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• Content Analysis | Guide, Methods & Examples

Content Analysis | Guide, Methods & Examples

Published on July 18, 2019 by Amy Luo . Revised on June 22, 2023.

Content analysis is a research method used to identify patterns in recorded communication. To conduct content analysis, you systematically collect data from a set of texts, which can be written, oral, or visual:

• Books, newspapers and magazines
• Speeches and interviews
• Web content and social media posts
• Photographs and films

Content analysis can be both quantitative (focused on counting and measuring) and qualitative (focused on interpreting and understanding).  In both types, you categorize or “code” words, themes, and concepts within the texts and then analyze the results.

Table of contents

What is content analysis used for, advantages of content analysis, disadvantages of content analysis, how to conduct content analysis, other interesting articles.

Researchers use content analysis to find out about the purposes, messages, and effects of communication content. They can also make inferences about the producers and audience of the texts they analyze.

Content analysis can be used to quantify the occurrence of certain words, phrases, subjects or concepts in a set of historical or contemporary texts.

Quantitative content analysis example

To research the importance of employment issues in political campaigns, you could analyze campaign speeches for the frequency of terms such as unemployment , jobs , and work  and use statistical analysis to find differences over time or between candidates.

In addition, content analysis can be used to make qualitative inferences by analyzing the meaning and semantic relationship of words and concepts.

Qualitative content analysis example

To gain a more qualitative understanding of employment issues in political campaigns, you could locate the word unemployment in speeches, identify what other words or phrases appear next to it (such as economy,   inequality or  laziness ), and analyze the meanings of these relationships to better understand the intentions and targets of different campaigns.

Because content analysis can be applied to a broad range of texts, it is used in a variety of fields, including marketing, media studies, anthropology, cognitive science, psychology, and many social science disciplines. It has various possible goals:

• Finding correlations and patterns in how concepts are communicated
• Understanding the intentions of an individual, group or institution
• Identifying propaganda and bias in communication
• Revealing differences in communication in different contexts
• Analyzing the consequences of communication content, such as the flow of information or audience responses

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• Unobtrusive data collection

You can analyze communication and social interaction without the direct involvement of participants, so your presence as a researcher doesn’t influence the results.

• Transparent and replicable

When done well, content analysis follows a systematic procedure that can easily be replicated by other researchers, yielding results with high reliability .

• Highly flexible

You can conduct content analysis at any time, in any location, and at low cost – all you need is access to the appropriate sources.

Focusing on words or phrases in isolation can sometimes be overly reductive, disregarding context, nuance, and ambiguous meanings.

Content analysis almost always involves some level of subjective interpretation, which can affect the reliability and validity of the results and conclusions, leading to various types of research bias and cognitive bias .

• Time intensive

Manually coding large volumes of text is extremely time-consuming, and it can be difficult to automate effectively.

If you want to use content analysis in your research, you need to start with a clear, direct  research question .

Example research question for content analysis

Is there a difference in how the US media represents younger politicians compared to older ones in terms of trustworthiness?

Next, you follow these five steps.

1. Select the content you will analyze

Based on your research question, choose the texts that you will analyze. You need to decide:

• The medium (e.g. newspapers, speeches or websites) and genre (e.g. opinion pieces, political campaign speeches, or marketing copy)
• The inclusion and exclusion criteria (e.g. newspaper articles that mention a particular event, speeches by a certain politician, or websites selling a specific type of product)
• The parameters in terms of date range, location, etc.

If there are only a small amount of texts that meet your criteria, you might analyze all of them. If there is a large volume of texts, you can select a sample .

2. Define the units and categories of analysis

Next, you need to determine the level at which you will analyze your chosen texts. This means defining:

• The unit(s) of meaning that will be coded. For example, are you going to record the frequency of individual words and phrases, the characteristics of people who produced or appear in the texts, the presence and positioning of images, or the treatment of themes and concepts?
• The set of categories that you will use for coding. Categories can be objective characteristics (e.g. aged 30-40 ,  lawyer , parent ) or more conceptual (e.g. trustworthy , corrupt , conservative , family oriented ).

Your units of analysis are the politicians who appear in each article and the words and phrases that are used to describe them. Based on your research question, you have to categorize based on age and the concept of trustworthiness. To get more detailed data, you also code for other categories such as their political party and the marital status of each politician mentioned.

3. Develop a set of rules for coding

Coding involves organizing the units of meaning into the previously defined categories. Especially with more conceptual categories, it’s important to clearly define the rules for what will and won’t be included to ensure that all texts are coded consistently.

Coding rules are especially important if multiple researchers are involved, but even if you’re coding all of the text by yourself, recording the rules makes your method more transparent and reliable.

In considering the category “younger politician,” you decide which titles will be coded with this category ( senator, governor, counselor, mayor ). With “trustworthy”, you decide which specific words or phrases related to trustworthiness (e.g. honest and reliable ) will be coded in this category.

4. Code the text according to the rules

You go through each text and record all relevant data in the appropriate categories. This can be done manually or aided with computer programs, such as QSR NVivo , Atlas.ti and Diction , which can help speed up the process of counting and categorizing words and phrases.

Following your coding rules, you examine each newspaper article in your sample. You record the characteristics of each politician mentioned, along with all words and phrases related to trustworthiness that are used to describe them.

5. Analyze the results and draw conclusions

Once coding is complete, the collected data is examined to find patterns and draw conclusions in response to your research question. You might use statistical analysis to find correlations or trends, discuss your interpretations of what the results mean, and make inferences about the creators, context and audience of the texts.

Let’s say the results reveal that words and phrases related to trustworthiness appeared in the same sentence as an older politician more frequently than they did in the same sentence as a younger politician. From these results, you conclude that national newspapers present older politicians as more trustworthy than younger politicians, and infer that this might have an effect on readers’ perceptions of younger people in politics.

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

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

Research bias

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

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A discussion of qualitative & quantitative research design, analyzability & a qualitative content analysis case study.

The following is a modified excerpt from Applied Qualitative Research Design: A Total Quality Framework Approach (Roller & Lavrakas, 2015, pp. 284-285).

Purpose & Scope The primary purpose of this primary qualitative content analysis study was to extend the existing literature on the portrayal of women’s roles in print media by examining the imagery and themes depicted of heterosexual college-educated women who leave the workforce to devote themselves to being stay-at-home mothers (a phenomenon referred to as “opting out”) across a wide, diverse range of print publications. More specifically, this research set out to investigate two areas of media coverage: the content (e.g., the women who are portrayed in the media and how they are described) and the context (e.g., the types of media and articles).

This study examined a 16-year period from 1988 to 2003. This 16-year period was chosen because 1988 was the earliest date on which the researchers had access to a searchable database for sampling, and 2003 was the year that the term “opting out” (referring to women leaving the workforce to become full-time mothers) became popular. The researchers identified 51 articles from 30 publications that represented a wide diversity of large-circulation print media. The researchers acknowledged that the sample “underrepresents articles appearing in small-town outlets” (p. 502).

Analyzability There are two aspects of the TQF Analyzability component — processing and verification. In terms of processing, the content data obtained by Kuperberg and Stone from coding revealed three primary patterns or themes in the depiction of women who opt out: “family first, child-centric”; “the mommy elite”; and “making choices.” The researchers discuss these themes at some length and support their findings by way of research literature and other references. In some instances, they report that their findings were in contrast to the literature (which presented an opportunity for future research in this area). Their final interpretation of the data includes their overall assertion that print media depict “traditional images of heterosexual women” (p. 510).

Important to the integrity of the analysis process, the researchers absorbed themselves in the sampled articles and, in doing so, identified inconsistencies in the research outcomes. For example, a careful reading of the articles revealed that many of the women depicted as stay-at-home mothers were actually employed in some form of paid work from home. The researchers also enriched the discussion of their findings by giving the reader some context relevant to the publications and articles. For example, they revealed that 45 of the 51 articles were from general interest newspapers or magazines, a fact that supports their research objective of analyzing print media that reach large, diverse audiences.

In terms of verification, the researchers performed a version of deviant case analysis in which they investigated contrary evidence to the assertion made by many articles that there is a growing trend in the proportion of women opting out. Citing research studies from the literature as well as actual trend data, the researchers stated that the articles’ claim that women were increasingly opting out had weak support.

Kuperberg, A., & Stone, P. (2008). The media depiction of women who opt out. Gender & Society , 22 (4), 497–517.

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Choosing the Right Analytical Approach: Thematic analysis vs. content analysis for data interpretation

In research, choosing the right approach to understand data is crucial for deriving meaningful insights. Researchers often struggle to pick the best method of data analysis because not all analytical approaches are equal when interpreting data. This is where content analysis and thematic analysis prove invaluable. These methodologies help systematically organize and interpret data to uncover subtle themes and patterns, transforming volumes of texts into impactful findings when applied skillfully.

Table of Contents

What Is Content Analysis?

Content analysis is defined as a data analysis method that adopts a systematic approach to examine textual, visual, or verbal communication data. Quantifying words, concepts, themes, phrases, characters, or sentences within a dataset helps draw meaningful conclusions from the information. This approach uncovers how often certain information appears, giving insights into the context and content of communication.

Example of content analysis: Analyze terms like “sustainability” and associated words (e.g., “quality”) in online reviews to understand how consumers weigh environmental concerns against product attributes.

What Is Thematic Analysis?

Thematic analysis involves identifying, analyzing, and reporting themes or patterns within qualitative data. It emphasizes broad themes from different sources that represent fundamental aspects of a phenomenon.

Example of thematic analysis: In a study on student feedback, codes such as satisfaction and frustration were grouped into themes of positive and negative experiences, offering insights into overall perceptions of educational quality.

How well do you know the difference between content analysis and thematic analysis? Take our 4-question quiz to test your knowledge of these key data analysis methods. 

Fill the Details to Check Your Score

Similarities and Differences Between Content Analysis and Thematic Analysis

Content analysis and thematic analysis are two qualitative data analysis approaches that share some key similarities. They both involve examining written information by breaking down the text into smaller content units. Despite employing distinct approaches, their shared objective is to generate fresh insights and knowledge from qualitative data sources. Both methods require a comprehensive understanding of the data through an iterative process. Using these methods, theoretical claims in the research can be made.

To gain a comprehensive understanding of the applications of content analysis and thematic analysis, it’s beneficial to explore their differences.

Given these key differences and similarities, it is crucial for researchers to understand both these aspects to select the most appropriate approach based on their research questions, data characteristics, and goals. Making an informed choice allows one to employ the technique that will best elucidate insights, generate new knowledge, and align with the overall research aims . Recognizing their nuances is key to unlocking their full potential for precise data interpretation.

Advantages and Disadvantages of Content Analysis and Thematic Analysis

By conducting a thoughtful evaluation of the pros and cons of both the methods, we can decide on which method to opt for. Here are the advantages and disadvantages of content analysis and thematic analysis:

Choosing the Right Method for Data Analysis: Content analysis or thematic analysis

Qualitative research relies on extracting meaning from complex data. However, not all analytical approaches are created equal. Researchers must select methods strategically based on the requirement of their research study. They need to understand the key differences between both the approached right from the research design stage. This knowledge guides the choice of optimal data analysis method aligned to the study goals. It helps researchers gain clarity regarding the technique to employ.

An insightful interpretation begins with the right analytical lens. By distinguishing approaches early on, researchers give themselves the best chance to unveil the crux of the data – paving the way for impactful qualitative discoveries.

How to Conduct Content Analysis

To fully unlock the potential of content analysis in understanding and comprehending data, researchers must follow systematic steps. Here are the steps for conducting content analysis:

How to Conduct Thematic Analysis

After deciding to employ thematic analysis, you can follow the six-step process for conducting thematic analysis outlined by Braun and Clarke.

Regardless of the data analysis method, it is crucial to grasp the functioning of both these approaches. This understanding enables you to make an informed decision about the most suitable method and accelerates your research process. Are you struggling to decide which is the best data analysis method for your research? Seek professional assistance for informed decisions and a smoother research journey.

Frequently Asked Questions

Content analysis quantifies and analyzes specific words, themes, or concepts within qualitative data, facilitating meaningful insights.

Thematic analysis serves the purpose of identifying significant patterns, or themes, within data, with the aim of addressing research objectives.

The main difference between content analysis and thematic analysis lies in their approach towards a dataset. Content analysis focuses on determining the frequency of categories, while thematic analysis the aim is to identify themes and organize the analysis cohesively.

The main stages of thematic analysis include: familiarization, initial coding, search for themes, refining themes, defining themes, and reporting.

The main stages of content analysis include: preparation, organization, analysis and interpretation.

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Implementing a digital rare disease case-finding tool in UK primary care: a qualitative study of health professionals’ experience

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Background Rare diseases affect millions of people globally, with a lifetime incidence of 1 in 17. They are complex, multisystem, severe disease, and patients experience a diagnostic delay averaging 5.6 years with associated misdiagnoses, inappropriate treatments, and anxiety. MendelScan is a digital case-finding tool that uses structured primary care data to identify patients at risk of being affected by one of a series of rare diseases. This qualitative study explored primary healthcare professionals’ experiences of implementing this technology.

Aim To develop an understanding of primary healthcare professionals’ experiences of implementing MendelScan with a focus on their perception of the technology and its implementation, challenges and opportunities.

Method A qualitative appraisal of implementing MendelScan using descriptive analysis of surveys and semi-structured interviews with professionals.

Results A total of 11 professionals from the two project areas participated. Participants included GPs, nurses, a genetic counsellor, and healthcare managers.

Participants reported that they received adequate support, the project increased confidence in integrating genetics in primary care, and that it may improve inequity in rare disease diagnosis. Professionals’ reservations were related to knowledge, time commitments, primary care pressures, contacting patients, data sharing and confidentiality, and overcoming clinical resistance in sharing data with a non-NHS external body.

Conclusion This study provides a valuable insight into the experiences of primary care professionals using a novel tool to identify rare diseases. The potential of this tool is promising with benefits for skill development. Large-scale implementation faces challenges related to primary care capacity, data, and funding.

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British Journal of General Practice

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Motives and modifying factors for giving or rejecting psychiatric diagnoses in general medicine and psychiatry – a qualitative interview study

• Hannah Tebartz van Elst   ORCID: orcid.org/0009-0003-8392-4080 1 ,
• Claudia Niehoff 1 &
• Jost Steinhäuser 1  

BMC Psychiatry volume  24 , Article number:  461 ( 2024 ) Cite this article

Metrics details

There is a discussion among general practitioners and psychiatrists regarding over-diagnosing versus under-reporting of psychiatric diagnoses. A deeper understanding of this topic is relevant for providing reasonable health care and for planning future studies. A crucial factor to understanding this discussion is the difference in the prevalence of a disease in each sector. One way to attain knowledge about such prevalences is the analysis of routine care data of the sector in question. However, diagnosis-related data might be modified by several additional influencing factors.

This study aims to explore what kind of motives and modifying factors play a role for or against giving psychiatric diagnoses in psychiatric and general medical settings.

Twenty-six semi-structured interviews were conducted with German physicians in the fields of general medicine and psychiatry. Interviews were analysed using content analysis.

The analysis revealed three major motivational categories for finding a diagnosis: (1) “objective matters” such as “categorisation for research”; (2) “functional and performance-related factors” such as “requirement for medication”, “billing aspects” that go with certain diagnoses or “access to adequate care” and (3) “Individual factors” such as the “personality of a physician”. Similarly, factors emerged that lead to not making psychiatric diagnoses like “fear of stigmatization among patients” or “detrimental insurance status with psychiatric diagnosis”. Additionally participants mentioned other reasons for “not diagnosing a psychiatric diagnosis“, such as “coding of other clinical pictures”.

The diagnostic process is a complex phenomenon that goes far beyond the identification of medical findings. This insight should be considered when processing and interpreting secondary data for designing health care systems or designing a study.

Peer Review reports

It is generally assumed that a medical diagnosis identifies a fact or names a condition or a disease, which then forms the basis for further treatment. In practice, however, the process of making a diagnosis is not exclusively based on empirical facts but depends on multiple factors. They may depend on the disease concept of the physician or of the patient, the physician’s overall diagnostic goal, the physician’s age and general diagnostic style and behavior, the consideration of what the impact of the diagnosis on the patient might be and aspects of the health care system [ 1 , 2 , 3 , 4 , 5 , 6 ].

Other relevant aspects might also influence a diagnosis, such as concerns about causing fear in patients or the fear of stigmatizing consequences [ 7 , 8 ]. Furthermore, the problem of “diagnostic uncertainty”, which may lead to a diagnosis not being made is also known [ 9 ].

Psychiatric diseases are of particular relevance, since their definition and detection are complex and more affected by the personal beliefs and attitudes of physicians and the background of patients [ 4 , 10 , 11 , 12 , 13 ].

The majority of people with mental health problems and potentially diagnosable mental disorders see and are treated by general practitioners (GPs) [ 14 ]. Studies show that in Germany, depending on the psychiatric diagnosis, 55–97% of patients with mental disorders are treated by GPs exclusively and are not seen by specialists [ 15 ].

Within the specialist field of psychiatry, there is concern regarding over-diagnosing [ 16 ]. Some authors pose the question of whether the harm of psychiatric over-diagnosis may outweigh the benefits [ 17 , 18 ] and whether physicians may struggle to distinguish between mental illness and typical behavior [ 19 , 20 ].

In contrast in the past, studies addressed whether or not GPs under-diagnose psychiatric diseases [ 21 , 22 , 23 ].

The German healthcare system operates on a social insurance model, funded through dedicated contributions [ 24 ]. Depending on their income, patients have the freedom to choose between statutory and private health insurance companies, as well as their preferred physicians in primary (general) or secondary (specialist) health care sector. Consultations with GPs or psychiatrists are covered by the respective insurance. The doctors’ remuneration is determined primarily by the contact with the patient and is financed by the Association of Statutory Health Insurance Physicians [ 5 ]. The amount of money that might be earned is budgeted for each specialty. However, diagnoses nonetheless are an important justification for billing a contact. In Germany, psychiatric diagnoses are coded under the International Statistical Classification of Diseases and Related Health Problems (ICD-10) [ 25 ], commonly referred to as “F-diagnoses”.

One obvious way to explain differences in experiencing over- or under-diagnosing from the perspective of a different specialty is that diagnostic and testing procedures used in the specialized field of psychiatry are not directly transferable to the prevalences in primary care. Since the prevalence of psychiatric disorders is considerably lower in the general practice setting, the false positive rate for screening tests is significantly higher [ 26 ]. For example when using a test validated in a specialized psychiatric setting in the more low-prevalence range of GPs, only one third of those diagnosed by the instrument are actually ill [ 23 ].

There is a considerable amount of literature dealing with the topic of psychiatric diagnoses per se (see additional file 1 in supplement ).

However, to meet the demands in mental health care, a profound knowledge about prevalences is necessary. Apart from specific research projects, routine care data to analyze the prevalences of diseases are still in their infancy in Germany [ 27 , 28 , 29 ].

The goal of this study was to identify reasons and motives for giving or rejecting psychiatric diagnoses in the different settings of GPs and psychiatrists. The rationale for this was that with a better understanding of the process of diagnosis, the understanding of routine care data as a source for the assessment of prevalence of psychiatric diseases as well as designing studies will improve.

To identify theoretical concepts from the literature, publications related to the topic were screened (for details see additional file 1 in supplement ) and complemented by searching cross references, internet browsers and e-books.

The following basic hypotheses were the basis of the semi structured guiding questions:

In addition to identifying a medical condition or illness, other factors play a qualitatively relevant role in the diagnosis of psychiatric disorders [ 30 ].

There are also specific reasons for not making such diagnoses, even though they would be indicated from a medical point of view [ 31 ].

The questions of the interview guide were therefore derived from informed concepts in the literature search as seen in the additional column in Table  1 and complemented by the authors own experiences (HTVE, medical student and doctoral thesis candidate; CN, MD and GP trainee; JS, GP and experienced in qualitative research).

The interview guideline covered aspects that might influence the process of assigning a psychiatric diagnosis. Open questions were formulated to allow detailed and rich responses by the physicians.

The interview guideline was revised by two experienced researchers in the field and finalized to include 12 questions (for details see Table  1 ).

We conducted semi-structured interviews focusing on the dynamics of physicians’ diagnostic processes in generating psychiatric diagnoses. For this study we let ourselves be guided by the COREQ-checklist (Consolidated Criteria for Reporting Qualitative Studies). The motives behind those dynamics were explored using the principles of the qualitative content analysis as described by Mayring [ 38 ].

Participant selection and recruitment

Physicians from the fields of psychiatry and general medicine were informed about the option to participate in the study both verbally (e.g. at the Congress of the German College of General Practice and Family Physicians in the year 2021) and by mail via a convenient network of colleagues in three German states (Baden-Württemberg, Bavaria, Schleswig-Holstein). Apart from this convenient sampling approach, a snowball system was also used. The main aim was to reach an equal number of psychiatrists and GPs.

Interview procedure

Telephone interviews were conducted with all participants who got in touch and who signed and returned the consent forms and met the inclusion criteria, such as medical qualification as GP or psychiatrist according to the German medical system and sufficient knowledge of German for the purpose of the interview. The telephone interviews took place from June to December 2021. They were performed by the same researcher (HTVE), who was trained in interviewing by the Institute of Family Medicine in Lübeck. Interviews were recorded with a voice recorder (“Voice Tracer DVT6110”), pseudonymized and transcribed using the transcription software f4 (version 4.2.). Three of the participants knew HTVE. In order to standardize the transcripts, they were created according to the transcription rules of the Institute of Family Medicine at the University of Lübeck. The interviews conducted were scheduled to last 30–45 min.

Data analysis

Subsequently, the transcripts were analyzed based on the principles of content analysis according to Mayring [ 38 ]. The participants quotes were cited to illustrate the results and each quote was identified by a pseudonymized number. The concepts of the interview guide were predetermined and therefore the first step of the analysis was deductive.

The essential content passages were identified and assigned to a main category as a coding unit. The coding unit was defined as a new subcategory or assigned to an existing subcategory. The main categories and subcategories were modified during the process if necessary to improve comprehensibility. It was also possible to develop new main categories and subcategories inductively. At the end of the process, a coding system with new main and sub-categories and corresponding anchor quotations was created. This process was carried out by two scientists independently of each other (HTVE & CN).

Once the development of the category system was complete, all the material marked as relevant in terms of content was reviewed again to ensure that no important content was overlooked in the structured summarization processes. At the end of the evaluation process, the independently created category systems were compared and discussed in a group process with an additional scientist (JS). In several meetings, both systems were discussed in detail, debated and merged in order to develop a final consensus version of the category system. In the course of these sessions, the different categories were assigned to four different thematic areas, which were derived from the main categories and guiding questions.

Ethical considerations

The Ethics Committee of the University of Lübeck approved the ethics application in April 2021 (Az. 21–120).

12 GPs and 14 psychiatrists took part in the study. Five physicians initially interested in the study did not participate, giving no reason. 54% of the participants were female with the average age of the participants being 54 years. On average, participants had 24 years of work experience. Further details of the demographics of our participants are presented in Table  2 .

The interviews lasted 30 min on average. GP interviews lasted 32 min on average (between 19 and 53 min) and psychiatrist interviews lasted 27 min (between 20 and 36 min).

The content analysis of all interviews revealed four major thematic domains: (i) Motives and modifying factors for giving or rejecting a psychiatric diagnosis, (ii) Methodological aspects of finding a diagnostic conclusion, (iii) Subjectively perceived diagnostic and therapeutic expectations in the medical system (physician’s perspective) and respective interprofessional cooperation issues, and (iv) Expectations of patients with psychiatric symptoms in the general medicine and psychiatric setting.

In this paper, we concentrate on the results of the first domain to focus on our main research question. In this domain, we identified three main categories in the process of giving or rejecting a diagnosis with five subcategories illustrated in Fig.  1 and detailed with several codes in Table  3 .

Motives and modifying factors that play a role for giving or rejecting psychiatric diagnoses. Model consisting of main and sub-categories of qualitative content analysis

Motives for diagnosing psychiatric disorders

Three different main categories could be identified that positively motivated physicians to attribute a psychiatric diagnosis:

Diagnosis as an objective matter

In our inductive analysis process, we defined diagnosis as an objective matter related to the determination of a fact. When asked why diagnoses were allocated, some of the responses addressed its objective nature.

In general, diagnoses serve to categorize patients, i.e. disease patterns, in order to distinguish them from one other. Other physicians mentioned that generating a diagnosis is indispensable for international research and communication.

“The aim is to form groups that are as uniform as possible so that they can be researched in the broadest sense.” P11 (P = Psychiatrist) .

Functional and performance-related factors

Functional and performance-related factors refer to different functions resulting from the diagnosis. In this context, it means that the content of the function has an intended mode of action or purpose.

Functional therapeutic factors

Most importantly, the diagnosis was seen as the basis for treatment by some physicians. This means that the diagnosis implicated specific action following guidelines and recommendations for the physicians like medications, illness prescriptions, psychotherapy and much more. Especially the sub-category of diagnosis as a condition for medication was mentioned frequently. In some statements physicians pointed out that there were situations where they were not convinced of the correctness of the diagnosis but still needed it in order to prescribe a certain drug.

“Or he has anxiety attacks that I do not yet consider sufficient to diagnose an anxiety disorder, but feel that I want to give him something for the exam so that he can simply pass it and get over this hurdle, so I make the appropriate diagnosis so that I can prescribe the medication. So that’s a functional diagnosis, if you like, and not a factual one.” P4 .

Functional administrative factors

Administrative tasks involve overseeing and organizing personal affairs or those of someone else, typically within a structured setting such as government agencies or organizations, in this case within the health care system as well as with insurance companies.

A related point was the requirement of a diagnosis for billing purposes from health insurance companies or the Ambulatory Health association, which practically forces physicians to make a diagnosis. Many physicians emphasized that they often felt they had to diagnose diseases they were not convinced of because of this billing pressure.

“Because you are really forced by the system to at least commit to one (…) so you can’t write: he came to see me but I don’t know what he has. That means you can’t bill for that.” P14 . “You can write a suspected diagnosis first. But after a quarter, i.e. after three months, the KV demands that you check it and make a confirmed diagnosis or drop it.” P13 .

(KV ◊ Association of Statutory Health Insurance Physicians)

In the German healthcare system some diagnoses generate more money for the treating physician than other diagnoses, which can lead to incentivization of specific diagnoses.

“And then there was a figure that implied money per patient per quarter if the patient had certain rather more serious diagnoses. Of course, this has, how shall I say, given a slight distortion to the more severe diagnoses.” P1 .

Some GPs emphasized the great influence of administrative needs of insurance companies on allocation of a diagnosis, one example being disability insurance.

“So if someone is unable to work because of a mental illness and this drags on for a certain period of time, then this also forces a diagnosis.” GP2 .

However, health insurers also required psychiatric diagnoses for certain services, which led physicians to make them.

“I can’t code it under a flu-like infection or normal exhaustion R53 for example, it wouldn’t get waved through, so it really has to be an adjustment disorder, it has to be, yes exactly, it has to be an F-diagnosis, so that the health insurance company says: “All right, it’s justified, we’ll pay for the psychotherapy”.” GP12 .

Information-providing factors

The term “information-providing factors” refers to the social or informative benefit for the recipients of the diagnosis, which is created by passing on the diagnosis and the information it contains. This means that the diagnoses include different treatment or therapy options, which can be helpful when communicating with other colleagues, but also with patients, and can help the patient understand more quickly.

“So if I say: “Someone has schizophrenia”, this is different from me saying to a colleague: “He has severe depression with psychotic symptoms”, for example. I think both have psychotic symptoms, but they have a different status and therefore a different value in treatment.” TNP10 .

Another aspect mentioned by the participants was that a psychiatric diagnosis can be a relief not only for the patient but also people around them, such as friends and partners, since the diagnosis may help them understand the patient’s behavior better. As an example, one physician spoke about the relieving effect of a diagnosis for the patient’s relatives, who as a consequence no longer blamed themselves.

Individual factors

Individual factors do not primarily relate to objective facts or specific functions of a diagnosis, but rather to individual framework conditions across situations.

Individual physician-dependent factors

In the interviews, it became apparent that there were also diagnostic styles that differed not only between the two specialist domains, but also within them. Some physicians justified this different way of thinking about and making diagnoses with individual differences of the physicians themselves. As an example, the individual personality of the physician was mentioned. Psychiatrists in particular seemed to have an intrinsic claim to make a diagnosis.

“When I interview someone and want to find out what they have, then for me, somehow the requirement is that I want to have a diagnosis” P5 .

Other structural differences, such as the self-image of the physician to be tolerant towards psychiatric diagnoses, also had an impact on making a diagnosis. Other individual factors were experience and expertise, as well as the generation of the physician.

“For example, with young general practitioners (…) I have the feeling that it is different, that they are already more informed about (…) that psychiatric diagnoses are just more of an option.” P2 .

The school of training also had an effect. In some universities, for example, some diagnoses were categorically excluded, which led the physicians to continue this practice in their later work.

“Well, I grew up as a purely behavioral psychiatrist. Also because I studied in < city>, where psychiatrists and psychosomatics are, at least on the face of it, mortal enemies. And as a consequence, I diagnose very few of these so-called somatoform disorders.” P11 .

One psychiatrist described a situation where other psychiatrists had given a diagnosis of a personality disorder to a difficult patient because they themselves were frustrated with the treatment, and diagnosing a personality disorder offered an excuse for the treatment failure.

“I have also often experienced that specifically borderline disorders, or also narcissistic personality, personality disorders – were given, more as a reaction to the annoyance of dealing with the patient for weeks, that you didn’t get on properly: “Ah, he must have a personality disorder.”” P11 .

Motives for not diagnosing

It also became apparent that there were several motives for not attributing diagnoses.

Objective matters

Many participants criticised the inaccuracy of psychiatric diagnoses as they often represent a mixture of norm variants and disease-like conditions. The different classification systems of the ICD and the Diagnostic and Statistical Manual of Mental Disorders (DSM) and their different categorisations were often cited as evidence of the model-like nature of the diagnostic categories. Syndrome diagnoses, which are common in the psychiatric field, were often taken up as a construct.

“Diagnoses are always, especially in psychiatry (…) almost always syndrome diagnoses, which means that there is often a certain vagueness in it and it is always a construct.” P8 .

Many physicians mentioned the problem that there are no intermediates between normal and pathological ratings in the coding systems. This led to physicians assigning diagnoses that they themselves doubted were real in order to obtain certain services for patients. Some physicians wanted alternative diagnoses that would better reflect these intermediate states.

“If I think that the patient has a condition that, unfortunately, if it were coded, could be a mental disorder, I mean now like a grief reaction or, you can be in a bad mood, that this is then immediately an F-diagnosis, there is nothing that can be coded so reasonably.” GP12 .

Some stated that many clinical pictures to be diagnosed according to the guidelines were often explainable and normal in the individual context. However, the health system would often turn this into a disease by forcing a diagnosis, even though physicians would normally regard this as a normal variant of health.

Some psychiatrists reported that insurance status also influenced whether or not the diagnosis was made. E.g. as patients being privately insured may receive their coded diagnosis with their invoice directly after contacting the physician for billing purposes together with the report on diagnostic findings. Whereas this is not the case for patients with a statutory health insurance.

Many physicians reported that they were cautious when making diagnoses, as the diagnosis could no longer be removed from the insurance companies’ patient records. Access to certain insurances, such as occupational disability or life insurance, could be more difficult or no longer possible. In addition, certain diagnoses can make it more difficult or even impossible to take out a loan or to become a civil servant.

“Then, of course, a confirmed diagnosis from my side would have consequences, not only in terms of stigmatization, but also, for example, for insurance companies or something like that later on. Once something like that is in there, it’s hard to get it out again.” GP2 .

The issue of stigmatization played a major role in the interviews. Physicians from both specialist areas reported that the fear of stigmatization influenced them when making a diagnosis. First, some physicians mentioned that especially the patients were afraid of experiencing stigmatization. At the same time, however, there was also mentioning of potential prejudice by other physicians if they were to read the diagnosis in the patient’s file.

“Let’s say a physiotherapist gets a prescription for physiotherapy and it says: F45.1 chronic pain disorder with psychological stress, then this might prejudice them against the patient.” GP12 .

Alternatives to not diagnosing psychiatric disorders

Because of the above-mentioned stigmatization on many levels, alternative ways of dealing with diagnoses were reported in the interviews. Often, for example, a more harmless diagnosis from the psychiatric classification system was chosen instead of the more valid one:

“Then I do try to merely classify it as an adjustment disorder, which is of course also a psychiatric diagnosis, but certainly the least disabling one for someone when it shows up in the health insurance documentation.” P8 .

Sometimes, however, the physicians chose a completely different diagnosis in order to guarantee the functional goal, e.g. sick leave.

“If I have a student who comes to me with love sickness, then I tell him quite clearly: “I’ll give you (…) a sick note. But I’ll put down stomach pain or flu.” GP12 .

This study supports the assumption that the diagnostic process is a complex phenomenon that goes far beyond the identification of medical facts. It suggests that routine care data, derived from the primary and specialist care system, do have important limitations. This insight needs to be considered when interpreting secondary data.

In our study, three different categories of motives for the diagnosis or non-diagnosis of psychiatric disorders were identified (objective factors, functional and performance-related factors and individual factors).

It is already known that diagnoses may also depend on other factors such as collegial norms, economic incentives, prodigious traditions or expectations of patients [14]. Psychodynamic and phenomenological elements can also play a role in the process between physician and patient when making diagnoses [15]. Therefore, the diagnostic process is much more complex and includes many facets, amongst others the need to understand patients [ 3 , 41 , 42 , 43 , 44 ].

This is an important limitation regarding the understanding of prevalence provided by routine care data in scientific literature. When reading international classification systems such as the ICD-system or the DSM-system [ 45 , 46 ], different S3-guidelines [ 47 ] or standard medical textbooks [ 35 ], reference is basically made to the presence or absence of medical findings when diagnostic entities are operationalized. However, the results of this study suggests that this is not always the case. This illustrates that it might be problematic to regard diagnostic data deriving from the primary and spezialized medical care system as representing true medical fact. The different views on over-diagnosis in specialized psychiatry and under-diagnosis in general medicine mentioned at the beginning [ 9 , 16 , 17 , 19 , 22 , 23 ] could thus be put in a different light. Our results suggest that physicians might be exposed to different influences such as individual or administrative aspects that lead them to make or not make certain diagnoses. Future studies should also address whether the experienced prevalence leads to an additional bias regarding the impression of under- or over-reporting of diagnoses.

A major topic in the interviews was functional and performance-related factors and in particular administrative functions of psychiatric diagnoses. Participants mentioned incentivization and billing implications of a diagnosis, but also referred to it as being a precondition before many health insurance companies will offer certain patient support services. This observation is in line with similar propositions in the literature, where implications of diagnoses for pensions, disability certificates, assessments of degrees of disability, death certificates etc. have been implicated [ 41 ]. It also became clear that individual factors such as individual physician-dependent factors also have an impact on the diagnostic process. This is in line with an Australian study with GPs which also found that diagnoses are highly dependent on individual characteristics of the physicians, such as age, sex and practice organization [ 48 ]. Other studies point out that patient-dependent factors like sex and race may also influence the diagnosis [ 11 , 12 ].

Among the motives found against making a diagnosis, the individual physician-dependent one was particularly prominent. Here, fear of stigmatization at various levels was mentioned many times, which led physicians to either not allocate diagnoses at all or to deviate and trivialize them. The literature confirms the feared stigmatization in various areas of social reality [ 7 , 49 , 50 ] such as the workplace [ 51 , 52 ] as well as experiences of discrimination in different areas of life and interpersonal relationships [ 53 ]. Another study found that physicians too exhibit stigmatizing behavior towards people with psychiatric disorders [ 33 ]. Yet another factor speaking against making psychiatric diagnoses were administrative factors. In this context the negative economic consequences of psychiatric diagnoses, which result from structural disadvantages in the regulations of insurance policies such as private life, health or occupational disability insurance have been pointed out [ 54 ]. In addition, it might well prove impossible to enter certain areas of civil service or specific professions like jobs in the police with such conditions.

It must also be emphasized that some participants reported that higher billing figures for certain diagnoses led them to code more severe diagnoses. However, not all countries rely on a multitude of health insurances, for instance Denmark, Sweden, and Norway. Given these obvious far-reaching detrimental consequences of psychiatric diagnoses, it is remarkable that there is still very little literature on this topic complex. More research is needed to better understand the impact of administrative factors like the incentives of the healthcare system and the influence of insurance conditions on making diagnoses.

If there are differences between the two medical specialties in the way of making a diagnosis, as suggested by research by Davidson and Fosgerau [ 21 ], this should be addressed in future studies.

Strengths and limitations

According to our literature search and to the best of our knowledge, to date there are no comparable studies that have explicitly and empirically dealt with the motives and modifying factors for giving or rejecting psychiatric diagnoses in the settings of psychiatric and GP out-patient care. In terms of socio-demographics, the gender and age distribution of the participants in this study is comparable regarding physicians and their specializations in Germany. Selection bias cannot be ruled out as a convenient sampling method was used. Therefore, participants who had already dealt intensively with the topic of psychiatric diagnoses might have rather participated. The interviewer was familiar with three participants which may have potentially influenced the interview dynamic.

Further quantitative studies could build on our suggested categorical model and extend it to analyze the role of socio-demographic factors or items like further specializations or places of medical training in detail. Due to the methodological limitations, no conclusions can be drawn for Germany or other countries since people in different geographical, social or cultural settings may face different structural and social realities and thus think differently about diagnosing. We can’t rule out that using a different qualitative approach other than telephone interviews e.g. face to face would have led to additional information.

Finally, all researchers are working in the field of family medicine, which might be a source of bias within the analysis due to their generalist perspective.

This study adds further weight to the notion that the diagnostic process is a complex phenomenon that goes far beyond the identification of medical facts or categorical diseases, which is especially clinically important for post-graduate trainees.

We were able to identify three different categories of motives to diagnose or not to diagnose psychiatric disorders (objective matters, functional as well as performance-related factors and individual factors). As a consequence, this may indicate that routine care data should be treated with a degree of caution if used to draw conclusions regarding health care demands or study design.

Also, given that psychiatric diagnoses affect the self-image, identity and self-worth of people much more than most other medical diagnoses, this insight is of utmost importance in general medicine and psychiatry. Stakeholders in the medical system should contemplate this and realize that the diagnostic process also depends on which sector of the medical system they work in.

Data availability

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

Abbreviations

Diagnostic and Statistical Manual of Mental Disordersl

General practitioner

International Statistical Classification of Diseases and Related Health Problems

Kassenärztliche Vereinigung = Association of Statutory Health Insurance Physicians)

Psychiatrist

Balint M. Der Arzt, sein patient und die Krankheit. Zwölfte Auflage. Stuttgart: Klett-Cotta; 2019. 502 S. (Fachbuch Klett-Cotta).

Google Scholar  

Alarcon RD. Culture and psychiatric diagnosis. Impact on DSM-IV and ICD-10. Psychiatr Clin North Am September. 1995;18(3):449–65.

Article   CAS   Google Scholar  

Dunn G. Patterns of psychiatric diagnosis in general practice: the Second National Morbidity Survey. Psychol Med August. 1986;16(3):573–81.

Zaninotto L, Altobrando A. Four Core concepts in Psychiatric diagnosis. Psychopathol 29 Dezember. 2021;55(2):73–81.

Article   Google Scholar  

Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Health System Review 2020.

Bohman B. Clinicians’ perceptions and practices of diagnostic assessment in psychiatric services. BMC Psychiatry 23 März. 2023;23(1):191.

Farley-Toombs C. The stigma of a psychiatric diagnosis: prevalence, implications and nursing interventions in clinical care settings. Crit Care Nurs Clin North Am März. 2012;24(1):149–56.

Rüsch N, Heland-Graef M, Berg-Peer J. Das Stigma psychischer Erkrankung: Strategien gegen Ausgrenzung und Diskriminierung: wissenschaftsbasiertes Sachbuch. 1. Auflage. München: Elsevier; 2021. 312 S.

Jutel A. Uncertainty and the inconvenient facts of diagnosis. Endeavour. 2021;45.

Choi MR, Eun HJ, Yoo TP, Yun Y, Wood C, Kase M. u. a. The effects of sociodemographic factors on psychiatric diagnosis. Psychiatry Investig September. 2012;9(3):199–208.

DelBello MP, Lopez-Larson MP, Soutullo CA, Strakowski SM. Effects of race on psychiatric diagnosis of hospitalized adolescents: a retrospective chart review. J Child Adolesc Psychopharmacol. 2001;11(1):95–103.

Article   CAS   PubMed   Google Scholar  

Warner R. Racial and sexual bias in psychiatric diagnosis: psychiatrists and other mental health professionals compared by race, sex, and discipline. J Nerv Ment Dis Mai. 1979;167(5):303–10.

Gupta M, Potter N, Goyer S. Diagnostic reasoning in Psychiatry: acknowledging an Explicit Role for Intersubjective Knowing. Philos Psychiatry Psychol 1 März. 2019;26:49–64.

Younès N, Hardy-Bayle MC, Falissard B, Kovess V, Chaillet MP, Gasquet I. Differing mental health practice among general practitioners, private psychiatrists and public psychiatrists. BMC Public Health 7 Oktober. 2005;5:104.

Gaebel W, Kowitz S, Fritze J, Zielasek J. Use of Health Care services by people with Mental Illness. Dtsch Ärztebl Int November. 2013;110(47):799–808.

John Brodersen, Lisa M, Schwartz C, Heneghan J, William O’Sullivan JK, Aronson. Steven Woloshin. Overdiagnosis: what it is and what it isn’t. BMJ Evid-Based Med 1 Februar. 2018;23(1):1.

Kazda L, Bell K, Thomas R, McGeechan K, Sims R, Barratt A. Overdiagnosis of Attention-Deficit/Hyperactivity disorder in children and adolescents: a systematic scoping review. JAMA Netw Open 1 April. 2021;4(4):e215335.

Frances A. Saving normal: an Insider’s revolt against out-of-control Psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life. Repr: Mariner Books; 2014. p. 352.

Freckelton I. Overdiagnosis in Psychiatry: how modern Psychiatry Lost its way while creating a diagnosis for almost all of Life’s misfortunes, by Paris Joel. Psychiatry Psychol Law 15 Mai. 2018;25(2):325–7.

Rose NS. Our psychiatric future: the politics of mental health. Cambridge: polity; 2019.

Davidsen AS, Fosgerau CF. What is depression? Psychiatrists’ and GPs’ experiences of diagnosis and the diagnostic process. Int J Qual Stud Health Well-Being. 2014;9:24866.

Article   PubMed   Google Scholar  

Scott J, Jennings T, Standart S, Ward R, Goldberg D. The impact of training in problem-based interviewing on the detection and management of psychological problems presenting in primary care. Br J Gen Pract J R Coll Gen Pract Juni. 1999;49(443):441–5.

CAS   Google Scholar  

Wiesemann A, Hensler S. Diskreditierende Versorgungsstudien in Deutschen Hausarztpraxen. ZFA - Z Für Allg Dezember. 2003;79(12):579–85.

van der Zee J, Kroneman MW. Bismarck or Beveridge: a beauty contest between dinosaurs. BMC Health Serv Res 26 Juni. 2007;7:94.

Weltgesundheitsorganisation, Dilling H, Mombour W, Schmidt M. Internationale Klassifikation psychischer Störungen - ICD-10 Kapitel V (F), klinisch-diagnostische Leitlinien zitieren. 10. Aufl. Hogrefe (Göttingen); 2015.

Mitchell AJ, Coyne JC. Screening for depression in clinical practice: an evidence-based guide. Oxford; New York: Oxford University Press; 2010. p. 395.

Laux G, editor. Herausgeber. Versorgungsforschung in Der Hausarztpraxis: Ergebnisse aus dem CONTENT-Projekt 2006–2009. München: Springer; 2010. 112 S.

Strumann C, Blickle PG, von Meißner WCG, Steinhäuser J. The use of routine data from primary care practices in Germany to analyze the impact of the outbreak of SARS-CoV-2 on the utilization of primary care services for patients with type 2 diabetes mellitus. BMC Prim Care 16 Dezember. 2022;23(1):327.

Slagman A, Hoffmann F, Horenkamp-Sonntag D, Swart E, Vogt V, Herrmann WJ. Analyse Von Routinedaten in Der Gesundheitsforschung: Validität, Generalisierbarkeit Und Herausforderungen. Z Für Allg 1 April. 2023;99(2):86–92.

McPherson S, Armstrong D. General practitioner management of depression: a systematic review. Qual Health Res August. 2012;22(8):1150–9.

Miedema B (BO), Tatemichi S, Thomas-Maclean R, Stoppard J, editors. Barriers to Treating Depression in the Family Physician’s Office. Can J Commun Ment Health. April 2004;23(1):37–46.

Goetz K, Mahnkopf J, Kornitzky A, Steinhäuser J. Difficult medical encounters and job satisfaction - results of a cross sectional study with general practitioners in Germany. BMC Fam Pract 9 Mai. 2018;19:57.

Lauber C, Anthony M, Ajdacic-Gross V, Rössler W. What about psychiatrists’ attitude to mentally ill people? Eur Psychiatry J Assoc Eur Psychiatr November. 2004;19(7):423–7.

Mader FH, Brückner T, Scherer M, editors. Programmierte Diagnostik in der Allgemeinmedizin: 92 Checklisten nach Braun für Anamnese, Untersuchung und Dokumentation. 6., vollständig überarbeitete und erweiterte Auflage. Berlin [Heidelberg]: Springer; 2019. 287 S.

Berger M, Angenendt J, editors. Psychische Erkrankungen: Klinik und Therapie. 3. Auflage. München Jena: Elsevier, Urban & Fischer; 2009. 1204 S.

Koch K, Miksch A, Schürmann C, Joos S, Sawicki PT. The German Health Care System in International Comparison. Dtsch Ärztebl Int April. 2011;108(15):255–61.

Younes N, Gasquet I, Gaudebout P, Chaillet MP, Kovess V, Falissard B. u. a. General practitioners’ opinions on their practice in mental health and their collaboration with mental health professionals. BMC Fam Pract 2 Mai. 2005;6(1):18.

Mayring P. Qualitative Inhaltsanalyse: Grundlagen und Techniken. 12., überarbeitete Auflage. Weinheim Basel: Beltz; 2015. 152 S.

KBV - Alter [Internet]. Kassenärztliche Bundesvereinigung (KBV); [zitiert 13. Februar 2024]. Alter. Verfügbar unter: https://gesundheitsdaten.kbv.de/cms/html/16397.php .

Teney C, Bürkin K, Becker R, Möser S, Lenkewitz S. Ärztinnen Und Ärzte in Deutschland: erste Ergebnisse Einer Bundesweiten Umfrage zu Beruflichen Erfahrungen, Zufriedenheit Und Einstellungen. Bremen: Universität Bremen, SOCIUM Forschungszentrum Ungleichheit und Sozialpolitik; 2017. p. 51.

Donner-Banzhoff N. Die ärztliche Diagnose: Erfahrung - Evidenz - Ritual. 1. Auflage. Bern: Hogrefe; 2022. 356 S. (Programmbereich Medizin).

North CS, Surís AM. Advances in Psychiatric diagnosis: past, Present, and Future. Behav Sci Basel Switz 26 April. 2017;7(2):27.

Hengeveld MW, Beekman ATF. [Psychiatric diagnosis: personalised by definition]. Tijdschr Voor Psychiatr. 2018;60(3):151–5.

Mason A, Liu D, Kasteridis P, Goddard M, Jacobs R, Wittenberg R. u. a. investigating the impact of primary care payments on underdiagnosis in dementia: a difference-in-differences analysis. Int J Geriatr Psychiatry August. 2018;33(8):1090–7.

Harrison J, Weber S, Jakob R, Chute C. ICD-11: an international classification of diseases for the twenty-first century. BMC Med Inf Decis Mak. 9. November 2021;21.

American Psychiatric Association. Herausgeber. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, D.C: American Psychiatric Association; 2013. p. 947.

Book   Google Scholar  

DGPPN BÄK KBV, AWMF, Härter M, Schorr S, Schneider F, Herausgeber. S3-Leitlinie/Nationale VersorgungsLeitlinie Unipolare Depression [Internet]. Berlin, Heidelberg: Springer; 2017 [zitiert 11. März 2023]. Verfügbar unter: http://link.springer.com/ https://doi.org/10.1007/978-3-662-52906-5 .

Davenport TA, Hickie IB, Naismith SL, Hadzi-Pavloviv D, Scott EM. Variability and predictors of mental disorder rates and medical practitioner responses across Australian general practices. Med J Aust 16 Juli. 2001;175(S1):S37–41.

Hazell CM, Berry C, Bogen-Johnston L, Banerjee M. Creating a hierarchy of mental health stigma: testing the effect of psychiatric diagnosis on stigma. BJPsych Open 26 September. 2022;8(5):e174.

O’Connor C, Kadianaki I, Maunder K, McNicholas F. How does psychiatric diagnosis affect young people’s self-concept and social identity? A systematic review and synthesis of the qualitative literature. Soc Sci Med 1982 September. 2018;212:94–119.

Baer N. Würden Sie einen psychisch behinderten Menschen anstellen? Z Für Sozialhilfe [Internet]. 2007 [zitiert 26. Januar 2023]; Verfügbar unter: https://www.e-periodica.ch/digbib/view?pid=zes-003:2007:104 ::192.

Brohan E, Henderson C, Wheat K, Malcolm E, Clement S, Barley EA. u. a. systematic review of beliefs, behaviours and influencing factors associated with disclosure of a mental health problem in the workplace. BMC Psychiatry 16 Februar. 2012;12(1):11.

Lasalvia A, Zoppei S, Van Bortel T, Bonetto C, Cristofalo D, Wahlbeck K. u. a. global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. Lancet Lond Engl 5 Januar. 2013;381(9860):55–62.

Sautermeister J, Skuban T, Lenz V, Herausgeber. Handbuch psychiatrisches Grundwissen für die Seelsorge. Freiburg Basel Wien: Herder; 2018. p. 752.

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Acknowledgements

We would like to thank all the participants who took part in the study, the people that helped with contacting physicians, the people who helped transcribe the interviews and the whole team at the Institute of Family Medicine in Lübeck, who were always available to help and answer questions.

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HTVE conducted the interviews and transcribed the material. HTVE and CN analyzed the data. In a joint group process with JS, the consensus version was produced with all findings. HTVE wrote the first draft of the manuscript, which was critically reviewed and approved by CN and JS. JS was the supervisor throughout the whole study and developed the study design.

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Tebartz van Elst, H., Niehoff, C. & Steinhäuser, J. Motives and modifying factors for giving or rejecting psychiatric diagnoses in general medicine and psychiatry – a qualitative interview study. BMC Psychiatry 24 , 461 (2024). https://doi.org/10.1186/s12888-024-05900-2

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Risk factors and service gaps affecting a sustainable work: a qualitative multi-stakeholder analysis in the context of persons with acquired brain injury living in Switzerland

• Katarzyna Karcz 1 ,
• Urban Schwegler 1 , 2 ,
• Barbara Schiffmann 1 &
• Monika E. Finger 1  

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Introduction

Along with the social and economic challenges posed by an aging society, creating work conditions that allow persons to stay healthy and work into old age has become a major task of Western societies. Retaining employment after returning to work is particularly difficult for individuals with a disability, as evidenced by the high rate of premature labor market dropout. Individuals with acquired brain injury (ABI) exemplify this challenge, as it often impairs cognitive, technical, and interpersonal abilities that are crucial in today’s labor market. To effectively support these individuals, vocational integration practitioners require comprehensive knowledge of risk factors for premature labor market dropout and effective strategies for sustainable work.

This study aimed to identify perceived risk factors and related service gaps regarding sustainable work for people with ABI, as reported by affected individuals, employers, vocational integration professionals, and health professionals.

Secondary data analysis. Data that was originally collected through seven focus groups and two interviews with persons with ABI, 15 interviews with employers, and 13 interviews with vocational integration and health professionals in the context of the project ‘Sustainable employment’ was re-analysed thematically.

Two major themes of risk factors were identified: (1) person-related factors (including the subthemes: post-ABI impairments; lack of understanding of post-ABI impairments; poor health management) and (2) environment-related factors (including the subthemes: challenges related to the service structure; insufficient knowledge and education about ABI; challenges at the workplace; difficulties in private life). While stakeholders noted the variety of the currently available services, they particularly pointed to the missing long-term monitoring and counseling services for persons with ABI following the initial return-to-work, reflecting a major challenge for sustainable work. An overarching gap related to the fragmentation of the service structure and the lack of case coordination along the working life.

Conclusions

Multiple stakeholders emphasized the importance of empowering individuals, ensuring easy access to professional support, and providing a suitable work environment to address key risk factors and facilitate sustainable work for individuals with ABI. Continuous coaching, long-term monitoring and counseling following return-to-work, were identified as potential strategies to achieve these goals.

Peer Review reports

Along with the socio-economic challenges posed by an aging society, creating work conditions that enable persons to stay healthy and able to work into old age has become a significant task of Western societies [ 1 , 2 , 3 , 4 , 5 ]. For persons with a disability, retaining employment after return-to-work (RTW) represents a particular challenge, as indicated by the high number of premature dropouts from the labor market among this group [ 6 , 7 , 8 , 9 ]. Therefore, vocational integration services aim to ensure the best possible conditions for supporting sustainable employment throughout a person’s lifespan. A sustainable work situation can be defined as ‘a person-job-workplace match that enables a person to remain healthy and satisfied at work over time, with a work performance meeting the expectations of both the person and the employer’ [ 10 ].

Persons with an acquired brain injury (ABI) make an exemplary case for the challenge of sustaining work over time as their health condition strongly affects the ability to perform cognitive, technical, and interpersonal tasks that are increasingly relevant in today’s labor market [ 11 , 12 , 13 , 14 , 15 ]. An acquired brain injury represents an incisive life event resulting in a high monetary and nonmonetary burden for those affected as well as the society [ 16 ]. Maintaining gainful employment after ABI is thus important not only for ensuring individuals’ financial self-sufficiency, self-worth, social inclusion as well as quality of life, but also for lowering socio-economic costs and increasing tax revenues [ 17 , 18 , 19 ]. ABI reflects a traumatic (i.e., due to an accident) or non-traumatic (i.e., due to a disease such as stroke) damage to the brain that occurs during life and is not related to any degenerative disease such as multiple sclerosis or Alzheimer. While a mild ABI may result in little to no limitations, severe injuries can lead to significant lifelong disability. ABI may involve a wide range of problems, including observable ones such as movement and balance disorders and non-observable ‘silent’ ones like concentration issues, increased fatigability, emotional instability, and planning difficulties [ 20 ]. While in some cases functioning may still improve several years after ABI onset [ 21 ], it is more common that people with ABI experience a decline in functioning over time [ 22 ].

Internationally, there exist approximately 73 million working-age people with ABI, with around 90’000 of them living in Switzerland [ 23 ]. RTW rates range from 11% to 85% globally [ 24 , 25 , 26 ]. In Switzerland, data on the employment rates for people with ABI is missing, but according to support organizations for people with ABI, a substantial number of those affected struggle to maintain their jobs or drop out from the labor market prematurely [ 27 ]. Sustainable employment is particularly hampered by non-visible impairments, that lead employers and co-workers but also people with ABI to overestimate affected workers’ abilities, resulting in a lack of support or the assignment to unsuitable work tasks. Such a work situation can lead to overwork and increased fatigue [ 28 , 29 ]. Discrepancies between the affected individual and the employer regarding the perception of job performance as well as an unstable work performance can also increase the risk for job loss [ 30 , 31 ].

In Switzerland, individuals with acute ABI that show significant neurological symptoms typically undergo two to twelve weeks of initial inpatient or outpatient neurorehabilitation. Subsequently, a range of services that are funded by the health, accident or disability insurance supports the recovery as well as the work and community integration of those affected [ 32 ]. The Swiss Disability Insurance (IV), a mandatory system funded by wage deductions and federal support, provides a disability pension based on income loss rather than the severity of the injury, which - in case of traumatic brain injuries – is complemented by accident insurance benefits. The IV also covers medical treatments, assistive devices as well as vocational integration services (e.g., vocational counselling, job placement) that are aimed at returning people to the labor market. Fragile Suisse represents the support organization for individuals with ABI in Switzerland and provides help with a particular focus on community integration, including work as well as social counseling with respect to the navigation through the administrative issues in the context of the health and social security system.

To provide optimal support services for persons with ABI, both service providers and payers require conclusive knowledge on risk factors for premature labor market dropout as well as strategies to optimally promote sustainable work. This knowledge may best be generated through a need-driven approach that incorporates the view of the key stakeholders in the vocational integration process. The present study thus aimed to identify risk factors and related service gaps regarding a sustainable work by taking individuals with ABI as an exemplary case and by integrating the view of those affected, their employers, as well as health and vocational integration professionals.

To address our research question, we carried out a secondary analysis of data collected in the context of our previous project ‘Sustainable employment’ [ 33 ]. Data was collected between May 2019 and July 2020.

Data source: the ‘Sustainable employment’ project

The original project aimed to identify barriers and facilitators to sustainable employment for individuals with a disability, specifically focusing on those with acquired brain injuries and spinal cord injuries (SCI) [ 33 ]. To respond to this study aim, we conducted focus group discussions and semi-structured interviews [ 34 , 35 ] with individuals with ABI and SCI [ 36 ], health and vocational integration professionals [ 37 ], as well as employers of persons with ABI and SCI [ 38 ]. Based on our finding that the availability and structure of vocational integration services were perceived as a major barrier to employment sustainability, especially for persons with ABI, we decided to conduct an in-depth secondary analysis of the qualitative data, focusing on perceived service gaps and their relation to the identified risk factors for sustainable employment of people with ABI. While the original project analyzed the perspective of all three stakeholder groups separately, the present study merges the perspectives of the stakeholder groups. In the current secondary analysis, the gathered data was re-analyzed thematically [ 34 , 39 ].

Participants

The sample included persons with ABI who worked for at least two years after the onset of their injury, employers with experience in employing an affected person as well as health and vocational integration professionals experienced in the topic of ABI. Individuals who were unable to go back to work successfully were not included as the ‘Sustainable employment’ project did not focus on factors affecting RTW but on barriers and facilitators to sustaining employment after having returned to work post-ABI. Employers represented companies of different sizes and sectors (private, public, non-profit). Professionals were expected to be familiar with the spectrum of the existing support services as well as with the administrative and legal regulations of the Swiss health and social security system.

We employed multiple recruitment strategies. Initially, we made announcements in the publications and on the webpage of Fragile Suisse, the support organization for individuals with ABI, their families, and professionals. Additionally, we distributed flyers via health and vocational integration professionals and received recommendations for candidate participants from two vocational rehabilitation departments and the work integration group of the Swiss Association of Rehabilitation. Finally, recruitment was facilitated through personal contacts of authors of this study (MF and BS).

Data collection

We conducted seven focus groups and two single interviews, including a total of 23 persons with ABI. In addition, we carried out 15 interviews with employers and 13 interviews with professionals. Sample characterstics are presented in Tables  1 , 2 and 3 . The focus group discussions included three affected persons, lasted between 90 and 120 min and took place in seminar rooms located at different cities in the German-speaking region of Switzerland. We chose focus groups as our primary data collection method for persons with ABI to facilitate discussions and the exchange of experiences among participants with different characteristics. Single interviews were offered to two volunteers who were unable to participate in the focus groups due to their ABI-related limitations. These interviews were conducted at participants’ homes and took between 45 and 90 min. Interviews with employers and professionals lasted between 30 and 70 min and were conducted at their workplace, except two being carried out at the Swiss Paraplegic Research Institute in Nottwil and three that were conducted online via Zoom. Interviews were chosen as data collection method for employers and professionals due to time constraints, organizational barriers and ethical issues (the necessity to maintain anonymity of persons with ABI). The focus groups and the interviews followed the same procedure of discussing facilitators and barriers for sustainable work, service gaps and risk factors for labor market dropout. Detailed information on the data collection is published elsewhere [ 36 , 37 , 38 ]. The guidelines of the focus groups and the interviews are provided in the supplementary material (S1-S4).

Focus groups and interviews were audio recorded, transcribed verbatim and anonymized. MF (a physiotherapist experienced in qualitative research) and BS (a sociologist experienced in qualitative research) conducted the focus group discussions and the interviews. The first author (KK, a sociologist and psychologist with experience in qualitative research) participated in all focus groups as an assistant and note-taker.

Data analysis

We conducted a thematic analysis according to Braun & Clarke [ 34 , 39 ] with an inductive coding throughout the process. Data were coded by KK using the software MaxQDA. Additionally, MF independently coded one interview from each participant group. KK and MF compared and discussed then the coding schemes until agreement was achieved. We operationalized risk factors as ‘aspects associated with an increased risk of unsustainable work’ and service gaps ‘as differences between the actual support provision and the participants’ support needs’. Risk factors were coded inductively (e.g., rapid fatigability, headache) and then grouped into subthemes of similar factors (e.g., post-ABI impairments). The subthemes formed the two overarching themes, i.e., person-related and environment-related factors. Identified service gaps were first coded inductively and then assigned to the related risk factors. The coding scheme and the assignment of the subthemes were extensively discussed among all authors throughout the coding process.

In the following, we describe the service gaps reported by our participants in relation to the perceived risk factors for sustainable work. Sub-themes are grouped into the overarching themes person-related and environment-related factors (see Table  4 ).

Person-related risk factors and service gaps

Post-abi impairments.

Individuals emphasized the negative impact of cognitive post-ABI impairments on their work performance, while employers highlighted the unstable health and the unpredictability of work performance, leading to difficulties in the work organization. A common problem represent the affected individuals’ inability to accurately assess and predict their own work capabilities, resulting in potential errors or unmet deadlines. All stakeholder groups agreed that a close monitoring by a vocational integration specialist during the return-to-work phase is essential, including professional coaching to adjust job demands based on the individual’s recovery state. Professionals pointed to the various work counseling services, typically funded by the IV, but noted that the accessibility and timing of these services are often unstructured and depend on whether vocational measures are part of the rehabilitation process or initiated later by requests of those affected, their general practitioner or a caregiver.

Lack of understanding of post-ABI impairments and poor health management

All stakeholder groups recognize that the poor understanding of ABI-related impairments and the inability to recognize body signals, like fatigue, jeopardizes stable employment. Without this awareness, it’s hard for those affected to develop a disability-friendly life and work style. Stakeholders emphasized the need for vocational integration specialists and psychologists that teach effective self-management strategies already during rehabilitation to empower persons with ABI and support in becoming experts in their own disability. However, professionals reported that medical staff’s tight schedules pose challenges to providing this education and care effectively during the medically-oriented initial rehabilitation.

Persons with ABI and health professionals consider ongoing personal coaching from neuropsychologists, occupational therapists, or vocational integration specialists as crucial for managing post-ABI challenges and adapting to new career paths. While such support is typically provided in neurorehabilitation, the awareness and availability of such services are lower among those with mild to moderate injuries who are discharged early from rehabilitation. Professionals also highlighted the need for extended neuropsychological coaching beyond the vocational integration phase to promote sustainable employment. Yet, accessing these services is difficult due to complex procedures, long waiting times for approvals, and limited resources of patient organizations.

Environment-related risk factors and service gaps

Challenges related to the service structure, fragmentation of services.

Service fragmentation was identified as a critical gap by all stakeholder groups, noting a poor coordination across different phases of working life. The RTW period was especially emphasized, with various services offered by governmental, non-governmental, inpatient, outpatient, and private institutions to support disability onset. However, stakeholders highlighted significant challenges in the coordination and accessibility of these services. Additionally, they pointed to regional differences in service regulations and financing, influenced by factors like workplace location, employer’s insurance, and availability of private insurance options.

Lack of case management across the work life

Participants reported a significant gap in case management across the work life of individuals with ABI, noting a lack of long-term coordination between various service settings such as inpatient, outpatient, and long-term care. They highlighted the absence of a dedicated person or institution to guide through the system procedures, leaving individuals with ABI to navigate their post-discharge care pathway independently.

Furthermore, all groups emphasized the need for long-term monitoring that integrates medical and work-related issues to address potential functional declines that could affect work performance. Despite this need, IV cases typically close after two years, assuming stabilization. Although the person or their employer can still apply for support even after integration has been completed, long waiting times for a counselling appointment and a high administrative burden often discourage both from contacting the IV. Participants pointed out that in these situations, the support of patient organizations is crucial for persons with ABI, their families and their employers. Patient organizations may take on case coordination in terms of acting as an intermediary between affected persons and the insurances or finding suitable providers (specialists, coaches, shift workers, etc.). When a patient organization was involved, its support was largely successful according to the study participants.

Fixed timelines in the vocational integration process

Participants criticized the rigidity of the vocational integration process for individuals with ABI, including the fixed timing of work capacity assessments used to determine disability pensions that often occure before individuals reached a stable recovery state. Shifting work capacity assessments until stable stage could lead to a more effective and sustainable RTW processes. In addition, persons with ABI would like more flexibility in their daily or weekly workload so as not to be overburdened when their work capacitiy fluctuates for health reasons – employers on the other hand pointed out that they need employees with a workload that is as reliable as possible. Although reassessment of work capacity is possible when it fluctuates due to health issues, it typically happens late, under duress, and involves lengthy administrative procedures. Professionals suggest that allowing for timely adjustments of workloads would prevent overburdening, and benefit the individual, the workplace as well as the social system both economically and health-wise.

Confusing and complicated administrative processes for persons with ABI

Although participants shared both, negative and positive examples of working with insurance companies, all stakeholders found dealing with administrative procedures or regular disability benefits revisions to be stressful and time-consuming. According to employers and professionals, the stress and frustration experienced by persons with ABI in dealing with insurance policies leads to further decline in their work performance.

Lack of common ABI-specific guidelines and inadequate funding

The absence of established guidelines, leads to insufficient funding due to a lack of legal support. Medical professionals highlight that this results in insufficient funding for adequately long inpatient stays in emergency, acute care, and initial rehabilitation, often causing missing or incomplete ABI diagnoses and inadequate vocational interventions. They urge the creation of standardized guidelines to support financial claims and recommend an interdisciplinary team, including neurologists or neuropsychologists, for diagnosing suspected ABI. Limited resources also restrict follow-up assessments to properly evaluate recovery post-ABI. Additionally, the lack of guidelines which would provide a basis for financial claims impedes also long-term support, such as job coaching for affected individuals and employers. Despite patient and employer organizations stepping in to some extent, fundraising and lack of resources create a barrier to meet the support needs.

Insufficient knowledge and education about ABI

Insufficient knowledge about ABI was identified as a significant gap in two areas. First, the discrepancies in professionals’ knowledge on ABI, its procedures, and its impact on daily life leads to inconsistent support, depending heavily on the competence and network of the case manager or specialist involved.

Second, professionals and affected persons reported a lack of knowledge about ABI and its impact on work and daily life among employers and co-workers, resulting in a lack of understanding of persons’ needs in relation to ABI-specific work adjustments. To address this, training HR staff or designating a person within the company to learn how to best support persons with ABI as well as their supervisors and co-workers could be a promising intervention target.

Workplace challenges

Poor person-job match.

One of the key challenges to maintain the work over time is to establish a good person-job match, which broadly refers to the fit between persons’ abilities, needs, and interests and the requirements and characteristics of their jobs [ 41 ]. As reported by all stakeholder groups, person-job mismatches were often related to too many or too difficult job tasks. In the long run, such situation can lead to overwork and premature dropout. To prevent these issues, it’s recommended that the final assessment of an employee’s work capacity and support needs should be conducted only after reaching a stable post-injury state, with regularly follow-ups regarding person-job match by both the employee and supervisor.

Workplace restructuring

All stakeholder groups perceived changes in the work situation as a risk factor due to the high level of adjustment required from those affected. Moreover, when the work environment changes, arrangements that have been put in place to support the employee are likely to be discontinued. Additional professional advice, such as coaching or mediation, should be offered on request for challenging cases. However, the availability and funding of such services is limited. Employers expressed a wish for a single point of contact or helpline where they could get immediate support regarding key issues or access to a specialist if needed.

Difficulties in private life

Professionals and employers frequently cited personal life issues as a significant risk factor for individuals with ABI. Family conflicts or changes in support networks can have a more negative impact than before the onset of ABI, draining personal resources and reducing work capabilities. To mitigate this, professionals recommend providing psychological support to family members and educating them about ABI consequences and available supports, such as through a helpline. At present no such services exist apart from support from patients organizations.

Based on a multi-stakeholder approach, our study identified service needs related to the sustainable employment of persons with ABI by linking existing services and perceived service gaps with main risk factors for sustainable work. We identified several person-related (e.g., lack of understanding of post-ABI impairments) and environment-related risk factors (e.g., fragmentation of services; workplace restructuring) associated with different stages of vocational integration (rehabilitation, work integration, and long-term work-related support).

Perceived service gaps were found to be highly interdependent and mainly related to accessibility, funding and availability of services. Service quality was mainly an issue in terms of poor professional commitment and ABI-related knowledge.

Person-related factors

Our results point to the need of services that enhance the understanding of ABI impacts on daily life, that empower individuals to assess their abilities, and that teach self-management of health. While self-management of disability in daily life is recognized as important [ 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ], rehabilitation and vocational integration services typically prioritize physical and vocational skills over person-centered skills, despite evidence supporting the importance of empowerment early on [ 24 , 25 , 26 , 27 , 28 ]. Most participants also reported difficulty accessing services focused on person-centered skills in outpatient or vocational settings after insurance claim closed, particularly for injuries deemed ‘minor’. This reflects a lack of recognition of ABI as a chronic condition that can improve or worsen over time [ 50 , 51 , 52 , 53 ]. Interdisciplinary guidelines and ABI-related training for professionals could improve the focus on person-centered skills in medical and vocational programs.

Environment-related factors

Our results suggest that an ideal setting for work integration would be on-the-job mentoring by a vocational counsellor who coordinates the patient’s skills and needs with the employer’s possibilities and expectations and the funding (insurance). Since there is no legal basis in Switzerland that obliges an employer to continue to employ a worker with reduced work capacity, a close cooperation with the employer is crucial for successful RTW and long-term employment. Participants of our study highlighted that the possibility of a partial pension can help persons with a disability and their employers to find a mutually agreed person-job match which is a central aspect of vocational integration [ 54 , 55 ].

When it comes to finding a new employment, injured workers are largely left to their own devices, due to limited support from the IV or public employment services, exacerbated by a lack of trained staff to assist those with invisible impairments like ABI [ 56 ]. Our findings imply that employment offices establish specialized units with medically trained staff to improve support for these individuals.

After RTW, both employer and employee must continually assess and adjust the work situation as needed. However, over 90% of companies in Switzerland are small and medium-sized enterprises [ 57 ] which do not have trained staff and cannot rely on their own resources. Therefore, when problems arise in terms of long-term health management, an official service with easy and widely known access to counseling and timely vocational support measures would be important to preserve sustainable employment. This could be managed by IV or through support organizations like Fragile Suisse [ 27 , 58 ].

Finally, the impact of ABI extends beyond the individual to affect caregivers and family members, who face significant unacknowledged burdens in terms of direct care, taking on household tasks, reduced social contact and financial losses due to reduced working hours. In Switzerland, this support goes widely unnoticed, although continuous overburden may lead to severe psychological, physical and social problems [ 27 ]. Enhancing caregiver support through standardized assessments and providing psychological and psychosocial support could mitigate the profound challenges they face.

The big picture

Despite Switzerland disposing one of the best health and social security systems globally [ 59 ], it suffers from significant fragmentation in financing and service provision across systems, institutions, providers, and settings. As visible in our results, different legal foundations, unclear responsibilities and poorly coordinated processes lead to patients receiving inadequate care despite the comprehensive range of services provided.

Recent legal revisions aim to improve work integration measures, with regional efforts enhancing coordination with local job offices. However, patients often hesitate to engage with administrative procedures, as navigating their complexities can be overwhelming. Fragile Suisse’s pilot projects [ 58 ], providing comprehensive support from medical incidents to social or professional reintegration, are well-received but under-resourced. These projects suggest that a Switzerland-wide formal case coordination approach could significantly improve vocational reintegration and sustainable work for people with ABI. Adopting a structured service pathway could enhance service overview, enable performance evaluation, and make the health and social systems more cost-effective. The Swiss Paraplegic Foundation’s model [ 60 ] for spinal paralysis could serve as a blueprint for managing ABI and other chronic conditions.

Strengths and limitations

A strength of our study was the inclusion of a broad range of stakeholders who are directly confronted with service needs and gaps across the work-lifespan of persons with ABI - from initial rehabilitation through vocational rehabilitation, sustained work, and retirement. Using this approach, we were able to identify individual service needs at the micro level and discuss overarching challenges at the meso and macro level that affect the continuum of service provision.

A limitation of this study is the analysis of previously collected data. Although, participants discussed services and service gaps for sustainable employment in the original interviews, services were not the main focus of the primary study. Additionally, the majority of persons with ABI were employed, therefore some risk factors could have been missed.

Practical, policy and research implications

Existing research underscores the importance of work for the psychosocial adjustment and health of individuals with ABI, with RTW contributing to higher self-esteem, life satisfaction, and economic independence [ 61 , 62 ]. Our study advocates for a policy shift towards funding coordinated long-term, participation-oriented interventions as part of a comprehensive service provision along the continuum of care.

Addressing fragmentation of services through the coordination of settings and measures would optimize not only the support for persons with ABI but also for people with other disability or long-term conditions and their sustainable work [ 63 , 64 ]. Establishing national guidelines developed and agreed upon by an interdisciplinary group of stakeholders (service providers, insurances, policy makers and affected persons as well as their employers) with the use of an integrated knowledge translation approach [ 65 , 66 , 67 ], and developing a framework to monitor service effectiveness are critical for optimizing interventions. Additionally, professional education and quality measures need enhancement.

Currently, Switzerland lacks a national database on ABI, service provision, and employment status. Therefore, cohort studies that track services, health, social, and RTW outcomes are essential for creating effective strategies. Adopting a mixed-methods approach that combines longitudinal labor market data with qualitative research will help to identify the most effective support strategies for sustainable work participation among those with ABI.

Our study highlights service gaps in vocational integration and long-term employment for persons with ABI in Switzerland, linking these gaps to existing risk factors for sustainable work. A key finding is the need for better integrated care and streamlined service pathways focused on sustainable vocational integration, including services that support person-centered skills and case coordination throughout the working life. The development of national guidelines for selecting and timing interventions, along with implementing a comprehensive monitoring system, could enhance the evaluation and optimization of intervention quality and service efficacy.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available in order to protect the anonymity of participants but are available from the corresponding author on reasonable request.

van der Klink JJLBU, Burdorf A, Schaufeli WB, Zijlstra FRH, Abma FI, Brouwer S, van der Wilt GJ. Sustainable employability – definition, conceptualization, and implications: a perspective based on the capability approach. Scand J Work Environ Health. 2016;42:71–9.

Article   PubMed   Google Scholar  

McCord A, Slater R. Social protection and sustainable employment. Barton, Australia: Department of Foreign Affairs and Trade; 2014.

Google Scholar  

Stephane Jacobzone EC, Chaplain E, Robine JM. The health of older persons in OECD countries: Is it improving fast enough to compensate for population ageing? OECD; 1999.

Burke RJ. Managing an aging and multi-generational workforce: Challenges and opportunities. The multi-generational and aging workforce. 2015:3–36.

Nagarajan NR, Sixsmith A. Policy initiatives to address the challenges of an older Population in the workforce. Ageing Int. 2023;48:41–77. https://doi.org/10.1007/s12126-021-09442-w .

Krahn GL. WHO World Report on disability: a review. Disabil Health J. 2011;4:141–2.

OECD. Sickness, disability and work: breaking the barriers: a synthesis of findings across OECD countries. Paris: OECD Publishing; 2010.

Book   Google Scholar  

Schuring M, Burdorf L, Kunst A, Mackenbach J. The effects of ill health on entering and maintaining paid employment: evidence in European countries. J Epidemiol Community Health. 2007;61:597–604.

Article   PubMed   PubMed Central   Google Scholar  

Van Rijn RM, Robroek SJ, Brouwer S, Burdorf A. Influence of poor health on exit from paid employment: a systematic review. Occup Environ Med. 2014;71:295–301.

Finger ME, Fekete C. Shifting the Focus from Work Reintegration to sustainability of employment. In: Bültmann U, Siegrist J, editors. Handbook of disability, work and health. Cham: Springer International Publishing; 2020. pp. 1–26.

Forslund MV, Arango-Lasprilla JC, Roe C, Perrin PB, Sigurdardottir S, Andelic N. Multi-level modelling of employment probability trajectories and employment stability at 1, 2 and 5 years after traumatic brain injury. Brain Injury. 2014;28:980–6. https://doi.org/10.3109/02699052.2014.888770 .

Scaratti C, Leonardi M, Sattin D, Schiavolin S, Willems M, Raggi A. Work-related difficulties in patients with traumatic brain injury: a systematic review on predictors and associated factors. Disabil Rehabil. 2017;39:847–55. https://doi.org/10.3109/09638288.2016.1162854 .

Benedictus MR, Spikman JM, van der Naalt J. Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work. Arch Phys Med Rehabil. 2010;91:1436–41. https://doi.org/10.1016/j.apmr.2010.06.019 .

Libeson L, Ross P, Downing M, Ponsford J. Factors associated with employment stability following traumatic brain injury, in a sample who have received comprehensive vocational rehabilitation. Disabil Rehabil. 2021:1–8. https://doi.org/10.1080/09638288.2021.1965229 .

Karcz K, Trezzini B, Escorpizo R, Schwegler U, Finger M. Factors associated with sustaining work after an acquired brain injury: a scoping review. Disabil Rehabil. 2022;44:6510–30. https://doi.org/10.1080/09638288.2021.1960439 .

Lee YS, Lee HY, Leigh JH, Choi Y, Kim HK, Oh BM. The socioeconomic Burden of Acquired Brain Injury among the Korean patients over 20 years of age in 2015–2017: a prevalence-based Approach. Brain Neurorehabil. 2021;14:e24. https://doi.org/10.12786/bn.2021.14.e24 .

Brannigan C, Galvin R, Walsh ME, Loughnane C, Morrissey EJ, Macey C, et al. Barriers and facilitators associated with return to work after stroke: a qualitative meta-synthesis. Disabil Rehabil. 2017;39:211–22. https://doi.org/10.3109/09638288.2016.1141242 .

Baldwin C, Brusco NK. The effect of vocational rehabilitation on return-to-work rates post stroke: a systematic review. Top Stroke Rehabil. 2011;18:562–72. https://doi.org/10.1310/tsr1805-562 .

Felmingham KL, Baguley IJ, Crooks J. A comparison of acute and postdischarge predictors of employment 2 years after traumatic brain injury. Arch Phys Med Rehabil. 2001;82:435–9. https://doi.org/10.1053/apmr.2001.21985 .

Article   CAS   PubMed   Google Scholar  

Stocchetti N, Zanier ER. Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review. Crit Care (London England). 2016;20:148. https://doi.org/10.1186/s13054-016-1318-1 .

Article   Google Scholar  

Ganesh A, Luengo-Fernandez R, Rothwell PM. Late functional improvement and 5-year poststroke outcomes: a population-based cohort study. J Neurol Neurosurg Psychiatry. 2020;91:831–9. https://doi.org/10.1136/jnnp-2019-322365 .

Corrigan JD, Hammond FM. Traumatic brain injury as a chronic health condition. Arch Phys Med Rehabil. 2013;94:1199–201. https://doi.org/10.1016/j.apmr.2013.01.023 .

World Health Organization (WHO). WHO Rehabilitation Need Estimator -40 of, US: 2022. Available from: https://vizhub.healthdata.org/rehabilitation/. Washington, US: Viz Hub University: Institute for Health Metrics and Evaluation; 2022. Available from: https://vizhub.healthdata.org/rehabilitation/ . Cited 2022 41 15.07.2022.

Trygged S, Ahacic K, Kareholt I. Income and education as predictors of return to working life among younger stroke patients. BMC Public Health. 2011;11: 742. https://doi.org/10.1186/1471-2458-11-742 .

Radford K, Phillips J, Drummond A, Sach T, Walker M, Tyerman A, et al. Return to work after traumatic brain injury: cohort comparison and economic evaluation. Brain Inj. 2013;27:507–20. https://doi.org/10.3109/02699052.2013.766929 .

van Velzen JM, van Bennekom CA, Edelaar MJ, Sluiter JK, Frings-Dresen MH. How many people return to work after acquired brain injury? A systematic review. Brain Injury. 2009;23:473–88. https://doi.org/10.1080/02699050902970737 .

Suisse F. Betreuende Angehörige Von Menschen Mit Hirnverletzung. Zurich: Fragile Suisse; 2019. Report No.

Phillips J, Gaffney K, Phillips M, Radford K. Return to work after stroke – feasibility of 6-year follow-up. Br J Occup Therapy. 2019;82:27–37. https://doi.org/10.1177/0308022618791976 .

Balasooriya-Smeekens C, Bateman A, Mant J, De Simoni A. Barriers and facilitators to staying in work after stroke: insight from an online forum. BMJ Open. 2016;6: e009974. https://doi.org/10.1136/bmjopen-2015-009974 .

Palstam A, Tornbom M, Sunnerhagen KS. Experiences of returning to work and maintaining work 7 to 8 years after a stroke: a qualitative interview study in Sweden. BMJ open. 2018;8:e021182. https://doi.org/10.1136/bmjopen-2017-021182 .

Libeson L, Downing M, Ross P, Ponsford J. The experience of return to work in individuals with traumatic brain injury (TBI): a qualitative study. Neuropsychological Rehabilitation. 2020;30:412–29. https://doi.org/10.1080/09602011.2018.1470987 .

De Pietro C, Camenzind P, Sturny I, Crivelli L, Edwards-Garavoglia S, Spranger A et al. Switzerland: health system review 2015.

Swiss National Science Foundation. Sustained gainful employment after spinal cord injury or traumatic brain injury: A mixed-methods work life course study. Available from: https://data.snf.ch/grants/grant/173322 . Cited 2023 19.09.2023.

Braun V, Clarke V. Successful qualitative research: A practical guide for beginners. Sage; 2013.

Gill P, Stewart K, Treasure E, Chadwick B. Methods of data collection in qualitative research: interviews and focus groups. Br Dent J. 2008;204:291–5. https://doi.org/10.1038/bdj.2008.192 .

Karcz K, Schiffmann B, Schwegler U, Staubli S, Finger ME. Facilitators and Barriers to Sustainable Employment After Spinal Cord Injury or Acquired Brain Injury: The Person’s Perspective. Front Rehabilitation Sci. 2022;3. doi: https://doi.org/10.3389/fresc.2022.872782 .

Finger ME, Karcz K, Schiffmann B, Staubli S, Hund-Georgiadis M, Escorpizo R. Factors influencing sustainable employment of persons with acquired brain injury (ABI) or spinal cord injury (SCI): A qualitative study evaluating the perspective of health and work professionals. Front Rehabil Sci. 2023;3:906567. https://doi.org/10.3389/fresc.2022.906567 .

Schiffmann B, Finger M, Karcz K, Staubli S, Trezzini B. Factors related to sustainable employment of people with acquired brain injury or spinal cord injury: the employer’s perspective. Front Rehabilitation Sci. 2022;3:876389. https://doi.org/10.3389/fresc.2022.876389 .

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3:77–101. https://doi.org/10.1191/1478088706qp063oa .

Ganzeboom HB. International standard classification of occupations ISCO-08 with ISEI-08 scores. Version of July (2010) 27:2010.

Nützi M, Trezzini B, Staubli S, Ronca E, Schwegler U. An interdisciplinary approach to job matching: developing an occupation-specific job matching tool for reintegrating persons with spinal cord injury into the labor market. Disabil Rehabil. 2020;42:2359–73. https://doi.org/10.1080/09638288.2018.1561958 .

Lorig KR, Sobel DS, Stewart AL, Brown BW Jr, Bandura A, Ritter P et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care (1999):5–14.

Fries JF, McShane D. Reducing need and demand for medical services in high-risk persons. A health education approach. West J Med. 1998;169:201.

CAS   PubMed   PubMed Central   Google Scholar  

Holman H, Lorig K. Patients as partners in managing chronic disease: partnership is a prerequisite for effective and efficient health care. British Medical Journal Publishing Group; 2000. p. 526-7.

Ory MG, Ahn S, Jiang L, Lorig K, Ritter P, Laurent DD, et al. National study of chronic disease self-management: six-month outcome findings. J Aging Health. 2013;25:1258–74.

Qama E, Rubinelli S, Diviani N. Factors influencing the integration of self-management in daily life routines in chronic conditions: a scoping review of qualitative evidence. BMJ open. 2022;12:e066647. https://doi.org/10.1136/bmjopen-2022-066647 .

Audulv Å, Asplund K, Norbergh K-G. The integration of chronic illness self-management. Qual Health Res. 2012;22:332–45.

Ambrosio L, Senosiain García JM, Riverol Fernández M, Anaut Bravo S, Díaz De Cerio Ayesa S, Ursúa Sesma ME, et al. Living with chronic illness in adults: a concept analysis. J Clin Nurs. 2015;24:2357–67.

Lorig KR, Holman HR. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003;26:1–7.

Cuthbert JP, Pretz CR, Bushnik T, Fraser RT, Hart T, Kolakowsky-Hayner SA, et al. Ten-year employment patterns of working age individuals after moderate to severe traumatic brain injury: a National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model systems Study. Arch Phys Med Rehabil. 2015;96:2128–36. https://doi.org/10.1016/j.apmr.2015.07.020 .

Putaala J. Ischemic stroke in young adults. Continuum (Minneapolis Minn). 2020;26:386–414. https://doi.org/10.1212/con.0000000000000833 .

Nelson LD, Temkin NR, Dikmen S, Barber J, Giacino JT, Yuh E, et al. Recovery after mild traumatic brain Injury in patients presenting to US Level I Trauma centers: a transforming research and clinical knowledge in traumatic Brain Injury (TRACK-TBI) study. JAMA Neurol. 2019;76:1049–59. https://doi.org/10.1001/jamaneurol.2019.1313 .

Manley G, Gardner AJ, Schneider KJ, Guskiewicz KM, Bailes J, Cantu RC, et al. A systematic review of potential long-term effects of sport-related concussion. Br J Sports Med. 2017;51:969–77. https://doi.org/10.1136/bjsports-2017-097791 .

Nutzi M, Trezzini B, Medici L, Schwegler U. Job matching: an interdisciplinary scoping study with implications for vocational rehabilitation counseling. Rehabil Psychol. 2017;62:45–68. https://doi.org/10.1037/rep0000119 .

Nützi M, Schwegler U, Staubli S, Ziegler R, Trezzini B. Factors, assessments and interventions related to job matching in the vocational rehabilitation of persons with spinal cord injury. Work (Reading Mass). 2019;64:117–34. https://doi.org/10.3233/WOR-192975 .

Teindl K, Thompson-Hodgetts S, Rashid M, Nicholas DB. Does visibility of disability influence employment opportunities and outcomes? A thematic analysis of multi-stakeholder perspectives. J Vocat Rehabil. 2018;49:367–77.

Eidgenossenschaft S. Swiss Economy – Facts and Figures: Schweizer Eidgenossenschaft; 2022 [5.06.2022]. Available from: https://www.eda.admin.ch/aboutswitzerland/en/home/wirtschaft/uebersicht/wirtschaft-fakten-und-zahlen.html .

Suisse F. Projekt Lotse. Available from: https://www.fragile.ch/ueber-fragile-suisse/projekte/projekt-lotse/ .

Tikkanen R, Osborne R, Mossialos E, Djordjevic A, Wharton GA. Switzerland New York, US: The Commonwealth Fund; 2020 [updated 2020.06.05. 10]. Available from: https://www.commonwealthfund.org/international-health-policy-center/countries/switzerland . Cited 2023 02.

Gross-Hemmi MH, Pacheco Barzallo D. People with spinal cord injury in Switzerland. Am J Phys Med Rehabil. 2017;96:S116-119. https://doi.org/10.1097/phm.0000000000000571 .

Gormley M, Devanaboyina M, Andelic N, Roe C, Seel RT, Lu J. Long-term employment outcomes following moderate to severe traumatic brain injury: a systematic review and meta-analysis. Brain injury. 2019:1–14. https://doi.org/10.1080/02699052.2019.1658222 .

Howe EI, Andelic N, Perrin PB, Roe C, Sigurdardottir S, Arango-Lasprilla JC, et al. Employment probability trajectories up to 10 years after Moderate-To-Severe traumatic brain Injury. Front Neurol. 2018;9:1051. https://doi.org/10.3389/fneur.2018.01051 .

Baanders AN, Rijken PM, Peters L. Labour participation of the chronically ill: a profile sketch. Eur J Public Health. 2002;12:124–30.

Loisel P, Anema JR. Handbook of work disability. Prevention and management: Springer; 2013.

Kothari A, McCutcheon C, Graham ID. Defining Integrated Knowledge Translation and moving Forward: a response to recent commentaries. Int J Health Policy Manag. 2017;6:299–300. https://doi.org/10.15171/ijhpm.2017.15 .

Springer MV, Skolarus LE. Community-based participatory research. Stroke. 2019;50:e48-50. https://doi.org/10.1161/strokeaha.118.024241 .

Grindell C, Coates E, Croot L, O’Cathain A. The use of co-production, co-design and co-creation to mobilise knowledge in the management of health conditions: a systematic review. BMC Health Serv Res. 2022;22:877. https://doi.org/10.1186/s12913-022-08079-y .

Verordnung über. Die humanforschung mit ausnahme der klinischen versuche. Humanforschungsverordnung, HFV; 2013.

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Acknowledgements

We would like to express our gratitude to all interview participants for sharing their expertise and for spending time and effort to accomplish this study. We are grateful to the supportive persons of Fragile Suisse and ParaWork for their help in recruiting suitable interview participants.

This work was supported by the Swiss National Science Foundation under grant no. 10001G_215144/1.

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MF, KK and US were responsible for designing the conceptual framework of the study. MF and BS recruited participants, MF, KK and BS conducted focus groups and interviews, KK coded and together with MF, BS and US analyzed the data and prepared the paper.

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Correspondence to Katarzyna Karcz .

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Ethical approval for the ‘Sustainable employment’ project was obtained from the ethical committee of North-West and Central Switzerland (EKNZ, study reference 2018 − 01317). All participants of ‘Sustainable employment’ project were informed about original study aims and provided their written informed consent to use collected data to investigate barriers and facilitators of sustainable employment of people with ABI. As a secondary analysis was a way of zooming in to deepen the findings, participants were not informed about this additional analysis. According to the Swiss law and ethical guidelines [ 68 ], collected data may be reused as long as it is anonymized, and sensitive data is protected. All methods were performed in accordance with the relevant guidelines and regulations.

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Karcz, K., Schwegler, U., Schiffmann, B. et al. Risk factors and service gaps affecting a sustainable work: a qualitative multi-stakeholder analysis in the context of persons with acquired brain injury living in Switzerland. BMC Health Serv Res 24 , 753 (2024). https://doi.org/10.1186/s12913-024-11128-3

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• http://orcid.org/0000-0002-6691-6287 Elizabeth Sutton 1 ,
• http://orcid.org/0000-0002-6345-1533 Mudathir Ibrahim 2 ,
• William Plath 3 ,
• Lesley Booth 4 ,
• http://orcid.org/0000-0001-6895-946X Mark Sujan 5 , 6 ,
• http://orcid.org/0000-0002-3210-8273 Peter McCulloch 3 ,
• http://orcid.org/0000-0003-0137-6432 Nicola Mackintosh 1
• 1 Health Sciences , University of Leicester , Leicester , UK
• 2 Department of General Surgery , Maimonides Medical Center , Brooklyn , New York , USA
• 3 Nuffield Department of Surgery , Oxford University , Oxford , UK
• 4 Cambridge Rare Disease Network , Cambridge , UK
• 5 Human Factors Everywhere , Woking , UK
• 6 Warwick Medical School , University of Warwick , Coventry , UK
• Correspondence to Dr Elizabeth Sutton, Health Sciences, University of Leicester, Leicester, United Kingdom; es225{at}le.ac.uk

Background The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND).

Methods The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory.

Results We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms.

Conclusions This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.

• qualitative research
• safety culture
• patient safety
• healthcare quality improvement

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjqs-2024-017132

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Despite a small but growing number of patient-led escalation systems in use internationally over the last few years, we know little about what the barriers and enablers are in implementing such a system or what the impact might be on patients, relatives or staff.

WHAT THIS STUDY ADDS

This ethnographic study illustrates factors that helped ensure that patient-led escalation systems can operate as intended. Without organisational infrastructure and education to support cultural change, the benefits may not be realised.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Our study provides important learning for the implementation of Martha’s Rule in the UK (a policy meant to allow patients, families and advocates access to 24/7 review from a critical care outreach team). Successful implementation is likely to require infrastructural support, efforts to educate patients and staff and cultural change around the norms of patients and families speaking up about concerns.

Patient involvement in patient safety

There is a well-established body of literature on patient involvement in patient safety at the point of care across different areas of healthcare, including primary care 1 and in-hospital maternity care, 2 infection prevention and control 3 and in-hospital processes such as ward rounds 4 and handovers. 5 This involvement can include error reporting, monitoring and speaking up about their care. Indeed, the National Health Service (NHS) in England has a framework in place to involve patients both in their own safety and in safety governance. 6 The reported benefits of patient involvement in safety include early identification of potential threats, including missed diagnosis and safety errors, 7 8 and increased patient satisfaction with care. 9 However, research has also shown numerous challenges to patient involvement most notably in power relations leading to deference to medical authority, 10 differences in health condition and literacy and in age and status. 11 We still have some way to go to reconceptualise patient and family contributions as a source of resilience in healthcare and to build different forms of involvement into systems to ‘scaffold the quality and safety’ of patient care. 12

Patient involvement in escalation of care

Research studies have explored the involvement of patients and their relatives in spotting deterioration and escalating care, 13–17 but there is limited empirical evidence of clinical patient benefit to date. Research has found that when patients have raised concerns, their views are often ignored, 18 or given less credence than healthcare professionals’. 19 Patients’ questions may be greeted with suspicion by staff, 20 or contribute to perceptions that patients are ‘difficult’. 21 As a result, patients may fear the consequences of speaking up. 10 Fear of damaging their relationship with staff also risks threatening the trusting relationship. 22 By speaking up about concerns, patients risk becoming more vulnerable because of their dependence on others to care for them.

Rapid response systems (RRS) provide track and trigger criteria and established response processes so that either critical care outreach teams (CCOT) or medical emergency teams can be activated by ward teams to enable response for deteriorating patients. 23 Patient-led escalation systems enable patients and family members to alert critical care outreach or medical emergency teams directly. These systems are required by regulators in three Australian states 24 and in parts of the USA, 25 and in the UK the ‘Call for Concern’ model championed by the Royal Berkshire Hospital has been implemented in some NHS trusts. 26

Targeted patient education strategies to help patients detect changes in their conditions on medical and surgical wards have been found to ‘significantly improve patients’ self-efficacy to recognise and report deteriorating conditions’. 27 In terms of implementation evidence regarding patient-led escalation systems, Dwyer and colleagues evaluated activations of Ryan’s Rule within one hospital in Australia using chart review and found that the system was valued by users but staff were hesitant to embrace the system. 28 The ‘Call for Concern’ model was evaluated by Odell and colleagues who found that very few calls were placed within a 6-month period and despite positive views from patients and families, there were staff concerns about patients’ willingness to use the system. 26 A recent review of paediatric family-led escalation systems found that parents valued the system and reported positive experiences. However, the authors noted failure to offer multilingual information which made it difficult for non-English speakers to use the system. They also note that educating families about activating an escalation system when in the middle of an already stressful period is challenging and also impacts on staff workload at the time of admission. 16 29

However, there are still significant gaps in the evidence base, particularly regarding the contextual factors that influence adoption, implementation and normalisation of patient-led escalation systems. Research has largely been led from countries such as the USA which have established patient and family-led escalation systems; we still have much to learn about contextual influences within UK practice, particularly as these are likely to differ across settings (eg, adult vs paediatric care). This paper reports the findings of a qualitative process evaluation of the implementation of a patient-led care escalation system as part of the pilot stage of the Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND) study, 30 a quality improvement (QI) programme to improve rescue for emergency surgery patients. Our research question was ‘what are the enablers and barriers which affect the implementation of a patient-led escalation system at patient, professional and organisational level?’ Our ethnographic findings have both national and international relevance, given the introduction of Martha’s Rule in the NHS from April 2024, 31 which stipulates that all patients, carers, families and advocates must have access to a round-the-clock rapid review from a separate care team if they have concerns about a patient, and ongoing international efforts to systematise patient and family contributions to escalation of care in hospital settings.

Intervention development description

RESPOND is a QI programme based on Human Factors (HF) approaches to improving escalation of care following emergency abdominal surgery. The programme consists of four intervention strands. One of these is a patient-led escalation system entitled ‘Early 3S’ (See it Early, Speak up Early and Save lives Early), the design of which was informed by experiential data from patients who had experienced deterioration in their condition 18 (see online supplemental appendix 1 ). In line with the Medical Research Council framework for complex interventions, the development phase involved codevelopment of an HF-informed system, 32 via patient and staff workshops. The proposed response pathway developed from proposals for a buzzer system that alerted staff on the wards to a response triggered by the patient’s own mobile to reach an external ‘RESPOND’ person, that is, a CCOT member. However, given that at the time of the pilot study, a number of UK hospitals were without a CCOT, a ward-based nurse in charge responder was proposed as an alternative work-around if required (see table 1 for a Template for Intervention Description and Replication (TIDieR checklist 33 ). Other evidence-based components to support implementation were developed, including strategies for patient and staff education, 34 engagement 35 and audit and feedback. 36

Supplemental material

• View inline

Early 3S intervention package, Template for Intervention Descrition and Replication (TIDieR) description

Methods and analysis

Three hospitals in the south of England agreed to take part in the RESPOND pilot study, which was designed to test the feasibility of the intervention strands within a surgical care setting so that any refinements needed could be made prior to roll-out of RESPOND in a stepped wedge trial. 30 The process evaluation used a qualitative design; specifically ethnographic fieldwork in surgical units in these three hospitals between November 2022 and June 2023 (for more details about the sites see table 2 ).

Site characteristics

Ethnographic observations and interviews

Ethnographic observations were conducted in the preparatory codesign workshops and staff training stages in order to understand how the patient-led system was codeveloped. In the hospital, observations consisted of shadowing junior doctors and nurses and spending time on the main surgical wards, observing admissions, ward and board rounds, safety huddles, handovers and the general focus of work occurring in these wards for between 3 and 5 days per site. This enabled a better understanding of the context for implementing the intervention and the day-to-day work practices that it would fit within (eg, how information about the patient-led system was shared with patients on admission). Fieldwork consisted of over 100 hours of observations and informal conversations with over 40 members of staff including healthcare assistants, consultants and leads of CCOTs (where available). Posters informing staff of the researcher’s presence were in place throughout the observation periods at each unit. We also collected relevant documentation including escalation policies and procedures in each site. Fieldnotes were written up into Word documents. Lastly, we conducted a total of 18 staff interviews (2 consultants, 3 registrars and 1 junior doctor and with a range of 12 nursing staff) and nine interviews with patients who had been admitted for emergency surgery during November 2022 to June 2023 to understand factors influencing implementation of the patient-led escalation system.

Recruitment and data collection

Staff participants were recruited to the study if they worked within, or had managerial oversight of the selected surgical units and written consent to an interview was obtained. Semi-structured interviews took place in person and over teams where appropriate, using a semi-structured topic guide (see online supplemental appendix 2 ). Each lasted between 30 and 60 min. Patients who had experienced a deterioration during their care (see table 3 ) were given an information sheet about the study by research nurses in all three sites and were asked for their agreement to be approached for an interview by an experienced qualitative researcher (ES) who then obtained consent from the patient to contact them once discharged. This enabled participants’ time to recover and addressed participants’ concern about whether their involvement would affect their ongoing care. Patients were only recruited from site 1 owing to the input of an active research nurse in this site.

Patient characteristics

A topic guide was developed to explore the views of patients about using the system and about their views on the experiences in hospital (see online supplemental appendix 3 ). The interviews took place over the telephone and lasted between 30 min and an hour.

Interviews were transcribed verbatim and along with fieldnotes and documentation were imported into NVivo V.12 for analysis. Each transcript was read by ES and NM initially coded thematically and inductively for factors affecting implementation, 37 and deductively using the Normalisation Process Theoretical (NPT) framework. 38 A coding frame in NVivo 39 was produced in discussion between ES and NM. We drew on NPT to sensitise the research to the thinking, enacting and organisational work involved in implementation; particularly how new or modified practices associated with implementation were influenced by structural and relational elements. This enabled us to develop three analytical themes across the dataset: organisational infrastructural support; enabling changes to professional practice; and operationalising patient concerns.

Details of the local tailoring of the patient-led escalation system are provided in table 2 . In site 1, the Early 3S involved a CCOT, in site 2 the nurse in charge acted as the designated RESPOND person, while in site 3 the system was trialled with the nurse in charge as the designated RESPOND person but was discontinued after 2 months. There were very few calls to the Early 3S system in any of the three sites (see table 2 ). None of the patients we interviewed had used the Early 3S system. Supplementary quotations in each theme are provided in online supplemental appendix 4 .

Organisational infrastructural support

Having an established CCOT in place offered a level of infrastructural support for implementation of patient-led escalation. Nurse acceptance as to the value of the CCOT for supporting managing patient deterioration on the wards acted as a contextual enabling factor.

[The CCOT are] very present on the surgical floor […][patients] get the expert help they need, we get a bit of teaching, we get support and actually it’s quite nice when you have the time to be with the outreach nurses, because you learn so much from how they’re assessing their patients. (Senior nurse, site 1, INT 103)

Two of the sites had CCOTs in place but only one (site 1) had actively considered the introduction of a patient-led component; here the CCOT already had plans for a patient-led escalation system in development, and the RESPOND pilot helped provide impetus for its implementation. However, local needs and resourcing also shaped implementation plans. The CCOT was not involved at site 2 in the RESPOND pilot, as the CCOT comprised only a small team and members had been concerned about the number of calls they might receive.

The status of RESPOND as a research project (a pilot rather than organisationally mandated) created uncertainties about the sustainability of the interventions and contributed to a sense of ambivalence about the programme. In all sites, the intervention was designed to be ‘championed’ by key staff members. Support from champions diminished over time in sites 2 and 3 which had implications for supporting patient education about Early 3S to patients.

In sites 2 and 3, where no CCOT was involved and the nurse in charge was required to act as responder, interviews and observations revealed a lack of buy-in and ownership of this role.

[RESPOND team member asked] who had got the RESPOND phone, and nobody knew where it was, so she rang it and there was no ringing, the ward staff didn’t know where it was, nobody seemed even interested in where it was. And so [RESPOND team member] went to the other bay, and apparently the phone had been ringing in the drawer. (Fieldnotes, site 2, day 1)

Interviews and observations across all three sites showed the influence of staffing, workload and system-level changes introduced during and after COVID-19 on staff’s capacity to take on the implementation work needed to embed a patient-led escalation system into the wider organisation of surgical clinical work. High turnover in staffing, increased demand for beds and limited energy for improvement work were reported by a number of interviewees.

It’s not so much the rationale behind RESPOND that’s the problem. It’s your actual practicalities and your resources…And the fact that you’ve had all this turbulence on your ward. (Senior nurse, site 3, INT 06)

Across all sites, senior leadership support provided an enabling influence for implementation; in site 1, the patient-led escalation system was supported by the CCOT and by senior leaders from the consultant body and ward nursing team. In site 2, in contrast, there was no visible senior clinical-level commitment for the intervention, and in site 3 the intervention was withdrawn due to lack of support from nursing leaders.

There was not so much buy-in from the management on the ward. It’s a very busy unit, it is very understaffed, we’d just come out of COVID, staff morale was very low, and that has been everybody’s priority, is to raise staff morale. This was seen very much as an extra, and nice to be able to do but not part of day-to-day, which I think is kind of where we got stuck. (Senior nurse, site 3, INT 07)

Nursing leadership resistance to the intervention at this site linked to organisational and practice priorities as well as competing forms of essential safety work. Mandatory assessments (eg, falls, nutrition, pressure areas) with a specific focus on reducing the risk of avoidable harm were reported to take precedence, leaving little room for other non-mandatory forms of patient safety work.

Enabling changes to professional practice

The RESPOND pilot provided a preparatory general education programme for ward staff about the intervention, together with promotional material (see table 1 ). RESPOND staff visited the sites regularly to support implementation. However, high ward staff turnover and workloads made it challenging to move beyond limited communication about operationalising the patient-led escalation system to in-depth discussions about the value and legitimacy of systematising patients’ voice into escalation processes within surgical work practice.

At site 1, there was general support for the principle of patient-led escalation as their model provided an alternative escalation pathway, outside the ward team. ‘ I think the 3S system is excellent, I think there is a role for patients feeling they have another point of access ’ (Consultant, site 1, INT 05). However, in sites 2 and 3, nursing staff struggled to see the additional value that Early 3S could bring about. Their patient-led model relied on a responder from within the clinical ward team rather than a CCOT member; the latter importantly allowed for patients to escalate concerns not acknowledged by the patient’s clinical teams. Staff at site 3 found it difficult to differentiate between what they already had in place (the allocation of a lighter workload for the nurse in charge in order to help manage patients who were deteriorating) and this intervention.

Across all of the sites, the relational and organisational work required by nurses and healthcare assistants to bring patient-led escalation into practice was noted, particularly in times of high workloads and fluctuations in staffing levels.

It does take a lot of manpower […] you can look at it and think that’s gonna take me five min, but patients have questions, and it’s not just five min, and that is a lot of resource when you’re trying to do that as part of your already overstretched job. […] trying to sit down with every patient and spend up to sometimes 20 to 30 min with patients going through a leaflet. In such a high turnover area, it, it felt like once you’d done it once in a day you didn’t want to do it again. (Senior nurse, site 1, INT 03)

The excerpt above highlights how, even with a supportive CCOT in place at site 1, nurses raised concerns about the time it took to engage with Early 3S, both to fully understand it themselves and to explain it to patients. Lack of familiarity with the concept of patient-led escalation and calling criteria resulted in questions from patients, which in turn led to a lack of impetus from staff to promote the system, evident in this fieldnote.

I noticed that there was a package of leaflets, RESPOND Early 3S leaflets, two of them left on top of the nurses’ station, and that box did not move the entire time I was there, nobody took the leaflets out, nobody distributed them, nobody talked to the patients about them. (Site 2, fieldnotes, day 2)

Lack of patient activation of the system as intended across all sites reinforced the sense of its redundancy and raised issues about the role of activation data in sense making about ‘appropriate’ use of the system and the value of ‘false’ calls. Both nursing and medical staff expressed reservations about the value of Early 3S given the often fast trajectory of deterioration, which made it difficult for patients to contribute to the escalation process and the time-restricted nature of family member visits.

Some staff were worried that a patient-led escalation system could be perceived as exclusionary on the grounds that participation was likely to come from only certain patient groups. Patients and their families with higher levels of education were perceived as more likely to use the system, while patients from minority cultures or those with difficulty communicating in English were seen as less likely to use it. One nurse reported the ethical challenges of assessing which patients should get a leaflet, based on their ability to understand the materials. Fieldnotes revealed staff concerns as to whether the system was inclusive of all age groups and abilities.

I talked to a CCOT team member, who was concerned that a lot of the deteriorating patients were elderly, wouldn’t have a phone and wouldn’t have necessarily the wherewithal to call a number to get help. (Fieldnotes, site 2, day 3)

There was general discomfort from nurses from all three sites that a patient-led escalation system represented a shift in division of labour between professionals and patients, shifting responsibilities for escalating concerns onto the patients themselves while undermining their professional role as patient advocate.

[what we are saying to patients is] ‘we know that we’re not doing what we should be doing, and we don’t have confidence that we’re gonna actually recognise that deterioration, so we’re giving you the responsibility to let somebody else know, which I think is a little bit undermining of nursing care’. (Senior nurse, site 1, INT 04)

Some nurses also disputed the value of patient knowledge, citing that staff already had the technology available to track and trigger changes in condition and that only professional staff had the skills to interpret these changes, while other nurses reported questioning or disbelieving the validity of patient concerns.

Operationalising patient concerns

Despite promotional material (leaflets and posters) advertising the system, most of the patients reported knowing little about it, or were not clear whom the intervention was aimed at. This was the case across all sites, despite different forms of the intervention. Earlier iterations of the leaflet had focused on clinical signs of deterioration as calling criteria, but these had been replaced by a more generic criterion around concern. This simple descriptor on the promotional material created confusion; patients described being unsure when it was legitimate to call the Early 3S number. One patient thought that this translated to worries after discharge when they could call the Early 3S number from there. Two patients thought the system enabled families to make general enquiries about their care, while others thought a concern translated to a complaint about staff.

These findings highlight the limits of promotional materials and the need for ward-based education strategies to support the organisational work required to enact patient-led escalation into practice. Structuring the timing and format of the patient education on surgical wards to enable meaningful engagement appeared challenging at times, given the patient population (often elderly with cognitive impairment or acutely unwell).

While all interviewed patients thought the idea of a patient-led intervention was warranted, only three reported that they would use it for themselves while in hospital. Its value was linked to the provision of a safety net enacted via a relative’s advocacy role.

I would definitely use it hundred percent would be if I was in [a ward] with a relative that was telling me they didn’t understand what was going on. (Patient 0104)

However, organisational work was required to combat patient fears that the intervention itself disrupted social and cultural norms. Patients reported being dependent on staff for their care and did not want to ‘rock the boat’ or be perceived as a nuisance by their ward team as they perceived this as ‘going behind the ward team’s back’.

In this paper, we have reported on our process evaluation of the implementation of a patient-led escalation system as part of the RESPOND pilot study. We highlight organisational, professional and patient-led factors that influenced adoption and utilisation of this system within three surgical care settings. Our analysis potentially provides important learning for sites currently involved in implementing Martha’s Rule within the UK. RRS have been in operation internationally for over 20 years and despite attempts to reduce variability they still vary in composition, activation criteria and implementation processes, and benefits are not always realised. 40 Adding a patient-led activation component is likely to require similar cultural and system-level forms of support. Empirical research to date has largely relied on cohort studies, audit and referral reviews, focus groups and interview studies; this study brings novel ethnographic insights into relationships between the social context of surgical care and the application of patient-led escalation systems within the UK.

Our research highlights the significance of the wider care context including the pressure that staff were facing at the time of the fieldwork and its impact on the workforce. 41 Sites were struggling with turnover of staff and the impact of industrial action. Staff from all three sites reported challenging workforce conditions and exhaustion after COVID which is likely to have had a negative influence on implementation of the system. As Lawton and Thomas note, it is important that the impact of QI projects on staff well-being is taken account of. 42 In the same way that the ‘simple’ surgical checklist in reality involves challenging and disrupting norms, 43 an effective patient-led escalation system is likely to need significant infrastructural, cultural, professional and relational forms of support.

Healthcare systems face competing priorities and certain types of safety work are mandated and prioritised while the pilot of the patient-led escalation system was not. This created tensions, and staff had to make trade-offs over what they considered to be essential safety work. As Cribb notes, notions of ‘improvement’ in quality and safety are necessarily value laden and link to accountability frameworks. Clinicians are therefore often required to use ‘creative autonomy’ to make practical decisions between different safety priorities. 44 It will be interesting to see how the NHS implementation of Martha’s Rule will be prioritised against other initiatives in hospitals in England and what pressures it might create.

This paper highlights the extent to which organisational infrastructure such as well-established CCOTs with the capacity to take on additional workload is important in embedding changes in working practices. In line with other studies, we also found that having senior nursing and medical leadership support helped foster organisational commitment to new ways of working. 45

Our work suggests that staff education should stretch beyond simple communication strategies and instead should embrace working with staff to highlight the value of patient contributions and to enable cultural shifts in professional practice. In particular, when operationalised at ward level, staff were puzzled about the need for a patient-led escalation system and the additional value it might bring. Implementation created additional relational work and posed threats to nursing professionalism and emotional safety for patients. Staff education is likely to need to tackle issues around professionalism, as activations may be understood as complaints rather than concerns. 28 The complexities of managing hospital hierarchies and local cultures will also need exploring practically 46 as will some staff’s discomfort about displacing responsibility onto patients and families and the potential unintended impact this may have on trust and relationships. 21

Similarly, patient education should extend beyond promotional materials and encompass patient concerns about undermining ward-based healthcare professionals and reluctance to add to or burden already busy staff. 47 48 Thought should be given to the timing and equity of patient education delivery.

Previous research has shown how vulnerable, dependent patients invoke the social contract of the sick role, 49 as a way of keeping themselves safe. They invite care by being a good patient. 50 When patients are vulnerable, they need to be able to trust those providing their care. Patient-led escalation systems potentially threaten to disrupt that relationship by casting doubt on the professionals directly looking after them and their ability to provide good care. Speaking up to staff who are more powerful than they are potentially leaves them doubly vulnerable and at risk of damaging the very relationships they depend on. 50 Our research draws attention to the significance of hierarchies and relationships for the design of supportive educational strategies.

Our analysis reinforces the points made by Bell and Martinez 51 who propose that, in order to promote a culture of speaking up, changes should be made to the way organisations listen to patients, and the norms of the hospital culture. In order to empower patients and their family to activate patient-led systems, there is a need to address cultural norms to ensure that patients feel psychologically safe to do so. They note ‘the importance of organisational learning, patient experience, respect and prevention of emotional/psychological distress’. Similarly, Halvorsen and colleagues suggest that the process of truly empowering people requires more time to be given to the patient to address their needs and concerns and for a mutual and respectful relationship to develop. 52 This is difficult to achieve, given the often pressurised and demanding healthcare context.

Our findings raise questions about how best to operationalise patient-led escalation systems in acute medical and surgical settings. In paediatric care, where this type of approach has been championed widely, 16 29 53 children’s parents are often beside them for up to 24 hours/day. They would, therefore, be in a better position to ‘stop the line’ 51 than relatives of patients in adult acute care, who are often only present sporadically.

Our study provides insights for those healthcare systems who are seeking to systematise patients, families and carers’ contributions to escalation of care. Our findings suggest that successful implementation of a patient-led escalation system is likely to require both infrastructural support and educational strategies to enable social and cultural change, notably to support the relational and organisational work needed for the concept to become acceptable to professional and patient groups.

Strengths and limitations

Despite being a process evaluation of a pilot study, our findings offer useful insights for those currently involved in the implementation of Martha’s Rule in the UK, and for others involved in international efforts to embed patient-led escalation into rescue systems. We were able to interview a wide range of surgical unit staff and spend many hours observing on the units which enabled us to illustrate meaningfully strengths and challenges to implementation of a patient-led escalation system. Unfortunately, we were only able to recruit a small number of patients but their views on the Early 3S system were strikingly similar.

Conclusions

Our paper has highlighted how patient-led escalation of care is a complex sociotechnical practice. It shows the effort that is required from all parties to when introducing a new way of escalating care. It highlights the importance of an equitable system with the right support in place, so that everyone understands what the intervention is trying to achieve, and the value that it can bring. Our work highlights the difficulty of ensuring the right conditions to implement such a system in a healthcare climate where staff are under mounting pressure with increasing demands on their time.

Ethics statements

Patient consent for publication.

Consent obtained directly from patient(s)

Ethics approval

This study involves human participants and was approved by Oxford C Research Ethics Committee (21/SC/0363). Participants gave informed consent to participate in the study before taking part.

• McDonald R ,
• Campbell S , et al
• McCourt C ,
• Rayment J , et al
• Brewster L ,
• Botti M , et al
• Drach-Zahavy A ,
• NHS England and NHS Improvement
• O’Hara JK ,
• Reynolds C ,
• Moore S , et al
• Entwistle VA ,
• McCaughan D ,
• Watt IS , et al
• Birkeland S ,
• Bismark M ,
• Barry MJ , et al
• Doherty Stavropoulou
• Jacklin R ,
• Sevdalis N , et al
• Conner M , et al
• McKinney A ,
• Fitzsimons D ,
• Blackwood B , et al
• Mackintosh NJ ,
• Easter A , et al
• Cresham Fox S ,
• Marufu TC , et al
• Peacock G ,
• Crotty M , et al
• Ibrahim M , et al
• Solbjør M ,
• Steinsbekk A
• Winters BD ,
• Weaver SJ ,
• Pfoh ER , et al
• Bucknall T ,
• Quinney R ,
• Booth L , et al
• Raymond J ,
• Copper T , et al
• Chan W-CS ,
• Huggan PJ , et al
• Flenady T ,
• Kahl J , et al
• Massie S , et al
• ↵ The RESPOND Programme , 2024 . Available : https://www.nds.ox.ac.uk/research/the-respond-programme
• NHS England
• de Vos MS , et al
• Hoffmann TC ,
• Glasziou PP ,
• Boutron I , et al
• LeCaire TJ ,
• Hundt AS , et al
• Batalden M ,
• Batalden P ,
• Margolis P , et al
• Hollnagel PE
• Bracher M , et al
• Cameron E , et al
• Søreide E ,
• Cooksley T ,
• Astbury S ,
• Dixon-Woods M ,
• Goeschel CA , et al
• Entwistle V ,
• Geerligs L ,
• Rankin NM ,
• Shepherd HL , et al
• Leslie GD ,
• Marshall AP
• Ngoya Ntumba M ,
• Edwards E ,
• Haegdorens F , et al
• Eborall H , et al
• Halvorsen K ,
• Hansen C , et al
• Hanson CC ,
• Randolph GD ,
• Erickson JA , et al

X @LizSule, @MarkSujan, @McCullochP

Contributors ES conducted the data collection and analysis and produced the initial draft of the manuscript. MI and WP implemented the intervention and commented on drafts. LB reviewed and commented on drafts. MS reviewed, commented and edited drafts. PM is the chief investigator, reviewed and commented on drafts. NM is the qualitative lead and overall guarantor, conducted analysis and reviewed and edited the work.

Funding Health Services Research Programme (NIHR200868).

Disclaimer This research study is funded by the National Institute for Health Research (NIHR) [Programme Grants for Applied Research of NIHR programme 200868]. The research is also supported by the National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Research Collaboration (GM PSRC). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Open access
• Published: 11 June 2024

Perception of enhanced learning in medicine through integrating of virtual patients: an exploratory study on knowledge acquisition and transfer

• Zhien Li 1 ,
• Maryam Asoodar 1 ,
• Nynke de Jong 2 ,
• Tom Keulers 3 ,
• Xian Liu 1 &
• Diana Dolmans 1  

BMC Medical Education volume  24 , Article number:  647 ( 2024 ) Cite this article

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Introduction

Virtual Patients (VPs) have been shown to improve various aspects of medical learning, however, research has scarcely delved into the specific factors that facilitate the knowledge gain and transfer of knowledge from the classroom to real-world applications. This exploratory study aims to understand the impact of integrating VPs into classroom learning on students’ perceptions of knowledge acquisition and transfer.

The study was integrated into an elective course on “Personalized Medicine in Cancer Treatment and Care,” employing a qualitative and quantitative approach. Twenty-two second-year medical undergraduates engaged in a VP session, which included role modeling, practice with various authentic cases, group discussion on feedback, and a plenary session. Student perceptions of their learning were measured through surveys and focus group interviews and analyzed using descriptive statistics and thematic analysis.

Quantitative data shows that students highly valued the role modeling introduction, scoring it 4.42 out of 5, and acknowledged the practice with VPs in enhancing their subject matter understanding, with an average score of 4.0 out of 5. However, students’ reflections on peer dialogue on feedback received mixed reviews, averaging a score of 3.24 out of 5. Qualitative analysis (of focus-group interviews) unearthed the following four themes: ‘Which steps to take in clinical reasoning’, ‘Challenging their reasoning to enhance deeper understanding’, ‘Transfer of knowledge ‘, and ' Enhance Reasoning through Reflections’. Quantitative and qualitative data are cohered.

The study demonstrates evidence for the improvement of learning by incorporating VPs with learning activities. This integration enhances students’ perceptions of knowledge acquisition and transfer, thereby potentially elevating students’ preparedness for real-world clinical settings. Key facets like expert role modeling and various authentic case exposures were valued for fostering a deeper understanding and active engagement, though with some mixed responses towards peer feedback discussions. While the preliminary findings are encouraging, the necessity for further research to refine feedback mechanisms and explore a broader spectrum of medical disciplines with larger sample sizes is underscored. This exploration lays a groundwork for future endeavors aimed at optimizing VP-based learning experiences in medical education.

Peer Review reports

In Medical Education, a persistent challenge lies in the bridge between acquiring theoretical knowledge and applying it in real-world clinical scenarios. Many medical students struggle with translating their classroom learning into practical settings. The primary challenge lies in effectively translating the concepts students have learned into authentic patient interactions. This gap is particularly concerning because it affects the quality of patient care, as medical students are not just learning to acquire knowledge but must be able to apply this knowledge in complex healthcare settings.

One approach to address this challenge is the use of Virtual Patients (VPs), a computer-based simulation of real-life clinical scenarios for students to train clinical skills [ 1 ]. Research has shown that using VPs in the classroom can effectively improve various aspects of learning, from core knowledge and clinical reasoning to decision-making skills and knowledge transfer [ 2 , 3 , 4 , 5 ]. The VPs provide students with the opportunity to practice skills in a safe and controlled simulation environment.

Recent studies have focused on optimizing the design and arrangement of VPs as part of learning activities to facilitate both knowledge acquisition and retention [ 6 , 7 , 8 ]. For instance, Verkuyl, Hughes [ 8 ] demonstrated that using VPs as gamification tools can improve students’ confidence, engagement, and satisfaction.

However, studies focusing on the specific factors that contribute to these improvements when integrating VPs into the classroom are limited, particularly in understanding how to use VPs in the classroom to facilitate the transfer of knowledge students’ gain from the class to the subsequent studying stage of their education and eventual practice.

Acquisition and transfer of knowledge are critical factors in medical education, as medical students must be able to apply their knowledge and skills to real-world clinical scenarios [ 9 ]. Research suggests that for the effective transfer of knowledge, students should be immersed in authentic environments, enabling the transition of learned competencies to advanced stages [ 10 , 11 , 12 , 13 ].

Despite the consensus on the efficacy of VPs as a tool, there is a gap in understanding how to integrate VPs in the classroom to optimize students’ learning, especially in facilitating learning transfer. The effectiveness of VPs is not just in their use but also in how they are used by students to enhance their understanding on how to reason and make decisions about medical treatments when dealing with clinical cases. Without a clear and deep understanding, we risk underutilizing their potential and losing opportunities for medical students to become well prepared for real-world clinical scenarios.

Certain elements, such as role modeling instruction [ 14 , 15 , 16 ], using various authentic cases [ 17 , 18 , 19 ], and engaging in peer discussions on feedback [ 20 , 21 , 22 ], emerge as potential key components that could be integrated to maximize the knowledge acquisition via VPs. For instance, Stalmeijer, Dolmans [ 23 ] show how an expert, serving as a role model, provides guidance that facilitates student learning by demonstrating clinical skills and reasoning out loud. While there is ample evidence supporting the advantages of inclusion of VPs in education, there is not enough research focusing on the detailed aspects of effective instructional design techniques. This paper delves into these components, seeking to understand how the VP integration influences students’ learning and knowledge transfer. Figure  1 shows the theoretical framework of how integrating VPs in class affects students’ learning and might impact the transfer of learning in a simulated VP environment to practice.

Relationship of implementing, impact factor, and transfer of training

This exploratory study aims to investigate how instructional design elements such as role modeling, various authentic cases, and peer dialogues on feedback within VP sessions affect students’ learning from the learner’s perceptions. The core research question in this study focuses on how the implementation of role modeling, various authentic cases, and peer dialogue on feedback in VPs, influences learners’ perception of knowledge gain and transfer in personalized medicine.

The study was conducted at Maastricht University in the elective course, “Personalized Medicine in Cancer Treatment and Care”. This course is open to second-year undergraduate medical students of Maastricht University.

Participants

Initially, 24 students enrolled in this course for the academic year of 2022–2023, and 22 students participated in the Virtual Patient session. In total, 19 students voluntarily completed the survey designed to evaluate their experiences and perceptions of the Virtual Patients session. Thereafter, 9 of the 19 survey respondents voluntarily agreed to participate in three focus group interviews, with 2–4 students in each focus group. Students were informed that participation in this research study had no impact on student’s academic performance or their continuation in their studies.

Intervention

The instructional approach for the VP cases was structured in a specific format for the students. Figure  2 shows the instructional design for VP integration. The first stage was a role-modeling phase, where an expert demonstrated the clinical reasoning process using VP Case A. This was followed by a practice session where students worked in pairs on two different VP cases (Case B and C). After that, students formed two larger groups each including 5 or 6 students, and discussed the system feedback that was provided by VP platform. Finally, the expert summarized the session and addressed students’ questions. The whole intervention lasted 120 min. Figure  1 gives an overview of the intervention steps.

The flow of integrated virtual patient session

1. Role modeling (30 min): The intervention started with an expert, a clinician with teaching experience, demonstrating a clinical case (Case A) and showing the clinical reasoning process by thinking aloud. The expert served as a role model in showcasing the approach toward clinical problem-solving, provided supportive information, and demonstrated how to proceed through the case. The aim of the role modeling session was to empower students to apply the insights and methodology gained from experts in case A to solve subsequent cases (case B and case C), Although these cases shared similarities in underlying principles, they diverged on patient characteristics such as age, complications, and smoking history that can influence patient treatment outcomes.

2 and 3. Two VP pair tasks (20 min each): In this segment, the 22 participating students were paired, resulting in 11 pairs. These pairs were then divided into two groups. Group 1 (6 pairs) and group 2 (5 pairs) alternated in going through Case B and Case C to account for the practice effect. These cases were variations of the clinical cases introduced during the role-modeling demonstration, differing in patient characteristics such as age, complications, and smoking history to challenge the students’ reasoning. Students were encouraged to work collaboratively.

4. Feedback discussion (30 min): Upon completion of the VP cases, an automated feedback is immediately provided about the reasoning analysis. Participants were instructed to save this feedback for later discussion. After that, Students were organized into groups of six, based on the sequence in which they engaged with the cases. For instance, those who first practiced with Case B and then proceeded to Case C formed Group (1) Conversely, students who started with case C and then moved on to case B were assembled into Group (2) To foster meaningful dialogue, students engaged in discussions focused on the feedback generated by the Virtual Patient system, guided by a printed discussion guide distributed to each group (see Appendix 2 ). The discussion aimed to deepen students’ understanding and enrich their conversations about the cases they had just completed.

5. Plenary (15 min): This part lasted 15 min. Hosted by the expert to summarize the session and address questions or doubts raised by students.

During the practice and discussion sessions, the expert circulated among the groups to offer additional guidance and support.

The virtual patient cases

Three Virtual Patient (VP) cases (Case A, B, and C) were created to enhance students’ comprehension of specific concepts, knowledge, and skills in clinical reasoning. The VP practice was developed on the P-Scribe ( www.pscribe.nl ) learning platform, a web-based e-learning system based in the Netherlands. The platform facilitates the design and implementation of text-based VP sessions (Appendix 4 ).

While these cases shared a foundation on authentic head and neck cancer treatment, they were characterized by varying patient characteristics in terms of age, gender, and medical history (anamnesis).

VP case flow chart

Within each VP case, students were presented with a scenario related to neck cancer. Figure  3 shows the chart of a VP case. Each case starts with an overview of the patient and their medical history which students had to use to make an initial assessment. After this, students encountered a mix of multiple-choice and open-ended practice questions. These questions guided students in planning diagnostics, formulating a diagnosis, and devising a treatment plan tailored to the patient’s specific needs. Immediate feedback was provided after students submitted each response, and comprehensive summative feedback was given at the conclusion of each case to foster understanding and learning from any potential misjudgments or oversights (See Appendix 4 ).

Measurement instruments

Learning-perception survey : The survey (Appendix 1 ) consisted of 20 items, structured into five primary sections: general experience, intended learning outcome, role modeling, practicing with various authentic cases, and reflection on peer dialogue around feedback. The first item asked about students’ general experience through the whole session. The second item focused on their perception of intended learning outcomes. Six items then focused on the students’ perceptions of learning through role modeling followed by 5 items addressing perceptions related to their learning on practicing with authentic cases. The final seven items explored students’ perception of learning from dialogue around feedback. Participants indicated their level of agreement for each statement using a 5-point Likert scale: 1 denoting “Strongly Disagree”, 2 for “Disagree”, 3 for “Neutral”, 4 for “Agree”, and 5 for “Strongly Agree”. For interpretation, average scores below 3 were considered as “in need for improvement”, those of 4 or higher as ‘good’, and those between 3 and 4 as ‘neutral’.

Focus group interviews : Three focus group interviews (Appendix 3 ) were conducted to dive deeper into students’ perceptions of their learning experience, knowledge gain, and knowledge transfer in real-world settings. The focus group took place after the survey and the survey data did not affect the development of the focus group questions. In focus group 1, two students, in focus group 2, two students and in focus group 3, five students participated. The interviews were structured around a series of questions that explored students’ perceptions of their learning across specifically designed sections. These sections included Role Modeling, Practice with Various Authentic Cases, and Dialogue around Feedback. The structure aimed to understand students’ perspectives on each key component of the learning sections.

The analysis of the survey data was conducted by calculating the mean, standard deviation, and the Alpha Coefficient for the responses pertaining to each of the five key dimensions of the survey. The mean score provided an indicator of the average student perception, while the standard deviation offered insights into the variability of the responses. The Alpha Coefficient, a measure of internal consistency, was computed to assess the reliability of the survey dimensions. Through these statistical measures, an overall understanding of the students’ perceptions regarding the various aspects of the Virtual Patients was attained, facilitating a robust analysis aligned with the research objectives.

The focus-group interview data were analyzed following the thematic analysis procedure set out by Braun and Clarke [ 24 ]: (1) familiarize yourself with your data, (2) generate initial codes, (3) search for themes, (4) review themes, (5) define and name themes, and (6) produce the report. The interview was guided by pre-existing frameworks or theories in medical education. This ensured the capture of major aspects of the VP learning experience as underscored in the existing literature: role modeling, using various authentic cases, and peer dialogue around feedback [ 16 , 17 , 18 , 20 , 21 ]. The focus group interview was recorded, transcribed, and coded by three team members and ordered in initial themes (Z.L, M.A, and X.L). These themes were discussed with the larger team. We used a process of inductive and deductive analysis and used the three design principles of role modeling, practice with various authentic cases, and group discussion on feedback as sensitizing concepts to study the data [ 24 ]. Thereafter, quantitative and qualitative analyses were collectively appraised, compared, and checked for inconsistencies. In this triangulation, the themes identified in focus-group interviews were explanatory to the descriptive statistics of the survey.

Trustworthiness

Several measures were taken to enhance the study’s trustworthiness. First, triangulation was achieved by employing multiple data collection methods, including surveys and focus group interviews. The interview data collection continued until saturation was reached, ensuring a comprehensive understanding of the student’s experiences and perceptions. Secondly, the coding process followed an iterative approach. Team members initially coded transcripts independently, and then met to reach a consensus before moving on to code subsequent transcripts. Three researchers conducted the coding independently to minimize bias and enhance the validity of the findings. Finally, a member check among a sample of the focus group interviewees was conducted. In response to the question asking whether they agreed with summaries of preliminary results and would provide comments, confirmatory responses were received as well as some minor additional comments and clarifications. The latter were taken into account in the analysis and interpretation of the data.

Ethical approval

The Maastricht University Ethical Committee reviewed and approved this study. The approval number is FHML-REC/2023/021.

The findings from both the survey data and focus group interviews were presented to explore students’ perceptions of the effectiveness of the Virtual Patient (VP) Session in enhancing their clinical reasoning skills.

Survey data

The survey explored students’ perceptions across five key dimensions: General Experience, Intended Learning Outcome, Role Modeling, Practicing with Various Authentic Cases, and students’ reflection on Peer Dialogue around Feedback. The students scored the VP sessions on 20 items (Table  1 ). The scores varied between M = 2.95 to M = 4.58, on a scale of 1–5.

For the General Experience of Virtual Patient Session (Items Q1-Q2) the average score was M = 4.13 (SD = 0.70). Specifically, the overall experience was positively rated at M = 4.11. The component that assessed the improvement of clinical reasoning skills received an average score of M = 4.16.

Regarding the Students’ Perception of Learning from Role Modeling (Items Q3-Q8), the average score was M = 4.38 (SD = 0.61). Students agreed that the expert demonstration at the start of the session helped them understand the intended learning outcomes and was useful in guiding them through the Virtual Patient cases, with scores ranging from M = 4.26 to M = 4.58.

Students’ perception of learning from practicing with various authentic cases (Items Q9-Q13), received an average score of M = 4.00 (SD = 0.86). The scores measured the students’ perception of how well the provided Virtual Patient cases matched their current level of understanding, enhanced their comprehension of the subject matter, and helped them grasp the complexities inherent in real-world clinical scenarios.

For their perception of learning from Peer Dialogue around Feedback (Questions 14–20), the average score was M = 3.24 (SD = 1.05). These scores measure the students’ perception of the effectiveness of peer dialogue in enhancing understanding, generating strategies to address feedback, and prioritizing areas of improvement.

Focus group interview data

The interviews revealed five themes: ' Which steps to take in clinical reasoning’, ' Asking challenging questions to enhance deeper understanding of knowledge’, ‘The variety in cases helps to enhance transfer to the real world’, and ‘Deeper understanding of reasoning through reflections’.

Which steps to take in clinical reasoning

Students acknowledged the expert’s initial demonstration helped them to develop structured knowledge and gain understanding of the clinical reasoning process.

I think it (Role modeling) helps to find a pattern in clinical reasoning as well. At first, it (the expert) explained to us. For example, are there possible lymph nodes? Yes or no. Then you need to do this and this…Then you can make kind of…pattern that differs for the diagnosis and the prognosis. So you can make kind of a diagram in your head. Which you can use later on. And your knowledge becomes more structured. (Focus Group 2, Student B)

Students also perceived that the integrated practice with Virtual Patients helped them to anticipate the subsequent steps in clinical reasoning. They indicated the patterns learned through practicing with virtual Patients helped them understand the procedures they needed to follow to evaluate the patient.

I think now I know the steps which they (the procedural) followed to evaluate the patient, so first we can do this and then that. First, you determine the TNM (Tumour, Node, Metastasis) staging and do the endoscopy, then the TNM staging, and then you make the treatment plan. Now it’s more clear how they do those steps. (Focus Group 1, Student A)

Moreover, students thought the pair work and dialogue helped them think and clarify with each other what steps they needed to do in clinical reasoning when they had different opinions.

Yeah, that (pair working) was really nice because you can discuss, like I think do this and the other one says, you know, I think do that step, and then you’re already discussing the answers which is really nice to have. (The discussion) really make you think about the steps. (Focus Group 1, Student b)

Challenging their reasoning to enhance deeper understanding

Students reported how the course design differed from other blocks. According to the students, the VP practice was particularly beneficial in helping them integrate knowledge, and make the knowledge their own.

It (the VP practice) helps you to integrate knowledge because other blocks are really only lectures, they are all listening and listening. So the virtual patient was really nice to make this stuff our own. (Focus Group 2, Student A)

Students indicated the examples given by the expert helped them get a better understanding of the more detailed TNM (Tumor, Node, Metastasis) table, that are used in clinical reasoning.

Yeah, she (the expert) gave examples and guided the reading of the tables for TNM (Tumor, Node, Metastasis) staging, and those were also in the Virtual Patient cases, but because she already used them once and explained how we have to use them, it became more clear to us, what these tables are for and how they are used (Focus Group 1, Student B) .

The students noted that in VP practice sessions, compared with passive learning in traditional lectures, they were challenged to engage directly with the material by making clinical decisions, such as selecting appropriate tests to reach a diagnosis.

In lectures, we passively learn the trajectory from symptoms to diagnosis. During Virtual Patient practice, we actively process it. So you have to make decisions and select the test etc. (Focus Group 2, Student B)

Students indicated that practicing with the VP cases challenged them to look up information and reasoned by themselves. They gave an example of the imaging practice in which they were tasked with examining specific body parts in medical images on their own, they thought they were challenged to reason about what they saw instead of getting the information directly.

Yeah, also the (medical) imaging in the assignments where you need to look at a specific part of the body, normally you just see a picture and someone says, yeah, this is the stomach or this is the heart, whatever, and now you need to look it up yourself and think about it yourself, what you see, so that really helps. (Focus Group 1, Student B)

Furthermore, they emphasized the questions asked by experts challenged them to think, put the knowledge in their own words and apply the knowledge with their own reasoning.

The questions she (the expert) asked really make you think about the things she’s learning(teaching). So if she asks questions, you’re really thinking, and yeah, you’re challenged to put it in your own words. (Focus Group 1, Student B) For instance, she (the expert) asked questions that not from official guidelines, instead, it came from where widely doctor worked and her personal experiences. I applied what she said with my own reasoning behind it. (Focus Group 2, Student B)

Transfer of knowledge

Students perceived that practicing with VP cases in different situations offered them hands-on experience, where they actively engaged with various situations, which prepared them for future patient interactions.

Having cases that are closer to the real world, like the comorbidity we discussed, would make it more realistic. (For instance, ) What if he also has obesity or diabetes? Those are the patients that we are going to see in the future. So it helps out a lot to have those different conditions as well. (Focus Group 2, Student B)

Students also indicated their preference for the structured approach of the VP session, where an initial demonstration by an expert, sharing their clinical experience, followed by hands-on practice with VP cases was perceived to enhance transfer to practice. This method, as described by the student, bridged the gap between theoretical knowledge and practical application. They think this structure made the knowledge clear and further helped them to transfer their knowledge from theory to practice.

You (the Virtual Patient session that integrated with role modeling, authentic VP practice, and peer discussion around feedback) made it (the clinical reasoning) clear for me because of the first case we discussed with the teacher. Well, he discussed it and showed us how to think, and how to get things from certain perspectives with risk factors, age, et cetera. And then we do it ourselves. We had to find out what was wrong and go on. So I quite liked it. It gave me a deeper understanding. (Focus Group 3, Student A)

Students indicated the sense of practical immersion is amplified by the “side information that you don’t really need” (Focus Group 3, Student E) from the cases. They highlighted the side information represented the interaction with real patients and made them think of clinical situations in real-world settings.

(Side) information would be more realistic, also side information that you don’t really need because a patient also tells you a lot of things, and some of those things aren’t as important, but you still need to decide if they are important or not. What do you see, why do you see it, what’s different than normal. (Focus Group 3, Student E)

Moreover, several students indicated that the hypothetical “what-if” discussions during the role modeling session helped them with reasoning, prompting them to consider complications that might arise in real-life medical situations.

So for example, about age, it’s more difficult to do a treatment above 70. (What if that patient) has things like smoking history and that kind of stuff. I think it’s really valuable because you have already had an example about it (Demonstrating Case A). (Focus Group 1, Student A)

Students indicated that the diagnosis practice in VP led them to realize the difference in real-world scenarios. They said while in the simulated environment might seem easy to choose multiple diagnostic options, in the real world, medical professionals must make more selective decisions due to limitations. They think this experience taught them to think of prioritizing and decision-making in a realistic medical setting.

Yeah, maybe also there (in VP cases) were also a question about which imaging techniques you would use and then it was Echo or CT, MRI, there was also an option where you could listen to the lungs and some of the people also checked that one, but it isn’t really necessary, so you think it only takes one minute, so why not, but in the real world there isn’t always time to do everything, so it’s also good to think what is really necessary and what’s not. (Focus Group 1, Student A)

Enhance reasoning through reflections

During the VP session, students received feedback and conducted conversations around the feedback provided by the Virtual Patient system. Students thought the peer dialogues around feedback provided opportunities for collective reflection and insights, allowing them to pinpoint areas of improvement.

I thought that (the peer dialogue) was really useful, because sometimes one person, for example, when the teacher explains everything, you don’t pick up everything he says. She (your peer) might pick up a different thing, and I pick up a different thing, and we can ask each other, do you know how this works? So I thought that was really useful. (Focus Group 3, Student B)

The students emphasized the importance of expressing and discussing different opinions. They noted that such interactions could provide new insights and perspectives that they would not have considered independently, thereby enriching their understanding.

When you do have different opinions, I think they (your peers) can give you insight that you maybe didn’t have for yourself. So you can add to each other’s knowledge. If somebody has another view, then we can discuss it. It (the discussion) brightens my tunnel view. Also having to say it (the knowledge) out loud and explaining your thoughts to someone else can also help, I think. (Focus Group 2, Student A)

When talking about the peer dialogues around feedback during the VP session, Some students highlighted the benefits of immediate feedback, which provided them with clarity and instant validation. However, others saw value in delayed feedback, as it fostered discussion and multiple interpretations.

I liked that the Virtual Patient program, that it gave you immediate feedback. That was really handy. And I also liked the discussion afterward so we could speak about it a bit more (Focus Group 3, Student B) . There was immediate feedback on most questions, so you knew if you had been correct or wrong. But for the learning process it might be handy to have that after the group discussion, because now we all have the same answer. (Focus Group 2, Student B)

The study demonstrated the perception of students’ learning and knowledge transfer by integrating VP cases with role modeling introductions, and peer dialogue around feedback, specifically in the context of personalized medicine in cancer treatment and care. The survey reflected a positive learning experience and students reported they gained a better understanding of the clinical reasoning process as well as which steps to take when dealing with a clinical case through this specific course design with integration of VP cases. Qualitative data showed that the integration of VPs into the educational setting clearly shifted the students from being passive observers in a traditional lecture-based format to active participants in a simulated clinical environment. This shift is in line with previous research findings, which suggest that the use of VPs in clinical training actively engages learners and encourages the application of their knowledge [ 4 ].

The quantitative data revealed that students highly valued the role modeling session, as indicated by the high average scores. Qualitative data explained that the role modeling session enabled students to not only observe the clinical process being demonstrated but also to engage in active thinking by interacting with the expert. As discussed by Cruess, Cruess [ 15 ], role modeling not only consciously imparts knowledge but also unconsciously influences students’ attitudes and behaviors, making the learning experience more relatable to the clinical environment. In this study, by sharing clinical reasoning and personal anecdotes during the class, experts made the learning experience more relatable to the clinical environment that students would face in the future. This mirrored the role modeling research by Morgenroth, Ryan [ 25 ] which emphasizes the importance of role models in shaping the self-concept and motivation of individuals. Moreover, the qualitative data showed that the demonstration by the expert serves as a fundamental pre-knowledge for students to cover the knowledge gap and prepare them with the following practice. This finding aligns with van Merrienboer’s scaffolding concept emphasizing the importance of initial expert guidance in learning processes [ 16 ].

Followed by the role modeling demonstration, students practiced on two VP cases in pairs and perceived that the VP practice enhanced their clinical reasoning skills, and also helped them understand the real-world clinical setting. The result showed that the variety and real-life complexity of cases in the VP sessions were perceived to be essential for students’ knowledge gain and transfer. The positive perception of various authentic cases aligns with previous research highlighting the importance of exposure to diverse and authentic scenarios in medical training [ 17 , 18 ]. Moreover, the hypothetical “what-if” scenarios further enhanced students’ analytical abilities, preparing them for the multifaceted challenges they would encounter in real-world medical situations. Survey responses (Q10, mean = 4.37; Q13, mean = 4.05 in Table  1 ) indicated a consensus among students on the improvement with this practice in understanding and applying knowledge. Our findings corroborate with Jonassen and Hernandez-Serrano [ 26 ]’s study emphasis on the importance of authentic learning environments for effective knowledge transfer.

After the practice, students discussed the feedback provided by the VP system. Despite its mixed quantitative reception, the peer dialogue on feedback was qualitatively found to be a vital component for promoting critical thinking, discussion, and reflection. The Feedback from the VPs, both immediate and delayed, along with peer dialogue, emerged as crucial elements in students’ learning process. In this study, students showed different preferences for receiving feedback. Some students preferred immediate feedback, however, others preferred delayed feedback. How feedback was provided notably influenced peer interactions. Given that immediate feedback was dispensed upon submission of answers, the peer dialogues automatically started when students noticed disparities or encountered obstacles. Such dialogues not only served to resolve ambiguities but also fostered collective reflection, enhancing comprehension of the subject. By vocalizing their thoughts and engaging in active discussions, students were able to solidify their understanding and uncover nuances they might have missed otherwise. This aligns with the importance of engaging in peer discussions on feedback as outlined in the theoretical background [ 20 , 21 , 22 ].

When looking at the integration of VP cases with the particular course design, students perceived that the expert demonstration, followed by VP practice, and peer dialogue around feedback fostered a comprehensive understanding, allowing them to integrate diverse clinical knowledge, which in turn promoted understanding. The “Watch-think-do-reflect” structure not only ensured better knowledge retention but also enhanced students’ enthusiasm towards the subject. Observing model demonstrations enabled students to assimilate clinical nuances and contemplate real-world applications. Subsequent hands-on practice with VP cases fortified their cognitive structures, honing their clinical reasoning. Ultimately, students perceived that reflective peer discussions on feedback solidified their learnings, enhancing knowledge retention.

Limitations

This study employed a survey and focus group interviews that provided a comprehensive understanding of students’ perceptions of learning. However, there are several limitations. The study had a small sample size and was conducted in the context of an elective course, which may limit the generalizability of the findings. Furthermore, the study was exploratory in nature and did not measure actual learning outcomes or long-term retention, which are critical aspects of educational impact.

Implications for future research

Future research should investigate whether integrating Virtual Patients (VPs) into classroom activities enhance student learning outcomes by incorporating learning assessments and involving larger and more diverse participant groups to validate our findings. Additionally, a deeper analysis of students’ reasoning processes and interactions could provide insights into how and why knowledge gain and transfer are fostered or hindered. Furthermore, it is also important to understand the most beneficial moment for integrating VPs into educational settings to enhance transfer from a simulated to a real practice setting. This understanding could inform the development of more effective educational strategies and interventions.

The integration of Virtual Patients into classroom learning appears to offer a promising approach to enrich medical education. Key elements such as role modeling and various authentic cases contribute positively to students’ perception of learning, as well as peer dialogue on feedback. However, the approach to peer dialogue on feedback may need to be refined for more consistent benefits. Furthermore, studies with larger sample sizes and broader participant groups are essential to provide robust support for the efficacy of this educational approach and its components.

Data availability

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

Cook DA, Triola MM. Virtual patients: a critical literature review and proposed next steps. Med Educ. 2009;43(4):303–11.

Article   Google Scholar  

Garrett BM, Callear D. The value of intelligent multimedia simulation for teaching clinical decision-making skills. Nurse Educ Today. 2001;21(5):382–90.

Peddle M, Bearman M, Nestel D. Virtual patients and nontechnical skills in undergraduate health professional education: an integrative review. Clin Simul Nurs. 2016;12(9):400–10.

Sanders CL, Kleinert HL, Free T, Slusher I, Clevenger K, Johnson S, et al. Caring for children with intellectual and developmental disabilities: virtual patient instruction improves students’ knowledge and comfort level. J Pediatr Nurs. 2007;22(6):457–66.

Sijstermans R, Jaspers MWM, Bloemendaal PM, Schoonderwaldt EM. Training inter-physician communication using the dynamic patient Simulator®. Int J Med Informatics. 2007;76(5):336–43.

Buttussi F, Chittaro L. Effects of different types of virtual reality display on presence and learning in a safety training scenario. IEEE Trans Vis Comput Graph. 2017;24(2):1063–76.

Makransky G, Bonde MT, Wulff JS, Wandall J, Hood M, Creed PA, et al. Simulation based virtual learning environment in medical genetics counseling: an example of bridging the gap between theory and practice in medical education. BMC Med Educ. 2016;16(1):1–9.

Verkuyl M, Hughes M, Tsui J, Betts L, St-Amant O, Lapum JL. Virtual gaming simulation in nursing education: a focus group study. J Nurs Educ. 2017;56(5):274–80.

Burke LA, Hutchins HM. Training transfer: an integrative literature review. Hum Resour Dev Rev. 2007;6(3):263–96.

Durning SJ, Artino AR Jr, Schuwirth L, Van Der Vleuten C. Clarifying assumptions to enhance our understanding and assessment of clinical reasoning. Acad Med. 2013;88(4):442–8.

Marei HF, Donkers J, Al-Eraky MM, van Merrienboer JJ. The effectiveness of sequencing virtual patients with lectures in a deductive or inductive learning approach. Med Teach. 2017;39(12):1268–74.

Marei HF, Donkers J, Al-Eraky MM, Van Merrienboer JJ. Collaborative use of virtual patients after a lecture enhances learning with minimal investment of cognitive load. Med Teach. 2019;41(3):332–9.

Tolsgaard MG, Jepsen RM, Rasmussen MB, Kayser L, Fors U, Laursen LC, et al. The effect of constructing versus solving virtual patient cases on transfer of learning: a randomized trial. Perspect Med Educ. 2016;5:33–8.

Burgess A, Oates K, Goulston K. Role modelling in medical education: the importance of teaching skills. Clin Teach. 2016;13(2):134–7.

Cruess SR, Cruess RL, Steinert Y. Role modelling—making the most of a powerful teaching strategy. BMJ. 2008;336(7646):718–21.

Van Merriënboer JJ, Kirschner PA. Ten steps to complex learning: a systematic approach to four-component instructional design: Routledge; 2017.

Google Scholar  

Berman NB, Durning SJ, Fischer MR, Huwendiek S, Triola MM. The role for virtual patients in the future of medical education. Acad Med. 2016;91(9):1217–22.

Lowell VL, Yang M. Authentic learning experiences to improve online instructor’s performance and self-efficacy: the design of an online mentoring program. TechTrends. 2023;67(1):112–23.

Sevy-Biloon J, Chroman T. Authentic use of technology to improve EFL communication and motivation through international language exchange video chat. Teach Engl Technol. 2019;19(2):44–58.

Dmoshinskaia N, Gijlers H, de Jong T. Giving feedback on peers’ concept maps as a learning experience: does quality of reviewed concept maps matter? Learn Environ Res. 2022;25(3):823–40.

Foster A, Chaudhary N, Kim T, Waller JL, Wong J, Borish M, et al. Using virtual patients to teach empathy: a randomized controlled study to enhance medical students’ empathic communication. Simul Healthc. 2016;11(3):181–9.

Schillings M, Roebertsen H, Savelberg H, Whittingham J, Dolmans D. Peer-to-peer dialogue about teachers’ written feedback enhances students’ understanding on how to improve writing skills. Educational Stud. 2020;46(6):693–707.

Stalmeijer RE, Dolmans DH, Snellen-Balendong HA, van Santen-Hoeufft M, Wolfhagen IH, Scherpbier AJ. Clinical teaching based on principles of cognitive apprenticeship: views of experienced clinical teachers. Acad Med. 2013;88(6):861–5.

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101.

Morgenroth T, Ryan MK, Peters K. The motivational theory of role modeling: how role models influence role aspirants’ goals. Rev Gen Psychol. 2015;19(4):465–83.

Jonassen DH, Hernandez-Serrano J. Case-based reasoning and instructional design: using stories to support problem solving. Education Tech Research Dev. 2002;50(2):65–77.

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Acknowledgements

Thanks to all the participants and education workers who contributed to the study. ZL was supported by a scholarship granted by the China Scholarship Council. Thanks for the support of my family, and thanks Ang Li for joining our family.

ZL was supported by a scholarship granted by the China Scholarship Council (CSC, 202208440100).

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ZL, MA, DD, and NJ conceived of the presented idea. MA and DD verified the analytical methods. TK and ZL contribute to the creation of learning materials. ZL analyzed the data and drafted the manuscript under the supervision of MA and DD. All authors contributed to the article and approved the submitted version.

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Li, Z., Asoodar, M., de Jong, N. et al. Perception of enhanced learning in medicine through integrating of virtual patients: an exploratory study on knowledge acquisition and transfer. BMC Med Educ 24 , 647 (2024). https://doi.org/10.1186/s12909-024-05624-7

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DOI : https://doi.org/10.1186/s12909-024-05624-7

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