qualitative research is most aligned with which paradigm

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The Four Types of Research Paradigms: A Comprehensive Guide

5-minute read

• 22nd January 2023

In this guide, you’ll learn all about the four research paradigms and how to choose the right one for your research.

Introduction to Research Paradigms

A paradigm is a system of beliefs, ideas, values, or habits that form the basis for a way of thinking about the world. Therefore, a research paradigm is an approach, model, or framework from which to conduct research. The research paradigm helps you to form a research philosophy, which in turn informs your research methodology.

Your research methodology is essentially the “how” of your research – how you design your study to not only accomplish your research’s aims and objectives but also to ensure your results are reliable and valid. Choosing the correct research paradigm is crucial because it provides a logical structure for conducting your research and improves the quality of your work, assuming it’s followed correctly.

Three Pillars: Ontology, Epistemology, and Methodology

Before we jump into the four types of research paradigms, we need to consider the three pillars of a research paradigm.

Ontology addresses the question, “What is reality?” It’s the study of being. This pillar is about finding out what you seek to research. What do you aim to examine?

Epistemology is the study of knowledge. It asks, “How is knowledge gathered and from what sources?”

Methodology involves the system in which you choose to investigate, measure, and analyze your research’s aims and objectives. It answers the “how” questions.

Let’s now take a look at the different research paradigms.

1.   Positivist Research Paradigm

The positivist research paradigm assumes that there is one objective reality, and people can know this reality and accurately describe and explain it. Positivists rely on their observations through their senses to gain knowledge of their surroundings.

In this singular objective reality, researchers can compare their claims and ascertain the truth. This means researchers are limited to data collection and interpretations from an objective viewpoint. As a result, positivists usually use quantitative methodologies in their research (e.g., statistics, social surveys, and structured questionnaires).

This research paradigm is mostly used in natural sciences, physical sciences, or whenever large sample sizes are being used.

2.   Interpretivist Research Paradigm

Interpretivists believe that different people in society experience and understand reality in different ways – while there may be only “one” reality, everyone interprets it according to their own view. They also believe that all research is influenced and shaped by researchers’ worldviews and theories.

As a result, interpretivists use qualitative methods and techniques to conduct their research. This includes interviews, focus groups, observations of a phenomenon, or collecting documentation on a phenomenon (e.g., newspaper articles, reports, or information from websites).

3.   Critical Theory Research Paradigm

The critical theory paradigm asserts that social science can never be 100% objective or value-free. This paradigm is focused on enacting social change through scientific investigation. Critical theorists question knowledge and procedures and acknowledge how power is used (or abused) in the phenomena or systems they’re investigating.

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Researchers using this paradigm are more often than not aiming to create a more just, egalitarian society in which individual and collective freedoms are secure. Both quantitative and qualitative methods can be used with this paradigm.

4.   Constructivist Research Paradigm

Constructivism asserts that reality is a construct of our minds ; therefore, reality is subjective. Constructivists believe that all knowledge comes from our experiences and reflections on those experiences and oppose the idea that there is a single methodology to generate knowledge.

This paradigm is mostly associated with qualitative research approaches due to its focus on experiences and subjectivity. The researcher focuses on participants’ experiences as well as their own.

Choosing the Right Research Paradigm for Your Study

Once you have a comprehensive understanding of each paradigm, you’re faced with a big question: which paradigm should you choose? The answer to this will set the course of your research and determine its success, findings, and results.

To start, you need to identify your research problem, research objectives , and hypothesis . This will help you to establish what you want to accomplish or understand from your research and the path you need to take to achieve this.

You can begin this process by asking yourself some questions:

• What is the nature of your research problem (i.e., quantitative or qualitative)?
• How can you acquire the knowledge you need and communicate it to others? For example, is this knowledge already available in other forms (e.g., documents) and do you need to gain it by gathering or observing other people’s experiences or by experiencing it personally?
• What is the nature of the reality that you want to study? Is it objective or subjective?

Depending on the problem and objective, other questions may arise during this process that lead you to a suitable paradigm. Ultimately, you must be able to state, explain, and justify the research paradigm you select for your research and be prepared to include this in your dissertation’s methodology and design section.

Using Two Paradigms

If the nature of your research problem and objectives involves both quantitative and qualitative aspects, then you might consider using two paradigms or a mixed methods approach . In this, one paradigm is used to frame the qualitative aspects of the study and another for the quantitative aspects. This is acceptable, although you will be tasked with explaining your rationale for using both of these paradigms in your research.

Choosing the right research paradigm for your research can seem like an insurmountable task. It requires you to:

●  Have a comprehensive understanding of the paradigms,

●  Identify your research problem, objectives, and hypothesis, and

●  Be able to state, explain, and justify the paradigm you select in your methodology and design section.

Although conducting your research and putting your dissertation together is no easy task, proofreading it can be! Our experts are here to make your writing shine. Your first 500 words are free !

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Educational Research Basics by Del Siegle

Qualitative research paradigm.

I am amazed how often we hear qualitative researchers applying their standards to quantitative research or quantitative researchers applying their standards to qualitative research. Each functions within different assumptions. Finding fault with one approach with the standards of another does little to promote understanding. Each approach should be judges on its theoretical basis.

The Assumptions of Qualitative Designs

• Qualitative researchers are concerned primarily with process , rather than outcomes or products.
• Qualitative researchers are interested in meaning: ­how people make sense of their lives, experiences, and their structures of the world.
• The qualitative researcher is the primary instrument for data collection and analysis. Data are mediated through this human instrument, rather than through inventories, questionnaires, or machines.
• Qualitative research involves fieldwork . The researcher physically goes to the people, setting, site, or institution to observe or record behavior in its natural setting.
• Qualitative research is descriptive in that the researcher is interested in process, meaning, and understanding gained through words or pictures.
• The process of qualitative research is inductive in that the researcher builds abstractions, concepts, hypotheses, and theories from details.

…..Merriam, S. B. (1988). Case study research in education: A qualitative approach. San Francisco, CA: Jossey-Bass.

….. Creswell, J. W. (1994). Research design: Qualitative & quantitative approaches . Thousand Oaks, CA: Sage Publications.

Arguments Supporting Qualitative Inquiry

• Human behavior is significantly influenced by the setting in which it occurs; thus one must study that behavior in situations. The physical setting (­e.g., schedules, space, pay, and rewards­) and the internalized notions of norms, traditions, roles, and values are crucial contextual variables. Research must be conducted in the setting where all the contextual variables are operating.
• Past researchers have not been able to derive meaning…from experimental research.
• The research techniques themselves, in experimental research, [can]…affect the findings. The lab, the questionnaire, and so on, [can]…become artifacts. Subjects [can become]…either suspicious and wary, or they [can become]…aware of what the researchers want and try to please them. Additionally, subjects sometimes do not know their feelings, interactions, and behaviors, so they cannot articulate them to respond to a questionnaire.
• One cannot understand human behavior without understanding the framework within which subjects interpret their thoughts, feelings, and actions. Researchers need to understand the framework. In fact, the “objective ” scientist, by coding and standardizing, may destroy valuable data while imposing her world on the subjects.
• Field study research can explore the processes and meanings of events.

…..Marshall, C., & Rossman, G. (1980). Designing qualitative research . Newbury Park, CA: Sage.

Predispositions of Quantitative and Qualitative Modes of Inquiry

Although some social science researchers (Lincoln & Guba, 1985; Schwandt, 1989) perceive qualitative and quantitative approaches as incompatible, others (Patton, 1990; Reichardt & Cook, 1979) believe that the skilled researcher can successfully combine approaches. The argument usually becomes muddled because one party argues from the underlying philosophical nature of each paradigm, and the other focuses on the apparent compatibility of the research methods, enjoying the rewards of both numbers and words. Because the positivist and the interpretivist paradigms rest on different assumptions about the nature of the world, they require different instruments and procedures to find the type of data desired. This does not mean, however, that the positivist never uses interviews nor that the interpretivist never uses a survey. They may, but such methods are supplementary, not dominant….Different approaches allow us to know and understand different things about the world….Nonetheless, people tend to adhere to the methodology that is most consonant with their socialized worldview. (p. 9)

….. Glesne, C., & Peshkin, A. (1992). Becoming qualitative researchers: An introduction. White Plains, NY: Longman.

Contrasting Positivist and Naturalist Axioms (Beliefs and Assumptions)

….. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry . Newbury Park, CA: Sage Publications.

….. Spradley, J. P. (1979). The ethnographic interview. Fort Worth, TX: Harcourt Brace Jovanovich College Publishers.

Five popular types of Qualitative Research are

• Ethnography
• Phenomenological
• Grounded Theory

Del Siegle, Ph.D [email protected] www.delsiegle.info

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• Published: May 2018
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A paradigm is a world view held by members of a research community. It determines what humans can know and how to undertake research to generate knowledge. It shapes how research is undertaken and how quality is judged. In mixed methods evaluations combining qualitative research and RCTs, the implicit paradigm is often post-positivism. There are alternative paradigms such as participatory action research and realist evaluation. The status of qualitative research within a mixed methods evaluation may depend on the paradigm adopted. Researchers undertaking qualitative research may adopt a different philosophical stance from those undertaking the RCT. It is important to have team discussions about paradigms throughout a mixed methods evaluation to understand the variety of stances within the team. This chapter focuses on the range of paradigms researchers adopt and some of the challenges researchers face when combining qualitative research and RCTs within different paradigms.

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Chapter 2: Foundations of qualitative research – paradigms, philosophical underpinnings

Darshini Ayton and Tess Tsindos

Learning outcomes

Upon completion of this chapter, you should be able to:

• Recognise and understand the four main paradigms that underpin research.
• Understand how paradigms differ between qualitative and quantitative research.
• Describe the differences between approaches in inductive and deductive research.

What is a paradigm ?

All research takes place within a paradigm. A paradigm is a worldview – a framework of beliefs, values and methods. For researchers, the paradigm or worldview framing their research informs the meaning they interpret from the data. Each researcher works within their own, unique paradigm; this includes the techniques they choose for collecting and analysing data. 1 There are four main research paradigms in social science (see Table 2.1. ) :

• positivist , or scientific , paradigm
• interpretivist , or constructivist , paradigm (also known as the naturalistic paradigm)
• radical , or critical , paradigm
• post – structuralist paradigm. 2,3

These paradigms reflect the researcher ’ s beliefs about what is reality (ontology), knowledge (epistemology), the means to obtain ing knowledge (methodology) and the values of the researcher (axiology). 3 We might think of ontology as ‘what is true’ and epistemology as ‘how do we know those truths?’. The positivist paradigm is suited to quantitative research because it is grounded in the notion of cause and effect . T he remaining three paradigms are suited to qualitative research because they are grounded in exploration and understanding . 3  

Qualitative research is embedded in the interpretivist, or constructivist paradigm. The understandings and beliefs of interpretivism or constructivism can be considered in terms of:

• Assumptions and values: The research seeks to understand what it is to be human, and the significance and meanings people ascribe to life events. It aims to identify what is important and what is evidence. 4
• Researcher–participant relationship: The relationship is ‘intersubjective’ – that is, the researcher is the listener and interpreter of the data obtained from the participant. The researcher discovers the truth of a situation through thinking and analysis, rather than sensory observation. Interpretation is required. 4
• Methodology (the research approach): Qualitative research includes study designs such as descriptive, phenomenology, action research, case study, grounded theory and ethnography. 4 These are covered in section 2 of this textbook.
• Ontology (the nature of reality): The researcher recognises that there are multiple subjective realities, and that these are socially constructed in the interactions between research participants and between the researcher and participants. 5
• Epistemology (the theory of knowledge, or how knowledge is created): Knowledge is derived from the everyday. The researcher creates meaning from the data through their thinking and analysis of the data informed by their encounters with participants. 3
• Axiology (the value and ethics of the research): The research will reflect the values of the researcher who aims to present a balanced interpretation of the results. 5

A good example of the interpretivist or constructivist paradigm is a study exploring physical and bodily pain. We humans each experience pain differently, due to many factors, including how we were socialised to respond to pain in our family and communities, our individual pain threshold, our past experiences of pain and the context of our current pain – what else is happening in that moment of pain. Thus, it is reasonable to say that pain is socially constructed. In health care, pain is measured on a numerical scale, but it is the person’s perception of the pain that determines the number assigned to their pain (self-report). We may therefore question whether there is an objective, scientific method for measuring pain. A common facilitator for pain relief – paracetamol – reduces pain for some people and not for others. Consider why this is the case. (It is the person’s perception of what is working to relieve their perceived pain.) Positivists do not rely on subjective experiences, only facts and a singular truth: objectivity. Constructionists and intepretivists contend that subjective and social experiences create reality, and that there are many truths.

Although it is not one of the four main paradigms, post-positivism is another paradigm that appears in the literature. Post-positivism asserts that there are multiple and competing views of science, and multiple truths. Therefore, researchers cannot be completely objective, unbiased and value-free, as the positivist paradigm asserts. 4 This shift in perspective from positivism to post-positivism has led to the incorporation of qualitative methods into the post-positivist paradigm, to enable the research to explore participants’ experiences of the phenomenon under study. This paradigm is included in Table 2.1. since its basic ontology is similar to the positivist paradigm. 6

Table 2.1. Research paradigms in social science

In Table 2.2. an article is provided to highlight the different components of the research paradigms. Note: The aims are reproduced verbatim from the papers (word for word).

Table 2.2. Examples of paradigms within published research

Approaches in qualitative methods

Approaches are how a researcher intends to carry out their research. In qualitative research, there are two main approaches:

• Inductive: Driven by the participants and their data

An inductive approach employs a ‘whole world’ view and includes the wider social and historical context. It considers the layers that surround the individual – temporal, spatial, ideational, institutional and structural, and focuses on meanings, ideas and experiences. The inductive approach is concerned with participants’ subjective views. When examining what participants have said in an interview, the researcher searches for themes, setting aside preconceived notions. 6 (Review the example in Chapter 3 of exploring seniors’ perceptions of health and loneliness. T he theoretical drive of the research is inductive because it is describ ing and explor ing the perceptions of seniors . ) An inductive research approa ch is hypothesis – generating – this means the researchers do not have preconceived ideas of what they will find in their research and data , and hypotheses will be generated in the process of analysing the data . 6

• Deductive: Driven by a pre-existing theory, framework or series of questions

A deductive approach can employ a theory or framework to guide the research, and responses are usually categorised into pre-determined labels (most often called ‘codes’). This is usually how questionnaires or structured interviews are interpreted. The pre-determined codes are based on the questions asked in interviews or focus groups. A deductive approach, particularly in the positivist paradigm, is hypothesis-testing – the researchers are looking for evidence of specific ideas, concepts and relationships in the research and data. 5

All research takes place within a paradigm, consciously or subconsciously; that is, regardless of whether this is understood by the researcher. To interpret the data well, qualitative researchers must explore and acknowledge their own framework of beliefs, values and methods informing the meaning of their data. Qualitative research is embedded in the interpretivist paradigm. Four main paradigms have been explored and explained in this chapter.

• Donmoyer R. Paradigm. In: Given LM, ed. The SAGE Encyclopedia of Qualitative Research Methods .  SAGE Publications; 2008:591-595.
• Denzin NK, Lincoln YS. The SAGE Handbook of Qualitative Research. SAGE Publications; 2006.
• Giddings LS, Grant BM. Mixed methods research for the novice researcher. Contemp Nurse. 2006;23(1):3-11. doi:10.5172/conu.2006.23.1.3
• Levers, M-JD. Philosophical paradigms, grounded theory, and perspectives on emergence. SAGE Open . 2013;3(4). doi:10.1177/2158244013517243
• Kivunja C, Kuyini AB. Understanding and applying research paradigms in educational contexts. International Journal of Higher Education. 2017;6(5):26-41. doi:10.5430/ijhe.v6n5p26
• Morse JM. The paradox of qualitative research design. Qual Health Res. 2003;13(10):1335-1336. doi:10.1177/1049732303258368
• Loeb M, Bartholomew A, Hashmi M, et al. Medical masks versus N95 respirators for preventing COVID-19 among health care workers: a randomized trial. Ann Intern Med. 2022;175(12):1629-1638. doi:10.7326/M22-1966
• Sterling MR, Tseng E, Poon A, et al. Experiences of home health care workers in New York City during the coronavirus disease 2019 pandemic: a qualitative analysis. JAMA Intern Med. 2020;180(11):1453-1459. doi:10.1001/jamainternmed.2020.3930
• Ananda-Rajah M, Veness B, Berkovic D, Parker C, Kelly G, Ayton D. Hearing the voices of Australian healthcare workers during the COVID-19 pandemic. BMJ Leader. 2021;5:31-35. doi:10.1136/leader-2020-000386
• Boulton M, Garnett A, Webster F. A Foucauldian discourse analysis of media reporting on the nurse-as-hero during COVID-19. Nurs Inq. 2022;29(3):e12471. doi:10.1111/nin.12471

Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Darshini Ayton and Tess Tsindos is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Criteria for Good Qualitative Research: A Comprehensive Review

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• Published: 18 September 2021
• Volume 31 , pages 679–689, ( 2022 )

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• Drishti Yadav   ORCID: orcid.org/0000-0002-2974-0323 1  

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Good Qualitative Research: Opening up the Debate

Beyond qualitative/quantitative structuralism: the positivist qualitative research and the paradigmatic disclaimer.

What is Qualitative in Research

Avoid common mistakes on your manuscript.

Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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Yadav, D. Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Edu Res 31 , 679–689 (2022). https://doi.org/10.1007/s40299-021-00619-0

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Components of safe nursing care in the intensive care units: a qualitative study

• Mozhdeh Tajari 1 ,
• Tahereh Ashktorab 2 &
• Abbas Ebadi 3  

BMC Nursing volume  23 , Article number:  613 ( 2024 ) Cite this article

Metrics details

Patient safety is a global health issue that affects patients worldwide. Providing safe care in the intensive care units (ICUs) is one of the most crucial tasks for nurses. Numerous factors can impact the capacity of nurses to deliver safe care within ICUs. Consequently, this study was undertaken with the aim of identifying the components of safe nursing care in ICUs.

The current research constitutes a qualitative conventional content analysis study conducted from January 2022 to June 2022. The study participants comprised nurses, intensivists, nurse responsible for patient safety, paramedic, patients, and patients’ family member, totaling 21 individuals selected through purposive sampling. Data collection involved individual, in-depth, and semi-structured interviews. Subsequently, data analysis was performed utilizing the approach outlined by Graneheim and Lundman (Nurse Educ Today 24(2):105–12, 2004), leading to the identification of participants’ perspectives.

Three themes were identified as components of safe nursing care in ICUs. These themes include professional behavior (with categories: Implementation of policies, organizing communication, professional ethics), holistic care (with categories: systematic care, comprehensive care of all systems), and safety-oriented organization (with categories: human resource management and safe environment).

Conclusions

The findings of this study underscore the significance of advocating for safe nursing practices in ICUs by emphasizing professional conduct, holistic care, and safety-focused organizational structures. These results align with existing research, suggesting that by introducing tailored interventions and tactics informed by these elements, a safer environment for nursing care can be established for ICUs patients.

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One of the most crucial indicatorsof quality care is safety (Atashzadeh Shoorideh et al. [ 1 ]). Safety refers to the prevention of all unintentional or intentional harm, such as injury or death due to adverse medication reactions, patient misidentification, or nosocomial infections by healthcare providers (Butler and Hupp [ 2 ]). Recently defined by the World Health Organization in 2021, patient safety is a framework of organized activities that establish cultures, processes, behaviors, technologies, and environments within healthcare organizations. This framework aims to consistently and effectively identify risks, preventable harm, and reduce the likelihood of their occurrence (Organization [ 3 ]).

Unsafe care has significantly contributed to serious medical accidents worldwide (AL-Mugheed et al. [ 4 ]), and the social cost of patient injuries has been reported to be in the trillions of dollars annually (Organization [ 3 ]). Hospital-acquired serious injuries account for 6% of occupied hospital beds and about 7 million hospital admissions per year (Butler and Hupp [ 2 ]). Evidence shows that patient safety is a global health concern that affects patients worldwide, including both developed and developing countries (Austin et al. [ 5 ]).

Patient safety is even more crucial in intensive care units (ICUs) because they are among the most critical hospital units where nurses play a vital role (Mahmoudi [ 6 ]). In these units, the risk of adverse events is heightened due to factors such as the complexity of the patient’s condition and treatment, the presence of numerous electronic devices and equipment, patients’ lack of awareness, and their reliance on nurses and life-support equipment (Marzban et al. [ 7 ]). Apart from patients, nurses also face unique challenges like high job stress, extended working hours, burnout, dissatisfaction, moral dilemmas, conflicts with patients’ families, and decisions regarding end-of-life care (LeClaire et al. [ 8 ]).

According to a study conducted in Brazil, factors affecting patient safety in relation to nursing staff included the workload of staff, training and professional qualification of staff, teamwork, contractual employment, lack of job security, and destructive behaviors (Oliveira et al. [ 9 ]). In the study by Naderi et al. (Naderi [ 10 ])in Iran, the factors affecting patient safety include human resources status, management and organization, interaction and teamwork, medications, equipment, medical environment, patient-related factors, improving patient quality and safety, importance of documentation, evaluation and monitoring, medical errors, and barriers and challenges (Naderi [ 10 ]). In a study by Lima et al. (D’Lima et al. [ 11 ]), concepts obtained in relation to employee risk perception and patient safety included employee individual factors (sub-theme including pragmatism versus perfectionism), team factors (two sub-themes including team dynamics and interdisciplinary tensions), unit factors (sub-theme including achieving dynamic balance), and organizational factors (sub-theme including risk perception) (D’Lima et al. [ 11 ]). Another study identified factors such as nurse error awareness, nurse well-being, teamwork, non-punitive environment, work management, hospital leadership, and ICU leadership as effective factors for safe ICU care (Garrouste-Orgeas et al. [ 12 ]).

Vaismoradi (Vaismoradi [ 13 ])conducted a grounded theory study in Iran, presenting strategies aimed at enhancing safe care. These strategies encompassed altering attitudes and performance, eliminating organizational obstacles, fostering a culture of teamwork, enhancing the influence of nursing leadership, and cultivating a culture centered on safe nursing care. Furthermore, Vaismoradi emphasized the importance of redefining safe care and conducting guiding research in this domain as highly impactful strategies (Vaismoradi [ 13 ]).

Despite the existing researches in the realm of factors and elements associated with patient safety, a noticeable gap in within high-risk and critical units like ICUs is evident. Through the implementation of more targeted studies, it is possible to pinpoint the components of safe nursing care in ICUs that align with the cultural contexts and healthcare systems of different countries. The outcomes of this research at a micro level of management can serve as valuable resources for the education and training of nursing students and professionals, while at a macro level, they can inform the development and implementation of healthcare policies. Hence, this study was initiated with the aim of identifying the components of safe nursing care in ICUs.

Materials and methods

Study design and setting.

The present study is a conventional content analysis approach, carried out from January 2022 to June 2022. The research was conducted in 8 hospitals affiliated with three medical sciences universities in Tehran, the capital of Iran.

Participants

Through purposive sampling, a total of 21 participants were selected for interviews. The participants included 7 nurses, 2 head nurses, 1 clinical supervisor, 1 nurse responsible for patient safety, 5 intensivists, 2 patients, 1 patient family member (patient’s son), 1 patient safety officer from the Ministry of Health, Treatment, and Medical Education, and 1 paramedic. The initial participant selected for the study was a nurse who met the inclusion criteria, possessed extensive experience, and demonstrated effective communication skills. Subsequent participants were chosen based on the data collected from each participant.

Data collection

In this research, data was gathered through individual, in-depth and semi-structured interviews with individuals who met the specified inclusion criteria. interviews were conducted by the first author and recorded using a mobile device with the participants’ consent.

The inclusion criteria for the healthcare personnel involved having a minimum of two years of professional experience in the ICU or in units associated with patient safety. The selection of the two-year threshold was based on the completion of the mandatory manpower plan course and the acquisition of sufficient experience and knowledge. Patients were included if they had a Glasgow Coma Score (GCS) of 15, demonstrated clear speech abilities, and received approval from the ICU intensivist to participate in the interview.

The researcher took into account the diversity of participants in terms of gender, educational background, job position, and work experience, particularly in relation to the nurses. Data collection persisted until data saturation was achieved, and no new codes emerged. A concluding interview was carried out to confirm data saturation. Field notes were utilized for selecting subsequent samples and extracting the codes. During the initial meeting or telephone conversation, the study’s aims were elucidated to the 21 participants. In a subsequent communication, participants conveyed their decision to either agree or decline participation. Upon agreement, interview schedules were arranged. Notably, only one intensivist declined to participate. All interviews were conducted either at the hospital or the workplace. Prior to interviewing patients, consent was obtained from the intensivist, and schedules were coordinated with the head nurse of ICU to ensure minimal disruption to patient care and treatment processes.

The interviews comprised four parts: initial open questions, main questions, follow-up questions, and closed questions. The formulation of the questions was guided by the interview guide and involved consultation with members of the research team. Subsequently, a pilot interview was carried out to identify any weaknesses, leading to a redesign of the questions (Kallio et al. [ 14 ]) (Table 1 ).

Data analysis

Data analysis was conducted by the research team, which comprised a nursing doctoral student (first author) and two nursing professors (second and third authors). The first author performed the data analysis, whereas the remaining authors reviewed and made revisions to the codes, subcategories, and categories. The analysis procedures were conducted utilizing the conventional content analysis approach, following the guidelines proposed by Graniheim and Lundman (Graneheim and Lundman [ 15 ]).

Preparation phase

During this phase, decontextualization was conducted in the following manner. Initially, the interviews, and field notes were transcribed using Word software and thoroughly reviewed to capture the main idea. Subsequently, the semantic units were identified and coded. It is important to highlight that the participants were assigned names based on the sequence of the interviews to uphold anonymity. For instance, the first participant was designated as number 1, while the final participant was denoted as number 21.

Organizing phase

Through ongoing comparisons of codes and categories and iterative recategorization during the study meetings with the research team members, a total of 1997 codes were initially identified. Subsequently, through a process of reviewing the extracted codes multiple times, eliminating duplicates, and consolidating similar items, the number of codes was ultimately reduced to 1770. Initially, the codes were organized into subcategories, followed by the extraction of categories from the integration of these subcategories. Finally, themes were derived from the integration of categories. Ultimately, a comprehensive definition of the concept under investigation along with its associated structures was provided.

Reporting phase

During this phase, the processes of sampling, data collection, data analysis, and the subsequent results were documented and reported.

Data integrity and robustness

In this study, the trustworthiness of the results was enhanced by considering strategies in line with Lincoln and Guba’s four criteria for qualitative studies (Lincoln and Guba [ 16 ]).

Credibility: The credibility of this study is supported by the extensive experience of the first author in the research topic. She conducted her Master’s thesis on medication errors in critical care units and has accumulated numerous years of experience working in ICU as a nurse and head nurse. The data collection period was appropriately extended to ensure the researcher’s continued involvement in the study process. Participant selection aimed for maximum diversity in age, gender, work experience, and educational level. Data collection methods included in-depth interviews and field notes. The research process was overseen by a doctoral student in nursing with expertise in qualitative research. The interviews and initial coding were reviewed and approved by the participants, with any ambiguities promptly addressed. The complete transcripts of the interviews, along with the coding, were initially forwarded to the primary author. Following the incorporation of the feedback, the revised text was then shared with the secondary author for further input. The process of assigning codes to subcategories, identifying categories, and developing themes was carried out consistently throughout.

Transferability: This criterion pertains to the richness of descriptive data. In an effort to maximize transferability, participants were purposefully selected from various positions and across different ICUs, such as internal medicine, neurology, surgery, and trauma.

Dependability: It was ensured through the utilization of various data collection methods such as interviews and field notes, along with continuous analysis and precise documentation of all analysis stages. As the current research formed part of a doctoral thesis, all research phases, data analyses, and findings were documented in 6-month reports and reviewed by four referees.

Confirmability: To ensure confirmability, the researcher documented their preconceptions about the study subject to separate them and prevent bias. Additionally, during data collection, the researcher refrained from reviewing the findings of related or similar studies.

The Ethical Committee of Tehran Islamic Azad University of Medical Sciences, approved the study protocol (IR.IAU.TMU.REC.1399.481). Written informed consent was obtained from all the participant, and data confidentiality was guaranteed in accordance with rules and regulations, and consistent with the requirements of the Ethical Committee that approved the study. The participants were informed about the possible duration of the interviews, the freedom and authority to stop the interview whenever they felt necessary, how to maintain confidentiality of the information, and how the results of the study would be used.

The mean age of the participants in this study was 41.80 years, while the mean work experience of the health care members was 17. 16 years. The demographic characteristics of the participants are delineated in Table  2 .

The average duration of the interviews was 36.42 min, with a maximum duration of 80 min and a minimum duration of 20 min. A total of 1770 codes were extracted and categorized into 43 subcategories. These subcategories were further integrated to form 7 categories, and from these categories, 3 themes were identified (Table  3 ).

• Professional behavior

Participants in this study viewed Implementation of policies, organizing communication with team members, patients, and their families, and adherence to professional ethics as key components of professional behavior.

Implementation of policies

Implementation of policies was identified by all participants as a critical component of ensuring safe care and was frequently emphasized during the interviews. This encompassed various aspects such as appropriate execution of nursing procedure, Safe mechanical ventilation, Safe Medication Administration, Safe blood transfusion, Safe restraint, Proper care of patient connections, pain control, preventing falls, delirium, and deep vein thrombosis, adhering to infection control protocols, ensuring safe patient transfers, and obtaining informed consent. Given the extensive range of subcategories and the constraints on presenting all the details, we will highlight select quotes from a few of these subcategories.

For instance, with regard to the proper execution of protocols, one of the nurses stated:

“Less experienced nurses use the wrong routines of more experienced nurses and this becomes a habit. It is essential to assess the patient, review the doctor’s orders. In certain circumstances, the patient may have specific requirements, such as altering the dressing or removing a drain.” (Participant No. 8).

The nurse responsible for patient safety commented on the importance of safe blood transfusions.

“For blood transfusion, it is ensured that the nurse carefully matches the specifications of the blood bag with the patient’s wristband. Additionally, two nurses verify the blood bag. Patients are monitored regularly during transfusions to detect any side effects. They are also educated about potential side effects of blood transfusions and instructed on appropriate actions to take if such side effects manifest.” (Participant No. 5).

One of the intensivists commented on the inadequate management of the patient’s pain.

“Some nurses administer only muscle relaxants to patients before invasive procedures, which can be distressing. When patients are unable to move but still feel pain, it is crucial for healthcare providers to understand that muscle relaxants should be administered alongside painkillers. Prioritizing pain management for patients should be the primary concern for healthcare professionals.” (Participant No. 4).

One of the patients admitted to the ICU articulated his perception of infection control compliance in the following manner:

“Some nurses frequently disinfected their hands, although we did not observe this practice. It is possible that I overlooked it as well. Even the doctors engage in this behavior. was a doctor who visited the bed adjacent to mine. He touched various surfaces and then proceeded to examine me.” (Participant No 12).

Organizing communication

Participants highlighted various ways in which communication impacts safe nursing care in the ICU. This resulted in the identification of categories stemming from the integration of subcategories such as shift delivery using the ISBAR technique, proper utilization of identification wristbands, accurate documentation, communication with patients, and Inadequate team communication.

For instance, one of the head nurses described her encounter with the ISBAR technique as follows.

“Sometimes in the evening and night shifts, nurses may not follow protocols and not use the ISBAR technique for shift delivery and the next day we find many errors and failures.” (Participant No. 2).

The nurse responsible for patient safety emphasized the importance of proper utilization of identification wristbands.

“The identification wristband plays a crucial role in healthcare settings. Regrettably, there are instances where individuals overlook its significance. One of the key purposes of the wristband is to accurately identify the patient. An incident occurred where a mismatch between the blood bag and the patient’s bracelet led to an incorrect transfusion being administered.” (Participant No. 5).

In relation to inadequate team communication, an intensivist expressed the following viewpoint:

“When the patient had a fever in the middle of the night, the nurse did not report it. Later I found out that she was afraid of waking me up.” (Participant No. 4).

Professional ethics

Participants identified adherence to the principles of professional ethics as a prerequisite and integral part of safe nursing care. This category was formed from the subcategories of respecting patient privacy, human dignity, conscience and professional commitment.

Regarding respecting patient privacy, one of the ICU patients described her experience as follows:

“The first night, the nurses were gentlemen and they were very careful not to make me feel uncomfortable. The blanket was taken off me and I felt that my body was visible. They came to cover my body without me telling them. Or when he wanted to see the operation site, he would just push the blanket aside so that I wouldn’t be tortured. I don’t think anything made me happier at that moment. That’s what security means. It means that I feel.”  (Participant No. 12).

One of the nurses said the following about human dignity:

“When we are safe in the working environment, we are trained and respected by our superiors, we are guided, we do our work correctly and we also provide safe care. But if you are not respected as a person and your health is not protected, you don’t care about that department and that hospital. You just want to finish your shift and leave”. (Participant No. 11).

One of the intensivists commented on Conscience and work commitment as follows:

“A conscientious patient may express his wishes by sighing and moaning and making noise. Or, for example, report to our manager that we are neglecting him, but patients with a low level of consciousness may be neglected. It is up to us and our conscience to provide complete, accurate and correct care. Sometimes doctors and nurses can show inattention and immorality towards these patients”. (Participant No. 18).

• Holistic care

In addition to professional behavior, the participants mentioned other things to ensure the safe nursing care of ICU patients, which led to the formation of this theme with categories of systematic care and comprehensive care of all systems.

Systematic care

The participants were of the opinion that the implementation of the steps of the nursing process is one of the main conditions for the provision of safe care to patients. This category was formed from the subcategories of initial patient assessment, nursing diagnoses, planning, evaluation of care, continuous care and protection from harm and acquired complications.

The patient safety officer in the Ministry of Health, Treatment and Medical Education commented on the importance of the initial assessment of the patient:

“The initial assessment can lead to the safety of the patient. Whether they have an allergy or not. Whether they are at risk of falling or not. If it is assessed correctly, it can prevent future incidents. and determine the conditions of care. We need to see at what level the patient entered hospital and at what level they should be discharged. The side effects of the medication given to the patient should be reviewed. The nurse should deal with these issues”. (Participant No. 6).

One of the nurses pointed out the importance of care evaluation:

“At the beginning of my career, if the patient was in pain, I would give painkillers and I didn’t care whether the pain was controlled or not. Care evaluation brings reassurance to the patient. It means I go back and see if my care was useful or not”. (Participant No. 1).

One of the nurses with years of experience working in the ICU pointed out the importance of continuity of care:

“In my opinion, less attention is paid to the discussion of continuing care for terminal patients. Most ICU patients, because they are unlikely to return to their lives, often do not receive the necessary care, or it is not provided in a very accurate and safe way. For example, infection control is not followed. Medication administration protocols are not followed, or they may not administer many of the patient's medications. They do not do the gavage on time and say that it has no effect on the treatment. Somehow they let the patient die”. (Participant No. 13).

Comprehensive care of all systems

The participants believed that taking care of all body systems and paying attention to the patient’s body and mind is a guarantee of safe nursing care. This category was formed from the subcategories of respiratory care, digestive and nutritional care, nervous system care, genitourinary care, cardiovascular and haemodynamic care, skin and mucous membrane care, and attention to the mental, psychological and emotional state of the patient.

In terms of respiratory care, one of the expert nurses describes his performance as follows :

“I listen to the patient’s breathing at the very beginning of the shift. I look for the presence of distress in the patient. Whether he has rales or not. The chest is bilateral. And it goes up and down symmetrically. I look at the results of the ABG and even the colour and type of secretions. Because the change in the colour of the secretions can be due to pneumonia”. (Participant No. 7).

One of the head nurses also said about genitourinary care:

“Sometimes when a patient has oliguria, the nurse does not analyse to understand the cause of the oliguria. She quickly gives the patient furosemide. I have seen a lot of inexperienced staff. I tell them about the catheter route first and check the condition of the bladder. Then I check the amount of fluids given and the patient’s CVP. Then check the status of medications and tests. Finally, I report it to the intensivist doctor for a tell order or a I request to visit the patient. Don’t go to the last treatment first”. (Participant No. 2).

One of the patients also mentioned that paying attention to the mental, psychological and emotional state of the patient and their family is an important part of safe care:

“In those first moments I was scared and anxious because the nurse’s words and explanations were very good and calmed me down. After two days of feeling better, I really wanted to see my partner. Seeing my wife was more important to me than anything else. My heart was broken. Everything made me cry. But seeing my wife gave me peace. Even though it was short. I don’t know. Why did some allow it and others didn’t? I don’t know if it’s legal or not, but it seems to be a matter of taste”. (Participant No. 12).

Safety oriented organization

Participants believe that nurses’ efforts to provide safe care to patients depend on a safety focused organization. This content consists of human resource management and safe environment categories.

Human resource management

Employing qualified human resources, monitoring the performance of human resources, error reporting and control, arrangement of human resources, sufficient human resources supply, Providing general and specific training to human resources.

This category was formed from the subcategories of employing qualified human resources, monitoring the performance of human resources, error reporting and control, arrangement of human resources, sufficient human resources supply, Providing general and specific training to human resources..

Regarding the employing qualified human resources, the nurse responsible for patient safety said:

“We have a selection committee that asks questions of the nurses. Once they are accepted, the training starts. Ten hours of important safety and infection control instructions and report writing. We train them and then they go through 70 h of training under the supervision of the ICU supervisor. The supervisor fills in three checklists for each nurse, covering behavioral, general and specialist skills, and sends them to us. If he gets the required number of points, he starts work, otherwise the training has to be repeated”. (Participant No. 5).

The statement of one of the nurses regarding the arrangement of human resources was as follows:

“If I am in charge of the shift, I will divide the work carefully and I will try to arrange it in such a way that it is fair and each nurse has both patient with lots of work and with little work. Not that a nurse should have "two busy patients or two patients with little work”. I try not to give complicated patients to new and inexperienced nurses who cannot manage the patient”. (Participant No. 10).

One of the nurses, related to the sufficient human resources supply, said:

“Nurses’ salaries are paid late, their salaries are not commensurate with their work. There is no justice in the workplace, there is discrimination. There is job dissatisfaction. There is little encouragement and a lot of punishment. All of this prevents safe patient care. Besides, the nurse loses her motivation. That’s why I want to leave.”  (Participant No. 13).

Safe environment

This category was formed from the subcategories of safe equipment and safe structure.

With regard to safe equipment, the patient safety officer in the Ministry of Health, Treatment and Medical Education said:

“To provide safe care, the equipment must be safe. And then we expect safe care from the nurse. If our bed is not safe, how can we expect the nurse to prevent falls? If we have a lack of wavy mattress , how can we expect nurses to prevent pressure sores?”  (Participant No. 6).

Also, the statement of the nurse responsible for patient safety regarding the safe structure was as follows:

“The patient’s safety must be ensured from the moment they arrive at the hospital. From the elevators and the stairs to the door and the wall, etc . In the ICU, the conditions are more specific. In our hospital’s intensive care unit, one of the beds is placed in a corner where the nurse cannot see it. They always put an extra bed in front of this unit. Every time a patient has a CPR code in that unit, it takes a few minutes to remove the extra bed and bring the crash cart into the unit. Exactly, the golden time of CPR is lost”. (Participant No. 5).

The participants in this study have delineated the components of safe nursing care in the ICUs through the aforementioned scenarios. Consequently, drawing from the outcomes of this investigation, safe nursing care can be delineated as follows: Safe nursing care in the ICU is characterized by a holistic care that encompasses systematic and comprehensive care. In delivering such care, nurses exhibit professional behavior by implementation of policies, organizing communication with patients and peers, and upholding professional ethics. In a safety-oriented organization, safe nursing care is evidenced by the establishment of a safe environment and the effective management of human resources.

The present study was conducted with the aim of identifying the components of safe nursing care in the ICUs. Three themes were identified: professional behavior, systematic care, and safety-oriented organization. In this section, the results are compared and discussed with other studies.

The theme of professional behavior emerged by combining the categories implementation of policies, organizing communication, and professional ethics. The participants believe that safe care depends not only on following policies but also on adhering to the principles of professional ethics and organizing communication with all team members and patients.

In term of implementation of policies, Williams et al. concluded that adherence to guidelines can lead to faster diagnosis of sepsis (Williams [ 17 ]), and improves patient safety in medication prescribing (Nouhi et al. [ 18 ]). The results of the study by Santos et al. (Santos [ 19 ]) in Brazil showed that adherence to clinical guidelines leads to better outcomes in patient restraint, positive effect on pain and delirium (Carrothers et al. [ 20 ]; , Thomas et al. [ 21 ]), prevention of falls (Tuma et al. [ 22 ]), and prevention of deep vein thrombosis (Malhotra et al. [ 23 ]). However, it has been argued that adherence to guidelines may jeopardize the autonomy of the nurse, and the nurse may not be able to manage the situation effectively at times not foreseen in the guidelines (Barnard [ 24 ]). For this reason, it seems that, in addition to following the established guidelines, the nurse should have creativity and decision-making power, and be able to identify and prepare for possible out-of-procedure cases for the implementation of each procedure. In the present study, pain control was identified as one of the factors of safe care in the ICU, and most of the participants repeatedly mentioned the pain experience of patients hospitalized in the ICU; in the study conducted in the United States, more than 50% of patients on mechanical ventilation had experienced pain (Fink et al. [ 25 ]). However, in a Norwegian study, only 10% of ICU patients reported pain at rest and 27% reported pain during repositioning (Olsen et al. [ 26 ]). This discrepancy may be due to differences in facilities, equipment, quality of drugs, pain control protocols and nursing methods. It appears that many of the subcategories identified in the professional behavior theme as components of safe care have been introduced and confirmed in other studies. And the results of this study support the previous findings. However, it should be noted that the identification of these components does not necessarily guarantee their implementation, and their implementation requires multilateral planning. For example, despite the importance of safe drug therapy, Ateshzadeh et al. (Atashzadeh Shoorideh et al. [ 1 ])) showed that the level of compliance with drug administration standards was only 2.6% in hospitals under the University of Medical Sciences A in Tehran and 9.4% in hospitals under the University of Medical Sciences B (Atashzadeh Shoorideh et al. [ 1 ]). Regarding infection control, Randa et al. showed that nurses’ performance in hand washing, wearing gowns, gloves and masks was far from the standards (Randa et al. [ 27 ]). Another study found that only 10.83% of nurses avoided incorrect connections (Bayatmanesh et al. [ 28 ]).

The results of this study showed that organizing communication between nurses and other members of the care team is as effective as implementing policies. Haddeland et al. (Haddeland et al. [ 29 ])in Norway demonstrated the importance and need to improve the use of the ISBAR tool to improve patient safety. They concluded that it is essential that healthcare professionals work together to ensure that everyone has the same situational awareness and that good clinical practice is developed and maintained. Correct use of identification wristbands (Barbosa et al. [ 30 ]), accurate recording of all information related to investigations, interventions and their evaluation (Aldawood et al. [ 31 ]), and communication with the patient (Danis [ 32 ])are effective in improving patient safety. The results of the present study are supported by previous studies. In Iran, Abdi et al. (Abdi et al. [ 33 ])concluded that poor communication and lack of team spirit had a negative impact on patient safety (Abdi et al. [ 33 ]). In Saudi Arabia, Al-Dawood et al. (Aldawood et al. [ 31 ])showed that poor team communication was one of the barriers to reducing patient safety in the ICU. Ensuring effective communication is critical to maintaining patient safety and can be achieved by implementing standard communication protocols, providing regular training and education on effective communication, and promoting a culture of collaboration and teamwork (Muller et al. [ 34 ]). Despite the importance of communication to patient safety, the results of evaluations in Iran are disappointing. A review study by Moghadam et al. (Moghadam et al. [ 35 ]), which surveyed Iranian hospitals on the implementation of mandatory patient safety standards, found that the implementation of mandatory standards in the area of ‘interaction with patients and society’ received the lowest score.

According to the results of this research, the principles of professional ethics are necessary to ensure patient safety. The results of studies have shown that things such as respect for privacy (Timmins et al. [ 36 ]), respect for human dignity and worth (Sugarman [ 37 ]; , Smith and Cole [ 38 ]), conscience (Herzer and Pronovost [ 39 ])and professional commitment (Teng et al. [ 40 ]; , Al-Hamdan et al. [ 41 ])are the principles of safe care. The results of the study by Mohammadi et al. (Mohammadi [ 42 ]) in Iran on safe care in ICUs and its relationship with moral courage showed that there is a significant relationship between moral courage and the principles of safe care. In line with previous studies, the present study showed that professional ethics is an important component of safe care in ICUs.

The present study identified holistic care as another effective factor in providing safe care. Holistic care is the systematic and comprehensive care of all systems of the patient’s body. These findings support previous research highlighting the importance of systems thinking and safe care in improving patient safety and overall quality of care (Moazez et al. [ 43 ]). Based on the findings of the study by Wick et al. (Wick et al. [ 44 ]), comprehensive care that addresses the physical, emotional, social and spiritual needs of patients was introduced as a solution to improve outcomes and patient satisfaction. In the study on the design of safe nursing care tools by Rashvand et al. (Rashvand et al. [ 45 ]), attention to the physical needs and attention to the psychological needs of patients were introduced as the main factors of safe nursing care. In addition to the aforementioned studies, the findings of this study are consistent with the holistic and widely used theories in nursing. These include Martha Rogers’ theory, Margaret Newman’s theory and Watson’s theory. A comprehensive review of holistic theories shows that holistic nursing is a two-way human relationship process in which the nurse is attentive, purposeful and alert in the process of caring for the patient as a whole. The result is an improvement in the nurse’s and patient’s sense of wellbeing, quality of care and ultimately patient safety (Yazdi and Talebi [ 46 ]).

In addition to the cases mentioned, the results of this study show the importance of promoting safe care in ICUs through a safety-oriented organizational approach. The creation of a safe environment is also directly related to the safety of the structure and the provision of safe equipment. In line with the present study, Naderi et al. (Naderi [ 10 ])also introduced in their study the state of human resources, management and organization, interaction and teamwork, equipment, environment, and evaluation and monitoring as the main factors affecting patient safety in the hospital (Naderi [ 10 ]). In the study by Lima et al. (D’Lima et al. [ 11 ]), organizational factors were identified as a threat to patient safety. This means that when employees perceive a risk from the organization, they stop providing safe care to patients. In Oliveira et al.’s study (Oliveira et al. [ 9 ]), employee workload, training and professional qualifications, teamwork, contractual employment, lack of job security and disruptive behavior were introduced as factors that interfere with patient safety. In the theoretical model of safe care presented by Vaismoradi (Vaismoradi [ 13 ]) the removal of organizational barriers was identified as one of the strategies to improve patient safety . Thus, based on the results of the present study and other studies, it can be said that healthcare organizations play an important role in patient safety.

Research limitations

One of the limitations of the current study was the absence of theories related to patient safety, which compelled the researchers to resort to the conventional content analysis method.

Another limitation was the lack of specific studies in ICU departments, which made it difficult to compare the present study with similar studies.

In the present study, despite the use of observations and field notes, the primary method of data collection was interviewing the participants. In future studies, incorporating other data collection methods can enhance the depth of the study.

The researcher’s extensive background in working in the intensive care unit as a nurse and head nurse, along with their familiarity with non-safe care practices, posed a risk of introducing bias. To mitigate this bias during the interviews, the researcher endeavored to adopt a listening role and formulate questions in accordance with the interview guide.

A significant portion of the patients admitted to the ICU did not qualify for inclusion in the study as a result of their diminished level of consciousness, reliance on mechanical ventilation, and administration of sedative and hypnotic medications. Identifying suitable participants proved challenging, necessitating extensive consultations and diligent follow-up by the researcher.

Patients exhibited caution in sharing their negative experiences due to concerns about potential repercussions from staff. Building trust to encourage open communication without self-censorship proved to be a lengthy endeavor. In addition, in one particular case, the patient expressed concern about the proximity of her bed to the nursing station, fearing that her conversations would be overheard by the nursing staff. Consequently, in adherence to the patient’s comfort and in consultation with the anesthesiologist, the interview was relocated to a different room to ensure confidentiality and optimal clinical conditions.

Due to the COVID-19 pandemic and the associated restrictions on patient visits, access to the patient’s family was difficult. The researcher had to make several attempts to make appointments for interviews.

The provision of safe care in the ICU is influenced by various components. According to the findings of this study, nurses exhibit professional behavior, such as implementation of policies, organizing communication with team members, patients, and their families, and adherence to professional ethics. They also demonstrate holistic care by following the nursing process and considering the entire system. Conversely, healthcare organizations play a crucial role in ensuring safe care by providing appropriate equipment and maintaining environmental safety. A safety-focused organization can enhance the delivery of safe care to patients in the ICU by offering a secure environment and reliable equipment. This not only ensures patient safety but also boosts staff efficiency, reduces error risks, and ultimately enhances patient outcomes and overall care quality. Healthcare organizations can establish conditions for safe patient care by recruiting suitable staff, monitoring their performance, and addressing their training requirements. Competent nurses, through the provision of comprehensive and systematic care, can deliver safe and high-quality services to patients. It is imperative to emphasize that achieving the desired outcomes necessitates collaborative efforts among healthcare organizations, nurses, and other healthcare professionals.

Availability of data and materials

Due to university policies, the datasets generated and utilized for the present study are not publically accessible but are available from the corresponding author upon justifiable request.

Abbreviations

Intensive Care Unit

Glasgow Coma Score

Identify, Situation, Background, Assessment, Recommendation

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Acknowledgments

The present study is part of the findings of the doctoral thesis, which was completed after obtaining the necessary permissions from Tehran Islamic Azad University of Medical Sciences. The research team would like to thank the staff of this university and all the participants in this research.

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M.T, T.A and A.E contributed in study design. M.T contributed in data collection and wrote the manuscript. T.A, and A.E analyzed the data and revised the manuscript. All of the authors proved the final version of manuscript.

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Tajari, M., Ashktorab, T. & Ebadi, A. Components of safe nursing care in the intensive care units: a qualitative study. BMC Nurs 23 , 613 (2024). https://doi.org/10.1186/s12912-024-02281-5

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Clinical and scientific review of severe and enduring anorexia nervosa in intensive care settings: introducing an innovative treatment paradigm

• Joseph A Wonderlich 1 , 2 ,
• Dorian R Dodd 1 , 2 ,
• Cindy Sondag 2 ,
• Michelle Jorgensen 2 ,
• Candice Blumhardt 2 ,
• Alexandra N Evanson 2 ,
• Casey Bjoralt 2 &
• Stephen A Wonderlich 1  

Journal of Eating Disorders volume  12 , Article number:  131 ( 2024 ) Cite this article

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Anorexia nervosa is a serious and potentially lethal psychiatric disorder. Furthermore, there is significant evidence that some individuals develop a very long-standing form of the illness that requires a variety of different treatment interventions over time.

The primary goal of this paper was to provide a review of treatment strategies for severe and enduring anorexia nervosa (SE-AN) with the particular focus on treatments involving hospital care. Additionally, we wish to highlight a contemporary approach to such care and provide qualitative reactions to this model from both staff and patients.

A selective and strategic review of the treatment literature for SE-AN was conducted for the current paper. Emphasis was placed on clinical or scientific papers related to hospital-based care. Additionally, staff who work on a specific inpatient eating disorder unit with a substantial treatment program for SE-AN, along with a number of SE-AN patients were surveyed regarding their experiences working on, or receiving treatment on the unit. Importantly, the staff of this unit created a specific treatment protocol for individuals receiving hospital care. The results of the highlight both advantages and challenges of a hospital-based protocol oriented toward emphasizing quality of life, medical stability, and a health-promoting meal plan.

While there is general inconsistency with the type of treatment that is best suited to individuals with SE-AN, this is particularly true for higher levels of care that rely on inpatient hospital units or residential treatment settings. This is a highly significant clinical topic in need of further clinical and scientific examination.

Plain English summary

Anorexia nervosa is a serious illness which often persists for decades. Treatments for persistent anorexia nervosa are not well defined and there is considerable debate in the field about appropriate types of treatment strategies for these individuals. Such clinical uncertainty is particularly noteworthy in terms of the most appropriate types of care for these patients when they are hospitalized, which happens relatively frequently. Greater efforts are needed to develop inpatient programs for SE-AN that take into consideration their unique clinical needs.

Anorexia Nervosa (AN) is a serious and potentially lethal psychiatric disorder that is most typically seen in girls and young women, with a lifetime prevalence of 2–4% [ 1 , 2 ]. While AN is rare in some countries (e.g., Africa and Latin America) it is most prevalent in Europe, North America, and Australasia. AN is considered one of the most lethal psychiatric disorders with a crude mortality rate of 5% per decade and a standardized mortality ratio of around 6 [ 2 , 3 ].

Prospective longitudinal studies have consistently identified a subset of AN patients who have long-standing eating disorders, characterized by minimal improvement and significant impairment over decades (e.g. [ 4 , 5 ]). However, there has been significant variability across studies in terms of rates of remission and recovery from AN. Eddy and colleagues [ 5 ], suggested that the longer the duration of follow up in such prospective longitudinal designs, the greater the rates of recovery. Steinhausen [ 6 ] reported that in studies with follow up to four years since index diagnosis, recovery was approximately 33%, while studies with follow-ups ranging from 4 to 10 years average 47% recovered, and studies longer than 10 years in duration revealed recovery rates over 70%. Robinson [ 7 ] examined the same literature and concluded that rates of recovery after 10 years seemed to be declining compared to follow-ups ranging from 4 to 10 years. Eddy et al., [ 5 ] suggest that studies beyond 20 years of follow-up are not only limited, but the findings are even more inconsistent. For example, Theander [ 8 ] reported outcomes over 33 years of follow-up with 76% achieving recovery. However, two other studies [ 9 , 10 ] found that approximately 20 years after an initial hospitalization, around 50% of the sample of AN individuals was recovered. Ratnasuriya [ 11 ] reported that 20 years after hospitalization only 30% of the patients had a good outcome. Similarly, a study with a large sample of individuals treated for AN revealed that the longer the duration of the eating disorder, the lower the chance of recovery [ 12 ]. These findings are further supported by a recent systematic review on the treatment of eating disorders that showed that 40% of AN cases had partial or no remission of symptoms [ 13 ].

However, another important longitudinal study, by Eddy et al., [ 5 ] relied on a well-characterized and regularly assessed sample of both individuals with AN and bulimia nervosa (BN) over 22 years. In this study, the authors found that at the end of the first decade of illness, approximately 31% of the individuals with AN and 68% of the individuals with BN were recovered. Thus, BN appeared to be a much more remitting illness than AN. However, approximately two decades after the initial diagnosis, there was significant proportional change. At this point, approximately 63% of the individuals with AN and 68% of the individuals with BN had recovered. Approximately half of those with AN who had not recovered in the first decade did recover in the second decade. Interestingly, the recovery rate of BN did not change significantly over that decade. Thus, the study by Eddy and colleagues [ 5 ] suggests that recovery from AN may continue for decades after onset, but importantly, well over a third of the AN sample continued to have very significant AN moving into the third decade of the illness.

During the timeframe when many of these longitudinal studies were being conducted, clinicians were actively attempting to outline treatment strategies for long-term, persistent, and minimally remitting AN. Wonderlich and colleagues [ 14 ] summarized these clinical strategies, which were wide ranging and infrequently tested empirically. Overall, the collection of strategies reflected the informed experience of clinicians who had treated numerous patients with long-standing AN and served as a repository of clinical wisdom accrued largely during the 80s and 90s. Numerous recommendations and suggestions from these individuals still inform contemporary treatment strategies for SE-AN, such as establishing clear guidelines, the value of a team-oriented approach, the importance of meaningful treatment collaboration, inclusion of the patient’s family, avoidance of aggressive change-oriented techniques, and the potential value of psychiatric rehabilitation models of intervention. Additionally, Williams and colleagues [ 15 ] described an integrated treatment program which included staff from hospital-based eating disorder program along with a community-based mental health rehabilitation team and demonstrated some degree of efficacy.

An important point in the treatment literature for long-standing AN was the randomized controlled trial conducted by Touyz and colleagues [ 16 ]. This study compared the efficacy of 30 outpatient sessions of an adapted form of cognitive behavioral therapy (CBT) to an adapted form of specialist supportive clinical management (SSCM). Both treatments had a modified primary focus on enhancing quality of life and promoting harm reduction, rather than weight gain and symptom reduction. Both treatments had excellent retention of participants, with attrition rates under 15%. Comparisons between the two treatments revealed minimal differences in outcome. Furthermore, secondary analyses found a series of meaningful predictors of good response and revealed that quality of the therapeutic alliance was associated with positive responses, broadly [ 17 ]. Thus, this study offers support for the treatment of SE-AN and developing treatments that optimize patient engagement.

Several other empirical studies preliminarily have examined the impact of evidence-based, shorter-term treatments on SE-AN. Some of these studies suggested that treatments, such as CBT appear equally effective when delivered to individuals with AN versus individuals with SE-AN [ 18 ]. Similarly, two studies found that duration of illness was not a significant predictor of the outcome in structured treatment such as CBT and MANTRA [ 19 , 20 ]. However, in another study, which relied on practice guideline-based treatments, there was a significant difference in outcome between early stage versus SE-AN patients. Specifically, the SE-AN patients were less likely to improve in areas of work and social adjustment than the early stage patients and the SE-AN patients were more likely to access intensive services following treatment [ 21 ]. There are an increasing number of empirical studies with SE-AN patients which could ultimately impact effective treatment deliveries, however at this point in time, the number of these studies remains relatively limited and frequently constrained by sample size issues. Thus, there is a significant need for additional strategies to be tested with individuals, displaying long-standing and serious forms of AN.

Wonderlich and colleagues [ 22 ] outline a number of innovative treatment strategies which have been tested, at least preliminarily, in individuals with long-standing SE-AN. They highlight that there are new behavioral strategies (e.g., exposure paradigms [ 23 ], habit-oriented interventions [ 24 ], cognitive remediation therapy [ 25 ]), along with novel pharmacologic interventions, (e.g., ketamine [ 26 ], and dronabinol [ 27 ]) which may have potential value in treating longer standing forms of AN. Additionally, there are brain stimulation interventions (e.g., rTMS [ 28 ], DBS [ 29 ]) which continue to be tested in individuals with SE-AN and show either reasonable tolerability or preliminary efficacy. Also, there are system-oriented strategies that are being looked at, such as stepped-care treatment models [ 30 ] and novel “self-admission” approaches [ 31 ] to inpatient care. Again, preliminary data suggests these strategies may have value.

However, despite these newer developments, we agree with the general idea that the lack of understanding of SE-AN and the associated dearth of treatments represent a serious deficit in the eating disorder field. Moreover, we believe that this dearth of empirically supported treatments for SE-AN patients is even more of an urgent situation for higher levels of care in hospital based and residential treatment settings as many of these patients repeatedly utilize a higher level of care. The primary aim of this paper is to highlight that empirically informed treatments for SE-AN patients are particularly limited in higher levels of care, such as inpatient units, partial hospitals, and residential treatment centers. Furthermore, we want to highlight the significance of this dilemma and the impact it has on SE-AN patients, and the clinical teams who attempt to treat them in these environments. In the next section, we will provide an overview of this situation and describe an innovative program, which has recently been developed based on clinical need and expertise, to provide quality care for SE-AN patients and also support the treatment teams who are attempting to provide the intervention.

Higher levels of care and SE-AN

Historically, there has been some debate about the most preferred treatment setting for patients with SE-AN. Some individuals clearly suggest that outpatient treatment is appropriate if medical stability is maintained [ 32 ]. However, Strober [ 33 ] advocates for inpatient hospitalization for SE-AN and suggests that comprehensive coordinated care is best provided in such a setting. Woodside [ 34 ] provides broad strategy for SE-AN patients when hospitalized, which happens relatively frequently. He notes that many SE-AN patients cannot realistically conceive of recovery but are interested in incremental improvements in their eating disorder. Others are interested in pursuing enhanced quality of life or improving their overall condition. He highlights the importance of collaborative goal setting that is realistic and tailored to each individual patient. There are no minimum standards for goals, virtually any change is promoted. Woodside does not provide high levels of detail about the operations of the program over the course of a hospital stay, but does conclude that there is an urgent need for increased dialogue about the issues regarding inpatient care and SE-AN.

Banford et al. [ 35 ] offer comments about the idea that eating disorder treatment programs, both outpatient and inpatient, often pursue treatment goals that are inconsistent with SE-AN patient motivation. Furthermore, many of these programs are oriented toward more acute cases of AN, often of younger ages than many of the SE-AN patients. Thus, the authors highlight the possible problems for SE-AN patients when they are in traditional eating disorder programs. They emphasize that when SE-AN patients are integrated into recovery focused partial hospital programs with younger, more acute patients, problems may emerge and they recommend that SE-AN patients are best treated in a separate program with individualized goals and interventions. They highlight that there are very few descriptions of SE-AN specific hospital units in the eating disorder literature, but note that such patients are frequently admitted. They highlight that in an ideal SE-AN hospital unit, goals might include harm reduction, improved quality of life, achieving stabilization, reducing medical risk and decreasing crisis hospital dependency. Overall, they highlight an approach that is characterized by clinical flexibility, creativity, and adaptability for higher levels of care for SE-AN.

A recent systematic review of treatment interventions for SE-AN suggests that hospital-based care for SE-AN is not well understood and varies significantly across studies [ 36 ]. The evidence suggests that inpatient treatment for SE-AN may have a beneficial impact on eating disorder symptoms, but the evidence is unclear about whether or not such gains are maintained. Importantly, however, the five trials that are included in this review relied on a heterogenous collection of treatment strategies for these patients. Some programs were clearly oriented around cognitive behavioral therapy (CBT) while others were only partly based on CBT. Some programs included well defined nutrition plans, while others did not. Some programs relied on antidepressants while others did not. The length of the programs varied significantly, ranging from 3 to 5 months, which is a substantial variation. We would suggest that the clinical variability reported across the hospital-based programs in this review is representative of hospital programs broadly that treat individuals with SE-AN. In fact, this review provides support for the fundamental argument in the present paper, that there is a need for increased scientific and clinical attention to treatment protocols for SE-AN at higher levels of care.

Considerations for developing a treatment of SE-AN in higher levels of care

The Sanford Eating Disorders Unit in Fargo, North Dakota, is one of a declining number of hospital-based eating disorder programs with inpatient, partial hospital and intensive outpatient programming in the United States. In this program, we provide care annually to approximately 250 patients ranging in age from early adolescence throughout the life span. Additionally, we are one of a limited number of programs that openly accepts public insurance in the U.S. As such, we regularly provide care to individuals turned away from other treatment centers due to high medical complexity or insurance policies not covered by other programs. Typically, these individuals display SE-AN. Over time, the unit has attempted to develop a humane and effective approach to care for these individuals. In the hospital setting, we were forced to grapple with several ethical questions, such as whether we should provide care focused on full-weight restoration for a given SE-AN patient, when there is evidence to suggest that this approach has not worked well with the patient previously. Alternatively, should SE-AN patients be allowed to be admitted to the hospital without an active weight restoration based treatment plan, given the long-term risks of premature death in SE-AN? Thus, we sought to develop a treatment program that provides medical stabilization, promotes quality of life, and retains the possibility that one could, in fact, recover after years or decades of serious SE-AN [ 5 ].

In developing a standardized treatment approach for individuals with SE-AN, addressing the challenges associated with hospital-based care for individuals who vary significantly in terms of their desire or ability to restore weight was crucial. The heterogeneity of individuals with eating disorders is a significant issue in general but is even more significant in the shared space afforded by hospital treatment units. Thus, the typical hospital program for eating disorders must try to develop clinical programming to accommodate a wide variety of individuals. This may become particularly challenging when we consider that there is marked variability in the age of patients, the number of previous inpatient treatment episodes, and the total length of time they have been treated. In the case of AN, hospital programs must provide treatment programming for first-episode patients who are often adolescents and have significant family involvement, as well as long-standing patients with AN who may be significantly older, without family support.

Furthermore, there may be significant differences among SE-AN patients in terms of the degree to which the primary focus should be on weight-based recovery, or one that prioritizes a goal of maintaining medical stability and promoting quality of life. Importantly, these significant differences may, at times, be complicated for treatment teams in the hospital who are actively promoting weight-based recovery in one patient and maintaining medical stability and quality of life, or palliative or hospice care in another. Clearly, the complexity of patient experiences in a hospital environment with shared treatment programming and physical space limitations between patients is noteworthy, and a significant challenge for clinicians.

Another challenge for hospital-based programs is the impact of such diversity of patient characteristics on the distribution of valuable clinical resources. Hospital staff must repeatedly, and frequently, make decisions about who will be admitted when there is an opening for care. Should the opening be allocated to more acute, recent onset cases of AN in teenagers versus individuals with long-standing AN who have been hospitalized multiple times and not established significant weight restoration?

Furthermore, as we have noted previously, all of this clinical diversity and complexity in the hospital environment is increased because there is no well-defined, structured intervention for individuals with SE-AN in the hospital setting. As a result, there is often confusion about whether treatment goals for such individuals should focus on weight-based recovery versus medical stabilization with enhancement of quality of life. There is also uncertainty about what treatment approaches may be beneficial to SE-AN patients. For example, in the hospital, what type of psychological intervention may be most beneficial for individuals with SE-AN? Should dietary interventions be modified for such individuals? What is the role of pharmacotherapy in the treatment of SE-AN?

Given these challenges, and the lack of any clear guidance in the literature, we created an active treatment program track for hospitalized individuals with SE-AN. Due to the need to capitalize on existing resources, the SE-AN track was developed entirely integrated within our traditional eating disorder inpatient program. This means that all patients, regardless of whether they are on the SE-AN track, take part in group therapy and eat in the dining room together. In an effort to reduce potential conflicts arising in treatment as a result of a mixed milieu, some adjustments to therapeutics and dining room rules were implemented. These are described in more detail below.

When developing the SE-AN track, our primary goal was to help our SE-AN patients improve their quality of life, primarily by reducing the duration and frequency of hospitalizations and creating a more personalized treatment approach. Second, we aimed to provide transparency between patients and clinical staff regarding the rationale and procedures for treating individuals with SE-AN. Third, we sought to establish a highly collaborative agreement early in treatment between a patient and clinical staff regarding structured goals to reduce future long-term hospitalizations. Fourth, we aim to actively engage with the patient regarding discharge planning at the start of treatment. The primary objectives of the program are to maintain gains established during the hospital stay, develop an outpatient treatment plan with explicit targets, and provide a clear understanding of the procedures utilized in the long-term treatment plan (which may include repeated short-term, return hospital visits).

A description of a SE-AN treatment program at a higher level of care

In deciding to change treatment outcomes for SE-AN patients in the hospital, it became crucial to re-examine the treatment approaches generally used on the unit, given that they were designed for traditional treatment targets (e.g., full weight restoration). Changes were made across almost all therapeutic modalities (e.g., psychotherapy, psychiatric interventions, and nutritional rehabilitation). For example, our goal was no longer primarily focusing on three to four pounds of weight restoration a week in the hospital. We wondered what this would mean for dietitians working with SE-AN patients or when determining the length of hospitalization. Furthermore, in a patient’s psychotherapy, if quality of life is the outcome being measured, what should a therapist focus on in a session? Though specific quality of life interventions were not clear in the existing literature, what became clear to our team was the need to reduce the length and frequency of hospitalizations. We did not believe that a high-quality life could be achieved moving from hospital admission to hospital admission. However, SE-AN patients also often require significant time and support from providers at higher levels of care due to their high medical acuity arising from complications of their SE-AN. Thus, any quality of life focused treatment for individuals with SE-AN at higher levels of care must find a way to reduce time spent in the hospital by the patients, while also providing them significant ongoing support. This perspective (i.e., reducing frequency and length of hospitalizations while supporting the patients) became an overarching goal across all aspects of the SE-AN program. Below, we outline the fundamental procedures for the program.

Admission procedures and initiation of SE-AN treatment

As previously stated, one of the primary goals of the SE-AN program is to provide transparency and collaborative goal setting between patients and clinical staff. As such, discussing the SE-AN program goals should be started immediately, but not prescriptively. We believe the best approach for goal-setting is through collaborative formulation process among the treatment team and the patient, as this is one of the best ways to ensure adherence to treatment and improve clinical outcomes. Upon intake, patients are assessed as to whether they meet SE-AN criteria (e.g., duration of illness over seven years and multiple failed empirically supported treatment attempts) and their personal treatment goals are identified. Patients who meet these SE-AN criteria and express goals in line with improved quality of life and medical stability are informed of the SE-AN program. All new SE-AN patients are informed that their initial stay will be considered a brief evaluation stay of 2–4 weeks to achieve medical stability and assess readiness for the SE-AN program. During the first few days of the admission, patients meet with the provider to start an ongoing conversation about their therapeutic goals and receive psychoeducational materials about the SE-AN program. Patients are informed about the program’s guidelines, including working towards specific goals, SE-AN-specific interventions, length of stay, and discharge planning, all of which are presented below. If, at the end of the evaluation stay, the patient and team decide that the SE-AN program is suitable for the patient, the “ongoing admission” process is discussed. The details of the ongoing admission process will be described below. In short, this process ultimately allows the patient to return to the hospital on the SE-AN track for brief goal-oriented stabilization stays if they have adhered to their treatment plan for at least three months.

Treatment contract and goal setting

As noted by Woodside [ 34 ] collaborative goal setting that is realistic and tailored to each individual patient is crucial for treating individuals with SE-AN. While Woodside suggests that no goal is too small, we believe that at higher levels of care, goals must actively move the patient toward improved quality of life. Therefore, all patients with SE-AN in our program must set goals in three domains: quality of life improvement, ongoing medical stability, and maintaining a meal plan tailored to work with the patient’s goals (e.g., weight maintenance or varying degrees of weight restoration). Patients are asked to work with their treatment team in each domain to establish 2–3 measurable objectives that will help them move their lives forward. For example, a quality of life goal might be “going to get coffee once a week with a friend,” while an example of a goal to help a patient meet their meal plan requirements might be “establish appointments with an outpatient dietitian twice a month.” The treatment team retains measurable objectives created collaboratively to measure future progress and decide the suitability of continuing specific SE-AN programming for future admissions.

Furthermore, individuals with SE-AN often carry comorbidities that may be treatment-interfering (e.g., substance use, obsessive-compulsive disorder, post-traumatic stress disorder). If the treatment team, or patient, determine a patient’s comorbidities interfere with the SE-AN approach during the initial evaluation stay, additional goals must be set to address these ongoing issues either at the outpatient level of care or in a different treatment facility. For example, if a patient with SE-AN also experiences obsessive-compulsive behaviors, the patient and team must think through achievable goals (e.g., exposure and response prevention therapy or medication management) to reduce the impact on SE-AN treatment. These goals should be established with the treatment team and may range from traditional therapeutic interventions (e.g., exposure therapy or substance use treatment) to potentially more experimental approaches (e.g., repetitive transcranial magnetic stimulation [rTMS] or psychedelic-assisted psychotherapy) when indicated. The primary objectives regarding setting goals around comorbidities is to reduce treatment-interfering symptoms not directly related to the eating disorder outside the hospital and increase the likelihood an individual will be able to adhere to the treatment plan.

Another goal-related issue often pertains to step down and discharge planning. Following an inpatient admission on the SE-AN track, individuals may have the desire to step-down their level of care to a partial hospitalization program (PHP) or intensive outpatient program (IOP) to ensure a higher degree of aftercare compared to stepping down to outpatient therapy. As our primary goal is to improve quality of life outside of the hospital, our program has taken the stance that this is acceptable as long as there are specific, and clear goals that have been identified to work on while in the PHP or IOP. Additionally, we have occasionally utilized both PHP and IOP as the primary level of care for our SE-AN protocol; however, only for individuals who come to the hospital medically stable.

Specific interventions for SE-AN

Medical stability.

One of the immediate priorities of a SE-AN approach at a higher level of care is addressing the patients’ physical health and stabilizing any medical complications resulting from SE-AN. This includes addressing the various physical consequences of prolonged inadequate nutrition. Most crucially, medical experts should address issues such as cardiovascular complications, hypoglycemia, organ damage, electrolyte imbalances, and gastrointestinal distress that interferes with the ability to eat. While medication management of psychiatric comorbidities may also be necessary, the initial goal is to stabilize physical health so that there is a life remaining to improve.

Nutritional rehabilitation

An essential consideration for nutritional rehabilitation for individuals with SE-AN is the role of dietitians in the care team and developing simple, and achievable menu plans. While traditional goals, like improved diet variety, have been linked to sustained recovery following weight restoration treatments [ 37 ], the SE-AN program shifts away from what or how these patients eat, prioritizing only that they eat a sufficient amount. Thus, in collaboration with a dietitian, the SE-AN patient creates a meal plan based on foods they are already eating, described as “simple and doable.” While the dietitian works to ensure the patient meets their macronutrient targets (within what is possible given what the patient is willing and able to eat),, there is initially less concern about various food or meal challenges. Over time, if patients successfully adhere to their meal plan, they may choose to increase variety or do meal exposures during future SE-AN admissions. As has been discussed among our team while developing this program, some of these recommendations may challenge the traditional treatment targets utilized by dietitians in treating eating disorders. However, the concept of helping a patient find a meal plan to stabilize their weight and stop weight loss is a skill dietitians most likely already possess. Thus, this does not require extensive additional training. However, we encourage collaborative, and ongoing, discussions among the medical providers and the dietitians in determining various nutritional rehabilitation interventions, such as determining rate of increase in calories to stop weight loss while not destabilize the patient and potentially changes to the macronutrient breakdown of the diet to address medicals needs like treatment of edema. While many of the skills needed to treat SE-AN are already possessed by dietitians, specialized training for working with severely low-weighted, chronically-ill patients may want to be pursued by dietitians, or any of the team members, when it comes to how to best treat SE-AN patients nutritionally.

Another important consideration is how individuals with SE-AN utilize the dining room. Among providers, it has often been argued that the dining room is the most therapeutic intervention for individuals with eating disorders at a higher level of care. While this remains true for individuals with SE-AN, the dining room often serves a very different purpose. The primary function of the dining room is to support SE-AN patients who are trying a different eating model than what they have tried in previous treatments. For the treatment team, this might require changing the expectations in the dining room. For example, in our program, it is understood that patients with SE-AN may engage in some behaviors in the dining room that are often considered disordered. Rather than providing redirection for any eating disorder behavior (e.g., cutting food into small pieces, overuse of condiments), only behaviors that interfere with the patient’s ability to consume their expected nutritional goals (e.g., delaying the start of their meal until the last 5 min so that they are not able to finish their meal) receive redirection. Discussions between SE-AN patients and staff should be supportive, calming, and reassuring. Calm, kind, and reassuring non-verbal messages are also encouraged. Ideally, SE-AN patients should be able to complete their meal in food, given that the patient and dietitian agreed the meal was simple and doable, and that these patients are given only the amount of nutrition needed for medical stabilization and to support their own weight goals, which often means halting weight loss and stabilizing and maintaining current weight. However if a patient does not finish their meal in food, they are expected to consume the missed nutrition immediately following the meal via a liquid supplement. Repeated refusal of planned foods or supplements suggests that the patient is not able to utilize and benefit from the SE-AN program at this time, and calls into question the utility of future admissions under the SE-AN track. The team and the patient would collaboratively discuss expectations for treatment adherence and how nonadherence may decrease the likelihood of the patient being allowed to continue treatment in the SE-AN track.

As previously noted, one of the challenges of creating a hospital-based treatment for SE-AN is the potential interaction of these patients with other patients pursuing different treatment goals. While this might not be an issue in some settings, the dining room can often create a space of conflict between individuals on a traditional restoration plan and those on the SE-AN program. To reduce interference with patients on weight restoration programs, patients on the SE-AN program eat at a designated table within the dining room. These simple modifications are essential in dealing with the heterogeneity of the eating disorder patient population.

Psychotherapeutic interventions

Psychotherapeutic strategies for patients with eating disorders at higher levels of care, in general, are extremely varied, making decisions about psychotherapy interventions for individuals with SE-AN difficult [ 38 , 39 ]. Given that the goal of our SE-AN program is to promote quality of life and increase time outside of hospital units, we have shifted the programming towards values-oriented therapies [ 40 ] and skills-based distress tolerance interventions [ 41 ]. Acceptance and Commitment Therapy (ACT) techniques, like cognitive defusion and committed action, help patients deal with ruminative thinking, a hallmark of SE-AN, while pursuing valued goals following discharge from the hospital. Meanwhile, Dialectical Behavior Therapy (DBT) distress tolerance skills help SE-AN patients more effectively cope with the distress involved in changing eating disorder behaviors and resisting eating disorder urges, in order to approach valued personal goals, even when distressed. With these simple interventions, we hope to help patients increase their treatment motivation and adherence to the treatment plan. The hope is that this approach reduces the pressure on the patient and leads to greater hope and self-efficacy, as they take steps toward recovery in achievable ways, rather than having patients see recovery as an externally imposed goal that is also an insurmountable obstacle.

Additionally, conventional relapse prevention planning, consistent with Cognitive Behavioral Therapy (CBT), is also promoted to assist patients in adhering to clinical goals regarding relapse in the SE-AN program. An essential structural treatment issue is the need to strongly promote continued collaboration with the patient’s outpatient providers following discharge from the hospital program. Such ongoing collaboration is necessary for protecting gains made during the hospitalization.

Criteria for return visits and staying in the SE-AN program

Following discharge from a SE-AN hospital stay, patients are encouraged to immediately begin working towards the goals they set at intake to improve the quality of their life, adhere to their meal plan, and stay medically stable. If, after three months, the patient has been able to meet all of their goals, the patient should still be medically stable and have maintained their weight. Thus, SE-AN patients can return to treatment for 2–3 weeks to work on potential increases in their meal plan, maintaining their progress, or identify opportunities to enhance medical stability. However, patients who are meeting their goals and feel confident in their ability to continue doing so may choose to wait longer than three months before returning. If medically stable patients wait longer than three months, the expectation is still that they can return to treatment for short term stays if they have remained medically stable and have adhered to their individualized meal plan.

While the program aims to provide a more “doable” treatment option, it is necessary to recognize that there is less of a safety net with a maintenance intervention than a full-weight restoration treatment. The likelihood that there are slips, lapses, or relapses for individuals with SE-AN is still high. However, given the slower pace of treatment, getting back on track requires less effort than when relapse happens on traditional treatment approaches. Thus, the first step for any patient who slips on the SE-AN program is simply returning to their meal plan outlined at discharge. The patient-centered meal plan was created to be doable by the patient using foods they were already eating. Returning to the meal plan, the patient can maintain their current weight and potentially drift back to their discharge weight.

If a patient lapses and cannot maintain their weight, we may request that the patient delay return admission beyond three months and begin working to get back on track with their previous discharge plan to demonstrate that they can maintain their weight and stick to their meal plan outside the hospital. For patients unable to get back on track, we advise they seek treatment for medical stabilization. Once medically stable, if they can get back on track, the patient and treatment team must discuss whether it would be appropriate to return for continuation of the SE-AN program. Just as the creation of this program arose from the ethical considerations regarding continually trying unsuccessful full-weight restoration approaches with individuals with chronic anorexia nervosa, the SE-AN program must fall under the same scrutiny. For patients for whom the SE-AN program did not work, the treatment team and patient must carefully weigh the minimal potential for benefit of continuing in a treatment that has not proven to be effective, relative to the costs of continuing a treatment that is not working, as well as the missed opportunity of pursuing other potential treatments options. The treatment team needs to be willing to discuss all alternative options, including returning to weight restoration approaches or the initiation of palliative, or even hospice, care.

Staff and patient feedback

As reviewed above, there is a dearth of research on effective treatments at higher levels of care for patients with SE-AN. Furthermore, the heterogeneity of the limited existing research impedes the ability to meaningfully synthesize this work and translate it to clinical practice. Meanwhile, patients with SE-AN frequently request admissions for hospital care, and programs must decide, with little evidence to consult, how to best serve these patients. Absent empirical guidance or professional consensus on the best way to serve these patients, we believe that exposing higher levels of care treatment programs to professional scrutiny in order to prompt more in-depth discussion of treatment issues for this population would be beneficial. Additionally, without a generalizable understanding of hospital treatment for patients with SE-AN, program evaluations should be conducted within individual treatment programs to inform strengths and shortcomings of each specific program, from the perspective of the patients and staff. We recently began a quality assessment effort to elicit feedback on our program, in order to further refine and enhance the SE-AN treatment protocol. Below, we provide an overview of staff and patient feedback. Of note, this feedback was given as part of evaluation efforts for our particular program, rather than as part of a methodologically rigorous research protocol, and as such is not intended to create generalized knowledge about hospital treatment of SE-AN.

Staff feedback

Overall, staff feedback about the SE-AN treatment model has been quite positive. Staff responses consistently indicated that the SE-AN model seemed to give a sense of hopefulness for many patients, and provided a good opportunity for us to “meet patients where they’re at.” Staff acknowledged that this can be a last resort for patients without other options, who are deemed “too sick” or noncompliant and are thus turned away from many other programs. Staff also noted that the greater autonomy given to patients in SE-AN protocol is helpful for their treatment process and progress, and appears to contribute to an increase in effective collaboration between the patient and providers. Staff believe that patients find this approach to be more tolerable, which decreases patient resistance and defensiveness. Finally, staff appreciated being able to individualize treatment around identifying realistic goals for patients to achieve incremental change outside of the hospital, and felt that in this way they were helping to set the patients up for success rather than contributing to a treatment/relapse cycle.

Staff also noted challenging aspects of the SE-AN treatment model, and areas for improvement. Specifically, several staff noted that explaining this model can be difficult as some patients initially worry that providers are “giving up on them.” And although individualization of treatment is generally seen as a strength of the model (by staff and patients alike), staff note that this can also cause issues with consistency and clarity, and for some patients not in the SE-AN program, it can cause an increase in comparisons with others (e.g., patients questioning why other patients are allowed certain accommodations, but they are not). A third challenge noted was that some patients do not use the treatment model effectively. For example, doing it to placate family or outside providers by “doing treatment,” but without genuine collaborative intent, is inconsistent with the model. Finally, this model can lead to significant challenges when patients (and/or their families and outside providers) do not have a realistic understanding of the severity of and impairment from their disorder, which can cause disagreement between the patient and their team regarding what goals are realistic. For example, a patient who states they want to gain significant weight but is unable to adhere to even a maintenance meal plan while in the hospital, would be required to set a more realistic goal. Treatment staff indicated that patients can at times get fixated on the parameters of the SE-AN model, and consistently challenge the SE-AN model limits (e.g., on length of stay, being asked to set more realistic goals); working through this reactivity and conflict detracts from providers being able to more meaningfully work on the eating disorder itself and provide patients with the full benefit of this model.

Patient feedback

Overall, patient feedback has been positive, though somewhat more mixed than staff feedback. Generally, patient and staff feedback show good correspondence, with both groups noting similar strengths and weaknesses of the treatment model. On the positive side, patients voiced appreciation for the autonomy and individuality that this approach provided with regards to being able to tailor their goals to what is specific for them. Patients stated that they “felt heard” and that their team collaborated well with them. As one patient stated “I don’t need to have a 4-hour panic attack over…lasagna which I’m never going to eat outside treatment. It just made sense to me working on what I wanted to work on.” Patients described the program as “realistic” and “autonomy supporting” and “humane” because it is “not forcing something that’s not worked in the past. And it’s not forcing, like, the cookie cutter model on a person, because every person is unique.” One patient with a trauma history stated that being given autonomy over her own choices while being kept safe from her ED was like “nothing I’ve experienced before and I think so incredibly healing.” Another patient highlighted that “people with AN often desire a high need for control. This program helps give us some level of control while working on difficult recovery goals…. This is the first time where I feel like I am in control of my recovery. I’m no longer scared I am going to die. I am no longer going to the ER 1–2 times a week…. It really seems to be working.”

Some patients were conflicted on the theoretical approach to treatment. For example, one patient expressed appreciation that “skills are repeatedly used to help facilitate success on the outside” [outside the hospital], while another patient stated that “more of the process work could be utilized rather than skills over and over” because “if you’re on the SE-AN track you probably have learned that before and probably done those groups a million times.”

Patients struggled with the structure of the treatment model. Some stated that they “wish it was faster” though they know “this is the speed it has to be for me.” Patients also expressed a desire for even more individualization, though also acknowledged that it can be difficult to balance individualization and consistency. One patient stated that she has seen other patients “just messing around” and “not actually working…just doing your disorder in treatment.” So, while patients understand the need for structure and limitations, they tend to think those limits make sense in general and for other patients on the SE-AN model, but should be less rigid for themselves. Patients discussed feeling worried that they may not be allowed to return if they struggle and are unable to meet their goals in between hospital stays, which highlights the difficult balance between requiring patients to demonstrate that they are being helped by the treatment model (to ensure we are not enabling stagnation and continued disorder) while also making allowances for nonlinear recovery processes. Patients also expressed that the SE-AN model can feel limiting. One patient stated that as a result of the SE-AN treatment model she had “lower expectations for myself” and felt the “agenda for this stay was tainted by previous stays” and that “once labeled, no matter your willingness to move forward, regardless of want to go further, it’s shut down.” Several patients similarly commented that being “labeled” as SE-AN and being recommended to the SE-AN treatment model was originally hard as it made them feel hopeless and given up on, but that once the goals of this approach were more clearly communicated, they understood its value better. Finally, patients noted some concern about lack of community resources and understanding of this approach, with one patient stating “I am scared that other treatment programs won’t take an approach like this. It can also be hard to get my outpatient providers to understand the program.”

Staff and patient feedback takeaways

Overall, staff and patient feedback suggest that the SE-AN treatment protocol is beneficial in many ways, especially in providing a treatment option—one that has the potential to extend life and willingness to engage with treatment—for those who are “too sick” for other treatment or who feel they cannot tolerate or do not want full/traditional recovery. Areas for potential improvement have been highlighted. Specifically, further consideration should be given to balancing individualization with consistency and having clearer guidelines for when, and with whom, to hold rigid expectations and under what circumstances greater flexibility can be extended. It will be important to continue to develop better strategies to communicate clearly and collaboratively with patients around what being classified as SE-AN means and the potential benefits of the SE-AN model in a way that can instill hope rather than hopelessness. Also, greater attention should be paid to addressing patient dissatisfaction when they feel limited by the SE-AN model but may not be able or willing to do traditional treatment with full weight restoration. Finally, thorough integration of the SE-AN program with outpatient providers is critical, but it can be challenging to find outpatient providers who will accept patients with SE-AN and who will agree to work on the patient’s SE-AN goals rather than traditional recovery goals and weight restoration.

In summary, we have provided a brief overview of SE-AN both scientifically and clinically. We have also attempted to highlight the limited empirically supported treatment options for SE-AN, but wish to underscore that this dearth of treatment options is significantly pronounced at higher levels of care. Given the severity of SE-AN, it is a simple fact that these patients will often use hospital-based services, and thus, greater attention to this deficit is encouraged.

Our program developed a structured treatment program for SE-AN which highlights flexible goalsetting, high levels of collaboration between patient and clinical staff, and an emphasis on enhancing quality of life, medical stability, and adequate nutritional rehabilitation. Furthermore, the approach highlights the importance of tailoring treatment planning to a given patient and their collaboratively established goals. Explicit treatment contracts are developed with patients and include a shared understanding of targeted objectives. Additionally, there is a significant effort to develop a detailed plan for maintaining health and returning to treatment after discharge from the hospital. This may include future “booster” admissions for limited periods of time to assist patients in continuing to maintain, or incrementally advance, health related goal achievement. Presently, our survey of patients, and staff suggest that the program offers significant advantages for both the treatment team and the patient, but also the continued challenges that a program for SE-AN in a hospital environment must face. We would strongly recommend that clinicians and scientists work to establish empirically supported approaches to treating patients with SE-AN in a hospital environment. Given this is a necessary type of care for such patients and the very serious nature of this illness, it is worthy of such an investment.

Data availability

No datasets were generated or analysed during the current study.

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Wonderlich, J.A., Dodd, D.R., Sondag, C. et al. Clinical and scientific review of severe and enduring anorexia nervosa in intensive care settings: introducing an innovative treatment paradigm. J Eat Disord 12 , 131 (2024). https://doi.org/10.1186/s40337-024-01079-9

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What is Qualitative in Qualitative Research

Patrik aspers.

1 Department of Sociology, Uppsala University, Uppsala, Sweden

2 Seminar for Sociology, Universität St. Gallen, St. Gallen, Switzerland

3 Department of Media and Social Sciences, University of Stavanger, Stavanger, Norway

What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being “qualitative,” the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term “qualitative.” Then, drawing on ideas we find scattered across existing work, and based on Becker’s classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research.

If we assume that there is something called qualitative research, what exactly is this qualitative feature? And how could we evaluate qualitative research as good or not? Is it fundamentally different from quantitative research? In practice, most active qualitative researchers working with empirical material intuitively know what is involved in doing qualitative research, yet perhaps surprisingly, a clear definition addressing its key feature is still missing.

To address the question of what is qualitative we turn to the accounts of “qualitative research” in textbooks and also in empirical work. In his classic, explorative, interview study of deviance Howard Becker ( 1963 ) asks ‘How does one become a marijuana user?’ In contrast to pre-dispositional and psychological-individualistic theories of deviant behavior, Becker’s inherently social explanation contends that becoming a user of this substance is the result of a three-phase sequential learning process. First, potential users need to learn how to smoke it properly to produce the “correct” effects. If not, they are likely to stop experimenting with it. Second, they need to discover the effects associated with it; in other words, to get “high,” individuals not only have to experience what the drug does, but also to become aware that those sensations are related to using it. Third, they require learning to savor the feelings related to its consumption – to develop an acquired taste. Becker, who played music himself, gets close to the phenomenon by observing, taking part, and by talking to people consuming the drug: “half of the fifty interviews were conducted with musicians, the other half covered a wide range of people, including laborers, machinists, and people in the professions” (Becker 1963 :56).

Another central aspect derived through the common-to-all-research interplay between induction and deduction (Becker 2017 ), is that during the course of his research Becker adds scientifically meaningful new distinctions in the form of three phases—distinctions, or findings if you will, that strongly affect the course of his research: its focus, the material that he collects, and which eventually impact his findings. Each phase typically unfolds through social interaction, and often with input from experienced users in “a sequence of social experiences during which the person acquires a conception of the meaning of the behavior, and perceptions and judgments of objects and situations, all of which make the activity possible and desirable” (Becker 1963 :235). In this study the increased understanding of smoking dope is a result of a combination of the meaning of the actors, and the conceptual distinctions that Becker introduces based on the views expressed by his respondents. Understanding is the result of research and is due to an iterative process in which data, concepts and evidence are connected with one another (Becker 2017 ).

Indeed, there are many definitions of qualitative research, but if we look for a definition that addresses its distinctive feature of being “qualitative,” the literature across the broad field of social science is meager. The main reason behind this article lies in the paradox, which, to put it bluntly, is that researchers act as if they know what it is, but they cannot formulate a coherent definition. Sociologists and others will of course continue to conduct good studies that show the relevance and value of qualitative research addressing scientific and practical problems in society. However, our paper is grounded in the idea that providing a clear definition will help us improve the work that we do. Among researchers who practice qualitative research there is clearly much knowledge. We suggest that a definition makes this knowledge more explicit. If the first rationale for writing this paper refers to the “internal” aim of improving qualitative research, the second refers to the increased “external” pressure that especially many qualitative researchers feel; pressure that comes both from society as well as from other scientific approaches. There is a strong core in qualitative research, and leading researchers tend to agree on what it is and how it is done. Our critique is not directed at the practice of qualitative research, but we do claim that the type of systematic work we do has not yet been done, and that it is useful to improve the field and its status in relation to quantitative research.

The literature on the “internal” aim of improving, or at least clarifying qualitative research is large, and we do not claim to be the first to notice the vagueness of the term “qualitative” (Strauss and Corbin 1998 ). Also, others have noted that there is no single definition of it (Long and Godfrey 2004 :182), that there are many different views on qualitative research (Denzin and Lincoln 2003 :11; Jovanović 2011 :3), and that more generally, we need to define its meaning (Best 2004 :54). Strauss and Corbin ( 1998 ), for example, as well as Nelson et al. (1992:2 cited in Denzin and Lincoln 2003 :11), and Flick ( 2007 :ix–x), have recognized that the term is problematic: “Actually, the term ‘qualitative research’ is confusing because it can mean different things to different people” (Strauss and Corbin 1998 :10–11). Hammersley has discussed the possibility of addressing the problem, but states that “the task of providing an account of the distinctive features of qualitative research is far from straightforward” ( 2013 :2). This confusion, as he has recently further argued (Hammersley 2018 ), is also salient in relation to ethnography where different philosophical and methodological approaches lead to a lack of agreement about what it means.

Others (e.g. Hammersley 2018 ; Fine and Hancock 2017 ) have also identified the treat to qualitative research that comes from external forces, seen from the point of view of “qualitative research.” This threat can be further divided into that which comes from inside academia, such as the critique voiced by “quantitative research” and outside of academia, including, for example, New Public Management. Hammersley ( 2018 ), zooming in on one type of qualitative research, ethnography, has argued that it is under treat. Similarly to Fine ( 2003 ), and before him Gans ( 1999 ), he writes that ethnography’ has acquired a range of meanings, and comes in many different versions, these often reflecting sharply divergent epistemological orientations. And already more than twenty years ago while reviewing Denzin and Lincoln’ s Handbook of Qualitative Methods Fine argued:

While this increasing centrality [of qualitative research] might lead one to believe that consensual standards have developed, this belief would be misleading. As the methodology becomes more widely accepted, querulous challengers have raised fundamental questions that collectively have undercut the traditional models of how qualitative research is to be fashioned and presented (1995:417).

According to Hammersley, there are today “serious treats to the practice of ethnographic work, on almost any definition” ( 2018 :1). He lists five external treats: (1) that social research must be accountable and able to show its impact on society; (2) the current emphasis on “big data” and the emphasis on quantitative data and evidence; (3) the labor market pressure in academia that leaves less time for fieldwork (see also Fine and Hancock 2017 ); (4) problems of access to fields; and (5) the increased ethical scrutiny of projects, to which ethnography is particularly exposed. Hammersley discusses some more or less insufficient existing definitions of ethnography.

The current situation, as Hammersley and others note—and in relation not only to ethnography but also qualitative research in general, and as our empirical study shows—is not just unsatisfactory, it may even be harmful for the entire field of qualitative research, and does not help social science at large. We suggest that the lack of clarity of qualitative research is a real problem that must be addressed.

Towards a Definition of Qualitative Research

Seen in an historical light, what is today called qualitative, or sometimes ethnographic, interpretative research – or a number of other terms – has more or less always existed. At the time the founders of sociology – Simmel, Weber, Durkheim and, before them, Marx – were writing, and during the era of the Methodenstreit (“dispute about methods”) in which the German historical school emphasized scientific methods (cf. Swedberg 1990 ), we can at least speak of qualitative forerunners.

Perhaps the most extended discussion of what later became known as qualitative methods in a classic work is Bronisław Malinowski’s ( 1922 ) Argonauts in the Western Pacific , although even this study does not explicitly address the meaning of “qualitative.” In Weber’s ([1921–-22] 1978) work we find a tension between scientific explanations that are based on observation and quantification and interpretative research (see also Lazarsfeld and Barton 1982 ).

If we look through major sociology journals like the American Sociological Review , American Journal of Sociology , or Social Forces we will not find the term qualitative sociology before the 1970s. And certainly before then much of what we consider qualitative classics in sociology, like Becker’ study ( 1963 ), had already been produced. Indeed, the Chicago School often combined qualitative and quantitative data within the same study (Fine 1995 ). Our point being that before a disciplinary self-awareness the term quantitative preceded qualitative, and the articulation of the former was a political move to claim scientific status (Denzin and Lincoln 2005 ). In the US the World War II seem to have sparked a critique of sociological work, including “qualitative work,” that did not follow the scientific canon (Rawls 2018 ), which was underpinned by a scientifically oriented and value free philosophy of science. As a result the attempts and practice of integrating qualitative and quantitative sociology at Chicago lost ground to sociology that was more oriented to surveys and quantitative work at Columbia under Merton-Lazarsfeld. The quantitative tradition was also able to present textbooks (Lundberg 1951 ) that facilitated the use this approach and its “methods.” The practices of the qualitative tradition, by and large, remained tacit or was part of the mentoring transferred from the renowned masters to their students.

This glimpse into history leads us back to the lack of a coherent account condensed in a definition of qualitative research. Many of the attempts to define the term do not meet the requirements of a proper definition: A definition should be clear, avoid tautology, demarcate its domain in relation to the environment, and ideally only use words in its definiens that themselves are not in need of definition (Hempel 1966 ). A definition can enhance precision and thus clarity by identifying the core of the phenomenon. Preferably, a definition should be short. The typical definition we have found, however, is an ostensive definition, which indicates what qualitative research is about without informing us about what it actually is :

Qualitative research is multimethod in focus, involving an interpretative, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives. (Denzin and Lincoln 2005 :2)

Flick claims that the label “qualitative research” is indeed used as an umbrella for a number of approaches ( 2007 :2–4; 2002 :6), and it is not difficult to identify research fitting this designation. Moreover, whatever it is, it has grown dramatically over the past five decades. In addition, courses have been developed, methods have flourished, arguments about its future have been advanced (for example, Denzin and Lincoln 1994) and criticized (for example, Snow and Morrill 1995 ), and dedicated journals and books have mushroomed. Most social scientists have a clear idea of research and how it differs from journalism, politics and other activities. But the question of what is qualitative in qualitative research is either eluded or eschewed.

We maintain that this lacuna hinders systematic knowledge production based on qualitative research. Paul Lazarsfeld noted the lack of “codification” as early as 1955 when he reviewed 100 qualitative studies in order to offer a codification of the practices (Lazarsfeld and Barton 1982 :239). Since then many texts on “qualitative research” and its methods have been published, including recent attempts (Goertz and Mahoney 2012 ) similar to Lazarsfeld’s. These studies have tried to extract what is qualitative by looking at the large number of empirical “qualitative” studies. Our novel strategy complements these endeavors by taking another approach and looking at the attempts to codify these practices in the form of a definition, as well as to a minor extent take Becker’s study as an exemplar of what qualitative researchers actually do, and what the characteristic of being ‘qualitative’ denotes and implies. We claim that qualitative researchers, if there is such a thing as “qualitative research,” should be able to codify their practices in a condensed, yet general way expressed in language.

Lingering problems of “generalizability” and “how many cases do I need” (Small 2009 ) are blocking advancement – in this line of work qualitative approaches are said to differ considerably from quantitative ones, while some of the former unsuccessfully mimic principles related to the latter (Small 2009 ). Additionally, quantitative researchers sometimes unfairly criticize the first based on their own quality criteria. Scholars like Goertz and Mahoney ( 2012 ) have successfully focused on the different norms and practices beyond what they argue are essentially two different cultures: those working with either qualitative or quantitative methods. Instead, similarly to Becker ( 2017 ) who has recently questioned the usefulness of the distinction between qualitative and quantitative research, we focus on similarities.

The current situation also impedes both students and researchers in focusing their studies and understanding each other’s work (Lazarsfeld and Barton 1982 :239). A third consequence is providing an opening for critiques by scholars operating within different traditions (Valsiner 2000 :101). A fourth issue is that the “implicit use of methods in qualitative research makes the field far less standardized than the quantitative paradigm” (Goertz and Mahoney 2012 :9). Relatedly, the National Science Foundation in the US organized two workshops in 2004 and 2005 to address the scientific foundations of qualitative research involving strategies to improve it and to develop standards of evaluation in qualitative research. However, a specific focus on its distinguishing feature of being “qualitative” while being implicitly acknowledged, was discussed only briefly (for example, Best 2004 ).

In 2014 a theme issue was published in this journal on “Methods, Materials, and Meanings: Designing Cultural Analysis,” discussing central issues in (cultural) qualitative research (Berezin 2014 ; Biernacki 2014 ; Glaeser 2014 ; Lamont and Swidler 2014 ; Spillman 2014). We agree with many of the arguments put forward, such as the risk of methodological tribalism, and that we should not waste energy on debating methods separated from research questions. Nonetheless, a clarification of the relation to what is called “quantitative research” is of outmost importance to avoid misunderstandings and misguided debates between “qualitative” and “quantitative” researchers. Our strategy means that researchers, “qualitative” or “quantitative” they may be, in their actual practice may combine qualitative work and quantitative work.

In this article we accomplish three tasks. First, we systematically survey the literature for meanings of qualitative research by looking at how researchers have defined it. Drawing upon existing knowledge we find that the different meanings and ideas of qualitative research are not yet coherently integrated into one satisfactory definition. Next, we advance our contribution by offering a definition of qualitative research and illustrate its meaning and use partially by expanding on the brief example introduced earlier related to Becker’s work ( 1963 ). We offer a systematic analysis of central themes of what researchers consider to be the core of “qualitative,” regardless of style of work. These themes – which we summarize in terms of four keywords: distinction, process, closeness, improved understanding – constitute part of our literature review, in which each one appears, sometimes with others, but never all in the same definition. They serve as the foundation of our contribution. Our categories are overlapping. Their use is primarily to organize the large amount of definitions we have identified and analyzed, and not necessarily to draw a clear distinction between them. Finally, we continue the elaboration discussed above on the advantages of a clear definition of qualitative research.

In a hermeneutic fashion we propose that there is something meaningful that deserves to be labelled “qualitative research” (Gadamer 1990 ). To approach the question “What is qualitative in qualitative research?” we have surveyed the literature. In conducting our survey we first traced the word’s etymology in dictionaries, encyclopedias, handbooks of the social sciences and of methods and textbooks, mainly in English, which is common to methodology courses. It should be noted that we have zoomed in on sociology and its literature. This discipline has been the site of the largest debate and development of methods that can be called “qualitative,” which suggests that this field should be examined in great detail.

In an ideal situation we should expect that one good definition, or at least some common ideas, would have emerged over the years. This common core of qualitative research should be so accepted that it would appear in at least some textbooks. Since this is not what we found, we decided to pursue an inductive approach to capture maximal variation in the field of qualitative research; we searched in a selection of handbooks, textbooks, book chapters, and books, to which we added the analysis of journal articles. Our sample comprises a total of 89 references.

In practice we focused on the discipline that has had a clear discussion of methods, namely sociology. We also conducted a broad search in the JSTOR database to identify scholarly sociology articles published between 1998 and 2017 in English with a focus on defining or explaining qualitative research. We specifically zoom in on this time frame because we would have expect that this more mature period would have produced clear discussions on the meaning of qualitative research. To find these articles we combined a number of keywords to search the content and/or the title: qualitative (which was always included), definition, empirical, research, methodology, studies, fieldwork, interview and observation .

As a second phase of our research we searched within nine major sociological journals ( American Journal of Sociology , Sociological Theory , American Sociological Review , Contemporary Sociology , Sociological Forum , Sociological Theory , Qualitative Research , Qualitative Sociology and Qualitative Sociology Review ) for articles also published during the past 19 years (1998–2017) that had the term “qualitative” in the title and attempted to define qualitative research.

Lastly we picked two additional journals, Qualitative Research and Qualitative Sociology , in which we could expect to find texts addressing the notion of “qualitative.” From Qualitative Research we chose Volume 14, Issue 6, December 2014, and from Qualitative Sociology we chose Volume 36, Issue 2, June 2017. Within each of these we selected the first article; then we picked the second article of three prior issues. Again we went back another three issues and investigated article number three. Finally we went back another three issues and perused article number four. This selection criteria was used to get a manageable sample for the analysis.

The coding process of the 89 references we gathered in our selected review began soon after the first round of material was gathered, and we reduced the complexity created by our maximum variation sampling (Snow and Anderson 1993 :22) to four different categories within which questions on the nature and properties of qualitative research were discussed. We call them: Qualitative and Quantitative Research, Qualitative Research, Fieldwork, and Grounded Theory. This – which may appear as an illogical grouping – merely reflects the “context” in which the matter of “qualitative” is discussed. If the selection process of the material – books and articles – was informed by pre-knowledge, we used an inductive strategy to code the material. When studying our material, we identified four central notions related to “qualitative” that appear in various combinations in the literature which indicate what is the core of qualitative research. We have labeled them: “distinctions”, “process,” “closeness,” and “improved understanding.” During the research process the categories and notions were improved, refined, changed, and reordered. The coding ended when a sense of saturation in the material arose. In the presentation below all quotations and references come from our empirical material of texts on qualitative research.

Analysis – What is Qualitative Research?

In this section we describe the four categories we identified in the coding, how they differently discuss qualitative research, as well as their overall content. Some salient quotations are selected to represent the type of text sorted under each of the four categories. What we present are examples from the literature.

Qualitative and Quantitative

This analytic category comprises quotations comparing qualitative and quantitative research, a distinction that is frequently used (Brown 2010 :231); in effect this is a conceptual pair that structures the discussion and that may be associated with opposing interests. While the general goal of quantitative and qualitative research is the same – to understand the world better – their methodologies and focus in certain respects differ substantially (Becker 1966 :55). Quantity refers to that property of something that can be determined by measurement. In a dictionary of Statistics and Methodology we find that “(a) When referring to *variables, ‘qualitative’ is another term for *categorical or *nominal. (b) When speaking of kinds of research, ‘qualitative’ refers to studies of subjects that are hard to quantify, such as art history. Qualitative research tends to be a residual category for almost any kind of non-quantitative research” (Stiles 1998:183). But it should be obvious that one could employ a quantitative approach when studying, for example, art history.

The same dictionary states that quantitative is “said of variables or research that can be handled numerically, usually (too sharply) contrasted with *qualitative variables and research” (Stiles 1998:184). From a qualitative perspective “quantitative research” is about numbers and counting, and from a quantitative perspective qualitative research is everything that is not about numbers. But this does not say much about what is “qualitative.” If we turn to encyclopedias we find that in the 1932 edition of the Encyclopedia of the Social Sciences there is no mention of “qualitative.” In the Encyclopedia from 1968 we can read:

Qualitative Analysis. For methods of obtaining, analyzing, and describing data, see [the various entries:] CONTENT ANALYSIS; COUNTED DATA; EVALUATION RESEARCH, FIELD WORK; GRAPHIC PRESENTATION; HISTORIOGRAPHY, especially the article on THE RHETORIC OF HISTORY; INTERVIEWING; OBSERVATION; PERSONALITY MEASUREMENT; PROJECTIVE METHODS; PSYCHOANALYSIS, article on EXPERIMENTAL METHODS; SURVEY ANALYSIS, TABULAR PRESENTATION; TYPOLOGIES. (Vol. 13:225)

Some, like Alford, divide researchers into methodologists or, in his words, “quantitative and qualitative specialists” (Alford 1998 :12). Qualitative research uses a variety of methods, such as intensive interviews or in-depth analysis of historical materials, and it is concerned with a comprehensive account of some event or unit (King et al. 1994 :4). Like quantitative research it can be utilized to study a variety of issues, but it tends to focus on meanings and motivations that underlie cultural symbols, personal experiences, phenomena and detailed understanding of processes in the social world. In short, qualitative research centers on understanding processes, experiences, and the meanings people assign to things (Kalof et al. 2008 :79).

Others simply say that qualitative methods are inherently unscientific (Jovanović 2011 :19). Hood, for instance, argues that words are intrinsically less precise than numbers, and that they are therefore more prone to subjective analysis, leading to biased results (Hood 2006 :219). Qualitative methodologies have raised concerns over the limitations of quantitative templates (Brady et al. 2004 :4). Scholars such as King et al. ( 1994 ), for instance, argue that non-statistical research can produce more reliable results if researchers pay attention to the rules of scientific inference commonly stated in quantitative research. Also, researchers such as Becker ( 1966 :59; 1970 :42–43) have asserted that, if conducted properly, qualitative research and in particular ethnographic field methods, can lead to more accurate results than quantitative studies, in particular, survey research and laboratory experiments.

Some researchers, such as Kalof, Dan, and Dietz ( 2008 :79) claim that the boundaries between the two approaches are becoming blurred, and Small ( 2009 ) argues that currently much qualitative research (especially in North America) tries unsuccessfully and unnecessarily to emulate quantitative standards. For others, qualitative research tends to be more humanistic and discursive (King et al. 1994 :4). Ragin ( 1994 ), and similarly also Becker, ( 1996 :53), Marchel and Owens ( 2007 :303) think that the main distinction between the two styles is overstated and does not rest on the simple dichotomy of “numbers versus words” (Ragin 1994 :xii). Some claim that quantitative data can be utilized to discover associations, but in order to unveil cause and effect a complex research design involving the use of qualitative approaches needs to be devised (Gilbert 2009 :35). Consequently, qualitative data are useful for understanding the nuances lying beyond those processes as they unfold (Gilbert 2009 :35). Others contend that qualitative research is particularly well suited both to identify causality and to uncover fine descriptive distinctions (Fine and Hallett 2014 ; Lichterman and Isaac Reed 2014 ; Katz 2015 ).

There are other ways to separate these two traditions, including normative statements about what qualitative research should be (that is, better or worse than quantitative approaches, concerned with scientific approaches to societal change or vice versa; Snow and Morrill 1995 ; Denzin and Lincoln 2005 ), or whether it should develop falsifiable statements; Best 2004 ).

We propose that quantitative research is largely concerned with pre-determined variables (Small 2008 ); the analysis concerns the relations between variables. These categories are primarily not questioned in the study, only their frequency or degree, or the correlations between them (cf. Franzosi 2016 ). If a researcher studies wage differences between women and men, he or she works with given categories: x number of men are compared with y number of women, with a certain wage attributed to each person. The idea is not to move beyond the given categories of wage, men and women; they are the starting point as well as the end point, and undergo no “qualitative change.” Qualitative research, in contrast, investigates relations between categories that are themselves subject to change in the research process. Returning to Becker’s study ( 1963 ), we see that he questioned pre-dispositional theories of deviant behavior working with pre-determined variables such as an individual’s combination of personal qualities or emotional problems. His take, in contrast, was to understand marijuana consumption by developing “variables” as part of the investigation. Thereby he presented new variables, or as we would say today, theoretical concepts, but which are grounded in the empirical material.

Qualitative Research

This category contains quotations that refer to descriptions of qualitative research without making comparisons with quantitative research. Researchers such as Denzin and Lincoln, who have written a series of influential handbooks on qualitative methods (1994; Denzin and Lincoln 2003 ; 2005 ), citing Nelson et al. (1992:4), argue that because qualitative research is “interdisciplinary, transdisciplinary, and sometimes counterdisciplinary” it is difficult to derive one single definition of it (Jovanović 2011 :3). According to them, in fact, “the field” is “many things at the same time,” involving contradictions, tensions over its focus, methods, and how to derive interpretations and findings ( 2003 : 11). Similarly, others, such as Flick ( 2007 :ix–x) contend that agreeing on an accepted definition has increasingly become problematic, and that qualitative research has possibly matured different identities. However, Best holds that “the proliferation of many sorts of activities under the label of qualitative sociology threatens to confuse our discussions” ( 2004 :54). Atkinson’s position is more definite: “the current state of qualitative research and research methods is confused” ( 2005 :3–4).

Qualitative research is about interpretation (Blumer 1969 ; Strauss and Corbin 1998 ; Denzin and Lincoln 2003 ), or Verstehen [understanding] (Frankfort-Nachmias and Nachmias 1996 ). It is “multi-method,” involving the collection and use of a variety of empirical materials (Denzin and Lincoln 1998; Silverman 2013 ) and approaches (Silverman 2005 ; Flick 2007 ). It focuses not only on the objective nature of behavior but also on its subjective meanings: individuals’ own accounts of their attitudes, motivations, behavior (McIntyre 2005 :127; Creswell 2009 ), events and situations (Bryman 1989) – what people say and do in specific places and institutions (Goodwin and Horowitz 2002 :35–36) in social and temporal contexts (Morrill and Fine 1997). For this reason, following Weber ([1921-22] 1978), it can be described as an interpretative science (McIntyre 2005 :127). But could quantitative research also be concerned with these questions? Also, as pointed out below, does all qualitative research focus on subjective meaning, as some scholars suggest?

Others also distinguish qualitative research by claiming that it collects data using a naturalistic approach (Denzin and Lincoln 2005 :2; Creswell 2009 ), focusing on the meaning actors ascribe to their actions. But again, does all qualitative research need to be collected in situ? And does qualitative research have to be inherently concerned with meaning? Flick ( 2007 ), referring to Denzin and Lincoln ( 2005 ), mentions conversation analysis as an example of qualitative research that is not concerned with the meanings people bring to a situation, but rather with the formal organization of talk. Still others, such as Ragin ( 1994 :85), note that qualitative research is often (especially early on in the project, we would add) less structured than other kinds of social research – a characteristic connected to its flexibility and that can lead both to potentially better, but also worse results. But is this not a feature of this type of research, rather than a defining description of its essence? Wouldn’t this comment also apply, albeit to varying degrees, to quantitative research?

In addition, Strauss ( 2003 ), along with others, such as Alvesson and Kärreman ( 2011 :10–76), argue that qualitative researchers struggle to capture and represent complex phenomena partially because they tend to collect a large amount of data. While his analysis is correct at some points – “It is necessary to do detailed, intensive, microscopic examination of the data in order to bring out the amazing complexity of what lies in, behind, and beyond those data” (Strauss 2003 :10) – much of his analysis concerns the supposed focus of qualitative research and its challenges, rather than exactly what it is about. But even in this instance we would make a weak case arguing that these are strictly the defining features of qualitative research. Some researchers seem to focus on the approach or the methods used, or even on the way material is analyzed. Several researchers stress the naturalistic assumption of investigating the world, suggesting that meaning and interpretation appear to be a core matter of qualitative research.

We can also see that in this category there is no consensus about specific qualitative methods nor about qualitative data. Many emphasize interpretation, but quantitative research, too, involves interpretation; the results of a regression analysis, for example, certainly have to be interpreted, and the form of meta-analysis that factor analysis provides indeed requires interpretation However, there is no interpretation of quantitative raw data, i.e., numbers in tables. One common thread is that qualitative researchers have to get to grips with their data in order to understand what is being studied in great detail, irrespective of the type of empirical material that is being analyzed. This observation is connected to the fact that qualitative researchers routinely make several adjustments of focus and research design as their studies progress, in many cases until the very end of the project (Kalof et al. 2008 ). If you, like Becker, do not start out with a detailed theory, adjustments such as the emergence and refinement of research questions will occur during the research process. We have thus found a number of useful reflections about qualitative research scattered across different sources, but none of them effectively describe the defining characteristics of this approach.

Although qualitative research does not appear to be defined in terms of a specific method, it is certainly common that fieldwork, i.e., research that entails that the researcher spends considerable time in the field that is studied and use the knowledge gained as data, is seen as emblematic of or even identical to qualitative research. But because we understand that fieldwork tends to focus primarily on the collection and analysis of qualitative data, we expected to find within it discussions on the meaning of “qualitative.” But, again, this was not the case.

Instead, we found material on the history of this approach (for example, Frankfort-Nachmias and Nachmias 1996 ; Atkinson et al. 2001), including how it has changed; for example, by adopting a more self-reflexive practice (Heyl 2001), as well as the different nomenclature that has been adopted, such as fieldwork, ethnography, qualitative research, naturalistic research, participant observation and so on (for example, Lofland et al. 2006 ; Gans 1999 ).

We retrieved definitions of ethnography, such as “the study of people acting in the natural courses of their daily lives,” involving a “resocialization of the researcher” (Emerson 1988 :1) through intense immersion in others’ social worlds (see also examples in Hammersley 2018 ). This may be accomplished by direct observation and also participation (Neuman 2007 :276), although others, such as Denzin ( 1970 :185), have long recognized other types of observation, including non-participant (“fly on the wall”). In this category we have also isolated claims and opposing views, arguing that this type of research is distinguished primarily by where it is conducted (natural settings) (Hughes 1971:496), and how it is carried out (a variety of methods are applied) or, for some most importantly, by involving an active, empathetic immersion in those being studied (Emerson 1988 :2). We also retrieved descriptions of the goals it attends in relation to how it is taught (understanding subjective meanings of the people studied, primarily develop theory, or contribute to social change) (see for example, Corte and Irwin 2017 ; Frankfort-Nachmias and Nachmias 1996 :281; Trier-Bieniek 2012 :639) by collecting the richest possible data (Lofland et al. 2006 ) to derive “thick descriptions” (Geertz 1973 ), and/or to aim at theoretical statements of general scope and applicability (for example, Emerson 1988 ; Fine 2003 ). We have identified guidelines on how to evaluate it (for example Becker 1996 ; Lamont 2004 ) and have retrieved instructions on how it should be conducted (for example, Lofland et al. 2006 ). For instance, analysis should take place while the data gathering unfolds (Emerson 1988 ; Hammersley and Atkinson 2007 ; Lofland et al. 2006 ), observations should be of long duration (Becker 1970 :54; Goffman 1989 ), and data should be of high quantity (Becker 1970 :52–53), as well as other questionable distinctions between fieldwork and other methods:

Field studies differ from other methods of research in that the researcher performs the task of selecting topics, decides what questions to ask, and forges interest in the course of the research itself . This is in sharp contrast to many ‘theory-driven’ and ‘hypothesis-testing’ methods. (Lofland and Lofland 1995 :5)

But could not, for example, a strictly interview-based study be carried out with the same amount of flexibility, such as sequential interviewing (for example, Small 2009 )? Once again, are quantitative approaches really as inflexible as some qualitative researchers think? Moreover, this category stresses the role of the actors’ meaning, which requires knowledge and close interaction with people, their practices and their lifeworld.

It is clear that field studies – which are seen by some as the “gold standard” of qualitative research – are nonetheless only one way of doing qualitative research. There are other methods, but it is not clear why some are more qualitative than others, or why they are better or worse. Fieldwork is characterized by interaction with the field (the material) and understanding of the phenomenon that is being studied. In Becker’s case, he had general experience from fields in which marihuana was used, based on which he did interviews with actual users in several fields.

Grounded Theory

Another major category we identified in our sample is Grounded Theory. We found descriptions of it most clearly in Glaser and Strauss’ ([1967] 2010 ) original articulation, Strauss and Corbin ( 1998 ) and Charmaz ( 2006 ), as well as many other accounts of what it is for: generating and testing theory (Strauss 2003 :xi). We identified explanations of how this task can be accomplished – such as through two main procedures: constant comparison and theoretical sampling (Emerson 1998:96), and how using it has helped researchers to “think differently” (for example, Strauss and Corbin 1998 :1). We also read descriptions of its main traits, what it entails and fosters – for instance, an exceptional flexibility, an inductive approach (Strauss and Corbin 1998 :31–33; 1990; Esterberg 2002 :7), an ability to step back and critically analyze situations, recognize tendencies towards bias, think abstractly and be open to criticism, enhance sensitivity towards the words and actions of respondents, and develop a sense of absorption and devotion to the research process (Strauss and Corbin 1998 :5–6). Accordingly, we identified discussions of the value of triangulating different methods (both using and not using grounded theory), including quantitative ones, and theories to achieve theoretical development (most comprehensively in Denzin 1970 ; Strauss and Corbin 1998 ; Timmermans and Tavory 2012 ). We have also located arguments about how its practice helps to systematize data collection, analysis and presentation of results (Glaser and Strauss [1967] 2010 :16).

Grounded theory offers a systematic approach which requires researchers to get close to the field; closeness is a requirement of identifying questions and developing new concepts or making further distinctions with regard to old concepts. In contrast to other qualitative approaches, grounded theory emphasizes the detailed coding process, and the numerous fine-tuned distinctions that the researcher makes during the process. Within this category, too, we could not find a satisfying discussion of the meaning of qualitative research.

Defining Qualitative Research

In sum, our analysis shows that some notions reappear in the discussion of qualitative research, such as understanding, interpretation, “getting close” and making distinctions. These notions capture aspects of what we think is “qualitative.” However, a comprehensive definition that is useful and that can further develop the field is lacking, and not even a clear picture of its essential elements appears. In other words no definition emerges from our data, and in our research process we have moved back and forth between our empirical data and the attempt to present a definition. Our concrete strategy, as stated above, is to relate qualitative and quantitative research, or more specifically, qualitative and quantitative work. We use an ideal-typical notion of quantitative research which relies on taken for granted and numbered variables. This means that the data consists of variables on different scales, such as ordinal, but frequently ratio and absolute scales, and the representation of the numbers to the variables, i.e. the justification of the assignment of numbers to object or phenomenon, are not questioned, though the validity may be questioned. In this section we return to the notion of quality and try to clarify it while presenting our contribution.

Broadly, research refers to the activity performed by people trained to obtain knowledge through systematic procedures. Notions such as “objectivity” and “reflexivity,” “systematic,” “theory,” “evidence” and “openness” are here taken for granted in any type of research. Next, building on our empirical analysis we explain the four notions that we have identified as central to qualitative work: distinctions, process, closeness, and improved understanding. In discussing them, ultimately in relation to one another, we make their meaning even more precise. Our idea, in short, is that only when these ideas that we present separately for analytic purposes are brought together can we speak of qualitative research.

Distinctions

We believe that the possibility of making new distinctions is one the defining characteristics of qualitative research. It clearly sets it apart from quantitative analysis which works with taken-for-granted variables, albeit as mentioned, meta-analyses, for example, factor analysis may result in new variables. “Quality” refers essentially to distinctions, as already pointed out by Aristotle. He discusses the term “qualitative” commenting: “By a quality I mean that in virtue of which things are said to be qualified somehow” (Aristotle 1984:14). Quality is about what something is or has, which means that the distinction from its environment is crucial. We see qualitative research as a process in which significant new distinctions are made to the scholarly community; to make distinctions is a key aspect of obtaining new knowledge; a point, as we will see, that also has implications for “quantitative research.” The notion of being “significant” is paramount. New distinctions by themselves are not enough; just adding concepts only increases complexity without furthering our knowledge. The significance of new distinctions is judged against the communal knowledge of the research community. To enable this discussion and judgements central elements of rational discussion are required (cf. Habermas [1981] 1987 ; Davidsson [ 1988 ] 2001) to identify what is new and relevant scientific knowledge. Relatedly, Ragin alludes to the idea of new and useful knowledge at a more concrete level: “Qualitative methods are appropriate for in-depth examination of cases because they aid the identification of key features of cases. Most qualitative methods enhance data” (1994:79). When Becker ( 1963 ) studied deviant behavior and investigated how people became marihuana smokers, he made distinctions between the ways in which people learned how to smoke. This is a classic example of how the strategy of “getting close” to the material, for example the text, people or pictures that are subject to analysis, may enable researchers to obtain deeper insight and new knowledge by making distinctions – in this instance on the initial notion of learning how to smoke. Others have stressed the making of distinctions in relation to coding or theorizing. Emerson et al. ( 1995 ), for example, hold that “qualitative coding is a way of opening up avenues of inquiry,” meaning that the researcher identifies and develops concepts and analytic insights through close examination of and reflection on data (Emerson et al. 1995 :151). Goodwin and Horowitz highlight making distinctions in relation to theory-building writing: “Close engagement with their cases typically requires qualitative researchers to adapt existing theories or to make new conceptual distinctions or theoretical arguments to accommodate new data” ( 2002 : 37). In the ideal-typical quantitative research only existing and so to speak, given, variables would be used. If this is the case no new distinction are made. But, would not also many “quantitative” researchers make new distinctions?

Process does not merely suggest that research takes time. It mainly implies that qualitative new knowledge results from a process that involves several phases, and above all iteration. Qualitative research is about oscillation between theory and evidence, analysis and generating material, between first- and second -order constructs (Schütz 1962 :59), between getting in contact with something, finding sources, becoming deeply familiar with a topic, and then distilling and communicating some of its essential features. The main point is that the categories that the researcher uses, and perhaps takes for granted at the beginning of the research process, usually undergo qualitative changes resulting from what is found. Becker describes how he tested hypotheses and let the jargon of the users develop into theoretical concepts. This happens over time while the study is being conducted, exemplifying what we mean by process.

In the research process, a pilot-study may be used to get a first glance of, for example, the field, how to approach it, and what methods can be used, after which the method and theory are chosen or refined before the main study begins. Thus, the empirical material is often central from the start of the project and frequently leads to adjustments by the researcher. Likewise, during the main study categories are not fixed; the empirical material is seen in light of the theory used, but it is also given the opportunity to kick back, thereby resisting attempts to apply theoretical straightjackets (Becker 1970 :43). In this process, coding and analysis are interwoven, and thus are often important steps for getting closer to the phenomenon and deciding what to focus on next. Becker began his research by interviewing musicians close to him, then asking them to refer him to other musicians, and later on doubling his original sample of about 25 to include individuals in other professions (Becker 1973:46). Additionally, he made use of some participant observation, documents, and interviews with opiate users made available to him by colleagues. As his inductive theory of deviance evolved, Becker expanded his sample in order to fine tune it, and test the accuracy and generality of his hypotheses. In addition, he introduced a negative case and discussed the null hypothesis ( 1963 :44). His phasic career model is thus based on a research design that embraces processual work. Typically, process means to move between “theory” and “material” but also to deal with negative cases, and Becker ( 1998 ) describes how discovering these negative cases impacted his research design and ultimately its findings.

Obviously, all research is process-oriented to some degree. The point is that the ideal-typical quantitative process does not imply change of the data, and iteration between data, evidence, hypotheses, empirical work, and theory. The data, quantified variables, are, in most cases fixed. Merging of data, which of course can be done in a quantitative research process, does not mean new data. New hypotheses are frequently tested, but the “raw data is often the “the same.” Obviously, over time new datasets are made available and put into use.

Another characteristic that is emphasized in our sample is that qualitative researchers – and in particular ethnographers – can, or as Goffman put it, ought to ( 1989 ), get closer to the phenomenon being studied and their data than quantitative researchers (for example, Silverman 2009 :85). Put differently, essentially because of their methods qualitative researchers get into direct close contact with those being investigated and/or the material, such as texts, being analyzed. Becker started out his interview study, as we noted, by talking to those he knew in the field of music to get closer to the phenomenon he was studying. By conducting interviews he got even closer. Had he done more observations, he would undoubtedly have got even closer to the field.

Additionally, ethnographers’ design enables researchers to follow the field over time, and the research they do is almost by definition longitudinal, though the time in the field is studied obviously differs between studies. The general characteristic of closeness over time maximizes the chances of unexpected events, new data (related, for example, to archival research as additional sources, and for ethnography for situations not necessarily previously thought of as instrumental – what Mannay and Morgan ( 2015 ) term the “waiting field”), serendipity (Merton and Barber 2004 ; Åkerström 2013 ), and possibly reactivity, as well as the opportunity to observe disrupted patterns that translate into exemplars of negative cases. Two classic examples of this are Becker’s finding of what medical students call “crocks” (Becker et al. 1961 :317), and Geertz’s ( 1973 ) study of “deep play” in Balinese society.

By getting and staying so close to their data – be it pictures, text or humans interacting (Becker was himself a musician) – for a long time, as the research progressively focuses, qualitative researchers are prompted to continually test their hunches, presuppositions and hypotheses. They test them against a reality that often (but certainly not always), and practically, as well as metaphorically, talks back, whether by validating them, or disqualifying their premises – correctly, as well as incorrectly (Fine 2003 ; Becker 1970 ). This testing nonetheless often leads to new directions for the research. Becker, for example, says that he was initially reading psychological theories, but when facing the data he develops a theory that looks at, you may say, everything but psychological dispositions to explain the use of marihuana. Especially researchers involved with ethnographic methods have a fairly unique opportunity to dig up and then test (in a circular, continuous and temporal way) new research questions and findings as the research progresses, and thereby to derive previously unimagined and uncharted distinctions by getting closer to the phenomenon under study.

Let us stress that getting close is by no means restricted to ethnography. The notion of hermeneutic circle and hermeneutics as a general way of understanding implies that we must get close to the details in order to get the big picture. This also means that qualitative researchers can literally also make use of details of pictures as evidence (cf. Harper 2002). Thus, researchers may get closer both when generating the material or when analyzing it.

Quantitative research, we maintain, in the ideal-typical representation cannot get closer to the data. The data is essentially numbers in tables making up the variables (Franzosi 2016 :138). The data may originally have been “qualitative,” but once reduced to numbers there can only be a type of “hermeneutics” about what the number may stand for. The numbers themselves, however, are non-ambiguous. Thus, in quantitative research, interpretation, if done, is not about the data itself—the numbers—but what the numbers stand for. It follows that the interpretation is essentially done in a more “speculative” mode without direct empirical evidence (cf. Becker 2017 ).

Improved Understanding

While distinction, process and getting closer refer to the qualitative work of the researcher, improved understanding refers to its conditions and outcome of this work. Understanding cuts deeper than explanation, which to some may mean a causally verified correlation between variables. The notion of explanation presupposes the notion of understanding since explanation does not include an idea of how knowledge is gained (Manicas 2006 : 15). Understanding, we argue, is the core concept of what we call the outcome of the process when research has made use of all the other elements that were integrated in the research. Understanding, then, has a special status in qualitative research since it refers both to the conditions of knowledge and the outcome of the process. Understanding can to some extent be seen as the condition of explanation and occurs in a process of interpretation, which naturally refers to meaning (Gadamer 1990 ). It is fundamentally connected to knowing, and to the knowing of how to do things (Heidegger [1927] 2001 ). Conceptually the term hermeneutics is used to account for this process. Heidegger ties hermeneutics to human being and not possible to separate from the understanding of being ( 1988 ). Here we use it in a broader sense, and more connected to method in general (cf. Seiffert 1992 ). The abovementioned aspects – for example, “objectivity” and “reflexivity” – of the approach are conditions of scientific understanding. Understanding is the result of a circular process and means that the parts are understood in light of the whole, and vice versa. Understanding presupposes pre-understanding, or in other words, some knowledge of the phenomenon studied. The pre-understanding, even in the form of prejudices, are in qualitative research process, which we see as iterative, questioned, which gradually or suddenly change due to the iteration of data, evidence and concepts. However, qualitative research generates understanding in the iterative process when the researcher gets closer to the data, e.g., by going back and forth between field and analysis in a process that generates new data that changes the evidence, and, ultimately, the findings. Questioning, to ask questions, and put what one assumes—prejudices and presumption—in question, is central to understand something (Heidegger [1927] 2001 ; Gadamer 1990 :368–384). We propose that this iterative process in which the process of understanding occurs is characteristic of qualitative research.

Improved understanding means that we obtain scientific knowledge of something that we as a scholarly community did not know before, or that we get to know something better. It means that we understand more about how parts are related to one another, and to other things we already understand (see also Fine and Hallett 2014 ). Understanding is an important condition for qualitative research. It is not enough to identify correlations, make distinctions, and work in a process in which one gets close to the field or phenomena. Understanding is accomplished when the elements are integrated in an iterative process.

It is, moreover, possible to understand many things, and researchers, just like children, may come to understand new things every day as they engage with the world. This subjective condition of understanding – namely, that a person gains a better understanding of something –is easily met. To be qualified as “scientific,” the understanding must be general and useful to many; it must be public. But even this generally accessible understanding is not enough in order to speak of “scientific understanding.” Though we as a collective can increase understanding of everything in virtually all potential directions as a result also of qualitative work, we refrain from this “objective” way of understanding, which has no means of discriminating between what we gain in understanding. Scientific understanding means that it is deemed relevant from the scientific horizon (compare Schütz 1962 : 35–38, 46, 63), and that it rests on the pre-understanding that the scientists have and must have in order to understand. In other words, the understanding gained must be deemed useful by other researchers, so that they can build on it. We thus see understanding from a pragmatic, rather than a subjective or objective perspective. Improved understanding is related to the question(s) at hand. Understanding, in order to represent an improvement, must be an improvement in relation to the existing body of knowledge of the scientific community (James [ 1907 ] 1955). Scientific understanding is, by definition, collective, as expressed in Weber’s famous note on objectivity, namely that scientific work aims at truths “which … can claim, even for a Chinese, the validity appropriate to an empirical analysis” ([1904] 1949 :59). By qualifying “improved understanding” we argue that it is a general defining characteristic of qualitative research. Becker‘s ( 1966 ) study and other research of deviant behavior increased our understanding of the social learning processes of how individuals start a behavior. And it also added new knowledge about the labeling of deviant behavior as a social process. Few studies, of course, make the same large contribution as Becker’s, but are nonetheless qualitative research.

Understanding in the phenomenological sense, which is a hallmark of qualitative research, we argue, requires meaning and this meaning is derived from the context, and above all the data being analyzed. The ideal-typical quantitative research operates with given variables with different numbers. This type of material is not enough to establish meaning at the level that truly justifies understanding. In other words, many social science explanations offer ideas about correlations or even causal relations, but this does not mean that the meaning at the level of the data analyzed, is understood. This leads us to say that there are indeed many explanations that meet the criteria of understanding, for example the explanation of how one becomes a marihuana smoker presented by Becker. However, we may also understand a phenomenon without explaining it, and we may have potential explanations, or better correlations, that are not really understood.

We may speak more generally of quantitative research and its data to clarify what we see as an important distinction. The “raw data” that quantitative research—as an idealtypical activity, refers to is not available for further analysis; the numbers, once created, are not to be questioned (Franzosi 2016 : 138). If the researcher is to do “more” or “change” something, this will be done by conjectures based on theoretical knowledge or based on the researcher’s lifeworld. Both qualitative and quantitative research is based on the lifeworld, and all researchers use prejudices and pre-understanding in the research process. This idea is present in the works of Heidegger ( 2001 ) and Heisenberg (cited in Franzosi 2010 :619). Qualitative research, as we argued, involves the interaction and questioning of concepts (theory), data, and evidence.

Ragin ( 2004 :22) points out that “a good definition of qualitative research should be inclusive and should emphasize its key strengths and features, not what it lacks (for example, the use of sophisticated quantitative techniques).” We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. Qualitative research, as defined here, is consequently a combination of two criteria: (i) how to do things –namely, generating and analyzing empirical material, in an iterative process in which one gets closer by making distinctions, and (ii) the outcome –improved understanding novel to the scholarly community. Is our definition applicable to our own study? In this study we have closely read the empirical material that we generated, and the novel distinction of the notion “qualitative research” is the outcome of an iterative process in which both deduction and induction were involved, in which we identified the categories that we analyzed. We thus claim to meet the first criteria, “how to do things.” The second criteria cannot be judged but in a partial way by us, namely that the “outcome” —in concrete form the definition-improves our understanding to others in the scientific community.

We have defined qualitative research, or qualitative scientific work, in relation to quantitative scientific work. Given this definition, qualitative research is about questioning the pre-given (taken for granted) variables, but it is thus also about making new distinctions of any type of phenomenon, for example, by coining new concepts, including the identification of new variables. This process, as we have discussed, is carried out in relation to empirical material, previous research, and thus in relation to theory. Theory and previous research cannot be escaped or bracketed. According to hermeneutic principles all scientific work is grounded in the lifeworld, and as social scientists we can thus never fully bracket our pre-understanding.

We have proposed that quantitative research, as an idealtype, is concerned with pre-determined variables (Small 2008 ). Variables are epistemically fixed, but can vary in terms of dimensions, such as frequency or number. Age is an example; as a variable it can take on different numbers. In relation to quantitative research, qualitative research does not reduce its material to number and variables. If this is done the process of comes to a halt, the researcher gets more distanced from her data, and it makes it no longer possible to make new distinctions that increase our understanding. We have above discussed the components of our definition in relation to quantitative research. Our conclusion is that in the research that is called quantitative there are frequent and necessary qualitative elements.

Further, comparative empirical research on researchers primarily working with ”quantitative” approaches and those working with ”qualitative” approaches, we propose, would perhaps show that there are many similarities in practices of these two approaches. This is not to deny dissimilarities, or the different epistemic and ontic presuppositions that may be more or less strongly associated with the two different strands (see Goertz and Mahoney 2012 ). Our point is nonetheless that prejudices and preconceptions about researchers are unproductive, and that as other researchers have argued, differences may be exaggerated (e.g., Becker 1996 : 53, 2017 ; Marchel and Owens 2007 :303; Ragin 1994 ), and that a qualitative dimension is present in both kinds of work.

Several things follow from our findings. The most important result is the relation to quantitative research. In our analysis we have separated qualitative research from quantitative research. The point is not to label individual researchers, methods, projects, or works as either “quantitative” or “qualitative.” By analyzing, i.e., taking apart, the notions of quantitative and qualitative, we hope to have shown the elements of qualitative research. Our definition captures the elements, and how they, when combined in practice, generate understanding. As many of the quotations we have used suggest, one conclusion of our study holds that qualitative approaches are not inherently connected with a specific method. Put differently, none of the methods that are frequently labelled “qualitative,” such as interviews or participant observation, are inherently “qualitative.” What matters, given our definition, is whether one works qualitatively or quantitatively in the research process, until the results are produced. Consequently, our analysis also suggests that those researchers working with what in the literature and in jargon is often called “quantitative research” are almost bound to make use of what we have identified as qualitative elements in any research project. Our findings also suggest that many” quantitative” researchers, at least to some extent, are engaged with qualitative work, such as when research questions are developed, variables are constructed and combined, and hypotheses are formulated. Furthermore, a research project may hover between “qualitative” and “quantitative” or start out as “qualitative” and later move into a “quantitative” (a distinct strategy that is not similar to “mixed methods” or just simply combining induction and deduction). More generally speaking, the categories of “qualitative” and “quantitative,” unfortunately, often cover up practices, and it may lead to “camps” of researchers opposing one another. For example, regardless of the researcher is primarily oriented to “quantitative” or “qualitative” research, the role of theory is neglected (cf. Swedberg 2017 ). Our results open up for an interaction not characterized by differences, but by different emphasis, and similarities.

Let us take two examples to briefly indicate how qualitative elements can fruitfully be combined with quantitative. Franzosi ( 2010 ) has discussed the relations between quantitative and qualitative approaches, and more specifically the relation between words and numbers. He analyzes texts and argues that scientific meaning cannot be reduced to numbers. Put differently, the meaning of the numbers is to be understood by what is taken for granted, and what is part of the lifeworld (Schütz 1962 ). Franzosi shows how one can go about using qualitative and quantitative methods and data to address scientific questions analyzing violence in Italy at the time when fascism was rising (1919–1922). Aspers ( 2006 ) studied the meaning of fashion photographers. He uses an empirical phenomenological approach, and establishes meaning at the level of actors. In a second step this meaning, and the different ideal-typical photographers constructed as a result of participant observation and interviews, are tested using quantitative data from a database; in the first phase to verify the different ideal-types, in the second phase to use these types to establish new knowledge about the types. In both of these cases—and more examples can be found—authors move from qualitative data and try to keep the meaning established when using the quantitative data.

A second main result of our study is that a definition, and we provided one, offers a way for research to clarify, and even evaluate, what is done. Hence, our definition can guide researchers and students, informing them on how to think about concrete research problems they face, and to show what it means to get closer in a process in which new distinctions are made. The definition can also be used to evaluate the results, given that it is a standard of evaluation (cf. Hammersley 2007 ), to see whether new distinctions are made and whether this improves our understanding of what is researched, in addition to the evaluation of how the research was conducted. By making what is qualitative research explicit it becomes easier to communicate findings, and it is thereby much harder to fly under the radar with substandard research since there are standards of evaluation which make it easier to separate “good” from “not so good” qualitative research.

To conclude, our analysis, which ends with a definition of qualitative research can thus both address the “internal” issues of what is qualitative research, and the “external” critiques that make it harder to do qualitative research, to which both pressure from quantitative methods and general changes in society contribute.

Acknowledgements

Financial Support for this research is given by the European Research Council, CEV (263699). The authors are grateful to Susann Krieglsteiner for assistance in collecting the data. The paper has benefitted from the many useful comments by the three reviewers and the editor, comments by members of the Uppsala Laboratory of Economic Sociology, as well as Jukka Gronow, Sebastian Kohl, Marcin Serafin, Richard Swedberg, Anders Vassenden and Turid Rødne.

Biographies

is professor of sociology at the Department of Sociology, Uppsala University and Universität St. Gallen. His main focus is economic sociology, and in particular, markets. He has published numerous articles and books, including Orderly Fashion (Princeton University Press 2010), Markets (Polity Press 2011) and Re-Imagining Economic Sociology (edited with N. Dodd, Oxford University Press 2015). His book Ethnographic Methods (in Swedish) has already gone through several editions.

is associate professor of sociology at the Department of Media and Social Sciences, University of Stavanger. His research has been published in journals such as Social Psychology Quarterly, Sociological Theory, Teaching Sociology, and Music and Arts in Action. As an ethnographer he is working on a book on he social world of big-wave surfing.

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Contributor Information

Patrik Aspers, Email: [email protected] .

Ugo Corte, Email: [email protected] .

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