qualitative research articles in education

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• Published: 08 September 2024

Longitudinal analysis of teacher self-efficacy evolution during a STEAM professional development program: a qualitative case study

• Haozhe Jiang   ORCID: orcid.org/0000-0002-7870-0993 1 ,
• Ritesh Chugh   ORCID: orcid.org/0000-0003-0061-7206 2 ,
• Xuesong Zhai   ORCID: orcid.org/0000-0002-4179-7859 1 , 3   nAff7 ,
• Ke Wang 4 &
• Xiaoqin Wang 5 , 6  

Humanities and Social Sciences Communications volume  11 , Article number:  1162 ( 2024 ) Cite this article

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Despite the widespread advocacy for the integration of arts and humanities (A&H) into science, technology, engineering, and mathematics (STEM) education on an international scale, teachers face numerous obstacles in practically integrating A&H into STEM teaching (IAT). To tackle the challenges, a comprehensive five-stage framework for teacher professional development programs focussed on IAT has been developed. Through the use of a qualitative case study approach, this study outlines the shifts in a participant teacher’s self-efficacy following their exposure to each stage of the framework. The data obtained from interviews and reflective analyses were analyzed using a seven-stage inductive method. The findings have substantiated the significant impact of a teacher professional development program based on the framework on teacher self-efficacy, evident in both individual performance and student outcomes observed over eighteen months. The evolution of teacher self-efficacy in IAT should be regarded as an open and multi-level system, characterized by interactions with teacher knowledge, skills and other entrenched beliefs. Building on our research findings, an enhanced model of teacher professional learning is proposed. The revised model illustrates that professional learning for STEAM teachers should be conceived as a continuous and sustainable process, characterized by the dynamic interaction among teaching performance, teacher knowledge, and teacher beliefs. The updated model further confirms the inseparable link between teacher learning and student learning within STEAM education. This study contributes to the existing body of literature on teacher self-efficacy, teacher professional learning models and the design of IAT teacher professional development programs.

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Introduction.

In the past decade, there has been a surge in the advancement and widespread adoption of Science, Technology, Engineering, and Mathematics (STEM) education on a global scale (Jiang et al. 2021 ; Jiang et al. 2022 ; Jiang et al. 2023 ; Jiang et al. 2024a , b ; Zhan et al. 2023 ; Zhan and Niu 2023 ; Zhong et al. 2022 ; Zhong et al. 2024 ). Concurrently, there has been a growing chorus of advocates urging the integration of Arts and Humanities (A&H) into STEM education (e.g., Alkhabra et al. 2023 ; Land 2020 ; Park and Cho 2022 ; Uştu et al. 2021 ; Vaziri and Bradburn 2021 ). STEM education is frequently characterized by its emphasis on logic and analysis; however, it may be perceived as deficient in emotional and intuitive elements (Ozkan and Umdu Topsakal 2021 ). Through the integration of Arts and Humanities (A&H), the resulting STEAM approach has the potential to become more holistic, incorporating both rationality and emotional intelligence (Ozkan and Umdu Topsakal 2021 ). Many studies have confirmed that A&H can help students increase interest and develop their understanding of the contents in STEM fields, and thus, A&H can attract potential underrepresented STEM learners such as female students and minorities (Land 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ). Despite the increasing interest in STEAM, the approaches to integrating A&H, which represent fundamentally different disciplines, into STEM are theoretically and practically ambiguous (Jacques et al. 2020 ; Uştu et al. 2021 ). Moreover, studies have indicated that the implementation of STEAM poses significant challenges, with STEM educators encountering difficulties in integrating A&H into their teaching practices (e.g., Boice et al. 2021 ; Duong et al. 2024 ; Herro et al. 2019 ; Jacques et al. 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ). Hence, there is a pressing need to provide STEAM teachers with effective professional training.

Motivated by this gap, this study proposes a novel five-stage framework tailored for teacher professional development programs specifically designed to facilitate the integration of A&H into STEM teaching (IAT). Following the establishment of this framework, a series of teacher professional development programs were implemented. To explain the framework, a qualitative case study is employed, focusing on examining a specific teacher professional development program’s impact on a pre-service teacher’s self-efficacy. The case narratives, with a particular focus on the pre-service teacher’s changes in teacher self-efficacy, are organized chronologically, delineating stages before and after each stage of the teacher professional development program. More specifically, meaningful vignettes of the pre-service teacher’s learning and teaching experiences during the teacher professional development program are offered to help understand the five-stage framework. This study contributes to understanding teacher self-efficacy, teacher professional learning model and the design of IAT teacher professional development programs.

Theoretical background

The conceptualization of steam education.

STEM education can be interpreted through various lenses (e.g., Jiang et al. 2021 ; English 2016 ). As Li et al. (2020) claimed, on the one hand, STEM education can be defined as individual STEM disciplinary-based education (i.e., science education, technology education, engineering education and mathematics education). On the other hand, STEM education can also be defined as interdisciplinary or cross-disciplinary education where individual STEM disciplines are integrated (Jiang et al. 2021 ; English 2016 ). In this study, we view it as individual disciplinary-based education separately in science, technology, engineering and mathematics (English 2016 ).

STEAM education emerged as a new pedagogy during the Americans for the Arts-National Policy Roundtable discussion in 2007 (Perignat and Katz-Buonincontro 2019 ). This pedagogy was born out of the necessity to enhance students’ engagement, foster creativity, stimulate innovation, improve problem-solving abilities, and cultivate employability skills such as teamwork, communication and adaptability (Perignat and Katz-Buonincontro 2019 ). In particular, within the framework of STEAM education, the ‘A’ should be viewed as a broad concept that represents arts and humanities (A&H) (Herro and Quigley 2016 ; de la Garza 2021 , Park and Cho 2022 ). This conceptualization emphasizes the need to include humanities subjects alongside arts (Herro and Quigley 2016 ; de la Garza 2021 ; Park and Cho 2022 ). Sanz-Camarero et al. ( 2023 ) listed some important fields of A&H, including physical arts, fine arts, manual arts, sociology, politics, philosophy, history, psychology and so on.

In general, STEM education does not necessarily entail the inclusion of all STEM disciplines collectively (Ozkan and Umdu Topsakal 2021 ), and this principle also applies to STEAM education (Gates 2017 ; Perignat and Katz-Buonincontro 2019 ; Quigley et al. 2017 ; Smith and Paré 2016 ). As an illustration, Smith and Paré ( 2016 ) described a STEAM activity in which pottery (representing A&H) and mathematics were integrated, while other STEAM elements such as science, technology and engineering were not included. In our study, STEAM education is conceptualized as an interdisciplinary approach that involves the integration of one or more components of A&H into one or more STEM school subjects within educational activities (Ozkan and Umdu Topsakal 2021 ; Vaziri and Bradburn 2021 ). Notably, interdisciplinary collaboration entails integrating one or more elements from arts and humanities (A&H) with one or more STEM school subjects, cohesively united by a shared theme while maintaining their distinct identities (Perignat and Katz-Buonincontro 2019 ).

In our teacher professional development programs, we help mathematics, technology, and science pre-service teachers integrate one component of A&H into their disciplinary-based teaching practices. For instance, we help mathematics teachers integrate history (a component of A&H) into mathematics teaching. In other words, in our study, integrating A&H into STEM teaching (IAT) can be defined as integrating one component of A&H into the teaching of one of the STEM school subjects. The components of A&H and the STEM school subject are brought together under a common theme, but each of them remains discrete. Engineering is not taught as an individual subject in the K-12 curriculum in mainland China. Therefore, A&H is not integrated into engineering teaching in our teacher professional development programs.

Self-efficacy and teacher self-efficacy

Self-efficacy was initially introduced by Bandura ( 1977 ) as a key concept within his social cognitive theory. Bandura ( 1997 ) defined self-efficacy as “people’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives” (p. 71). Based on Bandura’s ( 1977 ) theory, Tschannen-Moran et al. ( 1998 ) defined the concept of teacher self-efficacy Footnote 1 as “a teacher’s belief in her or his ability to organize and execute the courses of action required to successfully accomplish a specific teaching task in a particular context” (p. 233). Blonder et al. ( 2014 ) pointed out that this definition implicitly included teachers’ judgment of their ability to bring about desired outcomes in terms of students’ engagement and learning. Moreover, OECD ( 2018 ) defined teacher self-efficacy as “the beliefs that teachers have of their ability to enact certain teaching behavior that influences students’ educational outcomes, such as achievement, interest, and motivation” (p. 51). This definition explicitly included two dimensions: teachers’ judgment of the ability related to their teaching performance (i.e., enacting certain teaching behavior) and their influence on student outcomes.

It is argued that teacher self-efficacy should not be regarded as a general or overarching construct (Zee et al. 2017 ; Zee and Koomen 2016 ). Particularly, in the performance-driven context of China, teachers always connect their beliefs in their professional capabilities with the educational outcomes of their students (Liu et al. 2018 ). Therefore, we operationally conceptualize teacher self-efficacy as having two dimensions: self-efficacy in individual performance and student outcomes (see Table 1 ).

Most importantly, given its consistent association with actual teaching performance and student outcomes (Bray-Clark and Bates 2003 ; Kelley et al. 2020 ), teacher self-efficacy is widely regarded as a pivotal indicator of teacher success (Kelley et al. 2020 ). Moreover, the enhancement of teaching self-efficacy reflects the effectiveness of teacher professional development programs (Bray-Clark and Bates 2003 ; Kelley et al. 2020 ; Wong et al. 2022 ; Zhou et al. 2023 ). For instance, Zhou et al. ( 2023 ) claimed that in STEM teacher education, effective teacher professional development programs should bolster teachers’ self-efficacy “in teaching the content in the STEM discipline” (p. 2).

It has been documented that teachers frequently experience diminished confidence and comfort when teaching subject areas beyond their expertise (Kelley et al. 2020 ; Stohlmann et al. 2012 ). This diminished confidence extends to their self-efficacy in implementing interdisciplinary teaching approaches, such as integrated STEM teaching and IAT (Kelley et al. 2020 ). For instance, Geng et al. ( 2019 ) found that STEM teachers in Hong Kong exhibited low levels of self-efficacy, with only 5.53% of teachers rating their overall self-efficacy in implementing STEM education as higher than a score of 4 out of 5. Additionally, Hunter-Doniger and Sydow ( 2016 ) found that teachers may experience apprehension and lack confidence when incorporating A&H elements into the classroom context, particularly within the framework of IAT. Considering the critical importance of teacher self-efficacy in STEM and STEAM education (Kelley et al. 2020 ; Zakariya, 2020 ; Zhou et al. 2023 ), it is necessary to explore effective measures, frameworks and teacher professional development programs to help teachers improve their self-efficacy regarding interdisciplinary teaching (e.g., IAT).

Teacher professional learning models

The relationship between teachers’ professional learning and students’ outcomes (such as achievements, skills and attitudes) has been a subject of extensive discussion and research for many years (Clarke and Hollingsworth 2002 ). For instance, Clarke and Hollingsworth ( 2002 ) proposed and validated the Interconnected Model of Professional Growth, which illustrates that teacher professional development is influenced by the interaction among four interconnected domains: the personal domain (teacher knowledge, beliefs and attitudes), the domain of practice (professional experimentation), the domain of consequence (salient outcomes), and the external domain (sources of information, stimulus or support). Sancar et al. ( 2021 ) emphasized that teachers’ professional learning or development never occurs independently. In practice, this process is inherently intertwined with many variables, including student outcomes, in various ways (Sancar et al. 2021 ). However, many current teacher professional development programs exclude real in-class teaching and fail to establish a comprehensive link between teachers’ professional learning and student outcomes (Cai et al. 2020 ; Sancar et al. 2021 ). Sancar et al. ( 2021 ) claimed that exploring the complex relationships between teachers’ professional learning and student outcomes should be grounded in monitoring and evaluating real in-class teaching, rather than relying on teachers’ self-assessment. It is essential to understand these relationships from a holistic perspective within the context of real classroom teaching (Sancar et al. 2021 ). However, as Sancar et al. ( 2021 ) pointed out, such efforts in teacher education are often considered inadequate. Furthermore, in the field of STEAM education, such efforts are further exacerbated.

Cai et al. ( 2020 ) proposed a teacher professional learning model where student outcomes are emphasized. This model was developed based on Cai ( 2017 ), Philipp ( 2007 ) and Thompson ( 1992 ). It has also been used and justified in a series of teacher professional development programs (e.g., Calabrese et al. 2024 ; Hwang et al. 2024 ; Marco and Palatnik 2024 ; Örnek and Soylu 2021 ). The model posits that teachers typically increase their knowledge and modify their beliefs through professional teacher learning, subsequently improving their classroom instruction, enhancing teaching performance, and ultimately fostering improved student learning outcomes (Cai et al. 2020 ). Notably, this model can be updated in several aspects. Firstly, prior studies have exhibited the interplay between teacher knowledge and beliefs (e.g., Basckin et al. 2021 ; Taimalu and Luik 2019 ). This indicates that the increase in teacher knowledge and the change in teacher belief may not be parallel. The two processes can be intertwined. Secondly, the Interconnected Model of Professional Growth highlights that the personal domain and the domain of practice are interconnected (Clarke and Hollingsworth 2002 ). Liu et al. ( 2022 ) also confirmed that improvements in classroom instruction may, in turn, influence teacher beliefs. This necessitates a reconsideration of the relationships between classroom instruction, teacher knowledge and teacher beliefs in Cai et al.’s ( 2020 ) model. Thirdly, the Interconnected Model of Professional Growth also exhibits the connections between the domain of consequence and the personal domain (Clarke and Hollingsworth 2002 ). Hence, the improvement of learning outcomes may signify the end of teacher learning. For instance, students’ learning feedback may be a vital source of teacher self-efficacy (Bandura 1977 ). Therefore, the improvement of student outcomes may, in turn, affect teacher beliefs. The aforementioned arguments highlight the need for an updated model that integrates Cai et al.’s ( 2020 ) teacher professional learning model with Clarke and Hollingsworth’s ( 2002 ) Interconnected Model of Professional Growth. This integration may provide a holistic view of the teacher’s professional learning process, especially within the complex contexts of STEAM teacher education.

The framework for teacher professional development programs of integrating arts and humanities into STEM teaching

In this section, we present a framework for IAT teacher professional development programs, aiming to address the practical challenges associated with STEAM teaching implementation. Our framework incorporates the five features of effective teacher professional development programs outlined by Archibald et al. ( 2011 ), Cai et al. ( 2020 ), Darling-Hammond et al. ( 2017 ), Desimone and Garet ( 2015 ) and Roth et al. ( 2017 ). These features include: (a) alignment with shared goals (e.g., school, district, and national policies and practice), (b) emphasis on core content and modeling of teaching strategies for the content, (c) collaboration among teachers within a community, (d) adequate opportunities for active learning of new teaching strategies, and (e) embedded follow-up and continuous feedback. It is worth noting that two concepts, namely community of practice and lesson study, have been incorporated into our framework. Below, we delineate how these features are reflected in our framework.

(a) The Chinese government has issued a series of policies to facilitate STEAM education in K-12 schools (Jiang et al. 2021 ; Li and Chiang 2019 ; Lyu et al. 2024 ; Ro et al. 2022 ). The new curriculum standards released in 2022 mandate that all K-12 teachers implement interdisciplinary teaching, including STEAM education. Our framework for teacher professional development programs, which aims to help teachers integrate A&H into STEM teaching, closely aligns with these national policies and practices supporting STEAM education in K-12 schools.

(b) The core content of the framework is IAT. Specifically, as A&H is a broad concept, we divide it into several subcomponents, such as history, culture, and visual and performing arts (e.g., drama). We are implementing a series of teacher professional development programs to help mathematics, technology and science pre-service teachers integrate these subcomponents of A&H into their teaching Footnote 2 . Notably, pre-service teachers often lack teaching experience, making it challenging to master and implement new teaching strategies. Therefore, our framework provides five step-by-step stages designed to help them effectively model the teaching strategies of IAT.

(c) Our framework advocates for collaboration among teachers within a community of practice. Specifically, a community of practice is “a group of people who share an interest in a domain of human endeavor and engage in a process of collective learning that creates bonds between them” (Wenger et al. 2002 , p. 1). A teacher community of practice can be considered a group of teachers “sharing and critically observing their practices in growth-promoting ways” (Näykki et al. 2021 , p. 497). Long et al. ( 2021 ) claimed that in a teacher community of practice, members collaboratively share their teaching experiences and work together to address teaching problems. Our community of practice includes three types of members. (1) Mentors: These are professors and experts with rich experience in helping pre-service teachers practice IAT. (2) Pre-service teachers: Few have teaching experience before the teacher professional development programs. (3) In-service teachers: All in-service teachers are senior teachers with rich teaching experience. All the members work closely together to share and improve their IAT practice. Moreover, our community includes not only mentors and in-service teachers but also pre-service teachers. We encourage pre-service teachers to collaborate with experienced in-service teachers in various ways, such as developing IAT lesson plans, writing IAT case reports and so on. In-service teachers can provide cognitive and emotional support and share their practical knowledge and experience, which may significantly benefit the professional growth of pre-service teachers (Alwafi et al. 2020 ).

(d) Our framework offers pre-service teachers various opportunities to engage in lesson study, allowing them to actively design and implement IAT lessons. Based on the key points of effective lesson study outlined by Akiba et al. ( 2019 ), Ding et al. ( 2024 ), and Takahashi and McDougal ( 2016 ), our lesson study incorporates the following seven features. (1) Study of IAT materials: Pre-service teachers are required to study relevant IAT materials under the guidance of mentors. (2) Collaboration on lesson proposals: Pre-service teachers should collaborate with in-service teachers to develop comprehensive lesson proposals. (3) Observation and data collection: During the lesson, pre-service teachers are required to carefully observe and collect data on student learning and development. (4) Reflection and analysis: Pre-service teachers use the collected data to reflect on the lesson and their teaching effects. (5) Lesson revision and reteaching: If needed, pre-service teachers revise and reteach the lesson based on their reflections and data analysis. (6) Mentor and experienced in-service teacher involvement: Mentors and experienced in-service teachers, as knowledgeable others, are involved throughout the lesson study process. (7) Collaboration on reporting: Pre-service teachers collaborate with in-service teachers to draft reports and disseminate the results of the lesson study. Specifically, recognizing that pre-service teachers often lack teaching experience, we do not require them to complete all the steps of lesson study independently at once. Instead, we guide them through the lesson study process in a step-by-step manner, allowing them to gradually build their IAT skills and confidence. For instance, in Stage 1, pre-service teachers primarily focus on studying IAT materials. In Stage 2, they develop lesson proposals, observe and collect data, and draft reports. However, the implementation of IAT lessons is carried out by in-service teachers. This approach prevents pre-service teachers from experiencing failures due to their lack of teaching experience. In Stage 3, pre-service teachers implement, revise, and reteach IAT lessons, experiencing the lesson study process within a simulated environment. In Stage 4, pre-service teachers engage in lesson study in an actual classroom environment. However, their focus is limited to one micro-course during each lesson study session. It is not until the fifth stage that they experience a complete lesson study in an actual classroom environment.

(e) Our teacher professional development programs incorporate assessments specifically designed to evaluate pre-service teachers’ IAT practices. We use formative assessments to measure their understanding and application of IAT strategies. Pre-service teachers receive ongoing and timely feedback from peers, mentors, in-service teachers, and students, which helps them continuously refine their IAT practices throughout the program. Recognizing that pre-service teachers often have limited contact with real students and may not fully understand students’ learning needs, processes and outcomes, our framework requires them to actively collect and analyze student feedback. By doing so, they can make informed improvements to their instructional practice based on student feedback.

After undergoing three rounds of theoretical and practical testing and revision over the past five years, we have successfully finalized the optimization of the framework design (Zhou 2021 ). Throughout each cycle, we collected feedback from both participants and researchers on at least three occasions. Subsequently, we analyzed this feedback and iteratively refined the framework. For example, we enlisted the participation of in-service teachers to enhance the implementation of STEAM teaching, extended practice time through micro-teaching sessions, and introduced a stage of micro-course development within the framework to provide more opportunities for pre-service teachers to engage with real teaching situations. In this process, we continuously improved the coherence between each stage of the framework, ensuring that they mutually complement one another. The five-stage framework is described as follows.

Stage 1 Literature study

Pre-service teachers are provided with a series of reading materials from A&H. On a weekly basis, two pre-service teachers are assigned to present their readings and reflections to the entire group, followed by critical discussions thereafter. Mentors and all pre-service teachers discuss and explore strategies for translating the original A&H materials into viable instructional resources suitable for classroom use. Subsequently, pre-service teachers select topics of personal interest for further study under mentor guidance.

Stage 2 Case learning

Given that pre-service teachers have no teaching experience, collaborative efforts between in-service teachers and pre-service teachers are undertaken to design IAT lesson plans. Subsequently, the in-service teachers implement these plans. Throughout this process, pre-service teachers are afforded opportunities to engage in lesson plan implementation. Figure 1 illustrates the role of pre-service teachers in case learning. In the first step, pre-service teachers read about materials related to A&H, select suitable materials, and report their ideas on IAT lesson design to mentors, in-service teachers, and fellow pre-service teachers.

Note: A&H refers to arts and humanities.

In the second step, they liaise with the in-service teachers responsible for implementing the lesson plan, discussing the integration of A&H into teaching practices. Pre-service teachers then analyze student learning objectives aligned with curriculum standards, collaboratively designing the IAT lesson plan with in-service teachers. Subsequently, pre-service teachers present lesson plans for feedback from mentors and other in-service teachers.

In the third step, pre-service teachers observe the lesson plan’s implementation, gathering and analyzing feedback from students and in-service teachers using an inductive approach (Merriam 1998 ). Feedback includes opinions on the roles and values of A&H, perceptions of the teaching effect, and recommendations for lesson plan implementation and modification. The second and third steps may iterate multiple times to refine the IAT lesson plan. In the fourth step, pre-service teachers consolidate all data, including various versions of teaching instructions, classroom videos, feedback, and discussion notes, composing reflection notes. Finally, pre-service teachers collaborate with in-service teachers to compile the IAT case report and submit it for publication.

Stage 3 Micro-teaching

Figure 2 illustrates the role of pre-service teachers in micro-teaching. Before entering the micro-classrooms Footnote 3 , all the discussions and communications occur within the pre-service teacher group, excluding mentors and in-service teachers. After designing the IAT lesson plan, pre-service teachers take turns implementing 40-min lesson plans in a simulated micro-classroom setting. Within this simulated environment, one pre-service teacher acts as the teacher, while others, including mentors, in-service teachers, and other fellow pre-service teachers, assume the role of students Footnote 4 . Following the simulated teaching, the implementer reviews the video of their session and self-assesses their performance. Subsequently, the implementer receives feedback from other pre-service teachers, mentors, and in-service teachers. Based on this feedback, the implementer revisits steps 2 and 3, revising the lesson plan and conducting the simulated teaching again. This iterative process typically repeats at least three times until the mentors, in-service teachers, and other pre-service teachers are satisfied with the implementation of the revised lesson plan. Finally, pre-service teachers complete reflection notes and submit a summary of their reflections on the micro-teaching experience. Each pre-service teacher is required to choose at least three topics and undergo at least nine simulated teaching sessions.

Stage 4 Micro-course development

While pre-service teachers may not have the opportunity to execute the whole lesson plans in real classrooms, they can design and create five-minute micro-courses Footnote 5 before class, subsequently presenting these videos to actual students. The process of developing micro-courses closely mirrors that of developing IAT cases in the case learning stage (see Fig. 1 ). However, in Step 3, pre-service teachers assume dual roles, not only as observers of IAT lesson implementation but also as implementers of a five-minute IAT micro-course.

Stage 5 Classroom teaching

Pre-service teachers undertake the implementation of IAT lesson plans independently, a process resembling micro-teaching (see Fig. 2 ). However, pre-service teachers engage with real school students in partner schools Footnote 6 instead of simulated classrooms. Furthermore, they collect feedback not only from the mentors, in-service teachers, and fellow pre-service teachers but also from real students.

To provide our readers with a better understanding of the framework, we provide meaningful vignettes of a pre-service teacher’s learning and teaching experiences in one of the teacher professional development programs based on the framework. In addition, we choose teacher self-efficacy as an indicator to assess the framework’s effectiveness, detailing the pre-service teacher’s changes in teacher self-efficacy.

Research design

Research method.

Teacher self-efficacy can be measured both quantitatively and qualitatively (Bandura 1986 , 1997 ; Lee and Bobko 1994 ; Soprano and Yang 2013 ; Unfried et al. 2022 ). However, researchers and theorists in the area of teacher self-efficacy have called for more qualitative and longitudinal studies (Klassen et al. 2011 ). As some critiques stated, most studies were based on correlational and cross-sectional data obtained from self-report surveys, and qualitative studies of teacher efficacy were overwhelmingly neglected (Henson 2002 ; Klassen et al. 2011 ; Tschannen-Moran et al. 1998 ; Xenofontos and Andrews 2020 ). There is an urgent need for more longitudinal studies to shed light on the development of teacher efficacy (Klassen et al. 2011 ; Xenofontos and Andrews 2020 ).

This study utilized a longitudinal qualitative case study methodology to delve deeply into the context (Jiang et al. 2021 ; Corden and Millar 2007 ; Dicks et al. 2023 ; Henderson et al. 2012 ; Matusovich et al. 2010 ; Shirani and Henwood 2011 ), presenting details grounded in real-life situations and analyzing the inner relationships rather than generalize findings about the change of a large group of pre-service teachers’ self-efficacy.

Participant

This study forms a component of a broader multi-case research initiative examining teachers’ professional learning in the STEAM teacher professional development programs in China (Jiang et al. 2021 ; Wang et al. 2018 ; Wang et al. 2024 ). Within this context, one participant, Shuitao (pseudonym), is selected and reported in this current study. Shuitao was a first-year graduate student at a first-tier Normal university in Shanghai, China. Normal universities specialize in teacher education. Her graduate major was mathematics curriculum and instruction. Teaching practice courses are offered to students in this major exclusively during their third year of study. The selection of Shuitao was driven by three primary factors. Firstly, Shuitao attended the entire teacher professional development program and actively engaged in nearly all associated activities. Table 2 illustrates the timeline of the five stages in which Shuitao was involved. Secondly, her undergraduate major was applied mathematics, which was not related to mathematics teaching Footnote 7 . She possessed no prior teaching experience and had not undergone any systematic study of IAT before her involvement in the teacher professional development program. Thirdly, her other master’s courses during her first two years of study focused on mathematics education theory and did not include IAT Footnote 8 . Additionally, she scarcely participated in any other teaching practice outside of the teacher professional development program. As a pre-service teacher, Shuitao harbored a keen interest in IAT. Furthermore, she discovered that she possessed fewer teaching skills compared to her peers who had majored in education during their undergraduate studies. Hence, she had a strong desire to enhance her teaching skills. Consequently, Shuitao decided to participate in our teacher professional development program.

Shuitao was grouped with three other first-year graduate students during the teacher professional development program. She actively collaborated with them at every stage of the program. For instance, they advised each other on their IAT lesson designs, observed each other’s IAT practice and offered constructive suggestions for improvement.

Research question

Shuitao was a mathematics pre-service teacher who participated in one of our teacher professional development programs, focusing on integrating history into mathematics teaching (IHT) Footnote 9 . Notably, this teacher professional development program was designed based on our five-stage framework for teacher professional development programs of IAT. To examine the impact of this teacher professional development program on Shuitao’s self-efficacy related to IHT, this case study addresses the following research question:

What changes in Shuitao’s self-efficacy in individual performance regarding integrating history into mathematics teaching (SE-IHT-IP) may occur through participation in the teacher professional development program?

What changes in Shuitao’s self-efficacy in student outcomes regarding integrating history into mathematics teaching (SE-IHT-SO) may occur through participation in the teacher professional development program?

Data collection and analysis

Before Shuitao joined the teacher professional development program, a one-hour preliminary interview was conducted to guide her in self-narrating her psychological and cognitive state of IHT.

During the teacher professional development program, follow-up unstructured interviews were conducted once a month with Shuitao. All discussions in the development of IHT cases were recorded, Shuitao’s teaching and micro-teaching were videotaped, and the reflection notes, journals, and summary reports written by Shuitao were collected.

After completing the teacher professional development program, Shuitao participated in a semi-structured three-hour interview. The objectives of this interview were twofold: to reassess her self-efficacy and to explore the relationship between her self-efficacy changes and each stage of the teacher professional development program.

Interview data, discussions, reflection notes, journals, summary reports and videos, and analysis records were archived and transcribed before, during, and after the teacher professional development program.

In this study, we primarily utilized data from seven interviews: one conducted before the teacher professional development program, five conducted after each stage of the program, and one conducted upon completion of the program. Additionally, we reviewed Shuitao’s five reflective notes, which were written after each stage, as well as her final summary report that encompassed the entire teacher professional development program.

Merriam’s ( 1998 ) approach to coding data and inductive approach to retrieving possible concepts and themes were employed using a seven-stage method. Considering theoretical underpinnings in qualitative research is common when interpreting data (Strauss and Corbin 1990 ). First, a list based on our conceptual framework of teacher self-efficacy (see Table 1 ) was developed. The list included two codes (i.e., SE-IHT-IP and SE-IHT-SO). Second, all data were sorted chronologically, read and reread to be better understood. Third, texts were coded into multi-colored highlighting and comment balloons. Fourth, the data for groups of meanings, themes, and behaviors were examined. How these groups were connected within the conceptual framework of teacher self-efficacy was confirmed. Fifth, after comparing, confirming, and modifying, the selective codes were extracted and mapped onto the two categories according to the conceptual framework of teacher self-efficacy. Accordingly, changes in SE-IHT-IP and SE-IHT-SO at the five stages of the teacher professional development program were identified, respectively, and then the preliminary findings came (Strauss and Corbin 1990 ). In reality, in Shuitao’s narratives, SE-IHT-IP and SE-IHT-SO were frequently intertwined. Through our coding process, we differentiated between SE-IHT-IP and SE-IHT-SO, enabling us to obtain a more distinct understanding of how these two aspects of teacher self-efficacy evolved over time. This helped us address the two research questions effectively.

Reliability and validity

Two researchers independently analyzed the data to establish inter-rater reliability. The inter-rater reliability was established as kappa = 0.959. Stake ( 1995 ) suggested that the most critical assertions in a study require the greatest effort toward confirmation. In this study, three methods served this purpose and helped ensure the validity of the findings. The first way to substantiate the statement about the changes in self-efficacy was by revisiting each transcript to confirm whether the participant explicitly acknowledged the changes (Yin 2003 ). Such a check was repeated in the analysis of this study. The second way to confirm patterns in the data was by examining whether Shuitao’s statements were replicated in separate interviews (Morris and Usher 2011 ). The third approach involved presenting the preliminary conclusions to Shuitao and affording her the opportunity to provide feedback on the data and conclusions. This step aimed to ascertain whether we accurately grasped the true intentions of her statements and whether our subjective interpretations inadvertently influenced our analysis of her statements. Additionally, data from diverse sources underwent analysis by at least two researchers, with all researchers reaching consensus on each finding.

As each stage of our teacher professional development programs spanned a minimum of three months, numerous documented statements regarding the enhancement of Shuitao’s self-efficacy regarding IHT were recorded. Notably, what we present here offers only a concise overview of findings derived from our qualitative analysis. The changes in Shuitao’s SE-IHT-IP and SE-IHT-SO are organized chronologically, delineating the period before and during the teacher professional development program.

Before the teacher professional development program: “I have no confidence in IHT”

Before the teacher professional development program, Shuitao frequently expressed her lack of confidence in IHT. On the one hand, Shuitao expressed considerable apprehension about her individual performance in IHT. “How can I design and implement IHT lesson plans? I do not know anything [about it]…” With a sense of doubt, confusion and anxiety, Shuitao voiced her lack of confidence in her ability to design and implement an IHT case that would meet the requirements of the curriculum standards. Regarding the reasons for her lack of confidence, Shuitao attributed it to her insufficient theoretical knowledge and practical experience in IHT:

I do not know the basic approaches to IHT that I could follow… it is very difficult for me to find suitable historical materials… I am very confused about how to organize [historical] materials logically around the teaching goals and contents… [Furthermore,] I am [a] novice, [and] I have no IHT experience.

On the other hand, Shuitao articulated very low confidence in the efficacy of her IHT on student outcomes:

I think my IHT will have a limited impact on student outcomes… I do not know any specific effects [of history] other than making students interested in mathematics… In fact, I always think it is difficult for [my] students to understand the history… If students cannot understand [the history], will they feel bored?

This statement suggests that Shuitao did not fully grasp the significance of IHT. In fact, she knew little about the educational significance of history for students, and she harbored no belief that her IHT approach could positively impact students. In sum, her SE-IHT-SO was very low.

After stage 1: “I can do well in the first step of IHT”

After Stage 1, Shuitao indicated a slight improvement in her confidence in IHT. She attributed this improvement to her acquisition of theoretical knowledge in IHT, the approaches for selecting history-related materials, and an understanding of the educational value of history.

One of Shuitao’s primary concerns about implementing IHT before the teacher professional development program was the challenge of sourcing suitable history-related materials. However, after Stage 1, Shuitao explicitly affirmed her capability in this aspect. She shared her experience of organizing history-related materials related to logarithms as an example.

Recognizing the significance of suitable history-related materials in effective IHT implementation, Shuitao acknowledged that conducting literature studies significantly contributed to enhancing her confidence in undertaking this initial step. Furthermore, she expressed increased confidence in designing IHT lesson plans by utilizing history-related materials aligned with teaching objectives derived from the curriculum standards. In other words, her SE-IHT-IP was enhanced. She said:

After experiencing multiple discussions, I gradually know more about what kinds of materials are essential and should be emphasized, what kinds of materials should be adapted, and what kinds of materials should be omitted in the classroom instructions… I have a little confidence to implement IHT that could meet the requirements [of the curriculum standards] since now I can complete the critical first step [of IHT] well…

However, despite the improvement in her confidence in IHT following Stage 1, Shuitao also expressed some concerns. She articulated uncertainty regarding her performance in the subsequent stages of the teacher professional development program. Consequently, her confidence in IHT experienced only a modest increase.

After stage 2: “I participate in the development of IHT cases, and my confidence is increased a little bit more”

Following Stage 2, Shuitao reported further increased confidence in IHT. She attributed this growth to two main factors. Firstly, she successfully developed several instructional designs for IHT through collaboration with in-service teachers. These collaborative experiences enabled her to gain a deeper understanding of IHT approaches and enhance her pedagogical content knowledge in this area, consequently bolstering her confidence in her ability to perform effectively. Secondly, Shuitao observed the tangible impact of IHT cases on students in real classroom settings, which reinforced her belief in the efficacy of IHT. These experiences instilled in her a greater sense of confidence in her capacity to positively influence her students through her implementation of IHT. Shuitao remarked that she gradually understood how to integrate suitable history-related materials into her instructional designs (e.g., employ a genetic approach Footnote 10 ), considering it as the second important step of IHT. She shared her experience of developing IHT instructional design on the concept of logarithms. After creating several iterations of IHT instructional designs, Shuitao emphasized that her confidence in SE-IHT-IP has strengthened. She expressed belief in her ability to apply these approaches to IHT, as well as the pedagogical content knowledge of IHT, acquired through practical experience, in her future teaching endeavors. The following is an excerpt from the interview:

I learned some effective knowledge, skills, techniques and approaches [to IHT]… By employing these approaches, I thought I could [and] I had the confidence to integrate the history into instructional designs very well… For instance, [inspired] by the genetic approach, we designed a series of questions and tasks based on the history of logarithms. The introduction of the new concept of logarithms became very natural, and it perfectly met the requirements of our curriculum standards, [which] asked students to understand the necessity of learning the concept of logarithms…

Shuitao actively observed the classroom teaching conducted by her cooperating in-service teacher. She helped her cooperating in-service teacher in collecting and analyzing students’ feedback. Subsequently, discussions ensued on how to improve the instructional designs based on this feedback. The refined IHT instructional designs were subsequently re-implemented by the in-service teacher. After three rounds of developing IHT cases, Shuitao became increasingly convinced of the significance and efficacy of integrating history into teaching practices, as evidenced by the following excerpt:

The impacts of IHT on students are visible… For instance, more than 93% of the students mentioned in the open-ended questionnaires that they became more interested in mathematics because of the [historical] story of Napier… For another example, according to the results of our surveys, more than 75% of the students stated that they knew log a ( M  +  N ) = log a M  × log a N was wrong because of history… I have a little bit more confidence in the effects of my IHT on students.

This excerpt highlights that Shuitao’s SE-IHT-SO was enhanced. She attributed this enhancement to her realization of the compelling nature of history and her belief in her ability to effectively leverage its power to positively influence her students’ cognitive and emotional development. This also underscores the importance of reinforcing pre-service teachers’ awareness of the significance of history. Nonetheless, Shuiato elucidated that she still retained concerns regarding the effectiveness of her IHT implementation. Her following statement shed light on why her self-efficacy only experienced a marginal increase in this stage:

Knowing how to do it successfully and doing it successfully in practice are two totally different things… I can develop IHT instructional designs well, but I have no idea whether I can implement them well and whether I can introduce the history professionally in practice… My cooperation in-service teacher has a long history of teaching mathematics and gains rich experience in educational practices… If I cannot acquire some required teaching skills and capabilities, I still cannot influence my students powerfully.

After stage 3: “Practice makes perfect, and my SE-IHT-IP is steadily enhanced after a hit”

After successfully developing IHT instructional designs, the next critical step was the implementation of these designs. Drawing from her observations of her cooperating in-service teachers’ IHT implementations and discussions with other pre-service teachers, Shuitao developed her own IHT lesson plans. In Stage 3, she conducted simulated teaching sessions and evaluated her teaching performance ten times Footnote 11 . Shuitao claimed that her SE-IHT-IP steadily improved over the course of these sessions. According to Shuitao, two main processes in Stage 3 facilitated this steady enhancement of SE-IHT-IP.

On the one hand, through the repeated implementation of simulated teaching sessions, Shuitao’s teaching proficiency and fluency markedly improved. Shuitao first described the importance of teaching proficiency and fluency:

Since the detailed history is not included in our curriculum standards and textbooks, if I use my historical materials in class, I have to teach more contents than traditional teachers. Therefore, I have to teach proficiently so that teaching pace becomes a little faster than usual… I have to teach fluently so as to use each minute efficiently in my class. Otherwise, I cannot complete the teaching tasks required [by curriculum standards].

As Shuitao said, at the beginning of Stage 3, her self-efficacy even decreased because she lacked teaching proficiency and fluency and was unable to complete the required teaching tasks:

In the first few times of simulated teaching, I always needed to think for a second about what I should say next when I finish one sentence. I also felt very nervous when I stood in the front of the classrooms. This made my narration of the historical story between Briggs and Napier not fluent at all. I paused many times to look for some hints on my notes… All these made me unable to complete the required teaching tasks… My [teaching] confidence took a hit.

Shuitao quoted the proverb, “practice makes perfect”, and she emphasized that it was repeated practice that improved her teaching proficiency and fluency:

I thought I had no other choice but to practice IHT repeatedly… [At the end of Stage 3,] I could naturally remember most words that I should say when teaching the topics that I selected… My teaching proficiency and fluency was improved through my repeated review of my instructional designs and implementation of IHT in the micro-classrooms… With the improvement [of my teaching proficiency and fluency], I could complete the teaching tasks, and my confidence was increased as well.

In addition, Shuitao also mentioned that through this kind of self-exploration in simulated teaching practice, her teaching skills and capabilities (e.g., blackboard writing, abilities of language organization abilities, etc.) improved. This process was of great help to her enhancement of SE-IHT-IP.

On the other hand, Shuitao’s simulated teaching underwent assessment by herself, with mentors, in-service teachers and fellow pre-service teachers. This comprehensive evaluation process played a pivotal role in enhancing her individual performance and self-efficacy. Reflecting on this aspect, Shuitao articulated the following sentiments in one of her reflection reports:

By watching the videos, conducting self-assessment, and collecting feedback from others, I can understand what I should improve or emphasize in my teaching. [Then,] I think my IHT can better meet the requirements [of curriculum standards]… I think my teaching performance is getting better and better.

After stage 4: “My micro-courses influenced students positively, and my SE-IHT-SO is steadily enhanced”

In Stage 4, Shuitao commenced by creating 5-min micro-course videos. Subsequently, she played these videos in her cooperating in-service teachers’ authentic classroom settings and collected student feedback. This micro-course was played at the end of her cooperating in-service teachers’ lesson Footnote 12 . Shuitao wrote in her reflections that this micro-course of logarithms helped students better understand the nature of mathematics:

According to the results of our surveys, many students stated that they knew the development and evolution of the concept of logarithms is a long process and many mathematicians from different countries have contributed to the development of the concept of logarithms… This indicated that my micro-course helped students better understand the nature of mathematics… My micro-course about the history informed students that mathematics is an evolving and human subject and helped them understand the dynamic development of the [mathematics] concept…

Meanwhile, Shuitao’s micro-course positively influenced some students’ beliefs towards mathematics. As evident from the quote below, integrating historical context into mathematics teaching transformed students’ perception of the subject, boosting Shuitao’s confidence too.

Some students’ responses were very exciting… [O]ne [typical] response stated, he always regarded mathematics as abstract, boring, and dreadful subject; but after seeing the photos of mathematicians and great men and learning the development of the concept of logarithms through the micro-course, he found mathematics could be interesting. He wanted to learn more the interesting history… Students’ such changes made me confident.

Furthermore, during post-class interviews, several students expressed their recognition of the significance of the logarithms concept to Shuitao, attributing this realization to the insights provided by prominent figures in the micro-courses. They also conveyed their intention to exert greater effort in mastering the subject matter. This feedback made Shuitao believe that her IHT had the potential to positively influence students’ attitudes towards learning mathematics.

In summary, Stage 4 marked Shuitao’s first opportunity to directly impact students through her IHT in authentic classroom settings. Despite implementing only brief 5-min micro-courses integrating history during each session, the effectiveness of her short IHT implementation was validated by student feedback. Shuitao unequivocally expressed that students actively engaged with her micro-courses and that these sessions positively influenced them, including attitudes and motivation toward mathematics learning, understanding of mathematics concepts, and beliefs regarding mathematics. These collective factors contributed to a steady enhancement of her confidence in SE-IHT-SO.

After stage 5: “My overall self-efficacy is greatly enhanced”

Following Stage 5, Shuitao reported a significant increase in her overall confidence in IHT, attributing it to gaining mastery through successful implementations of IHT in real classroom settings. On the one hand, Shuitao successfully designed and executed her IHT lesson plans, consistently achieving the teaching objectives mandated by curriculum standards. This significantly enhanced her SE-IHT-IP. On the other hand, as Shuitao’s IHT implementation directly influenced her students, her confidence in SE-IHT-SO experienced considerable improvement.

According to Bandura ( 1997 ), mastery experience is the most powerful source of self-efficacy. Shuitao’s statements confirmed this. As she claimed, her enhanced SE-IHT-IP in Stage 5 mainly came from the experience of successful implementations of IHT in real classrooms:

[Before the teacher professional development program,] I had no idea about implementing IHT… Now, I successfully implemented IHT in senior high school [classrooms] many times… I can complete the teaching tasks and even better completed the teaching objectives required [by the curriculum standards]… The successful experience greatly enhances my confidence to perform well in my future implementation of IHT… Yeah, I think the successful teaching practice experience is the strongest booster of my confidence.

At the end of stage 5, Shuitao’s mentors and in-service teachers gave her a high evaluation. For instance, after Shuitao’s IHT implementation of the concept of logarithms, all mentors and in-service teachers consistently provided feedback that her IHT teaching illustrated the necessity of learning the concept of logarithms and met the requirements of the curriculum standards very well. This kind of verbal persuasion (Bandura 1997 ) enhanced her SE-IHT-IP.

Similarly, Shuitao’s successful experience of influencing students positively through IHT, as one kind of mastery experience, powerfully enhanced her SE-IHT-SO. She described her changes in SE-IHT-SO as follows:

I could not imagine my IHT could be so influential [before]… But now, my IHT implementation directly influenced students in so many aspects… When I witnessed students’ real changes in various cognitive and affective aspects, my confidence was greatly improved.

Shuitao described the influence of her IHT implementation of the concept of logarithms on her students. The depiction is grounded in the outcomes of surveys conducted by Shuitao following her implementation. Shuitao asserted that these results filled her with excitement and confidence regarding her future implementation of IHT.

In summary, following Stage 5 of the teacher professional development program, Shuitao experienced a notable enhancement in her overall self-efficacy, primarily attributed to her successful practical experience in authentic classroom settings during this stage.

A primary objective of our teacher professional development programs is to equip pre-service teachers with the skills and confidence needed to effectively implement IAT. Our findings show that one teacher professional development program, significantly augmented a participant’s TSE-IHT across two dimensions: individual performance and student outcomes. Considering the pressing need to provide STEAM teachers with effective professional training (e.g., Boice et al. 2021 ; Duong et al. 2024 ; Herro et al. 2019 ; Jacques et al. 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ), the proposed five-stage framework holds significant promise in both theoretical and practical realms. Furthermore, this study offers a viable solution to address the prevalent issue of low levels of teacher self-efficacy in interdisciplinary teaching, including IAT, which is critical in STEAM education (Zhou et al. 2023 ). This study holds the potential to make unique contributions to the existing body of literature on teacher self-efficacy, teacher professional learning models and the design of teacher professional development programs of IAT.

Firstly, this study enhances our understanding of the development of teacher self-efficacy. Our findings further confirm the complexity of the development of teacher self-efficacy. On the one hand, the observed enhancement of the participant’s teacher self-efficacy did not occur swiftly but unfolded gradually through a protracted, incremental process. Moreover, it is noteworthy that the participant’s self-efficacy exhibited fluctuations, underscoring that the augmentation of teacher self-efficacy is neither straightforward nor linear. On the other hand, the study elucidated that the augmentation of teacher self-efficacy constitutes an intricate, multi-level system that interacts with teacher knowledge, skills, and other beliefs. This finding resonates with prior research on teacher self-efficacy (Morris et al. 2017 ; Xenofontos and Andrews 2020 ). For example, our study revealed that Shuitao’s enhancement of SE-IHT-SO may always be interwoven with her continuous comprehension of the significance of the A&H in classroom settings. Similarly, the participant progressively acknowledged the educational value of A&H in classroom contexts in tandem with the stepwise enhancement of SE-IHT-SO. Factors such as the participant’s pedagogical content knowledge of IHT, instructional design, and teaching skills were also identified as pivotal components of SE-IHT-IP. This finding corroborates Morris and Usher ( 2011 ) assertion that sustained improvements in self-efficacy stem from developing teachers’ skills and knowledge. With the bolstering of SE-IHT-IP, the participant’s related teaching skills and content knowledge also exhibited improvement.

Methodologically, many researchers advocate for qualitative investigations into self-efficacy (e.g., Philippou and Pantziara 2015; Klassen et al. 2011 ; Wyatt 2015 ; Xenofontos and Andrews 2020 ). While acknowledging limitations in sample scope and the generalizability of the findings, this study offers a longitudinal perspective on the stage-by-stage development of teacher self-efficacy and its interactions with different factors (i.e., teacher knowledge, skills, and beliefs), often ignored by quantitative studies. Considering that studies of self-efficacy have been predominantly quantitative, typically drawing on survey techniques and pre-determined scales (Xenofontos and Andrews, 2020 ; Zhou et al. 2023 ), this study highlights the need for greater attention to qualitative studies so that more cultural, situational and contextual factors in the development of self-efficacy can be captured.

Our study provides valuable practical implications for enhancing pre-service teachers’ self-efficacy. We conceptualize teacher self-efficacy in two primary dimensions: individual performance and student outcomes. On the one hand, pre-service teachers can enhance their teaching qualities, boosting their self-efficacy in individual performance. The adage “practice makes perfect” underscores the necessity of ample teaching practice opportunities for pre-service teachers who lack prior teaching experience. Engaging in consistent and reflective practice helps them develop confidence in their teaching qualities. On the other hand, pre-service teachers should focus on positive feedback from their students, reinforcing their self-efficacy in individual performance. Positive student feedback serves as an affirmation of their teaching effectiveness and encourages continuous improvement. Furthermore, our findings highlight the significance of mentors’ and peers’ positive feedback as critical sources of teacher self-efficacy. Mentors and peers play a pivotal role in the professional growth of pre-service teachers by actively encouraging them and recognizing their teaching achievements. Constructive feedback from experienced mentors and supportive peers fosters a collaborative learning environment and bolsters the self-confidence of pre-service teachers. Additionally, our research indicates that pre-service teachers’ self-efficacy may fluctuate. Therefore, mentors should be prepared to help pre-service teachers manage teaching challenges and setbacks, and alleviate any teaching-related anxiety. Mentors can help pre-service teachers build resilience and maintain a positive outlook on their teaching journey through emotional support and guidance. Moreover, a strong correlation exists between teacher self-efficacy and teacher knowledge and skills. Enhancing pre-service teachers’ knowledge base and instructional skills is crucial for bolstering their overall self-efficacy.

Secondly, this study also responds to the appeal to understand teachers’ professional learning from a holistic perspective and interrelate teachers’ professional learning process with student outcome variables (Sancar et al. 2021 ), and thus contributes to the understanding of the complexity of STEAM teachers’ professional learning. On the one hand, we have confirmed Cai et al.’s ( 2020 ) teacher professional learning model in a new context, namely STEAM teacher education. Throughout the teacher professional development program, the pre-service teacher, Shuitao, demonstrated an augmentation in her knowledge, encompassing both content knowledge and pedagogical understanding concerning IHT. Moreover, her beliefs regarding IHT transformed as a result of her engagement in teacher learning across the five stages. This facilitated her in executing effective IHT teaching and improving her students’ outcomes. On the other hand, notably, in our studies (including this current study and some follow-up studies), student feedback is a pivotal tool to assist teachers in discerning the impact they are effectuating. This enables pre-service teachers to grasp the actual efficacy of their teaching efforts and subsequently contributes significantly to the augmentation of their self-efficacy. Such steps have seldom been conducted in prior studies (e.g., Cai et al. 2020 ), where student outcomes are often perceived solely as the results of teachers’ instruction rather than sources informing teacher beliefs. Additionally, this study has validated both the interaction between teaching performance and teacher beliefs and between teacher knowledge and teacher beliefs. These aspects were overlooked in Cai et al.’s ( 2020 ) model. More importantly, while Clarke and Hollingsworth’s ( 2002 ) Interconnected Model of Professional Growth illustrates the connections between the domain of consequence and the personal domain, as well as between the personal domain and the domain of practice, it does not adequately clarify the complex relationships among the factors within the personal domain (e.g., the interaction between teacher knowledge and teacher beliefs). Therefore, our study also supplements Clarke and Hollingsworth’s ( 2002 ) model by addressing these intricacies. Based on our findings, an updated model of teacher professional learning has been proposed, as shown in Fig. 3 . This expanded model indicates that teacher learning should be an ongoing and sustainable process, with the enhancement of student learning not marking the conclusion of teacher learning, but rather serving as the catalyst for a new phase of learning. In this sense, we advocate for further research to investigate the tangible impacts of teacher professional development programs on students and how those impacts stimulate subsequent cycles of teacher learning.

Note: Paths in blue were proposed by Cai et al. ( 2020 ), and paths in yellow are proposed and verified in this study.

Thirdly, in light of the updated model of teacher professional learning (see Fig. 3 ), this study provides insights into the design of teacher professional development programs of IAT. According to Huang et al. ( 2022 ), to date, very few studies have set goals to “develop a comprehensive understanding of effective designs” for STEM (or STEAM) teacher professional development programs (p. 15). To fill this gap, this study proposes a novel and effective five-stage framework for teacher professional development programs of IAT. This framework provides a possible and feasible solution to the challenges of STEAM teacher professional development programs’ design and planning, and teachers’ IAT practice (Boice et al. 2021 ; Herro et al. 2019 ; Jacques et al. 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ).

Specifically, our five-stage framework incorporates at least six important features. Firstly, teacher professional development programs should focus on specific STEAM content. Given the expansive nature of STEAM, teacher professional development programs cannot feasibly encompass all facets of its contents. Consistent with recommendations by Cai et al. ( 2020 ), Desimone et al. ( 2002 ) and Garet et al. ( 2001 ), an effective teacher professional development program should prioritize content focus. Our five-stage framework is centered on IAT. Throughout an 18-month duration, each pre-service teacher is limited to selecting one subcomponent of A&H, such as history, for integration into their subject teaching (i.e., mathematics teaching, technology teaching or science teaching) within one teacher professional development program. Secondly, in response to the appeals that teacher professional development programs should shift from emphasizing teaching and instruction to emphasizing student learning (Cai et al. 2020 ; Calabrese et al. 2024 ; Hwang et al. 2024 ; Marco and Palatnik 2024 ; Örnek and Soylu 2021 ), our framework requires pre-service teachers to pay close attention to the effects of IAT on student learning outcomes, and use students’ feedback as the basis of improving their instruction. Thirdly, prior studies found that teacher education with a preference for theory led to pre-service teachers’ dissatisfaction with the quality of teacher professional development program and hindered the development of pre-service teachers’ teaching skills and teaching beliefs, which also widened the gap between theory and practice (Hennissen et al. 2017 ; Ord and Nuttall 2016 ). In this regard, our five-stage framework connects theory and teaching practice closely. In particular, pre-service teachers can experience the values of IAT not only through theoretical learning but also through diverse teaching practices. Fourthly, we build a teacher community of practice tailored for pre-service teachers. Additionally, we aim to encourage greater participation of in-service teachers in such teacher professional development programs designed for pre-service educators in STEAM teacher education. By engaging in such programs, in-service teachers can offer valuable teaching opportunities for pre-service educators and contribute their insights and experiences from teaching practice. Importantly, pre-service teachers stand to gain from the in-service teachers’ familiarity with textbooks, subject matter expertise, and better understanding of student dynamics. Fifthly, our five-stage framework lasts for an extended period, spanning 18 months. This duration ensures that pre-service teachers engage in a sustained and comprehensive learning journey. Lastly, our framework facilitates a practical understanding of “integration” by offering detailed, sequential instructions for blending two disciplines in teaching. For example, our teacher professional development programs prioritize systematic learning of pedagogical theories and simulated teaching experiences before pre-service teachers embark on real STEAM teaching endeavors. This approach is designed to mitigate the risk of unsuccessful experiences during initial teaching efforts, thereby safeguarding pre-service teachers’ teacher self-efficacy. Considering the complexity of “integration” in interdisciplinary teaching practices, including IAT (Han et al. 2022 ; Ryu et al. 2019 ), we believe detailed stage-by-stage and step-by-step instructions are crucial components of relevant pre-service teacher professional development programs. Notably, this aspect, emphasizing structural instructional guidance, has not been explicitly addressed in prior research (e.g., Cai et al. 2020 ). Figure 4 illustrates the six important features outlined in this study, encompassing both established elements and the novel addition proposed herein, describing an effective teacher professional development program.

Note: STEAM refers to science, technology, engineering, arts and humanities, and mathematics.

The successful implementation of this framework is also related to the Chinese teacher education system and cultural background. For instance, the Chinese government has promoted many university-school collaboration initiatives, encouraging in-service teachers to provide guidance and practical opportunities for pre-service teachers (Lu et al. 2019 ). Influenced by Confucian values emphasizing altruism, many experienced in-service teachers in China are eager to assist pre-service teachers, helping them better realize their teaching career aspirations. It is reported that experienced in-service teachers in China show significantly higher motivation than their international peers when mentoring pre-service teachers (Lu et al. 2019 ). Therefore, for the successful implementation of this framework in other countries, it is crucial for universities to forge close collaborative relationships with K-12 schools and actively involve K-12 teachers in pre-service teacher education.

Notably, approximately 5% of our participants dropped out midway as they found that the IAT practice was too challenging or felt overwhelmed by the number of required tasks in the program. Consequently, we are exploring options to potentially simplify this framework in future iterations.

Without minimizing the limitations of this study, it is important to recognize that a qualitative longitudinal case study can be a useful means of shedding light on the development of a pre-service STEAM teacher’s self-efficacy. However, this methodology did not allow for a pre-post or a quasi-experimental design, and the effectiveness of our five-stage framework could not be confirmed quantitatively. In the future, conducting more experimental or design-based studies could further validate the effectiveness of our framework and broaden our findings. Furthermore, future studies should incorporate triangulation methods and utilize multiple data sources to enhance the reliability and validity of the findings. Meanwhile, owing to space limitations, we could only report the changes in Shuitao’s SE-IHT-IP and SE-IHT-SO here, and we could not describe the teacher self-efficacy of other participants regarding IAT. While nearly all of the pre-service teachers experienced an improvement in their teacher self-efficacy concerning IAT upon participating in our teacher professional development programs, the processes of their change were not entirely uniform. We will need to report the specific findings of these variations in the future. Further studies are also needed to explore the factors contributing to these variations. Moreover, following this study, we are implementing more teacher professional development programs of IAT. Future studies can explore the impact of this framework on additional aspects of pre-service STEAM teachers’ professional development. This will help gain a more comprehensive understanding of its effectiveness and potential areas for further improvement. Additionally, our five-stage framework was initially developed and implemented within the Chinese teacher education system. Future research should investigate how this framework can be adapted in other educational systems and cultural contexts.

The impetus behind this study stems from the burgeoning discourse advocating for the integration of A&H disciplines into STEM education on a global scale (e.g., Land 2020 ; Park and Cho 2022 ; Uştu et al. 2021 ; Vaziri and Bradburn 2021 ). Concurrently, there exists a pervasive concern regarding the challenges teachers face in implementing STEAM approaches, particularly in the context of IAT practices (e.g., Boice et al. 2021 ; Herro et al. 2019 ; Jacques et al. 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ). To tackle this challenge, we first proposed a five-stage framework designed for teacher professional development programs of IAT. Then, utilizing this innovative framework, we implemented a series of teacher professional development programs. Drawing from the recommendations of Bray-Clark and Bates ( 2003 ), Kelley et al. ( 2020 ) and Zhou et al. ( 2023 ), we have selected teacher self-efficacy as a key metric to examine the effectiveness of the five-stage framework. Through a qualitative longitudinal case study, we scrutinized the influence of a specific teacher professional development program on the self-efficacy of a single pre-service teacher over an 18-month period. Our findings revealed a notable enhancement in teacher self-efficacy across both individual performance and student outcomes. The observed enhancement of the participant’s teacher self-efficacy did not occur swiftly but unfolded gradually through a prolonged, incremental process. Building on our findings, an updated model of teacher learning has been proposed. The updated model illustrates that teacher learning should be viewed as a continuous and sustainable process, wherein teaching performance, teacher beliefs, and teacher knowledge dynamically interact with one another. The updated model also confirms that teacher learning is inherently intertwined with student learning in STEAM education. Furthermore, this study also summarizes effective design features of STEAM teacher professional development programs.

Data availability

The datasets generated and/or analyzed during this study are not publicly available due to general data protection regulations, but are available from the corresponding author on reasonable request.

In their review article, Morris et al. ( 2017 ) equated “teaching self-efficacy” and “teacher self-efficacy” as synonymous concepts. This perspective is also adopted in this study.

An effective teacher professional development program should have specific, focused, and clear content instead of broad and scattered ones. Therefore, each pre-service teacher can only choose to integrate one subcomponent of A&H into their teaching in one teacher professional development program. For instance, Shuitao, a mathematics pre-service teacher, participated in one teacher professional development program focused on integrating history into mathematics teaching. However, she did not explore the integration of other subcomponents of A&H into her teaching during her graduate studies.

In the micro-classrooms, multi-angle, and multi-point high-definition video recorders are set up to record the teaching process.

In micro-teaching, mentors, in-service teachers, and other fellow pre-service teachers take on the roles of students.

In China, teachers can video record one section of a lesson and play them in formal classes. This is a practice known as a micro-course. For instance, in one teacher professional development program of integrating history into mathematics teaching, micro-courses encompass various mathematics concepts, methods, ideas, history-related material and related topics. Typically, teachers use these micro-courses to broaden students’ views, foster inquiry-based learning, and cultivate critical thinking skills. Such initiatives play an important role in improving teaching quality.

Many university-school collaboration initiatives in China focus on pre-service teachers’ practicum experiences (Lu et al. 2019 ). Our teacher professional development program is also supported by many K-12 schools in Shanghai. Personal information in videos is strictly protected.

In China, students are not required to pursue a graduate major that matches their undergraduate major. Most participants in our teacher professional development programs did not pursue undergraduate degrees in education-related fields.

Shuitao’s university reserves Wednesday afternoons for students to engage in various programs or clubs, as classes are not scheduled during this time. Similarly, our teacher professional development program activities are planned for Wednesday afternoons to avoid overlapping with participants’ other coursework commitments.

History is one of the most important components of A&H (Park and Cho 2022 ).

To learn more about genetic approach (i.e., genetic principle), see Jankvist ( 2009 ).

For the assessment process, see Fig. 2 .

Shuitao’s cooperating in-service teacher taught the concept of logarithms in Stage 2. In Stage 4, the teaching objective of her cooperating in-service teacher’s review lesson was to help students review the concept of logarithms to prepare students for the final exam.

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Acknowledgements

This research is funded by 2021 National Natural Science Foundation of China (Grant No.62177042), 2024 Zhejiang Provincial Natural Science Foundation of China (Grant No. Y24F020039), and 2024 Zhejiang Educational Science Planning Project (Grant No. 2024SCG247).

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Xuesong Zhai

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Authors and Affiliations

College of Education, Zhejiang University, Hangzhou, China

Haozhe Jiang & Xuesong Zhai

School of Engineering and Technology, CML‑NET & CREATE Research Centres, Central Queensland University, North Rockhampton, QLD, Australia

Ritesh Chugh

Hangzhou International Urbanology Research Center & Zhejiang Urban Governance Studies Center, Hangzhou, China

Department of Teacher Education, Nicholls State University, Thibodaux, LA, USA

School of Mathematical Sciences, East China Normal University, Shanghai, China

Xiaoqin Wang

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Conceptualization - Haozhe Jiang; methodology - Haozhe Jiang; software - Xuesong Zhai; formal analysis - Haozhe Jiang & Ke Wang; investigation - Haozhe Jiang; resources - Haozhe Jiang, Xuesong Zhai & Xiaoqin Wang; data curation - Haozhe Jiang & Ke Wang; writing—original draft preparation - Haozhe Jiang & Ritesh Chugh; writing—review and editing - Ritesh Chugh & Ke Wang; visualization - Haozhe Jiang, Ke Wang & Xiaoqin Wang; supervision - Xuesong Zhai & Xiaoqin Wang; project administration - Xuesong Zhai & Xiaoqin Wang; and funding acquisition - Xuesong Zhai & Xiaoqin Wang. All authors have read and agreed to the published version of the manuscript.

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Jiang, H., Chugh, R., Zhai, X. et al. Longitudinal analysis of teacher self-efficacy evolution during a STEAM professional development program: a qualitative case study. Humanit Soc Sci Commun 11 , 1162 (2024). https://doi.org/10.1057/s41599-024-03655-5

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Qualitative Inquiry in Education: Theory and Practice (QIETP) is a biannual peer-reviewed journal focusing on qualitative research methods, theories, and applications in the field of education. The main purpose of the journal is to contribute to the expansion and deepening of knowledge, discussions, and applications of qualitative research in education.

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Qualitative Research in Early Childhood Education and Care Implementation

• Wendy K. Jarvie 1  

International Journal of Child Care and Education Policy volume  6 ,  pages 35–43 ( 2012 ) Cite this article

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Governments around the world have boosted their early childhood education and care (ECEC) engagement and investment on the basis of evidence from neurological studies and quantitative social science research. The role of qualitative research is less understood and under-valued. At the same time the hard evidence is only of limited use in helping public servants and governments design policies that work on the ground. The paper argues that some of the key challenges in ECEC today require a focus on implementation. For this a range of qualitative research is required, including knowledge of organisational and parent behaviour, and strategies for generating support for change. This is particularly true of policies and programs aimed at ethnic minority children. It concludes that there is a need for a more systematic approach to analysing and reporting ECEC implementation, along the lines of “implementation science” developed in the health area.

Introduction

Research conducted over the last 15 years has been fundamental to generating support for ECEC policy reform and has led to increased government investments and intervention in ECEC around the world. While neurological evidence has been a powerful influence on ECEC policy practitioners, quantitative research has also been persuasive, particularly randomised trials and longitudinal studies providing evidence (1) on the impact of early childhood development experiences to school success, and to adult income and productivity, and (2) that properly constructed government intervention, particularly for the most disadvantaged children, can make a significant difference to those adult outcomes. At the same time the increased focus on evidence-informed policy has meant experimental/quantitative design studies have become the “gold standard” for producing knowledge (Denzin & Lincoln, 2005 ), and pressures for improved reporting and accountability have meant systematic research effort by government has tended to focus more on data collection and monitoring, than on qualitative research (Bink, 2007 ). In this environment the role of qualitative research has been less valued by senior government officials.

Qualitative Research-WhatIs It?

The term qualitative research means different things to different people (Denzin & Lincoln, 2005 ). For some researchers it is a way of addressing social justice issues and thus is part of radical politics to give power to the marginalised. Others see it simply as another research method that complements quantitative methodologies, without any overt political function. Whatever the definition of qualitative research, or its role, a qualitative study usually:

Features an in depth analysis of an issue, event, entity, or process. This includes literature reviews and meta studies that draw together findings from a number of studies.

Is an attempt to explain a highly complex and/or dynamic issue or process that is unsuited to experimental or quantitative analysis.

Includes a record of the views and behaviours of the players — it studies the world from the perspective of the participating individual.

Cuts across disciplines, fields and subject matter.

Uses a range of methods in one study, such as participant observation; in depth interviewing of participants, key stakeholders, and focus groups; literature review; and document analysis.

High quality qualitative research requires high levels of skill and judgement. Sometimes it requires pulling together information from a mosaic of data sources and can include quantitative data (the latter is sometimes called mixed mode studies). From a public official perspective, the weaknesses of qualitative research can include (a) the cost-it can be very expensive to undertake case studies if there are a large number of participants and issues, (b) the complexity — the reports can be highly detailed, contextually specific examples of implementation experience that while useful for service delivery and front line officials are of limited use for national policy development, (c) difficultyin generalising from poor quality and liable to researcher bias, and (d) focus, at times, more on political agendas of child rights than the most cost-effective policies to support the economic and social development of a nation. It has proved hard for qualitative research to deliver conclusions that are as powerful as those from quantitative research. Educational research too, has suffered from the view that education academics have over-used qualitative research and expert judgement, with little rigorous or quantitative verification (Cook & Gorard, 2007 ).

Qualitative Research and Early Childhood Education and Care

In fact, the strengths of qualitative ECEC research are many, and their importance for government, considerable. Qualitative research has been done in all aspects of ECEC operations and policies, from coordinating mechanisms at a national level (OECD, 2006 ), curriculum frameworks (Office for Children and Early Childhood Development, 2008 ), and determining the critical elements of preschool quality (Siraj-Blatchford et al., 2003 ), to developing services at a community level including effective outreach practices and governance arrangements. Qualitative research underpins best practice guides and regulations (Bink, 2007 ). Cross country comparative studies on policies and programs rely heavily on qualitative research methods.

For public officials qualitative components of program evaluations are essential to understanding how a program has worked, and to what extent variation in outcomes and impacts from those expected, or between communities, are the result of local or national implementation issues or policy flaws. In addition, the public/participant engagement in qualitative components of evaluations can reinforce public trust in public officials and in government more broadly.

In many ways the contrast between quantitative and qualitative research is a false dichotomy and an unproductive comparison. Qualitative research complements quantitative research, for example, through provision of background material and identification of research questions. Much quantitative research relies on qualitative research to define terms, and to identify what needs to be measured. For example, the Effective Provision of PreSchool Education (EPPE) studies, which have been very influential and is a mine of information for policy makers, rely on initial qualitative work on what is quality in a kindergarten, and how can it be assessed systematically (Siraj-Blatchford et al., 2003 ). Qualitative research too can elucidate the “how” of a quantitative result. For example, quantitative research indicates that staff qualifications are strongly associated with better child outcomes, but it is qualitative work that shows that it is not the qualification per se that has an impact on child outcomes-rather it is the ability of staff to create a high quality pedagogic environment (OECD, 2012 ).

Challenges of Early Childhood Education and Care

Systematic qualitative research focused on the design and implementation of government programs is essential for governments today.

Consider some of the big challenges facing governments in early childhood development (note this is not a complete list):

Creating coordinated national agendas for early childhood development that bring together education, health, family and community policies and programs, at national, provincial and local levels (The Lancet, 2011 ).

Building parent and community engagement in ECEC/Early Childhood Development (ECD), including increasing parental awareness of the importance of early childhood services. In highly disadvantaged or dysfunctional communities this also includes increasing their skills and abilities to provide a healthy, stimulating and supportive environment for young children, through for example parenting programs (Naudeau, Kataoka, Valerio, Neuman & Elder, 2011 ; The Lancet, 2011 ; OECD, 2012 ).

Strategies and action focused on ethnic minority children, such as outreach, ethnic minority teachers and teaching assistants and informal as well as formal programs.

Enhancing workforce quality, including reducing turnover, and improved practice (OECD, 2012 ).

Building momentum and advocacy to persuade governments to invest in the more “invisible” components of quality such as workforce professional development and community liaison infrastructure; and to maintain investment over significant periods of time (Jarvie, 2011 ).

Driving a radical change in the way health/education/familyservicepro fessions and their agencies understand each other and to work together. Effectively integrated services focused on parents, children and communities can only be achieved when professions and agencies step outside their silos (Lancet, 2011 ). This would include redesign of initial training and professional development, and fostering collaborations in research, policy design and implementation.

There are also the ongoing needs for,

Identifying and developing effective parenting programs that work in tandem with formal ECEC provision.

Experiments to determine if there are lower cost ways of delivering quality and outcomes for disadvantaged children, including the merits of adding targeted services for these children on the base of universal services.

Figuring out how to scale up from successful trials (Grunewald & Rolnick, 2007 ; Engle et al., 2011 ).

Working out how to make more effective transitions between preschool and primary school.

Making research literature more accessible to public officials (OECD, 2012 ).

Indeed it can be argued that some of the most critical policy and program imperatives are in areas where quantitative research is of little help. In particular, qualitative research on effective strategies for ethnic minority children, their parents and their communities, is urgently needed. In most countries it is the ethnic minority children who are educationally and economically the most disadvantaged, and different strategies are required to engage their parents and communities. This is an area where governments struggle for effectiveness, and public officials have poor skills and capacities. This issue is common across many developed and developing countries, including countries with indigenous children such as Australia, China, Vietnam, Chile, Canada and European countries with migrant minorities (OECD, 2006 ; COAG, 2008 ; World Bank, 2011 ). Research that is systematic and persuasive to governments is needed on for example, the relative effectiveness of having bilingual environments and ethnic minority teachers and teaching assistants in ECEC centres, compared to the simpler community outreach strategies, and how to build parent and community leadership.

Many countries are acknowledging that parental and community engagement is a critical element of effective child development outcomes (OECD, 2012 ). Yet public officials, many siloed in education and child care ministries delivering formal ECEC services, are remote from research on raising parent awareness and parenting programs. They do not see raising parental skills and awareness as core to their policy and program responsibilities. Improving parenting skills is particularly important for very young children (say 0–3) where the impact on brain development is so critical. It has been argued there needs to be a more systematic approach to parenting coach/support programs, to develop a menu of options that we know will work, to explore how informal programs can work with formal programs, and how health programs aimed young mothers or pregnant women can be enriched with education messages (The Lancet, 2011 ).

Other areas where qualitative research could assist are shown in Table 1 (see p. 40).

Implementation Science in Early Childhood Education and Care

Much of the suggested qualitative research in Table 1 is around program design and implementation . It is well-known that policies often fail because program design has not foreseen implementation issues or implementation has inadequate risk management. Early childhood programs are a classic example of the “paradox of non-evidence-based implementation of evidence-based practice” (Drake, Gorman & Torrey, 2005). Governments recognise that implementation is a serious issue: there may be a lot of general knowledge about “what works”, but there is minimal systematic information about how things actually work . One difficulty is that there is a lack of a common language and conceptual framework to describe ECEC implementation. For example, the word “consult” can describe a number of different processes, from public officials holding a one hour meeting with available parents in alocation,to ongoing structures set up which ensureall communityelementsare involved and reflect thespectrum of community views, and tocontinue tobuild up community awareness and engagement over time.

There is a need to derive robust findingsof generic value to public officials, for program design. In the health sciences, there is a developing literature on implementation, including a National implementation Research Network based in the USA, and a Journal of Implementation Science (Fixsen, Naoom, Blasé, Friedman & Wallace, 2005 ). While much of the health science literature is focused on professional practice, some of the concepts they have developed are useful for other fields, such as the concept of “fidelity” of implementation which describes the extent to which a program or service has been implemented as designed. Education program implementation is sometimes included in these fora, however, there is no equivalent significant movement in early childhood education and care.

A priority in qualitative research for ECEC of value to public officials would then appear to be a systematic focus on implementation studies, which would include developing a conceptual framework and possibly a language for systematic description of implementation, as well as, meta-studies. This need not start from scratch-much of the implementation science literature in health is relevant, especially the components around how to influence practitioners to incorporate latest evidence-based research into their practice, and the notions of fidelity of implementation. It could provide an opportunity to engage providers and ECE professionals in research, where historically ECEC research has been weak.

Essential to this would be collaborative relationships between government agencies, providers and research institutions, so that there is a flow of information and findings between all parties.

Quantitative social science research, together with studies of brain development, has successfully made the case for greater investment in the early years.There has been less emphasis on investigating what works on the ground especially for the most disadvantaged groups, and bringing findings together to inform government action. Yet many of the ECEC challenges facing governments are in implementation, and in ensuring that interventions are high quality. This is particularly true of interventions to assist ethnic minority children, who in many countries are the most marginalised and disadvantaged. Without studies that can improve the quality of ECEC implementation, governments, and other bodies implementing ECEC strategies, are at risk of not delivering the expected returns on early childhood investment. This could, over time, undermine the case for sustained government support.

It is time for a rebalancing of government research activity towards qualitative research, complemented by scaled up collaborations with ECEC providers and research institutions. A significant element of this research activity could usefully be in developing a more systematic approach to analysing and reporting implementation, and linking implementation to outcomes. This has been done quite effectively in the health sciences. An investment in developing an ECEC ‘implementation science’ would thus appear to be a worthy of focus for future work.

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This paper was originally prepared for the OECD Early Childhood Education and Care Network Meeting, 24 January 2012, Oslo, Norway.

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Jarvie, W.K. Qualitative Research in Early Childhood Education and Care Implementation. ICEP 6 , 35–43 (2012). https://doi.org/10.1007/2288-6729-6-2-35

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Sense of Belonging in Early Childhood: A Study in an Early Childhood Education Center in Türkiye

• Published: 10 September 2024

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• Hacer Tekerci   ORCID: orcid.org/0000-0002-8866-6557 1 &
• Fırat Çöplü   ORCID: orcid.org/0000-0001-8173-4564 2  

The aim of this study was to provide a multidimensional perspective on the attachment of children who were identified as different and maladaptive in their classrooms in a preschool education institution in the Mediterranean region of Türkiye. The study was carried out by collecting qualitative and quantitative data with triangulation method. Within the scope of the study, interviews were conducted with the teachers, the mothers of children, and the children; four girls and three boys, the youngest of whom was 58 months old and the oldest of whom was 74 months old. In addition, the Belonging Scale was applied to the children and observations were conducted by the researchers. As a result of the research, it was found that the weakest structures in children's perceptions of belonging were at the level of attachment to friends and family. The qualitative data supported the findings that the quality of children's relationships with their peers, siblings and mothers were effective on children's emotional state, and children showed complaint and violence behaviour patterns as conflict resolution strategies. In addition, it can be stated that teachers lack knowledge and understanding of the pedagogy of belonging and that children cannot gain conflict resolution and independence skills.

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The data that support the findings of this study are available from the corresponding author, [H.T.], upon reasonable request.

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Incorporating equity, diversity and inclusion (EDI) into the education and assessment of professionalism for healthcare professionals and trainees: a scoping review

• Darsh Shah 1 ,
• Nima Behravan 1 ,
• Nujud Al-Jabouri 2 &
• Matthew Sibbald 1 , 2  

BMC Medical Education volume  24 , Article number:  991 ( 2024 ) Cite this article

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Current definitions of professionalism for healthcare trainees often lack equity, diversity and inclusion (EDI) in the expectations and assessment of professionalism. While professionalism teaching is incorporated in healthcare training, equity-deserving groups still experience discrimination. This scoping review investigates the literature to understand how EDI and associated domains of cultural humility, and advocacy can be incorporated in healthcare trainees’ education and assessment of professionalism.

The Arksey and O’Malley framework was applied to this scoping review. MEDLINE, Embase & PsychINFO were searched up to March 2023, with terms surrounding health professionals, professionalism, EDI, cultural humility, and advocacy. Titles and abstracts ( n  = 3870) and full-texts ( n  = 140) were independently screened by two reviewers. Articles were included if they focused on EDI, cultural humility, or advocacy among healthcare students/trainees, and had outcomes related to professionalism. Articles lacking discussion of professionalism as an outcome were excluded. Themes were generated by mutual discussion. Risk of bias was assessed using the Cote et al. and Medical Education Research Study Quality Instrument (MERSQI) tools.

48 articles underwent thematic analysis. Studies investigated the disciplines of medicine, nursing, social work, physiotherapy, and dentistry. Most studies were qualitative in methodology ( n  = 23). Three themes emerged: (1) EDI-related interventions are associated with improved professionalism of healthcare trainees/workers ( n  = 21). Interventions employed were either an EDI-associated educational course ( n  = 8) or an exchange program to promote EDI competencies among trainees ( n  = 13). (2) Trainee definitions and perceptions of professionalism include themes related to EDI and cultural humility ( n  = 12). (3) Current standards of professionalism are perceived as non-inclusive towards historically-marginalized populations ( n  = 15). Literature investigating advocacy as it relates to professionalism is limited.

This review identified that core EDI principles and its associated domains of cultural humility and advocacy are often viewed as integral to professionalism. These findings create a strong impetus to incorporate EDI principles within professionalism frameworks in healthcare education. Future research should employ standardized tools for professionalism assessment to provide more conclusive evidence. Incorporating patient perspectives of professionalism can inform actionable recommendations for fostering inclusive healthcare environments.

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Introduction

In the healthcare pedagogical literature, professionalism has often been broadly defined as a set of characteristics, competencies and attitudes that are expected of a healthcare professional or trainee [ 1 ]. A paper published in the American Medical Association Journal of Ethics suggests that upholding equity is amongst the most important roles of a physician by stating: “Organizational, system, and policy reform demand that professionalism be redefined in terms of its capacity to motivate equity in health professions education and clinical practice” [ 2 ]. However, despite attempts of healthcare institutions to define specific domains and competencies in their professionalism frameworks, concepts of EDI, cultural humility and advocacy are often omitted in these frameworks [ 2 ].

An example of a healthcare professionalism framework is one developed by the Michael G. DeGroote School of Medicine (MGDSM) at McMaster University in Hamilton, Ontario, Canada. This framework is called the Professionalism in Practice (PIP) framework, which teaches and holds its learners accountable to the following core domains of professionalism: professional responsibility and integrity, pursuit of excellence/insight, personal interactions, as well as EDI and Indigenous reconciliation [ 3 ]. As noted here, the MGDSM makes a deliberate effort to outline EDI and Indigenous reconciliation as a core domain to uphold as a standard of its learners’ and providers’ professionalism. Another example of a healthcare professionalism framework is that developed by the National Taiwan University College of Medicine (NTUCM). The NTUCM developed this medical professionalism framework through contributions from stakeholders, including chairs of hospital departments, residents, and attending physicians. The resultant consensus framework consisted of 8 domains: integrity, humanism, altruism, communication, clinical competence, ethics, excellence, and accountability [ 4 ]. Despite some overlap between the healthcare professionalism frameworks of NTUCM and MGDSM, various competencies are not shared across the two frameworks. For example, the NTUCM framework does not explicitly have a domain pertinent to EDI, cultural humility or advocacy [ 4 ]. Therefore, due to the inherent subjectivity and lack of unison in the definitions and domains of professionalism frameworks at different institutions, crucial concepts such as EDI, cultural humility and advocacy may be left out of professionalism curricula and frameworks.

Numerous studies find that EDI, cultural humility and advocacy are beneficial for both patients and healthcare teams. A review paper found that multiple studies suggest patient outcomes are improved by more diverse teams, and that healthcare environments that are identified as diverse are found to be less prone to disputes in times of change [ 5 ]. Additionally, despite the efforts of healthcare institutions in teaching, assessing and upholding professionalism expectations from their trainees, discriminatory practices and consequent healthcare disparities still persist. For instance, in Canada, Black and Indigenous communities continue to experience discrimination when seeking healthcare services [ 6 , 7 , 8 , 9 , 10 ]. In an ethnographic study conducted in an emergency department (ED) in a large teaching hospital in a Western Canadian city, it was found that many Indigenous patients felt they were being judged on the basis of their identity, and that presumptions were made that their visits to the ED were due to illegitimate pain issues or inappropriate reasons [ 6 ]. An important example of discriminatory healthcare practices against Indigenous communities is that of Joyce Echaquan, an Indigenous patient at a Quebec hospital who, moments before her passing, recorded a video displaying her screaming in pain while her healthcare providers made distasteful remarks towards her based on racially-charged stereotypes [ 7 ]. Additionally, a qualitative study on self-identified Black individuals who lived in Montréal during the COVID-19 pandemic found several themes regarding internalized anti-Black racism amongst healthcare providers, including the presence of insensitivity towards racial discrimination by some providers [ 8 ].

The discriminatory practices and healthcare disparities amongst patients of equity-deserving backgrounds noted above [ 6 , 7 , 8 , 9 , 10 ], combined with the lack of emphasis on EDI in healthcare professionalism definitions [ 2 ], creates a strong impetus for redefining expectations of professionalism from healthcare professionals and trainees to encompass concepts of cultural humility and advocacy.

This scoping review systematically searches the literature to evaluate how EDI and associated domains of cultural humility and advocacy are related to and can be incorporated into the standards, teaching and evaluation of professionalism for healthcare workers and trainees.

Research question

This scoping review aggregates the existing evidence on the following research question: What literature is available on how principles of equity , diversity and inclusion (EDI) are incorporated in the education and assessment of professionalism for health professions trainees?

Approach to terminology

This paper utilizes the terminology recommended by the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) to guide language, narrative, and concepts as our standard for inclusive language that promotes health equity. For instance, per the AMA and AAMC recommendations, the terms “cultural competency”, “minority/minority groups” and “equality” as commonly found in the literature, are substituted with terms such as “cultural humility/safety”, “(people from) racial and ethnic groups’’ and “equity”, respectively [ 11 ].

Materials and methods

We adopted scoping review methodology to understand the breadth and depth of literature pertaining to the principles of EDI in professionalism education and assessment [ 12 ]. We were guided by Arksey and O’Malley’s methodological framework for scoping reviews, which includes five main stages (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing and reporting the results [ 13 ]. We reported our process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist through multiple rounds of feedback and modification by our research team [ 14 ].

Eligibility criteria

Studies were included if (1) the population was practicing health professionals and trainees working in the fields of medicine, nursing, social work, rehabilitation, multidisciplinary healthcare teams, medical education, dentistry, midwifery, and pharmacy (2) the outcome was related to professionalism within the objectives, methodology, or results sections, and (3) professionalism was linked to EDI, cultural humility, or advocacy. Studies were excluded if they (1) were not in English, (2) did not focus on professionalism outcomes, (3) did not focus on our population of interest, and (4) were grey literature publications (e.g. conference proceedings, abstracts, non-peer reviewed reports). Considering that both empirical and non-empirical studies have the potential to yield meaningful findings on concepts of EDI and professionalism, no restrictions were placed on study design.

Search strategy

A preliminary search was conducted to identify keywords and subject headings related to our research question. The final search strategy was developed in consultation among the research team members and a librarian at McMaster Health Sciences Library. Three electronic databases were searched from inception to March 7, 2023: Embase, Medline and PsycINFO. Search terms were designed to capture concepts of “advocacy” AND “cultural humility” AND “healthcare professionals” AND “healthcare trainees” AND “professionalism” AND “professional development.” Search terms were adapted for each database as subject headings or keywords where appropriate (See Appendix S1 , Additional File 1 ). To identify any non-indexed literature, we hand searched the reference list of included studies and Google Scholar. The search strategy used the same search term combinations as described above and was limited to literature published in peer-reviewed journals only. Grey literature, such as individual institution’s professionalism frameworks, were not included. Covidence software was used to manage citations, including removing duplicates and screening [ 15 ].

A revised search was conducted between March 7th 2023 to April 1st 2024 with an identical search strategy to identify advances in the literature. A set of 204 unique records were identified for which abstract and full-text screening were completed. We did not identify any new studies meeting inclusion/exclusion criteria that added substantial evidence to the results of our study.

Screening process

A pilot screening test of the eligibility criteria was conducted by two independent reviewers (NA, DS, or NB) on a small sample of studies. Reviewers met to discuss their agreement level and the eligibility criteria was modified for clarity. Following this pilot test, two independent reviewers (NA, DS, or NB) screened titles and abstracts to evaluate their eligibility against the inclusion and exclusion criteria. Studies that passed the initial screening process underwent full-text screening by two independent reviewers (NA, DS, or NB). Disagreements at any screening stage were resolved by a third reviewer or consensus-based discussion. A PRISMA-ScR flowchart was used to show the process of study selection (Fig.  1 ).

Data extraction

A data extraction sheet was developed by the authors and used to organize data from included studies. Data extraction was divided among three members (NA, DS or NB) and was conducted using the Excel software. All extracted data was reviewed by a different member (NA, DS or NB). The final extraction table included (1) study characteristics (i.e., authors, publication year, country), (2) sample characteristics (i.e., number of participants, population description), (3) methodological characteristics (i.e., study design, program description/recruitment), and (4) study outcomes related to professionalism (See Appendix S2 , Additional File 1 ).

Quality appraisal

One reviewer (NA, DS or NB) assessed the quality of studies using tools for qualitative and quantitative data. This consisted of the Medical Education Research Study Quality Instrument (MERSQI) for quantitative studies, and a qualitative study grid published by Côté et al. [ 16 , 17 ].

Data analysis

This review qualitatively analyzed the data following the thematic analysis approach [ 18 ]. Three reviewers (NA, DS & NB) independently categorized data according to their meaning and content. Subsequently, key themes were independently identified and formulated. These themes were then compared and any disagreements were resolved with discussion-based consensus, arriving at three main themes.

Literature scope and characteristics

Results of the initial search are presented in Fig.  1 , including rationales for excluded articles. The data searches yielded 4194 unique records, with 125 selected for full-text review. After screening against eligibility criteria, 34 articles were included for data extraction. Included articles spanned publication between 2005 and 2023. An additional 24 articles were identified from hand-searching of included studies, of which 14 met eligibility criteria, producing a total of 48 articles included in our analysis.

PRISMA-ScR Flow Diagram

Most studies involved medical trainees or physicians ( n  = 18). Other professions examined in the literature included nursing, social work, dentistry, midwifery, and physical therapists. Most studies were based in the United States ( n  = 19) among other countries such as Australia ( n  = 4), the United Kingdom ( n  = 1), Canada ( n  = 4), and Turkey ( n  = 3) with eleven studies being multinational ( n  = 11). The majority of studies were qualitative in nature ( n  = 23) followed by mixed-methods ( n  = 10), commentaries ( n  = 8), and quantitative ( n  = 7). Characteristics of the studies divided by themes can be found in the supplementary material (Appendix S2 , Additional File 1 ) Among qualitative studies, methods of evaluating professionalism were predominantly based on participant interviews ( n  = 16) followed by surveys ( n  = 13), written narratives ( n  = 9), and literature review ( n  = 3). Quantitative measures included internally designed Likert scales to measure participants’ perspectives ( n  = 14) with few studies employing validated tools ( n  = 3). Twenty-one studies employed an EDI training intervention, split between educational courses ( n  = 8) and clinical placements ( n  = 11). A summary of quality appraisal is presented in the supplementary material (See Appendix S3 , Additional File 1 ).

Theme 1: EDI-related interventions are associated with improved professionalism of healthcare trainees/professionals

Most studies investigated outcomes after an EDI-oriented intervention on professionalism outcomes among participants ( n  = 21). Studies within this theme are divided based on their intervention of an educational course ( n  = 8) or an exchange clinical placement ( n  = 13). Topics of the educational courses included health advocacy, cultural humility, and spirituality/religion [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ]. All eight studies reported an improvement in professionalism or professional identity formation. Four of the eight studies explicitly link professionalism and EDI concepts [ 19 , 20 , 22 , 26 ]. In one study, first-year medical students completed a 10-month community health elective course aimed to expand cultural humility and advocacy in the context of adolescent care [ 22 ]. Reflective essays completed at the end of the course revealed that 90% of students noted an increase in knowledge and skills of professionalism [ 22 ]. These findings are seen across healthcare disciplines including nursing, pharmacy, social work, and other allied health. A 10-week interprofessional course aimed at developing cultural humility induced professional growth in addition to improved cultural proficiency among nursing, pharmacy, and social work trainees [ 26 ]. These studies demonstrate improved professionalism as an outcome for EDI-promotion through healthcare education.

Studies employing clinical placement interventions as methods of EDI-training revolved around either rural community or international placements [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. Professionalism outcomes included a heterogenous combination of reflections on patient-clinican and interprofessional interactions [ 32 , 34 ]. All thirteen studies report improvement in domains of professionalism secondary to exchange programs within different cultural settings [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. A 4-week exchange between Japanese and UK medical students was associated with professionalism outcomes including social justice and resource stewardship [ 38 ]. Five of the thirteen studies explicitly connect domains of EDI to professionalism or professional development [ 28 , 29 , 33 , 36 , 37 ]. In these cases, cross-cultural experiences directly improve professionalism in participants [ 31 , 33 , 36 ]. Remaining studies describe parallel improvements in cultural humility and professionalism as outcomes of the intervention with implicit associations between the two concepts [ 27 , 39 ].

Theme 2: operationalization of professionalism revealed themes of EDI

A second subset of studies assessed trainee conceptualization of health professionalism within their respective field of practice ( n  = 12) [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ]. These studies investigate the attitudes, perspectives, and competencies of trainees on professionalism in relationship to domains of EDI. Trainees note that adaptibility and humility are critical elements of professionalism, which extends to adapting to cultural and social norms [ 51 ]. Inability to accomodate differences in gender norms, language, or cultural beliefs are sources of professionalism dilemmas [ 44 ]. Hamdan Alshammari and Alboliteeh applied a structural equation model to questionnaire responses of 587 nurses in Saudi Arabia. They find significant correlations between dimensions of professionalism and cultural competency [ 50 ]. Similarly, practitioner perceptions of cultural competency are closely related to perceptions of professional development rather than formal health professional education [ 43 ]. A bidirectional relationship between professionalism and themes of EDI is demonstrated in the literature. Topics of EDI including cultural humility and health advocacy are often cited as core components of professional development [ 47 , 51 ]. Simultaneously, medical trainees, physicians, and researchers identify a need to integrate professionalism assessment within the development of an effective cultural humility curricula [ 46 ]. Conventional professionalism values such patient centeredness, bias recognition and clinical skills are necessary for cultural humility [ 46 ]. Therefore, not only is EDI training a contributing factor to professionalism, professional identity development is required for acquisition of EDI competencies.

Theme 3: current standards of professionalism are perceived as non-inclusive

The final set of studies explored the perspectives of trainees and practitioners from equity-deserving groups (n= [ 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ]. Specifically, researchers investigated perceptions of professionalism in the workplace with reference to gender identity, sexual orientation, race/ethnicity and other EDI-associated demographic factors [ 52 , 53 ]. Participants from equity-deserving groups routinely experience professionalism as culturally and ethnically restrictive [ 53 ]. In these studies, professionalism is defined as a reflection of the cultural norms and expectations of the dominant social group [ 59 ]. Given the historical context in which professionalism was established, these norms often stem from the “White male identity” [ 53 ]. Consequently, trainees and practitioners that deviate from existing definitions of professionalism in terms of racial or ethnic identity, culture, skin colour, gender identity, sexual orientation, or colour are at a disadvantage. Survey of practitioners from equity-deserving backgrounds notes increased criticism over professional actions and increased pressure to conform. Furthermore, cultural and ethnic incongruity with the professionalism standard inhibits professional development to positions of leadership [ 54 , 55 ]. This literature is also surrounded by a handful of recent commentaries by physicians on the current inequities faced by equity-deserving populations [ 59 , 60 , 61 , 62 , 63 , 64 , 65 ]. Rosenberg and colleagues discuss three cases in which professionalism standards propagated disparities within medicine. One case is of a Latin medical student who was deemed unprofessional in a clinical examination as she was wearing Latin earrings [ 61 ]. Dr. AbdelHameid shares her experiences as a Black physician burden by an expectation to comply with racially charged interactions with patients and colleagues in order to align with professionalism expectations [ 62 ]. International medical graduates highlight the unique challenges of adapting to professionalism norms due to the inherent interconnectedness of professional identity and cultural schemata [ 65 ]. A common motif remains a sense of rigidity in definitions of professionalism with limited ethnic expression afforded to practitioners [ 59 , 62 ]. Accordingly, there is increasing support for the existing definitions of professionalism to include measures of equity, diversity, and cultural humility [ 52 , 55 , 56 ]. Professionalism is viewed as a tool to promote anti-discriminatory practice within the clinical landscape [ 54 ]. Advocacy is proposed as a valuable competency for trainees to induce changes in institutional professionalism standards [ 53 ]. Strategies to centre equity and inclusion include increased justice within professionalism assessment and greater value for diverse populations on clinical teams [ 65 ]. Patient facing strategies outlined by studies within this theme include greater humility for structural inequities faced by marginalized populations and attention to positionality in patient care (Fig.  2 ) [ 65 ].

The aim of this scoping review was to characterize existing literature surrounding EDI, cultural humility, and advocacy principles in professionalism education, assessment, or experiences for healthcare trainees and practitioners. EDI and professionalism are explored in three predominant modalities. EDI-interventions such as educational courses improve professionalism outcomes among learners (Fig.  2 ) [ 19 , 22 , 24 ]. In the present studies, rural and foreign exchange programs are intended to produce improvements in cultural humility. Previous research supports the beneficial outcomes of short-term overseas programs in cultural humility [ 65 , 67 ]. The present studies extend this finding by demonstrating concurrent improvements in professionalism [ 32 , 34 , 38 ]. Furthermore, there is a direct and positive correlation between professional and cultural competencies measured among practitioners [ 50 ]. These findings further support an interconnected model of professionalism and cultural humility.

Integrated model of professionalism including EDI, cultural humility, and health advocacy

Interventions promoting advocacy as a domain of professionalism were more limited in the literature [ 20 ]. While there is a strong agreement for advocacy as a professional responsibility, the scope of the healthcare practitioner as an advocate remains unclear and may contribute to the lack of organized interventions in this area [ 68 , 69 , 70 , 71 ]. Nevertheless, Peluso and colleagues (2013) discuss the success of a four-week “advocacy and activism” module as a component of medical students’ professionalism education. Advocacy is frequently cited within the scope of professional competencies of healthcare trainees [ 72 , 73 ]. Therefore, structured assessment of advocacy education in professionalism remains an area requiring further investigation.

Development and revision of professionalism frameworks rely on values expressed by trainees and practitioners [ 73 , 74 ]. Studies in the first and second domains of our findings cumulatively express an inherent relationship between EDI and professionalism. Interventions to promote EDI competencies, whether it be through educational courses or clinical placements, foster professionalism amongst learners. Healthcare trainees and professionals conceptualize EDI competencies as core values of professionalism in contrast to existing frameworks that lack EDI domains [ 45 , 75 ]. Conversely, healthcare practitioners with formed professional identities tend to demonstrate greater awareness for EDI [ 39 ]. An application of social learning theory translated from engineering profession consolidates this bidirectional relationship in which successful professional identity formation is necessary to acquire values of EDI [ 76 ]. These findings suggest that EDI and professionalism are interrelated domains rather than mutually exclusive competencies.

Commentaries around this topic in the literature signify the disparity faced by individuals from equity-deserving groups due to the lack of EDI integration in current professionalism standards. Narratives from equity deserving groups recall experiences of suppressing their cultural, racial, sexual, and other personal identities to conform with definitions of professionalism. Expression of personal identity that doesn’t align with definitions of professionalism is viewed as unprofessional, hinding individuals from equity deserving groups from attaining positions of leadership [ 62 ]. The coin model of privilege and critical allyship, as described by Nixon, conceptualizes each system of inequity as a coin. These coins provide unearned power to certain individuals based on their relationship to the system of inequity. It elegantly highlights the disparity in power to reform systems of inequity disproportionately given to populations of historic domination [ 77 ]. In our context, the coin signifies existing standards of professionalism by which health professionals are trained and held accountable. Current standards are viewed as exclusive to professionals from equity-deserving groups, rendering their placement on their bottom of the professionalism “coin” and resulting in an unearned disadvantage. The path towards critical allyship requires efforts from those in positions of privilege to reshape these frameworks, incorporating greater awareness of domains of EDI as core competencies of the health professional. Greater emphasis on the values of EDI in the professionalism standards will help bridge health disparities, reflected in improved patient outcomes and higher quality care [ 78 , 79 ]. Current challenges to enacting these changes stems from a performative attitude towards professionalism. Professionalism, if reduced to a checklist of behaviours, fails to capture the commitment to social justice required to institute change [ 63 ]. Attitudes and beliefs of professionalism assessment also remains a challenge, as trainees are more hesitant to engage in advocacy if their institutions are viewed as hostile towards advocacy efforts [ 53 ]. Engaging trainees in the design of professionalism education may prove to be instrumental in instigating change [ 53 ].

Limitations of the literature

Most studies assessed changes in professionalism or measures of EDI with self-reported techniques such as questionnaires, written reflections, or interviews. A few studies use validated tools for assessment of professional development [ 22 ] while most rely on the interpretation of student feedback or internally constructed questionnaires [ 25 , 26 ]. Over the last three decades, an increasing number of validated professionalism tools have been developed based on existing frameworks of professionalism [ 79 , 80 ]. Professionalism assessment inventories are available across medicine, nursing, and pharmacy and demonstrate high reliability and content validity compared to self-report measures [ 80 , 81 , 82 ]. However these tools remain scarce, in-part due to unclear definitions of professionalism, and thus self-report measures are favoured [ 83 ]. Increased use of these tools would support more valid assessments of professionalism in the context of EDI-associated interventions. Studies present in this review engaged solely health trainees and professionals with self-assessment of professionalism. Perspectives from patients are a valuable, and often underutilized, source for gauging professionalism in clinical settings [ 75 ]. Studies investigating patient perception of professionalism in the context of EDI training may serve as a valuable measure for the integration of these concepts.

Limitations of our study

The literature search was developed according to the starting framework of the professionalism-in-practice (PIP) developed at McMaster University [ 3 ]. The framework provides guidance towards query terms related to domains of EDI. Therefore, the conceptualization of the present literature is within the context of the applied framework. Other frameworks may have informed a different strategy to investigate literature on professionalism [ 73 , 84 ]. Secondly, our study aims to promote more equity-oriented language according to the AAMC guide to language promoting health equity [ 11 ]. In this context, we opted to use terms such as “cultural humility” in place of “cultural competency”. However, we acknowledge that those terms are not interchangeable in all contexts [ 85 ].

Conclusion and future directions

To our knowledge, our study is the first to review literature around EDI and professionalism in the healthcare setting. We demonstrate that a significant body of research supports the integration of domains of EDI into professionalism education and assessment across interdisciplinary programs. Interventions aimed to improve measures of EDI concordantly improved measures of professionalism. Domains of EDI, cultural humility, and advocacy correlate with professionalism noted both by self-reported measures and quantitative surveys of health professionals. Current models of professionalism are viewed as non-inclusive to practitioners of equity-deserving groups. These juxtaposing findings suggest an increasing need for the revision of definitions of professionalism to better address competencies of EDI across healthcare disciplines.

We expect this study to drive future research and serve as a support for the development and revision of professionalism frameworks with domains of EDI, cultural humility, and advocacy. The Michael G. DeGroote school of Medicine from which our work is based recently revised its internal model of professionalism to include a domain of EDI [ 3 ]. This revision aims to further address the disparities faced by patients and practitioners of equity-deserving backgrounds. We recommend revisions in professionalism frameworks to serve as a foundation for deeper implementation of EDI in existing health professions training through various modalities including educational opportunities, tools, and mentorship programs. The literature reviewed in this study support the use of interprofessional educational courses. Alternatively electives that increase exposure to equity deserving groups is a feasible form of EDI training for professionalism development. EDI is also increasingly being incorporated into healthcare simulation with recent development of tools for trainees to reflect on simulation training from an EDI perspective [ 85 , 86 , 87 ]. In addition to educational courses and clinical placements discussed in this review, individualized support towards professional identity formation of trainees from equity deserving groups is in emergently recognized aspect of professionalism education [ 88 ]. The University of Toronto’s diversity mentorship initiative have successfully aimed to support professionalism among students from equity-deserving groups, demonstrating the effectiveness of structured mentorship in fostering professional growth within these populations [ 88 ]. Incorporation of EDI into professionalism education for health professionals is a longitudinal endeavour starting at revision of existing frameworks and definitions of professionalism., We hope our work drives the evidence-based design of professionalism frameworks guiding health professional education and standards of assessment.

Data availability

The authors confirm that all relevant data, including the search strategy, databases used, and the papers used in data extraction and analysis are included in the article, or can be found in the supplementary files.

Abbreviations

Equity, Diversity and Inclusion

Medical Education Research Study Quality Instrument

Michael G. DeGroote School of Medicine

Nominal Group Technique

National Taiwan University College of Medicine

Professionalism in Practice

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews

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Acknowledgements

We would like to express our gratitude to Dr. Dorothy Bakker and other members of the Michael G. DeGroote School of Medicine Professionalism Education Committee for their guidance in the development of a scoping search strategy and journal selection.

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MS defined the research topic and study design, and as a more experienced researcher in the team, provided mentorship and constructive feedback throughout the research process. MS also guided the team in journal selection. DS, NB and NA were responsible for the development of the search strategy, devising inclusion and exclusion criteria, screening titles, abstracts and full-text articles, conducting thematic analyses and manuscript writing, with MS providing continued guidance throughout all these steps. All authors thoroughly reviewed the manuscript and provided edits and constructive feedback. The final version of the manuscript was approved by all authors. We would like to declare DS, NB and NA all as first authors with equal contributions and division of tasks throughout the research process.

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Shah, D., Behravan, N., Al-Jabouri, N. et al. Incorporating equity, diversity and inclusion (EDI) into the education and assessment of professionalism for healthcare professionals and trainees: a scoping review. BMC Med Educ 24 , 991 (2024). https://doi.org/10.1186/s12909-024-05981-3

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Bridging the generational gap between nurses and nurse managers: a qualitative study from Qatar

• Ahmad A. Abujaber 1 ,
• Abdulqadir J. Nashwan   ORCID: orcid.org/0000-0003-4845-4119 1 ,
• Mark D. Santos 1 ,
• Nabeel F. Al-Lobaney 1 ,
• Rejo G. Mathew 1 ,
• Jamsheer P. Alikutty 1 ,
• Jibin Kunjavara 3 &
• Albara M. Alomari 2  

BMC Nursing volume  23 , Article number:  623 ( 2024 ) Cite this article

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The nursing workforce comprises multiple generations, each with unique values, beliefs, and expectations that can influence communication, work ethic, and professional relationships. In Qatar, the generational gap between nurses and nurse managers poses challenges to effective communication and teamwork, impacting job satisfaction and patient outcomes.

This study investigates the generational gap between nurses and nurse managers in Qatar, aiming to identify strategies to enhance collaboration and create a positive work environment.

A qualitative research design was used, involving semi-structured interviews with 20 participants, including frontline nurses and senior nurse managers. Participants were purposively sampled to represent different generations. Data were collected through face-to-face and virtual interviews, then transcribed and thematically analyzed.

Four key themes emerged: Optimizing the Work Environment : Older generations preferred transformational and situational leadership, while younger nurses valued respect, teamwork, accountability, and professionalism. Strengthening Work Atmosphere through Communication and values : Older nurses favored face-to-face communication, while younger nurses preferred digital tools. Cultivating Respect and Empathy : Younger nurses emphasized fairness in assignments and promotions, while older nurses focused on empathy and understanding. Dynamic Enhancement of Healthcare Systems : Younger nurses were more adaptable to technology and professional development, while older nurses prioritized clinical care and patient outcomes.

The study reveals significant generational differences in leadership preferences, communication styles, and adaptability to technology. Addressing these gaps through effective leadership, ongoing education, and open communication can improve job satisfaction and patient care.

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Introduction

The nursing profession faces a significant challenge of a multigenerational workforce that can cause conflict and hinder effective communication, especially between nurse managers and nurses [ 1 ]. In addition, a literature review of studies conducted over the past two decades indicates that the generational gap between nurses and nurse managers is a complex phenomenon requiring concerted efforts to address it [ 2 , 3 ].

The nursing workforce comprises four generations, including the Baby Boomers (born between 1946 and 1964), Generation X (born between 1965 and 1979), Generation Y or Millennials (born between 1980 and 1994), and Generation Z (born after 1995) [ 4 ]. These generations have unique values, beliefs, attitudes, and expectations that influence their communication style, work ethic, and approach to work [ 4 ].

In 2013, Hendricks and Cope discussed the impact of generational differences on the nursing workforce and the challenges it presents for nurse managers [ 5 ]. They searched various databases electronically and found that generational diversity affects nurses’ attitudes, beliefs, work habits, and expectations. The paper suggested that accepting and embracing this diversity can lead to a more harmonious work environment and facilitate nurse retention [ 5 ].

The article focused on the cultural and work ethic differences between Baby Boomers and Generation Xers, with Baby Boomers primarily managing the workforce [ 6 ]. Baby Boomers are described as driven and dedicated, equating work with self-worth and personal fulfillment [ 6 ]. At the same time, Generation Xers have ideas of an acceptable workplace, and their terms of employment are usually non-negotiable [ 6 ]. The article summarized recent literature and studies to guide healthcare leadership in recruiting, retaining, and managing Generation X workers in the nursing field [ 6 ].

Similarly, Carver & Candela (2008) conducted a study to inform nurse managers about the generational differences among nurses and how they affect the work environment [ 7 ]. With four generations in the nursing workforce, understanding the characteristics of each generation can lead to increased job satisfaction, productivity, and decreased turnover [ 7 ]. Considering generational differences as part of an overall strategy to increase organizational commitment can improve nursing work environments and address the global nursing shortage [ 7 ]. Managers should increase their knowledge of generational diversity to tap into the strengths of each generation [ 7 ]. In addition, Younger nurses have different career expectations than their older colleagues [ 8 ]. They seek a balanced lifestyle with reasonable work hours, demand to use the latest technology, and expect to be vocal team members [ 8 ].

Managing a multigenerational workforce requires recognizing and valuing the strengths of each generation. Leaders who maximize everyone’s talents and address individual and generational needs can create synergy and improve team performance. Each generation brings unique strengths to the workforce that should be celebrated and utilized to the organization’s advantage. Meeting the needs of each employee, such as providing opportunities for advancement, work/life balance, compensation, benefits, and learning and development, can lead to higher-functioning work teams [ 9 ]. Nurse leaders should know their employees’ multigenerational characteristics and expectations and provide timely and specific feedback to manage them effectively [ 9 ]. With an appreciation of multigenerational differences and a commitment to higher-functioning work teams, leaders can improve organizational efficiency and patient care outcomes [ 9 ].

To bridge the generational gap in nursing, the SIT offers a comprehensive approach to enhancing communication, collaboration, and teamwork between nurses and nurse managers [ 5 ]. This involves acknowledging and respecting each generation’s unique characteristics, values, and experiences, which fosters a better understanding and more effective cooperation. Establishing a shared vision and goal for patient care unites nurses and nurse managers, helping to overcome any multigenerational conflicts that might arise in the workplace [ 5 ]. Additionally, encouraging multigenerational communication and mentoring is vital. This can be facilitated through programs where experienced nurses share their knowledge and skills with younger colleagues, promoting a cohesive and supportive team environment. Furthermore, providing training and development opportunities tailored to each generation’s diverse learning styles and preferences is essential for building a more skilled and competent workforce [ 10 ].

The literature indicates that the generational gap between nurses and nurse managers is a global complex phenomenon that can affect communication, work values, job satisfaction, retention, and quality of care [ 11 ]. Nursing leaders can recognize generational differences in values and behaviors as potential strengths. By gaining a deeper understanding of generational influences, these insights can be harnessed to develop effective strategies that sustain the diverse yet shrinking nursing workforce. Leveraging generational differences can also create positive work environments, enhance quality and productivity, and ultimately improve patient care. As generational differences increasingly become a critical aspect of diversity, it is essential to understand the dynamics between work engagement and meaningful work across generational cohorts to tailor approaches that align with each organization’s unique needs [ 12 , 13 ].

Understanding how to bridge the generational gap in nursing is crucial for nurses and nurse managers to work together effectively and provide better patient care, ultimately leading to improved patient outcomes. This study aims to enhance workplace communication and collaboration by identifying and addressing the factors contributing to multigenerational workplace conflicts. By doing so, nurses and nurse managers can build more cohesive and supportive teams, resulting in a more positive work environment. Finally, addressing the generational gap in nursing benefits the workplace and enables the organization to develop a more engaged and motivated workforce. Multigenerational learning and development opportunities can increase job satisfaction and retention. Recognizing and valuing the unique perspectives and experiences each generation brings is essential.

Study significance

To the best of our knowledge, no studies have been conducted in Qatar that addressed the generational gap among nurses. In line with this, the study aims to identify and compare the work engagement levels and managerial approaches among nurses and nurse managers across different generations and explore and propose effective strategies for improving communication, collaboration, and job contentment in an intergenerational work environment. The findings will contribute to the nursing profession’s knowledge and provide practical solutions for managing a diverse nursing workforce in Qatar.

This study utilized a descriptive qualitative research design. After considering the participants’ time limits, commitments, and convenience, data were collected through semi-structured interviews with nurses and nurse managers (Executive and assistant executive directors of nursing). The authors developed the interview questions for this study (Supplementary File 1). Participants were recruited from healthcare facilities within the organization through purposive sampling. The sample size was determined based on the data saturation point, where no new themes or perspectives emerged. Interviews were conducted face-to-face or virtually, depending on the participant’s preference and availability. With the participant’s permission, interviews were audio-recorded to aid in accurate transcription and were thematically analyzed.

Development of the interview guide

The interview guide was thoughtfully developed to capture participants’ experiences and insights effectively. The process began with an in-depth review of studies examining the generational gap between nurses and managers, identifying key themes such as work engagement, organizational environment, communication, and technological advancement. These themes provided the framework for creating open-ended questions to elicit detailed and reflective responses. Probing questions were also included to deepen the data collected by clarifying and expanding on participants’ initial answers. The draft questions underwent multiple rounds of review and refinement to ensure clarity, relevance, and the elimination of bias, with potential input from qualitative research experts.

Qualitative research aimed to generate a deep understanding of the generational gap between nurses and their managers. This understanding could not be answered in a quantitative approach. Several strategies were employed throughout the research process to ensure the credibility of the findings.

Firstly, to ensure the credibility of the data collected, the researcher established trust and rapport with the participants. This was achieved by being transparent about the research aims, building rapport, and showing genuine interest in the participants’ experiences. The researcher also ensured that the participants felt comfortable sharing their experiences and opinions by creating a safe and non-judgmental environment.

Secondly, data triangulation was used to enhance the credibility of the data. Data triangulation involves using multiple data sources to provide a more comprehensive understanding of the phenomenon being studied.

Thirdly, the researcher conducted member checking to validate the data collected. Member checking involved sharing the findings with the participants and asking for their feedback on whether the findings accurately represented their experiences and opinions. This process ensured that the researcher’s interpretation of the data aligned with the participants’ experiences and perceptions.

Fourthly, the researcher engaged in reflexivity throughout the research process. Reflexivity involves reflecting on the researcher’s biases, values, and assumptions that might have influenced the research process and findings. By being aware of their biases, the researcher ensured they did not influence the data collection or interpretation of the findings.

Finally, the researcher used a systematic and rigorous approach to analyze the data collected. This study used thematic analysis to identify patterns and themes in the data. The analysis was conducted using a coding scheme, and the findings were supported with quotes from the participants, enhancing the credibility of the findings.

Study population and setting

The participants were approached using a purposive sampling technique. A total of 20 participants were expected to join the study. All participants were approached based on an email from the corporate nursing mail group. The participants of this study met the following criteria: they represented diverse generations, with 3–4 from each of the subsequent generations: Generation X (1965–1980), Generation Y (1981–1996), and Generation Z (1997–2012); they had joined HMC for at least one year; and they were willing to participate in the study.

Study procedures

Before conducting the study, the researcher had obtained the consent of the participants (Research Information Sheet). Interviews were done face-to-face or virtually, depending on the participants’ preferences and availability. During the interviews, conversations were audio-recorded to facilitate transcriptions of the responses, completed within 24 h of the interview, and reviewed by two study researchers. The data saturation was determined by redundancy of information is indicated when similar patterns, themes, or categories keep appearing in the data, and no new information is being uncovered during additional interviews or data collection efforts.

The richness and depth of the data collected are critical. Saturation is considered reached when the data sufficiently explores and explains the research questions and key concepts, providing a comprehensive understanding of the phenomenon. Data saturation was reached after twenty interviews; however, two additional interviews were conducted to confirm this. Ethical principles were strictly observed, primarily explaining the nature and purpose of the study before obtaining their consent to participate. Identifiers were removed from the transcripts, and codes were used to label participants (e.g., Participants 1, 2, etc.). Participants were informed that they had the right to withdraw from the study at any time should they decide not to participate in further sessions.

Data analysis

Initially, all interviews were professionally transcribed verbatim, with pseudonyms used to anonymize participants and protect their identities. Both authors (JK and NFA) thoroughly read and re-read the transcripts multiple times to become familiar with the content and ensure the transcripts accurately reflected the audio recordings. then applied an inductive coding approach, deriving codes directly from the data rather than imposing them beforehand. This involved systematically identifying and highlighting significant quotes and segments within the transcripts that were relevant to the research questions. These initial codes were subsequently organized into potential themes by grouping together codes that shared a common essence or underlying concept. Following this, the researchers organized these initial codes into potential themes by grouping codes that shared a common essence or underlying concept.

The potential themes underwent a two-phase review and refinement process. In the first phase, the researchers reviewed the coded data extracts to ensure they coherently supported the identified themes. In the second phase, the themes were examined in relation to the entire data set to confirm that they accurately represented the data and captured the full range of participants’ experiences. Some themes were modified, combined, or discarded during this process based on their relevance and data representation.

The final step involved crafting a coherent and compelling narrative that provided a detailed account of each theme. The report included illustrative quotes from participants to substantiate the themes and vividly depict their experiences. This structured approach ensured that the analysis was thorough and that the resulting themes were deeply rooted in the data. By following Braun and Clarke’s six-step process, the study moved from raw transcripts to well-defined themes that offer meaningful insights into the generational gap among nurses and Nurse managers.

This study had a cohort of ten frontline nurses from the new generation and ten senior nurse managers from the old generation, as shown in Table  1 . The mean age of the new generation was 32.4 years (SD 4.9 years). The nurses had an average of 8.3 years of overall work experience (SD 3.09 years), specifically at Hamad Medical Corporation (HMC); they had a mean work experience of 4.7 years (SD 1.1 years). Gender distribution among the participants was 80% male and 20% female. This demographic profile reveals a well-experienced group, particularly regarding their tenure at HMC, providing a stable basis for analyzing their professional perspectives and experiences.

On the other hand, the old generation demographics: 60% were Executive Directors and 40% were Assistant Executives. Most participants belonged to Generation X (ages 44 to 59 years old), suggesting a consistent age distribution. On average, the executives had 27.9 years of overall work experience (SD 9.46 years), highlighting substantial professional tenure with considerable variability. Specifically, their mean work experience at Hamad Medical Corporation (HMC) was 17.4 years (SD 8.24 years), reflecting a diverse range of service durations at this institution. The gender distribution was evenly split, with 50% male and 50% female participants. Details on the demographic data of the old generation participants are detailed in Table  2 . Three major themes were derived from the study, as illustrated in Fig.  1 .

The major themes and Sub-Themes derived from the study

Optimizing the working environment

Healthy work environments that maximize the health and well-being of nurses are essential in achieving good patient and societal outcomes, as well as optimal organizational performance. This theme consisted of three sub-themes: Influencing leadership style, Patient outcome and nurse satisfaction, and Adaptation of technological advancement.

Influential leadership styles

When investigating the leadership style, all older generations consistently agreed to prefer the transformational one because of its capacity to inspire and motivate frontline staff. However, to respond to specific situational demands, the older generation in our study modified and combined aspects of situational and democratic leadership.

Which type of leadership I’m following is transformational leadership. But sometimes , we can take that democratic leadership in some situations , but not all of it. We can say situational leadership at the same time. But any leadership style you will follow should be , I can tell , a combination of some practice and attitude toward your staff”. (Participant 17).

On the other hand, the new generation perceives leadership style by retrieving the inner values of their leaders, such as respect, teamwork, accountability, and professionalism.

“Actually , our leaders primarily lead by maintaining a good relationship , and he is making sense of decreasing the distance between the higher and lower positions. So , I can say that I share the same attitudes and values with my senior managers , but it might differ from one person to another.” ( Participant 1).

Enhanced patient outcomes and nurses’ satisfaction

The older generation perceived the working environment as a motivator for enhancing patient outcomes. Mainly, they are putting serving humanity at the top of their priority, which might be achieved through creativity, collaboration, and compassion. As articulated by Participant 7, “I believe that exerting the best effort in one’s job demonstrates ownership and respect for the profession. Serving humanity , I prioritize creativity , collaboration , and compassion in my work”.

This quote demonstrates the deep values held by this group, highlighting their strategy of combining individual achievement with a wider humanitarian influence.

The new generation views the working environment as a vital element in improving nurses’ satisfaction, considering many contributing factors, such as the current status of the global economy and the opportunities for nurses to work and move abroad. As elaborated by Participant 13,

“I think we can see a difference between the young and the old generation , and I think the way they look at nursing as a profession. There is a big difference between all the new generations , and I can see how the old generation looks at it. The older generation is looking at ways to help people. It is a way to provide support for older people. Unfortunately , I think the new generation has started looking at it as a job—more than a way of helping people. And I believe there are many different reasons for this. I think about the economic status around the world , and the other thing that you know is that I believe the world is open nowadays for nurses to travel around. Therefore , it’s started becoming a job more than a profession. Unfortunately , that’s why people start looking at it in a completely different way , which is not something good.” (Participant 13).

Adaptation to technological advancements

When examining the technological aspects, the older generation acknowledges the presence of the gab. Most of them believe the gap exists because they adhere to the old practices they learned previously.

“There is a noticeable difference between the younger and older generations of nurses , primarily due to advancements in technology and medical knowledge. Younger nurses are often more up-to-date with the latest care techniques and medical research , as they can access various modern resources. Older nurses , however , may adhere to practices they learned earlier in their careers , which might not incorporate recent technological changes”. (Participant 16)

On the other hand, the new generation views new technologies as an easy-to-adopt opportunity. They like to use the new potentials that come with AI. For example, the new generation is becoming more dependent on technology due to the greater benefits it provides compared to traditional approaches in terms of diagnosis and treatment.

“Technology is a significant factor for us , being part of the newer generation. It’s very important in our year of nursing. We use computers , advanced machines , and electronic documentation , which differ from past practices.”(participant 10) . “The younger generation is adapting more easily to new technologies and software , like using EMR for documentation. The older generation , who are used to manual documentation , find it harder to adapt to this new system in patient care. I’ve also heard that some facilities are using GPS and AI systems to assist in diagnoses and results. So , artificial intelligence is becoming a part of nursing , and younger generations are adapting more easily to it. It will take time for the older generation to adapt because they are accustomed to different practices”. (Participant 8)

Strengthening the work atmosphere through communication and values

Effective communication enhances working relationships and knowledge translation and reduces conflict responsible for errors, improving patient safety. This theme consisted of three sub-themes, diverse and practical communication approaches, positive work atmosphere cultivation, and emphasis on shared values across teams.

Diverse and effective communication approaches

The older generation emphasizes the importance of training sessions on communication skills and advanced technologies to bridge the gap with the new generation. Moreover, they believe the new generation needs to be more skilled in direct interpersonal communication.

“Effective communication strategies that bridge generational gaps should be promoted. This could include training on communication best practices and the use of technology for older nurses and encouraging younger nurses to develop strong interpersonal skills for face-to-face interactions”. (Participant 20) “The older generations , always think of , they are more of insightful , in terms of , in the meetings they will be able to translate or interpret the information much differently. And that’s how I see.”( Participants − 18) .

According to the new generation, effective and direct communication without any mediator can enhance the work atmosphere and ease professional communication with older generations. It can help the new generation have more chances to interact with the old generation.

“Certainly , open and direct communication is helpful. As previously said , it is crucial to have someone who can assist in communicating with my manager in my home country. Establishing a direct line of communication with my management and developing a robust professional connection without intermediaries is vital. I appreciate the older generation’s facilitation of an open-door policy , as it cultivates a direct and efficient communication atmosphere.” (Participant 1).

Positive work atmosphere cultivation

When examining the intergenerational dynamics in the workplace, the findings indicated that differences in experience, training, and access to technology significantly impact the work environment and the level of collaboration among employees. As one participant articulated,

“The work atmosphere impacts collaboration. I think it does impact that and impacts these differences from one generation to another. It’s not about good and bad , but it’s rather about the differences in the experiences , differences in the training , and differences in the work environment as well as the availability of technology. So , I would say that there is a difference.” (Participant 19). However, the new generation focuses on the technological aspect and how that might affect the work atmosphere positively.

Emphasis on shared values across teams

Conflicts arise when older generations rely on experience while new generations prefer evidence-based practices. This affects workplace shared values.

“For instance , there might be a conflict over a non-scientifically backed common practice. The older generation might argue that they’ve been doing it for years without issues. However , from a knowledge-based perspective , the practice might be incorrect. Overall , the older generation’s viewpoint is based on their experience , where they haven’t seen negative outcomes. Conversely , the new generation would argue based on scientific principles and current best practices. The older generation might resist changing to these new practices. So , conflicts like these might arise from differing viewpoints on practices and approaches.” (Participant 9) .

The new generations perceive shared values as part of the staff-manager relationship and can’t isolate it. When the old generation leads, the staff investigates the old generation’s way of leading, which will affect the new generation’s attitudes and values. Consequently, the new generation still takes the old generation as an example to be followed. This meaning can be found in Participant 1 answers. “Actually , our leaders primarily lead by maintaining a good relationship , and he is making sense of decreasing the distance between the higher and lower positions. So , I can say that I share the same attitudes and values with my senior managers , but it might differ from one person to another.” ( Participant 1) .

Cultivating respect and empathy

This theme focuses on two subthemes: commitment to fairness and fostering a sense of purpose among staff.

Commitment to fairness

The results of the older generation highlight the importance of fostering empathy in the workplace. Participant 20 suggests promoting understanding by encouraging the new generation to consider their colleagues’ perspectives and motivations, enhancing mutual respect and cooperation.

“Encourage Empathy: Foster empathy among employees by encouraging them to put themselves in each other’s shoes. Encouraging individuals to consider the motivations and experiences of their colleagues can lead to better understanding” (Participant 20). “They can challenge you as a leader and they can challenge each other. That’s how you build a better workplace to have a conversation , a clear professional conversation. If you want to build a professional conversation , the two respect the critiques to respect the differences. So those differences are not conflicts. Differences are differences of opinion due to the experiences everybody can brings in.”(Participants 18) .

However, the new generation demands that older generations be more open to work-related discussions, assignments, and promotion opportunities. They believe the new generation has a greater chance to be promoted if they get a fair chance as they are equipped and well-educated. This was clear by Participant 9.“ Compared to the older generation , the new generation of nurses has more opportunities for service and promotion based on education. In the past , nurses often held diplomas or auxiliary nursing qualifications , with the attitude focused primarily on patient care. Now , there’s a trend towards having more knowledgeable nurses capable of providing advanced care”( Participant 9).

Fostering a sense of purpose among staff

A sense of purpose plays a crucial role in developing cohesive nursing teams by promoting transparent communication and mutual learning, as emphasized by Participant 18.

“The most effective way that I felt worked during this period is the mentorship , working closely with the people and letting them have open communication all the time , providing the proper support , and providing the platform to share the experience and knowledge while you are learning or why they are learning from , and this learning process will be from both. So , this sharing of information through a clear mentorship , in one way or another , will create a culture of mutual respect , and this will end with time; this is not just easy; it takes time. But eventually , if it is done appropriately from the beginning , it will formulate a more cohesive nursing team.“(Participant 18).

The sense of purpose was more obvious among the new generation’s responses, as can be seen in Participant 7’s response: “ Our teamwork is initially built on collaboration , where each nurse supports and enhances the work of others.”

Dynamic enhancement of healthcare systems

The new generation is more adaptable to technological changes and modern healthcare systems. They often embrace new approaches and value work-life balance and a more collaborative approach to patient care. Older nurses have been exposed to a traditional healthcare system and may have had to adapt to technological changes later in their careers.

Continuous education and professional development

The new generation is involved in all nursing and patient care areas. They are advancing in roles such as nurse advocates and nurse researchers. So, the new generation is expanding into new fields and trying to improve the nursing career by pursuing education and professional development. In contrast, the older generation focuses more on clinical areas and patient outcomes.

“There are more options available now , especially for the younger generations. Previously , options were limited. You would start at a hospital or a specific department and stay there. With education and different pathways , you can work in patient care or move into education or other areas. This variety of options makes it easier for the younger generations.” (Participant:8) . “The other thing that when you are dealing with the old generation , you’ll find the love to be with the patient , patient bedside dealing with the patient day today.” (Participant:13) .

Promotion of organizational openness and transparency

The old generation perceived transparency as the need for the new and old generations to openly discuss changes, address concerns, and collaboratively adapt to evolving practices, fostering a transparent and supportive environment in the nursing profession. “Create an environment where nurses and nurse managers can openly discuss changes in the profession , address concerns , and work together to adapt” (Participant 20).

The new generation perceives transparency as a valuable key to promoting change. Participant No. 1’s answers reveal this meaning: “By open communication , that will help. Straight communication and effective communication indeed will help in preparing for the change. As I mentioned before , I need some help or someone to communicate with my manager in my home country. Also , by ensuring that there is no second person between you and your manager , maintain good relationships.”(Participant:1).

This study assessed the generational gap between the new and the old generation. We have identified four main themes: optimizing the working environment, strengthening the work atmosphere through communication and values, cultivating respect and empathy, and dynamic enhancement of healthcare systems. Overall, the results of this study identify the generational gap between these two generations. Moreover, the findings of this research shed light on significant subthemes that highlight the evolving dynamics within the nursing profession, particularly the differences and similarities between new and old generations. The demographic data provided a clear understanding of the structure of both generations, with a notable representation of male staff nurses in the new generation and a diverse range of experiences in healthcare.

Working environment

Perceiving the work environment was evident as a generational gap in our study; the leadership style and other subthemes were also identified. This study discovered that the older generation significantly promotes effective leadership styles, including transformational and situational leadership. These styles enhance teamwork, promote autonomy, and ensure a supportive work environment. This is consistent with the findings of Cummings et al. (2018), who highlighted that transformational leadership positively impacts nurse satisfaction and patient outcomes by fostering a supportive and communicative work environment [ 14 ]. Furthermore, situational leadership is vital for the older generation in dynamic critical care units, offering flexibility to address staff readiness levels effectively [ 15 ].

On the other hand, the new generation stressed the importance of inner values such as respect, teamwork, accountability, and professionalism rather than the leadership style of the old generation. The new generation’s focus on internal values suggests a potential shift in organizational culture that prioritizes individual integrity and an attitude of collaboration over traditional hierarchical leadership approaches. This trend indicates that future healthcare entities’ strategies may incrementally prioritize cultivating an environment where ethical behaviors, mutual respect, and collective responsibility play crucial roles in achieving organizational success. This result is consistent with another study done by Boamah et al. (2018), who found that supportive leadership practices enhance nurses’ work engagement and patient care quality, emphasizing the need for recognition and acknowledgment strategies to boost job satisfaction [ 16 ].

In addition, our study evidently shows generational differences in adaptation to technological advancements, with the new generation demonstrating a higher ability to adopt new technologies into their practice. This finding is supported by Lera et al. (2020), who noted that the new generation is more comfortable with modern digital tools and evidence-based practices​ than the old generation [ 17 ].

Strengthening work atmosphere through communication and values

The current study has found that generational differences in communication preferences exist, with the new generation leveraging technology for more accessible communication. In contrast, the old generation prefers face-to-face interactions for clearer understanding. This aligns with the findings of Rosi et al. (2019), who noted that younger healthcare professionals are more likely to use digital communication tools, whereas the older generation favors traditional methods [ 18 ]. Effective communication strategies that bridge these generational gaps are crucial. Training on communication best practices and the use of technology for the old generation, as well as encouraging the new generation to develop strong interpersonal skills for face-to-face interactions, are crucial [ 19 ].

Regular feedback mechanisms are crucial for identifying and addressing concerns related to the work atmosphere. Boamah et al. (2018) suggest that understanding and addressing generational differences in work preferences can improve team cohesion and reduce conflicts, ultimately leading to better patient care [ 16 ]. The study participants also emphasized the importance of feedback in creating a positive work environment, consistent with the findings of Lin et al. (2021), who stressed the value of input in fostering a supportive workplace [ 20 ]. The current study found that creating a work culture where debate is encouraged, disagreements are respectful, and active listening helps build a team-oriented mindset. This finding aligns with research by Flores et al. (2023), who noted that promoting shared values and respectful communication enhances team cohesion and collaboration [ 21 ].

The current study has found another generational gap in respect and empathy. The new generation emphasizes the importance of having fair assignments, work-related discussions, and promotion opportunities [ 22 ]. Choi et al. (2018), consistent with our study, reported that fair clinical assignments will enhance staff satisfaction, improve nurses’ working conditions, and positively impact patient outcomes [ 23 ].

Professional self-concept is crucial to staff satisfaction, retention, and well-being [ 24 ]. The sense of purpose is part of the nurse’s professional self-concept; hence, the old generation, especially the leaders, must promote staff well-being by considering their purpose and fostering an environment of mutual benefit [ 25 ]. This finding aligns with the current study, which revealed that the new generation views a sense of purpose as fundamental to their professional needs.

The healthcare system is generally considered a significant influence on nursing careers. Regardless of generation, the healthcare system affects nurses and healthcare providers as it is continuously changed, modified, and developed, creating new challenges and opportunities for healthcare providers.

The progression of nursing practice has been significantly influenced by advancements in education and professional development, leading to a shift in roles and opportunities for nurses. The new generation, who are more adaptable to technological changes and evidence-based practices, are increasingly moving into diverse roles beyond traditional clinical settings. They are now prominent in fields such as nurse advocacy, research, and education, reflecting a broadening of the nursing profession and ultimately enhancing healthcare systems. This shift contrasts with the experiences of the older generation who have primarily focused on direct patient care within clinical environments. Recent studies support this trend. For instance, a study found that new nurses are more likely to engage in continuous education and seek roles that allow for more incredible professional growth and diversification than older nurses [ 26 ].

Our study revealed that creating an environment that promotes openness and transparency is essential for fostering effective communication and collaboration between different generations of nurses. Fostering mentorship and knowledge sharing bridges the generational gap and ensures the transmission of valuable experiences and practices. An open dialogue between nurses and nurse managers about changes in the profession, concerns, and adaptation strategies is critical for cohesive teamwork. These findings are consistent with Bragadóttir et al. (2022), which indicate that organizational transparency and open communication channels significantly enhance teamwork and job satisfaction among nursing staff [ 24 ].

This study highlights the evolving dynamics within the nursing profession, focusing on generational differences and similarities. The new generation is more skillful at integrating technology and embracing diverse roles beyond traditional clinical settings, whereas the old generation brings valuable experience and historical perspectives. Effective leadership, continuous education, and open communication are critical for optimizing the work environment, enhancing nurse satisfaction, and improving patient outcomes. Bridging the generational gap through mentorship and fostering a culture of respect and empathy are essential for a cohesive and resilient healthcare system.

Recommendations

Future research should explore strategies to effectively bridge the generational gap in nursing by integrating leadership styles, communication preferences, and technology adoption across different generations. Longitudinal studies could examine how generational dynamics evolve as new generations enter the workforce and older generations transition out, providing insights into the sustainability of organizational changes. Additionally, expanding research to diverse healthcare settings and cultural contexts would enhance the generalizability of findings. At the same time, intervention studies could test the effectiveness of tailored mentorship programs, continuous education initiatives, and organizational transparency in fostering intergenerational collaboration and improving patient care outcomes.

The study’s methodology, including potential sampling bias due to purposive selection, interviewer bias, and the subjective nature of data saturation, could also influence the results. Additionally, the context-specific nature of the study and the use of virtual interviews might limit the depth and transferability of the findings. Finally, time constraints may have restricted the comprehensiveness of the data collected.

Implications for nursing management

Nurse managers should adopt a multi-faceted leadership approach, embracing both transformational and situational styles, to meet the diverse needs of a multigenerational workforce. Implementing targeted communication training and fostering an environment of respect and empathy can improve team cohesion and patient outcomes. Investing in continuous professional development and technological training will further support the integration of new and experienced nurses.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors would like to acknowledge the nurses and nurse managers who participated in the study.

This study was funded by the Medical Research Center at Hamad Medical Corporation (MRC-01-23-206).

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Department of Nursing, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar

Ahmad A. Abujaber, Abdulqadir J. Nashwan, Mark D. Santos, Nabeel F. Al-Lobaney, Rejo G. Mathew & Jamsheer P. Alikutty

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Albara M. Alomari

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AAA, AJN: Conceptualization. NFA, MDS, JK: Formal analysis.AAA, AJN, MDS, NFA, RGM, JPA, JK, AMA: Methodology, Data curation, Manuscript writing (draft and final review). All authors read and approved the final manuscript.

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Abujaber, A.A., Nashwan, A.J., Santos, M.D. et al. Bridging the generational gap between nurses and nurse managers: a qualitative study from Qatar. BMC Nurs 23 , 623 (2024). https://doi.org/10.1186/s12912-024-02296-y

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Qualitative Research: Data Collection, Analysis, and Management

Introduction.

In an earlier paper, 1 we presented an introduction to using qualitative research methods in pharmacy practice. In this article, we review some principles of the collection, analysis, and management of qualitative data to help pharmacists interested in doing research in their practice to continue their learning in this area. Qualitative research can help researchers to access the thoughts and feelings of research participants, which can enable development of an understanding of the meaning that people ascribe to their experiences. Whereas quantitative research methods can be used to determine how many people undertake particular behaviours, qualitative methods can help researchers to understand how and why such behaviours take place. Within the context of pharmacy practice research, qualitative approaches have been used to examine a diverse array of topics, including the perceptions of key stakeholders regarding prescribing by pharmacists and the postgraduation employment experiences of young pharmacists (see “Further Reading” section at the end of this article).

In the previous paper, 1 we outlined 3 commonly used methodologies: ethnography 2 , grounded theory 3 , and phenomenology. 4 Briefly, ethnography involves researchers using direct observation to study participants in their “real life” environment, sometimes over extended periods. Grounded theory and its later modified versions (e.g., Strauss and Corbin 5 ) use face-to-face interviews and interactions such as focus groups to explore a particular research phenomenon and may help in clarifying a less-well-understood problem, situation, or context. Phenomenology shares some features with grounded theory (such as an exploration of participants’ behaviour) and uses similar techniques to collect data, but it focuses on understanding how human beings experience their world. It gives researchers the opportunity to put themselves in another person’s shoes and to understand the subjective experiences of participants. 6 Some researchers use qualitative methodologies but adopt a different standpoint, and an example of this appears in the work of Thurston and others, 7 discussed later in this paper.

Qualitative work requires reflection on the part of researchers, both before and during the research process, as a way of providing context and understanding for readers. When being reflexive, researchers should not try to simply ignore or avoid their own biases (as this would likely be impossible); instead, reflexivity requires researchers to reflect upon and clearly articulate their position and subjectivities (world view, perspectives, biases), so that readers can better understand the filters through which questions were asked, data were gathered and analyzed, and findings were reported. From this perspective, bias and subjectivity are not inherently negative but they are unavoidable; as a result, it is best that they be articulated up-front in a manner that is clear and coherent for readers.

THE PARTICIPANT’S VIEWPOINT

What qualitative study seeks to convey is why people have thoughts and feelings that might affect the way they behave. Such study may occur in any number of contexts, but here, we focus on pharmacy practice and the way people behave with regard to medicines use (e.g., to understand patients’ reasons for nonadherence with medication therapy or to explore physicians’ resistance to pharmacists’ clinical suggestions). As we suggested in our earlier article, 1 an important point about qualitative research is that there is no attempt to generalize the findings to a wider population. Qualitative research is used to gain insights into people’s feelings and thoughts, which may provide the basis for a future stand-alone qualitative study or may help researchers to map out survey instruments for use in a quantitative study. It is also possible to use different types of research in the same study, an approach known as “mixed methods” research, and further reading on this topic may be found at the end of this paper.

The role of the researcher in qualitative research is to attempt to access the thoughts and feelings of study participants. This is not an easy task, as it involves asking people to talk about things that may be very personal to them. Sometimes the experiences being explored are fresh in the participant’s mind, whereas on other occasions reliving past experiences may be difficult. However the data are being collected, a primary responsibility of the researcher is to safeguard participants and their data. Mechanisms for such safeguarding must be clearly articulated to participants and must be approved by a relevant research ethics review board before the research begins. Researchers and practitioners new to qualitative research should seek advice from an experienced qualitative researcher before embarking on their project.

DATA COLLECTION

Whatever philosophical standpoint the researcher is taking and whatever the data collection method (e.g., focus group, one-to-one interviews), the process will involve the generation of large amounts of data. In addition to the variety of study methodologies available, there are also different ways of making a record of what is said and done during an interview or focus group, such as taking handwritten notes or video-recording. If the researcher is audio- or video-recording data collection, then the recordings must be transcribed verbatim before data analysis can begin. As a rough guide, it can take an experienced researcher/transcriber 8 hours to transcribe one 45-minute audio-recorded interview, a process than will generate 20–30 pages of written dialogue.

Many researchers will also maintain a folder of “field notes” to complement audio-taped interviews. Field notes allow the researcher to maintain and comment upon impressions, environmental contexts, behaviours, and nonverbal cues that may not be adequately captured through the audio-recording; they are typically handwritten in a small notebook at the same time the interview takes place. Field notes can provide important context to the interpretation of audio-taped data and can help remind the researcher of situational factors that may be important during data analysis. Such notes need not be formal, but they should be maintained and secured in a similar manner to audio tapes and transcripts, as they contain sensitive information and are relevant to the research. For more information about collecting qualitative data, please see the “Further Reading” section at the end of this paper.

DATA ANALYSIS AND MANAGEMENT

If, as suggested earlier, doing qualitative research is about putting oneself in another person’s shoes and seeing the world from that person’s perspective, the most important part of data analysis and management is to be true to the participants. It is their voices that the researcher is trying to hear, so that they can be interpreted and reported on for others to read and learn from. To illustrate this point, consider the anonymized transcript excerpt presented in Appendix 1 , which is taken from a research interview conducted by one of the authors (J.S.). We refer to this excerpt throughout the remainder of this paper to illustrate how data can be managed, analyzed, and presented.

Interpretation of Data

Interpretation of the data will depend on the theoretical standpoint taken by researchers. For example, the title of the research report by Thurston and others, 7 “Discordant indigenous and provider frames explain challenges in improving access to arthritis care: a qualitative study using constructivist grounded theory,” indicates at least 2 theoretical standpoints. The first is the culture of the indigenous population of Canada and the place of this population in society, and the second is the social constructivist theory used in the constructivist grounded theory method. With regard to the first standpoint, it can be surmised that, to have decided to conduct the research, the researchers must have felt that there was anecdotal evidence of differences in access to arthritis care for patients from indigenous and non-indigenous backgrounds. With regard to the second standpoint, it can be surmised that the researchers used social constructivist theory because it assumes that behaviour is socially constructed; in other words, people do things because of the expectations of those in their personal world or in the wider society in which they live. (Please see the “Further Reading” section for resources providing more information about social constructivist theory and reflexivity.) Thus, these 2 standpoints (and there may have been others relevant to the research of Thurston and others 7 ) will have affected the way in which these researchers interpreted the experiences of the indigenous population participants and those providing their care. Another standpoint is feminist standpoint theory which, among other things, focuses on marginalized groups in society. Such theories are helpful to researchers, as they enable us to think about things from a different perspective. Being aware of the standpoints you are taking in your own research is one of the foundations of qualitative work. Without such awareness, it is easy to slip into interpreting other people’s narratives from your own viewpoint, rather than that of the participants.

To analyze the example in Appendix 1 , we will adopt a phenomenological approach because we want to understand how the participant experienced the illness and we want to try to see the experience from that person’s perspective. It is important for the researcher to reflect upon and articulate his or her starting point for such analysis; for example, in the example, the coder could reflect upon her own experience as a female of a majority ethnocultural group who has lived within middle class and upper middle class settings. This personal history therefore forms the filter through which the data will be examined. This filter does not diminish the quality or significance of the analysis, since every researcher has his or her own filters; however, by explicitly stating and acknowledging what these filters are, the researcher makes it easer for readers to contextualize the work.

Transcribing and Checking

For the purposes of this paper it is assumed that interviews or focus groups have been audio-recorded. As mentioned above, transcribing is an arduous process, even for the most experienced transcribers, but it must be done to convert the spoken word to the written word to facilitate analysis. For anyone new to conducting qualitative research, it is beneficial to transcribe at least one interview and one focus group. It is only by doing this that researchers realize how difficult the task is, and this realization affects their expectations when asking others to transcribe. If the research project has sufficient funding, then a professional transcriber can be hired to do the work. If this is the case, then it is a good idea to sit down with the transcriber, if possible, and talk through the research and what the participants were talking about. This background knowledge for the transcriber is especially important in research in which people are using jargon or medical terms (as in pharmacy practice). Involving your transcriber in this way makes the work both easier and more rewarding, as he or she will feel part of the team. Transcription editing software is also available, but it is expensive. For example, ELAN (more formally known as EUDICO Linguistic Annotator, developed at the Technical University of Berlin) 8 is a tool that can help keep data organized by linking media and data files (particularly valuable if, for example, video-taping of interviews is complemented by transcriptions). It can also be helpful in searching complex data sets. Products such as ELAN do not actually automatically transcribe interviews or complete analyses, and they do require some time and effort to learn; nonetheless, for some research applications, it may be a valuable to consider such software tools.

All audio recordings should be transcribed verbatim, regardless of how intelligible the transcript may be when it is read back. Lines of text should be numbered. Once the transcription is complete, the researcher should read it while listening to the recording and do the following: correct any spelling or other errors; anonymize the transcript so that the participant cannot be identified from anything that is said (e.g., names, places, significant events); insert notations for pauses, laughter, looks of discomfort; insert any punctuation, such as commas and full stops (periods) (see Appendix 1 for examples of inserted punctuation), and include any other contextual information that might have affected the participant (e.g., temperature or comfort of the room).

Dealing with the transcription of a focus group is slightly more difficult, as multiple voices are involved. One way of transcribing such data is to “tag” each voice (e.g., Voice A, Voice B). In addition, the focus group will usually have 2 facilitators, whose respective roles will help in making sense of the data. While one facilitator guides participants through the topic, the other can make notes about context and group dynamics. More information about group dynamics and focus groups can be found in resources listed in the “Further Reading” section.

Reading between the Lines

During the process outlined above, the researcher can begin to get a feel for the participant’s experience of the phenomenon in question and can start to think about things that could be pursued in subsequent interviews or focus groups (if appropriate). In this way, one participant’s narrative informs the next, and the researcher can continue to interview until nothing new is being heard or, as it says in the text books, “saturation is reached”. While continuing with the processes of coding and theming (described in the next 2 sections), it is important to consider not just what the person is saying but also what they are not saying. For example, is a lengthy pause an indication that the participant is finding the subject difficult, or is the person simply deciding what to say? The aim of the whole process from data collection to presentation is to tell the participants’ stories using exemplars from their own narratives, thus grounding the research findings in the participants’ lived experiences.

Smith 9 suggested a qualitative research method known as interpretative phenomenological analysis, which has 2 basic tenets: first, that it is rooted in phenomenology, attempting to understand the meaning that individuals ascribe to their lived experiences, and second, that the researcher must attempt to interpret this meaning in the context of the research. That the researcher has some knowledge and expertise in the subject of the research means that he or she can have considerable scope in interpreting the participant’s experiences. Larkin and others 10 discussed the importance of not just providing a description of what participants say. Rather, interpretative phenomenological analysis is about getting underneath what a person is saying to try to truly understand the world from his or her perspective.

Once all of the research interviews have been transcribed and checked, it is time to begin coding. Field notes compiled during an interview can be a useful complementary source of information to facilitate this process, as the gap in time between an interview, transcribing, and coding can result in memory bias regarding nonverbal or environmental context issues that may affect interpretation of data.

Coding refers to the identification of topics, issues, similarities, and differences that are revealed through the participants’ narratives and interpreted by the researcher. This process enables the researcher to begin to understand the world from each participant’s perspective. Coding can be done by hand on a hard copy of the transcript, by making notes in the margin or by highlighting and naming sections of text. More commonly, researchers use qualitative research software (e.g., NVivo, QSR International Pty Ltd; www.qsrinternational.com/products_nvivo.aspx ) to help manage their transcriptions. It is advised that researchers undertake a formal course in the use of such software or seek supervision from a researcher experienced in these tools.

Returning to Appendix 1 and reading from lines 8–11, a code for this section might be “diagnosis of mental health condition”, but this would just be a description of what the participant is talking about at that point. If we read a little more deeply, we can ask ourselves how the participant might have come to feel that the doctor assumed he or she was aware of the diagnosis or indeed that they had only just been told the diagnosis. There are a number of pauses in the narrative that might suggest the participant is finding it difficult to recall that experience. Later in the text, the participant says “nobody asked me any questions about my life” (line 19). This could be coded simply as “health care professionals’ consultation skills”, but that would not reflect how the participant must have felt never to be asked anything about his or her personal life, about the participant as a human being. At the end of this excerpt, the participant just trails off, recalling that no-one showed any interest, which makes for very moving reading. For practitioners in pharmacy, it might also be pertinent to explore the participant’s experience of akathisia and why this was left untreated for 20 years.

One of the questions that arises about qualitative research relates to the reliability of the interpretation and representation of the participants’ narratives. There are no statistical tests that can be used to check reliability and validity as there are in quantitative research. However, work by Lincoln and Guba 11 suggests that there are other ways to “establish confidence in the ‘truth’ of the findings” (p. 218). They call this confidence “trustworthiness” and suggest that there are 4 criteria of trustworthiness: credibility (confidence in the “truth” of the findings), transferability (showing that the findings have applicability in other contexts), dependability (showing that the findings are consistent and could be repeated), and confirmability (the extent to which the findings of a study are shaped by the respondents and not researcher bias, motivation, or interest).

One way of establishing the “credibility” of the coding is to ask another researcher to code the same transcript and then to discuss any similarities and differences in the 2 resulting sets of codes. This simple act can result in revisions to the codes and can help to clarify and confirm the research findings.

Theming refers to the drawing together of codes from one or more transcripts to present the findings of qualitative research in a coherent and meaningful way. For example, there may be examples across participants’ narratives of the way in which they were treated in hospital, such as “not being listened to” or “lack of interest in personal experiences” (see Appendix 1 ). These may be drawn together as a theme running through the narratives that could be named “the patient’s experience of hospital care”. The importance of going through this process is that at its conclusion, it will be possible to present the data from the interviews using quotations from the individual transcripts to illustrate the source of the researchers’ interpretations. Thus, when the findings are organized for presentation, each theme can become the heading of a section in the report or presentation. Underneath each theme will be the codes, examples from the transcripts, and the researcher’s own interpretation of what the themes mean. Implications for real life (e.g., the treatment of people with chronic mental health problems) should also be given.

DATA SYNTHESIS

In this final section of this paper, we describe some ways of drawing together or “synthesizing” research findings to represent, as faithfully as possible, the meaning that participants ascribe to their life experiences. This synthesis is the aim of the final stage of qualitative research. For most readers, the synthesis of data presented by the researcher is of crucial significance—this is usually where “the story” of the participants can be distilled, summarized, and told in a manner that is both respectful to those participants and meaningful to readers. There are a number of ways in which researchers can synthesize and present their findings, but any conclusions drawn by the researchers must be supported by direct quotations from the participants. In this way, it is made clear to the reader that the themes under discussion have emerged from the participants’ interviews and not the mind of the researcher. The work of Latif and others 12 gives an example of how qualitative research findings might be presented.

Planning and Writing the Report

As has been suggested above, if researchers code and theme their material appropriately, they will naturally find the headings for sections of their report. Qualitative researchers tend to report “findings” rather than “results”, as the latter term typically implies that the data have come from a quantitative source. The final presentation of the research will usually be in the form of a report or a paper and so should follow accepted academic guidelines. In particular, the article should begin with an introduction, including a literature review and rationale for the research. There should be a section on the chosen methodology and a brief discussion about why qualitative methodology was most appropriate for the study question and why one particular methodology (e.g., interpretative phenomenological analysis rather than grounded theory) was selected to guide the research. The method itself should then be described, including ethics approval, choice of participants, mode of recruitment, and method of data collection (e.g., semistructured interviews or focus groups), followed by the research findings, which will be the main body of the report or paper. The findings should be written as if a story is being told; as such, it is not necessary to have a lengthy discussion section at the end. This is because much of the discussion will take place around the participants’ quotes, such that all that is needed to close the report or paper is a summary, limitations of the research, and the implications that the research has for practice. As stated earlier, it is not the intention of qualitative research to allow the findings to be generalized, and therefore this is not, in itself, a limitation.

Planning out the way that findings are to be presented is helpful. It is useful to insert the headings of the sections (the themes) and then make a note of the codes that exemplify the thoughts and feelings of your participants. It is generally advisable to put in the quotations that you want to use for each theme, using each quotation only once. After all this is done, the telling of the story can begin as you give your voice to the experiences of the participants, writing around their quotations. Do not be afraid to draw assumptions from the participants’ narratives, as this is necessary to give an in-depth account of the phenomena in question. Discuss these assumptions, drawing on your participants’ words to support you as you move from one code to another and from one theme to the next. Finally, as appropriate, it is possible to include examples from literature or policy documents that add support for your findings. As an exercise, you may wish to code and theme the sample excerpt in Appendix 1 and tell the participant’s story in your own way. Further reading about “doing” qualitative research can be found at the end of this paper.

CONCLUSIONS

Qualitative research can help researchers to access the thoughts and feelings of research participants, which can enable development of an understanding of the meaning that people ascribe to their experiences. It can be used in pharmacy practice research to explore how patients feel about their health and their treatment. Qualitative research has been used by pharmacists to explore a variety of questions and problems (see the “Further Reading” section for examples). An understanding of these issues can help pharmacists and other health care professionals to tailor health care to match the individual needs of patients and to develop a concordant relationship. Doing qualitative research is not easy and may require a complete rethink of how research is conducted, particularly for researchers who are more familiar with quantitative approaches. There are many ways of conducting qualitative research, and this paper has covered some of the practical issues regarding data collection, analysis, and management. Further reading around the subject will be essential to truly understand this method of accessing peoples’ thoughts and feelings to enable researchers to tell participants’ stories.

Appendix 1. Excerpt from a sample transcript

The participant (age late 50s) had suffered from a chronic mental health illness for 30 years. The participant had become a “revolving door patient,” someone who is frequently in and out of hospital. As the participant talked about past experiences, the researcher asked:

• What was treatment like 30 years ago?
• Umm—well it was pretty much they could do what they wanted with you because I was put into the er, the er kind of system er, I was just on
• endless section threes.
• Really…
• But what I didn’t realize until later was that if you haven’t actually posed a threat to someone or yourself they can’t really do that but I didn’t know
• that. So wh-when I first went into hospital they put me on the forensic ward ’cause they said, “We don’t think you’ll stay here we think you’ll just
• run-run away.” So they put me then onto the acute admissions ward and – er – I can remember one of the first things I recall when I got onto that
• ward was sitting down with a er a Dr XXX. He had a book this thick [gestures] and on each page it was like three questions and he went through
• all these questions and I answered all these questions. So we’re there for I don’t maybe two hours doing all that and he asked me he said “well
• when did somebody tell you then that you have schizophrenia” I said “well nobody’s told me that” so he seemed very surprised but nobody had
• actually [pause] whe-when I first went up there under police escort erm the senior kind of consultants people I’d been to where I was staying and
• ermm so er [pause] I . . . the, I can remember the very first night that I was there and given this injection in this muscle here [gestures] and just
• having dreadful side effects the next day I woke up [pause]
• . . . and I suffered that akathesia I swear to you, every minute of every day for about 20 years.
• Oh how awful.
• And that side of it just makes life impossible so the care on the wards [pause] umm I don’t know it’s kind of, it’s kind of hard to put into words
• [pause]. Because I’m not saying they were sort of like not friendly or interested but then nobody ever seemed to want to talk about your life [pause]
• nobody asked me any questions about my life. The only questions that came into was they asked me if I’d be a volunteer for these student exams
• and things and I said “yeah” so all the questions were like “oh what jobs have you done,” er about your relationships and things and er but
• nobody actually sat down and had a talk and showed some interest in you as a person you were just there basically [pause] um labelled and you
• know there was there was [pause] but umm [pause] yeah . . .

This article is the 10th in the CJHP Research Primer Series, an initiative of the CJHP Editorial Board and the CSHP Research Committee. The planned 2-year series is intended to appeal to relatively inexperienced researchers, with the goal of building research capacity among practising pharmacists. The articles, presenting simple but rigorous guidance to encourage and support novice researchers, are being solicited from authors with appropriate expertise.

Previous articles in this series:

Bond CM. The research jigsaw: how to get started. Can J Hosp Pharm . 2014;67(1):28–30.

Tully MP. Research: articulating questions, generating hypotheses, and choosing study designs. Can J Hosp Pharm . 2014;67(1):31–4.

Loewen P. Ethical issues in pharmacy practice research: an introductory guide. Can J Hosp Pharm. 2014;67(2):133–7.

Tsuyuki RT. Designing pharmacy practice research trials. Can J Hosp Pharm . 2014;67(3):226–9.

Bresee LC. An introduction to developing surveys for pharmacy practice research. Can J Hosp Pharm . 2014;67(4):286–91.

Gamble JM. An introduction to the fundamentals of cohort and case–control studies. Can J Hosp Pharm . 2014;67(5):366–72.

Austin Z, Sutton J. Qualitative research: getting started. C an J Hosp Pharm . 2014;67(6):436–40.

Houle S. An introduction to the fundamentals of randomized controlled trials in pharmacy research. Can J Hosp Pharm . 2014; 68(1):28–32.

Charrois TL. Systematic reviews: What do you need to know to get started? Can J Hosp Pharm . 2014;68(2):144–8.

Competing interests: None declared.

Further Reading

Examples of qualitative research in pharmacy practice.

• Farrell B, Pottie K, Woodend K, Yao V, Dolovich L, Kennie N, et al. Shifts in expectations: evaluating physicians’ perceptions as pharmacists integrated into family practice. J Interprof Care. 2010; 24 (1):80–9. [ PubMed ] [ Google Scholar ]
• Gregory P, Austin Z. Postgraduation employment experiences of new pharmacists in Ontario in 2012–2013. Can Pharm J. 2014; 147 (5):290–9. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Marks PZ, Jennnings B, Farrell B, Kennie-Kaulbach N, Jorgenson D, Pearson-Sharpe J, et al. “I gained a skill and a change in attitude”: a case study describing how an online continuing professional education course for pharmacists supported achievement of its transfer to practice outcomes. Can J Univ Contin Educ. 2014; 40 (2):1–18. [ Google Scholar ]
• Nair KM, Dolovich L, Brazil K, Raina P. It’s all about relationships: a qualitative study of health researchers’ perspectives on interdisciplinary research. BMC Health Serv Res. 2008; 8 :110. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pojskic N, MacKeigan L, Boon H, Austin Z. Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists. Res Soc Adm Pharm. 2014; 10 (2):341–54. [ PubMed ] [ Google Scholar ]

Qualitative Research in General

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Group Dynamics in Focus Groups

• Farnsworth J, Boon B. Analysing group dynamics within the focus group. Qual Res. 2010; 10 (5):605–24. [ Google Scholar ]

Social Constructivism

• Social constructivism. Berkeley (CA): University of California, Berkeley, Berkeley Graduate Division, Graduate Student Instruction Teaching & Resource Center; [cited 2015 June 4]. Available from: http://gsi.berkeley.edu/gsi-guide-contents/learning-theory-research/social-constructivism/ [ Google Scholar ]

Mixed Methods

• Creswell J. Research design: qualitative, quantitative, and mixed methods approaches. Thousand Oaks (CA): Sage Publications; 2009. [ Google Scholar ]

Collecting Qualitative Data

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Constructivist Grounded Theory

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