research Collaboration (PSRC).

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Z.B. led on the day-to-day running of the project and data collection. A.T. oversaw the running of this project as Principal Investigator and provided project management expertise. A.R-B. and C.L.R. led on data interpretation and analysis and writing of this manuscript. C.E. provided methodological expertise on data collection, interpretation, and analysis. J.J., J.E., B.H., A.H. provided topic input, interpretation and analysis. J.E. supported the recruitment of participants. A.B. and R.B. contributed in their appointment as patient champions with lived-experience and ensured appropriateness and sensitivity throughout the entire research process. All authors read, provided comments on, and approved the final manuscript.

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Robinson-Barella, A., Richardson, C.L., Bayley, Z. et al. “ Starting to think that way from the start” : approaching deprescribing decision-making for people accessing palliative care - a qualitative exploration of healthcare professionals views. BMC Palliat Care 23 , 221 (2024). https://doi.org/10.1186/s12904-024-01523-2

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ethics in qualitative research issues and challenges

The challenges of medical students in their internship : a qualitative study from Iran

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Published: 02 September 2024
Volume 17 , article number 241 , ( 2024 )

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Parmida Azizi 1 ,
Amir Hossein Jalalpour 1 , 2 ,
Soodeh Jahangiri 3 ,
Fatemeh Shaygani 1 , 2 ,
Milad Ahmadi Marzaleh 4 ,
Hafez Shojaadini 1 , 2 &
Ahmad Nemati 2 , 5

Background and objectives

Medical students experience different types of challenges during their MD program, which become more challenging when it comes to the internship, putting too much pressure on them. This study aimed to explore the challenges of medical interns of Shiraz University of Medical Sciences (SUMS), Shiraz, Iran.

In this qualitative research, which was conducted from September 2023 March 2024, medical interns of SUMS were selected using purposeful sampling method. The data were collected through deep and semi-structured interviews, and it was continued until data saturation was achieved. The data analysis was performed through thematic content analysis.

A total of 13 participants (6 men and 7 women) with a mean ± SD age of 25 ± 1.6 years were interviewed. The challenges of medical interns consisted of 423 meaning units, 79 open codes, 14 subthemes, and 6 main themes; the main themes consisted of educational challenges, challenges following university regulations, health and behavioral issues, economic/employment-related issues, sociocultural and recreational challenges, and ethical issues.

The results of this study highlight the necessity for reforms in the medical internship phase aiming to tackle interns’ issues and establish a supportive and nurturing environment for future medical doctors.

Students’ and Faculty Perspectives Toward the Role and Value of the Hidden Curriculum in Undergraduate Medical Education: a Qualitative Study from Saudi Arabia

Exploring nursing faculty, managers, newly graduated nurses, and students’ experiences of nursing internship program implementation in Iran: a descriptive qualitative study

Exploring the experiences and expectations of pharmacist interns in large general hospitals in China: from the perspective of interns

Explore related subjects.

Medical Ethics
Artificial Intelligence

Introduction

Medicine is a field of study with great importance in society as it encompasses the knowledge, skills, and practices needed for the diagnosis, treatment, and prevention of illnesses. Studying medicine not only provides individuals with a rewarding and fulfilling career but also plays a crucial role in promoting the overall health and well-being of communities across the globe [ 1 , 2 ]. The importance of studying medicine can be observed through multiple aspects, such as its influence on individual lives, healthcare systems, and advancements in the field of medical science. Medical internship plays a crucial role in shaping the future of healthcare professionals by offering them practical exposure and hands-on experience in real clinical settings, enabling them to use theoretical knowledge, improve clinical skills, and acquire practical experience to various specialties they may choose for their residency. Internships serve as a connection between academic education and practical work experience, allowing interns to work under the guidance of experienced healthcare professionals, observe patient care, take part in medical procedures, and interact with multidisciplinary teams. The responsibilities of medical interns include patients’ assessment, diagnosis, treatment planning, and follow-up care, all being supervised by the attendings, residents, and nursing staff. Moreover, interns are responsible for documenting the patients’ information, participating in rounds and conferences, engaging in research activities, and cooperating with healthcare teams to ensure the delivery of high-quality patient care [ 3 ].

On the other side, it is frequently accompanied by a number of challenges that can significantly affect both the learning process and the overall well-being of the students [ 3 ]. According to previous studies, medical interns often encounter various types of stress, such as excessive workloads, exam pressures, and challenges in maintaining a healthy work-life balance [ 4 , 5 , 6 ]. Moreover, they are reported to have high rates of depression, yet many do not seek mental health treatment due to time constraints, limited accessibility, and concerns about confidentiality, which tragically increases the risk of suicide among them [ 7 , 8 , 9 ].

To improve the quality of internship experiences, it is crucial to have a clear understanding of the specific challenges faced by medical interns, particularly in the aftermath of the COVID-19 crisis. Therefore, this study aimed to provide valuable insights into specific areas that pose obstacles to medical interns’ growth and development, which would help policymakers to design evidence-based plans to mitigate or overcome them.

Study design and data collection

This qualitative research was conducted from September 2023 to March 2024 in Shiraz, Iran. The data in this study was carried out through deep and semi-structured interviews with the target population. Medical interns of SUMS, who had completed at least one year of their internship program were eligible to participate in this study.

They were selected through purposive sampling, and after providing them with information about the objectives of the study, they were enrolled if they expressed willingness to participate. If they preferred to have a phone interview, we performed the interview as they wished. Written informed consent was obtained from each of them, and their verbal consent were recorded during the interviews.

It should be noted that in order to maintain diversity in the target group, interns of both genders, with different ages, races, ethnicities, nationalities, and serving in different wards were invited to participate.

The interviews began with a primary question: “What challenges did you face in your internship period?” Additionally, follow-up/probing questions like “How?“, “Why?“, and “May you explain more?” were also asked. Furthermore, some of the questions were adjusted and modified based on the analysis of the initial interviews. The interviews took place at a convenient time for the participants and were conducted in a quiet location. To ensure uninterrupted recording of the interviewees’ voices, two tape recorders were used, thus minimizing any potential problems or disruptions.

Data analysis

Data collection and analysis were done concurrently. The interviewer precisely transcribed the recorded audio files and took notes during the interviews. Following each interview, the transcript was written and thoroughly reviewed multiple times to gain a general understanding of its content. The data analysis for this part involved utilizing the smith method [ 10 ]. The texts were carefully reviewed, and the meaning units were extracted. Then, open codes were shaped, and we categorized them into subthemes. Next, the main themes were created via interpretation of the subthemes. The interviews continued until data was saturated, and no new codes was extracted. Finally, the study finished with a total of 13 interviews, ranging from 28 to 42 min, with an average time of 34 ± 8 min.

Trustworthiness

To ensure the quality of the study, we used the Guba and Lincoln method [ 11 ], which encompasses four criteria: credibility, confirmability, dependability, and transferability [ 12 ].

Credibility, was assured through multiple methods to ensure data are appropriate. For example, extensive engagement with data was performed through in-depth interviews and persistent observation which facilitated bracketing. Also, data source, investigator, and theoretical triangulation were used. Internal checks were done participant validation or member checks, researcher’s self-monitoring and expert member checks. Also, external checks were done through peer debriefing. Searching for disconfirming evidence was considered. Moreover, all contributors of this study specially the corresponding author have a great background in qualitative research which increased the study’s credibility.

The data transferability was ensured by providing a comprehensive explanation and thick description of the topic, along with the characteristics of the interviewees, and through the collection and analysis of the data. Also, purposive sampling technique was used to select participants can be the representative of the target population.

To increase dependability, a prominent independent researcher specializing in qualitative research, who had no involvement in this project, was recruited to conduct audits evaluating the research process and results.

Data confirmability was ensured by the lead researcher by meticulously recording and documenting every stage of the research process. Also, the audit trail increased confirmability.

Overall, 7 women and 6 men participated in this study. Their mean ± SD age was 25 ± 1.6 years. In addition, the mean time from starting the internship period was 12.5 ± 4.4 months (Table 1 ).

After performing deep and semi-structured phone interviews, we identified the participants’ challenges during their internship program. Totally, 423 meaning units and 79 open codes were extracted. Then, we reached 14 subthemes; finally, six main themes including educational challenges, challenges following university rules, health and behavioral issues, economic/employment-related issues, sociocultural and recreational challenges, and ethical issues were provided (Fig. 1 ).

Main themes of the challenges of medical interns

More details in terms of their challenges are explained below as well as in Table 2 .

Challenges of medical interns

Educational challenges.

The first theme extracted from the data analysis was educational challenges, which included the sub-themes of limited medical knowledge, amount of study materials and number of exams, lack of a proper training in the internship stage, and challenges regarding MD Thesis.

According to the interviews with medical interns, they felt challenges regarding their medical knowledge. Inadequate medical knowledge and amount of study materials and number of exams were the issues that made them feel so stressed. One of the participants noted:

“All people, I mean attendings, residents, and even our family members, think that an intern knows everything, while it is not the case. The number of study materials and exams were so large that I could not even read the reference books completely once, and I had to read summary books to pass the non-standard and very difficult exams. This, this high expectation makes me much worried and stressed, to the point where I don’t even dare to ask the residents and attendings about what I don’t know because I am afraid of becoming embarrassed.” (Participant 1, male).

Lack of a proper training in internship stage was another important challenge, which was reported by many of them. They claimed that the curriculum of the MD, as well as its internship, is very specialized and super-specialized and does not prepare them for functioning as a GP. This disproportion of training with the educational level makes them very worried about how they should offer healthcare services for the manpower planning after their graduation. One of the participants mentioned:

“All trainings are specialized and super-specialized and focus on complicated patients. We only have two months of internship related to family medicine, while the focus of our internship should be in this area. Maybe, I will never enter the specialization level, so why should I attend such complicated trainings instead of GP- related training? Can you believe I know how to manage liver cirrhosis, but I don’t know what to do if a patient comes in with diarrhea or a cold.” (Participant 3, female).

Moreover, many of the participants expressed their dissatisfaction with presenting too many lectures from their reference books instead of receiving practical trainings by attendings. They also express concerns about group training of medical students across all stages of education, from studentship to fellowship. They believe that this type of training could be beneficial, considering that each educational stage has different educational needs. Additionally, they mentioned that many educational materials are out of date, hindering them from receiving a quality practical training. Furthermore, some participants had complained about MD thesis they have to offer to be graduated. In this regard, an intern said:

“The internship itself is already very demanding, and adding a thesis to it only increases the pressure on an individual. Throughout the seven-year medical program, there is minimal focus on research, yet, during the internship, we are required to conduct research amidst heavy workload at hospital, sleep deprivation, numerous lectures and exams, which can be overwhelming. I had to request a leave from the hospital wards to collect data for my research, and the attendings assumed that I was using thesis project as an excuse to skip my clinical duties. Personally, I find the thesis to be pointless, as my passion lies in clinical practice, not in research.” (Participant 8, female).

Challenges following university regulations

The second theme extracted from the data analysis was negative experiences related to university regulations. Some interns in this study were worried about inappropriate regulations established by the university or ministry of health. One of them said:

“Every single day, they establish a new legislation, leading to a lack of stability. See how much the expenses of man-power planning and service obligations have increased based on the recent unfair laws. As per regulations, interns are not allowed to engage in additional employment or even take more shifts for making money, risking suspension. Additionally, these irrational and unfair regulations created many challenges for those who want to immigrate. Well, obviously, when we can’t even predict the future of our career and life, we get anxious. You can see that many of our friends committed suicide in the country because they could not bear this level of instability and pressure.” (Participant 11, male).

Health and behavioral issues

The third theme identified through data analysis pertained to the health and behavioral problems experienced by medical students because of their internship. It included the sub-themes of physical health issues, psychological health issues, and behavioral issues.

Due to the interviews with medical interns, they reported experiencing various physical symptoms such as persistent headaches, backaches, neck pain, muscle pain, fatigue, insomnia, poor-quality sleep, and gastrointestinal issues that either began or worsened during their internship due to the excessive pressure they faced during this period. Additionally, most of the participants stated that they suffered from transitory psychological problems in their internship stage such as stress, anxiety, irritablity and nervousness, and aggression. An intern mentioned:

“I am aware that I become extremely anxious and nervous in this period. I feel irritable, short-tempered, and would easily get into arguments with everyone. All people know that insufficient sleep and eating problems can lead to increased aggression, decreased attention span and concentration, and impaired memory. How can I be expected to study effectively after only getting four hours of sleep following a 24-hour shift? After a full day’s shift, the following day I am exhausted, and upon waking up, I feel completely confused due to my disrupted sleep pattern. Thus, at this point, my focus is solely on getting through each day and surviving, and I no longer care about becoming a good physician or anything else. You know, at this stage nothing can make me happy, and I don’t enjoy anything. I just want to survive.” (Participant 13, male).

Moreover, many of them mentioned that low confidence, fear of making medical errors, feeling of guilt following medical errors and persistent self-blame, overthinking, feeling of inadequacy and worthlessness, and feeling of embarrassment and humiliation were among the negative emotions they experienced during this period, causing significant distress for them. Additionally, a few participants mentioned that feelings of loneliness, and lack of hope and motivation led to depression and a few participants claimed that, after couple of months of starting depression without treatment, they reported experiencing delusions or suicidal thoughts. A participant noted:

“For five months, I had no social contact with anyone, and I couldn’t tolerate even a little more pressure. I had completely isolated myself. I thought that I, who wanted to serve humanity, could not manage even one hospital ward now. I was ready to give my all so that I could leave the hospital 5 minutes earlier. I told the residents and attendings that I was not feeling well, but they did not believe me, and they thought I wanted to make an excuse. I think our health is not important for them; they look at us as a work force, not a human or patient. My music taste changed, and I only listened to heavy metal music. Every night, I cried and hoped that I wouldn’t wake up and would die. Every time I took a shower, I saw this scene that I am drowned in my own blood. I thought if I did not have the courage to commit suicide, at least I could change my lifestyle to the point where death would happen to me, for example, smoking cigarettes, using drugs, drinking alcohol.” (Participant 2, male).

Also, some of them said that they started or increased risky behaviors such as using tobacco and drugs, multiple sexual contacts with various partners and unsafe driving during this period because they thought it could reduce their mental pressure and anxiety.

Economic/employment-related issues

The fourth theme identified through data analysis was the economic and employment-related issues; all the participants emphasized this as the most significant challenge that was a burden on them during this period. An intern claimed:

“The money we receive is not a salary as it is not tied to the hours or workload we put in. It’s merely a small allowance, ranging between 40 and 60 dollars per month. This amount is insufficient to cover our basic needs. Thus, I have to get other jobs; however, I know this is illegal. I have reached a point where I prefer not to rely on my family for even the smallest expenses, and I feel embarrassed about it. I constantly worry about running out of money midway through the month. The stress of the internship itself is too much, which is also added. Now, all our peers in other majors have provided basic amenities for themselves, but what about us? At this age, we have nothing.” (Participant 9, male).

Sociocultural and recreational challenges

The fifth theme extracted through data analysis was challenges in sociocultural and recreational areas. The participants believe that high workload and its consequences have left them in a situation where they no longer care about their sociocultural habits and plans and recreational and leisure plans and even quit them. Two participants noted:

“At this age, I feel very lonely, and I really like to date someone and get married, but I find myself lacking time, money, sufficient rest, and peace of mind. Therefore, it would be better for me to be single; otherwise, love failure will add to my other misfortunes.” (Participant 6, female).

“I used to exercise, but since the internship, I didn’t have the time for that anymore and that ruined my mood a lot. I don’t have time to join my friends’ gatherings or even taking a trip; of course, I don’t have the money either.” (Participant 10, female).

Ethical issues

The sixth theme extracted through data analysis is ethical issues, which included the sub-themes of job-related abuse, research-related abuse, and violence and harassment. They complained that they were given unrelated mandatory tasks that they must perform due to a strict hierarchical and leveling system and if they disagree, there would be consequences for them. They particularly expressed sadness from being bullied by the residents and thought that the hierarchical system made an opportunity for residents to abuse medical interns. In terms of research, they also stated that some residents and attendings recruited the interns in their research projects; finally, they did not respect the authorship rights of interns. Also, some of them stated that they were harassed verbally, physically, visually, and sexually by some attendings, residents, and professors.

Discussions

Based on our findings, medical students experience several challenges in their internship period including educational challenges, challenges following university regulations, health and behavioral issues, economic/employment-related issues, sociocultural and recreational challenges, and ethical issues.

Similar to our research which showed that medical interns thought they did not have enough medical knowledge to work independently in their internship, a study by Capinpuyan and Miguel discussed the challenges faced by interns due to their lack of experience and knowledge, which can potentially lead to harming patients they serve [ 13 ]. Additionally, a study by D’Eon focused on the knowledge loss of senior undergraduate medical students and emphasized the issue of retaining information among these students [ 14 ]. Also, our study showed that medical interns complained regarding memorizing a large volume of study materials and lack of enough time for studying them. Moreover, they felt difficulties regarding overwhelming exams with non-standard questions. Furthermore, medical interns criticized not receiving proper training in this period. Similarly, a study by Kulkarni showed that medical interns claimed to have insufficient training, supervision, and support, impacting the interns’ ability to acquire necessary skills and competencies [ 14 ]. Therefore, it is recommended that hands-on training for interns should be prioritized with a specific emphasis on equipping them with the necessary skills and knowledge for a GP-related roles and associated responsibilities. MD thesis was another challenge medical interns were faced with. Given that the MD program is a professional program and not research one, the provision of the thesis should be removed so that the interns can better focus on their clinical works.

Moreover, the unstable, irrational, and unfair regulations by universities and Ministry of Health in Iran pose a concern for medical interns, leading to uncertainty in making decisions about their future and exacerbating their anxiety. While evidence shows that the migration of Iranian medical doctors has been a significant issue, leading to a substantial exodus of healthcare professionals from Iran [ 15 ], recent strict laws are not the solution and the situation only increases the anger of doctors and medical students in Iran and make them more determined to emigrate. Also, the allowance they receive should be sufficient to meet all their expenses, eliminating the need for them to seek additional employment during this critical period.

Our research findings have demonstrated that medical interns encounter a range of health concerns and behavioral issues. In this regard, a study by Howie et al. indicated that better physical health and lower body pain of medical students were associated with their participating in any leisure time physical activity and having a quality sleep [ 16 ]. Similar to our research, two studies investigated the mental health consequences, including depression, anxiety, stress, insomnia, and loneliness, among intern doctors, shedding light on the psychological challenges faced by interns, particularly during the COVID-19 pandemic [ 17 , 18 ]. Also, a research by Zhao et al. indicated that many medical interns in Kenya and Uganda reported suffering from stress, depression and burnout, working unreasonable hours due to staff shortages, and being treated like they are nobody [ 19 ]. Additionally, a study conducted by Jahangiri et al. mentioned that medical students in Iran had a high level of depression and suicidal thoughts [ 20 ] and a recent research by Ghorbanpour et al. demonstrated that 25% of medical students of SUMS reported experiencing suicidal ideation [ 21 ]. Moreover, our findings revealed that high-risk behaviors among medical interns were an important concern. Similarly, a study by Marcon et al. demonstrates that there is a high-risk of alcohol drinking among medical students, among which tobacco and cannabis use and family income were the most important predictors [ 22 ]. Likewise, a study carried out by Shabila et al. also revealed that medical students in Erbil, Iraq, reported high frequencies of several serious risky driving behaviors [ 23 ]. In contrast to our results, research showed that most of sexually active medical students had a safe sex and monogamous relationships, and a low percentage was engaged in high-risk behaviors like involvement with commercial sex workers or multiple sexual partners [ 24 ]. Health issues and behavioral issues of medical interns are very important challenges which call for an immediate action. It is recommended that the interns’ physical, mental, and behavioral well-being should be regularly monitored to promptly identify and address any new symptoms that may arise.

According to our results, interns also face financial difficulties stemming from inadequate allowance and no work permit. The lack of financial support for interns can impact the quality of their work and study [ 13 ]. This highlights the need to address this issue through allocating more budgets.

Our research found the medical interns had challenges regarding their sociocultural and recreational activities. Evidence showed that participating in sociocultural and recreational activities was essential for the youth to experience personal development, connect socially, and enhance their skills. Involvement in arts and cultural endeavors can bring about advantages like strengthening social ties, offering personal enjoyment, and fostering skill enhancement [ 25 ]. Nevertheless, juggling these activities alongside the rigors of medical training can pose a difficulty for medical interns, necessitating efficient time management and prioritization to uphold a harmonious work-life balance. Many students lack the knowledge of how to establish a balance between their work and personal life and effectively utilize their free time. Therefore, it is essential to receive training from experienced consultants in this matter and have their situation continuously assessed. Furthermore, it is advised that universities periodically plan compulsory and free recreational programs for medical interns to improve their physical and mental well-being.

The present study also demonstrated that medical interns felt abused in terms of their clinical job and research. Therefore, supportive regulations should be established to clearly outline their responsibilities and rights, ensuring that no one can abuse them because of their undergraduate level of education. Moreover, a few participants were bothered by some types of violence and harassment. In this regard, a study indicated that 3 out of 4 female interns experienced sexual harassment [ 26 ], which is a high rate and needs further investigations. It is a very important and sensitive challenge, requiring a more reliable and intern-centered supervisory system to ensure the dignity of interns regardless of the power of attendings and residents and the hierarchical system.

Limitations

While purposive sampling is a valuable tool, it may pose a bias to the research regarding be informative and representative. So, we tried to establish specific, justifiable criteria for selecting participants based on the research questions and aims, which made the sampling rationale explicit and reduced researcher bias. Also, the maximum variation sampling was considered to help capture a higher range of perspectives and increase generalizability, although we know that the qualitative studies cannot be generalizable in the same statistical sense as quantitative research Moreover, an iterative approach of sampling, analyzing and re-sampling was done to ensure theoretical saturation, allowed us to fill gaps in the sample as they emerge.

Based on the obtained results, medical interns have various challenges, especially regarding their psychological health and economic status. It is suggested that policymakers and decision-makers in ministry of health and medical sciences universities should establish necessary reforms regarding medical students ‘challenges during the internship period and develop strategies to tackle the issues faced by them.

Data availability

The datasets used and analyzed during the current study available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to express their gratitude to all those who participated in this study.

This project was partly supported by a grant from Shiraz University of Medical Sciences (code: 28868).

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Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran

Parmida Azizi, Amir Hossein Jalalpour, Fatemeh Shaygani & Hafez Shojaadini

Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran

Amir Hossein Jalalpour, Fatemeh Shaygani, Hafez Shojaadini & Ahmad Nemati

Endocrine and Metabolism Research Institute, Iran University of Medical Sciences, Tehran, Iran

Soodeh Jahangiri

Department of Health in Disasters and Emergencies, Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

Milad Ahmadi Marzaleh

Mashhad University of Medical Sciences, Mashhad, Iran

Ahmad Nemati

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Contributions

F.Sh. and M.A.M. were responsible for the study conception and design. All authors prepared the first draft of the manuscript. All authors did the analysis of the data and supervised the study. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Milad Ahmadi Marzaleh .

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The study proposal was approved by ethics committee of Shiraz University of Medical Sciences encoded IR.SUMS.NUMIMG.REC.1402.151. Informed consent was obtained from all subjects. Prior to conducting each interview, all participants were given sufficient information regarding the study objectives, and written consent was obtained from them. The interviewees were assured that the interviews would remain confidential, and audio files and notes would be saved anonymously. They were also informed that they could withdraw from the study at any stage they wish.

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Azizi, P., Jalalpour, A.H., Jahangiri, S. et al. The challenges of medical students in their internship : a qualitative study from Iran. BMC Res Notes 17 , 241 (2024). https://doi.org/10.1186/s13104-024-06883-9

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Conclusions: Ethical principles can be used to guide the research in addressing the initial and ongoing issues arising from qualitative research in order to meet the goals of the research as well as to maintain the rights of the research participants. JOURNAL OF NURSING SCHOLARSHIP, 2000; 33:1, 93-96. ©2001 SIGMA THETA TAU INTERNATIONAL.
PDF Ethics in Qualitative Research
ika Latusek11.1 IntroductionQualitative researchers working in the diverse field of social sciences need to address ethical issues at every stage of the research process (Clegg and Slife 2009), regardless of the perspective, research design or methods o. data collection they opt for. As is widely recognised, ethical thinking in qualitative ...
Ethical challenges in qualitative research: examples from practice
Abstract. This article examines the many ethical challenges that are specific to qualitative research. These challenges concern the issues of informed consent procedures, the researcher-participant relationship, risk-benefit ratio, confidentiality and the dual role of the nurse-researcher. Each challenge will be examined and practical examples ...
PDF Ethics in Qualitative Research: Issues and Challenges
therefore I will dwell in some depth on ethical issues in qualitative research. Moreover, certain qualitative research approaches such as action research, biography, phenomenology and ethnographic methods do pose complex challenges to an ethical conduct of research and therefore merit a closer scrutiny.
Ethical issues in qualitative research: challenges and options
Ethical considerations were involved in every stage of this research as they are viewed as necessary in providing a qualitative study concerning the role of the researcher (Sanjari et al., 2014 ...
Ethics in Qualitative Research: A View of the Participants' and
This paper illustrates how certain ethical challenges in qualitative research necessitate sustained attention of two interconnected worlds: the world of the researcher and the world ... 2009). Ethical problems in qualitative research (issues that may rise when a researcher gains access to a community and the effect the researcher may have on ...
Ethical Considerations for Qualitative Research Methods During the
Ethical Considerations for Qualitative Research Methods ...
Full article: Advancing human and social dimensions in balanced
The research protocols and procedures were thoroughly reviewed and granted ethical clearance under the approval number QU-IRB 1467-E/23. Furthermore, in accordance with ethical standards for research involving human participants, informed consent was obtained from all individual participants involved in this study.
(PDF) Data Collection in Research: Methods, Challenges, and Ethical
Data Collection in Research: Methods, Challenges, and Ethical Considerations. April 2024; ... logistical issues during the data collection process. ... typically used in qualitative research, ...
"Starting to think that way from the start": approaching deprescribing
Background Deprescribing has been defined as the planned process of reducing or stopping medications that may no longer be beneficial or are causing harm, with the goal of reducing medication burden while improving patient quality of life. At present, little is known about the specific challenges of decision-making to support deprescribing for patients who are accessing palliative care. By ...
Exploring autistic employment and retention realities: A qualitative
The central question of this research is: What are the positive features and challenges in the Dutch landscape regarding employment and retention of autistic individuals? Method This qualitative research study employed an inductive approach, with introduction of a deductive element based on the researchers' familiarity with the social model ...
The challenges of medical students in their internship : a qualitative
Medical students experience different types of challenges during their MD program, which become more challenging when it comes to the internship, putting too much pressure on them. This study aimed to explore the challenges of medical interns of Shiraz University of Medical Sciences (SUMS), Shiraz, Iran. In this qualitative research, which was conducted from September 2023 March 2024, medical ...

Difficult but important questions about the ethics of qualitative research

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ETHICS IN QUALITATIVE RESEARCH: ISSUES AND CHALLENGES

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“ Starting to think that way from the start” : approaching deprescribing decision-making for people accessing palliative care - a qualitative exploration of healthcare professionals views

Conclusions

Trial registration

Recruitment and sampling

Semi-structured interviews

Data analysis

Ethical approval

Participant demographics

Theme 1: Professional attitudes, competency and responsibility towards deprescribing

Recognising the challenges associated with deprescribing decisions

Theme 2: changing the culture of deprescribing

Educating and empowering patients

Theme 3: involving patients (and others) in deprescribing decision-making

Reflections on language used to establish shared conversations around deprescribing

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The challenges of medical students in their internship : a qualitative study from Iran

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Students’ and Faculty Perspectives Toward the Role and Value of the Hidden Curriculum in Undergraduate Medical Education: a Qualitative Study from Saudi Arabia

Exploring nursing faculty, managers, newly graduated nurses, and students’ experiences of nursing internship program implementation in Iran: a descriptive qualitative study

Exploring the experiences and expectations of pharmacist interns in large general hospitals in China: from the perspective of interns

Introduction

Study design and data collection

Data analysis

Trustworthiness

Challenges of medical interns

Challenges following university regulations

Health and behavioral issues

Economic/employment-related issues

Sociocultural and recreational challenges

Ethical issues

Discussions

Limitations

Data availability

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