qualitative research experiences in using semi structured interviews

• DOI: 10.1016/B978-008043972-3/50022-0
• Corpus ID: 151625339

Qualitative Research: Experiences in Using Semi-Structured Interviews

• Joanne Horton , R. Macve , Geert Struyven
• Published 2004

255 Citations

Use of semi-structured interviews to investigate teacher perceptions of student collaboration, interview-based research in accounting 2000–2014: informal norms, translation and vibrancy, interview-based research in accounting 2000-2014: a review, analysis of social norms of interview-based papers in brazilian accounting journals from 2010 to 2019, a qualitative study gaining an insight into specialist’s experiences of parenting styles and their beliefs surrounding the impact it has on childhood criminality, ‘who introduced granny to facebook’: an exploration of everyday family interactions in web-based communication environments, silent voices: an exploratory study of caribbean immigrant parents' and children's interaction with teachers in toronto, grounded theory in management research: through the lens of gender-based pay disparity, ust research online ust research online, users' perceptions and uses of financial reports of small and medium companies (smcs) in transitional economies: qualitative evidence from vietnam, 6 references, private lives and public accounts, business research projects for students, european rule-making in accounting: the seventh directive as a case study, the event study: an industrial strength method, on the usefulness of earnings and earnings research: lessons and directions from two decades of empirical research, planned changes in accounting principles for uk life insurance companies: a preliminary investigation of stock market impact, related papers.

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Qualitative research: experience in using semi-structured interviews

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Towards a More Comprehensive Understanding of the Roles of Management Accountants

An analysis of visitor behaviour using time blocks: a study of ski destinations in greece, mandatory public benefit reporting as a basis for charity accountability: findings from england and wales, architects' design process in solar-integrated architecture in sweden, europeanization as a cause of euroscepticism : comparing the outlooks of parties in eastern and western europe : bulgaria (ataka), romania (prm), the netherlands (pvv) and germany (die republikaner), business research projects for students, european rule-making in accounting: the seventh directive as a case study, private lives and public accounts, planned changes in accounting principles for uk life insurance companies: a preliminary investigation of stock market impact, on the usefulness of earnings and earnings research: lessons and directions from two decades of empirical research, related papers (5), the real life guide to accounting research: a behind the scenes view of using qualitative research methods, how many interviews are enough: an experiment with data saturation and variability, research design: qualitative, quantitative, and mixed methods approaches, qualitative research on accounting: some thoughts on what occurs behind the scene, social research methods.

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• Published: 15 September 2022

Interviews in the social sciences

• Eleanor Knott   ORCID: orcid.org/0000-0002-9131-3939 1 ,
• Aliya Hamid Rao   ORCID: orcid.org/0000-0003-0674-4206 1 ,
• Kate Summers   ORCID: orcid.org/0000-0001-9964-0259 1 &
• Chana Teeger   ORCID: orcid.org/0000-0002-5046-8280 1  

Nature Reviews Methods Primers volume  2 , Article number:  73 ( 2022 ) Cite this article

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In-depth interviews are a versatile form of qualitative data collection used by researchers across the social sciences. They allow individuals to explain, in their own words, how they understand and interpret the world around them. Interviews represent a deceptively familiar social encounter in which people interact by asking and answering questions. They are, however, a very particular type of conversation, guided by the researcher and used for specific ends. This dynamic introduces a range of methodological, analytical and ethical challenges, for novice researchers in particular. In this Primer, we focus on the stages and challenges of designing and conducting an interview project and analysing data from it, as well as strategies to overcome such challenges.

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Introduction.

In-depth interviews are a qualitative research method that follow a deceptively familiar logic of human interaction: they are conversations where people talk with each other, interact and pose and answer questions 1 . An interview is a specific type of interaction in which — usually and predominantly — a researcher asks questions about someone’s life experience, opinions, dreams, fears and hopes and the interview participant answers the questions 1 .

Interviews will often be used as a standalone method or combined with other qualitative methods, such as focus groups or ethnography, or quantitative methods, such as surveys or experiments. Although interviewing is a frequently used method, it should not be viewed as an easy default for qualitative researchers 2 . Interviews are also not suited to answering all qualitative research questions, but instead have specific strengths that should guide whether or not they are deployed in a research project. Whereas ethnography might be better suited to trying to observe what people do, interviews provide a space for extended conversations that allow the researcher insights into how people think and what they believe. Quantitative surveys also give these kinds of insights, but they use pre-determined questions and scales, privileging breadth over depth and often overlooking harder-to-reach participants.

In-depth interviews can take many different shapes and forms, often with more than one participant or researcher. For example, interviews might be highly structured (using an almost survey-like interview guide), entirely unstructured (taking a narrative and free-flowing approach) or semi-structured (using a topic guide ). Researchers might combine these approaches within a single project depending on the purpose of the interview and the characteristics of the participant. Whatever form the interview takes, researchers should be mindful of the dynamics between interviewer and participant and factor these in at all stages of the project.

In this Primer, we focus on the most common type of interview: one researcher taking a semi-structured approach to interviewing one participant using a topic guide. Focusing on how to plan research using interviews, we discuss the necessary stages of data collection. We also discuss the stages and thought-process behind analysing interview material to ensure that the richness and interpretability of interview material is maintained and communicated to readers. The Primer also tracks innovations in interview methods and discusses the developments we expect over the next 5–10 years.

We wrote this Primer as researchers from sociology, social policy and political science. We note our disciplinary background because we acknowledge that there are disciplinary differences in how interviews are approached and understood as a method.

Experimentation

Here we address research design considerations and data collection issues focusing on topic guide construction and other pragmatics of the interview. We also explore issues of ethics and reflexivity that are crucial throughout the research project.

Research design

Participant selection.

Participants can be selected and recruited in various ways for in-depth interview studies. The researcher must first decide what defines the people or social groups being studied. Often, this means moving from an abstract theoretical research question to a more precise empirical one. For example, the researcher might be interested in how people talk about race in contexts of diversity. Empirical settings in which this issue could be studied could include schools, workplaces or adoption agencies. The best research designs should clearly explain why the particular setting was chosen. Often there are both intrinsic and extrinsic reasons for choosing to study a particular group of people at a specific time and place 3 . Intrinsic motivations relate to the fact that the research is focused on an important specific social phenomenon that has been understudied. Extrinsic motivations speak to the broader theoretical research questions and explain why the case at hand is a good one through which to address them empirically.

Next, the researcher needs to decide which types of people they would like to interview. This decision amounts to delineating the inclusion and exclusion criteria for the study. The criteria might be based on demographic variables, like race or gender, but they may also be context-specific, for example, years of experience in an organization. These should be decided based on the research goals. Researchers should be clear about what characteristics would make an individual a candidate for inclusion in the study (and what would exclude them).

The next step is to identify and recruit the study’s sample . Usually, many more people fit the inclusion criteria than can be interviewed. In cases where lists of potential participants are available, the researcher might want to employ stratified sampling , dividing the list by characteristics of interest before sampling.

When there are no lists, researchers will often employ purposive sampling . Many researchers consider purposive sampling the most useful mode for interview-based research since the number of interviews to be conducted is too small to aim to be statistically representative 4 . Instead, the aim is not breadth, via representativeness, but depth via rich insights about a set of participants. In addition to purposive sampling, researchers often use snowball sampling . Both purposive and snowball sampling can be combined with quota sampling . All three types of sampling aim to ensure a variety of perspectives within the confines of a research project. A goal for in-depth interview studies can be to sample for range, being mindful of recruiting a diversity of participants fitting the inclusion criteria.

Study design

The total number of interviews depends on many factors, including the population studied, whether comparisons are to be made and the duration of interviews. Studies that rely on quota sampling where explicit comparisons are made between groups will require a larger number of interviews than studies focused on one group only. Studies where participants are interviewed over several hours, days or even repeatedly across years will tend to have fewer participants than those that entail a one-off engagement.

Researchers often stop interviewing when new interviews confirm findings from earlier interviews with no new or surprising insights (saturation) 4 , 5 , 6 . As a criterion for research design, saturation assumes that data collection and analysis are happening in tandem and that researchers will stop collecting new data once there is no new information emerging from the interviews. This is not always possible. Researchers rarely have time for systematic data analysis during data collection and they often need to specify their sample in funding proposals prior to data collection. As a result, researchers often draw on existing reports of saturation to estimate a sample size prior to data collection. These suggest between 12 and 20 interviews per category of participant (although researchers have reported saturation with samples that are both smaller and larger than this) 7 , 8 , 9 . The idea of saturation has been critiqued by many qualitative researchers because it assumes that meaning inheres in the data, waiting to be discovered — and confirmed — once saturation has been reached 7 . In-depth interview data are often multivalent and can give rise to different interpretations. The important consideration is, therefore, not merely how many participants are interviewed, but whether one’s research design allows for collecting rich and textured data that provide insight into participants’ understandings, accounts, perceptions and interpretations.

Sometimes, researchers will conduct interviews with more than one participant at a time. Researchers should consider the benefits and shortcomings of such an approach. Joint interviews may, for example, give researchers insight into how caregivers agree or debate childrearing decisions. At the same time, they may be less adaptive to exploring aspects of caregiving that participants may not wish to disclose to each other. In other cases, there may be more than one person interviewing each participant, such as when an interpreter is used, and so it is important to consider during the research design phase how this might shape the dynamics of the interview.

Data collection

Semi-structured interviews are typically organized around a topic guide comprised of an ordered set of broad topics (usually 3–5). Each topic includes a set of questions that form the basis of the discussion between the researcher and participant (Fig.  1 ). These topics are organized around key concepts that the researcher has identified (for example, through a close study of prior research, or perhaps through piloting a small, exploratory study) 5 .

a | Elaborated topics the researcher wants to cover in the interview and example questions. b | An example topic arc. Using such an arc, one can think flexibly about the order of topics. Considering the main question for each topic will help to determine the best order for the topics. After conducting some interviews, the researcher can move topics around if a different order seems to make sense.

Topic guide

One common way to structure a topic guide is to start with relatively easy, open-ended questions (Table  1 ). Opening questions should be related to the research topic but broad and easy to answer, so that they help to ease the participant into conversation.

After these broad, opening questions, the topic guide may move into topics that speak more directly to the overarching research question. The interview questions will be accompanied by probes designed to elicit concrete details and examples from the participant (see Table  1 ).

Abstract questions are often easier for participants to answer once they have been asked more concrete questions. In our experience, for example, questions about feelings can be difficult for some participants to answer, but when following probes concerning factual experiences these questions can become less challenging. After the main themes of the topic guide have been covered, the topic guide can move onto closing questions. At this stage, participants often repeat something they have said before, although they may sometimes introduce a new topic.

Interviews are especially well suited to gaining a deeper insight into people’s experiences. Getting these insights largely depends on the participants’ willingness to talk to the researcher. We recommend designing open-ended questions that are more likely to elicit an elaborated response and extended reflection from participants rather than questions that can be answered with yes or no.

Questions should avoid foreclosing the possibility that the participant might disagree with the premise of the question. Take for example the question: “Do you support the new family-friendly policies?” This question minimizes the possibility of the participant disagreeing with the premise of this question, which assumes that the policies are ‘family-friendly’ and asks for a yes or no answer. Instead, asking more broadly how a participant feels about the specific policy being described as ‘family-friendly’ (for example, a work-from-home policy) allows them to express agreement, disagreement or impartiality and, crucially, to explain their reasoning 10 .

For an uninterrupted interview that will last between 90 and 120 minutes, the topic guide should be one to two single-spaced pages with questions and probes. Ideally, the researcher will memorize the topic guide before embarking on the first interview. It is fine to carry a printed-out copy of the topic guide but memorizing the topic guide ahead of the interviews can often make the interviewer feel well prepared in guiding the participant through the interview process.

Although the topic guide helps the researcher stay on track with the broad areas they want to cover, there is no need for the researcher to feel tied down by the topic guide. For instance, if a participant brings up a theme that the researcher intended to discuss later or a point the researcher had not anticipated, the researcher may well decide to follow the lead of the participant. The researcher’s role extends beyond simply stating the questions; it entails listening and responding, making split-second decisions about what line of inquiry to pursue and allowing the interview to proceed in unexpected directions.

Optimizing the interview

The ideal place for an interview will depend on the study and what is feasible for participants. Generally, a place where the participant and researcher can both feel relaxed, where the interview can be uninterrupted and where noise or other distractions are limited is ideal. But this may not always be possible and so the researcher needs to be prepared to adapt their plans within what is feasible (and desirable for participants).

Another key tool for the interview is a recording device (assuming that permission for recording has been given). Recording can be important to capture what the participant says verbatim. Additionally, it can allow the researcher to focus on determining what probes and follow-up questions they want to pursue rather than focusing on taking notes. Sometimes, however, a participant may not allow the researcher to record, or the recording may fail. If the interview is not recorded we suggest that the researcher takes brief notes during the interview, if feasible, and then thoroughly make notes immediately after the interview and try to remember the participant’s facial expressions, gestures and tone of voice. Not having a recording of an interview need not limit the researcher from getting analytical value from it.

As soon as possible after each interview, we recommend that the researcher write a one-page interview memo comprising three key sections. The first section should identify two to three important moments from the interview. What constitutes important is up to the researcher’s discretion 9 . The researcher should note down what happened in these moments, including the participant’s facial expressions, gestures, tone of voice and maybe even the sensory details of their surroundings. This exercise is about capturing ethnographic detail from the interview. The second part of the interview memo is the analytical section with notes on how the interview fits in with previous interviews, for example, where the participant’s responses concur or diverge from other responses. The third part consists of a methodological section where the researcher notes their perception of their relationship with the participant. The interview memo allows the researcher to think critically about their positionality and practice reflexivity — key concepts for an ethical and transparent research practice in qualitative methodology 11 , 12 .

Ethics and reflexivity

All elements of an in-depth interview can raise ethical challenges and concerns. Good ethical practice in interview studies often means going beyond the ethical procedures mandated by institutions 13 . While discussions and requirements of ethics can differ across disciplines, here we focus on the most pertinent considerations for interviews across the research process for an interdisciplinary audience.

Ethical considerations prior to interview

Before conducting interviews, researchers should consider harm minimization, informed consent, anonymity and confidentiality, and reflexivity and positionality. It is important for the researcher to develop their own ethical sensitivities and sensibilities by gaining training in interview and qualitative methods, reading methodological and field-specific texts on interviews and ethics and discussing their research plans with colleagues.

Researchers should map the potential harm to consider how this can be minimized. Primarily, researchers should consider harm from the participants’ perspective (Box  1 ). But, it is also important to consider and plan for potential harm to the researcher, research assistants, gatekeepers, future researchers and members of the wider community 14 . Even the most banal of research topics can potentially pose some form of harm to the participant, researcher and others — and the level of harm is often highly context-dependent. For example, a research project on religion in society might have very different ethical considerations in a democratic versus authoritarian research context because of how openly or not such topics can be discussed and debated 15 .

The researcher should consider how they will obtain and record informed consent (for example, written or oral), based on what makes the most sense for their research project and context 16 . Some institutions might specify how informed consent should be gained. Regardless of how consent is obtained, the participant must be made aware of the form of consent, the intentions and procedures of the interview and potential forms of harm and benefit to the participant or community before the interview commences. Moreover, the participant must agree to be interviewed before the interview commences. If, in addition to interviews, the study contains an ethnographic component, it is worth reading around this topic (see, for example, Murphy and Dingwall 17 ). Informed consent must also be gained for how the interview will be recorded before the interview commences. These practices are important to ensure the participant is contributing on a voluntary basis. It is also important to remind participants that they can withdraw their consent at any time during the interview and for a specified period after the interview (to be decided with the participant). The researcher should indicate that participants can ask for anything shared to be off the record and/or not disseminated.

In terms of anonymity and confidentiality, it is standard practice when conducting interviews to agree not to use (or even collect) participants’ names and personal details that are not pertinent to the study. Anonymizing can often be the safer option for minimizing harm to participants as it is hard to foresee all the consequences of de-anonymizing, even if participants agree. Regardless of what a researcher decides, decisions around anonymity must be agreed with participants during the process of gaining informed consent and respected following the interview.

Although not all ethical challenges can be foreseen or planned for 18 , researchers should think carefully — before the interview — about power dynamics, participant vulnerability, emotional state and interactional dynamics between interviewer and participant, even when discussing low-risk topics. Researchers may then wish to plan for potential ethical issues, for example by preparing a list of relevant organizations to which participants can be signposted. A researcher interviewing a participant about debt, for instance, might prepare in advance a list of debt advice charities, organizations and helplines that could provide further support and advice. It is important to remember that the role of an interviewer is as a researcher rather than as a social worker or counsellor because researchers may not have relevant and requisite training in these other domains.

Box 1 Mapping potential forms of harm

Social: researchers should avoid causing any relational detriment to anyone in the course of interviews, for example, by sharing information with other participants or causing interview participants to be shunned or mistreated by their community as a result of participating.

Economic: researchers should avoid causing financial detriment to anyone, for example, by expecting them to pay for transport to be interviewed or to potentially lose their job as a result of participating.

Physical: researchers should minimize the risk of anyone being exposed to violence as a result of the research both from other individuals or from authorities, including police.

Psychological: researchers should minimize the risk of causing anyone trauma (or re-traumatization) or psychological anguish as a result of the research; this includes not only the participant but importantly the researcher themselves and anyone that might read or analyse the transcripts, should they contain triggering information.

Political: researchers should minimize the risk of anyone being exposed to political detriment as a result of the research, such as retribution.

Professional/reputational: researchers should minimize the potential for reputational damage to anyone connected to the research (this includes ensuring good research practices so that any researchers involved are not harmed reputationally by being involved with the research project).

The task here is not to map exhaustively the potential forms of harm that might pertain to a particular research project (that is the researcher’s job and they should have the expertise most suited to mapping such potential harms relative to the specific project) but to demonstrate the breadth of potential forms of harm.

Ethical considerations post-interview

Researchers should consider how interview data are stored, analysed and disseminated. If participants have been offered anonymity and confidentiality, data should be stored in a way that does not compromise this. For example, researchers should consider removing names and any other unnecessary personal details from interview transcripts, password-protecting and encrypting files and using pseudonyms to label and store all interview data. It is also important to address where interview data are taken (for example, across borders in particular where interview data might be of interest to local authorities) and how this might affect the storage of interview data.

Examining how the researcher will represent participants is a paramount ethical consideration both in the planning stages of the interview study and after it has been conducted. Dissemination strategies also need to consider questions of anonymity and representation. In small communities, even if participants are given pseudonyms, it might be obvious who is being described. Anonymizing not only the names of those participating but also the research context is therefore a standard practice 19 . With particularly sensitive data or insights about the participant, it is worth considering describing participants in a more abstract way rather than as specific individuals. These practices are important both for protecting participants’ anonymity but can also affect the ability of the researcher and others to return ethically to the research context and similar contexts 20 .

Reflexivity and positionality

Reflexivity and positionality mean considering the researcher’s role and assumptions in knowledge production 13 . A key part of reflexivity is considering the power relations between the researcher and participant within the interview setting, as well as how researchers might be perceived by participants. Further, researchers need to consider how their own identities shape the kind of knowledge and assumptions they bring to the interview, including how they approach and ask questions and their analysis of interviews (Box  2 ). Reflexivity is a necessary part of developing ethical sensibility as a researcher by adapting and reflecting on how one engages with participants. Participants should not feel judged, for example, when they share information that researchers might disagree with or find objectionable. How researchers deal with uncomfortable moments or information shared by participants is at their discretion, but they should consider how they will react both ahead of time and in the moment.

Researchers can develop their reflexivity by considering how they themselves would feel being asked these interview questions or represented in this way, and then adapting their practice accordingly. There might be situations where these questions are not appropriate in that they unduly centre the researchers’ experiences and worldview. Nevertheless, these prompts can provide a useful starting point for those beginning their reflexive journey and developing an ethical sensibility.

Reflexivity and ethical sensitivities require active reflection throughout the research process. For example, researchers should take care in interview memos and their notes to consider their assumptions, potential preconceptions, worldviews and own identities prior to and after interviews (Box  2 ). Checking in with assumptions can be a way of making sure that researchers are paying close attention to their own theoretical and analytical biases and revising them in accordance with what they learn through the interviews. Researchers should return to these notes (especially when analysing interview material), to try to unpack their own effects on the research process as well as how participants positioned and engaged with them.

Box 2 Aspects to reflect on reflexively

For reflexive engagement, and understanding the power relations being co-constructed and (re)produced in interviews, it is necessary to reflect, at a minimum, on the following.

Ethnicity, race and nationality, such as how does privilege stemming from race or nationality operate between the researcher, the participant and research context (for example, a researcher from a majority community may be interviewing a member of a minority community)

Gender and sexuality, see above on ethnicity, race and nationality

Social class, and in particular the issue of middle-class bias among researchers when formulating research and interview questions

Economic security/precarity, see above on social class and thinking about the researcher’s relative privilege and the source of biases that stem from this

Educational experiences and privileges, see above

Disciplinary biases, such as how the researcher’s discipline/subfield usually approaches these questions, possibly normalizing certain assumptions that might be contested by participants and in the research context

Political and social values

Lived experiences and other dimensions of ourselves that affect and construct our identity as researchers

In this section, we discuss the next stage of an interview study, namely, analysing the interview data. Data analysis may begin while more data are being collected. Doing so allows early findings to inform the focus of further data collection, as part of an iterative process across the research project. Here, the researcher is ultimately working towards achieving coherence between the data collected and the findings produced to answer successfully the research question(s) they have set.

The two most common methods used to analyse interview material across the social sciences are thematic analysis 21 and discourse analysis 22 . Thematic analysis is a particularly useful and accessible method for those starting out in analysis of qualitative data and interview material as a method of coding data to develop and interpret themes in the data 21 . Discourse analysis is more specialized and focuses on the role of discourse in society by paying close attention to the explicit, implicit and taken-for-granted dimensions of language and power 22 , 23 . Although thematic and discourse analysis are often discussed as separate techniques, in practice researchers might flexibly combine these approaches depending on the object of analysis. For example, those intending to use discourse analysis might first conduct thematic analysis as a way to organize and systematize the data. The object and intention of analysis might differ (for example, developing themes or interrogating language), but the questions facing the researcher (such as whether to take an inductive or deductive approach to analysis) are similar.

Preparing data

Data preparation is an important step in the data analysis process. The researcher should first determine what comprises the corpus of material and in what form it will it be analysed. The former refers to whether, for example, alongside the interviews themselves, analytic memos or observational notes that may have been taken during data collection will also be directly analysed. The latter refers to decisions about how the verbal/audio interview data will be transformed into a written form, making it suitable for processes of data analysis. Typically, interview audio recordings are transcribed to produce a written transcript. It is important to note that the process of transcription is one of transformation. The verbal interview data are transformed into a written transcript through a series of decisions that the researcher must make. The researcher should consider the effect of mishearing what has been said or how choosing to punctuate a sentence in a particular way will affect the final analysis.

Box  3 shows an example transcript excerpt from an interview with a teacher conducted by Teeger as part of her study of history education in post-apartheid South Africa 24 (Box  3 ). Seeing both the questions and the responses means that the reader can contextualize what the participant (Ms Mokoena) has said. Throughout the transcript the researcher has used square brackets, for example to indicate a pause in speech, when Ms Mokoena says “it’s [pause] it’s a difficult topic”. The transcription choice made here means that we see that Ms Mokoena has taken time to pause, perhaps to search for the right words, or perhaps because she has a slight apprehension. Square brackets are also included as an overt act of communication to the reader. When Ms Mokoena says “ja”, the English translation (“yes”) of the word in Afrikaans is placed in square brackets to ensure that the reader can follow the meaning of the speech.

Decisions about what to include when transcribing will be hugely important for the direction and possibilities of analysis. Researchers should decide what they want to capture in the transcript, based on their analytic focus. From a (post)positivist perspective 25 , the researcher may be interested in the manifest content of the interview (such as what is said, not how it is said). In that case, they may choose to transcribe intelligent verbatim . From a constructivist perspective 25 , researchers may choose to record more aspects of speech (including, for example, pauses, repetitions, false starts, talking over one another) so that these features can be analysed. Those working from this perspective argue that to recognize the interactional nature of the interview setting adequately and to avoid misinterpretations, features of interaction (pauses, overlaps between speakers and so on) should be preserved in transcription and therefore in the analysis 10 . Readers interested in learning more should consult Potter and Hepburn’s summary of how to present interaction through transcription of interview data 26 .

The process of analysing semi-structured interviews might be thought of as a generative rather than an extractive enterprise. Findings do not already exist within the interview data to be discovered. Rather, researchers create something new when analysing the data by applying their analytic lens or approach to the transcripts. At a high level, there are options as to what researchers might want to glean from their interview data. They might be interested in themes, whereby they identify patterns of meaning across the dataset 21 . Alternatively, they may focus on discourse(s), looking to identify how language is used to construct meanings and therefore how language reinforces or produces aspects of the social world 27 . Alternatively, they might look at the data to understand narrative or biographical elements 28 .

A further overarching decision to make is the extent to which researchers bring predetermined framings or understandings to bear on their data, or instead begin from the data themselves to generate an analysis. One way of articulating this is the extent to which researchers take a deductive approach or an inductive approach to analysis. One example of a truly inductive approach is grounded theory, whereby the aim of the analysis is to build new theory, beginning with one’s data 6 , 29 . In practice, researchers using thematic and discourse analysis often combine deductive and inductive logics and describe their process instead as iterative (referred to also as an abductive approach ) 30 , 31 . For example, researchers may decide that they will apply a given theoretical framing, or begin with an initial analytic framework, but then refine or develop these once they begin the process of analysis.

Box 3 Excerpt of interview transcript (from Teeger 24 )

Interviewer : Maybe you could just start by talking about what it’s like to teach apartheid history.

Ms Mokoena : It’s a bit challenging. You’ve got to accommodate all the kids in the class. You’ve got to be sensitive to all the racial differences. You want to emphasize the wrongs that were done in the past but you also want to, you know, not to make kids feel like it’s their fault. So you want to use the wrongs of the past to try and unite the kids …

Interviewer : So what kind of things do you do?

Ms Mokoena : Well I normally highlight the fact that people that were struggling were not just the blacks, it was all the races. And I give examples of the people … from all walks of life, all races, and highlight how they suffered as well as a result of apartheid, particularly the whites… . What I noticed, particularly my first year of teaching apartheid, I noticed that the black kids made the others feel responsible for what happened… . I had a lot of fights…. A lot of kids started hating each other because, you know, the others are white and the others were black. And they started saying, “My mother is a domestic worker because she was never allowed an opportunity to get good education.” …

Interviewer : I didn’t see any of that now when I was observing.

Ms Mokoena : … Like I was saying I think that because of the re-emphasis of the fact that, look, everybody did suffer one way or the other, they sort of got to see that it was everybody’s struggle … . They should now get to understand that that’s why we’re called a Rainbow Nation. Not everybody agreed with apartheid and not everybody suffered. Even all the blacks, not all blacks got to feel what the others felt . So ja [yes], it’s [pause] it’s a difficult topic, ja . But I think if you get the kids to understand why we’re teaching apartheid in the first place and you show the involvement of all races in all the different sides , then I think you have managed to teach it properly. So I think because of my inexperience then — that was my first year of teaching history — so I think I — maybe I over-emphasized the suffering of the blacks versus the whites [emphasis added].

Reprinted with permission from ref. 24 , Sage Publications.

From data to codes

Coding data is a key building block shared across many approaches to data analysis. Coding is a way of organizing and describing data, but is also ultimately a way of transforming data to produce analytic insights. The basic practice of coding involves highlighting a segment of text (this may be a sentence, a clause or a longer excerpt) and assigning a label to it. The aim of the label is to communicate some sort of summary of what is in the highlighted piece of text. Coding is an iterative process, whereby researchers read and reread their transcripts, applying and refining their codes, until they have a coding frame (a set of codes) that is applied coherently across the dataset and that captures and communicates the key features of what is contained in the data as it relates to the researchers’ analytic focus.

What one codes for is entirely contingent on the focus of the research project and the choices the researcher makes about the approach to analysis. At first, one might apply descriptive codes, summarizing what is contained in the interviews. It is rarely desirable to stop at this point, however, because coding is a tool to move from describing the data to interpreting the data. Suppose the researcher is pursuing some version of thematic analysis. In that case, it might be that the objects of coding are aspects of reported action, emotions, opinions, norms, relationships, routines, agreement/disagreement and change over time. A discourse analysis might instead code for different types of speech acts, tropes, linguistic or rhetorical devices. Multiple types of code might be generated within the same research project. What is important is that researchers are aware of the choices they are making in terms of what they are coding for. Moreover, through the process of refinement, the aim is to produce a set of discrete codes — in which codes are conceptually distinct, as opposed to overlapping. By using the same codes across the dataset, the researcher can capture commonalities across the interviews. This process of refinement involves relabelling codes and reorganizing how and where they are applied in the dataset.

From coding to analysis and writing

Data analysis is also an iterative process in which researchers move closer to and further away from the data. As they move away from the data, they synthesize their findings, thus honing and articulating their analytic insights. As they move closer to the data, they ground these insights in what is contained in the interviews. The link should not be broken between the data themselves and higher-order conceptual insights or claims being made. Researchers must be able to show evidence for their claims in the data. Figure  2 summarizes this iterative process and suggests the sorts of activities involved at each stage more concretely.

As well as going through steps 1 to 6 in order, the researcher will also go backwards and forwards between stages. Some stages will themselves be a forwards and backwards processing of coding and refining when working across different interview transcripts.

At the stage of synthesizing, there are some common quandaries. When dealing with a dataset consisting of multiple interviews, there will be salient and minority statements across different participants, or consensus or dissent on topics of interest to the researcher. A strength of qualitative interviews is that we can build in these nuances and variations across our data as opposed to aggregating them away. When exploring and reporting data, researchers should be asking how different findings are patterned and which interviews contain which codes, themes or tropes. Researchers should think about how these variations fit within the longer flow of individual interviews and what these variations tell them about the nature of their substantive research interests.

A further consideration is how to approach analysis within and across interview data. Researchers may look at one individual code, to examine the forms it takes across different participants and what they might be able to summarize about this code in the round. Alternatively, they might look at how a code or set of codes pattern across the account of one participant, to understand the code(s) in a more contextualized way. Further analysis might be done according to different sampling characteristics, where researchers group together interviews based on certain demographic characteristics and explore these together.

When it comes to writing up and presenting interview data, key considerations tend to rest on what is often termed transparency. When presenting the findings of an interview-based study, the reader should be able to understand and trace what the stated findings are based upon. This process typically involves describing the analytic process, how key decisions were made and presenting direct excerpts from the data. It is important to account for how the interview was set up and to consider the active part that the researcher has played in generating the data 32 . Quotes from interviews should not be thought of as merely embellishing or adding interest to a final research output. Rather, quotes serve the important function of connecting the reader directly to the underlying data. Quotes, therefore, should be chosen because they provide the reader with the most apt insight into what is being discussed. It is good practice to report not just on what participants said, but also on the questions that were asked to elicit the responses.

Researchers have increasingly used specialist qualitative data analysis software to organize and analyse their interview data, such as NVivo or ATLAS.ti. It is important to remember that such software is a tool for, rather than an approach or technique of, analysis. That said, software also creates a wide range of possibilities in terms of what can be done with the data. As researchers, we should reflect on how the range of possibilities of a given software package might be shaping our analytical choices and whether these are choices that we do indeed want to make.

Applications

This section reviews how and why in-depth interviews have been used by researchers studying gender, education and inequality, nationalism and ethnicity and the welfare state. Although interviews can be employed as a method of data collection in just about any social science topic, the applications below speak directly to the authors’ expertise and cutting-edge areas of research.

When it comes to the broad study of gender, in-depth interviews have been invaluable in shaping our understanding of how gender functions in everyday life. In a study of the US hedge fund industry (an industry dominated by white men), Tobias Neely was interested in understanding the factors that enable white men to prosper in the industry 33 . The study comprised interviews with 45 hedge fund workers and oversampled women of all races and men of colour to capture a range of experiences and beliefs. Tobias Neely found that practices of hiring, grooming and seeding are key to maintaining white men’s dominance in the industry. In terms of hiring, the interviews clarified that white men in charge typically preferred to hire people like themselves, usually from their extended networks. When women were hired, they were usually hired to less lucrative positions. In terms of grooming, Tobias Neely identifies how older and more senior men in the industry who have power and status will select one or several younger men as their protégés, to include in their own elite networks. Finally, in terms of her concept of seeding, Tobias Neely describes how older men who are hedge fund managers provide the seed money (often in the hundreds of millions of dollars) for a hedge fund to men, often their own sons (but not their daughters). These interviews provided an in-depth look into gendered and racialized mechanisms that allow white men to flourish in this industry.

Research by Rao draws on dozens of interviews with men and women who had lost their jobs, some of the participants’ spouses and follow-up interviews with about half the sample approximately 6 months after the initial interview 34 . Rao used interviews to understand the gendered experience and understanding of unemployment. Through these interviews, she found that the very process of losing their jobs meant different things for men and women. Women often saw job loss as being a personal indictment of their professional capabilities. The women interviewed often referenced how years of devaluation in the workplace coloured their interpretation of their job loss. Men, by contrast, were also saddened by their job loss, but they saw it as part and parcel of a weak economy rather than a personal failing. How these varied interpretations occurred was tied to men’s and women’s very different experiences in the workplace. Further, through her analysis of these interviews, Rao also showed how these gendered interpretations had implications for the kinds of jobs men and women sought to pursue after job loss. Whereas men remained tied to participating in full-time paid work, job loss appeared to be a catalyst pushing some of the women to re-evaluate their ties to the labour force.

In a study of workers in the tech industry, Hart used interviews to explain how individuals respond to unwanted and ambiguously sexual interactions 35 . Here, the researcher used interviews to allow participants to describe how these interactions made them feel and act and the logics of how they interpreted, classified and made sense of them 35 . Through her analysis of these interviews, Hart showed that participants engaged in a process she termed “trajectory guarding”, whereby they sought to monitor unwanted and ambiguously sexual interactions to avoid them from escalating. Yet, as Hart’s analysis proficiently demonstrates, these very strategies — which protect these workers sexually — also undermined their workplace advancement.

Drawing on interviews, these studies have helped us to understand better how gendered mechanisms, gendered interpretations and gendered interactions foster gender inequality when it comes to paid work. Methodologically, these studies illuminate the power of interviews to reveal important aspects of social life.

Nationalism and ethnicity

Traditionally, nationalism has been studied from a top-down perspective, through the lens of the state or using historical methods; in other words, in-depth interviews have not been a common way of collecting data to study nationalism. The methodological turn towards everyday nationalism has encouraged more scholars to go to the field and use interviews (and ethnography) to understand nationalism from the bottom up: how people talk about, give meaning, understand, navigate and contest their relation to nation, national identification and nationalism 36 , 37 , 38 , 39 . This turn has also addressed the gap left by those studying national and ethnic identification via quantitative methods, such as surveys.

Surveys can enumerate how individuals ascribe to categorical forms of identification 40 . However, interviews can question the usefulness of such categories and ask whether these categories are reflected, or resisted, by participants in terms of the meanings they give to identification 41 , 42 . Categories often pitch identification as a mutually exclusive choice; but identification might be more complex than such categories allow. For example, some might hybridize these categories or see themselves as moving between and across categories 43 . Hearing how people talk about themselves and their relation to nations, states and ethnicities, therefore, contributes substantially to the study of nationalism and national and ethnic forms of identification.

One particular approach to studying these topics, whether via everyday nationalism or alternatives, is that of using interviews to capture both articulations and narratives of identification, relations to nationalism and the boundaries people construct. For example, interviews can be used to gather self–other narratives by studying how individuals construct I–we–them boundaries 44 , including how participants talk about themselves, who participants include in their various ‘we’ groupings and which and how participants create ‘them’ groupings of others, inserting boundaries between ‘I/we’ and ‘them’. Overall, interviews hold great potential for listening to participants and understanding the nuances of identification and the construction of boundaries from their point of view.

Education and inequality

Scholars of social stratification have long noted that the school system often reproduces existing social inequalities. Carter explains that all schools have both material and sociocultural resources 45 . When children from different backgrounds attend schools with different material resources, their educational and occupational outcomes are likely to vary. Such material resources are relatively easy to measure. They are operationalized as teacher-to-student ratios, access to computers and textbooks and the physical infrastructure of classrooms and playgrounds.

Drawing on Bourdieusian theory 46 , Carter conceptualizes the sociocultural context as the norms, values and dispositions privileged within a social space 45 . Scholars have drawn on interviews with students and teachers (as well as ethnographic observations) to show how schools confer advantages on students from middle-class families, for example, by rewarding their help-seeking behaviours 47 . Focusing on race, researchers have revealed how schools can remain socioculturally white even as they enrol a racially diverse student population. In such contexts, for example, teachers often misrecognize the aesthetic choices made by students of colour, wrongly inferring that these students’ tastes in clothing and music reflect negative orientations to schooling 48 , 49 , 50 . These assessments can result in disparate forms of discipline and may ultimately shape educators’ assessments of students’ academic potential 51 .

Further, teachers and administrators tend to view the appropriate relationship between home and school in ways that resonate with white middle-class parents 52 . These parents are then able to advocate effectively for their children in ways that non-white parents are not 53 . In-depth interviews are particularly good at tapping into these understandings, revealing the mechanisms that confer privilege on certain groups of students and thereby reproduce inequality.

In addition, interviews can shed light on the unequal experiences that young people have within educational institutions, as the views of dominant groups are affirmed while those from disadvantaged backgrounds are delegitimized. For example, Teeger’s interviews with South African high schoolers showed how — because racially charged incidents are often framed as jokes in the broader school culture — Black students often feel compelled to ignore and keep silent about the racism they experience 54 . Interviews revealed that Black students who objected to these supposed jokes were coded by other students as serious or angry. In trying to avoid such labels, these students found themselves unable to challenge the racism they experienced. Interviews give us insight into these dynamics and help us see how young people understand and interpret the messages transmitted in schools — including those that speak to issues of inequality in their local school contexts as well as in society more broadly 24 , 55 .

The welfare state

In-depth interviews have also proved to be an important method for studying various aspects of the welfare state. By welfare state, we mean the social institutions relating to the economic and social wellbeing of a state’s citizens. Notably, using interviews has been useful to look at how policy design features are experienced and play out on the ground. Interviews have often been paired with large-scale surveys to produce mixed-methods study designs, therefore achieving both breadth and depth of insights.

In-depth interviews provide the opportunity to look behind policy assumptions or how policies are designed from the top down, to examine how these play out in the lives of those affected by the policies and whose experiences might otherwise be obscured or ignored. For example, the Welfare Conditionality project used interviews to critique the assumptions that conditionality (such as, the withdrawal of social security benefits if recipients did not perform or meet certain criteria) improved employment outcomes and instead showed that conditionality was harmful to mental health, living standards and had many other negative consequences 56 . Meanwhile, combining datasets from two small-scale interview studies with recipients allowed Summers and Young to critique assumptions around the simplicity that underpinned the design of Universal Credit in 2020, for example, showing that the apparently simple monthly payment design instead burdened recipients with additional money management decisions and responsibilities 57 .

Similarly, the Welfare at a (Social) Distance project used a mixed-methods approach in a large-scale study that combined national surveys with case studies and in-depth interviews to investigate the experience of claiming social security benefits during the COVID-19 pandemic. The interviews allowed researchers to understand in detail any issues experienced by recipients of benefits, such as delays in the process of claiming, managing on a very tight budget and navigating stigma and claiming 58 .

These applications demonstrate the multi-faceted topics and questions for which interviews can be a relevant method for data collection. These applications highlight not only the relevance of interviews, but also emphasize the key added value of interviews, which might be missed by other methods (surveys, in particular). Interviews can expose and question what is taken for granted and directly engage with communities and participants that might otherwise be ignored, obscured or marginalized.

Reproducibility and data deposition

There is a robust, ongoing debate about reproducibility in qualitative research, including interview studies. In some research paradigms, reproducibility can be a way of interrogating the rigour and robustness of research claims, by seeing whether these hold up when the research process is repeated. Some scholars have suggested that although reproducibility may be challenging, researchers can facilitate it by naming the place where the research was conducted, naming participants, sharing interview and fieldwork transcripts (anonymized and de-identified in cases where researchers are not naming people or places) and employing fact-checkers for accuracy 11 , 59 , 60 .

In addition to the ethical concerns of whether de-anonymization is ever feasible or desirable, it is also important to address whether the replicability of interview studies is meaningful. For example, the flexibility of interviews allows for the unexpected and the unforeseen to be incorporated into the scope of the research 61 . However, this flexibility means that we cannot expect reproducibility in the conventional sense, given that different researchers will elicit different types of data from participants. Sharing interview transcripts with other researchers, for instance, downplays the contextual nature of an interview.

Drawing on Bauer and Gaskell, we propose several measures to enhance rigour in qualitative research: transparency, grounding interpretations and aiming for theoretical transferability and significance 62 .

Researchers should be transparent when describing their methodological choices. Transparency means documenting who was interviewed, where and when (without requiring de-anonymization, for example, by documenting their characteristics), as well as the questions they were asked. It means carefully considering who was left out of the interviews and what that could mean for the researcher’s findings. It also means carefully considering who the researcher is and how their identity shaped the research process (integrating and articulating reflexivity into whatever is written up).

Second, researchers should ground their interpretations in the data. Grounding means presenting the evidence upon which the interpretation relies. Quotes and extracts should be extensive enough to allow the reader to evaluate whether the researcher’s interpretations are grounded in the data. At each step, researchers should carefully compare their own explanations and interpretations with alternative explanations. Doing so systematically and frequently allows researchers to become more confident in their claims. Here, researchers should justify the link between data and analysis by using quotes to justify and demonstrate the analytical point, while making sure the analytical point offers an interpretation of quotes (Box  4 ).

An important step in considering alternative explanations is to seek out disconfirming evidence 4 , 63 . This involves looking for instances where participants deviate from what the majority are saying and thus bring into question the theory (or explanation) that the researcher is developing. Careful analysis of such examples can often demonstrate the salience and meaning of what appears to be the norm (see Table  2 for examples) 54 . Considering alternative explanations and paying attention to disconfirming evidence allows the researcher to refine their own theories in respect of the data.

Finally, researchers should aim for theoretical transferability and significance in their discussions of findings. One way to think about this is to imagine someone who is not interested in the empirical study. Articulating theoretical transferability and significance usually takes the form of broadening out from the specific findings to consider explicitly how the research has refined or altered prior theoretical approaches. This process also means considering under what other conditions, aside from those of the study, the researcher thinks their theoretical revision would be supported by and why. Importantly, it also includes thinking about the limitations of one’s own approach and where the theoretical implications of the study might not hold.

Box 4 An example of grounding interpretations in data (from Rao 34 )

In an article explaining how unemployed men frame their job loss as a pervasive experience, Rao writes the following: “Unemployed men in this study understood unemployment to be an expected aspect of paid work in the contemporary United States. Robert, a white unemployed communications professional, compared the economic landscape after the Great Recession with the tragic events of September 11, 2001:

Part of your post-9/11 world was knowing people that died as a result of terrorism. The same thing is true with the [Great] Recession, right? … After the Recession you know somebody who was unemployed … People that really should be working.

The pervasiveness of unemployment rendered it normal, as Robert indicates.”

Here, the link between the quote presented and the analytical point Rao is making is clear: the analytical point is grounded in a quote and an interpretation of the quote is offered 34 .

Limitations and optimizations

When deciding which research method to use, the key question is whether the method provides a good fit for the research questions posed. In other words, researchers should consider whether interviews will allow them to successfully access the social phenomena necessary to answer their question(s) and whether the interviews will do so more effectively than other methods. Table  3 summarizes the major strengths and limitations of interviews. However, the accompanying text below is organized around some key issues, where relative strengths and weaknesses are presented alongside each other, the aim being that readers should think about how these can be balanced and optimized in relation to their own research.

Breadth versus depth of insight

Achieving an overall breadth of insight, in a statistically representative sense, is not something that is possible or indeed desirable when conducting in-depth interviews. Instead, the strength of conducting interviews lies in their ability to generate various sorts of depth of insight. The experiences or views of participants that can be accessed by conducting interviews help us to understand participants’ subjective realities. The challenge, therefore, is for researchers to be clear about why depth of insight is the focus and what we should aim to glean from these types of insight.

Naturalistic or artificial interviews

Interviews make use of a form of interaction with which people are familiar 64 . By replicating a naturalistic form of interaction as a tool to gather social science data, researchers can capitalize on people’s familiarity and expectations of what happens in a conversation. This familiarity can also be a challenge, as people come to the interview with preconceived ideas about what this conversation might be for or about. People may draw on experiences of other similar conversations when taking part in a research interview (for example, job interviews, therapy sessions, confessional conversations, chats with friends). Researchers should be aware of such potential overlaps and think through their implications both in how the aims and purposes of the research interview are communicated to participants and in how interview data are interpreted.

Further, some argue that a limitation of interviews is that they are an artificial form of data collection. By taking people out of their daily lives and asking them to stand back and pass comment, we are creating a distance that makes it difficult to use such data to say something meaningful about people’s actions, experiences and views. Other approaches, such as ethnography, might be more suitable for tapping into what people actually do, as opposed to what they say they do 65 .

Dynamism and replicability

Interviews following a semi-structured format offer flexibility both to the researcher and the participant. As the conversation develops, the interlocutors can explore the topics raised in much more detail, if desired, or pass over ones that are not relevant. This flexibility allows for the unexpected and the unforeseen to be incorporated into the scope of the research.

However, this flexibility has a related challenge of replicability. Interviews cannot be reproduced because they are contingent upon the interaction between the researcher and the participant in that given moment of interaction. In some research paradigms, replicability can be a way of interrogating the robustness of research claims, by seeing whether they hold when they are repeated. This is not a useful framework to bring to in-depth interviews and instead quality criteria (such as transparency) tend to be employed as criteria of rigour.

Accessing the private and personal

Interviews have been recognized for their strength in accessing private, personal issues, which participants may feel more comfortable talking about in a one-to-one conversation. Furthermore, interviews are likely to take a more personable form with their extended questions and answers, perhaps making a participant feel more at ease when discussing sensitive topics in such a context. There is a similar, but separate, argument made about accessing what are sometimes referred to as vulnerable groups, who may be difficult to make contact with using other research methods.

There is an associated challenge of anonymity. There can be types of in-depth interview that make it particularly challenging to protect the identities of participants, such as interviewing within a small community, or multiple members of the same household. The challenge to ensure anonymity in such contexts is even more important and difficult when the topic of research is of a sensitive nature or participants are vulnerable.

Increasingly, researchers are collaborating in large-scale interview-based studies and integrating interviews into broader mixed-methods designs. At the same time, interviews can be seen as an old-fashioned (and perhaps outdated) mode of data collection. We review these debates and discussions and point to innovations in interview-based studies. These include the shift from face-to-face interviews to the use of online platforms, as well as integrating and adapting interviews towards more inclusive methodologies.

Collaborating and mixing

Qualitative researchers have long worked alone 66 . Increasingly, however, researchers are collaborating with others for reasons such as efficiency, institutional incentives (for example, funding for collaborative research) and a desire to pool expertise (for example, studying similar phenomena in different contexts 67 or via different methods). Collaboration can occur across disciplines and methods, cases and contexts and between industry/business, practitioners and researchers. In many settings and contexts, collaboration has become an imperative 68 .

Cheek notes how collaboration provides both advantages and disadvantages 68 . For example, collaboration can be advantageous, saving time and building on the divergent knowledge, skills and resources of different researchers. Scholars with different theoretical or case-based knowledge (or contacts) can work together to build research that is comparative and/or more than the sum of its parts. But such endeavours also carry with them practical and political challenges in terms of how resources might actually be pooled, shared or accounted for. When undertaking such projects, as Morse notes, it is worth thinking about the nature of the collaboration and being explicit about such a choice, its advantages and its disadvantages 66 .

A further tension, but also a motivation for collaboration, stems from integrating interviews as a method in a mixed-methods project, whether with other qualitative researchers (to combine with, for example, focus groups, document analysis or ethnography) or with quantitative researchers (to combine with, for example, surveys, social media analysis or big data analysis). Cheek and Morse both note the pitfalls of collaboration with quantitative researchers: that quality of research may be sacrificed, qualitative interpretations watered down or not taken seriously, or tensions experienced over the pace and different assumptions that come with different methods and approaches of research 66 , 68 .

At the same time, there can be real benefits of such mixed-methods collaboration, such as reaching different and more diverse audiences or testing assumptions and theories between research components in the same project (for example, testing insights from prior quantitative research via interviews, or vice versa), as long as the skillsets of collaborators are seen as equally beneficial to the project. Cheek provides a set of questions that, as a starting point, can be useful for guiding collaboration, whether mixed methods or otherwise. First, Cheek advises asking all collaborators about their assumptions and understandings concerning collaboration. Second, Cheek recommends discussing what each perspective highlights and focuses on (and conversely ignores or sidelines) 68 .

A different way to engage with the idea of collaboration and mixed methods research is by fostering greater collaboration between researchers in the Global South and Global North, thus reversing trends of researchers from the Global North extracting knowledge from the Global South 69 . Such forms of collaboration also align with interview innovations, discussed below, that seek to transform traditional interview approaches into more participatory and inclusive (as part of participatory methodologies).

Digital innovations and challenges

The ongoing COVID-19 pandemic has centred the question of technology within interview-based fieldwork. Although conducting synchronous oral interviews online — for example, via Zoom, Skype or other such platforms — has been a method used by a small constituency of researchers for many years, it became (and remains) a necessity for many researchers wanting to continue or start interview-based projects while COVID-19 prevents face-to-face data collection.

In the past, online interviews were often framed as an inferior form of data collection for not providing the kinds of (often necessary) insights and forms of immersion face-to-face interviews allow 70 , 71 . Online interviews do tend to be more decontextualized than interviews conducted face-to-face 72 . For example, it is harder to recognize, engage with and respond to non-verbal cues 71 . At the same time, they broaden participation to those who might not have been able to access or travel to sites where interviews would have been conducted otherwise, for example people with disabilities. Online interviews also offer more flexibility in terms of scheduling and time requirements. For example, they provide more flexibility around precarious employment or caring responsibilities without having to travel and be away from home. In addition, online interviews might also reduce discomfort between researchers and participants, compared with face-to-face interviews, enabling more discussion of sensitive material 71 . They can also provide participants with more control, enabling them to turn on and off the microphone and video as they choose, for example, to provide more time to reflect and disconnect if they so wish 72 .

That said, online interviews can also introduce new biases based on access to technology 72 . For example, in the Global South, there are often urban/rural and gender gaps between who has access to mobile phones and who does not, meaning that some population groups might be overlooked unless researchers sample mindfully 71 . There are also important ethical considerations when deciding between online and face-to-face interviews. Online interviews might seem to imply lower ethical risks than face-to-face interviews (for example, they lower the chances of identification of participants or researchers), but they also offer more barriers to building trust between researchers and participants 72 . Interacting only online with participants might not provide the information needed to assess risk, for example, participants’ access to a private space to speak 71 . Just because online interviews might be more likely to be conducted in private spaces does not mean that private spaces are safe, for example, for victims of domestic violence. Finally, online interviews prompt further questions about decolonizing research and engaging with participants if research is conducted from afar 72 , such as how to include participants meaningfully and challenge dominant assumptions while doing so remotely.

A further digital innovation, modulating how researchers conduct interviews and the kinds of data collected and analysed, stems from the use and integration of (new) technology, such as WhatsApp text or voice notes to conduct synchronous or asynchronous oral or written interviews 73 . Such methods can provide more privacy, comfort and control to participants and make recruitment easier, allowing participants to share what they want when they want to, using technology that already forms a part of their daily lives, especially for young people 74 , 75 . Such technology is also emerging in other qualitative methods, such as focus groups, with similar arguments around greater inclusivity versus traditional offline modes. Here, the digital challenge might be higher for researchers than for participants if they are less used to such technology 75 . And while there might be concerns about the richness, depth and quality of written messages as a form of interview data, Gibson reports that the reams of transcripts that resulted from a study using written messaging were dense with meaning to be analysed 75 .

Like with online and face-to-face interviews, it is important also to consider the ethical questions and challenges of using such technology, from gaining consent to ensuring participant safety and attending to their distress, without cues, like crying, that might be more obvious in a face-to-face setting 75 , 76 . Attention to the platform used for such interviews is also important and researchers should be attuned to the local and national context. For example, in China, many platforms are neither legal nor available 76 . There, more popular platforms — like WeChat — can be highly monitored by the government, posing potential risks to participants depending on the topic of the interview. Ultimately, researchers should consider trade-offs between online and offline interview modalities, being attentive to the social context and power dynamics involved.

The next 5–10 years

Continuing to integrate (ethically) this technology will be among the major persisting developments in interview-based research, whether to offer more flexibility to researchers or participants, or to diversify who can participate and on what terms.

Pushing the idea of inclusion even further is the potential for integrating interview-based studies within participatory methods, which are also innovating via integrating technology. There is no hard and fast line between researchers using in-depth interviews and participatory methods; many who employ participatory methods will use interviews at the beginning, middle or end phases of a research project to capture insights, perspectives and reflections from participants 77 , 78 . Participatory methods emphasize the need to resist existing power and knowledge structures. They broaden who has the right and ability to contribute to academic knowledge by including and incorporating participants not only as subjects of data collection, but as crucial voices in research design and data analysis 77 . Participatory methods also seek to facilitate local change and to produce research materials, whether for academic or non-academic audiences, including films and documentaries, in collaboration with participants.

In responding to the challenges of COVID-19, capturing the fraught situation wrought by the pandemic and the momentum to integrate technology, participatory researchers have sought to continue data collection from afar. For example, Marzi has adapted an existing project to co-produce participatory videos, via participants’ smartphones in Medellin, Colombia, alongside regular check-in conversations/meetings/interviews with participants 79 . Integrating participatory methods into interview studies offers a route by which researchers can respond to the challenge of diversifying knowledge, challenging assumptions and power hierarchies and creating more inclusive and collaborative partnerships between participants and researchers in the Global North and South.

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Acknowledgements

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A pre-written interview outline for a semi-structured interview that provides both a topic structure and the ability to adapt flexibly to the content and context of the interview and the interaction between the interviewer and participant. Others may refer to the topic guide as an interview protocol.

Here we refer to the participants that take part in the study as the sample. Other researchers may refer to the participants as a participant group or dataset.

This involves dividing a population into smaller groups based on particular characteristics, for example, age or gender, and then sampling randomly within each group.

A sampling method where the guiding logic when deciding who to recruit is to achieve the most relevant participants for the research topic, in terms of being rich in information or insights.

Researchers ask participants to introduce the researcher to others who meet the study’s inclusion criteria.

Similar to stratified sampling, but participants are not necessarily randomly selected. Instead, the researcher determines how many people from each category of participants should be recruited. Recruitment can happen via snowball or purposive sampling.

A method for developing, analysing and interpreting patterns across data by coding in order to develop themes.

An approach that interrogates the explicit, implicit and taken-for-granted dimensions of language as well as the contexts in which it is articulated to unpack its purposes and effects.

A form of transcription that simplifies what has been said by removing certain verbal and non-verbal details that add no further meaning, such as ‘ums and ahs’ and false starts.

The analytic framework, theoretical approach and often hypotheses, are developed prior to examining the data and then applied to the dataset.

The analytic framework and theoretical approach is developed from analysing the data.

An approach that combines deductive and inductive components to work recursively by going back and forth between data and existing theoretical frameworks (also described as an iterative approach). This approach is increasingly recognized not only as a more realistic but also more desirable third alternative to the more traditional inductive versus deductive binary choice.

A theoretical apparatus that emphasizes the role of cultural processes and capital in (intergenerational) social reproduction.

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Methodology

Semi-Structured Interview | Definition, Guide & Examples

Published on January 27, 2022 by Tegan George . Revised on June 22, 2023.

A semi-structured interview is a data collection method that relies on asking questions within a predetermined thematic framework. However, the questions are not set in order or in phrasing.

In research, semi-structured interviews are often qualitative in nature. They are generally used as an exploratory tool in marketing, social science, survey methodology, and other research fields.

They are also common in field research with many interviewers, giving everyone the same theoretical framework, but allowing them to investigate different facets of the research question .

• Structured interviews : The questions are predetermined in both topic and order.
• Unstructured interviews : None of the questions are predetermined.
• Focus group interviews : The questions are presented to a group instead of one individual.

Table of contents

What is a semi-structured interview, when to use a semi-structured interview, advantages of semi-structured interviews, disadvantages of semi-structured interviews, semi-structured interview questions, how to conduct a semi-structured interview, how to analyze a semi-structured interview, presenting your results (with example), other interesting articles, frequently asked questions about semi-structured interviews.

Semi-structured interviews are a blend of structured and unstructured types of interviews.

• Unlike in an unstructured interview, the interviewer has an idea of what questions they will ask.
• Unlike in a structured interview, the phrasing and order of the questions is not set.

Semi-structured interviews are often open-ended, allowing for flexibility. Asking set questions in a set order allows for easy comparison between respondents, but it can be limiting. Having less structure can help you see patterns, while still allowing for comparisons between respondents.

Semi-structured interviews are best used when:

• You have prior interview experience. Spontaneous questions are deceptively challenging, and it’s easy to accidentally ask a leading question or make a participant uneasy.
• Your research question is exploratory in nature. Participant answers can guide future research questions and help you develop a more robust knowledge base for future research.

Just like in structured interviews, it is critical that you remain organized and develop a system for keeping track of participant responses. However, since the questions are less set than in a structured interview, the data collection and analysis become a bit more complex.

Differences between different types of interviews

Make sure to choose the type of interview that suits your research best. This table shows the most important differences between the four types.

Fixed questions
Fixed order of questions
Fixed number of questions
Option to ask additional questions

Semi-structured interviews come with many advantages.

Best of both worlds

No distractions, detail and richness.

However, semi-structured interviews also have their downsides.

Low validity

High risk of research bias, difficult to develop good semi-structured interview questions.

Since they are often open-ended in style, it can be challenging to write semi-structured interview questions that get you the information you’re looking for without biasing your responses. Here are a few tips:

• Define what areas or topics you will be focusing on prior to the interview. This will help you write a framework of questions that zero in on the information you seek.
• Write yourself a guide to refer to during the interview, so you stay focused. It can help to start with the simpler questions first, moving into the more complex ones after you have established a comfortable rapport.
• Be as clear and concise as possible, avoiding jargon and compound sentences.
• How often per week do you go to the gym? a) 1 time; b) 2 times; c) 3 times; d) 4 or more times
• If yes: What feelings does going to the gym bring out in you?
• If no: What do you prefer to do instead?
• If yes: How did this membership affect your job performance? Did you stay longer in the role than you would have if there were no membership?

Once you’ve determined that a semi-structured interview is the right fit for your research topic , you can proceed with the following steps.

Step 1: Set your goals and objectives

You can use guiding questions as you conceptualize your research question, such as:

• What are you trying to learn or achieve from a semi-structured interview?
• Why are you choosing a semi-structured interview as opposed to a different type of interview, or another research method?

If you want to proceed with a semi-structured interview, you can start designing your questions.

Step 2: Design your questions

Try to stay simple and concise, and phrase your questions clearly. If your topic is sensitive or could cause an emotional response, be mindful of your word choices.

One of the most challenging parts of a semi-structured interview is knowing when to ask follow-up or spontaneous related questions. For this reason, having a guide to refer back to is critical. Hypothesizing what other questions could arise from your participants’ answers may also be helpful.

Step 3: Assemble your participants

There are a few sampling methods you can use to recruit your interview participants, such as:

• Voluntary response sampling : For example, sending an email to a campus mailing list and sourcing participants from responses.
• Stratified sampling of a particular characteristic trait of interest to your research, such as age, race, ethnicity, or gender identity.

Step 4: Decide on your medium

It’s important to determine ahead of time how you will be conducting your interview. You should decide whether you’ll be conducting it live or with a pen-and-paper format. If conducted in real time, you also need to decide if in person, over the phone, or via videoconferencing is the best option for you.

Note that each of these methods has its own advantages and disadvantages:

• Pen-and-paper may be easier for you to organize and analyze, but you will receive more prepared answers, which may affect the reliability of your data.
• In-person interviews can lead to nervousness or interviewer effects, where the respondent feels pressured to respond in a manner they believe will please you or incentivize you to like them.

Step 5: Conduct your interviews

As you conduct your interviews, keep environmental conditions as constant as you can to avoid bias. Pay attention to your body language (e.g., nodding, raising eyebrows), and moderate your tone of voice.

Relatedly, one of the biggest challenges with semi-structured interviews is ensuring that your questions remain unbiased. This can be especially challenging with any spontaneous questions or unscripted follow-ups that you ask your participants.

After you’re finished conducting your interviews, it’s time to analyze your results. First, assign each of your participants a number or pseudonym for organizational purposes.

The next step in your analysis is to transcribe the audio or video recordings. You can then conduct a content or thematic analysis to determine your categories, looking for patterns of responses that stand out to you and test your hypotheses .

Transcribing interviews

Before you get started with transcription, decide whether to conduct verbatim transcription or intelligent verbatim transcription.

• If pauses, laughter, or filler words like “umm” or “like” affect your analysis and research conclusions, conduct verbatim transcription and include them.
• If not, you can conduct intelligent verbatim transcription, which excludes fillers, fixes any grammatical issues, and is usually easier to analyze.

Transcribing presents a great opportunity for you to cleanse your data . Here, you can identify and address any inconsistencies or questions that come up as you listen.

Your supervisor might ask you to add the transcriptions to the appendix of your paper.

Coding semi-structured interviews

Next, it’s time to conduct your thematic or content analysis . This often involves “coding” words, patterns, or recurring responses, separating them into labels or categories for more robust analysis.

Due to the open-ended nature of many semi-structured interviews, you will most likely be conducting thematic analysis, rather than content analysis.

• You closely examine your data to identify common topics, ideas, or patterns. This can help you draw preliminary conclusions about your participants’ views, knowledge or experiences.
• After you have been through your responses a few times, you can collect the data into groups identified by their “code.” These codes give you a condensed overview of the main points and patterns identified by your data.
• Next, it’s time to organize these codes into themes. Themes are generally broader than codes, and you’ll often combine a few codes under one theme. After identifying your themes, make sure that these themes appropriately represent patterns in responses.

Analyzing semi-structured interviews

Once you’re confident in your themes, you can take either an inductive or a deductive approach.

• An inductive approach is more open-ended, allowing your data to determine your themes.
• A deductive approach is the opposite. It involves investigating whether your data confirm preconceived themes or ideas.

After your data analysis, the next step is to report your findings in a research paper .

• Your methodology section describes how you collected the data (in this case, describing your semi-structured interview process) and explains how you justify or conceptualize your analysis.
• Your discussion and results sections usually address each of your coded categories.
• You can then conclude with the main takeaways and avenues for further research.

Example of interview methodology for a research paper

Let’s say you are interested in vegan students on your campus. You have noticed that the number of vegan students seems to have increased since your first year, and you are curious what caused this shift.

You identify a few potential options based on literature:

• Perceptions about personal health or the perceived “healthiness” of a vegan diet
• Concerns about animal welfare and the meat industry
• Increased climate awareness, especially in regards to animal products
• Availability of more vegan options, making the lifestyle change easier

Anecdotally, you hypothesize that students are more aware of the impact of animal products on the ongoing climate crisis, and this has influenced many to go vegan. However, you cannot rule out the possibility of the other options, such as the new vegan bar in the dining hall.

Since your topic is exploratory in nature and you have a lot of experience conducting interviews in your work-study role as a research assistant, you decide to conduct semi-structured interviews.

You have a friend who is a member of a campus club for vegans and vegetarians, so you send a message to the club to ask for volunteers. You also spend some time at the campus dining hall, approaching students at the vegan bar asking if they’d like to participate.

Here are some questions you could ask:

• Do you find vegan options on campus to be: excellent; good; fair; average; poor?
• How long have you been a vegan?
• Follow-up questions can probe the strength of this decision (i.e., was it overwhelmingly one reason, or more of a mix?)

Depending on your participants’ answers to these questions, ask follow-ups as needed for clarification, further information, or elaboration.

• Do you think consuming animal products contributes to climate change? → The phrasing implies that you, the interviewer, do think so. This could bias your respondents, incentivizing them to answer affirmatively as well.
• What do you think is the biggest effect of animal product consumption? → This phrasing ensures the participant is giving their own opinion, and may even yield some surprising responses that enrich your analysis.

After conducting your interviews and transcribing your data, you can then conduct thematic analysis, coding responses into different categories. Since you began your research with several theories about campus veganism that you found equally compelling, you would use the inductive approach.

Once you’ve identified themes and patterns from your data, you can draw inferences and conclusions. Your results section usually addresses each theme or pattern you found, describing each in turn, as well as how often you came across them in your analysis. Feel free to include lots of (properly anonymized) examples from the data as evidence, too.

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

• Student’s  t -distribution
• Normal distribution
• Null and Alternative Hypotheses
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Data cleansing
• Reproducibility vs Replicability
• Peer review
• Prospective cohort study

Research bias

• Implicit bias
• Cognitive bias
• Placebo effect
• Hawthorne effect
• Hindsight bias
• Affect heuristic
• Social desirability bias

A semi-structured interview is a blend of structured and unstructured types of interviews. Semi-structured interviews are best used when:

• You have prior interview experience. Spontaneous questions are deceptively challenging, and it’s easy to accidentally ask a leading question or make a participant uncomfortable.

The four most common types of interviews are:

• Structured interviews : The questions are predetermined in both topic and order. 
• Semi-structured interviews : A few questions are predetermined, but other questions aren’t planned.

Social desirability bias is the tendency for interview participants to give responses that will be viewed favorably by the interviewer or other participants. It occurs in all types of interviews and surveys , but is most common in semi-structured interviews , unstructured interviews , and focus groups .

Social desirability bias can be mitigated by ensuring participants feel at ease and comfortable sharing their views. Make sure to pay attention to your own body language and any physical or verbal cues, such as nodding or widening your eyes.

This type of bias can also occur in observations if the participants know they’re being observed. They might alter their behavior accordingly.

The interviewer effect is a type of bias that emerges when a characteristic of an interviewer (race, age, gender identity, etc.) influences the responses given by the interviewee.

There is a risk of an interviewer effect in all types of interviews , but it can be mitigated by writing really high-quality interview questions.

Inductive reasoning is a bottom-up approach, while deductive reasoning is top-down.

Inductive reasoning takes you from the specific to the general, while in deductive reasoning, you make inferences by going from general premises to specific conclusions.

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How to use and assess qualitative research methods

Loraine busetto.

1 Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany

Wolfgang Wick

2 Clinical Cooperation Unit Neuro-Oncology, German Cancer Research Center, Heidelberg, Germany

Christoph Gumbinger

Associated data.

Not applicable.

This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.

The aim of this paper is to provide an overview of qualitative research methods, including hands-on information on how they can be used, reported and assessed. This article is intended for beginning qualitative researchers in the health sciences as well as experienced quantitative researchers who wish to broaden their understanding of qualitative research.

What is qualitative research?

Qualitative research is defined as “the study of the nature of phenomena”, including “their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived” , but excluding “their range, frequency and place in an objectively determined chain of cause and effect” [ 1 ]. This formal definition can be complemented with a more pragmatic rule of thumb: qualitative research generally includes data in form of words rather than numbers [ 2 ].

Why conduct qualitative research?

Because some research questions cannot be answered using (only) quantitative methods. For example, one Australian study addressed the issue of why patients from Aboriginal communities often present late or not at all to specialist services offered by tertiary care hospitals. Using qualitative interviews with patients and staff, it found one of the most significant access barriers to be transportation problems, including some towns and communities simply not having a bus service to the hospital [ 3 ]. A quantitative study could have measured the number of patients over time or even looked at possible explanatory factors – but only those previously known or suspected to be of relevance. To discover reasons for observed patterns, especially the invisible or surprising ones, qualitative designs are needed.

While qualitative research is common in other fields, it is still relatively underrepresented in health services research. The latter field is more traditionally rooted in the evidence-based-medicine paradigm, as seen in " research that involves testing the effectiveness of various strategies to achieve changes in clinical practice, preferably applying randomised controlled trial study designs (...) " [ 4 ]. This focus on quantitative research and specifically randomised controlled trials (RCT) is visible in the idea of a hierarchy of research evidence which assumes that some research designs are objectively better than others, and that choosing a "lesser" design is only acceptable when the better ones are not practically or ethically feasible [ 5 , 6 ]. Others, however, argue that an objective hierarchy does not exist, and that, instead, the research design and methods should be chosen to fit the specific research question at hand – "questions before methods" [ 2 , 7 – 9 ]. This means that even when an RCT is possible, some research problems require a different design that is better suited to addressing them. Arguing in JAMA, Berwick uses the example of rapid response teams in hospitals, which he describes as " a complex, multicomponent intervention – essentially a process of social change" susceptible to a range of different context factors including leadership or organisation history. According to him, "[in] such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect" [ 8 ] . Instead of limiting oneself to RCTs, Berwick recommends embracing a wider range of methods , including qualitative ones, which for "these specific applications, (...) are not compromises in learning how to improve; they are superior" [ 8 ].

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 – 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

Given that qualitative research is characterised by flexibility, openness and responsivity to context, the steps of data collection and analysis are not as separate and consecutive as they tend to be in quantitative research [ 13 , 14 ]. As Fossey puts it : “sampling, data collection, analysis and interpretation are related to each other in a cyclical (iterative) manner, rather than following one after another in a stepwise approach” [ 15 ]. The researcher can make educated decisions with regard to the choice of method, how they are implemented, and to which and how many units they are applied [ 13 ]. As shown in Fig.  1 , this can involve several back-and-forth steps between data collection and analysis where new insights and experiences can lead to adaption and expansion of the original plan. Some insights may also necessitate a revision of the research question and/or the research design as a whole. The process ends when saturation is achieved, i.e. when no relevant new information can be found (see also below: sampling and saturation). For reasons of transparency, it is essential for all decisions as well as the underlying reasoning to be well-documented.

Iterative research process

While it is not always explicitly addressed, qualitative methods reflect a different underlying research paradigm than quantitative research (e.g. constructivism or interpretivism as opposed to positivism). The choice of methods can be based on the respective underlying substantive theory or theoretical framework used by the researcher [ 2 ].

Data collection

The methods of qualitative data collection most commonly used in health research are document study, observations, semi-structured interviews and focus groups [ 1 , 14 , 16 , 17 ].

Document study

Document study (also called document analysis) refers to the review by the researcher of written materials [ 14 ]. These can include personal and non-personal documents such as archives, annual reports, guidelines, policy documents, diaries or letters.

Observations

Observations are particularly useful to gain insights into a certain setting and actual behaviour – as opposed to reported behaviour or opinions [ 13 ]. Qualitative observations can be either participant or non-participant in nature. In participant observations, the observer is part of the observed setting, for example a nurse working in an intensive care unit [ 18 ]. In non-participant observations, the observer is “on the outside looking in”, i.e. present in but not part of the situation, trying not to influence the setting by their presence. Observations can be planned (e.g. for 3 h during the day or night shift) or ad hoc (e.g. as soon as a stroke patient arrives at the emergency room). During the observation, the observer takes notes on everything or certain pre-determined parts of what is happening around them, for example focusing on physician-patient interactions or communication between different professional groups. Written notes can be taken during or after the observations, depending on feasibility (which is usually lower during participant observations) and acceptability (e.g. when the observer is perceived to be judging the observed). Afterwards, these field notes are transcribed into observation protocols. If more than one observer was involved, field notes are taken independently, but notes can be consolidated into one protocol after discussions. Advantages of conducting observations include minimising the distance between the researcher and the researched, the potential discovery of topics that the researcher did not realise were relevant and gaining deeper insights into the real-world dimensions of the research problem at hand [ 18 ].

Semi-structured interviews

Hijmans & Kuyper describe qualitative interviews as “an exchange with an informal character, a conversation with a goal” [ 19 ]. Interviews are used to gain insights into a person’s subjective experiences, opinions and motivations – as opposed to facts or behaviours [ 13 ]. Interviews can be distinguished by the degree to which they are structured (i.e. a questionnaire), open (e.g. free conversation or autobiographical interviews) or semi-structured [ 2 , 13 ]. Semi-structured interviews are characterized by open-ended questions and the use of an interview guide (or topic guide/list) in which the broad areas of interest, sometimes including sub-questions, are defined [ 19 ]. The pre-defined topics in the interview guide can be derived from the literature, previous research or a preliminary method of data collection, e.g. document study or observations. The topic list is usually adapted and improved at the start of the data collection process as the interviewer learns more about the field [ 20 ]. Across interviews the focus on the different (blocks of) questions may differ and some questions may be skipped altogether (e.g. if the interviewee is not able or willing to answer the questions or for concerns about the total length of the interview) [ 20 ]. Qualitative interviews are usually not conducted in written format as it impedes on the interactive component of the method [ 20 ]. In comparison to written surveys, qualitative interviews have the advantage of being interactive and allowing for unexpected topics to emerge and to be taken up by the researcher. This can also help overcome a provider or researcher-centred bias often found in written surveys, which by nature, can only measure what is already known or expected to be of relevance to the researcher. Interviews can be audio- or video-taped; but sometimes it is only feasible or acceptable for the interviewer to take written notes [ 14 , 16 , 20 ].

Focus groups

Focus groups are group interviews to explore participants’ expertise and experiences, including explorations of how and why people behave in certain ways [ 1 ]. Focus groups usually consist of 6–8 people and are led by an experienced moderator following a topic guide or “script” [ 21 ]. They can involve an observer who takes note of the non-verbal aspects of the situation, possibly using an observation guide [ 21 ]. Depending on researchers’ and participants’ preferences, the discussions can be audio- or video-taped and transcribed afterwards [ 21 ]. Focus groups are useful for bringing together homogeneous (to a lesser extent heterogeneous) groups of participants with relevant expertise and experience on a given topic on which they can share detailed information [ 21 ]. Focus groups are a relatively easy, fast and inexpensive method to gain access to information on interactions in a given group, i.e. “the sharing and comparing” among participants [ 21 ]. Disadvantages include less control over the process and a lesser extent to which each individual may participate. Moreover, focus group moderators need experience, as do those tasked with the analysis of the resulting data. Focus groups can be less appropriate for discussing sensitive topics that participants might be reluctant to disclose in a group setting [ 13 ]. Moreover, attention must be paid to the emergence of “groupthink” as well as possible power dynamics within the group, e.g. when patients are awed or intimidated by health professionals.

Choosing the “right” method

As explained above, the school of thought underlying qualitative research assumes no objective hierarchy of evidence and methods. This means that each choice of single or combined methods has to be based on the research question that needs to be answered and a critical assessment with regard to whether or to what extent the chosen method can accomplish this – i.e. the “fit” between question and method [ 14 ]. It is necessary for these decisions to be documented when they are being made, and to be critically discussed when reporting methods and results.

Let us assume that our research aim is to examine the (clinical) processes around acute endovascular treatment (EVT), from the patient’s arrival at the emergency room to recanalization, with the aim to identify possible causes for delay and/or other causes for sub-optimal treatment outcome. As a first step, we could conduct a document study of the relevant standard operating procedures (SOPs) for this phase of care – are they up-to-date and in line with current guidelines? Do they contain any mistakes, irregularities or uncertainties that could cause delays or other problems? Regardless of the answers to these questions, the results have to be interpreted based on what they are: a written outline of what care processes in this hospital should look like. If we want to know what they actually look like in practice, we can conduct observations of the processes described in the SOPs. These results can (and should) be analysed in themselves, but also in comparison to the results of the document analysis, especially as regards relevant discrepancies. Do the SOPs outline specific tests for which no equipment can be observed or tasks to be performed by specialized nurses who are not present during the observation? It might also be possible that the written SOP is outdated, but the actual care provided is in line with current best practice. In order to find out why these discrepancies exist, it can be useful to conduct interviews. Are the physicians simply not aware of the SOPs (because their existence is limited to the hospital’s intranet) or do they actively disagree with them or does the infrastructure make it impossible to provide the care as described? Another rationale for adding interviews is that some situations (or all of their possible variations for different patient groups or the day, night or weekend shift) cannot practically or ethically be observed. In this case, it is possible to ask those involved to report on their actions – being aware that this is not the same as the actual observation. A senior physician’s or hospital manager’s description of certain situations might differ from a nurse’s or junior physician’s one, maybe because they intentionally misrepresent facts or maybe because different aspects of the process are visible or important to them. In some cases, it can also be relevant to consider to whom the interviewee is disclosing this information – someone they trust, someone they are otherwise not connected to, or someone they suspect or are aware of being in a potentially “dangerous” power relationship to them. Lastly, a focus group could be conducted with representatives of the relevant professional groups to explore how and why exactly they provide care around EVT. The discussion might reveal discrepancies (between SOPs and actual care or between different physicians) and motivations to the researchers as well as to the focus group members that they might not have been aware of themselves. For the focus group to deliver relevant information, attention has to be paid to its composition and conduct, for example, to make sure that all participants feel safe to disclose sensitive or potentially problematic information or that the discussion is not dominated by (senior) physicians only. The resulting combination of data collection methods is shown in Fig.  2 .

Possible combination of data collection methods

Attributions for icons: “Book” by Serhii Smirnov, “Interview” by Adrien Coquet, FR, “Magnifying Glass” by anggun, ID, “Business communication” by Vectors Market; all from the Noun Project

The combination of multiple data source as described for this example can be referred to as “triangulation”, in which multiple measurements are carried out from different angles to achieve a more comprehensive understanding of the phenomenon under study [ 22 , 23 ].

Data analysis

To analyse the data collected through observations, interviews and focus groups these need to be transcribed into protocols and transcripts (see Fig.  3 ). Interviews and focus groups can be transcribed verbatim , with or without annotations for behaviour (e.g. laughing, crying, pausing) and with or without phonetic transcription of dialects and filler words, depending on what is expected or known to be relevant for the analysis. In the next step, the protocols and transcripts are coded , that is, marked (or tagged, labelled) with one or more short descriptors of the content of a sentence or paragraph [ 2 , 15 , 23 ]. Jansen describes coding as “connecting the raw data with “theoretical” terms” [ 20 ]. In a more practical sense, coding makes raw data sortable. This makes it possible to extract and examine all segments describing, say, a tele-neurology consultation from multiple data sources (e.g. SOPs, emergency room observations, staff and patient interview). In a process of synthesis and abstraction, the codes are then grouped, summarised and/or categorised [ 15 , 20 ]. The end product of the coding or analysis process is a descriptive theory of the behavioural pattern under investigation [ 20 ]. The coding process is performed using qualitative data management software, the most common ones being InVivo, MaxQDA and Atlas.ti. It should be noted that these are data management tools which support the analysis performed by the researcher(s) [ 14 ].

From data collection to data analysis

Attributions for icons: see Fig. ​ Fig.2, 2 , also “Speech to text” by Trevor Dsouza, “Field Notes” by Mike O’Brien, US, “Voice Record” by ProSymbols, US, “Inspection” by Made, AU, and “Cloud” by Graphic Tigers; all from the Noun Project

How to report qualitative research?

Protocols of qualitative research can be published separately and in advance of the study results. However, the aim is not the same as in RCT protocols, i.e. to pre-define and set in stone the research questions and primary or secondary endpoints. Rather, it is a way to describe the research methods in detail, which might not be possible in the results paper given journals’ word limits. Qualitative research papers are usually longer than their quantitative counterparts to allow for deep understanding and so-called “thick description”. In the methods section, the focus is on transparency of the methods used, including why, how and by whom they were implemented in the specific study setting, so as to enable a discussion of whether and how this may have influenced data collection, analysis and interpretation. The results section usually starts with a paragraph outlining the main findings, followed by more detailed descriptions of, for example, the commonalities, discrepancies or exceptions per category [ 20 ]. Here it is important to support main findings by relevant quotations, which may add information, context, emphasis or real-life examples [ 20 , 23 ]. It is subject to debate in the field whether it is relevant to state the exact number or percentage of respondents supporting a certain statement (e.g. “Five interviewees expressed negative feelings towards XYZ”) [ 21 ].

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 – 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

Three common mixed methods designs

In the convergent parallel design, a qualitative study is conducted in parallel to and independently of a quantitative study, and the results of both studies are compared and combined at the stage of interpretation of results. Using the above example of EVT provision, this could entail setting up a quantitative EVT registry to measure process times and patient outcomes in parallel to conducting the qualitative research outlined above, and then comparing results. Amongst other things, this would make it possible to assess whether interview respondents’ subjective impressions of patients receiving good care match modified Rankin Scores at follow-up, or whether observed delays in care provision are exceptions or the rule when compared to door-to-needle times as documented in the registry. In the explanatory sequential design, a quantitative study is carried out first, followed by a qualitative study to help explain the results from the quantitative study. This would be an appropriate design if the registry alone had revealed relevant delays in door-to-needle times and the qualitative study would be used to understand where and why these occurred, and how they could be improved. In the exploratory design, the qualitative study is carried out first and its results help informing and building the quantitative study in the next step [ 26 ]. If the qualitative study around EVT provision had shown a high level of dissatisfaction among the staff members involved, a quantitative questionnaire investigating staff satisfaction could be set up in the next step, informed by the qualitative study on which topics dissatisfaction had been expressed. Amongst other things, the questionnaire design would make it possible to widen the reach of the research to more respondents from different (types of) hospitals, regions, countries or settings, and to conduct sub-group analyses for different professional groups.

How to assess qualitative research?

A variety of assessment criteria and lists have been developed for qualitative research, ranging in their focus and comprehensiveness [ 14 , 17 , 27 ]. However, none of these has been elevated to the “gold standard” in the field. In the following, we therefore focus on a set of commonly used assessment criteria that, from a practical standpoint, a researcher can look for when assessing a qualitative research report or paper.

Assessors should check the authors’ use of and adherence to the relevant reporting checklists (e.g. Standards for Reporting Qualitative Research (SRQR)) to make sure all items that are relevant for this type of research are addressed [ 23 , 28 ]. Discussions of quantitative measures in addition to or instead of these qualitative measures can be a sign of lower quality of the research (paper). Providing and adhering to a checklist for qualitative research contributes to an important quality criterion for qualitative research, namely transparency [ 15 , 17 , 23 ].

Reflexivity

While methodological transparency and complete reporting is relevant for all types of research, some additional criteria must be taken into account for qualitative research. This includes what is called reflexivity, i.e. sensitivity to the relationship between the researcher and the researched, including how contact was established and maintained, or the background and experience of the researcher(s) involved in data collection and analysis. Depending on the research question and population to be researched this can be limited to professional experience, but it may also include gender, age or ethnicity [ 17 , 27 ]. These details are relevant because in qualitative research, as opposed to quantitative research, the researcher as a person cannot be isolated from the research process [ 23 ]. It may influence the conversation when an interviewed patient speaks to an interviewer who is a physician, or when an interviewee is asked to discuss a gynaecological procedure with a male interviewer, and therefore the reader must be made aware of these details [ 19 ].

Sampling and saturation

The aim of qualitative sampling is for all variants of the objects of observation that are deemed relevant for the study to be present in the sample “ to see the issue and its meanings from as many angles as possible” [ 1 , 16 , 19 , 20 , 27 ] , and to ensure “information-richness [ 15 ]. An iterative sampling approach is advised, in which data collection (e.g. five interviews) is followed by data analysis, followed by more data collection to find variants that are lacking in the current sample. This process continues until no new (relevant) information can be found and further sampling becomes redundant – which is called saturation [ 1 , 15 ] . In other words: qualitative data collection finds its end point not a priori , but when the research team determines that saturation has been reached [ 29 , 30 ].

This is also the reason why most qualitative studies use deliberate instead of random sampling strategies. This is generally referred to as “ purposive sampling” , in which researchers pre-define which types of participants or cases they need to include so as to cover all variations that are expected to be of relevance, based on the literature, previous experience or theory (i.e. theoretical sampling) [ 14 , 20 ]. Other types of purposive sampling include (but are not limited to) maximum variation sampling, critical case sampling or extreme or deviant case sampling [ 2 ]. In the above EVT example, a purposive sample could include all relevant professional groups and/or all relevant stakeholders (patients, relatives) and/or all relevant times of observation (day, night and weekend shift).

Assessors of qualitative research should check whether the considerations underlying the sampling strategy were sound and whether or how researchers tried to adapt and improve their strategies in stepwise or cyclical approaches between data collection and analysis to achieve saturation [ 14 ].

Good qualitative research is iterative in nature, i.e. it goes back and forth between data collection and analysis, revising and improving the approach where necessary. One example of this are pilot interviews, where different aspects of the interview (especially the interview guide, but also, for example, the site of the interview or whether the interview can be audio-recorded) are tested with a small number of respondents, evaluated and revised [ 19 ]. In doing so, the interviewer learns which wording or types of questions work best, or which is the best length of an interview with patients who have trouble concentrating for an extended time. Of course, the same reasoning applies to observations or focus groups which can also be piloted.

Ideally, coding should be performed by at least two researchers, especially at the beginning of the coding process when a common approach must be defined, including the establishment of a useful coding list (or tree), and when a common meaning of individual codes must be established [ 23 ]. An initial sub-set or all transcripts can be coded independently by the coders and then compared and consolidated after regular discussions in the research team. This is to make sure that codes are applied consistently to the research data.

Member checking

Member checking, also called respondent validation , refers to the practice of checking back with study respondents to see if the research is in line with their views [ 14 , 27 ]. This can happen after data collection or analysis or when first results are available [ 23 ]. For example, interviewees can be provided with (summaries of) their transcripts and asked whether they believe this to be a complete representation of their views or whether they would like to clarify or elaborate on their responses [ 17 ]. Respondents’ feedback on these issues then becomes part of the data collection and analysis [ 27 ].

Stakeholder involvement

In those niches where qualitative approaches have been able to evolve and grow, a new trend has seen the inclusion of patients and their representatives not only as study participants (i.e. “members”, see above) but as consultants to and active participants in the broader research process [ 31 – 33 ]. The underlying assumption is that patients and other stakeholders hold unique perspectives and experiences that add value beyond their own single story, making the research more relevant and beneficial to researchers, study participants and (future) patients alike [ 34 , 35 ]. Using the example of patients on or nearing dialysis, a recent scoping review found that 80% of clinical research did not address the top 10 research priorities identified by patients and caregivers [ 32 , 36 ]. In this sense, the involvement of the relevant stakeholders, especially patients and relatives, is increasingly being seen as a quality indicator in and of itself.

How not to assess qualitative research

The above overview does not include certain items that are routine in assessments of quantitative research. What follows is a non-exhaustive, non-representative, experience-based list of the quantitative criteria often applied to the assessment of qualitative research, as well as an explanation of the limited usefulness of these endeavours.

Protocol adherence

Given the openness and flexibility of qualitative research, it should not be assessed by how well it adheres to pre-determined and fixed strategies – in other words: its rigidity. Instead, the assessor should look for signs of adaptation and refinement based on lessons learned from earlier steps in the research process.

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 – 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

While some authors argue that randomisation can be used in qualitative research, this is not commonly the case, as neither its feasibility nor its necessity or usefulness has been convincingly established for qualitative research [ 13 , 27 ]. Relevant disadvantages include the negative impact of a too large sample size as well as the possibility (or probability) of selecting “ quiet, uncooperative or inarticulate individuals ” [ 17 ]. Qualitative studies do not use control groups, either.

Interrater reliability, variability and other “objectivity checks”

The concept of “interrater reliability” is sometimes used in qualitative research to assess to which extent the coding approach overlaps between the two co-coders. However, it is not clear what this measure tells us about the quality of the analysis [ 23 ]. This means that these scores can be included in qualitative research reports, preferably with some additional information on what the score means for the analysis, but it is not a requirement. Relatedly, it is not relevant for the quality or “objectivity” of qualitative research to separate those who recruited the study participants and collected and analysed the data. Experiences even show that it might be better to have the same person or team perform all of these tasks [ 20 ]. First, when researchers introduce themselves during recruitment this can enhance trust when the interview takes place days or weeks later with the same researcher. Second, when the audio-recording is transcribed for analysis, the researcher conducting the interviews will usually remember the interviewee and the specific interview situation during data analysis. This might be helpful in providing additional context information for interpretation of data, e.g. on whether something might have been meant as a joke [ 18 ].

Not being quantitative research

Being qualitative research instead of quantitative research should not be used as an assessment criterion if it is used irrespectively of the research problem at hand. Similarly, qualitative research should not be required to be combined with quantitative research per se – unless mixed methods research is judged as inherently better than single-method research. In this case, the same criterion should be applied for quantitative studies without a qualitative component.

The main take-away points of this paper are summarised in Table ​ Table1. 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

Take-away-points

• Assessing complex multi-component interventions or systems (of change) • What works for whom when, how and why? • Focussing on intervention improvement	• Document study • Observations (participant or non-participant) • Interviews (especially semi-structured) • Focus groups	• Transcription of audio-recordings and field notes into transcripts and protocols • Coding of protocols • Using qualitative data management software
• Combinations of quantitative and/or qualitative methods, e.g.: • : quali and quanti in parallel • : quanti followed by quali • : quali followed by quanti	• Checklists • Reflexivity • Sampling strategies • Piloting • Co-coding • Member checking • Stakeholder involvement	• Protocol adherence • Sample size • Randomization • Interrater reliability, variability and other “objectivity checks” • Not being quantitative research

Acknowledgements

Abbreviations.

EVT	Endovascular treatment
RCT	Randomised Controlled Trial
SOP	Standard Operating Procedure
SRQR	Standards for Reporting Qualitative Research

Authors’ contributions

LB drafted the manuscript; WW and CG revised the manuscript; all authors approved the final versions.

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The authors declare no competing interests.

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Qualitative Research: Semi-structured Expert Interview

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• Patric Finkbeiner 2  

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In Chap. 5 , the motivational factors were ranked according to the relevance observed (Table 5.6 ). In the second phase of this qualitative methodology, the researcher begins with the explanation of different interview types and the justification for choosing semi-structured expert interviews for testing or adding to the factors obtained by PO.

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Translation: the Law of Informational Self-determination.

e.g. “wanna” instead of “want to”

Engl.: “You sit together with your boss and discuss and talk a bit” (23_25).

Engl.: “Yes good, first these things are discussed internally” (02_04).

Engl.: “We know each other quite well” (01_06).

Engl.: “I have experienced cases, when I just went online and started looking. Somewhere […] some community, you can still get some ideas” (23_13).

Engl.: “that one tries to help each other” (02_16).

Engl.: “our boss feel attacked on his professional honor” (14_06).

Engl.: “I think i have the ambition to just wangle some things. I take my time and persist and stay longer. I can go till 7 or 7:30”(23_47).

Engl.: “it must be fun, that is the essential” (03_24).

Engl.: “Interest are very important for me” (21_46).

Engl.: “when you have to motivate yourself” (20_43).

Engl.: “think logical that what I preach to all of them” (20_28).

Engl.: “I don’t expect that everyone knows everything—I have to know where to find it!” (10_14).

Engl.: “Yes, but the communication is very important” (06_14).

Engl.: “don’t ask […] if they do not communicate” (10_31).

Engl.: “that he can decide himself, what makes sense and what not” (02_02).

Engl.: “a good interhuman relationship and a good common basis” (17_45).

Engl.: “that the companionship is correct, as well as the interpersonal atmosphere” (10_33).

Engl.: “boss, because someone has to be there to take a decision” (23_08).

Engl.: “I usually carry a whip, but sometimes I also pet them” (06_38).

Engl.: “then I watch and check how the work proceeds” (03_16).

Engl.: “one relies on the workers, who have expertise” (07_30).

Engl.: “trust should be given, and then it should work out fine” (23_28).

Engl.: “has been in the profession for 30 years” (02_24).

Engl.: “that is because of the experience and the age” (23_37).

Engl.: “and the age pays a role and that are all factors” (03_26).

Engl.: “many things are basic repair knowledge which sometimes is missing” (23_51).

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Finkbeiner, P. (2017). Qualitative Research: Semi-structured Expert Interview. In: Social Media for Knowledge Sharing in Automotive Repair. Springer, Cham. https://doi.org/10.1007/978-3-319-48544-7_6

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The use of semi-structured interviews in qualitative research: strengths and weaknesses

What needs to be considered before collecting data through semi-structured interviews? How does thinking about analysis before questioning help or hinder interviewing practice? How should the strengths and weaknesses of the method be evaluated? To cite this paper: Newton, Nigel (2010) The use of semi-structured interviews in qualitative research: strengths and weaknesses. Paper submitted in part completion of the requirements of the degree of Doctor of Philosophy, University of Bristol. Retrieved online at http://www.academia.edu/1561689/The_use_of_semi-structured_interviews_in_qualitative_research_strengths_and_weaknesses on [date accessed]

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Research Aim Investigation exploring how and why the UK government currently use social media twitter to engage with UK citizens, through analysing the @number10gov twitter page. Objectives Investigate and develop a framework for the style of tweets that exists within the @number10gov twitter page Investigate how UK citizens on twitter use tools to engage in political debate Discover to what level people engage with tweets made by @number10gov Develop an understanding of why the current government use twitter

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Susan Steward , ELENA NARDI

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Paul Tosey , James Lawley , Rupert Meese

This paper shows how an innovative method of questioning called Clean Language can enhance the authenticity and rigour of interview-based qualitative research. We investigate the specific potential of Clean Language as a method for eliciting naturally occurring metaphors in order to provide in-depth understanding of a person's symbolic world; despite substantial interest in metaphors in the field of organizational and management research there is a lack of explicit, systematic methods for eliciting naturally occurring metaphors. We also demonstrate how Clean Language can improve qualitative research more widely by addressing the propensity for researchers inadvertently to introduce extraneous metaphors into an interviewee's account at both data collection and interpretation stages. Data are presented from a collaborative academic–practitioner project in which Clean Language was used as a method of interviewing to elicit the metaphors of six mid-career managers, relating to the way they experienced work–life balance. The first contribution of this paper is to demonstrate the potential of Clean Language for eliciting naturally occurring metaphors in order to provide in-depth understanding of a person's symbolic world. The second contribution is to show how Clean Language can enhance the rigour and authenticity of interview-based qualitative research more widely.

Bill Brodie

This research focuses on language learning motivations within a group of 820 trainee teachers of English in the German Federal State of Brandenburg between the years 1994 and 2000. The unique social and political situation in former East Germany post-1989 engendered a fascinating spectrum of motivational mixtures among these participants - from pure intrinsic interest in learning English at one end to fear of redundancy at the other due to falling birth rates and the threatened disappearance of previous subject specialisms. Motivational mixtures among this target group were researched using constructs and research instruments that draw on a number of previous research models – integrative/instrumental and intrinsic/extrinsic paradigms, as well as a range of socio-cognitive heuristics. In response to calls from recent researchers such as Oxford and Dörnyei, this study researches motivation as a multi-faceted phenomenon requiring the researcher to get beyond the limitations of one or other particular motivational model which may tend to oversimplify motivational complexities. There is also increasing awareness among researchers that motivation is not a static phenomenon but changes over time with circumstances. This study, while not strictly speaking longitudinal, has a longitudinal aspect. I have attempted to trace the development of motivational mixtures during pre-actional, actional and post-actional phases of a three-year commitment by participants to the English retraining programme. In particular, I have used this multi-factorial and quasi-longitudinal approach to ascertain the range of mixtures of motivations within the target sample. I found that most participants undertook the English retraining programme with varied motivations reflecting intrinsic interest and significant external pressures. I then sought to analyse whether intrinsic motivation levels waned during the actional phase under the sheer pressures of involvement in the programme. On the contrary, results of this research have suggested that intrinsic motivation grew stronger across the group at large. In the post-actional phase, this increased motivation in at least 90% of the sample led to a generally positive commitment to ongoing linguistic improvement and to using English for pleasure and professional purposes. The State-institutionalised retraining scheme was a success achieved at considerable personal cost by participants - but real, personalised and lasting motivation among the participants was not part of the sacrifice. Most interestingly, it emerges in this research that different types of motivation seemed to fuse in individuals’ experience - particularly under sustained pressure. It proved necessary to use a wide range of motivational constructs and terminology to map out the diverse motivational components within the sample, but interview statements seem to point to a blending of motivations that transcends even this multi-factorial approach. “Personal interest” which began as intrinsic interest in English itself, was seen to fuse with instrumental sources of motivation and, when under pressure, to be fired by something even more deep-seated - a raw, primal motivation best summed up in the phrase “This is not going to beat me.” It emerges therefore that motivational complexities may be misleadingly interpreted if we do not perceive how new compounds evolve in each individual as a result of blending motivations across time and under pressure. Just as water is more than a combination of its separate components, hydrogen and oxygen, motivation may be described by analysing its individual components, but the whole is always more - and other – than the sum of the parts. This result underlines the need to be careful not to channel motivation research findings into too narrow categories based on traditional models of motivational theory, and points to the need for further research to establish more subtle, differentiated and individualised profiles of motivational mixtures within groups and individuals.

Tamjid Mujtaba , Melissa Rodd , Michael J Reiss

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Semi-Structured Interviews in Qualitative Research

Unveiling insights of semi-structured interviews in qualitative research, the methods for nuanced understanding and robust data analysis.

Qualitative research explores the rich complexities of human experiences, perceptions, and meanings. In the research area, semi-structured interviews emerge as a versatile method to gather in-depth insights from participants. Unlike rigidly structured interviews, semi-structured interviews provide a flexible framework that combines predetermined questions with the freedom to explore emergent topics and probe deeper into participants’ thoughts and experiences. This article aims to show the purpose, benefits, and best practices of utilizing semi-structured interviews in qualitative research. By understanding how this approach facilitates a nuanced exploration of research questions, researchers can harness its potential to capture the multifaceted nature of human phenomena and gain rich and meaningful data that enhances the understanding of diverse social, psychological, and cultural phenomena.

What Are Semi-structured Interviews In Qualitative Research?

A semi-structured interview is a qualitative research method that combines aspects of both structured and unstructured interviews. In a semi-structured interview, the researcher prepares a set of predetermined questions or topics to guide the conversation with the participant, but there is also room for flexibility and follow-up questions based on the participant’s responses. This allows for a more conversational and exploratory approach, enabling the researcher to delve deeper into specific areas of interest and capture detailed and nuanced information.

Also read: What’s the Difference: Qualitative vs Quantitative Research?

Semi-structured interviews enable researchers to explore participants’ perspectives, experiences, and perceptions in-depth. They can uncover rich narratives, personal insights, and contextual details that may not emerge in more standardized interview formats. The open-ended nature of semi-structured interviews allows for a holistic understanding of the research topic and captures the complexity of human experiences.

The Purpose Of Semi-Structured Interviews

Semi-structured interviews serve as a dynamic means of collecting qualitative data, allowing researchers to engage in a conversation with participants while maintaining a certain level of flexibility. These interviews enable researchers to explore research questions, delve into participants’ perspectives, and gain a comprehensive understanding of the studied phenomena. The purpose of semi-structured interviews extends beyond factual information; it aims to uncover participants’ perceptions, beliefs, values, and emotions, providing valuable insights into their subjective experiences.

When To Use A Semi-Structured Interview?

When conducting qualitative research, the decision to use a semi-structured interview approach is influenced by various factors. Semi-structured interviews are particularly suitable when exploring complex and multifaceted topics that require full understanding. They are valuable when researchers aim to capture participants’ perspectives, experiences, and narratives in a flexible and open-ended manner. Semi-structured interviews are effective when the research objectives involve exploring diverse viewpoints, identifying patterns and themes, and gaining insights into individuals’ thoughts and emotions. Additionally, this approach is advantageous when researchers seek to establish rapport and build a collaborative relationship with participants, as it allows for meaningful and interactive conversations. The use of semi-structured interviews empowers researchers to investigate the richness of participants’ experiences while maintaining a level of versatility and adaptability in data collection.

Benefits Of Semi-Structured Interviews

Flexibility and Adaptability: Semi-structured interviews offer a balance between structure and flexibility, allowing researchers to adapt their questioning based on participant responses. This approach enables researchers to examine specific areas of interest, explore unexpected avenues, and capture nuanced information that may not emerge in rigidly structured interviews.

Participant-Centered Approach: Semi-structured interviews place participants at the center of the research process, valuing their perspectives and experiences. By creating a conversational and comfortable atmosphere, researchers can foster trust and rapport, encouraging participants to share their thoughts openly. This approach facilitates a collaborative and co-constructed knowledge-building process, capturing the complexity of participants’ lived experiences.

In-Depth Exploration: Through semi-structured interviews, researchers can delve deeply into participants’ narratives, unraveling intricate details and uncovering hidden meanings. The open-ended nature of these interviews allows for rich descriptions, personal anecdotes, and contextual insights, enabling researchers to gain a comprehensive understanding of the research topic.

Disadvantages Of Semi-Structured Interviews

While semi-structured interviews offer several benefits, it is important to consider their potential disadvantages in qualitative research. One disadvantage is the possibility of interviewer bias or influence. As the interviewer plays an active role in guiding the interview, their personal biases, assumptions, or interpretations may inadvertently shape the participants’ responses. This can compromise the objectivity of the data collected. Another challenge is the time-consuming nature of semi-structured interviews. Conducting interviews, transcribing, and analyzing the data can be a lengthy process, requiring substantial time and resources.

Also read: A Problem Called Sampling Bias

Additionally, the quality of the data obtained may depend on the interviewer’s skills and experience in conducting interviews and eliciting rich responses from participants. If the interviewer lacks proper training or expertise, the quality and depth of the data collected may be compromised. Lastly, the open-ended nature of semi-structured interviews may lead to a vast amount of qualitative data that can be challenging to analyze and interpret, requiring careful attention and rigorous analysis techniques.

Key Considerations For Conducting Semi-Structured Interviews

After confirming that a semi-structured interview aligns with the research topic, the following sequential steps are used to prepare and conduct a semi-structured interview:

Step 1: Define The Objective And Research Scope

Begin by clarifying the purpose of the semi-structured interview and why it is the most suitable research method for the study. Consider the specific knowledge or insights that are intended to be gained through the interview process.

Step 2: Develop Well-Designed Interview Questions

Craft the interview questions to be open-ended, simple, and concise. Take care with the choice of words, particularly when discussing sensitive topics. Ensure that the questions allow for participants to provide detailed and nuanced responses.

Step 3: Identify The Target Group(s) For The Interview

Determine the specific population or groups to engage with during the semi-structured interview. Depending on the size of the target group, utilize random or stratified sampling techniques to select a representative sample. Alternatively, if the group is small, the interview may be with all potential participants.

Step 4: Plan The Logistics Of The Interview

Decide on the details of how, when, and where the interview will take place. Obtain consent from participants and provide them with advance notice of the interview date, time, and location. Choose an environment conducive to open and comfortable communication.

Step 5: Conduct The Interviews

Initiate the interviews by engaging in a casual conversation to establish rapport and build trust with the participants. During face-to-face interviews, actively listen to respondents, paying attention to their non-verbal cues such as body language, gestures, and vocal changes. Maintain a non-judgmental, empathetic, and friendly demeanor throughout the interview process.

Step 6: Transcribe The Interview Recordings

Transcribe the audio or video recordings of the semi-structured interviews. Transcription converts spoken content into written form, aiding in data analysis. Seek appropriate resources or tools to assist you in effectively transcribing the interviews.

Step 7: Code And Categorize The Data

Next, analyze the data collected from the semi-structured interviews. Coding involves carefully examining the transcribed data to identify recurring patterns, themes, and categories. This process helps in organizing and making sense of the information obtained. Consider using specialized coding interview software to streamline this task.

Also read: Mastering Analysis: The Role of Codebook Qualitative Research

Step 8: Analyze The Coded Data

Once the coding process is complete, analyze the coded data to gain meaningful insights. Utilize qualitative data analysis tools, such as Delve, to explore the data more deeply and uncover valuable findings. Draw connections between themes and patterns to develop a comprehensive understanding of the interview outcomes.

Step 9: Present Findings In A Research Paper Or Report

Transform the analysis into a coherent narrative by presenting the results in a research paper or report. Communicate the story behind the data, emphasizing key insights and supporting evidence. Structure the paper to effectively convey the significance and implications of findings in relation to research objectives.

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Strengths and Weaknesses of Semi-Structured Interviews in Qualitative Research: A Critical Essay

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Development of Qualitative Semi-Structured Interview Guide for Case Study Research

• Nuzhat Naz, Fozia Gulab, Mahnaz Aslam

Interviewing is an effective strategy to acquire data for qualitative research that uses case studies as a research methodology.  It helps to explain, understand, and explore research subjects' opinions, behavior, and experiences to narrow down the area of research that researcher is interested to discover while listening to them being involved through dialogue. Therefore, structured or semi-structured interviews become effective tools of knowing the experiences and perceptions of research subjects relating to central themes of area of investigation. The aim of this research is to share with researchers the systematic process to be followed in developing semi-structured interview guides. Literature review suggests five distinct phases that the researcher needs to be mindful of when developing a qualitative semi-structured interview guide; they must identify if the prerequisites for conducting a semi-structured interview are met, utilize previously acquired knowledge, formulate a preliminary guide, pilot test it, and then present the completed semi-structured interview guide. Salient features of each phase are explained through literary support followed by researcher’s experience of working on each phase to proceed in developing the interview guide.  A well-developed semi- structured interview guide becomes an authentic and valid source of data collection whereas weakly developed semi-structured interview guide distorts the findings of research resulting in unreliable, inaccurate and invalid data collected.

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Semistructured interviewing in primary care research: a balance of relationship and rigour

Lisa M Vaughn .

https://doi.org/ 10.1136/fmch-2018-000057

Semistructured in-depth interviews are commonly used in qualitative research and are the most frequent qualitative data source in health services research. This method typically consists of a dialogue between researcher and participant, guided by a flexible interview protocol and supplemented by follow-up questions, probes and comments. The method allows the researcher to collect open-ended data, to explore participant thoughts, feelings and beliefs about a particular topic and to delve deeply into personal and sometimes sensitive issues. The purpose of this article was to identify and describe the essential skills to designing and conducting semistructured interviews in family medicine and primary care research settings. We reviewed the literature on semistructured interviewing to identify key skills and components for using this method in family medicine and primary care research settings. Overall, semistructured interviewing requires both a relational focus and practice in the skills of facilitation. Skills include: (1) determining the purpose and scope of the study; (2) identifying participants; (3) considering ethical issues; (4) planning logistical aspects; (5) developing the interview guide; (6) establishing trust and rapport; (7) conducting the interview; (8) memoing and reflection; (9) analysing the data; (10) demonstrating the trustworthiness of the research; and (11) presenting findings in a paper or report. Semistructured interviews provide an effective and feasible research method for family physicians to conduct in primary care research settings. Researchers using semistructured interviews for data collection should take on a relational focus and consider the skills of interviewing to ensure quality. Semistructured interviewing can be a powerful tool for family physicians, primary care providers and other health services researchers to use to understand the thoughts, beliefs and experiences of individuals. Despite the utility, semistructured interviews can be intimidating and challenging for researchers not familiar with qualitative approaches. In order to elucidate this method, we provide practical guidance for researchers, including novice researchers and those with few resources, to use semistructured interviewing as a data collection strategy. We provide recommendations for the essential steps to follow in order to best implement semistructured interviews in family medicine and primary care research settings.

• Introduction

Semistructured interviews can be used by family medicine researchers in clinical settings or academic settings even with few resources. In contrast to large-scale epidemiological studies, or even surveys, a family medicine researcher can conduct a highly meaningful project with interviews with as few as 8–12 participants. For example, Chang and her colleagues, all family physicians, conducted semistructured interviews with 10 providers to understand their perspectives on weight gain in pregnant patients. 1 The interviewers asked questions about providers’ overall perceptions on weight gain, their clinical approach to weight gain during pregnancy and challenges when managing weight gain among pregnant patients. Additional examples conducted by or with family physicians or in primary care settings are summarised in table 1 . 1–6

From our perspective as seasoned qualitative researchers, conducting effective semistructured interviews requires: (1) a relational focus, including active engagement and curiosity, and (2) practice in the skills of interviewing. First, a relational focus emphasises the unique relationship between interviewer and interviewee. To obtain quality data, interviews should not be conducted with a transactional question-answer approach but rather should be unfolding, iterative interactions between the interviewer and interviewee. Second, interview skills can be learnt. Some of us will naturally be more comfortable and skilful at conducting interviews but all aspects of interviews are learnable and through practice and feedback will improve. Throughout this article, we highlight strategies to balance relationship and rigour when conducting semistructured interviews in primary care and the healthcare setting.

Qualitative research interviews are ‘attempts to understand the world from the subjects’ point of view, to unfold the meaning of peoples’ experiences, to uncover their lived world prior to scientific explanations’ (p 1). 7 Qualitative research interviews unfold as an interviewer asks questions of the interviewee in order to gather subjective information about a particular topic or experience. Though the definitions and purposes of qualitative research interviews vary slightly in the literature, there is common emphasis on the experiences of interviewees and the ways in which the interviewee perceives the world (see table 2 for summary of definitions from seminal texts).

The most common type of interview used in qualitative research and the healthcare context is semistructured interview. 8 Figure 1 highlights the key features of this data collection method, which is guided by a list of topics or questions with follow-up questions, probes and comments. Typically, the sequencing and wording of the questions are modified by the interviewer to best fit the interviewee and interview context. Semistructured interviews can be conducted in multiple ways (ie, face to face, telephone, text/email, individual, group, brief, in-depth), each of which have advantages and disadvantages. We will focus on the most common form of semistructured interviews within qualitative research—individual, face-to-face, in-depth interviews.

Key characteristics of semistructured interviews.

Purpose of semistructured interviews

The overall purpose of using semistructured interviews for data collection is to gather information from key informants who have personal experiences, attitudes, perceptions and beliefs related to the topic of interest. Researchers can use semistructured interviews to collect new, exploratory data related to a research topic, triangulate other data sources or validate findings through member checking (respondent feedback about research results). 9 If using a mixed methods approach, semistructured interviews can also be used in a qualitative phase to explore new concepts to generate hypotheses or explain results from a quantitative phase that tests hypotheses. Semistructured interviews are an effective method for data collection when the researcher wants: (1) to collect qualitative, open-ended data; (2) to explore participant thoughts, feelings and beliefs about a particular topic; and (3) to delve deeply into personal and sometimes sensitive issues.

Designing and conducting semistructured interviews

In the following section, we provide recommendations for the steps required to carefully design and conduct semistructured interviews with emphasis on applications in family medicine and primary care research (see table 3 ).

Steps for designing and conducting semistructured interviews

Step 1: determining the purpose and scope of the study.

The purpose of the study is the primary objective of your project and may be based on an anecdotal experience, a review of the literature or previous research finding. The purpose is developed in response to an identified gap or problem that needs to be addressed.

Research questions are the driving force of a study because they are associated with every other aspect of the design. They should be succinct and clearly indicate that you are using a qualitative approach. Qualitative research questions typically start with ‘What’, ‘How’ or ‘Why’ and focus on the exploration of a single concept based on participant perspectives. 10

Step 2: identifying participants

After deciding on the purpose of the study and research question(s), the next step is to determine who will provide the best information to answer the research question. Good interviewees are those who are available, willing to be interviewed and have lived experiences and knowledge about the topic of interest. 11 12 Working with gatekeepers or informants to get access to potential participants can be extremely helpful as they are trusted sources that control access to the target sample.

Sampling strategies are influenced by the research question and the purpose of the study. Unlike quantitative studies, statistical representativeness is not the goal of qualitative research. There is no calculation of statistical power and the goal is not a large sample size. Instead, qualitative approaches seek an in-depth and detailed understanding and typically use purposeful sampling. See the study of Hatch for a summary of various types of purposeful sampling that can be used for interview studies. 12

‘How many participants are needed?’ The most common answer is, ‘it depends’—it depends on the purpose of the study, what kind of study is planned and what questions the study is trying to answer. 12–14 One common standard in qualitative sample sizes is reaching thematic saturation, which refers to the point at which no new thematic information is gathered from participants. Malterud and colleagues discuss the concept of information power , or a qualitative equivalent to statistical power, to determine how many interviews should be collected in a study. They suggest that the size of a sample should depend on the aim, homogeneity of the sample, theory, interview quality and analytic strategy. 14

Step 3: considering ethical issues

An ethical attitude should be present from the very beginning of the research project even before you decide who to interview. 15 This ethical attitude should incorporate respect, sensitivity and tact towards participants throughout the research process. Because semistructured interviewing often requires the participant to reveal sensitive and personal information directly to the interviewer, it is important to consider the power imbalance between the researcher and the participant. In healthcare settings, the interviewer or researcher may be a part of the patient’s healthcare team or have contact with the healthcare team. The researchers should ensure the interviewee that their participation and answers will not influence the care they receive or their relationship with their providers. Other issues to consider include: reducing the risk of harm; protecting the interviewee’s information; adequately informing interviewees about the study purpose and format; and reducing the risk of exploitation. 10

Step 4: planning logistical aspects

Careful planning particularly around the technical aspects of interviews can be the difference between a great interview and a not so great interview. During the preparation phase, the researcher will need to plan and make decisions about the best ways to contact potential interviewees, obtain informed consent, arrange interview times and locations convenient for both participant and researcher, and test recording equipment. Although many experienced researchers have found themselves conducting interviews in less than ideal locations, the interview location should avoid (or at least minimise) interruptions and be appropriate for the interview (quiet, private and able to get a clear recording). 16 For some research projects, the participants’ homes may make sense as the best interview location. 16

Initial contacts can be made through telephone or email and followed up with more details so the individual can make an informed decision about whether they wish to be interviewed. Potential participants should know what to expect in terms of length of time, purpose of the study, why they have been selected and who will be there. In addition, participants should be informed that they can refuse to answer questions or can withdraw from the study at any time, including during the interview itself.

Audio recording the interview is recommended so that the interviewer can concentrate on the interview and build rapport rather than being distracted with extensive note taking 16 (see table 4 for audio-recording tips). Participants should be informed that audio recording is used for data collection and that they can refuse to be audio recorded should they prefer.

Most researchers will want to have interviews transcribed verbatim from the audio recording. This allows you to refer to the exact words of participants during the analysis. Although it is possible to conduct analyses from the audio recordings themselves or from notes, it is not ideal. However, transcription can be extremely time consuming and, if not done yourself, can be costly.

In the planning phase of research, you will want to consider whether qualitative research software (eg, NVivo, ATLAS.ti, MAXQDA, Dedoose, and so on) will be used to assist with organising, managing and analysis. While these tools are helpful in the management of qualitative data, it is important to consider your research budget, the cost of the software and the learning curve associated with using a new system.

Step 5: developing the interview guide

Semistructured interviews include a short list of ‘guiding’ questions that are supplemented by follow-up and probing questions that are dependent on the interviewee’s responses. 8 17 All questions should be open ended, neutral, clear and avoid leading language. In addition, questions should use familiar language and avoid jargon.

Most interviews will start with an easy, context-setting question before moving to more difficult or in-depth questions. 17 Table 5 gives details of the types of guiding questions including ‘grand tour’ questions, 18 core questions and planned and unplanned follow-up questions.

To illustrate, online supplementary appendix A presents a sample interview guide from our study of weight gain during pregnancy among young women. We start with the prompt, ‘Tell me about how your pregnancy has been so far’ to initiate conversation about their thoughts and feelings during pregnancy. The subsequent questions will elicit responses to help answer our research question about young women’s perspectives related to weight gain during pregnancy.

After developing the guiding questions, it is important to pilot test the interview. Having a good sense of the guide helps you to pace the interview (and not run out of time), use a conversational tone and make necessary adjustments to the questions.

Like all qualitative research, interviewing is iterative in nature—data collection and analysis occur simultaneously, which may result in changes to the guiding questions as the study progresses. Questions that are not effective may be replaced with other questions and additional probes can be added to explore new topics that are introduced by participants in previous interviews. 10

Step 6: establishing trust and rapport

Interviews are a special form of relationship, where the interviewer and interviewee converse about important and often personal topics. The interviewer must build rapport quickly by listening attentively and respectfully to the information shared by the interviewee. 19 As the interview progresses, the interviewer must continue to demonstrate respect, encourage the interviewee to share their perspectives and acknowledge the sensitive nature of the conversation. 20

To establish rapport, it is important to be authentic and open to the interviewee’s point of view. It is possible that the participants you recruit for your study will have preconceived notions about research, which may include mistrust. As a result, it is important to describe why you are conducting the research and how their participation is meaningful. In an interview relationship, the interviewee is the expert and should be treated as such—you are relying on the interviewee to enhance your understanding and add to your research. Small behaviours that can enhance rapport include: dressing professionally but not overly formal; avoiding jargon or slang; and using a normal conversational tone. Because interviewees will be discussing their experience, having some awareness of contextual or cultural factors that may influence their perspectives may be helpful as background knowledge.

Step 7: conducting the interview

Location and set-up.

The interview should have already been scheduled at a convenient time and location for the interviewee. The location should be private, ideally with a closed door, rather than a public place. It is helpful if there is a room where you can speak privately without interruption, and where it is quiet enough to hear and audio record the interview. Within the interview space, Josselson 15 suggests an arrangement with a comfortable distance between the interviewer and interviewee with a low table in between for the recorder and any materials (consent forms, questionnaires, water, and so on).

Beginning the interview

Many interviewers start with chatting to break the ice and attempt to establish commonalities, rapport and trust. Most interviews will need to begin with a brief explanation of the research study, consent/assent procedures, rationale for talking to that particular interviewee and description of the interview format and agenda. 11 It can also be helpful if the interviewer shares a little about who they are and why they are interested in the topic. The recording equipment should have already been tested thoroughly but interviewers may want to double-check that the audio equipment is working and remind participants about the reason for recording.

Interviewer stance

During the interview, the interviewer should adopt a friendly and non-judgemental attitude. You will want to maintain a warm and conversational tone, rather than a rote, question-answer approach. It is important to recognise the potential power differential as a researcher. Conveying a sense of being in the interview together and that you as the interviewer are a person just like the interviewee can help ease any discomfort. 15

Active listening

During a face-to-face interview, there is an opportunity to observe social and non-verbal cues of the interviewee. These cues may come in the form of voice, body language, gestures and intonation, and can supplement the interviewee’s verbal response and can give clues to the interviewer about the process of the interview. 21 Listening is the key to successful interviewing. 22 Listening should be ‘attentive, empathic, nonjudgmental, listening in order to invite, and engender talk’ 15 15 (p 66). Silence, nods, smiles and utterances can also encourage further elaboration from the interviewee.

Continuing the interview

As the interview progresses, the interviewer can repeat the words used by the interviewee, use planned and unplanned follow-up questions that invite further clarification, exploration or elaboration. As DiCicco-Bloom and Crabtree 10 explain: ‘Throughout the interview, the goal of the interviewer is to encourage the interviewee to share as much information as possible, unselfconsciously and in his or her own words’ (p 317). Some interviewees are more forthcoming and will offer many details of their experiences without much probing required. Others will require prompting and follow-up to elicit sufficient detail.

As a result, follow-up questions are equally important to the core questions in a semistructured interview. Prompts encourage people to continue talking and they can elicit more details needed to understand the topic. Examples of verbal probes are repeating the participant’s words, summarising the main idea or expressing interest with verbal agreement. 8 11 See table 6 for probing techniques and example probes we have used in our own interviewing.

Step 8: memoing and reflection

After an interview, it is essential for the interviewer to begin to reflect on both the process and the content of the interview. During the actual interview, it can be difficult to take notes or begin reflecting. Even if you think you will remember a particular moment, you likely will not be able to recall each moment with sufficient detail. Therefore, interviewers should always record memos —notes about what you are learning from the data. 23 24 There are different approaches to recording memos: you can reflect on several specific ideas, or create a running list of thoughts. Memos are also useful for improving the quality of subsequent interviews.

Step 9: analysing the data

The data analysis strategy should also be developed during planning stages because analysis occurs concurrently with data collection. 25 The researcher will take notes, modify the data collection procedures and write reflective memos throughout the data collection process. This begins the process of data analysis.

The data analysis strategy used in your study will depend on your research question and qualitative design—see the study of Creswell for an overview of major qualitative approaches. 26 The general process for analysing and interpreting most interviews involves reviewing the data (in the form of transcripts, audio recordings or detailed notes), applying descriptive codes to the data and condensing and categorising codes to look for patterns. 24 27 These patterns can exist within a single interview or across multiple interviews depending on the research question and design. Qualitative computer software programs can be used to help organise and manage interview data.

Step 10: demonstrating the trustworthiness of the research

Similar to validity and reliability, qualitative research can be assessed on trustworthiness. 9 28 There are several criteria used to establish trustworthiness: credibility (whether the findings accurately and fairly represent the data), transferability (whether the findings can be applied to other settings and contexts), confirmability (whether the findings are biased by the researcher) and dependability (whether the findings are consistent and sustainable over time).

Step 11: presenting findings in a paper or report

When presenting the results of interview analysis, researchers will often report themes or narratives that describe the broad range of experiences evidenced in the data. This involves providing an in-depth description of participant perspectives and being sure to include multiple perspectives. 12 In interview research, the participant words are your data. Presenting findings in a report requires the integration of quotes into a more traditional written format.

• Conclusions

Though semistructured interviews are often an effective way to collect open-ended data, there are some disadvantages as well. One common problem with interviewing is that not all interviewees make great participants. 12 29 Some individuals are hard to engage in conversation or may be reluctant to share about sensitive or personal topics. Difficulty interviewing some participants can affect experienced and novice interviewers. Some common problems include not doing a good job of probing or asking for follow-up questions, failure to actively listen, not having a well-developed interview guide with open-ended questions and asking questions in an insensitive way. Outside of pitfalls during the actual interview, other problems with semistructured interviewing may be underestimating the resources required to recruit participants, interview, transcribe and analyse the data.

Despite their limitations, semistructured interviews can be a productive way to collect open-ended data from participants. In our research, we have interviewed children and adolescents about their stress experiences and coping behaviours, young women about their thoughts and behaviours during pregnancy, practitioners about the care they provide to patients and countless other key informants about health-related topics. Because the intent is to understand participant experiences, the possible research topics are endless.

Due to the close relationships family physicians have with their patients, the unique settings in which they work, and in their advocacy, semistructured interviews are an attractive approach for family medicine researchers, even if working in a setting with limited research resources. When seeking to balance both the relational focus of interviewing and the necessary rigour of research, we recommend: prioritising listening over talking; using clear language and avoiding jargon; and deeply engaging in the interview process by actively listening, expressing empathy, demonstrating openness to the participant’s worldview and thanking the participant for helping you to understand their experience.

• Further Reading

Edwards R, & Holland J. (2013). What is qualitative interviewing?: A&C Black.

Josselson R. Interviewing for qualitative inquiry: A relational approach. Guilford Press, 2013.

Kvale S. InterViews: An Introduction to Qualitative Research Interviewing. SAGE, London, 1996.

Pope C, & Mays N. (Eds). (2006). Qualitative research in health care.

• Supplementary files
• Publication history

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Open Access

Peer-reviewed

Research Article

Rural suicide in Newfoundland and Labrador: A qualitative exploration of health care providers’ perspectives

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Psychology, University of Guelph, Guelph, Ontario, Canada, Department of Psychology, Grenfell Campus, Memorial University of Newfoundland and Labrador, St. John’s, Newfoundland and Labrador, Canada

Roles Writing – review & editing

Affiliation Department of Psychology, Grenfell Campus, Memorial University of Newfoundland and Labrador, St. John’s, Newfoundland and Labrador, Canada

Affiliation Department of Psychology, University of Guelph, Guelph, Ontario, Canada

Roles Conceptualization, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review & editing

• Tyler R. Pritchard, 
• Jennifer L. Buckle, 
• Kristel Thomassin, 
• Stephen P. Lewis

• Published: August 12, 2024
• https://doi.org/10.1371/journal.pone.0306929
• Reader Comments

Introduction

Residents of rural regions may have higher and unique suicide risks. Newfoundland and Labrador (NL) is a Canadian province replete with rural regions. Despite an abundance of rural suicide research, heterogeneity in rural regions may preclude amalgamating findings to inform prevention efforts. Thus, exploring the unique needs of NL is needed. Importantly, health care providers (HCP) may afford unique perspectives on the suicide-related needs or concerns of rural life. We asked HCPs of residents of rural NL their perceived suicide risk factors, concerns, and needs for rural NL.

Twelve HCPs of rural residents of NL completed virtual semi-structured interviews. Interviews were analysed using reflexive thematic analysis [ 13 , 14 ].

HCPs noted individual, psychological, social, and practical factors linked to rural-suicide risk and subsequent needs. Findings highlight the unique challenges of residing and providing health care in rural NL and inform prevention and intervention efforts.

Citation: Pritchard TR, Buckle JL, Thomassin K, Lewis SP (2024) Rural suicide in Newfoundland and Labrador: A qualitative exploration of health care providers’ perspectives. PLoS ONE 19(8): e0306929. https://doi.org/10.1371/journal.pone.0306929

Editor: Joseph Banoub, Fisheries and Oceans Canada, CANADA

Received: April 22, 2024; Accepted: June 25, 2024; Published: August 12, 2024

Copyright: © 2024 Pritchard et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The recordings and transcripts analysed during the current study are not publicly available due to the sensitive nature and potential for identifying participants or their patients mentioned during interviews. These restrictions are part of the ethics approval from the University of Guelph’s Research Ethics Board; data requests can be submitted to [email protected] .

Funding: This research was partially supported by the first author's graduate school funding. Specifically, through the Social Sciences and Humanities Research Council Award (752-2018-2155). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Suicide is a global health concern with over 700,000 deaths by suicide each year [ 1 ]. Canada is no exception, with approximately 12 Canadians dying by suicide each day [ 2 ] (Statistics Canada, 2020). Indeed, suicide is multifactorially influenced [ 3 ], underscoring the need for a multi-pronged approach to curb suicide risk. Research points to several unique contexts that may carry particular risk for suicidal ideations and behaviours (SIBs). Of note, individuals living in rural areas may be at a higher suicide risk compared to their nonrural counterparts [ 4 ].

Despite an abundance of research examining suicide in rural settings, a recent review of rural suicidology points to several key concerns in the field [ 5 ]. First, a lack of clarity and consistency in the definition of ‘rural’ limits the extent to which findings across studies can be integrated. Findings from this comprehensive review indicate that researchers often study heterogeneous populations but adopt the umbrella term ‘rural’ in reference to the population being studied. This may lead to conclusions and recommendations that do not fit within or across studies. Second, there are relatively few studies investigating differences in rural and nonrural regions with regard to suicidal ideations or non-death behaviours; instead, suicide death is primarily the focus in rural suicidology, despite ideations being more common and having the potential to be impairing across life domains [ 6 ]. For example, in Canada, approximately 0.01% of the population will die by suicide each year while 2.6% will have thoughts of suicide [ 2 ]. Accordingly, expanding the scope of rural suicidology beyond death is imperative to inform theory and augment prevention efforts. Last, that there is a dearth of studies investigating suicide in rural Canada, with a few notable exceptions [ 7 , 8 ]. Importantly, inconsistencies in rural definitions impede the ability to apply the existing literature to support rural Canadians. Furthermore, rural Canada is likely different from rural regions in other nations due to unique country-specific contexts (e.g., geographic, social, economic, and political climate). Along these lines, regions likely vary within Canada (e.g., across provinces) and within provinces.

Suicide rates vary substantially between Canadian provinces and seem to be particularly high for Newfoundland and Labrador (NL). Indeed, a recent time-trend analysis highlighted that the suicide rates in NL have increased three-fold from 1981 to 2018 [ 9 ], with current rates above 11 per 100,000 [ 2 ]. Importantly, over half of suicide deaths in NL are individuals from rural areas [ 8 ]. Understanding the unique suicide-related considerations relevant for rural NL is needed for prevention efforts.

One important way to gain insight is drawing from the perspectives of health care providers (HCPs). Indeed, HCPs play a key role in inquiring about suicidal thoughts [ 10 ] and are often the initial point of contact for mental health concerns. Thus, HCPs are integral to the identification and management of suicidal ideations or behaviours. As a result, HCPs can provide a ground-level and in-depth account of challenges with health service provision related to rural suicide. Some HCPs’ views related to suicidal ideations or behaviours have been examined in prior work [ 11 , 12 ]. However, this work did not specifically consider rural providers nor their perspectives of rural suicide risk. In line with the previous concerns regarding heterogeneity in rural definitions and regions [ 5 ], understanding the unique perspectives of HCPs in rural NL can inform how to best address the concerning suicide rates in the province.

The current study is, to our knowledge, the first to seek the perspectives of HCPs of rural NLs regarding factors that place rural residents at increased risk for suicide, which informs the potential unique needs of rural regions. Hence, the present study aimed to address the following question: What do HCPs perceive as suicide risk factors, concerns, and needs for residents of rural Newfoundland and Labrador?

Participants

The current sample was derived from a larger online study examining perspectives, risks, and experiences with suicide among HCPs in NL. The larger study took place between July 22, 2021, and January 12, 2022. Of the 157 HCPs who completed the online set of questionnaires, 35 (22.30%) indicated that they would like to participate in a virtual one-to-one interview. Of these, 12 (34.29%) completed an interview. Interviews took place between May 20, 2022, and August 28, 2022. These participants were predominantly White (91.67%) and identified as women (91.67%). The average age of participants was 36.38 years ( SD = 5.6; range = 28–43). One participant did not respond to demographic questions.

Of the 12 HCPs who took part in the study, six were social workers (50%), three were registered nurses (25%), two were psychologists (16.67%) and one was a paramedic (8.33%). The sample represented all four health authorities in NL at the time of the study: Labrador-Grenfell, Western, Central, and Eastern. Most participants resided in a rural region ( n = 9; 75%) and primarily worked with individuals who likewise resided in rural regions. Specifically, the average proportion of patient rosters residing in rural regions was 97.25% ( SD = 7.00); seven individuals indicated that 100% of their patient roster resided in rural regions. Importantly, given our research goals, participants self-determined what was considered ‘rural’.

In addition to demographic questions, participants completed a semi-structured interview with the first author. Interviews lasted an average of 63 minutes ( SD = 9.90 minutes; range = 36–92 minutes). Interview probes (see S1 Appendix ) were relevant to the study’s goals; additionally, due to the semi-structured nature, interviews often focused on information that participants, by nature of their in-depth discussions, believed to be relevant to the study’s questions.

The study received ethics clearance from the University of Guelph’s research ethics board (REB#: 21-03-022) and the NL Health Research Ethics Authority (HREB#: 2021.077). In addition, consent to conduct research with HCPs employed by health authorities was obtained from all the provincial health authorities that existed at the time of the study.

As part of the larger questionnaire study, participants were recruited from advertisements posted to social media and emails sent to NL-based health listservs and HCP organizations. Interested participants could access the study by clicking a link within the advertisement. The participants in this study indicated their interest in a one-to-one interview at the end of the online questionnaire study.

Interested participants were emailed a consent form for review and a list of potential dates and times (90-minute blocks) to complete the interview. Participants emailed the first author to indicate their written consent and to book a meeting time. Participants were then sent a secure meeting link to a private and secure online WebEx meeting. During the meeting, the first author provided information about the study and participants were given opportunity to ask questions. Participants were then sent a link to a demographic questionnaire, which participants completed remotely via Qualtrics XM. All participants completed online interviews with recorded video and audio. Once the interviews were completed, participants were provided information on how to access the study’s results upon completion and given information about local mental health resources should participation in the study raise any personal issues or concerns. These resources were also sent in email format. The interview audio was transcribed by Otter.ai software and exported as text files. Files were checked for accuracy by the first author. The resultant transcripts (i.e., interview content) served as the data for analyses.

Interviews were analysed using reflexive thematic analysis (TA) [ 13 , 14 ]. The experiential approach to TA appropriately addressed the research question through predetermined steps to analysis [ 13 ] that seek to understand the essence of participants’ meaning and experiences relevant to rural suicide. Specifically, we followed the steps typical of a TA: 1) Becoming familiar with the text by reading through transcripts and re-watching the interviews to ensure accurate transcription and recording initial thoughts and ideas in margins of transcripts; 2) Begin to formally code smaller units of text into potential codes using NVivo software, which was an iterative process that involved collating data by potential codes; 3) Search for themes, which were determined by the frequency and saliency of participants’ language; 4) Themes were fine-tuned and finalised into a coherent thematic map; 5) Generate apt names and definitions that reflect the core meaning of each theme; 6) Last, write up the results of the analysis with text excerpts to illustrate the themes. The first author coded the interviews and the first and last authors met weekly to bi-weekly to discuss the analysis. All other team members contributed to the interpretation and final thematic map.

Importantly, the analyses were informed by a systems perspective (e.g., Developmental Systems Theory [DST]) [ 15 ]. Specifically, individuals are seen as being influenced by various components of a complex system of co-acting levels (i.e., bidirectional and reciprocal), which include biological, psychological, social, cultural, and temporal influences. All levels influence a person and, thus, warrant attention to inform suicide prevention and intervention.

Data sharing

The recordings and transcripts analysed during the current study are not publicly available due to the sensitive nature and potential for identifying participants or their patients mentioned during interviews.

Several core themes and subthemes represent the interpretation of experiences of rural HCPs. What follows are explanations of these themes/subthemes, in addition to verbatim quotes from participants to demonstrate the essence and groundedness of the themes. The results are structured to start at the broadest level of influence and transition inward (i.e., from cultural → interpersonal → individual). However, given the nature of DST, themes often cut across levels of influence, marking the importance of reciprocal interactions among these levels [ 16 ].

Our research question focused on the risks, concerns, and needs related to suicide in rural areas. In line with this goal, participants were asked to speak to potential suicide risks in rural NL. Two important themes emerged from the interviews regarding suicide: i) The Rural Context and the Individual and ii) Service Provision Difficulties (see Fig 1 ). Each theme reflects the impact of various levels of a system that may impact the development of suicidal ideations or behaviours in residents of rural regions. Furthermore, themes may reflect the interplay between levels of influence (e.g., an individual with a health care system).

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• TIFF original image

https://doi.org/10.1371/journal.pone.0306929.g001

The Rural context and the individual

The theme Rural Context and the Individual represents the broader sociocultural factors of rural regions that interact within individual-level factors that might increase an individual’s suicide risk. This theme was composed of five subthemes, which participants indicated were factors that increased suicide risk in rural NL, namely: a lack of anonymity, stigma toward mental health difficulties, normalized risky substance use, a misalignment between the self and rural identity, and economic/vocational challenges.

Lack of anonymity.

Participants referred to a lack of anonymity resulting from small region dynamics that seemed to increase residents’ reluctance to engage with mental health services. For example, participants discussed the greater possibility for dual relationships with residents, which can impede help seeking. Indeed, participants mentioned that HCPs who also played other roles for rural residents (e.g., neighbour) could be a barrier to sharing mental health symptoms or distress, which may preclude help seeking and, thus, contribute to suicide risk. This was reflected in the following interview excerpt:

…thinking about the clinics in rural areas, you know, maybe some people don’t want to go because the person working there is their neighbour, or, you know, is their sister-in-law, or whoever it is, you know. Maybe they don’t want someone close to them knowing their deep dark troubles. You know, there’s no anonymity. (Participant 2)

Another individual similarly shared:

I might be your doctor. But our kids might also be in hockey together. And I’m gonna see you in the supermarket, and I’m gonna see you at the gym, or I’m gonna see you when I’m out for a walk with the dogs. And we’re gonna say ‘hi’ at the post office, because we’re both members of this teeny, tiny community. (Participant 1)

Others talked about the notion that community members are often aware of each other’s personal lives, as the following participant noted: “But it can be really difficult because everybody knows your business all the time . And that is a really stressful thing for people” (Participant 10). Having residents, including community HCPs, more involved or aware of the details of each other’s lives indicates how lack of anonymity may be an important obstacle in help seeking.

Stigma toward mental health difficulties.

In line with a lack of anonymity, more stigma in rural areas compared to non-rural counterparts was also noted by HCPs as an impediment to help seeking for residents. Whereas a lack of anonymity focuses more on the dual relationships experienced in rural settings or the increased awareness between community members, this subtheme more pertains to the unique attitudes towards help seeking in rural regions. In line with this, one participant reflected on the views of mental health and suicide in rural areas, indicating that:

I get it, mental health stigma is a universal issue right now. But it seems to be worse in rural Newfoundland. People just don’t seem to get just how mental health and suicide are real issues. And then they look down on other people who might, you know, need to get help for those issues. It’s very sad. (Participant 3)

Another participant discussed ‘toxic masculinity’ and how it often interferes with an individual’s help seeking, and how rural NL seems to be particularly at risk: “ …the way we socialize men . It’s fucked up . Newfoundland and Labrador has a lot of , I hate to have to say this , but I’m gonna say it , toxic masculinity . Like culturally , Newfoundland and Labrador , we’re 20 years behind everybody else” (Participant 4). This led to discussions on how to reduce suicide risk, which focused on reducing stigma and toxic masculinity:

We should be talking about it at an early age and de-stigmatizing it [mental health] . And talking about the different types of supports that aren’t just therapy. Because if again, if I if my mind is correct, it’s mostly men killing themselves or dying by suicide. Oh, no, we don’t say that [sarcastically] . Then it’s about attitudes about therapy, support, talking about your feelings, the way men communicate. Those openings… I think that’s tangible, right, like, you know, talking about violence, talking about feelings. From a young age in the school system. The way we socialize men has to change. (Participant 4)

Clearly, participants reflected on how stigma toward help seeking was an area of concern when considering suicide risk in rural areas.

Normalised risky substance use.

Many participants discussed the normalisation of substance use in rural areas as playing a role in heightened suicide risk. Substances included alcohol, marijuana, and illicit drugs. For example, one participant discussed that alcohol is being used at a younger age by rural residents when compared to previous generations, “I think everywhere rural has a huge alcohol issue . And it’s recognized and kind of accepted . But now the alcohol is in the younger crowd . And it’s… it’s scary to see the differences…see the changes over time” . (Participant 6)

Others reflected on higher incidences of alcohol misuse, “It’s like , all these small communities , you know , and I wouldn’t just say it’s in smaller communities , but there’s a lot of drug abuse and alcoholism” (Participant 7). Another participant reflected on their suicide prevention efforts that focused on reducing alcohol consumption, “So what we have focused on predominantly in our main safety pillar , is the correlation between alcohol consumption and these means of suicide . Because our research has also shown us that too… And that’s what we focused on was alcohol use , but again , there’s such a culture of , you know , drinking and drinking excessively , as opposed to social drinking , like you see in some other places” (Participant 5).

Others mentioned drug use, such as one participant who discussed an increased suicide risk in rural areas because of drug use:

And there’s so many different sides, every story, but a few of the kids are college-aged kids that left our site went home and committed suicide, there was drugs and alcohol involved. And obviously, they’re from rural [removed] and [removed] . …you’ll get people coming in that just needs to talk or vent and they’re like, ‘oh, a lot goes home and a lot of us drink and do drugs’. And that’s a big thing.” (Participant 10)

One participant commented how seasonal workers, which many rural residents in NL are, may have extended periods without work, which is related to increased substance use. For example, when discussing the winter months, during which Newfoundlanders and Labradorians who work in the fish industry are not working: “And then that tends to be when there’s more alcohol consumption , more drug use , and then more issues that would lead them to formal [mental health] service” (Participant 11). Another noted about some rotational workers at risk for suicide by feeling isolated from family, and using alcohol to cope:

Almost all the time that they’re home, they’re off time. And so they’re in the shed, and they’re partying, and they’re drinking, and they’re doing other things as opposed to being home, or doing things you would normally do with your family. So the family life is kind of turned upside down. And I think that does have something to do with their own anxiety, depression, maybe a feeling isolated, not connected… those kinds of things to their families ”. (Participant 5)

It seems, therefore, that participants consider risky drug use, particularly alcohol, as one factor that is related to later suicide risk.

Individual-rural identity misalignment.

Participants also discussed how rural residents can sometimes perceive that rural culture does not align with their identity. For example, given there is less cultural variability within a rural area, a potential misalignment between someone’s identity and rural culture may be more likely than in non-rural areas and can be a factor in mental health difficulties and suicide risk. Rural culture was often described as marked by outdoor activities and that issues may arise if a person does not enjoy these activities. As one participant noted, “ not everyone is outdoorsy” (Participant 2).

Another participant reflected on the potential struggles of growing up and not enjoying outdoor and related activities: “Some kids don’t enjoy the typical rural activities like hunting , fishing… even if their parents are very invested in those activities . And you can imagine how hard it is for those kids . Like , there’s five kids in the community and they’re the odd one out . ” (Participant 3). Others spoke of the impact of having fewer individuals to connect with who may be like-minded; “So if you’re from a rural area , you’ve got , like , this select amount of people that you can know , or like , you have a similar culture” (Participant 8). This individual continued to explain that, “If you’re an outlier in the culture , or the community… you don’t have a lot of options to feel supported” . In sum, participants perceived the potential difficulty in connecting to others in the community and the broader rural culture as a potential risk for some rural residents.

Unique economic and vocational challenges.

Participants often spoke of the changing economic and vocational landscape in NL. They commented on the faltering of typically relied-upon industries, such as the cod fishery, that has affected individuals’ identity and livelihood. For example, one participant noted that:

A sense of purpose, a strong sense… healthy sense of identity, I think is really difficult in Newfoundland, because of how much it’s changed, and the lack of jobs and the way that the landscape of opportunity industry has changed so much over the last 30 years since the [cod] moratorium. (Participant 4)

Another participant added how job loss interacted with other factors to increase suicide risk, “And so things happen , you know , loss of jobs , and you’re coming home . And when you get drugs in the mix , and things like that it can be it can be hard when your entire mix there knows every everything about what’s happening” (Participant 10). Others expressed that loss of employment impacts individuals’ sense of purpose and identity, “There’s a lot of unemployment in rural areas and remote areas … and unemployment doesn’t necessarily inspire people to live” (Participant 8). Similarly, another participant expressed:

So you go through periods where there’s high rates of employment, a project comes in to the shipyard or something like that, and there’s, you know, a whole bunch of people employed and things are well, you know, it doesn’t seem like people’s mental wellness is affected as much because they’re financially stable. And then we go through very long periods of very high unemployment rates, and people out of work … So, we see a lot of men with like trades backgrounds, having to go away for work. And then, you know, that kind of a lifestyle has its own challenges, of course, but even for individuals who stay around and are employed, like in the local companies, when they get a layoff, I mean, their employment has been such a big, you know, indicator of who they are that when they’re laid off, they lose that sense of who am I as an individual because I’m no longer an employee. (Participant 5)

As can be seen above, participants noted that the unique economic and vocational challenges of rural NL lead to numerous negative outcomes, all of which may increase the risk of suicide.

Service provision difficulties

Similar to the first theme, the second also comprised subthemes that focused on difficulties associated with providing care to rural residents. Specifically, participants pointed to a discrepancy between supply and demand for suicide-related mental health services, practical barriers to care, a lack of suicide-specific intervention training, a lack of policy/support from managers, and the onus on the provider for training.

Discrepancy between supply and demand.

Some participants reflected on the lack of professionals available to serve the mental health needs of rural residents. Participants discussed a lack of physicians, psychologists, nurses, and other professionals who play a role in suicide prevention and intervention. For example, one participant noted:

Take it from the top doctors on down, there’s a lack of doctors, when you’re waiting seven months for referral. And that’s going on here. They get referred to a counsellor and it’s a seven month wait to see him… or you see a suicide risk come in. They’re referred to a counsellor, but sorry, the counsellor is unavailable for two weeks. I’m like, this can’t wait two weeks, and you send them home with a parent that may or may not have to work or whatever… there’s a lack of actual warm bodies. (Participant 6)

Others talked about a lack of mental health professionals in their region such as psychologists. Participants often mentioned a lack of public mental health services, which limit who can access the already limited number of psychologists in the province.

We need the government, not just the Newfoundland government, but the federal government to fund psychologists… if I had to avail of a psychologist, I’m okay. I got medical and dental insurance. So my insurance will pay up to maybe, I don’t know, seven or eight hundred dollars, you know, you might get four or five sessions. Most people don’t have that. (Participant 7)

The desire to have more appropriately trained professionals serving within or near rural communities was also shared by participants. For example, one participant stated, “They need the professionals there in the communities . So I think they need access to these professionals , mental health professionals , there within , you know , an hour drive , maybe” (Participant 2).

Others discussed the reduced appeal of working in rural mental health care, which contributes to a mismatch in supply and demand. This was illustrated by the following individual: “But if those positions aren’t filled , because nobody wants to work in rural health care , and in some communities , it just… the service doesn’t exist” (Participant 1).

From the perspectives of the participants, there is a lack of services available to residents of rural NL. Participants noted this was the case for all health care professionals. This lack of health services may be due to lower service allotment and the difficulty in recruitment and retention of health care professionals in rural regions.

Practical barriers to care.

Participants also discussed the barriers experienced by HCPs in providing, and rural residents accessing, mental health and suicide-related services. For example, participants indicated that rural Newfoundland and Labrador has barriers to service provision, such as reduced technology and connectivity, poor weather conditions, and lengthy drives to provide or receive services. As one participant noted, “Even just having to drive two hours to a home visit in the middle of March . Like you don’t have cell phone coverage . The weather’s really bad . There’s a lot of wear and tear in your car” (Participant 1). This individual continued to explain that transportation is an ongoing barrier, “Yeah , there can be a Doorways [mental health walk-in service] clinician in your community . There can be a walk-in clinic , there can be a physician . But if you can’t get to them , you don’t get service . ”

Several participants referred to the technological challenges associated with mental health and suicide-related care in rural NL. In line with this, they noted that, while beneficial for some, telehealth was not a feasible method of receiving services for a large proportion of rural Newfoundlanders and Labradorians. For example, one individual noted:

And we’re really limited in what we can do to, to reach out because we’ve got all this wonderful technology that COVID brought us, you know, all the Facetimes and meetings like this, which is amazing… but it’s absolutely useless if you don’t have an internet connection, or a phone or a laptop… which a lot of our clients don’t have access to. (Participant 10)

Others reflected on their time living in rural areas to describe technology barriers, “Yes , I’ve lived in a couple of different areas where the internet is not super . And this was probably 10 years ago . So I don’t know… things have changed . But I’ve worked in areas that you know , there’s no cell reception” (Participant 2). Another individual noted, “I lived in one area that had dial-up internet . And this was in… 2013 , so not long ago . I couldn’t load the news , let alone sign onto a video chat . So how could you expect a patient to do it , especially if they’re in crisis ? ” (Participant 3).

Another participant noted that technological barriers are quite pervasive and in potentially unexpected areas, such as close to larger urban regions in NL, “I mean , we have patients , even in the St . John’s region , they don’t have phones” (Participant 1). It appears that numerous barriers exist that impede the availability and provision of health services to rural Newfoundlanders and Labradorians.

Lack of suicide-specific training.

The third aspect of service provision difficulties involved a lack of background, training, and opportunities for suicide-specific care. Participants often noted the limited training received through their formal education or by their current employers. Specifically, while some felt comfortable identifying suicide warning signs, there was little training regarding follow-up to suicide risk. As a result, individuals were often referred to emergency services, including hospitalization, which could create additional challenges in consistent, long-term suicide-related care. As clearly noted by one participant, “So there’s no training . We need training . People aren’t even talking about it” (Participant 12).

Individuals spoke about the lack of time or incentive to seek formal training: “There is no incentive to go and do training , specialised training ‘cause you have to pay for it yourself” (Participant 4). This same individual spoke about how underqualified they are at their position, yet were expected to provide evidence-based treatment without training:

People should not be doing this job with a Bachelor of Social Work, put that in your paper. I should not be doing this job. The only reason I’m good at my job is because of my personality and the amount of reading I’ve done in my life, my own personal experience… I still don’t think I should be doing the job. (Participant 4)

The fact that there was no mandatory training for suicide intervention was common across participants. Another participant noted “…it’s unreal , that I can’t believe that [suicide intervention training] hasn’t become a mandatory” (Participant 6). Participants also spoke to the larger issue that the professionals with extensive training are simply not available to rural regions, “A big problem with it is that the people who I think really are trained are just not available , always in rural areas” (Participant 2).

Some participants indicated that they completed Applied Suicide Intervention Skills Training (ASIST). However, ASIST is a short-term crisis identification intervention that seeks to then connect the individual in crisis to longer-term care, which is a critical component of suicide management. For example, one participant noted that ASIST is a community approach and by providing this as the main intervention received by HCPs, they are no different than general community members:

…the only training that we’ve really had, or that we’re offered is ASIST. …which I did when I was a student in my undergrad, and maybe at the time, it was a fitting type of training for the place that I was at. And for where I was in terms of like being a student, and also a community member, just having an awareness of like reacting suicide and things like that. But it’s still considered by [health authority] as like the training for professionals mental health clinic, which I would disagree with. You know, it’s not really preparatory, or comprehensive enough, as somebody who should know more than a community member… if it’s being offered to anybody who wants to have it, you then it’s saying like, you know, as much as anybody who is in the community. Right? Which we’re supposed to be specialists, more so than somebody just off the street, right? (Participant 8)

Ultimately, participants expressed a lack of suitable and specialized care related to suicide. Despite this, participants noted their willingness and desire to complete training, which was sometimes impeded by little incentive or support.

Lack of policy/support.

Participants often described that there was insufficient or conflicting policy regarding suicide prevention. For example, one participant reflected on their time working in various health authorities in NL. At the first authority, there was substantial policy and guidance around suicide assessment. However, when they moved to another health authority, they perceived that there was inadequate and desultory guidance for working with at-risk individuals. While discussing the current practice in their workplace, they noted, “Like , how do we react ? Because I’ve worked here for four years , where’s my package of assessments ? It’s literally , I’ve worked here for four years , someone [manager] told you literally say to the person [patient], ‘do you have a plan ? ’” (Participant 4). Another individual spoke about wanting a more comprehensive assessment strategy but being denied financing to purchase these assessments: “They [manager] will say like , ‘oh , well , you don’t need to do this test… you can tell if they’re okay or not , or base all just kind of on subjective information’” (Participant 8). Another participant expressed similar concerns over a lack of formal suicide assessment policy:

Coming here, I was shocked and all that there is no formal paperwork for that kind of stuff. There’s not even a rating, one that we fill out on a policy level. So I was kind of shocked by that. Because I think there is quite a high rate of new suicidal… suicide or suicide attempts in Newfoundland and Labrador. (Participant 3)

Another discussed their surprise when they learned that there was a lack of suicide-related policy in one specific health authority. For example:

When I came to [health authority] and to work for [location] . I was like, oh, so what’s the suicide policy? Because the very first day I worked here, I had a suicidal teenager. So they were like, oh, no, they’re not really is one [policy] you just like, you know, ask them if they have a plan to kill themselves. And like if you think they need to go to the hospital, tell them to go to the hospital. And I was like, don’t we? So like, I think [health authority] is underprepared, or under-policied, or under-structured when it comes to suicide. (Participant 4)

Others reflected on how management may not understand the unique challenges of rural practice because they themselves are not located in rural regions. As a result, they may not be able to relate to HCPs’ experiences or provide relevant support:

I mean, your manager might be in another part of the region, but you never physically see them ever. And you might have to wait a week to get a call back to consult on something. And if you’re sitting in somebody’s house, and they are saying, ‘I don’t want to live anymore’, you have a week. And I mean, that’s certainly not every manager, but there are some that are just inaccessible… and why are they inaccessible? (Participant 1)

Another HCP discussed how smaller mental health teams in NL are typically comprised of and managed by social workers, who may have a different approach to suicide assessment and intervention when compared to other health care professionals. This participant, a non-social worker, indicated that this can create challenges when seeking support, consultation, or guidance from managers. For example, a participant expressed, “my manager is a social worker who isn’t trained like me… they don’t approach assessments or treatment like I would . I hate to say it , but sometimes it feels like what’s the point of consultation when we view the major issues as different” (Participant 3).

Another participant noted the lack of consultation structure or integration between units that hinders supporting rural individuals. For example, this participant recounted being in a counselling session with a patient who indicated that they were planning suicide. After some discussion, the patient quickly and unexpectedly exited the telephone session. The participant reflected that, “And so for me , because I am not part of the mental health team , I was like , frig , like , what do I do ? So luckily , I walked down the hall . And it’s like , ‘Hi , I need to consult , I need to consult’ . And that should really be a formalized structure , instead of me hoping that somebody is at their desk” (Participant 1).

Indeed, as illustrated above, participants highlighted several difficulties that can arise from less cohesive relationships with managers and a lack of structure or policy regarding suicide prevention.

Onus on provider.

The last aspect of service provision difficulties focused on the provider bearing responsibility to acquire suitable suicide intervention training. Participants commented on the lack of formal and required trainings on suicide assessment and interventions. For example, one individual remarked that “We had one small… we call them learn modules , which is like a , you know , we go into our learning interface . And we do… it’s like probably a 20-minute video on suicide . And that’s not compulsory . That is if you choose to do it” (Participant 7). Others discussed how learning and professional development are not feasible in the rural public sector because of an increased workload:

Like, unless you’ve built the skill yourself, unless you’ve done the research, which from a public services kind of perspective, we don’t have the time to do it . Like there is no time built into my day or week to research things… I have a waitlist, there are people who are desperate for service. So it’s like, do I take two hours to… to read something? Or do I see two individuals who are desperate for service? (Participant 1)

Similarly, one participant explained that even if training were available, “…it wasn’t compulsory . And you know , for someone working Monday to Friday , eight to four , you can’t commit to that stuff , right ? Because they aren’t going to give you the time to do it ” (Participant 3). Ultimately, some participants perceive that getting suitable suicide-related training conflicts with the numerous other demands of their work and, inevitably, is given less priority over these other demands.

Suicidal ideations and behaviours may disproportionally and distinctively affect rural residents [ 5 ], highlighting the importance of tailored prevention and intervention efforts. The present study sought to understand the perspectives of healthcare providers (HCPs) for rural residents regarding suicide risk factors in rural regions. The unique suicide risk factors for Newfoundlanders and Labradorians, as identified by HCPs taking part in this study, have implications for intervention efforts to, ultimately, reduce suicides.

The participants’ perceived suicide-related risks seemed to be organised and may be best reflected through a systems approach, wherein there are macro- (e.g., rural culture) and micro-level (e.g., HCP and rural resident factors) considerations as well as interplay between biological, psychological, and social factors [ 17 , 18 ]. Indeed, themes seem to cut across and represent the interactions among levels of influence.

First, there are several Rural Context and Individual factors that HCPs highlighted as engendering suicide risk for rural NL residents. Rural communities were described as sometimes lacking anonymity. Past research highlights a nuanced relationship between anonymity, stigma, and disclosure. For example, individuals with higher degrees of embarrassment about their illness were more likely to disclose in an online and anonymous setting, marking the utility of anonymity for some individuals [ 19 ]. Others have noted that the type of mental disorder and severity of symptoms may impact an individual’s likelihood of disclosing in anonymous versus identifiable outlets [ 20 ]. Regardless, HCPs in this study perceived that a lack of anonymity is closely linked to stigma and may be a deterrent for seeking formal mental health and suicide-related services. Indeed, there is evidence from both service recipients and providers that stigma for mental illness or mental health difficulties is associated with reduced help-seeking, particularly for rural areas [ 21 , 22 ]. Although telehealth may mitigate this barrier by allowing individuals to have appointments from the privacy of their own home, the technological barriers of some rural residents frequently make telehealth a frustration versus a benefit. For example, one HCP in this study recounted having appointment cards thrown back in their face by a patient who expressed the uselessness of a video appointment because the patient did not have cellular or internet access.

In addition to lacking anonymity, HCPs highlighted that substance use, and in particular alcohol, is a common and normalised element of rural culture. Substance use has previously been linked to rural living [ 23 ]. Importantly, a recent meta-analysis of over 2 million individuals within 30 studies indicated a positive relation between alcohol use and suicide attempt and death [ 24 ]. Given that alcohol abstinence may not a be a feasible long-term strategy for many individuals, particularly if it is ingrained in a given culture, a harm reduction approach tailored to rural residents may be more beneficial for improving physical and psychological functioning, including reducing suicide risk [ 25 , 26 ].

HCPs also discussed factors related to individual residents of rural areas that may increase suicide risk in these areas. Here, they discussed a discrepancy between an individual’s identity and the larger rural culture as a potential suicide risk factor. While non-rural areas may have more cultural diversity with which residents can connect, rural areas present fewer opportunities for individuals who do not align or match with the dominant culture of a region. Indeed, this mismatch between individual beliefs, values, and preferred activities and those of the dominant culture, (i.e., cultural consonance) has been linked to psychological distress [ 27 ]. Furthermore, a disconnect between the individual and their community may be interpreted as one facet of the broad construct thwarted belongingness (e.g., loneliness and a lack of meaningful reciprocal relationships), which is purported to be an important contributor to suicidal ideation [ 28 , 29 ]. Similarly, other ideation-to-action suicide frameworks highlight the importance of perceptions of connection to people, but also more broadly to roles, work, or life purpose [ 30 ].

Beyond individuals’ cultural dissonance, HCPs reflected on the unique economic and vocational challenges of rural Newfoundlanders and Labradorians as risks for suicide. Specifically, they reflected on reductions in industry, such as the cod fishery; “Newfoundland has always been associated with fish, which dominated the economy for hundreds of years” [ 31 , p. 411]. The relation between unemployment and suicide has been noted internationally [ 32 ], with estimates indicating that for every 1% increase in unemployment, suicide rates increase by about 1–2% [ 33 , 34 ]. Therefore, for perceived suicide risks articulated by study participants, policy promoting financial and workplace stability for rural residents of NL may serve as suicide-mitigating factors.

Additionally, HPCs in this study reflected on rotation work as a vocational factor that may contribute to rural suicide risk, pointing to rotational workers often spending significant time away from friends and family, which may increase isolation. Isolation could result in lower perceptions of belongingness and connectedness, which are believed to be important causes of suicide [ 29 ]. Indeed, when NL industries decline (e.g., fishery), individuals may be required to work outside of their community or, at times, province. Extended periods away from family and friends, often on work camps or sites, may engender social disconnect from important support systems. HCPs noted that rotation work interferes with important social spheres, which may increase suicide risk. This aligns with contemporary suicide theory in which increased disconnect or decreased belonginess may be contributors to thoughts of suicide [ 29 , 30 ].

Several Service Provision factors are also relevant to understanding and addressing suicide risk in NL. HCPs in this study noted a Discrepancy Between Supply and Demand of suicide prevention and intervention resources in their regions. HCPs pointed to vacant positions of HCPs in rural areas, despite a steady demand for services. As a result, many residents are faced with extended wait times or lengthy travel to access services. Some residents simply cannot access recommended care, highlighting the inequalities in suicide-related service provision for rural residents. The perspectives of HCPs align with recent data that notes that rural Canadians comprise 17.8% of the total population [ 35 ], but 12.8% of family medicine physicians and 2.2% of specialist physicians serve rural regions [ 36 ]. Furthermore, the Eastern Health region of Newfoundland, which contains what might be considered the province’s only urban center had approximately 162 physicians per 100,000 individuals in 2021, marking a 1.1% decrease from 2017. However, Labrador-Grenfell, Western, and Central regions had 72, 99, and 73 physicians per 100,000 in 2021, marking decreases by 18.9%, 16.5%, and 2.6% since 2017, respectively [ 36 ]. The impact of the recent amalgamation of NLs four health authorities on service inequality remains to be seen.

Related to supply-demand discrepancies, another health care systems factor mentioned by participants pertained to Practical Barriers to Care that impede suicide-related care in rural NL. In particular, HCPs discussed the travel required to access healthcare, which is not feasible for all individuals. Others noted technological barriers that make telehealth or other electronic services frustrating, if not futile. Although there are noted benefits to mental health care in the digital age, such as self-initiated psychoeducation, fostering social connections, and reduced stigma in accessing services [ 37 ], rural residents in some areas of NL may not be afforded these potential benefits due to inadequate internet or cellular services.

HCPs also drew attention to a general Lack of Suicide-specific Intervention Training as a service provision barrier. A lack of training may be linked to more suicide risk-related hospitalizations. This is concerning given the potential for iatrogenic effects linked with hospitalization for suicidal ideations or behaviours. For example, hospitalization is linked to coercion and a loss of autonomy, all which may be linked to increase suicide risk or traumas [ 38 ]. Furthermore, hospitalization may not reduce long-term suicide risk and, in some cases, increases risk [ 39 ]. Thus, hospitalization is a last-line measure for at-risk individuals in some evidence-based treatments (i.e., avoiding hospitalisation in the Collaborative Assessment and Management of Suicidality [CAMS]) [ 40 ]. Increased hospitalizations may be linked to inadequate training in the assessment and management of suicide on the part of clinicians. Indeed, while some HCPs noted that they received some training, such as ASIST, the education on and implementation of evidence-based suicide interventions were said to be largely lacking in rural NL. In line with the subtheme that highlighted a disconnect between supply and demand, professionals with specific training in suicide-related interventions or opportunities to obtain evidence-based training seem needed in rural NL. Professionals, such as registered psychologists with comprehensive practitioner training that includes suicide risk assessment and management, may be in prime positions to fill the void with evidence-based treatments for suicidal ideations (e.g., CAMS) [ 41 ] or behaviours (e.g., Dialectical Behavior Therapy [DBT]) [ 42 ]. Unfortunately, difficulties in hiring such professionals may be a barrier to providing suitable services to residents of rural NL.

Additional service provision difficulties expressed by HCPs involved lack of consistency and limited support from policy and managers. Insufficient managerial support has been identified as a risk for burnout, including emotional exhaustion, depersonalization, and lack of personal accomplishment [ 43 ]; HCPs are no exception to the negative association between supervisor support and burnout [ 44 ]. Importantly, this may impact suicide-relevant care as, for example, HCPs may miss nuances in a patient’s presentation that would be considered a flag for suicide risk. Furthermore, some HCPs noted that managers and/or supervisors work from separate, distant, and, sometimes, non-rural regions, making them less exposed to and aware of the unique challenges associated with rural practice. This difference in physical location also makes them less available for immediate consultation. Thus, increasing the level of support or face-to-face interactions between rural HCPs and their supervisors or managers may help improve HCP well-being and reduce burnout, which may in turn improve service provision to rural residents.

The last subtheme relevant for service provision reflected HCPs perception that, given little direction from policy and/or managers, the onus is on them to seek out and complete suicide-specific training. Given rural HCPs high caseload, having to seek out additional training may be quite difficult. This may be complicated by the lack of psychologists providing outpatient public health services in NL, which was expressed by many of the participants. Psychologists’ ethical practice guidelines require them to maintain an up-to-date breadth of knowledge relevant to their practice, including suicide interventions [ 45 ]. As such, they may be afforded time to pursue additional training related to suicide as a component of their positions in health care.

Implications

Research. The use of a systems approach to understanding suicide risk may carry utility in future research. HCPs in the present study highlighted numerous factors that represent interacting levels of rural residents’ systems including cultural, social, and psychological (e.g., how individuals fit within the majority culture in their region). While the probes that were prepared for interviews inquired about participants’ perspectives on suicide-related risks at various levels of a system (e.g., individual, culture), participants seemed to naturally discuss aspects of a system with connected and transactional levels. This aligns with contemporary views of suicidal thoughts and behaviours, which are complex and influenced by multiple reciprocally interacting factors [ 46 ]. Researchers ought to continue exploring various levels of rural residents’ system to better understand indirect, direct, and causal risks of suicidal thoughts and behaviours. Importantly, creating models that incorporate the interactions of multiple levels may best describe, explain, and predict suicide. For example, developmental systems approaches [ 15 ] may provide a framework to comprehensively study suicide risk in rural regions. Conversely, focusing on individual or subsets of risk factors may do little for long-term suicide prevention efforts (see [ 3 ]). Incorporating rural-specific suicide risks into suicide theory or explaining how these factors manifest in theory-relevant constructs may strengthen the explanatory power of the theories.

Policy. Policy makers and influencers can draw on the results of this study to implement ground-level changes for HCPs. Indeed, barriers to care, lack of policy or support, and personal HCP responsibility for training were all discussed by the participants during the interviews. Other HCPs noted a lack of access to mental health professionals in rural regions, namely psychologists and psychiatrists, that causes a discrepancy in supply and demand. Additional recruitment initiatives and incentives to attract professionals to health care positions involving rural care is needed. A potential avenue for future research is to investigate HCPs perspectives on the factors linked to accepting or leaving a position in rural health care, which may help inform policy changes needed to recruit and retain HCPs. Furthermore, ensuring opportunities and time for current rural HCPs to complete professional development and related training would be beneficial. These factors are amenable at a policy or health authority level. Finally, HCPs highlighted the disparities in digital and virtual health provision in NL (e.g., barriers accessing technologies needed for virtual services). As a result, policy makers and influencers should work towards health services equity for those in rural and remote areas. For example, relevant policy can ensure that rural residents have access to digital and virtual health services in their homes or through central services hubs (e.g., leveraging health clinics or schools that have more reliable technology).

Clinical. HCPs highlighted several factors they thought to be important risk factors for suicide and other clinical professionals could benefit from awareness of the various cultural, social, and psychological factors in suicide risk assessment and, potentially, intervention. For example, empirically-informed approaches to reduce the consumption or the negative impacts of alcohol and other substances may benefit rural residents by reducing the likelihood of suicide attempts after acute alcohol use [ 47 ] or learning alternative coping skills. Motivational interviewing [ 48 ] may be a suitable intervention for substance use by helping individuals work through potential ambivalences about substance use. Otherwise, harm reduction approaches may be beneficial [ 25 ].

While some individuals present with thoughts, emotions, or behaviour indirectly linked to suicide, others may present specifically with direct suicidal thoughts or behaviours. While recognizing the challenges associated with rural health care, which is informed by the results of this study, it is recommended that clinicians implement evidence-based treatments for suicidality including DBT [ 42 ], CAMS [ 41 ], and Cognitive Behavioral Therapy for Suicide Prevention [ 49 ]. This largely begins at a policy and management level; HCP opportunities for training (i.e., allotted time and funding) must be given priority by administrators and policy makers. Practicing in these modalities will afford HCPs of rural residents the opportunity to better serve their patients and themselves. For example, perceptions of adequate suicide-related training are positively associated with self-efficacy and negatively associated with anxiety about working with patients [ 50 ]; however, these relationships are cross-sectional and do not indicate a causal effect.

In addition, reducing hospitalization as a first-line response to suicide risk may prevent a host of iatrogenic outcomes [ 38 ], some of which were discussed by HCPs in this study. Current approaches to managing suicide focus on reducing hospitalization (e.g., CAMS) [ 40 ] and increased collaboration between service settings (e.g., community health, emergency departments) may reduce the use of unnecessary hospitalisation.

Limitations. The results of this study must be interpreted within the context of its potential limitations. First, the impact of the COVID-19 pandemic on health care professionals cannot be underestimated. HCPs internationally have experienced increased burnout [ 51 ] and depressive symptoms [ 52 ], and an overall negative impact on well-being [ 53 ]. This may impact the willingness and ability of HCPs to participate in research; our study is no exception. Indeed, one participant was called to the emergency room during the interview, highlighting the competing and ongoing demands on HCPs. Furthermore, the rate of attrition in this study (34.29% of those indicating interest in an interview completed the interview) may reflect the high degree of fatigue and competing demands for HCPs in the current COVID-19 context. Within this context, the perspectives of HCP of rural residents may not be completely captured by this sample.

Second, sample characteristics may have limited the diversity of our results. Specifically, our sample was composed of predominantly White individuals who identified as women, whose perspectives likely vary from minority populations in NL. Furthermore, the sample contained no primary care physicians, who also likely receive suicide-related disclosures when working with rural NL residents. For example, one study of suicide disclosure indicated that 17% of the sample was asked about suicide by a medical doctor, whereas 4.2% were asked by a nurse [ 54 ]. Having additional professions or specializations in the sample to capture the range of services available–or unavailable–to people in rural NL may have identified perspectives not fully represented in this study.

Third, not all individuals disclose suicidal thoughts or behaviours to another. Indeed, one study investigating disclosure in a clinical sample reported varying reasons for (e.g., receiving help or support) and against disclosure (e.g., fear of rejection or hospitalisation) [ 55 ]. As a result, the HCPs’ experiences as captured by this study may only reflect perceived suicide risks for those who have already disclosed suicide to the HCPs. A logical extension of this study is to draw on the perspectives of rural residents with lived experience of suicidal thoughts or behaviours. This may partially bypass the potential limitation related to disclosure in this study and expand to our understanding of rural suicidology.

Concluding remarks

Suicide is a global health concern impacting thousands of Canadians each year [ 2 ]. Research has highlighted the increased risks faced by residents of rural areas [ 4 ]. However, rural has largely been a heterogeneous variable within the suicidology literature, with little consideration of the social aspects of the construct [ 5 ]. Newfoundland and Labrador is replete with regions that are typically considered rural and may face unique cultural, social, and economic risks for suicide. Given fewer mental health specific services, suicidal thoughts or behaviours may be disclosed to both general health care providers, such as nurses, or specialized providers, such as psychologists or social workers. Given this, HCPs are in a prime position to speak to the unique suicide risk factors for residents. This study provided an in-depth exploration of the experiences of HCPs for residents of rural NL regarding the perceived suicide risk factors for residents of rural regions.

Our study has several key findings that can benefit research, policy, and clinical practice. Several suicide risk factors were described by HCPs, ranging from macro- (e.g., broad rural culture) to micro-level (e.g., interactions between HCP and patient). The factors highlighted by HCPs in this study may provide clinicians with assessment and intervention focal points. Additionally, increased support, resources, and guidance from management and policymakers may facilitate HCPs’ ability to provide effective care for their patients and, thus, reduce their risk of suicide.

Supporting information

S1 appendix. focus group probing questions..

https://doi.org/10.1371/journal.pone.0306929.s001

Acknowledgments

We want to acknowledge and thank the health care providers who gave invaluable time out of their schedules to participate in this research.

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• Open access
• Published: 13 August 2024

Experiences of compassion fatigue among Generation Z nurses in the emergency department: a qualitative study in Shanghai, China

• Jinxia Jiang 1   na1 ,
• Shuyang Liu 1   na1 ,
• Chunwei Chi 1   na1 ,
• Jinling Xu 1 ,
• Li Zeng 3 &
• Hu Peng 1  

BMC Nursing volume  23 , Article number:  556 ( 2024 ) Cite this article

Metrics details

Due to the unique working environment and nature of work in emergency departments, nurses are prone to experiencing compassion fatigue (CF), leading to job burnout and attrition. As more Generation Z (Gen Z) nurses enter the emergency department with distinct personality traits compared to previous generations, studying their experiences with CF will inform future management strategies.

The qualitative phenomenological research method was utilised to investigate CF among Gen Z emergency nurses at a hospital in Shanghai, China. Data were collected through face-to-face semi-structured interviews and analyzed using Colaizzi’s seven-step phenomenological analysis method. Study participants were purposively selected.

Three main themes and nine sub-themes emerged from the study: secondary traumatic stress, including physiological symptoms, psychological symptoms, and behavioral changes; cumulative effects, including impaired empathy, interference with family life, and post-traumatic growth (PTG); coping strategies, including cognitive reconstruction, seeking support, and facilitating action.

Conclusions

The aim of this study is to investigate the experience of CF among Gen Z emergency nurses, providing managers with a reference for future management strategies. The significance of multi-dimensional support for Gen Z emergency nurses is underscored by our findings. Additionally, interventions that enhance resilience and competency can facilitate their psychological transformation after experiencing CF and promote accelerated personal growth.

Peer Review reports

Introduction

The emergency department serves as a comprehensive emergency medical service and research centre, encompassing emergency diagnosis, treatment, and intensive care. As an integral component of the emergency medical service system (EMSS), it represents the hospital’s primary hub for managing acute and critical patients, addressing a wide range of diseases, and undertaking demanding rescue and management responsibilities [ 1 ]. Moreover, it is the sole point of admission for emergency patients to the hospital. Due to the critical condition of patients, the myriad of diseases, intensive rescue interventions, and complex treatment measures, among other factors, emergency nurses (ENs) engage in prolonged periods of high-intensity physical and mental exertion. Consequently, their psychological state remains highly tense, experiencing greater levels of physical and mental pressure compared to medical personnel in other departments [ 2 ]. Additionally, due to the unique working environment of the emergency department, nurses frequently encounter a diverse range of critically ill patients and bear witness to the suffering and trauma experienced by both the patients themselves and their family members. They consistently provide empathetic care without adequate adjustment, which can result in compassion fatigue (CF) [ 3 ].

CF refers to a behavioural and emotional outcome that arises during the provision of assistance services, resulting in a decline in helpers’ attention or interest due to their empathetic response towards victims’ suffering or understanding of traumatic events experienced by them [ 4 ]. Both “compassion” and “direct contact with victims” serve as fundamental prerequisites for the occurrence of CF [ 5 ]. Compassion is an essential and pivotal professional attribute within nursing practice. Emergency nurses encounter patients of varying ages, diverse traumas, and distinct disease processes on a daily basis, consistently engaging with acute trauma populations such as those affected by car accidents, physical assaults, burns, and respiratory distress. CF arises when the cumulative level of nurses’ empathy surpasses their capacity for coping and recovery, leading to a range of physiological, social, emotional, spiritual, and cognitive effects [ 6 ]. These effects manifest as desensitisation, irritability, withdrawal from activities or interactions, insomnia, exhaustion, and feelings of diminished self-worth [ 7 ]. Hooper et al. investigated nurses in the intensive care unit, nephrology department, oncology department, emergency department, and other departments. They found that 86% of emergency nurses experienced moderate to severe CF [ 8 ]. Several studies have shown that 50% of nursing staff are at high risk for CF; additionally, more than 80% of nurses in the ICU, emergency department, and oncology department reported experiencing a moderate to high level of CF [ 9 , 10 ]. Failure to promptly recognise and intervene in CF can not only compromise the quality of care and patient satisfaction but also contribute to nurse job burnout, turnover, and subsequent social costs.

In recent years, the nursing profession has witnessed a gradual influx of Generation Z (Gen Z) individuals (those born between 1995 and 2012), who are increasingly exerting a growing influence [ 11 ]. They represent the most recent cohort of nursing graduates who have completed their education and entered clinical practice. Approximately 19% of China’s population comprises Gen Z. They live in China’s “4-2-1 families” (four elderly, two young, and one child), as shown in Fig.  1 , with unique intergenerational characteristics [ 12 ]. Influenced by the prevailing economy, culture, and society of their time, Gen Z exhibits a broad perspective, rational thinking, cautious deliberation, and a distinctive set of cognitive standards. As digital natives compared to other cohorts of young individuals, they possess an enhanced familiarity with the Internet and demonstrate independence while emphasising self-expression and prioritising quality of life [ 13 ].

China’s Gen Z “4-2-1” family diagram

Undoubtedly, the early career phase is characterised by susceptibility to various factors, negative emotions, and trauma, ultimately leading to the manifestation of job burnout. This vulnerability extends to Generation Z emergency nurses (Gen Z emergency nurses) who face a high risk of experiencing burnout [ 14 ]. Due to the unique population attributes and characteristics of Gen Z emergency nurses, they possess a distinctly divergent experience compared to previous generations. However, there is a dearth of pertinent research on compassion fatigue (CF) within this particular population. Investigating their experiences and coping strategies related to CF will help bridge the existing gap in academic literature and offer insights for nursing managers to better comprehend the psychological needs of Generation Z individuals, thereby facilitating effective support provision. Therefore, this study focuses on Gen Z emergency nurses in Shanghai, China as the research subjects and employs a phenomenological qualitative research method to explore their experiences of CF in clinical work. The aim is to enhance understanding of the favourable factors that enable Gen Z emergency nurses to effectively cope with CF in nursing practice, while also investigating how these factors can be optimised and unfavourable aspects of CF mitigated. Ultimately, this study provides a novel perspective and theoretical foundation for interventions aimed at promoting psychological rehabilitation among Gen Z emergency nurses following CF.

Study design

This study employed phenomenological research methods to investigate the phenomenon of compassion fatigue (CF) among Generation Z emergency nurses (Gen Z emergency nurses) at a hospital located in Shanghai, China. The phenomenological approach is a qualitative research methodology that aims to understand and explore the experiences and feelings of individuals encountering the same phenomenon from a first-person perspective [ 15 ]. This paper adhered to the SRQR (Qualitative Research Reporting Standard) [ 16 ], collected data through face-to-face semi-structured interviews, and analysed the data using Colaizzi’s phenomenological seven-step analysis method [ 17 ].

Study subjects

The participants in this study were purposefully sampled from a hospital in Shanghai, China, which holds the highest medical service qualification granted by the Ministry of Health. The hospital accommodates a total of 1,860 beds and employs 3,364 individuals, with over 1300 dedicated to nursing. Nursing discipline is recognized as a national key clinical discipline. The inclusion criteria for this study were as follows: (1) possession of a nurse qualification certificate issued by the People’s Republic of China; (2) birth year between 1995 and 2012; (3) minimum one-year experience in the emergency department. The exclusion criteria included: (1) nurses who were currently not employed, such as those on vacation or pursuing further studies; (2) non-permanent unit nurses, including those on rotation and studying; (3) mentally ill nurses. Seventeen nurses were ultimately recruited, all of whom provided informed consent and voluntarily participated in this study without any withdrawals occurring during the interview process. Detailed information can be found in Table  1 presented below.

Data collection

Data collection took place through face-to-face semi-structured in-depth interviews, conducted in a quiet and private ward of the emergency department between December 2023 and January 2024. The specific interview schedule was communicated in advance via WeChat. All participants provided informed consent and willingly volunteered to take part in this study. The interviewer, the first author of this study, holds a doctoral degree and has extensive experience in qualitative studies, demonstrating proficient language skills and rich research expertise. The entire interview process was audio-recorded while ensuring the confidentiality of respondents’ personal information. Interviews ranged from 30 to 60 min in duration, with an average of 46.7 min per participant. Before each interview, the interviewer introduced herself and explained the purpose and precautions of the interview to establish rapport with all participants. She also clarified the exact meaning of CF to ensure better understanding during the interviews. CF refers to the gradual decline in an individual’s empathetic response due to prolonged exposure to others’ pain, trauma, and negative emotions, resulting in feelings of boredom and fatigue [ 18 ]. Demographic inquiries were initiated at the start of the interview to gain insights into cultural disparities among respondents and foster mutual trust. Structured questions aligned with the interview outline were then posed, progressively delving deeper into the study’s objectives. The interview sought prompt clarifications for any ambiguities in questions and thoroughly explored key aspects. Another researcher meticulously recorded the interview, capturing non-verbal cues such as facial expressions, vocal tone, and body gestures exhibited by the respondents. All transcripts were returned to the participants for review to ensure factual accuracy [ 19 ]. After each interview, participants received a complimentary towel. Data collection and analysis were conducted concurrently, with data analysis reaching saturation [ 20 ] after the fifteenth respondent, further confirmed through two additional interviews. Respondent information was treated confidentially, with names anonymised using numerical codes. The interview outline was synthesised by the interviewers based on their research expertise and literature review, resulting in a finalised interview guide after two pre-interviews (data from these pre-interviews were not included in this study), as presented in Table  2 .

Data analysis

The data collection and analysis occurred simultaneously, with data extraction and analysis facilitated by Nvivo 14.0 computer software in conjunction with Colaizzi’s phenomenological seven-step analysis method [ 17 ]. To mitigate memory bias, each interview was transcribed in full within 24 h of completion. Any queries arising during data analysis were promptly addressed by contacting and seeking clarification from the participants via WeChat, as per the agreement to retain their contact information for subsequent studies. The two researchers who were systematically trained performed the data analysis following the steps illustrated in Fig.  2 , which visually adapts Colaizzi’s phenomenological seven-step analysis [ 17 ]. We offer a detailed visual representation of this comprehensive seven-step process, accompanied by corresponding reference.

Colaizzi’s phenomenological seven-step analysis method [ 17 ]

Study rigor

The SRQR (Qualitative Research Reporting Standard) framework guided this study [ 16 ]. To bolster credibility, the research context and methodology were extensively elucidated. Furthermore, the interviewer possessed deep theoretical acumen, vast scientific research experience, and adhered to a rigorous data collection protocol. Employing phenomenological epoche throughout the research ensured no manipulation or intervention with the study subjects, guarding against personal value biases in comprehending the phenomenon [ 21 ]. Two researchers, rigorously trained, meticulously analysed the research data using Colaizzi’s phenomenological seven-step analysis method [ 17 ]. The final themes and descriptions were validated by the respondents themselves [ 19 ], accurately reflecting the interviewees’ psychology.

Ethical consideration

This study received approval from the Ethics Committee of Shanghai Tenth People’s Hospital (Approval number: 23KN25). All participants provided informed consent and volunteered willingly for participation, with the option to withdraw at any stage. Participant privacy was prioritised, with numerical serial numbers replacing actual names.

Following analysis, three overarching themes and nine sub-themes emerged: (1) secondary traumatic stress, encompassing physiological symptoms, psychological symptoms, and behavioural changes; (2) cumulative effects, including impaired empathy, interference with family life, and post-traumatic growth (PTG); and (3) coping strategies, comprising cognitive reconstruction, support seeking, and action facilitation. Refer to Fig.  3 for detailed elucidation.

Themes and sub-themes extracted from the data

Theme 1: secondary traumatic stress

The term “secondary traumatic stress” denotes the emotional and behavioral reactions that naturally arise when learning about others’ traumatic experiences. It encompasses the stress experienced when assisting or wanting to aid traumatized individuals and is recognized as an occupational hazard for nurses. Gen Z emergency nurses frequently encounter a distressing work environment, where prolonged emotional exertion can easily lead to Compassion Fatigue (CF) and secondary traumatic stress. These are primarily characterized by sleep disturbances, exhaustion, anxiety, emotional detachment, and various physiological symptoms, psychological manifestations, and behavioral changes.

Sub-theme 1: physiological symptoms

The majority of respondents noted that CF often presents with a range of physiological symptoms, including sleep disorders like insomnia, nightmares, and frequent awakenings, as well as physical ailments such as exhaustion and debilitation. One nurse mentioned relying on medication to temporarily facilitate sleep. Exposure to trauma, particularly among younger patients, significantly impacts the emotional well-being of Gen Z emergency nurses, leading to heightened emotional stress and subsequent sleep disturbances like nightmares. For instance, one respondent recounted, “ There was a time when I dreamed about the 38-year-old dilated cardiomyopathy patient our team successfully treated. He was so young and constantly at risk of sudden death… ” (P2) Due to insufficient sleep, poor sleep quality, and other contributing factors, nurses often experience fatigue and lethargy, as expressed by one respondent, “ I always feel very tired and reluctant to move , so I basically rest at home. ” (P17).

Sub-theme 2: psychological symptoms

The majority of respondents reported experiencing psychological symptoms such as anxiety, irritability, pessimism, and helplessness following CF. The presence of high-intensity workloads and prolonged exposure to traumatic events significantly contribute to the negative emotional state observed among Gen Z emergency nurses. For example, one respondent shared, “ Sometimes when my husband talks to me , I get annoyed and feel like my temper is a bit on edge , just like firewood that’s ready to ignite (pouting) .” (P9) Some participants tended to project patients’ illnesses, particularly those in their own age group, onto themselves or their family members, leading to psychological distress. One respondent expressed, “ It’s horrible to think about the rest of life that will follow when we see a girl who initially came in because of eye trouble. I sometimes have bad eyes , I can’t get this disease too…? ” (P4) Additionally, traumatic experiences can exacerbate CF among Gen Z emergency nurses, resulting in manifestations of pessimism and helplessness. One respondent shared how a failed rescue attempt left a lasting impact, making her feel that life was fragile and short.

Sub-theme 3: behavioural changes

Many interviewees mentioned that CF further reduced their willingness to socialize, leading to behavioral changes such as withdrawal and apathy. As one respondent noted, “ I don’t bother others , and I don’t want to be bothered. ” (P4) Another interviewee said, “ I don’t want to think too much about it , and I’m too lazy to even bother(shaking head). ”(P7) Some interviewees also said they prefer to have only two to three close friends, as too complex social relationships can bring unnecessary pressure to themselves. Due to the unique nature of their work, long-term frequent exposure to trauma can make Gen Z emergency nurses prone to developing progressive emotional apathy and related phenomena. One respondent mentioned, “ Some family members signed a DNR (Do Not Resuscitate) , not wanting to prolong the patient’s suffering. Seeing him lying there in pain , I knew he wouldn’t be with us much longer. Though my heart was heavy , there was nothing I could do (shrugging her shoulders) .” (P10).

Theme 2: cumulative effects

Due to prolonged exposure to negative emotions and complex environmental factors, Gen Z emergency nurses often experience the cumulative effects of CF. These effects include impaired empathy, interference with family life, as well as Post-Traumatic Growth (PTG) in CF.

Sub-theme 1: impaired empathy

The emergency department imposes a heavy workload, a high number of critically ill patients, and an elevated risk level, potentially leading to a cumulative CF impact on Gen Z emergency nurses and impaired empathy. Respondents reported increased resistance to working overtime compared to previous experiences and diminished passion they once had. One interviewee mentioned, “ I don’t have the same passion as when I first started working. ” (P11) Moreover, workplace violence, including verbal abuse and threats, exacerbates the adverse cumulative effects of CF. One respondent said, “ One thing that deeply impressed me was a patient with severe multiple injuries from a car accident , who was dying and had no family. We prioritized treating the patient’s severe injuries through the green channel , but we still felt powerless. However , upon the arrival of the family members , they immediately began accusing our first aid efforts , which left me particularly frustrated (sighing). ” (P7).

Sub-theme 2: interference with family life

The majority of respondents highlighted the profound impact of CF on their families, with many reporting a persistent preoccupation with work-related unhappiness that adversely affected the overall family atmosphere. One respondent said, “ I bring my emotions from work home , even though I know I shouldn’t , but it’s hard to control , I’m not happy , and the family atmosphere is depressed (pouting). ” (P16) Some respondents were also bothered by their unintentional dissemination of bad emotions, “ Sometimes I unintentionally pass on negative emotional experiences to my family members , and later deeply regret it. ” (P13).

Sub-theme 3: post-traumatic growth

In addition to the adverse cumulative impact, some Gen Z emergency nurses experienced PTG following secondary traumatic stress induced by CF through multidimensional positive coping strategies. One interviewee expressed spiritual growth: “ The medical profession still has a long way to go in healing the wounded and saving the dying , and we must continue to make efforts on our journey of professional development. I am committed to constantly improving myself. ” (P1) Additionally, several participants highlighted the development of resilience, asserting that their resilience gradually improved following each first aid task assessment. This enhanced resilience also equipped them with greater strength to confront diverse challenges in future professional endeavours. Some interviewees also expressed their professional happiness in the PTG process: “ The mindset is super important , even though it can be tough sometimes. But overall , I can lend a hand to others and it feels amazing when vulnerable groups rely on me (smiling) .” (P15).

Theme 3: coping strategies

Some Gen Z emergency nurses effectively use available resources, seek multidimensional support, adapt their mindset and cognition, ultimately fostering PTG in the face of secondary traumatic stress caused by CF.

Sub-theme 1: cognitive reconstruction

The participants consistently emphasised the significance of cognitive reconstruction, aimed at enhancing their physical and mental well-being, primarily encompassing purposeful reflection, self-motivation, and downward social comparison. Through cognitive reconstruction, individuals can reassess and adapt their initial cognition, thereby facilitating the alleviation of negative emotions and fostering psychophysical equilibrium. The constructive and profound contemplation of traumatic events contributes to personal development: “ I also need to reflect on myself and look at the positive side of things , hoping to realise my value in the work. ”(P1) Some nurses help themselves against negative emotions by giving themselves positive psychological hints and self-motivation: “ Although the help of others is important , the key is to rely on yourself , believe in yourself , please yourself and surpass yourself (smiling) .”(P3) Additionally, downward comparison is also a good way to channel bad emotions; a nurse witnessed the profound impact of illnesses and came to a realisation that her life was remarkably gratifying: she possessed robust health and a blissful family. Ultimately, she comprehended the genuine essence of contentment.

Sub-theme 2: support seeking

The respondents unanimously emphasized the pivotal role of social support in managing CF, particularly through team resilience guidance and peer support. A conducive team atmosphere serves as a fundamental element for enhancing team resilience. One interviewer highlighted the exceptional working environment within their department, characterized by strong cohesion and collective efforts to overcome challenges. Our research findings also indicate that Gen Z emergency nurses exhibit a preference for limited exposure to the public, instead opting for participation in close-knit circles characterized by peer support rooted in shared discourse systems and cultural practices. This approach enables them to attain emotional consensus within their inner circle, thereby alleviating the distress of reality and facilitating emotional “healing”: “ I prefer not to talk to my family too much , as I worry about how it might affect them and they may not fully understand my work environment. My main intention is to share my emotions with friends who can relate , as we speak the same language and support each other through hard work and relaxation. I really enjoy this dynamic. ” (P14).

Sub-theme 3: action facilitation

The majority of respondents highlighted the significance of improving job competency and psychological adjustment abilities. One interviewee noted that Gen Z is a generation characterized by their courage to explore; thus, he expressed his commitment to enhancing theoretical knowledge and professional technical skills in order to better serve others. Another interviewee mentioned: “ Why is Teacher Wang (referring to the emergency professional tutor) able to handle many complex problems well? Because she’s experienced , she knows how to navigate complex clinical issues , so I’m actually learning all the time. ” (P17) Gen Z is inclined towards online socialization and relies on the Internet for expressing, transmitting, and acquiring information. The developmental trajectory of Gen Z closely aligns with the rapid growth of the internet in China. As digital natives, they exhibit a strong inclination towards independent learning through online platforms: “ To recharge my batteries more , I often go to Bilibili to learn some mind-body relaxation techniques in psychosomatic medicine , and I also go to Xiaohongshu and Douyin to release my mood (smiling) .” (P2) In addition, learning to maintain a balance between work and life can help cope with the negative effects of CF, as one respondent noted: “ I am not only a nurse , but also my parents’ daughter and my husband’s wife. ” (P9).

Through conducting in-depth interviews with 17 Gen Z emergency nurses, this study reveals that the experience of CF within this particular group can be categorized into three main components: secondary traumatic stress, cumulative effects, and coping strategies. Previous research has demonstrated that CF is influenced by various factors, encompassing individual and environmental aspects [ 22 , 23 ]. These influential factors exert their effects on individual nurses, leading to the manifestation of symptoms associated with CF, including physical, psychological, and behavioral dimensions. Ultimately, these symptoms can result in a range of significant consequences such as job burnout, diminished nursing quality, and even compromised patient safety [ 24 ] (as depicted in Fig.  4 ).

Influence and results of CF

However, our study revealed that CF not only resulted in trauma but also yielded positive effects among Gen Z emergency nurses. Following the experience of CF, numerous nurses effectively combated negative psychological impacts by actively regulating their emotions and mobilizing available resources, ultimately leading to the realization of PTG. This serves as a valuable resource for managers in formulating effective management strategies to foster PTG and alleviate CF among Gen Z emergency nurses. Consequently, this paper will discuss the following aspects, including: mobilizing multi-dimensional social support, promoting job competency, and improving resilience.

Given the prevailing challenges faced by Gen Z emergency nurses, such as excessive work pressure, conspicuous nurse-patient conflicts, and inadequate familial and social support networks, it becomes imperative to offer multidimensional social support mechanisms for mitigating their adverse emotional experiences. The current situation in China’s emergency departments is characterized by a pervasive lack of personnel and excessive patient volume [ 25 , 26 ]. Addressing the issue of manpower shortage during peak hours has garnered increasing attention. Establishing and enhancing a nursing pool has been empirically proven as an efficacious strategy for addressing the issue of nursing staff shortage [ 27 ]. By meticulously selecting nurses with exceptional comprehensive qualities and robust professional competencies, coupled with providing training on nursing skills and professional knowledge of relevant departments, they can proficiently manage staffing gaps arising from reduced nursing personnel or increased patient volumes. This not only facilitates the flexible allocation of human resources, thereby mitigating nurse fatigue, but also ensures that the high demands of the emergency department do not adversely affect the staffing of other departments. Effectively managing the nursing pool, however, involves overcoming several challenges, including the efficient allocation of resources across departments, seamless coordination of emergency responses, and the prevention of dissatisfaction that may arise from mismanagement or perceived unfair practices. Managers can address these challenges by equipping nurses with diverse professional training to enhance the flexibility of resource allocation, ensuring no single department is overly burdened. Utilizing a dynamic staffing model and predictive analytics enables them to forecast patient volumes in various departments and proactively adjust staffing levels to meet the overall needs of the hospital. Regular evaluations are crucial to continuously monitor the impact of staffing adjustments, making timely modifications in accordance with hospital policies to support all departments effectively. Furthermore, managers can also implement a group flexible scheduling scheme to assign nurses of different ages, years of experience, and professional titles into groups. Research has demonstrated that this scheduling model can effectively alleviate the psychological pressure experienced by night shift nurses, enhance their overall competence, foster team cohesion, and improve nursing quality [ 28 ]. In light of the prominent contradiction between nurses and patients, it is imperative for managers to provide training in effective communication skills tailored specifically for Gen Z emergency nurses. Given that this particular group of nurses has a relatively short tenure and tends to prefer online interactions over active engagement in face-to-face communication [ 29 ], enhancing their communication abilities through targeted skills training becomes even more crucial. In 2020, the American Nurses Association proposed that nurses should uphold a therapeutic relationship with patients [ 30 ], highlighting the need for enhanced emphasis on therapeutic communication. Although the term therapeutic communication is no longer unfamiliar in the field of nursing, some current clinical practices may still rely on superficial and non-therapeutic forms of communication in certain cases, as indicated by findings from a subset of the literature [ 31 ]. Similarly, in a 2018 quantitative study conducted by Adistie et al. in pediatric wards, 53.5% of parents ( n  = 101) reported that the nurses’ therapeutic communication was poor [ 32 ], which was not conducive to the development of a good nurse-patient relationship. It has been mentioned in the literature that the main reason for such problems is that nurses have received less training related to therapeutic communication and lack understanding of specific methods of therapeutic communication [ 33 ]. Given this, managers should review current literature on therapeutic communication, employ techniques such as role play, case teaching, and scenario simulation, combined with artificial intelligence, virtual reality and other Internet technologies to assist Gen Z emergency nurses to learn related knowledge of therapeutic communication. Additionally, previous studies have indicated that the implementation of a narrative nursing model in nursing management can effectively mitigate nurses’ job burnout and psychological pressure, while enhancing the quality of nursing care [ 34 ]. Hence, managers could explore a comprehensive narrative support system based on network resources. By guiding appropriate narratives, facilitating positive emotional release, empathetic listening, diary writing, and other techniques, Gen Z emergency nurses were encouraged to express their inner emotions to various attentive listeners. This not only facilitates managers in gaining a deeper comprehension of nurses’ genuine needs but also fosters mutual support and knowledge sharing among colleagues, enabling them to learn from one another and grow collectively, thereby attaining comprehensive support from families, friends, colleagues, and supervisors.

Resilience undoubtedly facilitates nurses in combating CF, recovering from setbacks, and fostering personal growth. Numerous intervention strategies have been proposed in the existing literature to enhance resilience. These strategies have been further enriched through their extensive application across diverse populations and situations, resulting in increasingly remarkable outcomes. For example, nursing managers can employ the resilience intervention strategy based on PERMA theory [ 35 ] to train Gen Z emergency nurses with low resilience. The specifics are illustrated in Fig.  5 .

Resilience intervention strategy based on PERMA theory

However, it would be unwise to solely focus on enhancing individuals’ resilience and disregard the influence of peripheral factors. It is also necessary to develop resilient leadership while promoting team resilience, which helps the entire team actively combat setbacks and difficulties and set ambitious goals. Improving team resilience involves several key aspects: fostering a positive team atmosphere, enhancing team members’ learning abilities, and facilitating information exchange [ 36 ]. Firstly, by strengthening team building and organizing collective activities, it helps to create a cohesive and friendly atmosphere within the department. Managers can establish clear team rules and norms while actively encouraging members to participate in group activities. Additionally, the implementation of group psychotherapy can effectively promote members’ mental health and alleviate psychological symptoms. Studies have shown that music therapy, aromatherapy, acupuncture, and traditional Chinese medicine massage have certain effects in the field of psychological therapy and can be used in the treatment of nurses’ burnout, CF, and other negative emotions [ 37 , 38 , 39 ]. Their simplicity, affordability, and low risk make them worthy of clinical promotion and use by managers. Secondly, managers can provide more opportunities for nurses to engage in communication and learning, guide team members to exchange and share information, and encourage senior nurses to impart experience, knowledge, as well as clinical operation skills to junior nurses. These measures will not only strengthen team resilience but also foster accelerated progress and greater cohesiveness within the entire team. Finally, the training of resilient leadership needs to strengthen managers’ own resilience. According to the “trickle-down effect,” the level of resilience and goal-setting by leaders significantly affects a team’s development trajectory [ 40 ]. Therefore, managers should receive training in terms of resilience and cognitive thinking modes. When selecting leaders, hospitals can adopt a rigorous application process and comprehensive screening mechanism, supplemented by psychological testing as an auxiliary means. This helps prioritize candidates who are capable, resilient, and possess leadership skills [ 41 ].

In this interview, numerous nurses emphasized that competency serves as a crucial tool in addressing CF. Studies have also emphasized the paramount importance of communication skills for nurses [ 42 ], encompassing both patient-nurse and nurse-medical worker communication. In addition to fostering effective nurse-patient communication, attention should also be directed towards enhancing nurse-medical and healthcare worker communication, as conflicts can detrimentally impact nursing quality and teamwork dynamics. Notably, divergent preferences in communication methods exist among different generations of nurses; while older nurses tend to favor face-to-face interactions, younger counterparts demonstrate proficiency in utilizing WeChat and email platforms [ 43 ]. Managers should possess a comprehensive understanding of and demonstrate utmost respect for the distinct communication styles exhibited by each generation of nurses while also focusing on enhancing the communication skills of Gen Z emergency nurses. Furthermore, considering the prevailing characteristics of contemporary educational models and Gen Z’s constant exposure to internet-based information, it is imperative to address the challenges faced by Gen Z emergency nurses during their transition from theoretical knowledge to practical application [ 44 ]. Therefore, managers should prioritize the continuous training of Gen Z emergency nurses after their induction. They should establish a support network for nurses and provide targeted guidance to enhance critical thinking ability, decision-making ability, and emergency response skills. By incorporating teaching methods such as situational simulation, nurses’ capacity to handle different emergencies can be cultivated, and their professional skills can be continuously strengthened. The aforementioned training on communication skills and practical skills can be facilitated by the ADDIE model, which encompasses a set of systematic approaches for instructional design and development [ 45 ]. The acronym ADDIE represents Analysis, Design, Development, Implementation, and Evaluation [ 45 ]. Employing this model in training programs enables managers to more precisely define the objectives, strategies, and outcomes of instruction, as depicted in Fig.  6 . Considering the inherent characteristics of Gen Z individuals, who may exhibit limited proficiency in teamwork [ 46 ], it is advisable for managers to motivate nurses from this generation to leverage their familiarity with the Internet and technological advancements. Encouraging their active participation in teams requiring assistance in these areas would enable them to effectively contribute their strengths towards collaborative efforts and enhance their professional identity.

Application framework of ADDIE model

Limitations

This study has the following limitations: the selected research subjects were only from Shanghai, China, and the management measures proposed in the discussion may not be applicable to the wider population, and cultural differences need to be further considered. However, this study offers valuable information for nursing management. In future research, we aim to broaden the scope of sample selection, employ a mixed-methods approach combining qualitative and quantitative research, and present more compelling insights.

Through interviews with 17 Gen Z emergency nurses, this study found that the experience of compassion fatigue of Gen Z emergency nurses shows dynamic changes, and some respondents can develop post-traumatic growth by actively mobilizing surrounding resources after experiencing compassion fatigue. In view of this, managers should pay attention to the importance of social support, provide or amplify the role of various protective factors, formulate scientific and effective management measures, accelerate the mentality change of Gen Z emergency nurses after compassion fatigue, and promote their growth as soon as possible.

Data availability

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

Abbreviations

• Compassion fatigue
• Generation Z

Post-traumatic growth

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Acknowledgements

We would like to thank the nurses who participated in this study.

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

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Jinxia Jiang, Shuyang Liu and Chunwei Chi contributed equally to this work.

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Emergency Department, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, China

Jinxia Jiang, Shuyang Liu, Chunwei Chi, Jinling Xu & Hu Peng

Department of Rehabilitation Medicine, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, China

Nursing Department, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China

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JJ, SL and CC: conception, design and revising the article critically for intellectual content. JJ, SL, CC, JX and YL: acquisition of data. JX, CC, LZ, HP and LS: analysis, interpretation of data and drafting the article. All authors contributed to the article and approved the submitted version.All authors reviewed the manuscript.

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Correspondence to Li Zeng or Hu Peng .

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Jiang, J., Liu, S., Chi, C. et al. Experiences of compassion fatigue among Generation Z nurses in the emergency department: a qualitative study in Shanghai, China. BMC Nurs 23 , 556 (2024). https://doi.org/10.1186/s12912-024-02193-4

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Factors critical for the successful delivery of telehealth to rural populations: a descriptive qualitative study

• Rebecca Barry   ORCID: orcid.org/0000-0003-2272-4694 1 ,
• Elyce Green   ORCID: orcid.org/0000-0002-7291-6419 1 ,
• Kristy Robson   ORCID: orcid.org/0000-0002-8046-7940 1 &
• Melissa Nott   ORCID: orcid.org/0000-0001-7088-5826 1  

BMC Health Services Research volume  24 , Article number:  908 ( 2024 ) Cite this article

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The use of telehealth has proliferated to the point of being a common and accepted method of healthcare service delivery. Due to the rapidity of telehealth implementation, the evidence underpinning this approach to healthcare delivery is lagging, particularly when considering the uniqueness of some service users, such as those in rural areas. This research aimed to address the current gap in knowledge related to the factors critical for the successful delivery of telehealth to rural populations.

This research used a qualitative descriptive design to explore telehealth service provision in rural areas from the perspective of clinicians and describe factors critical to the effective delivery of telehealth in rural contexts. Semi-structured interviews were conducted with clinicians from allied health and nursing backgrounds working in child and family nursing, allied health services, and mental health services. A manifest content analysis was undertaken using the Framework approach.

Sixteen health professionals from nursing, clinical psychology, and social work were interviewed. Participants mostly identified as female (88%) and ranged in age from 26 to 65 years with a mean age of 47 years. Three overarching themes were identified: (1) Navigating the role of telehealth to support rural healthcare; (2) Preparing clinicians to engage in telehealth service delivery; and (3) Appreciating the complexities of telehealth implementation across services and environments.

Conclusions

This research suggests that successful delivery of telehealth to rural populations requires consideration of the context in which telehealth services are being delivered, particularly in rural and remote communities where there are challenges with resourcing and training to support health professionals. Rural populations, like all communities, need choice in healthcare service delivery and models to increase accessibility. Preparation and specific, intentional training for health professionals on how to transition to and maintain telehealth services is a critical factor for delivery of telehealth to rural populations. Future research should further investigate the training and supports required for telehealth service provision, including who, when and what training will equip health professionals with the appropriate skill set to deliver rural telehealth services.

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Introduction

Telehealth is a commonly utilised application in rural health settings due to its ability to augment service delivery across wide geographical areas. During the COVID-19 pandemic, the use of telehealth became prolific as it was rapidly adopted across many new fields of practice to allow for healthcare to continue despite requirements for physical distancing. In Australia, the Medicare Benefits Scheme (MBS) lists health services that are subsidised by the federal government. Telehealth items were extensively added to these services as part of the response to COVID-19 [ 1 ]. Although there are no longer requirements for physical distancing in Australia, many health providers have continued to offer services via telehealth, particularly in rural areas [ 2 , 3 ]. For the purpose of this research, telehealth was defined as a consultation with a healthcare provider by phone or video call [ 4 ]. Telehealth service provision in rural areas requires consideration of contextual factors such as access to reliable internet, community members’ means to finance this access [ 5 ], and the requirement for health professionals to function across a broad range of specialty skills. These factors present a case for considering the delivery of telehealth in rural areas as a unique approach, rather than one portion of the broader use of telehealth.

Research focused on rural telehealth has proliferated alongside the rapid implementation of this service mode. To date, there has been a focus on the impact of telehealth on areas such as client access and outcomes [ 2 ], client and health professional satisfaction with services and technology [ 6 ], direct and indirect costs to the patient (travel cost and time), healthcare service provider staffing, lower onsite healthcare resource utilisation, improved physician recruitment and retention, and improved client access to care and education [ 7 , 8 ]. In terms of service implementation, these elements are important but do not outline the broader implementation factors critical to the success of telehealth delivery in rural areas. One study by Sutarsa et al. explored the implications of telehealth as a replacement for face-to-face services from the perspectives of general practitioners and clients [ 9 ] and articulated that telehealth services are not a like-for-like service compared to face-to-face modes. Research has also highlighted the importance of understanding the experience of telehealth in rural Australia across different population groups, including Aboriginal and Torres Strait Islander peoples, and the need to consider culturally appropriate services [ 10 , 11 , 12 , 13 ].

Research is now required to determine what the critical implementation factors are for telehealth delivery in rural areas. This type of research would move towards answering calls for interdisciplinary, qualitative, place-based research [ 12 ] that explores factors required for the sustainability and usability of telehealth in rural areas. It would also contribute to the currently limited understanding of implementation factors required for telehealth delivery to rural populations [ 14 ]. There is a reasonable expectation that there is consistency in the way health services are delivered, particularly across geographical locations. Due to the rapid implementation of telehealth services, there was limited opportunity to proactively identify factors critical for successful telehealth delivery in rural areas and this has created a lag in policy, process, and training. This research aimed to address this gap in the literature by exploring and describing rural health professionals’ experiences providing telehealth services. For the purpose of this research, rural is inclusive of locations classified as rural or remote (MM3-6) using the Modified Monash Model which considers remoteness and population size in its categorisation [ 15 ].

This research study adopted a qualitative descriptive design as described by Sandelowski [ 16 ]. The purpose of a descriptive study is to document and describe a phenomenon of interest [ 17 ] and this method is useful when researchers seek to understand who was involved, what occurred, and the location of the phenomena of interest [ 18 ]. The phenomenon of interest for this research was the provision of telehealth services to rural communities by health professionals. In line with this, a purposive sampling technique was used to identify participants who have experience of this phenomenon [ 19 ]. This research is reported in line with the consolidated criteria for reporting qualitative research [ 20 ] to enhance transparency and trustworthiness of the research process and results [ 21 ].

Research aims

This research aimed to:

Explore telehealth service provision in rural areas from the perspective of clinicians.

Describe factors critical to the successful delivery of telehealth in rural contexts.

Participant recruitment and data collection

People eligible to participate in the research were allied health (using the definition provided by Allied Health Professions Australia [ 22 ]) or nursing staff who delivered telehealth services to people living in the geographical area covered by two rural local health districts in New South Wales, Australia (encompassing rural areas MM3-6). Health organisations providing telehealth service delivery in the southwestern and central western regions of New South Wales were identified through the research teams’ networks and invited to be part of the research.

Telehealth adoption in these organisations was intentionally variable to capture different experiences and ranged from newly established (prompted by COVID-19) to well established (> 10 years of telehealth use). Organisations included government, non-government, and not-for-profit health service providers offering child and family nursing, allied health services, and mental health services. Child and family nursing services were delivered by a government health service and a not-for-profit specialist service, providing health professional advice, education, and guidance to families with a baby or toddler. Child and family nurses were in the same geographical region as the families receiving telehealth. Transition to telehealth services was prompted by the COVID-19 pandemic. The participating allied health service was a large, non-government provider of allied health services to regional New South Wales. Allied health professionals were in the same region as the client receiving telehealth services. Use of telehealth in this organisation had commenced prior to the COVID-19 pandemic. Telehealth mental health services were delivered by an emergency mental health team, located at a large regional hospital to clients in another healthcare facility or location to which the health professional could not be physically present (typically a lower acuity health service in a rural location).

Once organisations agreed to disseminate the research invitation, a key contact person employed at each health organisation invited staff to participate via email. Staff were provided with contact details of the research team in the email invitation. All recruitment and consent processes were managed by the research team to minimise risk of real or perceived coercion between staff and the key contact person, who was often in a supervisory or managerial position within the organisation. Data were collected using semi-structured interviews using an online platform with only the interviewer and participant present. Interviews were conducted by a research team member with training in qualitative data collection during November and December 2021 and were transcribed verbatim by a professional transcribing service. All participants were offered the opportunity to review their transcript and provide feedback, however none opted to do so. Data saturation was not used as guidance for participant numbers, taking the view of Braun and Clarke [ 23 ] that meaning is generated through the analysis rather than reaching a point of saturation.

Data analysis

Researchers undertook a manifest content analysis of the data using the Framework approach developed by Ritchie and Spencer [ 24 ]. All four co-authors were involved in the data analysis process. Framework uses five stages for analysis including (1) familiarisation (2) identifying a thematic framework based on emergent overarching themes, (3) application of the coding framework to the interview transcripts [indexing], (4) reviewing and charting of themes and subthemes, and (5) mapping and interpretation [ 24 , p. 178]. The research team analysed a common interview initially, identified codes and themes, then independently applied these to the remaining interviews. Themes were centrally recorded, reviewed, and discussed by the research team prior to inclusion into the thematic framework. Final themes were confirmed via collaborative discussion and consensus. The iterative process used to review and code data was recorded into an Excel spreadsheet to ensure auditability and credibility, and to enhance the trustworthiness of the analysis process.

This study was approved by the Greater Western NSW Human Research Ethics Committee and Charles Sturt University Human Research Ethics Committee (approval numbers: 2021/ETH00088 and H21215). All participants provided written consent.

Eighteen health professionals consented to be interviewed. Two were lost to follow-up, therefore semi-structured interviews were conducted with 16 of these health professionals, the majority of which were from the discipline of nursing ( n  = 13, 81.3%). Participant demographics and their pseudonyms are shown in Table  1 .

Participants mostly identified as female ( n  = 14, 88%) and ranged in age from 26 to 65 years with a mean age of 47 years. Participants all delivered services to rural communities in the identified local health districts and resided within the geographical area they serviced. The participants resided in areas classified as MM3-6 but were most likely to reside in an area classified MM3 (81%). Average interview time was 38 min, and all interviews were conducted online via Zoom.

Three overarching themes were identified through the analysis of interview transcripts with health professionals. These themes were: (1) Navigating the role of telehealth to support rural healthcare; (2) Preparing clinicians to engage in telehealth service delivery; and (3) Appreciating the complexities of telehealth implementation across services and environments.

Theme 1: navigating the role of telehealth to support rural healthcare

The first theme described clinicians’ experiences of using telehealth to deliver healthcare to rural communities, including perceived benefits and challenges to acceptance, choice, and access. Interview participants identified several factors that impacted on or influenced the way they could deliver telehealth, and these were common across the different organisational structures. Clinicians highlighted the need to consider how to effectively navigate the role of telehealth in supporting their practice, including when it would enhance their practice, and when it might create barriers. The ability to improve rural service provision through greater access was commonly discussed by participants. In terms of factors important for telehealth delivery in rural contexts, the participants demonstrated that knowledge of why and how telehealth was used were important, including the broadened opportunity for healthcare access and an understanding of the benefits and challenges of providing these services.

Access to timely and specialist healthcare for rural communities

Participants described a range of benefits using telehealth to contact small, rural locations and facilitate greater access to services closer to home. This was particularly evident when there was lack of specialist support in these areas. These opportunities meant that rural people could receive timely care that they required, without the burden of travelling significant distances to access health services.

The obvious thing in an area like this, is that years ago, people were being transported three hours just to see us face to face. It’s obviously giving better, more timely access to services. (Patrick)

Staff access to specialist support was seen as an important aspect for rural healthcare by participants, because of the challenges associated with lack of staffing and resources within these areas which potentially increased the risks for staff in these locations, particularly when managing clients with acute mental illnesses.

Within the metro areas they’ve got so many staff and so many hospitals and they can manage mental health patients quite well within those facilities, but with us some of these hospitals will have one RN on overnight and it’s just crappy for them, and so having us able to do video link, it kind of takes the pressure off and we’re happy to make the decisions and the risky decisions for what that person needs. (Tracey)

Participants described how the option to use telehealth to provide specialised knowledge and expertise to support local health staff in rural hospitals likely led to more appropriate outcomes for clients wanting to be able to remain in their community. Conversely, Amber described the implications if telehealth was not available.

If there was some reason why the telehealth wasn’t available… quite often, I suppose the general process be down to putting the pressure on the nursing and the medical staff there to make a decision around that person, which is not a fair or appropriate thing for them to do. (Amber)

Benefits and challenges to providing telehealth in rural communities

Complementing the advantage of reduced travel time to access services, was the ability for clients to access additional support via telehealth, which was perceived as a benefit. For example, one participant described how telehealth was useful for troubleshooting client’s problems rather than waiting for their next scheduled appointment.

If a mum rings you with an issue, you can always say to them “are you happy to jump onto My Virtual Care with me now?” We can do that, do a consult over My Virtual Care. Then I can actually gauge how mum is. (Jade)

While accessibility was a benefit, participants highlighted that rural communities need to be provided with choice, rather than the assumption that telehealth be the preferred option for everyone, as many rural clients want face-to-face services.

They’d all prefer, I think, to be able to see someone in person. I think that’s generally what NSW rural [want] —’cause I’m from country towns as well—there’s no substitute, like I said, for face-to-face assessment. (Adam)

Other, more practical limitations of broad adoption of telehealth raised by the participants included issues with managing technology and variability in internet connectivity.

For many people in the rural areas, it’s still an issue having that regular [internet] connection that works all the time. I think it’s a great option but I still think it’s something that some rural people will always have some challenges with because it’s not—there’s so many black spots and so many issues still with the internet connection in rural areas. Even in town, there’s certain areas that are still having lots of problems. (Chloe)

Participants also identified barriers related to assumptions that all clients will have access to technology and have the necessary data to undertake a telehealth consultation, which wasn’t always the case, particularly with individuals experiencing socioeconomic disadvantage.

A lot of [Aboriginal] families don’t actually have access to telehealth services. Unless they use their phone. If they have the technology on their phones. I found that was a little bit of an issue to try and help those particular clients to get access to the internet, to have enough data on their phone to make that call. There was a lot of issues and a lot of things that we were putting in complaints about as they were going “we’re using up a lot of these peoples’ data and they don’t have internet in their home.” (Evelyn).

Other challenges identified by the participants were related to use of telehealth for clients that required additional support. Many participants talked about the complexities of using an interpreter during a telehealth consultation for culturally and linguistically diverse clients.

Having interpreters, that’s another element that’s really, really difficult because you’re doing video link, but then you’ve also got the phone on speaker and you’re having this three-way conversation. Even that, in itself, that added element on video link is really, really tough. It’s a really long process. (Tracey)

In summary, this theme described some of the benefits and constraints when using telehealth for the delivery of rural health services. The participants demonstrated the importance of understanding the needs and contexts of individual clients, and accounting for this when making decisions to incorporate telehealth into their service provision. Understanding how and why telehealth can be implemented in rural contexts was an important foundation for the delivery of these services.

Theme 2: preparing clinicians to engage in telehealth service delivery

The preparation required for clinicians to engage with telehealth service delivery was highlighted and the participants described the unique set of skills required to effectively build rapport, engage, and carry out assessments with clients. For many participants who had not routinely used telehealth prior to the COVID-19 pandemic, the transition to using telehealth had been rapid. The participants reflected on the implications of rapidly adopting these new practices and the skills they required to effectively deliver care using telehealth. These skills were critical for effective delivery of telehealth to rural communities.

Rapid adoption of new skills and ways of working

The rapid and often unsupported implementation of telehealth in response to the COVID-19 pandemic resulted in clinicians needing to learn and adapt to telehealth, often without being taught or with minimal instruction.

We had to do virtual, virtually overnight we were changed to, “Here you go. Do it this way,” without any real education. It was learned as we went because everybody was in the same boat. Everyone was scrabbling to try and work out how to do it. (Chloe)

In addition to telehealth services starting quickly, telehealth provision requires clinicians to use a unique set of skills. Therapeutic interventions and approaches were identified as being more challenging when seeing a client through a screen, compared to being physically present together in a room.

The body language is hidden a little bit when you’re on teleconference, whereas when you’re standing up face to face with someone, or standing side by side, the person can see the whole picture. When you’re on the video link, the patient actually can’t—you both can’t see each other wholly. That’s one big barrier. (Adam)

There was an emphasis on communication skills such as active listening and body language that were required when engaging with telehealth. These skills were seen as integral to building rapport and connection. The importance of language in an environment with limited visualisation of body language, is further demonstrated by one participant describing how they tuned into the timing and flow of the conversation to avoid interrupting and how these skills were pertinent for using telehealth.

In the beginning especially, we might do this thing where I think they’ve finished or there’s a bit of silence, so I go to speak and then they go to speak at the same time, and that’s different because normally in person you can really gauge that quite well if they’ve got more to say. I think those little things mean that you’ve got to work a bit harder and you’ve got to bring those things to the attention of the client often. (Robyn)

Preparing clinicians to engage in telehealth also required skills in sharing clear and consistent information with clients about the process of interacting via telehealth. This included information to reassure the client that the telehealth appointment was private as well as prepare them for potential interruptions due to connection issues.

I think being really explicitly clear about the fact that with our setups we have here, no one can dial in, no one else is in my room even watching you. We’re not recording, and there’s a lot of extra information, I think around that we could be doing better in terms of delivering to the person. (Amber)

Becoming accustomed to working through the ‘window’

Telehealth was often described as a window and not a view of the whole person which presented limitations for clinicians, such as seeing nuance of expression. Participants described the difficulties of assessing a client using telehealth when you cannot see the whole picture such as facial expressions, movement, behaviour, interactions with others, dress, and hygiene.

I found it was quite difficult because you couldn’t always see the actual child or the baby, especially if they just had their phone. You couldn’t pick up the body language. You couldn’t always see the facial expressions. You couldn’t see the child and how the child was responding. It did inhibit a lot of that side of our assessing. Quite often you’d have to just write, “Unable to view child.” You might be able to hear them but you couldn’t see them. (Chloe)

Due to the window view, the participants described how they needed to pay even greater attention to eye contact and tone of voice when engaging with clients via telehealth.

I think the eye contact is still a really important thing. Getting the flow of what they’re comfortable with a little bit too. It’s being really careful around the tone of voice as well too, because—again, that’s the same for face-to-face, but be particularly careful of it over telehealth. (Amber)

This theme demonstrates that there are unique and nuanced skills required by clinicians to effectively engage in provision of rural healthcare services via telehealth. Many clinicians described how the rapid uptake of telehealth required them to quickly adapt to providing telehealth services, and they had to modify their approach rather than replicate what they would do in face-to-face contexts. Appreciating the different skills sets required for telehealth practice was perceived as an important element in supporting clinicians to deliver quality healthcare.

Theme 3: appreciating the complexities of telehealth implementation across services and environments

It was commonly acknowledged that there needed to be an appreciation by clinicians of the multiple different environments that telehealth was being delivered in, as well as the types of consultations being undertaken. This was particularly important when well-resourced large regional settings were engaging with small rural services or when clinicians were undertaking consultations within a client’s home.

Working from a different location and context

One of the factors identified as important for the successful delivery of services via telehealth was an understanding of the location and context that was being linked into. Participants regularly talked about the challenges when undertaking a telehealth consultation with clients at home, which impacted the quality of the consultation as it was easy to “ lose focus” (Kelsey) and become distracted.

Instead of just coming in with one child, they had all the kids, all wanting their attention. I also found that babies and kids kept pressing the screen and would actually disconnect us regularly. (Chloe)

For participants located in larger regional locations delivering telehealth services to smaller rural hospitals, it was acknowledged that not all services had equivalent resources, skills, and experience with this type of healthcare approach.

They shouldn’t have to do—they’ve gotta double-click here, login there. They’re relying on speakers that don’t work. Sometimes they can’t get the cameras working. I think telehealth works as long as it’s really user friendly. I think nurses—as a nurse, we’re not supposed to be—I know IT’s in our job criteria, but not to the level where you’ve got to have a degree in technology to use it. (Adam)

Participants also recognised that supporting a client through a telehealth consultation adds workload stress as rural clinicians are often having pressures with caseloads and are juggling multiple other tasks while trying to trouble shoot technology issues associated with a telehealth consultation.

Most people are like me, not great with computers. Sometimes the nurse has got other things in the Emergency Department she’s trying to juggle. (Eleanor)

Considerations for safety, privacy, and confidentiality

Participants talked about the challenges that arose due to inconsistencies in where and how the telehealth consultation would be conducted. Concerns about online safety and information privacy were identified by participants.

There’s the privacy issue, particularly when we might see someone and they might be in a bed and they’ve got a laptop there, and they’re not given headphones, and we’re blaring through the speaker at them, and someone’s three meters away in another bed. That’s not good. That’s a bit of a problem. (Patrick)

When telehealth was offered as an option to clients at a remote healthcare site, clinicians noted that some clients were not provided with adequate support and were left to undertake the consultation by themselves which could cause safety risks for the client and an inability for the telehealth clinician to control the situation.

There were some issues with patients’ safety though. Where the telehealth was located was just in a standard consult room and there was actually a situation where somebody self-harmed with a needle that was in a used syringe box in that room. Then it was like, you just can’t see high risk—environment. (Eleanor)

Additionally, participants noted that they were often using their own office space to conduct telehealth consultations rather than a clinical room which meant there were other considerations to think about.

Now I always lock my room so nobody can enter. That’s a nice little lesson learnt. I had a consult with a mum and some other clinicians came into my room and I thought “oh my goodness. I forgot to lock.” I’m very mindful now that I lock. (Jade)

This theme highlights the complexities that exist when implementing telehealth across a range of rural healthcare settings and environments. It was noted by participants that there were variable skills and experience in using telehealth across staff located in smaller rural areas, which could impact on how effective the consultation was. Participants identified the importance of purposely considering the environment in which the telehealth consultation was being held, ensuring that privacy, safety, and distractibility concerns have been adequately addressed before the consultation begins. These factors were considered important for the successful implementation of telehealth in rural areas.

This study explored telehealth service delivery in various rural health contexts, with 16 allied health and nursing clinicians who had provided telehealth services to people living in rural communities prior to, and during the COVID-19 pandemic. Reflections gained from clinicians were analysed and reported thematically. Major themes identified were clinicians navigating the role of telehealth to support rural healthcare, the need to prepare clinicians to engage in telehealth service delivery and appreciating the complexities of telehealth implementation across services and environments.

The utilisation of telehealth for health service delivery has been promoted as a solution to resolve access and equity issues, particularly for rural communities who are often impacted by limited health services due to distance and isolation [ 6 ]. This study identified a range of perceived benefits for both clients and clinicians, such as improved access to services across large geographic distances, including specialist care, and reduced travel time to engage with a range of health services. These findings are largely supported by the broader literature, such as the systematic review undertaken by Tsou et al. [ 25 ] which found that telehealth can improve clinical outcomes and increase the timeliness to access services, including specialist knowledge. Clinicians in our study also noted the benefits of using telehealth for ad hoc clinical support outside of regular appointment times, which to date has not been commonly reported in the literature as a benefit. Further investigation into this aspect may be warranted.

The findings from this study identify a range of challenges that exist when delivering health services within a virtual context. It was common for participants to highlight that personal preference for face-to-face sessions could not always be accommodated when implementing telehealth services in rural areas. The perceived technological possibilities to improve access can have unintended consequences for community members which may contribute to lack of responsiveness to community needs [ 12 ]. It is therefore important to understand the client and their preferences for using telehealth rather than making assumptions on the appropriateness of this type of health service delivery [ 26 ]. As such, telehealth is likely to function best when there is a pre-established relationship between the client and clinician, with clients who have a good knowledge of their personal health and have access to and familiarity with digital technology [ 13 ]. Alternatively, it is appropriate to consider how telehealth can be a supplementary tool rather than a stand-alone service model replacing face-to-face interactions [ 13 ].

As identified in this study, managing technology and internet connectivity are commonly reported issues for rural communities engaging in telehealth services [ 27 , 28 ]. Additionally, it was highlighted that within some rural communities with higher socioeconomic disadvantage, limited access to an appropriate level of technology and the required data to undertake a telehealth consult was a deterrent to engage in these types of services. Mathew et al. [ 13 ] found in their study that bandwidth impacted video consultations, which was further compromised by weather conditions, and clients without smartphones had difficulty accessing relevant virtual consultation software.

The findings presented here indicate that while telehealth can be a useful model, it may not be suitable for all clients or client groups. For example, the use of interpreters in telehealth to support clients was a key challenge identified in this study. This is supported by Mathew et al. [ 13 ] who identified that language barriers affected the quality of telehealth consultations and accessing appropriate interpreters was often difficult. Consideration of health and digital literacy, access and availability of technology and internet, appropriate client selection, and facilitating client choice are all important drivers to enhance telehealth experiences [ 29 ]. Nelson et al. [ 6 ] acknowledged the barriers that exist with telehealth, suggesting that ‘it is not the groups that have difficulty engaging, it is that telehealth and digital services are hard to engage with’ (p. 8). There is a need for telehealth services to be delivered in a way that is inclusive of different groups, and this becomes more pertinent in rural areas where resources are not the same as metropolitan areas.

The findings of this research highlight the unique set of skills required for health professionals to translate their practice across a virtual medium. The participants described these modifications in relation to communication skills, the ability to build rapport, conduct healthcare assessments, and provide treatment while looking at a ‘window view’ of a person. Several other studies have reported similar skillsets that are required to effectively use telehealth. Uscher-Pines et al. [ 30 ] conducted research on the experiences of psychiatrists moving to telemedicine during the COVID-19 pandemic and noted challenges affecting the quality of provider-patient interactions and difficulty conducting assessment through the window of a screen. Henry et al. [ 31 ] documented a list of interpersonal skills considered essential for the use of telehealth encompassing attributes related to set-up, verbal and non-verbal communication, relationship building, and environmental considerations.

Despite the literature uniformly agreeing that telehealth requires a unique skill set there is no agreement on how, when and for whom education related to these skills should be provided. The skills required for health professionals to use telehealth have been treated as an add-on to health practice rather than as a specialty skill set requiring learning and assessment. This is reflected in research such as that by Nelson et al. [ 6 ] who found that 58% of mental health professionals using telehealth in rural areas were not trained to use it. This gap between training and practice is likely to have arisen from the rapid and widespread implementation of telehealth during the COVID-19 pandemic (i.e. the change in MBS item numbers [ 1 ]) but has not been addressed in subsequent years. For practice to remain in step with policy and funding changes, the factors required for successful implementation of telehealth in rural practice must be addressed.

The lack of clarity around who must undertake training in telehealth and how regularly, presents a challenge for rural health professionals whose skill set has been described as a specialist-generalist that covers a significant breadth of knowledge [ 32 ]. Maintaining knowledge currency across this breadth is integral and requires significant resources (time, travel, money) in an environment where access to education can be limited [ 33 ]. There is risk associated with continually adding skills on to the workload of rural health professionals without adequate guidance and provision for time to develop and maintain these skills.

While the education required to equip rural health professionals with the skills needed to effectively use telehealth in their practice is developing, until education requirements are uniformly understood and made accessible this is likely to continue to pose risk for rural health professionals and the community members accessing their services. Major investment in the education of all health professionals in telehealth service delivery, no matter the context, has been identified as critical [ 6 ].

This research highlights that the experience of using telehealth in rural communities is unique and thus a ‘one size fits all’ approach is not helpful and can overlook the individual needs of a community. Participants described experiences of using telehealth that were different between rural communities, particularly for smaller, more remote rural locations where resources and staff support and experience using telehealth were not always equivalent to larger rural locations. Research has indicated the need to invest in resourcing and education to support expansion of telehealth, noting this is particularly important in rural, regional, and remote areas [ 34 ]. Our study recognises that this is an ongoing need as rural communities continue to have diverse experiences of using telehealth services. Careful consideration of the context of individual rural health services, including the community needs, location, and resource availability on both ends of the consultation is required. Use of telehealth cannot have the same outcomes in every area. It is imperative that service providers and clinicians delivering telehealth from metropolitan areas to rural communities appreciate and understand the uniqueness of every community, so their approach is tailored and is helpful rather than hindering the experience for people in rural communities.

Limitations

There are a number of limitations inherent to the design of this study. Participants were recruited via their workplace and thus although steps were taken to ensure they understood the research would not affect their employment, it is possible some employees perceived an association between the research and their employment. Health professionals who had either very positive or very negative experiences with telehealth may have been more likely to participate, as they may be more likely to want to discuss their experiences. In addition to this, only health services that were already connected with the researchers’ networks were invited to participate. Other limitations include purposive sampling, noting that the opinions of the participants are not generalisable. The participant group also represented mostly nursing professionals whose experiences with telehealth may differ from other health disciplines. Finally, it is important to acknowledge that the opinions of the health professionals who participated in the study, may not represent, or align with the experience and opinions of service users.

This study illustrates that while telehealth has provided increased access to services for many rural communities, others have experienced barriers related to variability in connectivity and managing technology. The results demonstrated that telehealth may not be the preferred or appropriate option for some individuals in rural communities and it is important to provide choice. Consideration of the context in which telehealth services are being delivered, particularly in rural and remote communities where there are challenges with resourcing and training to support health professionals, is critical to the success of telehealth service provision. Another critical factor is preparation and specific, intentional training for health professionals on how to transition to manage and maintain telehealth services effectively. Telehealth interventions require a unique skill set and guidance pertaining to who, when and what training will equip health professionals with the appropriate skill set to deliver telehealth services is still to be determined.

Data availability

The qualitative data collected for this study was de-identified before analysis. Consent was not obtained to use or publish individual level identified data from the participants and hence cannot be shared publicly. The de-identified data can be obtained from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge Georgina Luscombe, Julian Grant, Claire Seaman, Jennifer Cox, Sarah Redshaw and Jennifer Schwarz who contributed to various elements of the project.

The study authors are employed by Three Rivers Department of Rural Health. Three Rivers Department of Rural Health is funded by the Australian Government under the Rural Health Multidisciplinary Training (RHMT) Program.

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RB & EG contributed to the conceptualisation of the study and methodological design. RB & MN collected the research data. RB, EG, MN, KR contributed to analysis and interpretation of the research data. RB, EG, MN, KR drafted the manuscript. All authors provided feedback on the manuscript and approved the final submitted manuscript.

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Correspondence to Rebecca Barry .

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Barry, R., Green, E., Robson, K. et al. Factors critical for the successful delivery of telehealth to rural populations: a descriptive qualitative study. BMC Health Serv Res 24 , 908 (2024). https://doi.org/10.1186/s12913-024-11233-3

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Structured, Semi-Structured & Unstructured

The “Big 3” Interview Approaches Explained

By: Derek Jansen (MBA) | Expert Reviewer: Dr Eunice Rautenbach | July 2024

Interview Approaches 101

• The “Big 3” options
• Structured interviews
• Unstructured interviews
• Semi-structured interviews
• How to make the right choice

The “Big 3” Interview Approaches

When it comes to collecting data by means of interviews, there are three potential approaches you can take:

• Semi-structured
• Unstructured

Naturally, each of these approaches has its strengths and weaknesses , and the right choice will depend on your research aims and research questions. So, let’s dig into each of them to help you find the right option for your study.

Option 1: Structured Interviews

Structured interviews are akin to a well-rehearsed play. Each question is pre-determined , ensuring that every participant is asked the same set in the same order – similar to a survey. This rigidity allows you to achieve a high level of consistency in your approach and makes it easier to compare responses. Naturally, this approach also allows you to move through the interviewing process quite quickly – at least compared to the other options.

All that said, the structured approach can be something of a double-edged sword. Specifically, the emphasis on consistency presents a trade-off in terms of the depth of responses. Moreover, it limits your ability to explore unexpected but potentially relevant topics that crop up naturally during the conversation. In a nutshell then, we can say that the structured interview approach sacrifices flexibility for consistency .

So, when would it make sense to go the structured route?

As you can probably imagine, this approach is useful for projects where you need specific, comparable data from a large number of participants . For example, if your aims involved validating a theory across multiple, relatively large demographic groups, structured interviews could be a good fit. As with all methodological choices though, you’d need to carefully consider your research aims and questions to assess whether this approach would give you the type of data you need.

Option 2: Unstructured Interviews

Next, let’s head to the opposite side of the spectrum and look at unstructured interviews .

With unstructured interviews, the script is thrown out of the window, and the conversation is guided by the participants’ responses . Think of it more as a jazz improvisation rather than a classical concert. With this approach, you, as the interviewer, merely facilitate a free-flowing dialogue , letting your participants’ priorities and viewpoints steer the discussion. As you’d expect, unstructured interviews can do a great job of revealing unexpected insights and richly detailed personal stories.

The downside, of course, is the potential for time-consuming tangents . In some cases, you may also need to hold more than one round of interviews to collect follow-up information. Linked to this is the challenge of managing and analysing the large, diverse dataset that this interviewing approach generates. In other words, it’s once again a tradeoff. In this case, you’re trading consistency for depth and flexibility .

As you’d expect, unstructured interviews are ideal for studies that are exploratory in nature. For example, unstructured interviews could make sense for research aims that involve understanding personal experiences of trauma or the challenging journey of entrepreneurship. So, as always, the suitability of this approach depends on the nature of your research aims and research questions .

Need a helping hand?

Option 3: Semi-Structured Interviews

Last but not least, let’s move to the middle ground and take a look at semi-structured interviews .

As the name suggests, semi-structured interviews provide something of a balance between rigidity and flexibility – in other words, structured and unstructured. In practical terms, semi-structured interviews start with a set of guiding questions but allow the interviewer to digress, probe deeper, and explore emerging themes . Naturally, this sort of flexibility allows you to unearth richer, more nuanced data, and provide insights that a rigid question set might miss.

Sounds like the perfect blend, right?

Well, the challenge with this approach lies in the skill of the interviewer . Specifically, you need to maintain focus on the core questions while also being responsive to the flow of conversation – and managing the clock . This juggling act can be challenging, especially for first-time researchers. It’s easy to get distracted and sidetracked , especially if the participant is particularly chatty. So, you need to be skilled in directing a conversation to pull this approach off.

As you can probably guess, semi-structured interviews are particularly valuable in studies where understanding the diversity of perspectives or experiences is crucial. For instance, in researching the impact of a social policy, you might start with specific questions about the policy and then evolve into exploring its varied effects on individuals’ lives. In principle, semi-structured interviews provide the best of both worlds. But, be careful not to underestimate the skill required to execute these types of conversations well.

How To Choose

To quickly recap, the three types of interviews are structured , semi-structured and unstructured . Choosing the right type of interview for your study hinges on your research aims and questions.

• Structured interviews are a good option when you need clear, comparable data across a relatively large sample.
• On the flip side, if your research is centred on personal experiences or delves into uncharted territories, unstructured interviews can provide flexibility and allow you to capture a high level of depth.
• Last but not least, if your study aims to explore a phenomenon in-depth, while also retaining some level of comparability, semi-structured interviews could be a good fit.

For more information about interviewing stategies and qualitative research in general, be sure to visit the award-winning Grad Coach Blog . Alternatively, if you’d like more hands-on help, check out out Private Coaching service .

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Virtual interviews: A new norm in qualitative research during the Covid-19 pandemic

Olanrewaju Zaid, PhD researcher at University of Bradford Mohammed Abdullahi, Doctoral researcher at University of Warwick 7 Aug 2024

Virtual interviews have gained prominence among researchers from various fields as an effective method for qualitative data collection. The Covid-19 pandemic – with its movement restrictions, isolation measures and the contagious nature of the virus – has driven the transition from traditional face-to-face interviews to virtual or remote interviews using voice-over-internet-protocol (VoIP) technologies such as Microsoft Teams and Zoom.

The rise of remote work during the pandemic has solidified virtual interviews (VIs) as a key method for data collection. VIs closely resemble traditional in-person interviews, involving tasks such as recruiting suitable interviewees and scheduling interviews to avoid conflicts. Relying on VIs also requires a basic level of technological proficiency, including familiarity with computer or mobile phone operation.

The use of technology in virtual interviews is not new in qualitative research and has been considered a viable alternative to in-person interviews (Nehls et al., 2015; Sah et al., 2020). Scholars agree that the ethical considerations for virtual qualitative research are similar to those of in-person research (Roberts et al., 2021). However, VIs introduce an additional layer of security to verify the identities of both the interviewer and interviewee, ensuring the intended individuals participate and that the interview is conducted on a secure network to prevent data breaches.

‘Virtual interviews introduce an additional layer of security to verify the identities of both the interviewer and interviewee, ensuring the intended individuals participate and that the interview is conducted on a secure network to prevent data breaches.’

A set of ten fundamental principles has been proposed to ensure successful virtual interviews for both interviewees and interviewers (Chan et al., 2021). These principles are universally applicable and cover both human and technical aspects, including maintaining professionalism, addressing technology usability, creating a conducive environment, managing environmental factors, adopting a dual-role perspective, meticulous planning, clear communication, active engagement, flexibility, and the use of follow-up emails for gratitude or clarification.

Benefits of virtual interviews

Virtual interviews offer several advantages, highlighted during the Covid-19 pandemic. They provide scheduling flexibility, eliminate the need for physical travel, reduce time constraints, and mitigate health risks. One key benefit is the natural recording and transcription capabilities of certain software packages such as Zoom and Microsoft Teams (Singh et al., 2022). These platforms also provide alerts to remind participants of upcoming sessions. VIs have facilitated participation for individuals with mobility challenges and have streamlined international research involving locations with restricted access (Saarijärvi & Bratt, 2021).

Challenges of virtual interviews for both interviewers and interviewees

Despite their advantages, virtual interviews pose challenges that require investments in high-quality technology, testing and user training (Gray et al., 2020). They sometimes lack the non-verbal cues and body language essential for capturing lived experiences. Bias and engagement are significant challenges, as interviewees often participate from their comfortable environments, which may display personal artefacts or symbols such as political or religious paraphernalia. This comfort zone can lead to distractions, affecting response quality. Additionally, the auto-transcription feature offered by VIs may not always be accurate, and interviewers may become less familiar with the data (Sah et al., 2020).

Exploring the future of virtual interviews

A promising avenue for research is investigating how factors such as artificial intelligence, ergonomics, spatial disparities and virtual augmented reality may impact VoIP in virtual interview technologies across diverse geographical locations.

Chan, D., Fitzsimmons, C. M., Mandler, M. D., & Batista, P. J. (2021). Ten simple rules for acing virtual interviews. PLOS Computational Biology , 17 (6), e1009057. https://doi.org/10.1371/journal.pcbi.1009057

Gray, L. M., Wong-Wylie, G., Rempel, G. R., & Cook, K. (2020). Expanding qualitative research interviewing strategies: Zoom video communications. The Qualitative Report , 25 (5), 1292–1301. https://doi.org/10.46743/2160-3715/2020.4212

Nehls, K., Smith, B. D., & Schneider, H. (2015). Video-conferencing interviews in qualitative research. In S. Hai-Jew (Ed.), Enhancing qualitative and mixed methods research with technology (pp. 140–157). IGI Global.

Roberts, J. K., Pavlakis, A. E., & Richards, M. P. (2021). It’s more complicated than it seems: Virtual qualitative research in the COVID-19 era. International Journal of Qualitative Methods , 20 , https://doi.org/10.1177/16094069211002959

Saarijärvi, M., & Bratt, E. L. (2021). When face-to-face interviews are not possible: Tips and tricks for video, telephone, online chat, and email interviews in qualitative research. European Journal of Cardiovascular Nursing , 20 (4), 392–396. https://doi.org/10.1093/eurjcn/zvab038

Sah, L. K., Singh, D. R., & Sah, R. K. (2020). Conducting qualitative interviews using virtual communication tools amid COVID-19 pandemic: A learning opportunity for future research. Journal of Nepal Medical Association, 58 (232), 1103–1106. https://doi.org/10.31729/jnma.5738

Singh, H., Tang, T., Thombs, R., Armas, A., Nie, J. X., Nelson, M. L., & Gray, C. S. (2022). Methodological insights from a virtual, team-based rapid qualitative method applied to a study of providers’ perspectives of the COVID-19 pandemic impact on hospital-to-home transitions. International Journal of Qualitative Methods , 21 , 16094069221107144. https://doi.org/10.1177/16094069221107144

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