• Research article
  • Open access
  • Published: 14 June 2021

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

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

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

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

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

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


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

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

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

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

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

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

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

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

Setting and participants

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

Data collection

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

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

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

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

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

Data analysis

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

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

Ethical considerations

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

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

Distinction based on complexity of care

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

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

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

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

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

Organizing hospital care

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

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

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

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

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

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

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

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

Evidence-based practices in quality improvement work

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

Availability of data and materials

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


Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

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

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

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

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  • David Barrett 1 ,
  • http://orcid.org/0000-0003-1130-5603 Alison Twycross 2
  • 1 Faculty of Health Sciences , University of Hull , Hull , UK
  • 2 School of Health and Social Care , London South Bank University , London , UK
  • Correspondence to Dr David Barrett, Faculty of Health Sciences, University of Hull, Hull HU6 7RX, UK; D.I.Barrett{at}hull.ac.uk


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Qualitative research methods allow us to better understand the experiences of patients and carers; they allow us to explore how decisions are made and provide us with a detailed insight into how interventions may alter care. To develop such insights, qualitative research requires data which are holistic, rich and nuanced, allowing themes and findings to emerge through careful analysis. This article provides an overview of the core approaches to data collection in qualitative research, exploring their strengths, weaknesses and challenges.

Collecting data through interviews with participants is a characteristic of many qualitative studies. Interviews give the most direct and straightforward approach to gathering detailed and rich data regarding a particular phenomenon. The type of interview used to collect data can be tailored to the research question, the characteristics of participants and the preferred approach of the researcher. Interviews are most often carried out face-to-face, though the use of telephone interviews to overcome geographical barriers to participant recruitment is becoming more prevalent. 1

A common approach in qualitative research is the semistructured interview, where core elements of the phenomenon being studied are explicitly asked about by the interviewer. A well-designed semistructured interview should ensure data are captured in key areas while still allowing flexibility for participants to bring their own personality and perspective to the discussion. Finally, interviews can be much more rigidly structured to provide greater control for the researcher, essentially becoming questionnaires where responses are verbal rather than written.

Deciding where to place an interview design on this ‘structural spectrum’ will depend on the question to be answered and the skills of the researcher. A very structured approach is easy to administer and analyse but may not allow the participant to express themselves fully. At the other end of the spectrum, an open approach allows for freedom and flexibility, but requires the researcher to walk an investigative tightrope that maintains the focus of an interview without forcing participants into particular areas of discussion.

Example of an interview schedule 3

What do you think is the most effective way of assessing a child’s pain?

Have you come across any issues that make it difficult to assess a child’s pain?

What pain-relieving interventions do you find most useful and why?

When managing pain in children what is your overall aim?

Whose responsibility is pain management?

What involvement do you think parents should have in their child’s pain management?

What involvement do children have in their pain management?

Is there anything that currently stops you managing pain as well as you would like?

What would help you manage pain better?

Interviews present several challenges to researchers. Most interviews are recorded and will need transcribing before analysing. This can be extremely time-consuming, with 1 hour of interview requiring 5–6 hours to transcribe. 4 The analysis itself is also time-consuming, requiring transcriptions to be pored over word-for-word and line-by-line. Interviews also present the problem of bias the researcher needs to take care to avoid leading questions or providing non-verbal signals that might influence the responses of participants.

Focus groups

The focus group is a method of data collection in which a moderator/facilitator (usually a coresearcher) speaks with a group of 6–12 participants about issues related to the research question. As an approach, the focus group offers qualitative researchers an efficient method of gathering the views of many participants at one time. Also, the fact that many people are discussing the same issue together can result in an enhanced level of debate, with the moderator often able to step back and let the focus group enter into a free-flowing discussion. 5 This provides an opportunity to gather rich data from a specific population about a particular area of interest, such as barriers perceived by student nurses when trying to communicate with patients with cancer. 6

From a participant perspective, the focus group may provide a more relaxing environment than a one-to-one interview; they will not need to be involved with every part of the discussion and may feel more comfortable expressing views when they are shared by others in the group. Focus groups also allow participants to ‘bounce’ ideas off each other which sometimes results in different perspectives emerging from the discussion. However, focus groups are not without their difficulties. As with interviews, focus groups provide a vast amount of data to be transcribed and analysed, with discussions often lasting 1–2 hours. Moderators also need to be highly skilled to ensure that the discussion can flow while remaining focused and that all participants are encouraged to speak, while ensuring that no individuals dominate the discussion. 7


Participant and non-participant observation are powerful tools for collecting qualitative data, as they give nurse researchers an opportunity to capture a wide array of information—such as verbal and non-verbal communication, actions (eg, techniques of providing care) and environmental factors—within a care setting. Another advantage of observation is that the researcher gains a first-hand picture of what actually happens in clinical practice. 8 If the researcher is adopting a qualitative approach to observation they will normally record field notes . Field notes can take many forms, such as a chronological log of what is happening in the setting, a description of what has been observed, a record of conversations with participants or an expanded account of impressions from the fieldwork. 9 10

As with other qualitative data collection techniques, observation provides an enormous amount of data to be captured and analysed—one approach to helping with collection and analysis is to digitally record observations to allow for repeated viewing. 11 Observation also provides the researcher with some unique methodological and ethical challenges. Methodologically, the act of being observed may change the behaviour of the participant (often referred to as the ‘Hawthorne effect’), impacting on the value of findings. However, most researchers report a process of habitation taking place where, after a relatively short period of time, those being observed revert to their normal behaviour. Ethically, the researcher will need to consider when and how they should intervene if they view poor practice that could put patients at risk.

The three core approaches to data collection in qualitative research—interviews, focus groups and observation—provide researchers with rich and deep insights. All methods require skill on the part of the researcher, and all produce a large amount of raw data. However, with careful and systematic analysis 12 the data yielded with these methods will allow researchers to develop a detailed understanding of patient experiences and the work of nurses.

  • Twycross AM ,
  • Williams AM ,
  • Huang MC , et al
  • Onwuegbuzie AJ ,
  • Dickinson WB ,
  • Leech NL , et al
  • Twycross A ,
  • Emerson RM ,
  • Meriläinen M ,
  • Ala-Kokko T

Competing interests None declared.

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qualitative research nursing journal

Introduction to qualitative nursing research

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

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

Research 101: Descriptive statistics

Differentiating research, evidence-based practice, and quality improvement

How to appraise quantitative research articles

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

What is qualitative research?

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

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

Qualitative research designs

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

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

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

Sampling approaches

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

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

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

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

Data collection and analysis

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

qualitative research nursing journal

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

Evaluating a qualitative study

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

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

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

Application to nursing practice

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

qualitative research nursing journal

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

Successful implementation

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

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

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

Amankwaa L. Creating protocols for trustworthiness in qualitative research. J Cult Divers. 2016;23(3):121-7.

Cuthbert CA, Moules N. The application of qualitative research findings to oncology nursing practice. Oncol Nurs Forum . 2014;41(6):683-5.

Guba E, Lincoln Y. Competing paradigms in qualitative research . In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. Thousand Oaks, CA: SAGE Publications, Inc.;1994: 105-17.

Lincoln YS, Guba EG. Naturalistic Inquiry . Thousand Oaks, CA: SAGE Publications, Inc.; 1985.

Munhall PL. Nursing Research: A Qualitative Perspective . 5th ed. Sudbury, MA: Jones & Bartlett Learning; 2012.

Nicholls D. Qualitative research. Part 1: Philosophies. Int J Ther Rehabil . 2017;24(1):26-33.

Nicholls D. Qualitative research. Part 2: Methodology. Int J Ther Rehabil . 2017;24(2):71-7.

Nicholls D. Qualitative research. Part 3: Methods. Int J Ther Rehabil . 2017;24(3):114-21.

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. Acad Med . 2014;89(9):1245-51.

Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice . 10th ed. Philadelphia, PA: Wolters Kluwer; 2017.

Thorne S. Saturation in qualitative nursing studies: Untangling the misleading message around saturation in qualitative nursing studies. Nurse Auth Ed. 2020;30(1):5. naepub.com/reporting-research/2020-30-1-5

Whittemore R, Chase SK, Mandle CL. Validity in qualitative research. Qual Health Res . 2001;11(4):522-37.

Williams B. Understanding qualitative research. Am Nurse Today . 2015;10(7):40-2.

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Qualitative Research in Nursing and Health Professions Regulation

  • Allison Squires, PhD, RN, FAAN Allison Squires Search for articles by this author
  • Caroline Dorsen, PhD, FNP, RN Caroline Dorsen Search for articles by this author
  • Credentialing
  • government regulation
  • professional autonomy
  • qualitative research
  • • Explain the importance of qualitative research for studies about regulatory issues in nursing.
  • • Discuss the core concepts of qualitative research.
  • • Describe common methodological challenges researchers can encounter when conducting qualitative research on professional regulatory issues.
  • • Identify solutions that can enhance the quality, rigor, and trustworthiness of the findings for regulatory studies.
  • Blackman T.
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  • Bradley E.H.
  • Devers K.J.
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  • Vandermause R.
  • Edmundson L.
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  • Richardson J.C.

A Review of Core Qualitative Research Concepts

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A Note on Cross-language Qualitative Research on Regulatory Issues

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An Overview of Qualitative Study Designs Appropriate for Regulatory Studies

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Underutilized Qualitative Designs in Regulatory Research

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  • Carolan C.M.
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Design Dictates the Analytic Approach

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Samples, Sampling, and Saturation

  • Malterud K.
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Framing Findings

  • Scopus (245)
  • • Introducing quotes with a single sentence, rather than establishing the context of the quote and how it links to the theme
  • • Inserting overly long quotes to represent experiences or the phenomenon
  • • Failing to transition between quotes and the next paragraph without an explanatory or transition sentence
  • • Choosing quotes that do not represent the theme
  • • Inserting too many quotes
  • • Separating every quote, regardless of length (35 words or more should be in a separate paragraph), without integrating them into the paragraph for a seamless reading experience.

Choosing Quotes

Managing word count limitations, avoiding discussion pitfalls and the generalizability trap.

  • Carminati L.


Ce posttest, instructions, provider accreditation.

  • a. Local and national governmental oversight through health professions regulation is needed for professional practice.
  • b. Health professions are regulated in order to avoid a risk of harm to the public.
  • c. Congress mandates that all professions are regulated.
  • d. Both a and b
  • a. There are not enough studies to determine the effectiveness of qualitative research yet.
  • b. Quantitative research is more critical because it provides both exploratory and explanatory data.
  • c. Qualitative research can play a vital role in ensuring that the stakeholder’s voice is represented and their experiences inform the evaluation of regulations and their associated policies.
  • d. None of the above
  • a. Identification, modification, or abolition
  • b. Creation, modification, or elimination
  • c. Oversight, enforcement, or evaluation
  • d. Creation, development, or destruction
  • c. Data saturation
  • d. Reliability
  • a. Data saturation
  • b. Trustworthiness
  • a. Termination
  • b. Content closure
  • c. Conclusion
  • d. Data saturation
  • a. Rigorous
  • b. Trustworthy
  • c. Unbiased
  • d. Credible
  • a. Grounded theory
  • b. Phenomenology
  • c. Ethnography
  • d. Generic qualitative descriptive
  • a. The applicability of the results is immediately apparent and translatable into the real world.
  • b. The end goal of the study is to generate a theory from the data.
  • c. The study must describe the lived experience of a phenomenon.
  • d. Generic approaches offer flexibility for studying regulation and regulatory issues.
  • 12. Pragmatic qualitative studies _____
  • 13. Case studies _____
  • 14. Realist evaluations _____
  • a. Might work well exploring a state level analysis of a regulatory change
  • b. A way to compare contemporary and historical stakeholder perspectives around the legislative process or similar phenomena
  • c. Might be useful for studying how new regulations have affected those subject to them during the early phases of implementation
  • d. Contributes to the evidence to support or change a regulation
  • a. Recruit a sample size that will achieve data saturation.
  • b. Aim for a heterogeneous sample.
  • c. Plan to achieve a minimum sample size of 8 as a realistic and achievable goal in most cases.
  • d. Sample size has no impact on regulatory research.
  • a. Long quote
  • b. Strong opening sentence
  • d. Phenomenon
  • a. Representative of participants’ experiences
  • b. Improve the trustworthiness of results
  • c. Articulately or succinctly explain a phenomenon
  • d. All of the above
  • a. The discussion section may end up too “thin” because the authors have left no room in the word count for a robust discussion of the findings
  • b. The discussion section uses the first paragraph to summarize the findings from the study and how they are unique from the literature
  • c. The authors assume the findings are generalizable to the broader population.
  • a. They should include all findings, even if the content does not tie back to the original research question.
  • b. They can provide useful direction for others seeking to replicate the study in different contexts or with populations affected by the same regulations.
  • c. Suggestions for realistic, existing, measurable variables that might be sensitive to the effects of a regulation cannot be useful for a qualitative study focused on regulation.
  • d. Qualitative findings can always be applied to other regional, state, national, or international populations.

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  • • Explain the importance of qualitative research for studies about regulatory issues in nursing. 1 2 3 4 5 ___________________________________
  • • Discuss the core concepts of qualitative research. 1 2 3 4 5 ___________________________________
  • • Describe common methodological challenges researchers can encounter when conducting qualitative research on professional regulatory issues. 1 2 3 4 5 ___________________________________
  • • Identify solutions that can enhance the quality, rigor, and trustworthiness of the findings for regulatory studies. 1 2 3 4 5 ___________________________________
  • • Were the authors knowledgeable about the subject? 1 2 3 4 5 ___________________________________
  • • Were the methods of presentation (text, tables, figures, etc.) effective? 1 2 3 4 5 ___________________________________
  • • Was the content relevant to the objectives? 1 2 3 4 5 ___________________________________
  • • Was the article useful to you in your work? 1 2 3 4 5 ___________________________________
  • • Was there enough time allotted for this activity? 1 2 3 4 5 ___________________________________
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DOI: https://doi.org/10.1016/S2155-8256(18)30150-9


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Open Access


Research Article

A qualitative exploration of the challenges providers experience during peripartum management of patients with a body mass index ≥ 50 kg/m 2 and recommendations for improvement

Roles Conceptualization, Data curation, Investigation, Methodology, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America

ORCID logo

Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliation Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America

Roles Formal analysis, Project administration, Writing – original draft, Writing – review & editing

  • Michelle A. Kominiarek, 
  • Madison Lyleroehr, 
  • Jissell Torres


  • Published: May 16, 2024
  • https://doi.org/10.1371/journal.pone.0303497
  • Reader Comments

Table 1

The objective of this research was to conduct a qualitative study among a diverse group of providers to identify their clinical needs, barriers, and adverse safety events in the peripartum care of people with a body mass index (BMI) ≥ 50 kg/m 2 .

Obstetricians, anesthesiologists, certified nurse midwives, nurse practitioners, and nurses were invited to participate in focus group discussions if they were employed at the hospital for >6 months. Key concepts in the focus group guide included: (1) Discussion of challenging situations, (2) Current peripartum management approaches, (3) Patient and family knowledge and counseling, (4) Design and implementation of a guideline (e.g., checklist or toolkit) for peripartum care. The audiotaped focus groups were transcribed verbatim, uploaded to a qualitative analysis software program, and analyzed using inductive and constant comparative approaches. Emerging themes were summarized along with representative quotes.

Five focus groups of 27 providers were completed in 2023. The themes included staffing (level of experience, nursing-patient ratios, safety concerns), equipment (limitations of transfer mats, need for larger sizes, location for blood pressure cuff, patient embarrassment), titrating oxytocin (lack of guidelines, range of uses), monitoring fetal heart rate and contractions, patient positioning, and communication (lack of patient feedback, need for bias training, need for interdisciplinary relationships). Providers gave examples of items to include in a “BMI cart” and suggestions for a guideline including designated rooms for patients with a BMI ≥ 50 kg/m 2 , defining nursing ratios and oxytocin titration plans, postpartum incentive spirometer, and touch points with providers (nursing, physicians) at every shift change.


Providers discussed a range of challenges and described how current approaches to care may negatively affect the peripartum experience and pose threats to safety for patients with a BMI ≥ 50 kg/m 2 and their providers. We gathered information on improving equipment and communication among providers.

Citation: Kominiarek MA, Lyleroehr M, Torres J (2024) A qualitative exploration of the challenges providers experience during peripartum management of patients with a body mass index ≥ 50 kg/m 2 and recommendations for improvement. PLoS ONE 19(5): e0303497. https://doi.org/10.1371/journal.pone.0303497

Editor: Vidanka Vasilevski, Deakin University Faculty of Health, AUSTRALIA

Received: November 14, 2023; Accepted: April 26, 2024; Published: May 16, 2024

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

Data Availability: All relevant data are within the manuscript and its Supporting Information files ( S3 File ).

Funding: The author(s) received no specific funding for this work.

Competing interests: NO authors have competing interests.


In 2015–2016, 41.1% of women who were 20 years of age or older in the United States had obesity, defined as a body mass index (BMI) ≥ 30 kg/m 2 [ 1 ]. These statistics translate into a significant proportion of people at risk for having obesity during pregnancy. Obesity is an increasingly common challenge in contemporary labor management [ 2 ]. People with obesity are more likely to have an induction of labor and experience labor abnormalities [ 2 ]. Evidence also suggests a positive correlation between weight and the amount of intravenous oxytocin needed to deliver vaginally in either induced or augmented labor [ 3 – 8 ]. As such, titration of oxytocin during labor can be challenging if high infusion rates have been reached without cervical change. Obesity also increases the risk for cesarean delivery and its related morbidities such as surgical site infection, postpartum hemorrhage, and thromboembolism [ 9 ]. These risks are further amplified in people with class III obesity (BMI ≥ 40 kg/m 2 ) [ 10 ].

Morbidity and mortality related to pregnancy is a key priority area in patient care. There is limited evidence to guide care for people in the highest weight category or a BMI ≥ 50 kg/m 2 . Given the prevalence of obesity and obesity-related complications, it is important to identify opportunities to provide safe care immediately before, during, and after delivery, or peripartum care.

Most studies on provider experiences in the management of obesity have focused on prenatal care and relate to topics such as gestational weight gain [ 11 , 12 ]. These provider experiences have primarily been from providers such as nurse midwives or nurse practitioners and lack a multidisciplinary focus [ 12 , 13 ]. Furthermore, the prior studies do not address the management of the extremes of obesity. The purpose of this research was to conduct a qualitative study in which a diverse group of providers (e.g., obstetricians, anesthesiologists, nurse midwives, nurse practitioners, nurses) identified their clinical needs, barriers to optimal care, and safety events in the peripartum care of people with a BMI ≥ 50 kg/m 2 . Given that most adverse outcomes occur surrounding the time of delivery for people with a BMI ≥ 50 kg/m 2 , identifying and processing this information from obstetrical providers is an important next step in identifying best practices for peripartum care.

Materials and methods

Northwestern Medicine’s Prentice Women’s Hospital is the largest delivery hospital in Illinois, with over 11,000 deliveries every year. At our site, approximately 50% of patients have a BMI ≥ 30 kg/m 2 and 10% have a BMI ≥ 40 kg/m 2 . Thus, our providers have a depth of experience in the management of patients with higher BMIs. Obstetric safety events are considered key priority areas in patient care. Adaptations already in place at this site for patients with a BMI ≥ 50 kg/m 2 prior to the study were placement of a transfer mat on the patient’s bed at delivery admission, making a note in the electronic medical record dashboard regarding the BMI, and using 3g instead of 2g of cefazolin for antibiotic prophylaxis prior to a cesarean delivery.

The Northwestern University IRB approved this study. Reporting for this qualitative study was done in accordance with the Consolidated criteria for reporting qualitative research (COREQ) checklist ( S1 File ) [ 14 ]. The principal investigator (MAK) had prior experience with both quantitative and qualitative research with pregnant persons and their providers. The potential participants had previously worked with the principal investigator in clinical and research contexts. Providers were identified from departmental list-serves at the site. Providers were invited via email (purposive sampling) to participate in a one-time focus group to assess their experiences in the care of people with a BMI ≥ 50 kg/m 2 and elicit barriers and facilitators to optimal peripartum care. Providers were eligible if they were a physician (faculty, resident, fellow) in obstetrics or anesthesia, certified nurse midwife (CNM) or nurse practitioner (NP) in labor and delivery or postpartum, surgical assistant in the labor and delivery operating room, or a labor and delivery or postpartum registered nurse. Providers were also eligible if they were employed at the site for at least 6 months and were English-speaking. Focus groups were scheduled such that only people of the same provider type were in a group. The sample pool size was >100 faculty physicians, >100 nurses, >50 resident and fellow physicians, >20 certified nurse midwives or nurse practitioners, and <5 surgical assistants. Recruitment occurred between February 1, 2023 and May 24, 2023.

In person focus groups, estimated to last 45–60 minutes each, were scheduled in a hospital conference room when 3–5 providers indicated an availability to participate. Each provider was given a $50 gift card and a meal as compensation for their participation. The goal was to complete 4–5 focus groups with a total of 25–30 participants and 4–6 participants in each group. To help reach participation targets, individual interviews were presented as an option for providers who were interested in participating in the study but were unable to attend their group’s scheduled session. All focus groups were led by a master’s level (MA) female team member (ML), a research analyst with a decade of experience in qualitative research who did not know the participants prior to the study and vice versa. No specific characteristics were reported to the participants regarding the interviewer. The principal investigator (MAK) was also present during most of the focus groups, as was a research coordinator (JT), who took notes when present. Once informed written consent was obtained, participants then completed a 16-item questionnaire (“Provider Characteristics and Practice Patterns”) which contained closed and open-ended questions to assess practice specialty, years in practice, current approach to peripartum care of people with a BMI ≥ 50 kg/m 2 , and current use of any guidelines for peripartum care. The principal investigator designed the survey, and it was available for completion online via REDCap or on paper at the focus group session (and entered into REDCap afterwards), per the participants’ preference [ 15 , 16 ]. Key concepts in the focus group guide included: (1) Discussion of challenging situations for BMI ≥ 50 kg/m 2 , (2) Current peripartum management approaches, (3) Patient and family knowledge and counseling, (4) Design and implementation of a guideline (e.g., checklist or toolkit) for peripartum care of people with a BMI ≥ 50 kg/m 2 . Providers were encouraged to share their experiences in particularly difficult cases. The same focus group guide ( S2 File ) was used for all data collection sessions, and no edits were made to the guide during the data collection period.

The 16-item questionnaire data were summarized, and descriptive statistics were reported for the sample ( S3 File ). Responses to open-ended questions were sorted, organized, and checked with focus group and interview data for any significant discrepancies. The audiotaped focus groups were transcribed verbatim by a 3 rd party transcription system. Transcripts from the focus groups and interview were uploaded into the qualitative analysis software program, Dedoose version 9.0.46 (Los Angeles, California) and analyzed using inductive and constant comparative approaches [ 17 , 18 ]. The first three focus group transcripts were reviewed by ML using descriptive coding to create a preliminary codebook [ 19 ]. Transcripts were not returned to participants for comment or correction and participants did not provide feedback on the findings. The codebook ( S4 File ) included definitions and instructions for application of each code to ensure uniformity and avoid overlap during coding. The same three transcripts were then coded using the preliminary codebook. Additional details on code definitions were added as appropriate throughout the coding process. At the end of the coding process, some conceptually related codes were combined due to low usage.

Once coding was complete, reports for each individual code were downloaded from Dedoose. Every excerpt for each code was reviewed for uniformity. Each report was then summarized and reviewed for emergent themes, which were organized and summarized, along with representative quotes.

Five focus groups were completed in 2023, along with one interview for a provider who was unable to attend a scheduled focus group. Invited surgical assistants did not respond to the email invitations. Six additional providers (n = 2 nurses, n = 1 anesthesiology physician, n = 3 resident physician) were scheduled to attend a focus group but were not able to attend. In total, 27 providers participated. The demographics of the participants, as well as information about their clinical role and training, are detailed in Table 1 . Most participants were non-Hispanic White females, per self-report. Some providers’ (obstetrics-gynecology residents, anesthesiology fellows) time at the site was < 1 year, whereas some of the other providers reported longer employment at the site (40 years). Most participants made some type of adaptation to either intrapartum (92.6%) or postpartum (74.1%) care of patients with a BMI ≥ 50 kg/m 2 .


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Providers discussed a range of challenges, concerns, and needs regarding care for patients with a BMI ≥ 50 kg/m 2 . They discussed how aspects of care may negatively affect the labor and birth experience for these patients. Findings are presented by topic, so the barriers specific to each topic are discussed alongside implications for patients and opportunities for improvement.

The survey asked open-ended questions about what care modifications providers currently make for patients with a BMI ≥ 50 kg/m 2 . This distribution shows that many aspects of care are affected for patients with a BMI ≥ 50 kg/m 2 , which is consistent with the live discussions. ( Fig 1 )



While staffing was only mentioned once as a modification for patients with a BMI ≥ 50 kg/m 2 (represented in the “Misc.” category in Fig 1 ) in the open-ended questions on the survey, it was one of the major concerns the providers discussed during the focus groups. They reported needing more confidence and experience in major areas of care, like moving patients, monitoring contractions and fetal heart tones, and performing fundal checks. Providers found many tasks more difficult, such as constantly adjusting the monitors, trying to position patients, and keeping transfer mats in place. Additional staff help was often needed. Level of nursing experience closely tied into their actions in the labor course, such as this story from a nurse:

I think when I started as a nurse, I had a really hard time tracing higher BMI patients. But I was tracing this patient super, super well for all 12 hours of my shift. Come night shift, a newer nurse came on, did not trace the patient super well. And within 30 minutes, they had put internal monitors in that patient and didn’t even give it a second thought. So, now that patient is at increased risk of chorio. I think when things like that happen, it’s a little bit frustration.

Providers reported that providing care for patients with a BMI ≥ 50 kg/m 2 requires more clinical judgement and effort, which increases the difficulty in making labor and delivery decisions. One obstetrics-gynecology (OBGYN) faculty explained:

Decision to deliver can be very stressful, and if you are in a situation where you’re trying to deliver rapidly, the logistics of getting the patient transferred to the operating room, confirming there’s a level, and then just deciding about how to optimize your access–where to make the incision–all takes more time and thoughtfulness than in a non-super-obese patient. And so, I think the time delay there, you always think about that, and that’s something that’s unique in the care of that population. I think that sometimes influences your willingness to continue along the labor course, or to proceed more towards that delivery.

Finally, providers lamented that the increased time, effort, and additional help negatively affects other patients receiving care at the same time. Because providers spent more time with patients with a BMI ≥ 50 kg/m 2 , they had less time to spend with their other patients, affecting the patient experience for all.

The staffing challenges providers described contributed to two primary safety concerns that came up during discussions. First, providers discussed how performing some responsibilities, especially positioning and moving patients, can be a safety issue for patients as well as providers, especially when attempting to move patients on their own. One OB/GYN resident described this concern in detail:

And I think that maybe we should have–should we have like two to one nursing for some patients who have a higher BMI, or just have help for being able to help move them into different positions, like left, right, getting their legs over the peanut ball, sometimes. And also, it can sometimes be like a workforce injury or something, to smaller nurses who are trying to move very big patients; it’s also not safe for the nurses, sometimes. And so, having two people, or other mechanisms to help move patients, would be safer for our staff, and safer for them, ultimately, if that has any impact on their labor course, and decreasing C sections, and things like that.

Second, providers also expressed concerns regarding not being able to identify certain potentially serious issues. For example, a nurse described challenges around doing fundal checks:

You see these patients sometimes go their whole recovery and things seem fine. And then, they move right before they move to postpartum and they’re hemorrhaging because the whole time, it was so difficult to really feel the top of the fundus. That just makes it more difficult to get a really reliable check. And I think these patients have just such a disservice done to them because then, they end up in these situations that might not have been avoided because sometimes, if you’re going to bleed, you’re going to bleed. But it could have been caught earlier or prevented.

To address the various staffing barriers, both nurses and physicians supported changing to a two to one or one to one staffing model, either at key points during labor or for the entire labor course. They argued the advantages of this model could be better positioning, safer labor, better patient experience, and increased likelihood of a vaginal birth. A nurse described her thoughts on this type of staffing model:

When you’re able to be singled with a BMI patient, your care is so much better. You’re not worried about watching another baby on the monitor. You can actually be in there adjusting monitors as needed, flipping them as needed, and giving them the time because it takes extra time as we’ve all alluded adjusting the monitors and adjusting on the meds and everything. But just being able to give them the time. That way, it’s just so much better. And they have a better labor because you’re able to give them that experience.

Other suggestions for improving staffing included getting more help to move patients, designating a staff member to stock BMI supplies as well as having a designated BMI team. As one nurse stated, “ People should know that when they’re going in there and when someone is making assignments to know this girl has a BMI patient . Let’s not give her twins also in the other room .”

In terms of equipment, providers primarily criticized the transfer mats. While they acknowledged the mats were helpful, they also caused various frustrations for providers trying to optimize labor. Per the providers’ experiences, the mats often slid low in the bed and got easily bunched under patients because there was no way to secure them to the bed. Providers sometimes tried to secure them by tying them to the bed or placing them under a fitted sheet. However, these solutions can create additional challenges. As one nurse explained, “ in an emergency , if nobody has scissors on them , you can’t get the transfer mat off of the bed to transfer the patient to the OR [operating room] table . So , that ended up being kind of a barrier because it eliminated one problem and caused another .” Another nurse highlighted the effect the transfer mat can have on other aspects of care, adding:

So, what ends up happening is if you are actually turning your patient every hour or every half hour or whatever they need to be doing, the [transfer] mat gets all bunched and crazy underneath the patient. And especially when you’re flipping your patient hourly, it’s one nurse in there. And you can’t be adjusting the [transfer] mat and flipping the patient at the same time. It physically can’t happen. And so, I do think that our patients end up suffering because they don’t move as much and then, they don’t dilate as quickly. And then, they get infections. And it just kind of all snowballs.

Other equipment issues largely revolved around insufficient sizing. For example, providers mentioned the hospital gowns weren’t the correct size, the fetal monitoring belts were too thin, and phalanges on breast pumps were too small for their patients. In addition, they had troubles finding the correct IV needle and blood pressure cuff sizes. Finally, providers had issues keeping the proper equipment stocked in a streamlined manner.

Providers reported that using incorrect sized equipment led to safety issues. Also, when providers used the incorrect size blood pressure cuffs, they tended to place them on locations besides the upper arm. Providers worried that readings were inaccurate and inconsistent, creating additional issues in care. A resident described the various issues involving the blood pressure cuffs:

Another thing that I think about with our patients with a higher BMI is whenever I go into their rooms, it’s so variable where their blood pressure cuff will be on their body, and I get concerned about the accuracy of those readings, and if we are detecting accurate pressures for them, especially because they oftentimes will have more complex comorbidities. And so, not being aware of if they’re ever having an evolving preeclampsia picture is something I worry about. So, I think it might be helpful for us to know, like where is their blood pressure cuff currently, with the readings that we’re seeing? Is it on their wrist? Is it actually on their forearm? And I think we have different blood pressure cuff sizes, but very frequently patients always say that it’s super uncomfortable and they can’t tolerate it, so they get moved.

This resident, along with other providers, worried that incorrect sizes of bands, gowns, and blood pressure cuffs were uncomfortable and caused unnecessary embarrassment, therefore negatively impacting patients’ birth experience. In summary, the primary equipment needs were to have a stock of larger, wider range of sizes for various labor-related equipment so that patients can be comfortable, and measurements can be accurate.

When discussing safety concerns around patient airways, the CNM/NP group wondered why incentive spirometers were not widely utilized. One participant in the group summarized this need:

The other thing that I get called on when I’m covering the post-partum pager is O2 sats that drop in the post-partum period. I feel like I get quite a bit of calls about that. And I think for any patient after abdominal surgery, there is that concern for atelectasis after surgery. For some of these larger BMI patients who might also have like underlying sleep apnea, that just puts them at risk for all kinds of things post-partum. I really wish that we had more of an emphasis on utilizing incentive spirometry on post-partum with some of these patients who are at higher risk, too.

This group wished to see incentive spirometers used post-partum to aid with airway issues more commonly experienced by patients with a BMI ≥ 50 kg/m 2 . They mentioned how this equipment was used in other areas of the hospital, but they did not see it often where they worked. To implement use, the incentive spirometer would need to be ordered and the nurses would need to be taught how to use them in order to instruct patients.

Discussion across provider groups stressed the need for creating designated rooms, areas, or trays that are consistently stocked with the equipment most often used. Table 2 below and the certified nurse midwife and nurse practitioner group summarize this need:

CNM/NP 2: But maybe that’s why it would be better if it was a designated room. Then, you know the stocking, when they come in and stock the rooms, they’re also stocking the BMI cart. So, as opposed to relying on the non-traditional stockers as an added task. CNM/NP 1: The same way we check off the code carts. So, there is a designated person who checks off code carts every shift. Implementing that for the high-risk rooms because morbid obesity or high BMI is included in high risk.



While transfer mats were the most discussed piece of equipment, providers gave no suggestions on how to improve their use or keep them from sliding.

Titrating oxytocin

Providers felt as though guidance on titrating oxytocin to create adequate contractions for patients with a BMI ≥ 50 kg/m 2 was lacking. Many sensed that patients with a BMI ≥ 50 kg/m 2 required more oxytocin, but providers varied in how they approached the amount and timing of such increases in oxytocin. Several providers, including nurses themselves, mentioned that nurses are hesitant to adjust oxytocin levels above what is recommended for the general population. Communication on how to proceed differed depending on who they asked, adding to confusion.

Providers desired information on how to approach oxytocin, including the pharmacokinetics of oxytocin. Some suggested that talks (even if just on a recorded video) from physicians providing guidance and scientific justification on why it is appropriate to increase oxytocin levels would be helpful. They also wanted to see standards and streamlined communication regarding titration for patients over a certain BMI, so the approach is not so provider specific, as discussed below by one of the CNM/NP group participants:

Communication with the floor nursing staff in terms of Pitocin titration. We know that patients need more Pitocin when they have a higher BMI, but we struggle a little bit with that coordination. A lot of times, the patients–we can’t pick up contractions or the nurses are a little uncomfortable going above 20 or going above 30. So, maybe just, again, communication with everyone of yes, we know that these patients are going to require more Pitocin.

Providers across groups described major difficulties in monitoring contractions and fetal heart tones throughout the labor course. Even once established, keeping up monitoring was challenging, especially while moving or repositioning patients. Providers perceived that patients sometimes feel at fault when monitoring is lost since patients apologize and try not to move too much, yet providers know that staying still during labor is uncomfortable, difficult, and not ideal for labor progression. Monitoring belts often didn’t fit patients with a BMI ≥ 50 kg/m 2 .

Because of monitoring challenges, providers tended to transition to internal monitoring earlier than usual. These issues also compounded other safety concerns since monitoring is how providers measure contractions, determine the effectiveness of oxytocin, and make delivery decisions. One resident summed up many of these challenges:

We just have a lot of difficulties dealing with fetal heart tracing. And so, I think we frequently have to internalize those patients pretty early on in their labor course, which I always feel hesitant about, just increasing their risk of infection, and doing that so early on. But I also understand that it can be a burden to the nursing staff, constantly trying to adjust the monitors, in order to effectively trace their contractions; and again, the heart tracing.

The primary suggestion to improve monitoring was to improve the associated equipment, such as longer belts and monitors that adapt for a patient’s size.

Moving and positioning

Providers described various challenges in moving, positioning (and re-positioning), and transferring patients. They had trouble optimizing patients’ positioning for delivery, especially when the beds are too small and changing positions were physically difficult for the patient and the assisting provider. Providers reported asking for additional assistance because patients are numb from the epidural earlier and longer. As a result, nurses reported making fewer position changes, which concerned them because of the potential for slower cervical dilation, higher infection risk, and decreased chance of vaginal delivery. One nurse described these challenges:

I think in less emergent scenarios that also just movement, in general, doesn’t happen as frequently with our patients with high BMI’s. Movement and labor is crucial to get them to dilate, to help the baby have good heart rate. And both because I think, in general, it’s a lot of work to continually change the positions in our patients with BMIs.

Providers reported that difficult position changes could interrupt fetal monitoring and IV access, as well as negatively affect the ability to intubate patients if needed. Providers were concerned that the physical exertion needed to change position may also cause patients to lose stamina for labor.

To address these challenges, providers expressed a desire for training and guidance on the best positions. They also recommended designating additional staff to help with position changes, so the maneuvers are less physically exhausting for patients and providers alike.


There were challenges in communication between patients and providers. On the patient side, providers felt they did not adequately counsel regarding the risks of obesity and approaches to prevent negative outcomes. Providers also acknowledged that counseling on risks was challenging with all patients, primarily because most providers do not want to focus on what could go wrong, and providers do not want to unnecessarily scare patients. Many providers felt uncomfortable mentioning weight and shied away from doing so during counseling because they didn’t want to insult patients, perpetuate fat-shaming, medicalize childbirth, or make the patient feel like there is something wrong with them. As one resident described, “I definitely have a bias towards not mentioning weight, because I feel sometimes, I don’t want to make the patient feel uncomfortable, or I don’t want to instill distrust, or have them think that I’m thinking about their weight in a negative way.” Because of this hesitance to mention weight, providers said they sometimes do not give explanations for common issues that arise in labor or obtain a comprehensive medical history.

Providers also wished to receive more feedback from patients. Reviewing patient satisfaction surveys might inform them about how patients feel about their labor experience. Some lamented not knowing how to make patients more comfortable, how to reassure them, or how patients prefer to approach such a sensitive topic in counseling. Several wondered whether avoiding weight discussions make patients feel worse or keeps the subject taboo.

Some providers felt a disconnect between themselves and their patients, mentioning how difficulties in care can affect the patient-provider relationship. Communication gaps also contributed to certain misunderstandings. As one member of the anesthesia team explained, “sometimes I wish it was easier for patients to understand anesthesiologists are there for their safety, and we’re not there to be bad guys. I think there are a lot of mommy blogs that are against epidurals and that kind of thing, so it would be helpful if they understood more often it’s for safety purposes.”

Issues in provider communication seemed to stem from lack of specific guidelines. Without guidance, providers attempted to use procedures and standards for the general population for patients with a BMI ≥ 50 kg/m 2 , like those for oxytocin titration. Many mentioned that standard counseling language for patients with a BMI ≥ 50 kg/m 2 does not exist. Others worried the frustrations they felt from care challenges affected how they speak about patients.

To address communication issues with patients, providers wanted standardized language templates to counsel on topics like labor differences, expectations for being at the hospital (including early epidurals), monitoring, preventative actions, and outcomes. Some desired consistent, patient-centered conversations that frame high BMI as simply part of health history and normalize it. A resident explained:

And so, if maybe have training on the best way to approach those conversations, and do it in a way that is patient-centered, and is said in a way that is looking out for them, and shows that we actually–by saying these things, we care more about them, as opposed to saying it–and maybe people, I’m sure, in the past, because of their weight, have felt–just have poor experiences in healthcare because of all these things. And to have our message being received in the best way possible.

Regarding communication between providers, several explained that a quick meeting of team members or "time out" at shift change or other key times would sync the clinical concerns across all provider groups. Some wanted better interdisciplinary relationships and more opportunity for conversation among different provider groups. One OBGYN faculty member suggested the bedside nurse initiate any relevant pathway and take the lead on communications because that person “is the one running the show for the patient.”

Suggestions for improvement

Throughout discussions of the challenges they face, providers also offered suggestions on how to improve conditions, processes, and care for patients with a BMI ≥ 50 kg/m 2 . To capture all possible suggestions, they were also asked to imagine what they would include in a pathway or toolkit for care of patients with a BMI ≥ 50 kg/m 2 . A wealth of ideas emerged, primarily pertaining to guidelines, training, checklists, and patient tools.

Providers suggested implementing guidelines or protocols for many aspects of care so that, as one OBGYN faculty member stated, “everybody can be on the same page because not all of us are consistently experienced with this” They wanted guidelines for counseling, positioning, titration of oxytocin, internal monitoring, and staffing. In the study survey, half of providers (14, 51.9%) responded “Yes” when asked if they use guidelines for care of patients with a BMI ≥ 50 kg/m 2 , but only two named specific guidelines (American College of Obstetricians and Gynecologists, Society for Obstetric Anesthesia and Perinatology). Others only mentioned small-scale guidance, like using a transfer mat or ordering an x-ray after cesarean deliveries. These varied responses further stress the need for guidelines specific to patients with a BMI ≥ 50 kg/m 2 .

An array of training was suggested. Nurses desired training on managing oxytocin titration, including information on oxytocin receptors and IV oxytocin. They also wanted training on using ultrasound to place IVs to improve the IV placement experience. Some wanted training on position changes while others wanted training on how and where to use blood pressure cuffs and how to choose proper cuff size. Providers across groups wanted training on patient-centered counseling, sensitivity training, and implicit bias training to improve their communication and relationships. One participant in the CNM/NP group explained, “Including this in implicit bias I think would be helpful. We have implicit bias training. Sizeism is definitely something that exists in our society.”

To deliver training, providers suggested creating an online module they could complete on their own time. Some suggested including video explanations from physicians to engage providers. As one nurse described:

I think nurses want to know the rationale a lot of times. I think we probably know our Pitocin policy backwards and forwards. We all know how often you can go up. We all know when you turn it down. We all know that policy. But I think sometimes, maybe especially for new nurses who are learning to understand the rationale like why do we do it this way. There is a reason for most things. Some things I guess you could question. But for most things, there are reasons why we do it. And I think having those discussions with having some of our physician partners say this is done because there were studies done and they showed blah, blah.

Providers recommended various tools and referrals. They discussed ideas for handouts such as how to prepare for induction. One participant in the CNM/NP described what a handout to prepare for induction, for example, could look like:

Ideally, there would be a handout or something that they could give to the patients. We kind of talked about this a little bit. Anyone who is being induced for whatever reason, patients don’t know a lot about inductions, in general. And for each specific category whether you’re getting induced for obesity or hypertension, it would be nice to have a handout that you could give that they could read before they come into the hospital like this is the gist, the basics. These are the issues that could be a problem during labor and what you’re at higher risk for.

One participant in the CNM/NP group stated that whatever information they provided to patients in handouts should also be available online. Providers felt creating checklists would help patients as well as themselves. One resident posited:

Like having a checklist of things that we should be even more careful about thinking of, that we articulate out loud before the case, so everything we do is intentional, related to that patient, and their risk factors, because we are intentional; but sometimes, when you have to voice it out loud, that increases the intentionality; and also, discussion in the room, if needed, to make sure that we’re making the best choice for that patient.

An OBGYN faculty member added, “Honestly, having less to think about, like having these kits or these checklists that kind of free our brain power to do other stuff, is probably better.” Table 3 shows a full list of patient tools, resources and referrals suggested by providers across groups.



We aimed to explore the experiences of a diverse group of providers who provide peripartum care for people with a BMI ≥ 50 kg/m 2 . We determined six key themes of staffing, equipment, oxytocin use, monitoring of vital signs, movement and positioning, and communication. Issues in one area of care often affected others and cause additional issues, compounding the risk, safety concerns, and impact on patient experience.

Providers faced two particularly troubling paradoxes. They tried to promote vaginal delivery as much as possible. However, the numerous barriers providers faced during monitoring of vital signs (e.g., blood pressures, fetal heart rate, contraction pattern) made the labor process more challenging. Similarly, epidurals are recommended early in the labor process because placement can be technically challenging, and anesthesia is then readily available in the event of an emergency [ 20 ]. However, early placement limits a patient’s mobility for a longer duration during the labor, thereby requiring more interventions on behalf of providers and potentially increasing risks for protracted labor and complications such as thromboembolism. Although several provider groups felt their actions had the safety of their patient and their fetus as a priority, they felt as though the patient perception was sometimes the opposite.

Our findings are similar to prior studies of midwives, who also identified safety issues and different equipment requirements (i.e., larger beds and chairs) as well as the need for increased skills in providing care [ 13 , 21 – 23 ]. Prior studies have also identified themes such as a “creeping normality”, “feeling in the dark”, and referring to the obesity epidemic as a “runaway train” to describe how common obesity in pregnancy has become, the lack of guidance for management, and how rapidly the changes in weight have occurred [ 13 ]. These themes were similar to our providers whose common emotions ranged from frustration, fear, and uncertainty of how to provide a safe delivery in a stressful health environment.

The lack of existing guidelines or standardized aspects of care permeated throughout the discussions, especially for oxytocin which is typically administered through an IV and managed by nurses. Whether used for an induction or augmentation of labor, the dosing does not account for any anthropomorphic data such as a person’s weight or BMI, but instead is dosed according to a clinical effect (i.e., occurrence of contractions). Prior studies describe longer labors, slower progress in labor, and requiring more oxytocin to achieve a vaginal delivery as BMI increases [ 8 , 24 , 25 ]. The relationship between labor and oxytocin also involves oxytocin receptors in the myometrium and other feedback pathways including the autonomic nervous system [ 26 ]. Data to support alternative dosing regimens for oxytocin are limited. For example, a secondary analysis of a double-blinded randomized controlled trial of singletons ≥ 36 weeks of gestation evaluated high (initial and incremental rate of 6mIU/min) and standard oxytocin dose (initial and incremental rate of 2mIU/min) to determine if there was an effect modification among people with a BMI < 30 kg/m 2 or ≥ 30 kg/m 2 [ 27 ]. Although high dose oxytocin reduced the frequency of chorioamnionitis for people with a BMI < 30 kg/m 2 , there were no treatment effects for the outcomes of cesarean delivery, endometritis, postpartum hemorrhage, or a severe morbidity composite for people with a BMI ≥ 30 kg/m 2 [ 27 ]. Providers who lamented the lack of guidance on oxytocin use in our study were those most involved in its dosing and titration (nurses, certified nurse midwives, nurse practitioners, resident physicians). Certainly, this topic is an area in need of further research so that oxytocin dosing is safe and effective.

The topic of communication not only related to providers, but communications between providers and patients. Discussions about weight are sensitive ones, as has been previously described in studies about appropriate terms to use for weight and how to start the discussion about weight [ 28 , 29 ]. Providers felt as though no matter what words they used, they weren’t well-received and opted to avoid the topic altogether. Providers suggested tools for patient education (i.e., handouts, information on hospital website) and their own education (i.e., online modules, bias training).

Important information was gathered pertaining to how to improve care in the six thematic areas. It is possible that the feasible and tangible items for a “BMI cart” ( Table 2 ) could be adapted for most labor and delivery sites. Items for either a toolkit or checklist ( Table 3 ) are also thought to be practical, yet topics such as oxytocin titration require more research and nursing ratio adjustments also need to address any systems and/or financial issues.

We recognize the following limitations to this study. Patients were implicitly and explicitly missing from this work—implicitly in that the objective is to improve care for them, which was only examined from the perspective of their providers and explicitly in that multiple provider groups wondered what patients think and wanted more feedback from patients. Future studies could examine the peripartum experience of patients and their suggestions, which could inform and potentially enhance many of the improvements that providers suggested. The providers who participated in these focus groups work at a single urban hospital with a large volume of deliveries and diversity in complexity of deliveries as well as extremes of weight. As such, providers at different sites may not find these experiences similar to theirs or find the suggestions applicable to their care.

In summary, this group of providers, representing diverse roles in peripartum care, discussed a range of challenges and barriers to optimal care. They also described how current approaches to care may negatively affect the peripartum experience and pose threats to safety for patients with a BMI ≥ 50 kg/m 2 and their providers. A wealth of information was gathered regarding how to improve care in several areas.

Supporting information

S1 file. coreq checklist..


S2 File. Focus group guide.


S3 File. Data.


S4 File. Codebook for focus group transcript analysis.


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Qualitative Research Findings as Evidence: Utility in Nursing Practice

Wendy r. miller.

1311 N Street, Bedford, IN 47421, ude.iupui@lbeurtrw , Indiana University School of Nursing

The use of qualitative research methods in nursing research is common. There is a need for Clinical Nurse Specialists (CNSs) to become informed regarding how such qualitative findings can serve as evidence for nursing practice changes.

To inform CNSs of the meaning and utility of qualitative research findings. Implications for qualitative research findings as evidence in nursing practice are particularly discussed.


As the use of qualitative research methods proliferates throughout health care, and specifically nursing research studies, there is a need for Clinical Nurse Specialists (CNSs) to become informed regarding the potential utility of qualitative research findings in practice. In this column, the questions of what qualitative findings mean , how the ever-increasing amounts of qualitative research evidence can be used, and how such findings can contribute to evidence-based nursing practice, are considered. First, to provide readers with a context for the discussion, a brief overview of qualitative research and its theoretical underpinnings is included.

What is Qualitative Research?

Qualitative research refers to a method of inquiry in which the researcher, acting as data collection instrument, seeks to answer questions about how or why a particular phenomenon occurs. Questions regarding of what a phenomenon is comprised may also guide qualitative research 1 . The most fundamental assumption underlying qualitative research is that reality is something socially constructed on an individual basis 2 . Varied methods of qualitative research exist. Examples of qualitative methods employed in nursing research include grounded theory, phenomenology, ethnography, and qualitative description. Each method has its own assumptions and purposes and an appropriate method is chosen based on the research question. For example, a researcher investigating the process involved in the occurrence of a phenomenon would likely choose grounded theory, while a researcher interested in the meaning of the phenomenon would utilize phenomenology. Regardless of method, participants are purposefully enrolled based on their familiarity with the phenomenon. Data are generally collected via one or a combination of three mechanisms: interviews, observation, or document/photograph review. Data are analyzed inductively via specific, rigorous techniques and then organized in a manner which best answers the research question 3 . Importantly, the objective of qualitative research is not the accumulation of information, but the growth of understanding about phenomena of concern to nursing 4 .

The Nature of Qualitative Research Findings and their Use as Evidence

The way in which qualitative findings appear in research reports varies depending on the method utilized. Experts (Sandelowski and Kearney) in the field recommend categorizing qualitative findings in terms of the knowledge they generate, regardless of methodological origin. Sandelowski and Barroso 5 have developed a typology of qualitative research findings. In this typology, findings exist on a continuum. Categories on the far left side of the continuum (“no finding,” consisting of a report of raw data, and “topical survey,” consisting of an organization of the data in a table of contents format) are considered to be not research and not qualitative research, respectively. The remaining three categories on the right side of the continuum (“thematic survey,” consisting of patterns found in the data, “conceptual/thematic description,” in which concepts and themes are used to link and illuminate concepts in new ways, and “interpretive explanation,” the defining feature of which is a transformation of data into theories or full explanations of a phenomenon) are considered exploratory, descriptive, and explanatory, respectively. While the authors note that the goal of the typology is not to judge the quality of findings, the typology can assist readers in determining which types of findings should be omitted from evidence influencing practice (no finding and topical survey) and those which may be more sophisticated, furthest from the data, and potentially applicable to practice.

Kearney 6 , too, has put forth a categorization mechanism for qualitative findings based on their degree of complexity and discovery and asserts that their application as evidence in practice is based on the category in which they fall. Findings “bound by a priori frameworks” are produced via the application of existing sets of ideas to data without identifying new insights. These findings cannot serve as evidence. Findings comprised of “descriptive categories” are similar to those in the “topical survey” 5 and serve as a type of evidence that provides a map for previously unstudied experiences. “Shared pathway or meaning” findings portray linked themes or concepts, as well as an analyst’s ideas for practice implications. Findings that situate under the category of “depiction of experiential variation” not only describe the essence of an experience but portray how that experience varies depending on context. Finally, findings characterized as a “dense explanatory description” are considered the gold standard and explain human behavior and choice-making. 6 Findings in this category are most readily applied to clinical practice.

Now that the types of qualitative findings have been described, it is possible to discuss how such findings are used in nursing practice. A common misconception is that qualitative research findings are, by default, preliminary to quantitative studies, cannot stand alone, and lack generalizability 4 . Qualitative findings, however, can be complete by themselves. Sandelowski 4 differentiates between the generalizability of quantitative findings versus that of qualitative findings. Regarding quantitative findings, generalization is characterized by establishing universal laws for populations based on information from samples deemed to be similar to those populations, which cannot, nor is it meant to, be achieved with qualitative findings. Qualitative findings are not generalizable in the prevalent sense of the word—they do not provide laws or relationships that can be taken from a single sample and applied to entire populations. Rather, they are generalizable in a way that is particularly pertinent to nursing practice, in which there is an expectation that scientific findings, and nursing care itself, be tailored to unique individuals in their distinct contexts. That is, qualitative findings provide idiographic knowledge about human experiences to readers , who can apply qualitative findings to the care of individuals who are in situations similar to that of those in the sample from which findings came 4 . A prime example of the generalizability of qualitative findings is seen in Conrad’s 7 study, which reframed the problem of “non-compliance” to “self-regulation” whereby patients with epilepsy changed medication practices in order to exert control over their disease. The findings from this study have been generalizable in that they have, in the form of a self-regulation theory, helped in understanding the origins of seemingly self-destructive behavior associated with a wide range of “noncompliant” behavior related to childhood immunizations, safe sex practices, and self-management of asthma and diabetes 8 . As the above example demonstrates, a CNS who reads qualitative research can potentially gain insight into the behaviors, needs, and experiences of his or her patient population, informing CNS practice. For example, an obstetrics/neonatal CNS who learns about the etiologies of prenatal “non-compliance” behavior via reviewing qualitative research findings is armed with information to help him or her develop etiology-specific nursing interventions for mothers living this experience, rather than relying on more general interventions to improve treatment adherence.

Sandelowski 9 notes that qualitative findings can demonstrate instrumental, symbolic, and conceptual utility. Instrumental utilization refers to the concrete application of findings that have been made into new forms such as clinical guidelines, standards of care, appraisal tools, algorithms, and intervention protocols. Symbolic utilization is less concrete and does not result in a true practice change, but rather findings are used to legitimate a position or practice. Symbolic utilization of findings is often a precursor to instrumental utilization. Conceptual utilization is very intangible, and leads to the way in which a user thinks about providing care.

Qualitative findings have demonstrated independent instrumental utility in leading to key changes in clinical communication practices. The results of one study eventually led to the recommendation that active listening, appraisal, teaching, and social support be included in patient-family-provider communication. These findings were executed into practice directly and have led to improved outcomes 10 . A CNS could similarly directly apply qualitative findings to practice. For example, an oncology CNS who learned, via reading qualitative research, that oncology patients prefer a certain type of communication style at the end of life could work in the nursing sphere to educate nurses and develop with them a communication guide for these particular patients. The CNS could then measure pertinent outcomes associated with the intervention (patient satisfaction, for example). Qualitative findings also demonstrate instrumental utility by refining quantitative research. Qualitative findings often underlie the concepts measured in quantitative instruments. 9 Further, qualitative findings provide knowledge about how individual and contextual factors affect the impact of an intervention 11 and can explain subject variation on targeted outcomes of an intervention 12 . That is, qualitative methods can be used to investigate unexpected quantitative results or to explain why the effectiveness (success of an intervention in a research study) is not equal to its efficacy (success of an intervention in practice). For example, qualitative findings might inform a CNS of potential reasons a particular evidence-based intervention has not been effective in his or her patient population or for a specific patient. Conceptually and symbolically, qualitative findings are useful by increasing nurses’ understanding of patients’ experiences, thereby allowing for more tailored interventions in care, as well as the anticipation of problems that might be encountered by a particular patient in a particular context 9 . Qualitative findings inform a CNS’ understanding of patients’ experiences, improving his or her ability to develop specific, tailored interventions, particularly in the patient and nursing spheres, that will improve patient outcomes. For instance, a CNS who learned, via reading qualitative research, that ventilated patients’ chief concern is their inability to communicate while intubated could devise and implement nursing interventions that would allow for the use of alternative communication strategies for these patients. In effect, the experiences of patients in a certain situation (as captured via qualitative methods) have informed, and potentially improved, the care provided to other patients in that situation.

Kearney 6 has made explicit statements regarding the ways in which qualitative findings can directly impact nursing practice. First, findings can lead to clinical insight or empathy . In this simplest mode of application, nurses can learn “what it feels like” to be in a given illness situation, common factors encountered by patients in that situation, and different ways patients view an illness. Armed with this understanding, the nurse pays attention to new cues from the patient, can make sense of certain presumably aberrant behaviors, and provide support in a more informed way. Qualitative findings can also contribute to assessment of patient status or progress . Findings which portray a trajectory of illness can inform the development of clinical assessment tools for individual patients or, with further testing, a particular patient population. For example, if a nurse reads that there are five reactions from teenage mothers immediately following birth, he or she can monitor for specific cues and form questions to determine the patient’s reaction and possible needs. Qualitative findings can also be applied via anticipatory guidance . This type of application is somewhat interventionist, as nurses share qualitative findings directly with clients, offering a research-based perspective on what patients might be experiencing and how others have described that experience. Findings at the “shared pathway” level are needed for this application. Coaching is achieved when the nurse shares qualitative findings with clients and further advises regarding steps they should consider taking to reduce stress/symptoms and improve adaptation. This application requires higher-complexity findings.

Evaluating the Validity of Qualitative Research

How does one know if he or she can trust the results of a qualitative study? Unlike in quantitative research, in which there are checklists and p values available to guide such a decision, the evaluation of qualitative research is less clear-cut. While researchers have created checklists to ease the process by which the validity of qualitative findings is assessed 13 , experts in the field struggle to come to a consensus regarding the appropriate criteria for evaluating qualitative studies because, according to Sandelowski 14 and others 15 – 16 , no criteria can uniformly address quality in the many various methods used in qualitative research. That is, quality “looks different” from one qualitative method to the next. Sandelowski and Barroso 16 prefer that the quality of qualitative studies be judged based on criteria specific to the method being used. These authors offer a reading guide , to which readers of this journal are referred, which guides readers through evaluating the features of any qualitative report most relevant to its quality and use 16 .

Undeniably, qualitative methods have become a standard way in which researchers generate knowledge pertinent to nursing practice. Thus, CNSs are surrounded by much qualitative evidence with which they might lack familiarity in utilizing. Here, the discussion, though admittedly non-exhaustive, has hopefully illuminated to readers the value and potential utility of qualitative findings as evidence in nursing, including ways in which such findings can be immediately applied to practice. Further, readers have been exposed to the evaluation of qualitative studies and it is hoped that they will seek out the suggested sources in helping them to learn to read and critique qualitative studies so that data generated from such studies can be added to the CNS’s repertoire of evidence.


This column was made possible by Grant Number 2T32 NR007066 from the National Institute of Nursing Research

Wendy Miller is an Adult Health Clinical Nurse Specialist and a PhD in Nursing Science student at the Indiana University School of Nursing. She is studying the self-management of older adults with epilepsy and is supported by a T32 pre-doctoral training grant.

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