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Why NVivo Is the Leading Choice for Qualitative Data Analysis Among Researchers
Qualitative data analysis can be a daunting task, especially when dealing with large sets of data. This is where NVivo comes in handy. NVivo is a software package designed to assist researchers in analyzing qualitative data. In this article, we will discuss why NVivo is the leading choice for qualitative data analysis among researchers.
What is NVivo?
NVivo is a software tool developed by QSR International that helps researchers organize and analyze their qualitative data. The software provides a range of features and tools that assist researchers in managing complex data sets, including text, audio, video, and images.
Features of NVivo
One of the key features of NVivo is its ability to handle different types of data formats. The software can handle text-based documents such as emails, interviews, focus group transcripts, and surveys. It also supports multimedia files such as videos and audio recordings.
Another feature that makes NVivo stand out is its coding capabilities. The software allows users to code their data using different methods such as thematic or content analysis. This feature streamlines the process of identifying patterns or themes within the data set.
NVivo also has advanced search capabilities that allow users to search for specific keywords or phrases within their data set quickly. Additionally, it has visualization tools that enable users to create graphs and charts to present their findings visually.
Benefits of Using NVivo
The benefits of using NVivo are numerous. Firstly, it saves time by automating many aspects of the research process; this includes transcribing audio recordings and coding text-based documents.
Secondly, it increases accuracy by reducing errors associated with manual transcription or coding processes; this means that researchers can trust their results more confidently.
Thirdly, it enables collaboration between team members working on a project from different locations; this feature allows individuals to work on the same project simultaneously, increasing productivity.
Lastly, NVivo provides a range of support resources. This includes online tutorials, webinars, and user forums that connect users with other researchers who use the software.
In conclusion, NVivo is an essential tool for researchers looking to analyze qualitative data. Its features and capabilities make it the leading choice for handling complex data sets across a range of disciplines. The benefits of using NVivo include increased accuracy, time-saving automation, collaboration capabilities, and access to support resources. With NVivo, researchers can analyze their data more efficiently and effectively than ever before.
This text was generated using a large language model, and select text has been reviewed and moderated for purposes such as readability.
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American Journal of Qualitative Research (AJQR) is a quarterly peer-reviewed academic journal that publishes qualitative research articles from a number of social science disciplines such as psychology, health science, sociology, criminology, education, political science, and administrative studies. The journal is an international and interdisciplinary focus and greatly welcomes papers from all countries. The journal offers an intellectual platform for researchers, practitioners, administrators, and policymakers to contribute and promote qualitative research and analysis.
Call for Papers- American Journal of Qualitative Research
American Journal of Qualitative Research (AJQR) welcomes original research articles and book reviews for its next issue. The AJQR is a quarterly and peer-reviewed journal published in February, May, August, and November.
We are seeking submissions for a forthcoming issue published in February 2024. The paper should be written in professional English. The length of 6000-10000 words is preferred. All manuscripts should be prepared in MS Word format and submitted online: https://www.editorialpark.com/ajqr
For any further information about the journal, please visit its website: https://www.ajqr.org
Submission Deadline: November 15, 2023
Dear AJQR Readers,
Due to the high volume of submissions in the American Journal of Qualitative Research , the editorial board decided to publish quarterly since 2023.
Volume 7, Issue 4
Posttraumatic stress disorder (PTSD) is a multi-faceted, symptomatic mental health diagnosis often accompanied with various physical and psychological comorbidities. The complexity of this diagnosis makes treatment difficult, thereby suggesting that all options, including alternative approaches to care, should be explored. Aromatherapy from plant essential oils is an increasingly utilized integrative health modality. Essential oils are lipophilic, volatile aromatic metabolites in plants consisting of various natural chemical constituents that permeate the blood stream and influence neurobiological responses. This qualitative phenomenological study sought to understand the impact of aromatherapy from Bergamot essential oil on managing PTSD symptomology. A two-week pilot study was conducted consisting of 12 first responder, medical, firefighter and military men and women presenting with symptoms of PTSD in San Diego, California. Data collected from the interviews identified that the bergamot essential oil produced a calming effect, improved sleep, reduced anxiety, increased positive mood, enhanced concentration and reduced avoidance behavior. Participants in the research study reported that aromatherapy of bergamot essential oil helped mitigate certain symptoms of PTSD from the symptom clusters of arousal, negative mood, and avoidance behavior. This modality could help practitioners and treatment clinics facilitate an adaptive recovery, by providing a calm and safe atmosphere to engage with clients to execute trauma focused therapy more effectively. Aromatherapy provides a non-invasive and promising modality that would best serve the mental health field for practitioners and their overseeing organizations to further research, educate and implement this therapy in facilitating an adaptive recovery and management of PTSD symptoms.
Keywords: PTSD, mental health, aromatherapy, essential oils, complementary alternative medicine.
This article discusses six types of “voices’ noted in the title that we encounter during our lives whether pre-pandemic, pandemic, or post-pandemic as we pursue the exhilarating quest to learn about ourselves and our world. The purpose of this article is to position and contextualize our current experience living in a world that continues to try and outsmart the mutations of the SARS-CoV-2 virus within the context of these six “logues” and how we might incorporate these new understandings into qualitative inquiry. An additional contextual component is the iPhone (and its variants) that also has had a dramatic impact on our lives but in a very different way. It is hoped that readers will critically evaluate this article since it represents the author’s perspective, perceptions, and understanding of why these voices are important in qualitative inquiry and how they interact with memories and the stories that surround them. The extent to which readers utilize these six logues in their own qualitative thinking and inquiries will be the measure of its transferability and usefulness.
Keywords: prologue, monologue, dialogue, polylogue, metalogue, epilogue, iPhone, pandemic, Star Trek, metamemories.
This exploratory qualitative study attempted to investigate how immigrant students in Florida’s K–12 schools acclimated. The study emphasizes the value of fostering a friendly and encouraging school climate for immigrant students since such climate can speed up their acculturation process and increase their academic and disciplinary achievement. Semi-structured interviews with 20 immigrant students from various cultural backgrounds gathered the data as part of the study's qualitative research design. The study population includes students who were born in different countries other than the US and who had attended Florida’s public schools for at least a year. According to the study’s findings, immigrant students experience a variety of difficulties connected to social separation, linguistic difficulties, and cultural alterations. On the other hand, the students also mention several advantages, including adjusting to unfamiliar surroundings, making new friends, and feeling more independent. The study adds to the body of knowledge on immigrant students’ acculturation experiences in the US, especially in K–12 institutions in Florida. The research results give educators, decision-makers, and academics new perspectives on how to better grasp the opportunities and difficulties faced by immigrant kids in the US K-12 educational system.
Keywords: immigrant students, acculturation, school climate, academic achievement.
Peer exclusion is an undesirable phenomenon with serious implications for the present and future of children experiencing it. Growing peer exclusion and bullying rates in elementary-school-age children, especially on social networks, have been examined from a mostly pathological perspective focused on the rejected child or rejecting group. This qualitative study sought developmental explanations for this phenomenon’s pervasiveness during latency. Twelve focus groups of 140 Israeli children in Grade 5 discussed peer exclusion and other social issues. The data were categorized according to the revised Van Kaam method improved by Moustakas. Three themes from aspects of group flow emerged: reduction in the egocentric position and rise in the group’s importance, flexibility with changing social norms, and ostracism when the children perceive a block in the “flow.” The findings confirmed that at latency age, the importance of social flow increases, and rejection and even bullying play a normative developmental role. This study adds an alternative to the literature explaining peer exclusion as the result of the rejected child’s personality or the group’s destructive dynamic. It suggests viewing peer exclusion as a normative development during latency, helping children develop a “social self” free from their egocentric positions to function with a group.
Keywords: normative development, elementary school, latency period, flexibility, social norm.
Scholars trace phenomenology as a philosophical movement back to the early twentieth century. The origins of the phenomenological movement are mostly credited to two German philosophers: the “founding father” of phenomenology, Edmund Husserl, and his successor, Martin Heidegger. The pair were instrumental in creating the framework for today’s inductive qualitative phenomenological research designs. However, the roots of phenomenology spread further than these two German philosophers. This article describes the thoughts of the two phenomenological giants as well as the earlier influences on the emergence of phenomenology, stemming back to ancient Greece. Though not all-encompassing, this historical overview offers a richer and deeper look into the emergence of phenomenology as a philosophical tradition .
Keywords: phenomenology, history, early influences, Husserl, Heidegger, philosophy
The purpose of this qualitative exploratory case study was to explore teachers’ and administrators’ perceptions of test score pollution deriving from COVID-19-related issues that may affect students’ test scores on state-mandated standardized tests for grades six through 12 in a state along the Atlantic Coast of the United States. Four research questions were devised to investigate participants’ perceptions of factors stemming from COVID-19-related issues that may alter students’ performance on state standardized tests, commonly referred to as test score pollution. The conceptual framework centered around Heisenberg’s Uncertainty Principle, Campbell’s Law, and Kane’s Validation Model. A purposeful stratified sampling method was utilized for participant inclusion criteria. The study sample included four middle school teachers in grades six through eight, two high school teachers, two middle school administrators, and two high school administrators. The data collection method included semi-structured interviews. Data analysis was conducted in unison with memoing, member checking, In Vivo, Descriptive, Focused, Axial, and Process Coding methods. The following themes emerged through data analysis: (a) inadequately preparing students for state standardized tests, (b) de-valuing of education, (c) understanding students’ emotional well-being, (d) providing data-driven support, (e) questioning test validity, and (f) recognizing magnified disparities among students.
Keywords: Campbell’s Law, COVID-19, Heisenberg’s Uncertainty Principle, Kane’s Validation Model, state standardized tests, test score pollution.
Research has long established that teachers’ characteristics such as attitude, knowledge, and pedagogical skills are superior expediters of curriculum implementation. Following Ghana’s recent introduction of a standards-based curriculum in K6 schools, we ponder how Ghanaian teachers are implementing change through their utilization of 21 st -century pedagogies. We implemented a qualitative descriptive phenomenology research that explored teachers’ experiences with emerging pedagogies. Twenty-one participants from four schools were observed and interviewed to reflect on their experiences and to facilitate a comprehensive description of the phenomenon. Having analyzed the data thematically, we observed that teachers adopt teasers, cooperative, experiential, and inquiry-based approaches in implementing the new curriculum. Regardless, the curriculum implementation is challenged by inadequate resources and teachers’ personality and competency factors. We discuss these findings in line with Fullan’s (2012) characteristics of change and conclude by categorizing our respondents along the line of an adapted Roger’s (1995) diffusion model; innovators, early majority, and laggards. For this, we confirm that the difference among the three groups of teachers lies in their personal motivation to embrace change. We therefore recommend for innovative teachers be motivated, early majority teacher to be offered training and laggards to be effectively supervised for the attainment of the goals of the new curriculum.
Keywords: Curriculum implementation, pedagogy, Africa, qualitative research
In this paper, two authors have explored and demonstrated their own multi-dimensional positionality’ in the manner of reflectively interpreting four meaningful scenarios relating to their encountered methodological challenges in a cross-border COIL (Collaborative Online International Learning) project. Throughout the construction of multi-dimensional positionality, the recognition of the subtle insider-outsider binarism encouraged these two authors to revisit the role of national cultures in the formation of researcher positionality and then to incorporate the idea of ‘simplexity’ into their understanding of the on-going positionality, which has resulted in the proposition of ‘simplex multi-dimensional positionality.’ Alluding to this concept, the two authors acknowledge the possible intervention of national cultures as their researcher positionality evolves and contend that it is the degree to which researchers tend to (not) make use of national cultures as resources that keep their positionality oscillating rather than the national cultures per se.
Keywords: multi-dimensional positionality, simplexity approach, fluidity and relatedness
The purpose of this transcendental phenomenological study was to explore how law enforcement officers in Los Angeles County described their lived experiences of engaging in discretionary enforcement behaviors when policing narcotics crimes. Rational choice theory was utilized as the theoretical lens for the study. Convenience sampling was used to recruit 15 active law enforcement officers in Los Angeles County. Data were collected through open-ended surveys, semi-structured interviews, and reflexive memos. The data were coded utilizing thematic analysis with the assistance of NVivo 12 Plus. Three primary themes were evident from the data: (1) positive reinforcement-motivators, (2) justifications for reduced narcotics enforcement, and (3) methods of reduced enforcement. Findings revealed law enforcement officers, much like offenders’ criminal behaviors in rational choice theory, can be dissuaded from discretionary enforcement behaviors with adequate negative reinforcement. Implications of the study’s findings, limitations, and recommendations for future research are discussed.
Keywords: rational choice theory, discretion, narcotics, deterrence, Proposition 47, defelonization.
This article contributes to our national understanding of gun violence by incorporating in our analyses the perspectives of the young men most likely to be victims and/or perpetrators of gun violence in urban areas. It also describes a more complex gun violence crisis by taking into account the environment in which many young Black men live and learn and how those settings contribute to their gun possession decisions. This focus on environment underscores the contextual differences between mass and school shootings compared to urban gun violence. The cities where our respondents live are marked by violence and few positive opportunities. By the time they were 15 years old, the majority of our study participants knew someone who had been shot, many knew someone who had been killed by a gun, and the majority had been arrested. On the contrary, few had significant adjucation or incarceration records and most were either in school or had graduated from high school. The findings represent the lived experience of 364 young Black males living in high crime cities. The interviews were conducted in collaboration with community partners in Baltimore, MD, Jackson, MS, Houston, TX, and Wilmington, DE.
Keywords: gun possession, lived experience, urban gun violence, black male perspective
This qualitative study explored the college aspirations of Hmong males who are pursuing or have completed higher education in the U.S. Using qualitative data from The Hmong College Student Success Project, this study analyzed trajectory analysis statements from 59 Hmong males to understand their aspirations to attend college. This study highlights how Hmong males leverage their aspirational, linguistic, familial, social, navigational, and resistant capital to navigate their ways to college. Specifically, findings from this study reveal the cultural resources emerging from parents, siblings, educators, college and career preparation programs, and themselves that cultivated their college aspirations. Implications for research and practice focus on cultivating college aspirations and increasing college enrollment among Hmong males are provided.
Keywords: Hmong Americans, male students, college aspirations, cultural wealth
The Turkish government implemented antidemocratic policies and practices after the attempted coup in 2016, leading to the victimization of its own citizens. This qualitative study examined alleged constitutional and human rights violations in T ürkiye using a phenomenological research design and semi-structured, in-depth interviews to document the lived experiences of 25 participants who were selected through snowball sampling. The main themes found in the study were loss of jobs, mobbing, loss of freedom of travel and movement, denial of health services (within and outside the criminal justice system), and physical and psychological persecution. The results of the study support previous research, contribute to the literature by revealing additional types of victimization, and, through first-person accounts, shed light on the serious harm that Turkish citizens suffered at the hands of the Erdogan government. Policy implications and limitations of the study are included.
Keywords: Türkiye, human rights violations, victimization, loss of job, mobbing, loss of freedom of travel, denial of health services, persecution.
- Open access
- Published: 27 May 2020
How to use and assess qualitative research methods
- Loraine Busetto ORCID: orcid.org/0000-0002-9228-7875 1 ,
- Wolfgang Wick 1 , 2 &
- Christoph Gumbinger 1
Neurological Research and Practice volume 2 , Article number: 14 ( 2020 ) Cite this article
This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.
The aim of this paper is to provide an overview of qualitative research methods, including hands-on information on how they can be used, reported and assessed. This article is intended for beginning qualitative researchers in the health sciences as well as experienced quantitative researchers who wish to broaden their understanding of qualitative research.
What is qualitative research?
Qualitative research is defined as “the study of the nature of phenomena”, including “their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived” , but excluding “their range, frequency and place in an objectively determined chain of cause and effect” [ 1 ]. This formal definition can be complemented with a more pragmatic rule of thumb: qualitative research generally includes data in form of words rather than numbers [ 2 ].
Why conduct qualitative research?
Because some research questions cannot be answered using (only) quantitative methods. For example, one Australian study addressed the issue of why patients from Aboriginal communities often present late or not at all to specialist services offered by tertiary care hospitals. Using qualitative interviews with patients and staff, it found one of the most significant access barriers to be transportation problems, including some towns and communities simply not having a bus service to the hospital [ 3 ]. A quantitative study could have measured the number of patients over time or even looked at possible explanatory factors – but only those previously known or suspected to be of relevance. To discover reasons for observed patterns, especially the invisible or surprising ones, qualitative designs are needed.
While qualitative research is common in other fields, it is still relatively underrepresented in health services research. The latter field is more traditionally rooted in the evidence-based-medicine paradigm, as seen in " research that involves testing the effectiveness of various strategies to achieve changes in clinical practice, preferably applying randomised controlled trial study designs (...) " [ 4 ]. This focus on quantitative research and specifically randomised controlled trials (RCT) is visible in the idea of a hierarchy of research evidence which assumes that some research designs are objectively better than others, and that choosing a "lesser" design is only acceptable when the better ones are not practically or ethically feasible [ 5 , 6 ]. Others, however, argue that an objective hierarchy does not exist, and that, instead, the research design and methods should be chosen to fit the specific research question at hand – "questions before methods" [ 2 , 7 , 8 , 9 ]. This means that even when an RCT is possible, some research problems require a different design that is better suited to addressing them. Arguing in JAMA, Berwick uses the example of rapid response teams in hospitals, which he describes as " a complex, multicomponent intervention – essentially a process of social change" susceptible to a range of different context factors including leadership or organisation history. According to him, "[in] such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect" [ 8 ] . Instead of limiting oneself to RCTs, Berwick recommends embracing a wider range of methods , including qualitative ones, which for "these specific applications, (...) are not compromises in learning how to improve; they are superior" [ 8 ].
Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 , 10 , 11 , 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.
How to conduct qualitative research?
Given that qualitative research is characterised by flexibility, openness and responsivity to context, the steps of data collection and analysis are not as separate and consecutive as they tend to be in quantitative research [ 13 , 14 ]. As Fossey puts it : “sampling, data collection, analysis and interpretation are related to each other in a cyclical (iterative) manner, rather than following one after another in a stepwise approach” [ 15 ]. The researcher can make educated decisions with regard to the choice of method, how they are implemented, and to which and how many units they are applied [ 13 ]. As shown in Fig. 1 , this can involve several back-and-forth steps between data collection and analysis where new insights and experiences can lead to adaption and expansion of the original plan. Some insights may also necessitate a revision of the research question and/or the research design as a whole. The process ends when saturation is achieved, i.e. when no relevant new information can be found (see also below: sampling and saturation). For reasons of transparency, it is essential for all decisions as well as the underlying reasoning to be well-documented.
Iterative research process
While it is not always explicitly addressed, qualitative methods reflect a different underlying research paradigm than quantitative research (e.g. constructivism or interpretivism as opposed to positivism). The choice of methods can be based on the respective underlying substantive theory or theoretical framework used by the researcher [ 2 ].
The methods of qualitative data collection most commonly used in health research are document study, observations, semi-structured interviews and focus groups [ 1 , 14 , 16 , 17 ].
Document study (also called document analysis) refers to the review by the researcher of written materials [ 14 ]. These can include personal and non-personal documents such as archives, annual reports, guidelines, policy documents, diaries or letters.
Observations are particularly useful to gain insights into a certain setting and actual behaviour – as opposed to reported behaviour or opinions [ 13 ]. Qualitative observations can be either participant or non-participant in nature. In participant observations, the observer is part of the observed setting, for example a nurse working in an intensive care unit [ 18 ]. In non-participant observations, the observer is “on the outside looking in”, i.e. present in but not part of the situation, trying not to influence the setting by their presence. Observations can be planned (e.g. for 3 h during the day or night shift) or ad hoc (e.g. as soon as a stroke patient arrives at the emergency room). During the observation, the observer takes notes on everything or certain pre-determined parts of what is happening around them, for example focusing on physician-patient interactions or communication between different professional groups. Written notes can be taken during or after the observations, depending on feasibility (which is usually lower during participant observations) and acceptability (e.g. when the observer is perceived to be judging the observed). Afterwards, these field notes are transcribed into observation protocols. If more than one observer was involved, field notes are taken independently, but notes can be consolidated into one protocol after discussions. Advantages of conducting observations include minimising the distance between the researcher and the researched, the potential discovery of topics that the researcher did not realise were relevant and gaining deeper insights into the real-world dimensions of the research problem at hand [ 18 ].
Hijmans & Kuyper describe qualitative interviews as “an exchange with an informal character, a conversation with a goal” [ 19 ]. Interviews are used to gain insights into a person’s subjective experiences, opinions and motivations – as opposed to facts or behaviours [ 13 ]. Interviews can be distinguished by the degree to which they are structured (i.e. a questionnaire), open (e.g. free conversation or autobiographical interviews) or semi-structured [ 2 , 13 ]. Semi-structured interviews are characterized by open-ended questions and the use of an interview guide (or topic guide/list) in which the broad areas of interest, sometimes including sub-questions, are defined [ 19 ]. The pre-defined topics in the interview guide can be derived from the literature, previous research or a preliminary method of data collection, e.g. document study or observations. The topic list is usually adapted and improved at the start of the data collection process as the interviewer learns more about the field [ 20 ]. Across interviews the focus on the different (blocks of) questions may differ and some questions may be skipped altogether (e.g. if the interviewee is not able or willing to answer the questions or for concerns about the total length of the interview) [ 20 ]. Qualitative interviews are usually not conducted in written format as it impedes on the interactive component of the method [ 20 ]. In comparison to written surveys, qualitative interviews have the advantage of being interactive and allowing for unexpected topics to emerge and to be taken up by the researcher. This can also help overcome a provider or researcher-centred bias often found in written surveys, which by nature, can only measure what is already known or expected to be of relevance to the researcher. Interviews can be audio- or video-taped; but sometimes it is only feasible or acceptable for the interviewer to take written notes [ 14 , 16 , 20 ].
Focus groups are group interviews to explore participants’ expertise and experiences, including explorations of how and why people behave in certain ways [ 1 ]. Focus groups usually consist of 6–8 people and are led by an experienced moderator following a topic guide or “script” [ 21 ]. They can involve an observer who takes note of the non-verbal aspects of the situation, possibly using an observation guide [ 21 ]. Depending on researchers’ and participants’ preferences, the discussions can be audio- or video-taped and transcribed afterwards [ 21 ]. Focus groups are useful for bringing together homogeneous (to a lesser extent heterogeneous) groups of participants with relevant expertise and experience on a given topic on which they can share detailed information [ 21 ]. Focus groups are a relatively easy, fast and inexpensive method to gain access to information on interactions in a given group, i.e. “the sharing and comparing” among participants [ 21 ]. Disadvantages include less control over the process and a lesser extent to which each individual may participate. Moreover, focus group moderators need experience, as do those tasked with the analysis of the resulting data. Focus groups can be less appropriate for discussing sensitive topics that participants might be reluctant to disclose in a group setting [ 13 ]. Moreover, attention must be paid to the emergence of “groupthink” as well as possible power dynamics within the group, e.g. when patients are awed or intimidated by health professionals.
Choosing the “right” method
As explained above, the school of thought underlying qualitative research assumes no objective hierarchy of evidence and methods. This means that each choice of single or combined methods has to be based on the research question that needs to be answered and a critical assessment with regard to whether or to what extent the chosen method can accomplish this – i.e. the “fit” between question and method [ 14 ]. It is necessary for these decisions to be documented when they are being made, and to be critically discussed when reporting methods and results.
Let us assume that our research aim is to examine the (clinical) processes around acute endovascular treatment (EVT), from the patient’s arrival at the emergency room to recanalization, with the aim to identify possible causes for delay and/or other causes for sub-optimal treatment outcome. As a first step, we could conduct a document study of the relevant standard operating procedures (SOPs) for this phase of care – are they up-to-date and in line with current guidelines? Do they contain any mistakes, irregularities or uncertainties that could cause delays or other problems? Regardless of the answers to these questions, the results have to be interpreted based on what they are: a written outline of what care processes in this hospital should look like. If we want to know what they actually look like in practice, we can conduct observations of the processes described in the SOPs. These results can (and should) be analysed in themselves, but also in comparison to the results of the document analysis, especially as regards relevant discrepancies. Do the SOPs outline specific tests for which no equipment can be observed or tasks to be performed by specialized nurses who are not present during the observation? It might also be possible that the written SOP is outdated, but the actual care provided is in line with current best practice. In order to find out why these discrepancies exist, it can be useful to conduct interviews. Are the physicians simply not aware of the SOPs (because their existence is limited to the hospital’s intranet) or do they actively disagree with them or does the infrastructure make it impossible to provide the care as described? Another rationale for adding interviews is that some situations (or all of their possible variations for different patient groups or the day, night or weekend shift) cannot practically or ethically be observed. In this case, it is possible to ask those involved to report on their actions – being aware that this is not the same as the actual observation. A senior physician’s or hospital manager’s description of certain situations might differ from a nurse’s or junior physician’s one, maybe because they intentionally misrepresent facts or maybe because different aspects of the process are visible or important to them. In some cases, it can also be relevant to consider to whom the interviewee is disclosing this information – someone they trust, someone they are otherwise not connected to, or someone they suspect or are aware of being in a potentially “dangerous” power relationship to them. Lastly, a focus group could be conducted with representatives of the relevant professional groups to explore how and why exactly they provide care around EVT. The discussion might reveal discrepancies (between SOPs and actual care or between different physicians) and motivations to the researchers as well as to the focus group members that they might not have been aware of themselves. For the focus group to deliver relevant information, attention has to be paid to its composition and conduct, for example, to make sure that all participants feel safe to disclose sensitive or potentially problematic information or that the discussion is not dominated by (senior) physicians only. The resulting combination of data collection methods is shown in Fig. 2 .
Possible combination of data collection methods
Attributions for icons: “Book” by Serhii Smirnov, “Interview” by Adrien Coquet, FR, “Magnifying Glass” by anggun, ID, “Business communication” by Vectors Market; all from the Noun Project
The combination of multiple data source as described for this example can be referred to as “triangulation”, in which multiple measurements are carried out from different angles to achieve a more comprehensive understanding of the phenomenon under study [ 22 , 23 ].
To analyse the data collected through observations, interviews and focus groups these need to be transcribed into protocols and transcripts (see Fig. 3 ). Interviews and focus groups can be transcribed verbatim , with or without annotations for behaviour (e.g. laughing, crying, pausing) and with or without phonetic transcription of dialects and filler words, depending on what is expected or known to be relevant for the analysis. In the next step, the protocols and transcripts are coded , that is, marked (or tagged, labelled) with one or more short descriptors of the content of a sentence or paragraph [ 2 , 15 , 23 ]. Jansen describes coding as “connecting the raw data with “theoretical” terms” [ 20 ]. In a more practical sense, coding makes raw data sortable. This makes it possible to extract and examine all segments describing, say, a tele-neurology consultation from multiple data sources (e.g. SOPs, emergency room observations, staff and patient interview). In a process of synthesis and abstraction, the codes are then grouped, summarised and/or categorised [ 15 , 20 ]. The end product of the coding or analysis process is a descriptive theory of the behavioural pattern under investigation [ 20 ]. The coding process is performed using qualitative data management software, the most common ones being InVivo, MaxQDA and Atlas.ti. It should be noted that these are data management tools which support the analysis performed by the researcher(s) [ 14 ].
From data collection to data analysis
Attributions for icons: see Fig. 2 , also “Speech to text” by Trevor Dsouza, “Field Notes” by Mike O’Brien, US, “Voice Record” by ProSymbols, US, “Inspection” by Made, AU, and “Cloud” by Graphic Tigers; all from the Noun Project
How to report qualitative research?
Protocols of qualitative research can be published separately and in advance of the study results. However, the aim is not the same as in RCT protocols, i.e. to pre-define and set in stone the research questions and primary or secondary endpoints. Rather, it is a way to describe the research methods in detail, which might not be possible in the results paper given journals’ word limits. Qualitative research papers are usually longer than their quantitative counterparts to allow for deep understanding and so-called “thick description”. In the methods section, the focus is on transparency of the methods used, including why, how and by whom they were implemented in the specific study setting, so as to enable a discussion of whether and how this may have influenced data collection, analysis and interpretation. The results section usually starts with a paragraph outlining the main findings, followed by more detailed descriptions of, for example, the commonalities, discrepancies or exceptions per category [ 20 ]. Here it is important to support main findings by relevant quotations, which may add information, context, emphasis or real-life examples [ 20 , 23 ]. It is subject to debate in the field whether it is relevant to state the exact number or percentage of respondents supporting a certain statement (e.g. “Five interviewees expressed negative feelings towards XYZ”) [ 21 ].
How to combine qualitative with quantitative research?
Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 , 25 , 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig. 4 .
Three common mixed methods designs
In the convergent parallel design, a qualitative study is conducted in parallel to and independently of a quantitative study, and the results of both studies are compared and combined at the stage of interpretation of results. Using the above example of EVT provision, this could entail setting up a quantitative EVT registry to measure process times and patient outcomes in parallel to conducting the qualitative research outlined above, and then comparing results. Amongst other things, this would make it possible to assess whether interview respondents’ subjective impressions of patients receiving good care match modified Rankin Scores at follow-up, or whether observed delays in care provision are exceptions or the rule when compared to door-to-needle times as documented in the registry. In the explanatory sequential design, a quantitative study is carried out first, followed by a qualitative study to help explain the results from the quantitative study. This would be an appropriate design if the registry alone had revealed relevant delays in door-to-needle times and the qualitative study would be used to understand where and why these occurred, and how they could be improved. In the exploratory design, the qualitative study is carried out first and its results help informing and building the quantitative study in the next step [ 26 ]. If the qualitative study around EVT provision had shown a high level of dissatisfaction among the staff members involved, a quantitative questionnaire investigating staff satisfaction could be set up in the next step, informed by the qualitative study on which topics dissatisfaction had been expressed. Amongst other things, the questionnaire design would make it possible to widen the reach of the research to more respondents from different (types of) hospitals, regions, countries or settings, and to conduct sub-group analyses for different professional groups.
How to assess qualitative research?
A variety of assessment criteria and lists have been developed for qualitative research, ranging in their focus and comprehensiveness [ 14 , 17 , 27 ]. However, none of these has been elevated to the “gold standard” in the field. In the following, we therefore focus on a set of commonly used assessment criteria that, from a practical standpoint, a researcher can look for when assessing a qualitative research report or paper.
Assessors should check the authors’ use of and adherence to the relevant reporting checklists (e.g. Standards for Reporting Qualitative Research (SRQR)) to make sure all items that are relevant for this type of research are addressed [ 23 , 28 ]. Discussions of quantitative measures in addition to or instead of these qualitative measures can be a sign of lower quality of the research (paper). Providing and adhering to a checklist for qualitative research contributes to an important quality criterion for qualitative research, namely transparency [ 15 , 17 , 23 ].
While methodological transparency and complete reporting is relevant for all types of research, some additional criteria must be taken into account for qualitative research. This includes what is called reflexivity, i.e. sensitivity to the relationship between the researcher and the researched, including how contact was established and maintained, or the background and experience of the researcher(s) involved in data collection and analysis. Depending on the research question and population to be researched this can be limited to professional experience, but it may also include gender, age or ethnicity [ 17 , 27 ]. These details are relevant because in qualitative research, as opposed to quantitative research, the researcher as a person cannot be isolated from the research process [ 23 ]. It may influence the conversation when an interviewed patient speaks to an interviewer who is a physician, or when an interviewee is asked to discuss a gynaecological procedure with a male interviewer, and therefore the reader must be made aware of these details [ 19 ].
Sampling and saturation
The aim of qualitative sampling is for all variants of the objects of observation that are deemed relevant for the study to be present in the sample “ to see the issue and its meanings from as many angles as possible” [ 1 , 16 , 19 , 20 , 27 ] , and to ensure “information-richness [ 15 ]. An iterative sampling approach is advised, in which data collection (e.g. five interviews) is followed by data analysis, followed by more data collection to find variants that are lacking in the current sample. This process continues until no new (relevant) information can be found and further sampling becomes redundant – which is called saturation [ 1 , 15 ] . In other words: qualitative data collection finds its end point not a priori , but when the research team determines that saturation has been reached [ 29 , 30 ].
This is also the reason why most qualitative studies use deliberate instead of random sampling strategies. This is generally referred to as “ purposive sampling” , in which researchers pre-define which types of participants or cases they need to include so as to cover all variations that are expected to be of relevance, based on the literature, previous experience or theory (i.e. theoretical sampling) [ 14 , 20 ]. Other types of purposive sampling include (but are not limited to) maximum variation sampling, critical case sampling or extreme or deviant case sampling [ 2 ]. In the above EVT example, a purposive sample could include all relevant professional groups and/or all relevant stakeholders (patients, relatives) and/or all relevant times of observation (day, night and weekend shift).
Assessors of qualitative research should check whether the considerations underlying the sampling strategy were sound and whether or how researchers tried to adapt and improve their strategies in stepwise or cyclical approaches between data collection and analysis to achieve saturation [ 14 ].
Good qualitative research is iterative in nature, i.e. it goes back and forth between data collection and analysis, revising and improving the approach where necessary. One example of this are pilot interviews, where different aspects of the interview (especially the interview guide, but also, for example, the site of the interview or whether the interview can be audio-recorded) are tested with a small number of respondents, evaluated and revised [ 19 ]. In doing so, the interviewer learns which wording or types of questions work best, or which is the best length of an interview with patients who have trouble concentrating for an extended time. Of course, the same reasoning applies to observations or focus groups which can also be piloted.
Ideally, coding should be performed by at least two researchers, especially at the beginning of the coding process when a common approach must be defined, including the establishment of a useful coding list (or tree), and when a common meaning of individual codes must be established [ 23 ]. An initial sub-set or all transcripts can be coded independently by the coders and then compared and consolidated after regular discussions in the research team. This is to make sure that codes are applied consistently to the research data.
Member checking, also called respondent validation , refers to the practice of checking back with study respondents to see if the research is in line with their views [ 14 , 27 ]. This can happen after data collection or analysis or when first results are available [ 23 ]. For example, interviewees can be provided with (summaries of) their transcripts and asked whether they believe this to be a complete representation of their views or whether they would like to clarify or elaborate on their responses [ 17 ]. Respondents’ feedback on these issues then becomes part of the data collection and analysis [ 27 ].
In those niches where qualitative approaches have been able to evolve and grow, a new trend has seen the inclusion of patients and their representatives not only as study participants (i.e. “members”, see above) but as consultants to and active participants in the broader research process [ 31 , 32 , 33 ]. The underlying assumption is that patients and other stakeholders hold unique perspectives and experiences that add value beyond their own single story, making the research more relevant and beneficial to researchers, study participants and (future) patients alike [ 34 , 35 ]. Using the example of patients on or nearing dialysis, a recent scoping review found that 80% of clinical research did not address the top 10 research priorities identified by patients and caregivers [ 32 , 36 ]. In this sense, the involvement of the relevant stakeholders, especially patients and relatives, is increasingly being seen as a quality indicator in and of itself.
How not to assess qualitative research
The above overview does not include certain items that are routine in assessments of quantitative research. What follows is a non-exhaustive, non-representative, experience-based list of the quantitative criteria often applied to the assessment of qualitative research, as well as an explanation of the limited usefulness of these endeavours.
Given the openness and flexibility of qualitative research, it should not be assessed by how well it adheres to pre-determined and fixed strategies – in other words: its rigidity. Instead, the assessor should look for signs of adaptation and refinement based on lessons learned from earlier steps in the research process.
For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 , 38 , 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.
While some authors argue that randomisation can be used in qualitative research, this is not commonly the case, as neither its feasibility nor its necessity or usefulness has been convincingly established for qualitative research [ 13 , 27 ]. Relevant disadvantages include the negative impact of a too large sample size as well as the possibility (or probability) of selecting “ quiet, uncooperative or inarticulate individuals ” [ 17 ]. Qualitative studies do not use control groups, either.
Interrater reliability, variability and other “objectivity checks”
The concept of “interrater reliability” is sometimes used in qualitative research to assess to which extent the coding approach overlaps between the two co-coders. However, it is not clear what this measure tells us about the quality of the analysis [ 23 ]. This means that these scores can be included in qualitative research reports, preferably with some additional information on what the score means for the analysis, but it is not a requirement. Relatedly, it is not relevant for the quality or “objectivity” of qualitative research to separate those who recruited the study participants and collected and analysed the data. Experiences even show that it might be better to have the same person or team perform all of these tasks [ 20 ]. First, when researchers introduce themselves during recruitment this can enhance trust when the interview takes place days or weeks later with the same researcher. Second, when the audio-recording is transcribed for analysis, the researcher conducting the interviews will usually remember the interviewee and the specific interview situation during data analysis. This might be helpful in providing additional context information for interpretation of data, e.g. on whether something might have been meant as a joke [ 18 ].
Not being quantitative research
Being qualitative research instead of quantitative research should not be used as an assessment criterion if it is used irrespectively of the research problem at hand. Similarly, qualitative research should not be required to be combined with quantitative research per se – unless mixed methods research is judged as inherently better than single-method research. In this case, the same criterion should be applied for quantitative studies without a qualitative component.
The main take-away points of this paper are summarised in Table 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.
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Loraine Busetto, Wolfgang Wick & Christoph Gumbinger
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Busetto, L., Wick, W. & Gumbinger, C. How to use and assess qualitative research methods. Neurol. Res. Pract. 2 , 14 (2020). https://doi.org/10.1186/s42466-020-00059-z
Received : 30 January 2020
Accepted : 22 April 2020
Published : 27 May 2020
DOI : https://doi.org/10.1186/s42466-020-00059-z
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Original research article, a qualitative study of health workers' experiences during early surges in the covid-19 pandemic in the u.s.: implications for ongoing occupational health challenges.
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, United States
Background: Health workers (HWs) have faced significant threats to physical and psychological health during the COVID-19 pandemic. The recent surges associated with the spread of the delta variant in the U.S., coupled with political resistance to effective public health mitigation strategies, indicate that the risks experienced early in the pandemic are not likely to abate soon. This study sought to better understand the experiences, thoughts, concerns, and recommendations of HWs during one of the first major surges in the U.S. and to explore how these experiences might inform efforts to mitigate potential ongoing COVID-related negative health and psychological impacts on HWs.
Methods: HWs were recruited using a multi-faceted approach tailored to public health mitigation guidelines. Semi-structured interviews were conducted via video conference with front line HWs, support staff, and opioid use disorder service organization providers between April 1 and July 9, 2020 using the Social-Ecological Model as a framework. Interviews were audio-recorded and professionally transcribed; transcripts were analyzed inductively and deductively using thematic analytic methods, generating major themes and subthemes.
Results: A total of 22 HWs participated in the study; 14 were female; 3 identified as a member of a racial or ethnic minority population. Major themes identified included: (1) Institutions, Infrastructure, and the Pandemic; (2) Working Under Fire; (3) The Political Becomes Personal and (4) Hope. Themes and subthemes explicated the ways in which phenomena at personal, interpersonal, community, organizational, and societal levels affected HWs experiences and suggested potential mechanisms through which negative effects on HW mental health and health may be mitigated.
Conclusions: Previous global infectious disease epidemics have had profound negative effects on HWs' health and mental health. This study suggests the potential for similar negative impacts that may be exacerbated by the U.S.'s current sociopolitical milieu. Efforts to systematically describe and quantify these effects and to intervene to mitigate them are warranted.
As of September 9, 2021, COVID-19 had sickened more than 222 million people globally and killed more than 4.6 million ( 1 ). The U.S. currently has one of the highest number of cases per 100,000 people in the world and despite having only 4% of the world population, has accounted for an estimated 14% of deaths worldwide ( 2 ). New York and Massachusetts experienced major surges in COVID-19 cases in the early days of the U.S. pandemic when little was known about the virus's infectivity, its range of clinical manifestations, or effective treatments. The U.S.'s lack of public health infrastructure and the absence of a coordinated federal government response left state governments and health care systems struggling to procure personal protective equipment (PPE), reliable diagnostic tests, and testing supplies. Health systems and health workers (HWs) had to rapidly develop and test new clinical protocols and learn how to function in the face of great uncertainty. These and other challenges placed a substantial strain on health systems, service organizations, and their HWs. Failure to achieve widespread acceptance of effective mitigation strategies such as masking, social distancing, and vaccination, has led to multiple subsequent surges, extending the strain on health systems, service organizations, and HWs.
Studies of previous global infectious disease epidemics showed significant health and mental health consequences for HWs ( 3 – 6 ). A highly publicized suicide of a New York emergency medicine physician on April 26, 2020 was an early warning sign that the COVID-19 pandemic might also have serious consequences for HWs' mental health ( 7 ). Although there is currently no systematic approach to calculating the number of excess deaths among HWs related to COVID-19 in the U.S., a report by the National Nurses Union in September 2020 suggested that the excess HW deaths due to COVID-19 was more than 1,700 ( 8 ). The Kaiser Health Network, in partnership with The Guardian, has been tracking the number of COVID-19-related HW deaths, estimating ~3,176 excess deaths by mid-January 2021 ( 9 ), a number believed to be a substantial undercount due to the lack of robust tracking systems. Some of the earliest studies of the mental health impacts of the COVID-19 pandemic on HWs took place in countries such as China that experienced high infection rates in January and February, 2021. Relying primarily on survey data, these international studies suggested that HWs were experiencing increased rates of depression, anxiety, post-traumatic stress, and burnout ( 10 – 15 ). U.S.-based studies on the impacts of COVID-19 on HWs have largely consisted of surveys focused on mental health and have also demonstrated increased rates of depression, anxiety, and substance use ( 16 , 17 ).
Prior studies of HWs during the COVID-19 pandemic have provided important descriptions of the potential negative impacts of the pandemic on HWs' mental health. However, a more nuanced understanding of HWs' experiences during the pandemic, including the potential ways in which institutions and social phenomena may affect their experiences, is needed to be able to decrease the occupational risks experienced by HWs for approaching 2 years. This qualitative study aimed to address this gap in knowledge through interviews with U.S. HWs' across multiple health sectors during the earliest surges in the U.S.
Although there were no empiric data on the effects of the COVID-19 pandemic on HWs when this study was undertaken, the SARS epidemics in China and Hong Kong suggested that HWs could be at risk for pandemic-related mental health sequelae ( 3 – 6 , 18 ). The existence of the prior experiences provided a rationale for using both inductive and deductive approaches to studying HWs' COVID-19 experiences. The Social-Ecological Model (SEM) served as the theoretical framework for the study ( 19 ) and data collection and analysis were structured to allow for new theory to emerge ( 20 ). We selected the SEM because it posits that human development and behavior are influenced by nested individual, interpersonal, community, organizational and broader societal levels of influence. The model has been used extensively in public health and health care as an explanatory model and as an intervention framework. Part of the model's applicability for this study lies in its reflection of the nuances of complex systems of human health. The earliest days of the COVID-19 pandemic suggested that geopolitical, national and state governments, health care systems, community and individual factors would shape and be shaped by the pandemic. The SEM's inclusion of interrelated micro-, meso-, and macro-level social constructions makes it an apt theoretical framework for exploring nuances of HW's experiences with the COVID-19 pandemic.
Study Population and Recruitment
HWs participated in semi-structured interviews conducted via Zoom between April 1 and July 9, 2020. HWs were defined broadly as nurses, medical assistants, clerical staff, janitorial and food service staff, social workers, physicians, pharmacists and pharmacy technologists, psychologists, and community-based substance use service providers to be able to capture a broad range of experiences. A multimodal approach to recruitment was used in response to restrictions related to COVID-19 and anticipation that health workers might have limited availability. The first wave of recruitment included a convenience sample of HWs who were known professionally or personally by research team members and who worked in states experiencing current or recent surges. In the second wave of recruitment, leaders of a community-based coalition of organizations that provide services for people with opioid use disorder (OUD) in Massachusetts partnered with the research team to send an invitation to members on its list serv. One of the 16 people recruited during the first phase ultimately was unable to participate in an interview because they were too busy. Seven were recruited in the second wave; the total number on the list serv was not known. All interviewees were also asked to suggest additional HWs to interview (snowball sampling) ( 21 ) and three of the participants were recruited through this method. A letter of invitation that included the purpose of the study, details of what would be asked of participants, and contact information for the investigative team was sent via email with an attached consent form that was reviewed with participants at the start of interview sessions. Zoom interviews were scheduled at a mutually agreed upon time. The study was approved by the University of Massachusetts's Institutional Review Board.
A semi-structured interview guide was developed and pilot-tested for clarity and completeness. Question development was guided by the five SEM levels (individual, interpersonal, community, organizational, societal). The interview guide consisted of open-ended questions with probes related to key areas of interest, including the personal effects of social distancing/quarantine, family and community effects, organizational factors related to the participants' experiences, trusted sources of information, opinions regarding government responses, and positive impacts of the pandemic. The interview guide was amended in an iterative process to add probes as new concepts emerged during interviews. Interviews were conducted by SG, who has extensive experience with qualitative research methods ( 22 – 28 ) including studies in which she trained and supervised students and research assistants, as she did for the current study (KW, MF, NP, EC, and KC), and KC. Interviews were conducted via Zoom using audio and video in compliance with social distancing and travel restrictions in Massachusetts at the time. Interviews were conducted until data saturation was reached, defined as no new concepts emerging over three consecutive interviews, and achieved after ~16 interviews. Between 20 and 30 interviews were estimated to be needed to achieve data saturation based on the homogeneity of work setting among participants and the narrow focus of the study. This estimate was based on recommendations in methodological texts and papers as well as publications of similar studies.in journals with high impact factors ( 29 – 32 ). Interviews were audio-recorded and professionally transcribed verbatim and field notes were taken during the interviews.
Interview transcripts were analyzed using thematic analysis, applying a validated rapid analytic technique ( 33 ). This approach was utilized because it has been identified as an important method for research questions that address rapidly changing health and public health risks, such as those presented by the COVID-19 pandemic. Four members of the investigative team (KC, MF, EC, NP) reviewed a subset of the transcripts to familiarize themselves with the interview content. SG generated a template of broad themes derived from the interview questions for the first phase of the analysis; an open category was included on the template to allow for inclusion of concepts that may have fallen outside of either the structured portion of the template or the theoretical framework. Using a deductive approach, analysts each read a subset of the transcripts and identified key concepts which were entered on a separate form for each transcript. With supporting quotations. SG independently analyzed one of each of the other analysts' transcripts to assess agreement; differences in key concepts were resolved through discussion with the full team. In Phase 2 of the analysis, SG identified unifying themes across the key concepts identified in Phase 1 and applied an inductive approach to theorize connections between SEM levels. These unifying themes and connections were discussed with the full team and revised based on discussion, resulting in a comprehensive set of major themes and subthemes. A summary of themes was sent to participants for review and comment (member checking). During the analysis, reflexivity was considered and discussed. Considerations included that SG is a HW (primary care pediatrician and internist), a parent of school-aged children, and teaches an undergraduate-level elective on the U.S. opioid epidemic. EC, MF, NP, and KW had SG as a professor in an elective course in the spring semester of 2020, KC was a master's student advisee of SG's, and MD is an undergraduate research assistant working with SG.
Of the 22 HWs interviewed, 14 identified as female; 1 as Black, 2 as South Asian, and 18 as Caucasian/white; 7 were physicians and 6 worked in organizations serving people with opioid use disorder (OUD) ( Table 1 ). Concepts pertinent to the study's aims were identified at all SEM levels. Major themes are organized beginning with the outermost context of the SEM (Societal), such as government and state responses, and moving to the innermost (Interpersonal and Personal), such as impact on families, with a final broad theme. The interconnectedness of the SEM levels means that subthemes for each major theme often touch on multiple levels. Major themes included: (1) Institutions, Infrastructure, and the Pandemic (Societal level); (2) Working Under Fire (Organizational, Community, Interpersonal, and Personal levels); (3) The Political Becomes Personal (Interpersonal and Personal levels); and (4) Hope (Societal, Organizational, and Community levels). Major themes and subthemes are described in detail below with supporting quotations. Additional quotations are located in Table 2 . Participants' roles in the health care system and a unique study identifier are included in parentheses after quotations; additional details were not attributed to quotations to protect participant confidentiality.
Table 1 . Participant demographic characteristics.
Table 2 . Selected supplementary illustrative quotations.
Theme 1: Institutions, Infrastructure, and the Pandemic
Many HWs commented on the role of institutions and infrastructure in combatting the pandemic. The phenomena described in this theme were located primarily at the SEM Societal level. Subthemes included: (1) Federal, and State Government Responses: Coordination Confusion; (2) The Syndemic of Misinformation; and (3) Rules of the (Capitalist) Game. Included in these subthemes are perspectives on how international and domestic political and public health institutions shaped the early arc of the pandemic, and how institutions' responses shaped HWs' and others' perceptions of the institutions. Some HWs discussed the role of social media and the press in the pandemic response. Many HWs felt the lack of public health infrastructure impacted HWs' experiences early in the course of the pandemic and reflected on institutional failures in response to the pandemic.
Federal and State Government Responses: Coordination Confusion
A small number of HWs felt that the problems the U.S. was experiencing in its pandemic response were inevitable:
“ I don't know that this could have been avoided… I don't really have a lot of criticism of the government right now .” (Nurse practitioner, RJ3)
Most HWs felt that the federal government's response to the pandemic was inadequate and a major contributor to the rapidly worsening state of the pandemic in the U.S.
“ ... it seems pretty clear that it's [federal government response] not been coordinated… not been systematic. It's been seemingly random, at times brutal, at times… unjust… lacking compassion…It's frustrating to see… states are having to design their own disaster plans, because the power of the federal government is to align disaster response across states… instead, we've got a hodgepodge.” (Hospitalist, SG1)
One HW with knowledge of the federal government's disaster preparedness programs was puzzled as to why prior plans for such a pandemic were not being implemented.
“ It has been very… hard for me to understand… what came of all the [preparedness] programs... and whether or not they [agencies responsible for programs] were allowed to [be involved in decision-making], during what most people would call the Superbowl [of pandemic preparedness]. We've been talking about it for decades… We have a disinterested health care system. You have a totally underfunded public health system… the knowledge around the pandemic… exists in the military and the National Security Council. It does not exist in health departments.” (ED physician/administrator, SG2)
Some HWs noted and worried about the loss of trust in the federal government, including agencies such as the Centers for Disease Control and Prevention (CDC).
“ ... the erosion of faith in federal leadership and the ability to believe what the CDC was saying…, to believe that there would be an organized response… it is unconscionable and it's impossible for me to get my head around the damage that it has done forever.” (ED physician, SG3)
In comparison, although some HWs also felt their state governments could have instituted lockdowns sooner, most felt that their governors and state governments had stepped into the leadership void to provide clear, science-based, public health messaging and leadership.
The Syndemic of Misinformation
“ … we've got this, like, false information pandemic.” ( ED physician/researcher, SG6 )
Some HWs felt that it was difficult to obtain reliable up-to-date information about the pandemic due to the rapidly evolving state of knowledge about COVID-19. Others felt the volume of rapidly disseminated misinformation was problematic.
“ We sort of have this infodemic…the big examples...are…ACE inhibitors and Ibuprofen… and the hemoglobin hijacking theory... All these things start and then they get amplified by social media.” ( ED physician/researcher, SG6)
HWs described some of the reasons they did not trust certain sources of information.
“ When you have some big personalities… telling people that this is the way to do things and if you're not… you're wrong and you are killing people… when you start… speaking in absolutes… I start to… lose… respect for you as an authority… I worry that their concern is about public image and not so much getting the right answer .” (ED physician, SG8)
Social media was generally seen as unreliable because of the lack of its lack of scientific rigor.
“ I use Twitter professionally... and I actually shut it off about two or three weeks into COVID because I was...going to bed [and] I'm looking at Twitter and reading about … this person died and that person died... it was good for me to absorb...what was going on. But now I just shut Twitter off…because I'm like, ‘This is not helpful to me'… it was too anecdotal.” (Psychiatrist/researcher, SG9)
Many physicians relied on peer-reviewed journals and their medical societies for up-to-date accurate information. However, several also expressed concern that the quality of the studies published and the lack of understanding about “preprints” (papers reporting results of studies that have not been peer reviewed) were problematic.
“ It's been an interesting time in research because part of the [misinformation] problem are these preprint servers… they're not peer reviewed… I see many go straight through to other journals without significant changes even though there should be… it's a reminder that research is very much flawed…” (ED physician/researcher, SG6)
Rules of the (Capitalist) Game
One HW contrasted health care and public health systems' financial models and cultures, in the context of trying to understand the federal government's response.
“ Public health just doesn't really have a business model. It has a budget. It comes to them from tax dollars,...or grant…and health care does not think like that… within public offices, especially at the federal level, the … the understanding of how corporate health care is, is shockingly absent. Public sector folks come from public health departments. They're like do-gooders... and I say ‘Have you ever been inside a hospital... ever… had to cut budgets because you wanted to maximize margins to recruit a high-powered neurosurgeon?' and they're like, ‘What are you talking about?”' (ED physician/administrator, SG2)
Some HWs felt that the U.S.'s capitalist political economy was not structured to mount an effective response.
“… because there was no coordinated federal response, we were bidding against other hospitals, bidding up the price of PPE... in this super dysfunctional way… there are times when capitalism really doesn't work and this is one of them.” (Hospitalist, SG1)
“ One thing that bothered me was that we had this big meeting… where he had all the different CEOs of different companies come on and talk about what they were going to do. It felt like such a capitalist take .” (Pharmacy technician, EC3)
Another HW felt, similarly, that the U.S. response was what one would expect based on institutional structures.
“ Don't hate the player, hate the game – I see most of us, all of us, as just responding to the rules of engagement and the incentives that are outlined for us, right?... You can bellyache about how the rules of the game are not what you wish they were or you can try to rewrite the rules of the game.” (ED physician/administrator, SG2)
Theme 2: Working Under Fire
HWs discussed changes in their work since the surges began and the work-related challenges that they faced. Subthemes included: (1) The Myth of the Health Worker Hero; (2) Changes in Clinical Practice; (3) Organizational Leadership; and (4) Work Related Worries, Fears, and Loss. This major theme described HWs experiences that illustrated the toll the pandemic, government response, and citizens' behaviors was taking.
The Myth of the Health Worker Hero
A few physicians expressed frustration with society's framing of HWs as “heroes” and the unfair expectations they felt society had of HWs:
“ I'm gonna say that this [public applauding of HWs] has been seen as a positive… I think it's a really big negative. This whole… hero worship thing. I think it's nice that people are appreciating their nurses and their doctors and their health care providers…but I also think that this is sort of the problem… we just expect people [HWs] to fix things. We want a hero to come with their superpowers and just make it all better… we were telling people to stay home if you're sick… just wash your hands… and we got to a point, nobody wanted to listen and we have this whole, consequence because of it and now, we want our [HW] heroes to come in and clean up our mess. It just doesn't work that way. It just doesn't.” (ED physician, SG8)
“ I'm thinking about this one tweet. Early on, a nurse said she was taking a break from her job because she had an underlying health condition… People were attacking her, being like, oh you signed up for this. Yes, she signed up to care for people but under the caveat that she'd be provided the proper PPE and she wouldn't have to risk her own life .” (Pharmacy technician, EC3)
Some HWs also were puzzled, frustrated, or upset by factions of the public claiming the pandemic was not “real” and that people were not taking the pandemic seriously.
“ To see others not treating it [COVID] as a threat is disrespectful to not only… my family [who are HWs] , but other workers and essential workers .” (Pharmacy technician EC3)
Changes in Clinical Practice
“ It's completely disrupted our normal way of practicing medicine.” (ED physician, NP1)
When HWs talked about their experiences at work, much of the discussion centered on positive aspects of their experience and solidarity among coworkers. There were recommendations for continuing some of the changes in clinical practice and hope that they would result in long-lasting improvements.
“ [I] think that our teamwork in the ED is always fantastic… techs, nurses and EMS…but right now…we have a super appreciation because you're in a PPE room… and you have to do everything … to kind of spare people [co-workers] having to come in… I think that culture of collaboration, which we typically have been good at… is even enhanced and I would like to see that go forward.” (ED physician/researcher, SG6)
Some also discussed support from the community.
“ ... I know that a lot of local universities as well as hotels have been offering their spaces for health care workers that don't want to stay at their homes… to prevent transmission .” (Pharmacy tech, EC3)
Some HWs welcomed the increased use of telemedicine and the flexibility it provided,
“ ...[telemedicine] takes away...all these other barriers… people have huge transportation issues and can't get to their appointments or they don't feel like rolling out of bed and leaving their house to take… a half-hour bus ride to come here to see their therapist. They can actually have a conversation with their therapist while they're lying in bed. I mean people who are depressed, who are agoraphobic, who have anxiety leaving the home, … [telemedicine] takes away all of that.” (OUD treatment services manager, KC1)
while others felt telemedicine presented new challenges and potential inequities in care delivery.
Several HWs discussed how the response of leadership in their hospitals or organizations affected their experience with the pandemic surge. Some comments were positive,
“ The director is a very passionate but very direct person, a very practical person. Her supervision style has completely changed through this to be much more in tune with how the employees are doing mentally, much more in tune with our self-care, telling us it's okay to say no .” (OUD treatment coordinator, KC7)
and some were negative.
“ They [workplace supervisors] are like, ‘… you're not gonna wear N95 masks. You don't need to wear it.' Really? Okay. Tell that to the nurse who didn't wear an N95 mask and ended up with COVID.” (Hospital-based social worker, MF2)
“… they [administrators] were… mandating things that weren't feasible and forcing employees to … not do something because it wasn't really possible … [or] be insubordinate in order to actually do their job. … people who work in administration don't want to defer to people who do the actual work .” (OUD treatment coordinator, KC3)
Work-Related Worries, Fear, and Loss
HWs shared a broad range of work-related concerns in relation to the pandemic. Categories within this subtheme included health disparities and vulnerable populations, foregone health care, loss of personal connection with patients, loss of trust in the health care system, financial concerns, and provider burnout.
Worry about the pandemic's impact on people in vulnerable populations and the associated emerging racial/ethnic and socioeconomic disparities in who was contracting and dying from COVID-19 was among the most commonly discussed concerns.
“ … you got a white collar worker who can still work at home…it's still stressful… but nobody knows what other people are dealing with… I feel like it's going to be very easy to really not know how much other people are struggling…I think it has the potential to really worsen inequality in the country, but… sort of quietly and invisibly worsen it.” (ED physician/researcher, SG7)
“ I… think it's really challenging for our homeless population… I spoke to someone [known to ED staff and homeless] at the beginning of everything, and he [said], ‘That's okay [that public buildings with restrooms were closed], I'm just not going to eat so that I don't have to use the bathroom.”' (ED physician/researcher, SG7)
Many HWs also worried about patients forgoing health care due to fear of contracting COVID-19 if they went to a health care facility.
“ I see that a lot of people aren't coming to the hospital for preventive things. There's been a spike in people experiencing strokes and heart attacks because people aren't getting the treatment they need… there is that fear of going to the emergency room ... people are going to go months, if not years, without getting their proper dental checkups or primary care checkups or eye checkups – that's going to create years and years of damage for people. That's going to create more strain later on .” (Pharmacy technician, EC3)
Some HWs spoke about the diminished opportunity for personal connection when interacting with patients while gowned, masked and gloved.
“ … one more drastic difference in my day-to-day life is that my ability to connect with patients when I am wearing a ridiculous amount of gear and they cannot see my face and I cannot see their face is terrible.” (ED physician/researcher, SG7)
Some HWs also expressed concern about loss of trust in health care systems due to pandemic-related rumors and misinformation.
“ …it did feel…sad… that there were people saying that if you had coronavirus, that we would not do CPR [at hospital x]… EMS had heard this and stopped bringing patients to our hospital for a short period of time… I wonder what's gonna happen with people and their trust in the medical community. Are they gonna feel like the hospital is super dangerous and then never ever come back?...the effects of this are gonna linger …”(ED physician, SG8)
Concern for the financial stability of health care systems made some HWs worry about job security.
“ The hospital isn't doing well [financially]. It wasn't doing well before this…I think there's going to be a lot of people being laid off…” (Medical records staff, MF5)
Finally, some HWs also worried about the long-term mental health effects working in the pandemic conditions would have on HWs, including the possibility of having to decide on allocation of scarce resources such as ventilators.
“ ... moral distress… we talk about this in the emergency room, with situations where you know what should be done and you can't do it... if you're in a place where there's not enough ventilators and you want to put someone [on a ventilator but can't unless you take someone else off]...I think that that sort of thing is going to affect health care workers all over the country . (ED physician, SG8)
Theme 3: The Political Becomes Personal
HWs described both positive and negative impacts of the pandemic on their personal lives, noting often that personal effects were closely related to work effects. Subthemes for this major theme included: (1) Health Workers as Unintended Threats to the Public's Health; (2) An Emotional Toll; (3) Family: Disruptions and Silver Linings. These subthemes were largely related to Personal and Interpersonal SEM levels. Several physicians prefaced their discussion of how the pandemic was affecting them with comments about awareness of their socioeconomic privilege.
Health Workers as Unintended Threats to the Public's Health
Although the services HWs provided were often crucial to fighting the pandemic, some worried that their high risk of contracting COVID-19 made them a risk to patients and public health. This concern was compounded by the lack of reliable, rapid testing in the U.S. early in the pandemic. This may have contributed to the moral hazard experienced by health workers, whose work is intended to improve health and wellness and cause no harm.
“ I'm concerned with being able to get tested because I guess the fear is, jeez, what if I have the virus but I'm asymptomatic and I give it to someone else?” (Chiropractor, EB2)
An Emotional Toll
Many HWs described ways in which their experiences as a HW during the pandemic were negatively affecting their physical and emotional health and the impact of their work on the mental health of their children.
“ … my [own] sobriety has probably never been shakier than it has been during this time.… I … drove by a package store for 45 minutes. Back and forth having conversations in my head, ‘Who will know? What does it matter?' Luckily, I was up to the task, and it was just … a waste of gas and time, but I can definitely understand people with less momentum [with recovery] struggling even harder, because I wasn't reaching out and asking for help. I haven't been going to in-person meetings, so I don't get to see these people and let them know how I'm doing either.” (OUD treatment coordinator, KC7)
“ [my] 10 year old [has] told me many nights she just has a hard time turning her brain off because she's worried about people… an adjustment is having these big conversations with her, grownup conversations…people are dying.” (Nurse practitioner, RJ3)
Family: Disruptions and Silver Linings
The personal impacts that HWs described were often closely related to their family situation. For example, all public schools and many private schools in New York and Massachusetts had abruptly transitioned to on-line remote learning in mid-March and most daycares closed at this time, meaning HWs who were also parents were faced with needing to care for young children and supervise older children doing remote schooling while working.
In addition to worrying about putting the public at risk because of HWs' high risk of exposure to COVID-19, HWs also worried more about the risk they put their families at than the risk to themselves.
“ I know the risk associated with being an emergency physician but I signed up for those risks… that's what I do, that's part of my job. My family didn't… it's an emotional toll for all of us with a concern that we may bring this home to our family members .” (ED physician, NP1)
Some HWs also found that lockdown had positive aspects for their family.
“… it's like if you have a closet and... you're thinking of throwing things out of your closet ‘cause you wanna simplify things. But...if you have something that you bought and… that stuff is really nice and you used to wear it. You're like, you don't wanna get rid of it'cause you bought it and it's hard to let it go. But when you come into an empty closet, you could just buy what you wanna buy. You fill it with what… you're gonna wear and what you wanna have. So now it's like someone just came in and… cleaned out the closet. And now I can… add stuff back as I want ‘cause I'm not… trying to empty out a really full closet .” (Psychiatrist/researcher, SG9)
Others found it difficult to get work done while juggling home responsibilities and that increased work demands reduced the time they spent with their families.
“ I've always been kind of a workaholic but… week two of March through …the first week of April, I worked at least 18 hours a day… minimum… I'm actually spending the least amount of time with my kids… [than I have ever spent] in their whole lives...” (ED physician/researcher, SG6)
Some HWs found themselves questioning the importance of some of the non-clinical aspects of their work and the ways in which they had previously structured their days, with some hoping to preserve some of the slow down once lockdowns and social distancing requirements ended.
“ …probably for at least a month I was very scatterbrained and I was just like… first of all, who cares about [focus of HW's research] right now, you know?... Before this [interview] I had two meetings, one with primary care and one with surgeons about [research].... I was like ‘I do not give a shit'… it's not relevant right now…maybe it will be relevant again.” (ED physician/researcher, SG7)
Theme 4: Hope
In addition to silver linings discussed by HWs, some also described hopes that the pandemic could result in broader positive societal changes. The concepts related to this theme centered on Societal, Organizational and Community SEM levels.
“ I feel like if this country can use the pandemic to… [institute] paid sick leave, to pass policies that should have existed and should have been in place long ago… that could be a lovely silver lining…that we say, ‘Oh, we actually need to take care of everyone with these things rather than every man for themselves.”' (ED physician/researcher, SG7)
Some HWs hoped that the chaotic and fragmented response by the government and the health care system might advance discussions about addressing problems, big and small, in the health care system.
“ I am hopeful that the health care system will… in light of the PPE issue… think more about waste…like the amount of stuff we throw out that could be reusable .” (ED physician/researcher, SG7)
Interpretations in Relation to the Social Ecological Model
“ Man is an animal suspended in webs of significance he himself has spun.” – Clifford Geertz ( 34 )
The major themes and subthemes identified can be interpreted as a web of interactions involving the SEM levels ( Figure 1 ). In the U.S., historical social, cultural, and political phenomena have generated a strongly individualistic society with a largely unregulated capitalist political economy ( 35 ). The health care and public health systems that developed within these socio-political boundaries are largely siloed and divorced from each other ( 36 ). As one HW noted, these two systems in general, and unregulated capitalism in particular, are poorly designed for addressing pandemic challenges. The absence of effective federal leadership may have made it all the more challenging to overcome the limitations of the U.S.'s sociopolitical system design, or as one HW framed it, the “Rules of the Game”. Despite the obstacles these “Rules” can present, the thoughts and experiences HWs participating in this study described suggested how actions taking place at organizational, personal, and interpersonal levels may mitigate the effects of failures at societal and structural levels.
Figure 1 . Positive and negative influences on Health worker health across social ecological levels.
The COVID-19 pandemic's rapidly changing landscape has presented political, public health, medical, community, and individual challenges. Understanding the acute and long-term occupational health effects on HWs will likely require a diverse set of research methodologies. This study was one of the first to take an in-depth qualitative exploration of HWs experiences, feelings, and perceptions during the first surges of COVID-19 infections in the U.S. While much has been learned about the clinical and epidemiological aspects of the COVID-19 virus since data for this study were collected, narrative data such as reported in this study provide the context needed to address the social complexities of the pandemic ( 37 ). The U.S. continues to lack a coordinated federal response and public health mitigation strategies such as mask-wearing and vaccination have become deeply politicized, meaning that HWs' heavy workloads, isolation, anxiety, grief, and death are likely to continue for some time. As the virus spreads unabated across the nation and overwhelms health care systems, the narratives shared by the HWs who participated in this study offer insights into the potential short- and long-term impacts the pandemic may have on HWs' physical and mental health as well as potential approaches to mitigating risk. The themes identified in this study illuminate ways in which institutional and infrastructural failures have likely played a role in the U.S.'s pandemic experience but also showed sources of community, interpersonal and personal resilience, resourcefulness, and hope.
HWs in the U.S. have long had some of the highest rates of job-related stress, burnout, and suicide ( 38 , 39 ). Prior infectious disease epidemics, such as SARS and Ebola, demonstrated the disparate mortality, physical, and mental health effects such epidemics can have on HWs ( 40 ). The COVID-19 pandemic is affecting HWs across the globe on a scale not seen for more than a century. In the U.S., poor public health preparedness, lack of a coordinated national response, and failure of the federal government to act swiftly using the best scientific data available may have put HWs at even greater risk for physical and mental health sequelae than they might have otherwise experienced. A study led by the National Nurses Study and the Kaiser Foundation published in a special report by the National Academies of Science, Engineering, and Medicine described how the nation's lack of a uniform system to collect, collate and report illnesses and deaths of HWs related to COVID-19 impairs the ability to accurately monitor and develop interventions to mitigate HWs' risks ( 41 ). The report calls for a national system to track not only deaths directly due to work-related COVID-19 infection but collateral deaths, such as suicides due to the fatigue, stress, and burnout, and mental health morbidity. The report notes that accuracy of reporting improved significantly for nursing homes after the Centers for Medicaid and Medicare Services (CMS) implemented a new reporting policy in May of 2020 that included penalties for failure to comply, demonstrating that accurate collection of these data is possible. The results of the current study suggest that development of a robust system to rapidly track the effects of the pandemic and identification of best practices to mitigate the pandemic effects on HWs should be a national priority. These suggestions and other interventions suggested by this study, are consistent with the World Health Organization's Maintaining essential health services: operational guidance for the COVID-19 context , which outlines 10 operational strategies for maintaining essential health services, which involves protection of health workers' physical and mental health ( 42 ).
The themes identified in this study raise questions about the role of HWs in society and HWs' ethical responsibilities. While some HWs felt that the work-related risks they were experiencing were part of “what they signed up for,” others questioned whether their responsibility extended to putting their lives and their families' at risk. This questioning may have been magnified by the perceived lack of support for HWs evidenced by the federal government undermining public health messages about mitigation, failure to help procure adequate PPE, and large portions of the population electing not to wear masks, practice social distancing, or, once vaccines became available, to be vaccinated. Although nurses and other staff have unionized in some regions of the country, a large portion of health workers in the U.S are not part of a labor union. Working conditions during COVID have renewed interest in health worker organization ( 43 , 44 ). Physicians historically have not been thought of as workers requiring labor protection, but as employment arrangements have shifted so that more physicians are employed by hospital systems than working in private practice, the pandemic experience may raise questions as to whether there may be a role for more extensive labor organization in the future across all HW roles.
Even in the face of major stressors, themes of HW professionalism, caring, and hope emerged. A narrative review of resilience strategies to manage psychological distress among health care workers during the COVID-19 pandemic published in June 2020 suggested several approaches that tie to the current study's themes ( 45 ). For example, organizational justice and organizational strategies, including staff feedback sessions and demonstrating support for workers, link to the Organizational Leadership subtheme in the current study. It remains unclear what the widespread disregard for HWs' and their families' health and mental health may mean for sustaining an adequate workforce in some health professions or how to make clear the toll the behaviors that suggest lack of regard has had.
The results of this study should be considered in the context of its limitations. First, one of the goals of the study was to interview HWs in the midst of the first surges in the country. Because the duration of surges in Massachusetts and New York could not be predicted at the time and it was not certain other surges would follow, we relied on a convenience plus snowball sampling approach to recruit participants. This allowed us to recruit HWs quickly and include HWs with a diversity of roles in health care. This also meant that the HWs who were interviewed by someone they knew may have been more or less willing to share controversial or critical thoughts but the criticisms and difficult topics discussed by HWs suggest familiarity may have facilitated openness. The majority of HWs interviewed were white; interviews with Black, Latinx and otherwise socially marginalized HWs as well as HWs in the lowest paying HW jobs may have generated additional themes or alternative views of the themes identified. Interviewers were affiliated with a university in a state with a tradition of liberal politics. Although political affiliation data were not collected, the political divisions in the country may have meant that different perspectives may be obtained in states that experienced surges later in the course of the pandemic with differing majority political views. Some questions in the interview guide were tailored to the earliest days of COVID-19 spread and may have less relevance at the current stage of the pandemic. Although the interviews for this study were conducted in the beginning of the pandemic, the mental health and physical consequences affecting HWs are likely to continue and potentially worsen as infection and death rates continue to climb.
This study of U.S. HWs experiences in the early days of the COVID-19 pandemic generated important narrative insights into the unique physical and psychological risks to HWs and similarities to risks identified in prior serious respiratory viral infection epidemics such as SARS-CoV. Although little of the response to the pandemic to date has involved a coordinated effort at the federal or other level, it is of urgent importance that the health and well-being of HWs be protected. The potential need for change at multiple levels of the SEM that were suggested by this study that could be tested in a large representative sample of health workers. For example, at the Societal level, combining the national databases tracking health worker infection rates, morbidity and mortality, coordinating efforts to implement evidence-based protective interventions in health care settings while also trying to understand address the forces that have reduced concern for the collective good and addressing the problematic capacity for emergency response are high level needs. At the Organizational level, management training and guidelines for rapid assembly and performance of an incident command center may help support the coordination needed to protect health workers. Finally, making mental health care support and options for family support more readily accessible and affordable could potentially offer better support at the individual level.
Data Availability Statement
Raw data will be made available on reasonable request with any data that may risk loss of confidentiality redacted.
The studies involving human participants were reviewed and approved by University of Massachusetts, Amherst. The Ethics Committee waived the requirement of written informed consent for participation.
SG conceived of the study, trained team members, interviewed participants, led the analysis, and drafted the manuscript. KC, MF, EC, and NP made intellectual contributions to study development, interviewed participants, participated in the analysis, contributed to manuscript review and editing, and approved the final version. MD and KW made intellectual contributions to study development, participated in the analysis, contributed to manuscript review and editing, and approved the final version. All authors contributed to the article and approved the submitted version.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
The authors would like to thank the study participants for giving generously of their time and Cherry Sullivan and Michele Farry for connecting us to coalition members and their thoughtful suggestions on topical areas of interest to their community.
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Keywords: health worker, COVID-19, occupational health and safety, qualitative, mitigation
Citation: Goff SL, Wallace K, Putnam N, Fernandes M, Chow E, DaCosta M and Clary K (2022) A Qualitative Study of Health Workers' Experiences During Early Surges in the COVID-19 Pandemic in the U.S.: Implications for Ongoing Occupational Health Challenges. Front. Public Health 10:780711. doi: 10.3389/fpubh.2022.780711
Received: 21 September 2021; Accepted: 04 February 2022; Published: 15 March 2022.
Copyright © 2022 Goff, Wallace, Putnam, Fernandes, Chow, DaCosta and Clary. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Sarah L. Goff, email@example.com
This article is part of the Research Topic
Occupational Risks of Healthcare Personnel
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Qualitative research is a type of research that explores and provides deeper insights into real-world problems.  Instead of collecting numerical data points or intervene or introduce treatments just like in quantitative research, qualitative research helps generate hypotheses as well as further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a stand-alone study, purely relying on qualitative data or it could be part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and application of qualitative research.
Qualitative research at its core, ask open-ended questions whose answers are not easily put into numbers such as ‘how’ and ‘why’.  Due to the open-ended nature of the research questions at hand, qualitative research design is often not linear in the same way quantitative design is.  One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify.  Phenomena such as experiences, attitudes, and behaviors can be difficult to accurately capture quantitatively, whereas a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a certain time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify and it is important to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.
However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore ‘compete’ against each other and the philosophical paradigms associated with each, qualitative and quantitative work are not necessarily opposites nor are they incompatible.  While qualitative and quantitative approaches are different, they are not necessarily opposites, and they are certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined that there is a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated together.
Examples of Qualitative Research Approaches
Ethnography as a research design has its origins in social and cultural anthropology, and involves the researcher being directly immersed in the participant’s environment.  Through this immersion, the ethnographer can use a variety of data collection techniques with the aim of being able to produce a comprehensive account of the social phenomena that occurred during the research period.  That is to say, the researcher’s aim with ethnography is to immerse themselves into the research population and come out of it with accounts of actions, behaviors, events, etc. through the eyes of someone involved in the population. Direct involvement of the researcher with the target population is one benefit of ethnographic research because it can then be possible to find data that is otherwise very difficult to extract and record.
Grounded Theory is the “generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior.”  As opposed to quantitative research which is deductive and tests or verifies an existing theory, grounded theory research is inductive and therefore lends itself to research that is aiming to study social interactions or experiences.   In essence, Grounded Theory’s goal is to explain for example how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.
Phenomenology is defined as the “study of the meaning of phenomena or the study of the particular”.  At first glance, it might seem that Grounded Theory and Phenomenology are quite similar, but upon careful examination, the differences can be seen. At its core, phenomenology looks to investigate experiences from the perspective of the individual.  Phenomenology is essentially looking into the ‘lived experiences’ of the participants and aims to examine how and why participants behaved a certain way, from their perspective . Herein lies one of the main differences between Grounded Theory and Phenomenology. Grounded Theory aims to develop a theory for social phenomena through an examination of various data sources whereas Phenomenology focuses on describing and explaining an event or phenomena from the perspective of those who have experienced it.
One of qualitative research’s strengths lies in its ability to tell a story, often from the perspective of those directly involved in it. Reporting on qualitative research involves including details and descriptions of the setting involved and quotes from participants. This detail is called ‘thick’ or ‘rich’ description and is a strength of qualitative research. Narrative research is rife with the possibilities of ‘thick’ description as this approach weaves together a sequence of events, usually from just one or two individuals, in the hopes of creating a cohesive story, or narrative.  While it might seem like a waste of time to focus on such a specific, individual level, understanding one or two people’s narratives for an event or phenomenon can help to inform researchers about the influences that helped shape that narrative. The tension or conflict of differing narratives can be “opportunities for innovation”. 
Research paradigms are the assumptions, norms, and standards that underpin different approaches to research. Essentially, research paradigms are the ‘worldview’ that inform research.  It is valuable for researchers, both qualitative and quantitative, to understand what paradigm they are working within because understanding the theoretical basis of research paradigms allows researchers to understand the strengths and weaknesses of the approach being used and adjust accordingly. Different paradigms have different ontology and epistemologies . Ontology is defined as the "assumptions about the nature of reality” whereas epistemology is defined as the “assumptions about the nature of knowledge” that inform the work researchers do.  It is important to understand the ontological and epistemological foundations of the research paradigm researchers are working within to allow for a full understanding of the approach being used and the assumptions that underpin the approach as a whole. Further, it is crucial that researchers understand their own ontological and epistemological assumptions about the world in general because their assumptions about the world will necessarily impact how they interact with research. A discussion of the research paradigm is not complete without describing positivist, postpositivist, and constructivist philosophies.
Positivist vs Postpositivist
To further understand qualitative research, we need to discuss positivist and postpositivist frameworks. Positivism is a philosophy that the scientific method can and should be applied to social as well as natural sciences.  Essentially, positivist thinking insists that the social sciences should use natural science methods in its research which stems from positivist ontology that there is an objective reality that exists that is fully independent of our perception of the world as individuals. Quantitative research is rooted in positivist philosophy, which can be seen in the value it places on concepts such as causality, generalizability, and replicability.
Conversely, postpositivists argue that social reality can never be one hundred percent explained but it could be approximated.  Indeed, qualitative researchers have been insisting that there are “fundamental limits to the extent to which the methods and procedures of the natural sciences could be applied to the social world” and therefore postpositivist philosophy is often associated with qualitative research.  An example of positivist versus postpositivist values in research might be that positivist philosophies value hypothesis-testing, whereas postpositivist philosophies value the ability to formulate a substantive theory.
Constructivism is a subcategory of postpositivism. Most researchers invested in postpositivist research are constructivist as well, meaning they think there is no objective external reality that exists but rather that reality is constructed. Constructivism is a theoretical lens that emphasizes the dynamic nature of our world. “Constructivism contends that individuals’ views are directly influenced by their experiences, and it is these individual experiences and views that shape their perspective of reality”.  Essentially, Constructivist thought focuses on how ‘reality’ is not a fixed certainty and experiences, interactions, and backgrounds give people a unique view of the world. Constructivism contends, unlike in positivist views, that there is not necessarily an ‘objective’ reality we all experience. This is the ‘relativist’ ontological view that reality and the world we live in are dynamic and socially constructed. Therefore, qualitative scientific knowledge can be inductive as well as deductive.” 
So why is it important to understand the differences in assumptions that different philosophies and approaches to research have? Fundamentally, the assumptions underpinning the research tools a researcher selects provide an overall base for the assumptions the rest of the research will have and can even change the role of the researcher themselves.  For example, is the researcher an ‘objective’ observer such as in positivist quantitative work? Or is the researcher an active participant in the research itself, as in postpositivist qualitative work? Understanding the philosophical base of the research undertaken allows researchers to fully understand the implications of their work and their role within the research, as well as reflect on their own positionality and bias as it pertains to the research they are conducting.
The better the sample represents the intended study population, the more likely the researcher is to encompass the varying factors at play. The following are examples of participant sampling and selection: 
- Purposive sampling- selection based on the researcher’s rationale in terms of being the most informative.
- Criterion sampling-selection based on pre-identified factors.
- Convenience sampling- selection based on availability.
- Snowball sampling- the selection is by referral from other participants or people who know potential participants.
- Extreme case sampling- targeted selection of rare cases.
- Typical case sampling-selection based on regular or average participants.
Data Collection and Analysis
Qualitative research uses several techniques including interviews, focus groups, and observation.    Interviews may be unstructured, with open-ended questions on a topic and the interviewer adapts to the responses. Structured interviews have a predetermined number of questions that every participant is asked. It is usually one on one and is appropriate for sensitive topics or topics needing an in-depth exploration. Focus groups are often held with 8-12 target participants and are used when group dynamics and collective views on a topic are desired. Researchers can be a participant-observer to share the experiences of the subject or a non-participant or detached observer.
While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or in the environment of the participants, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed which may then be coded manually or with the use of Computer Assisted Qualitative Data Analysis Software or CAQDAS such as ATLAS.ti or NVivo.   
After the coding process, qualitative research results could be in various formats. It could be a synthesis and interpretation presented with excerpts from the data.  Results also could be in the form of themes and theory or model development.
To standardize and facilitate the dissemination of qualitative research outcomes, the healthcare team can use two reporting standards. The Consolidated Criteria for Reporting Qualitative Research or COREQ is a 32-item checklist for interviews and focus groups.  The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a wider range of qualitative research. 
Examples of Application
Many times a research question will start with qualitative research. The qualitative research will help generate the research hypothesis which can be tested with quantitative methods. After the data is collected and analyzed with quantitative methods, a set of qualitative methods can be used to dive deeper into the data for a better understanding of what the numbers truly mean and their implications. The qualitative methods can then help clarify the quantitative data and also help refine the hypothesis for future research. Furthermore, with qualitative research researchers can explore subjects that are poorly studied with quantitative methods. These include opinions, individual's actions, and social science research.
A good qualitative study design starts with a goal or objective. This should be clearly defined or stated. The target population needs to be specified. A method for obtaining information from the study population must be carefully detailed to ensure there are no omissions of part of the target population. A proper collection method should be selected which will help obtain the desired information without overly limiting the collected data because many times, the information sought is not well compartmentalized or obtained. Finally, the design should ensure adequate methods for analyzing the data. An example may help better clarify some of the various aspects of qualitative research.
A researcher wants to decrease the number of teenagers who smoke in their community. The researcher could begin by asking current teen smokers why they started smoking through structured or unstructured interviews (qualitative research). The researcher can also get together a group of current teenage smokers and conduct a focus group to help brainstorm factors that may have prevented them from starting to smoke (qualitative research).
In this example, the researcher has used qualitative research methods (interviews and focus groups) to generate a list of ideas of both why teens start to smoke as well as factors that may have prevented them from starting to smoke. Next, the researcher compiles this data. The research found that, hypothetically, peer pressure, health issues, cost, being considered “cool,” and rebellious behavior all might increase or decrease the likelihood of teens starting to smoke.
The researcher creates a survey asking teen participants to rank how important each of the above factors is in either starting smoking (for current smokers) or not smoking (for current non-smokers). This survey provides specific numbers (ranked importance of each factor) and is thus a quantitative research tool.
The researcher can use the results of the survey to focus efforts on the one or two highest-ranked factors. Let us say the researcher found that health was the major factor that keeps teens from starting to smoke, and peer pressure was the major factor that contributed to teens to start smoking. The researcher can go back to qualitative research methods to dive deeper into each of these for more information. The researcher wants to focus on how to keep teens from starting to smoke, so they focus on the peer pressure aspect.
The researcher can conduct interviews and/or focus groups (qualitative research) about what types and forms of peer pressure are commonly encountered, where the peer pressure comes from, and where smoking first starts. The researcher hypothetically finds that peer pressure often occurs after school at the local teen hangouts, mostly the local park. The researcher also hypothetically finds that peer pressure comes from older, current smokers who provide the cigarettes.
The researcher could further explore this observation made at the local teen hangouts (qualitative research) and take notes regarding who is smoking, who is not, and what observable factors are at play for peer pressure of smoking. The researcher finds a local park where many local teenagers hang out and see that a shady, overgrown area of the park is where the smokers tend to hang out. The researcher notes the smoking teenagers buy their cigarettes from a local convenience store adjacent to the park where the clerk does not check identification before selling cigarettes. These observations fall under qualitative research.
If the researcher returns to the park and counts how many individuals smoke in each region of the park, this numerical data would be quantitative research. Based on the researcher's efforts thus far, they conclude that local teen smoking and teenagers who start to smoke may decrease if there are fewer overgrown areas of the park and the local convenience store does not sell cigarettes to underage individuals.
The researcher could try to have the parks department reassess the shady areas to make them less conducive to the smokers or identify how to limit the sales of cigarettes to underage individuals by the convenience store. The researcher would then cycle back to qualitative methods of asking at-risk population their perceptions of the changes, what factors are still at play, as well as quantitative research that includes teen smoking rates in the community, the incidence of new teen smokers, among others.  
Qualitative research functions as a standalone research design or in combination with quantitative research to enhance our understanding of the world. Qualitative research uses techniques including structured and unstructured interviews, focus groups, and participant observation to not only help generate hypotheses which can be more rigorously tested with quantitative research but also to help researchers delve deeper into the quantitative research numbers, understand what they mean, and understand what the implications are. Qualitative research provides researchers with a way to understand what is going on, especially when things are not easily categorized. 
- Issues of Concern
As discussed in the sections above, quantitative and qualitative work differ in many different ways, including the criteria for evaluating them. There are four well-established criteria for evaluating quantitative data: internal validity, external validity, reliability, and objectivity. The correlating concepts in qualitative research are credibility, transferability, dependability, and confirmability.   The corresponding quantitative and qualitative concepts can be seen below, with the quantitative concept is on the left, and the qualitative concept is on the right:
- Internal validity--- Credibility
- External validity---Transferability
In conducting qualitative research, ensuring these concepts are satisfied and well thought out can mitigate potential issues from arising. For example, just as a researcher will ensure that their quantitative study is internally valid so should qualitative researchers ensure that their work has credibility.
Indicators such as triangulation and peer examination can help evaluate the credibility of qualitative work.
- Triangulation: Triangulation involves using multiple methods of data collection to increase the likelihood of getting a reliable and accurate result. In our above magic example, the result would be more reliable by also interviewing the magician, back-stage hand, and the person who "vanished." In qualitative research, triangulation can include using telephone surveys, in-person surveys, focus groups, and interviews as well as surveying an adequate cross-section of the target demographic.
- Peer examination: Results can be reviewed by a peer to ensure the data is consistent with the findings.
‘Thick’ or ‘rich’ description can be used to evaluate the transferability of qualitative research whereas using an indicator such as an audit trail might help with evaluating the dependability and confirmability.
- Thick or rich description is a detailed and thorough description of details, the setting, and quotes from participants in the research.  Thick descriptions will include a detailed explanation of how the study was carried out. Thick descriptions are detailed enough to allow readers to draw conclusions and interpret the data themselves, which can help with transferability and replicability.
- Audit trail: An audit trail provides a documented set of steps of how the participants were selected and the data was collected. The original records of information should also be kept (e.g., surveys, notes, recordings).
One issue of concern that qualitative researchers should take into consideration is observation bias. Here are a few examples:
- Hawthorne effect: The Hawthorne effect is the change in participant behavior when they know they are being observed. If a researcher was wanting to identify factors that contribute to employee theft and tells the employees they are going to watch them to see what factors affect employee theft, one would suspect employee behavior would change when they know they are being watched.
- Observer-expectancy effect: Some participants change their behavior or responses to satisfy the researcher's desired effect. This happens in an unconscious manner for the participant so it is important to eliminate or limit transmitting the researcher's views.
- Artificial scenario effect: Some qualitative research occurs in artificial scenarios and/or with preset goals. In such situations, the information may not be accurate because of the artificial nature of the scenario. The preset goals may limit the qualitative information obtained.
- Clinical Significance
Qualitative research by itself or combined with quantitative research helps healthcare providers understand patients and the impact and challenges of the care they deliver. Qualitative research provides an opportunity to generate and refine hypotheses and delve deeper into the data generated by quantitative research. Qualitative research does not exist as an island apart from quantitative research, but as an integral part of research methods to be used for the understanding of the world around us. 
- Enhancing Healthcare Team Outcomes
Qualitative research is important for all members of the health care team as all are affected by qualitative research. Qualitative research may help develop a theory or a model for health research that can be further explored by quantitative research. Much of the qualitative research data acquisition is completed by numerous team members including social works, scientists, nurses, etc. Within each area of the medical field, there is copious ongoing qualitative research including physician-patient interactions, nursing-patient interactions, patient-environment interactions, health care team function, patient information delivery, etc.
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Disclosure: Steven Tenny declares no relevant financial relationships with ineligible companies.
Disclosure: Janelle Brannan declares no relevant financial relationships with ineligible companies.
Disclosure: Grace Brannan declares no relevant financial relationships with ineligible companies.
This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.
- Cite this Page Tenny S, Brannan JM, Brannan GD. Qualitative Study. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
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