what is qualitative research in nursing

Nursing Research Guide

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What is qualitative research?

Qualitative research  in Nursing approaches a clinical question from a place of unknowing in an attempt to understand the complexity, depth, and richness of a particular situation from the perspective of the person or persons impacted by the situation (i.e., the subjects of the study).

Study subjects may include the patient(s), the patient's caregivers, the patient's family members, etc. Qualitative research may also include information gleaned from the investigator's or researcher's observations.

While typically more subjective than quantitative research (which focuses on measurements and numbers), qualitative research still employs a systematic approach.

Qualitative research  is generally preferred over quantitative research (which on measurements and numbers) when the clinical question centers around life experiences or meaning.

Adapted from:

• Wilson, B., Austria, M.J., & Casucci, T. (2021 March 21).  Understanding Quantitative and Qualitative Approaches  
• Chicca, J. (2020 June 5).  Introduction to qualitative nursing research.   American Nurse Journal.

Where can I find qualitative research?

Qualitative research can be found in numerous databases. Some good starting options are:

• CINAHL Ultimate Journal articles and eBooks in nursing and allied health.
• MEDLINE (EBSCOhost Web) Journal articles in medicine, life sciences, health care, and biomedical research.
• APA PsycINFO Articles from journals, newspapers, and magazines, along with eBooks in nearly every social science subject area.
• PubMed Citation search of journal articles and books in health and life sciences.

How can I find qualitative research?

Cinahl and/or  medline.

• Start at the Advanced Search  screen.
• Add a search term that represents the topic you are interested in into one (or more) of the search boxes.
• Scroll down until you see the Limit your results  section.
• Qualitative - High Sensitivity (broadest category/broad search)
• Qualitative - High Specificity (narrowest category/specific search)
• Qualitative - Best Balance (somewhere in between)
• Select or click the search button.

APA PsycINFO

• Start at the Advanced Search  screen.
• Use the  Methodology menu to select  Qualitative .

• Use the drop-down menu next the Enter search term  box to set the search to MeSH Terms
• Qualitative Research
• Nursing Methodology Research

How can I use keywords to search for qualitative research?

Try adding adding a keyword that might specifically identify qualitative research. You could add the term qualitative  to your search and/or your could add different types of qualitative research according to your specific needs and/or research assignment.

For example, consider the following types of qualitative research in light of the types of questions a researcher might be trying to answer with each qualitative research type: 

•   Clinical question: What happens to the quality of nursing practice when we implement a peer-mentoring system?
• Clinical question: How is patient autonomy promoted by a unit?
• Clinical question: What is the nursing role in end-of-life decisions?
• Clinical question: What discourses are used in nursing practice and how do they shape practice?
• Clinical question: How does Filipino culture influence childbirth experiences?
• Clinical question: What are the immediate underlying psychological and environmental causes of incivility in nursing?
• Clinical question: How does the basic social process of role transition happen within the context of advanced practice nursing transitions?
• Clinical question: When and why did nurses become researchers?
• Clinical question: How does one live with a diagnosis of scleroderma?
• Clinical question:  What is the lived experience of nurses who were admitted as patients on their home practice units?

Adapted from: Chicca, J. (2020 June 5).  Introduction to qualitative nursing research . American Nurse Journal.

Need more help?

Finding relevant qualitative research can be both difficult and time consuming. Once you conduct a search, you will need to review your search results and look at individual articles, their subject terms, and abstracts to determine if they are truly qualitative research articles. And that's a determination that only you can make.

If you still need help after trying the search strategies and tips suggested on this research guide, we encourage you to schedule an in-person or Zoom research appointment . Health Services librarian Rachel Riffe-Albright is a great bet, but any librarian would be happy to help!

Additonal resources on qualitative research

The following are research guides created by other academic libraries. While you likely will not have access to any of their linked resources, the tips and tricks shared may be useful to you as you search for qualitative research:

• What is Qualitative Research? from UTA Libraries at University of Texas Arlington
• Finding Qualitative Research Articles from Ashland University Library
• Finding Qualitative Research Articles from the Health Sciences Library at University of Washington
• Advanced Search Guide: Qualitative and Quantitative Studies from Southern Connecticut State University Library
• Finding Qualitative and Quantitative Studies in CINAHL from Southern Connecticut State University Library
• << Previous: Searching by Author & Theory
• Next: Searching for Systematic Reviews & Controlled Trials >>
• Last Updated: Apr 22, 2024 2:39 PM
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Art & Science Previous     Next

Qualitative research, leslie gelling reader in nursing, faculty of health, social care and education, anglia ruskin university, cambridge, england.

Qualitative research has an important role in helping nurses and other healthcare professionals understand patient experiences of health and illness. Qualitative researchers have a large number of methodological options and therefore should take care in planning and conducting their research. This article offers a brief overview of some of the key issues qualitative researchers should consider.

Nursing Standard . 29, 30, 43-47. doi: 10.7748/ns.29.30.43.e9749

This article has been subject to double blind peer review

Received: 06 November 2014

Accepted: 17 November 2014

Ethnography - focus groups - grounded theory - interviews - phenomenology - qualitative research

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25 March 2015 / Vol 29 issue 30

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Nursing Resources : Qualitative vs Quantitative

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Differences between Qualitative & Quantitative Research

" Quantitative research ," also called " empirical research ," refers to any research based on something that can be accurately and precisely measured.  For example, it is possible to discover exactly how many times per second a hummingbird's wings beat and measure the corresponding effects on its physiology (heart rate, temperature, etc.).

" Qualitative research " refers to any research based on something that is impossible to accurately and precisely measure.  For example, although you certainly can conduct a survey on job satisfaction and afterwards say that such-and-such percent of your respondents were very satisfied with their jobs, it is not possible to come up with an accurate, standard numerical scale to measure the level of job satisfaction precisely.

It is so easy to confuse the words "quantitative" and "qualitative," it's best to use "empirical" and "qualitative" instead.

Hint: An excellent clue that a scholarly journal article contains empirical research is the presence of some sort of statistical analysis

See "Examples of Qualitative and Quantitative" page under "Nursing Research" for more information.

• John M. Pfau Library

Examples of Qualitative vs Quantitiative

• << Previous: Table of Evidence
• Next: Types of Research within Qualitative and Quantitative >>
• Last Updated: Mar 19, 2024 10:39 AM
• URL: https://researchguides.library.wisc.edu/nursing

[Importance of qualitative research for nursing and nursing science]

Affiliation.

• 1 Universität Utrecht.
• PMID: 9370721

Qualitative research has an important place in nursing science and is becoming increasingly recognized. Qualitative research in nursing mainly deals with the lived experiences of patients and nurses. In the field of chronic illness, qualitative research has brought to the open some of the processes chronically ill patients undergo and what it means living with chronic illness. In addition, new insights were gained about the processes involved in receiving and in giving care. Qualitative research about chronic illness provided nurses with understanding of the lived experience of patients. This understanding is essential for good nursing care. However, qualitative research is not the only method and for some aspects of nursing not the adequate one. Qualitative and quantitative research are complementary.

Publication types

• English Abstract
• Adaptation, Psychological*
• Chronic Disease / psychology*
• Nursing Methodology Research / methods
• Nursing Methodology Research / standards*
• Reproducibility of Results
• Research Design*

• Open access
• Published: 11 May 2024

Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

• Jacqueline Maria Dias 1 ,
• Muhammad Arsyad Subu 1 ,
• Nabeel Al-Yateem 1 ,
• Fatma Refaat Ahmed 1 ,
• Syed Azizur Rahman 1 , 2 ,
• Mini Sara Abraham 1 ,
• Sareh Mirza Forootan 1 ,
• Farzaneh Ahmad Sarkhosh 1 &
• Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

257 Accesses

Metrics details

Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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A Review of Core Qualitative Research Concepts

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A Note on Cross-language Qualitative Research on Regulatory Issues

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An Overview of Qualitative Study Designs Appropriate for Regulatory Studies

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Underutilized Qualitative Designs in Regulatory Research

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Design Dictates the Analytic Approach

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Samples, Sampling, and Saturation

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Framing Findings

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

Choosing Quotes

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

• Carminati L.

Conclusions

Ce posttest, instructions, provider accreditation.

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

Evaluation Form (required)

• • Explain the importance of qualitative research for studies about regulatory issues in nursing. 1 2 3 4 5 ___________________________________
• • Discuss the core concepts of qualitative research. 1 2 3 4 5 ___________________________________
• • Describe common methodological challenges researchers can encounter when conducting qualitative research on professional regulatory issues. 1 2 3 4 5 ___________________________________
• • Identify solutions that can enhance the quality, rigor, and trustworthiness of the findings for regulatory studies. 1 2 3 4 5 ___________________________________
• • Were the authors knowledgeable about the subject? 1 2 3 4 5 ___________________________________
• • Were the methods of presentation (text, tables, figures, etc.) effective? 1 2 3 4 5 ___________________________________
• • Was the content relevant to the objectives? 1 2 3 4 5 ___________________________________
• • Was the article useful to you in your work? 1 2 3 4 5 ___________________________________
• • Was there enough time allotted for this activity? 1 2 3 4 5 ___________________________________
• Krefting L.
• Scopus (1949)

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• v.56(1); 2023 Jan

Qualitative Research in Healthcare: Necessity and Characteristics

1 Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

2 Ulsan Metropolitan City Public Health Policy’s Institute, Ulsan, Korea

3 Department of Nursing, Chung-Ang University, Seoul, Korea

Eun Young Choi

4 College of Nursing, Sungshin Women’s University, Seoul, Korea

Seung Gyeong Jang

5 Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Korea

Quantitative and qualitative research explore various social phenomena using different methods. However, there has been a tendency to treat quantitative studies using complicated statistical techniques as more scientific and superior, whereas relatively few qualitative studies have been conducted in the medical and healthcare fields. This review aimed to provide a proper understanding of qualitative research. This review examined the characteristics of quantitative and qualitative research to help researchers select the appropriate qualitative research methodology. Qualitative research is applicable in following cases: (1) when an exploratory approach is required on a topic that is not well known, (2) when something cannot be explained fully with quantitative research, (3) when it is necessary to newly present a specific view on a research topic that is difficult to explain with existing views, (4) when it is inappropriate to present the rationale or theoretical proposition for designing hypotheses, as in quantitative research, and (5) when conducting research that requires detailed descriptive writing with literary expressions. Qualitative research is conducted in the following order: (1) selection of a research topic and question, (2) selection of a theoretical framework and methods, (3) literature analysis, (4) selection of the research participants and data collection methods, (5) data analysis and description of findings, and (6) research validation. This review can contribute to the more active use of qualitative research in healthcare, and the findings are expected to instill a proper understanding of qualitative research in researchers who review qualitative research reports and papers.

Graphical abstract

INTRODUCTION

The definition of research varies among studies and scholars, and it is difficult to devise a single definition. The Oxford English Dictionary defines research as “a careful study of a subject, especially in order to discover new facts or information about it” [ 1 ], while Webster’s Dictionary defines research as “studious inquiry or examination - especially: investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories or laws in the light of new facts, or practical application of such new or revised theories or laws” [ 2 ]. Moreover, research is broadly defined as the process of solving unsolved problems to broaden human knowledge [ 3 ]. A more thorough understanding of research can be gained by examining its types and reasons for conducting it.

The reasons for conducting research may include practical goals, such as degree attainment, job promotion, and financial profit. Research may be based on one’s own academic curiosity or aspiration or guided by professors or other supervisors. Academic research aims can be further divided into the following: (1) accurately describing an object or phenomenon, (2) identifying general laws and establishing well-designed theories for understanding and explaining a certain phenomenon, (3) predicting future events based on laws and theories, and (4) manipulating causes and conditions to induce or prevent a phenomenon [ 3 ].

The appropriate type of research must be selected based on the purpose and topic. Basic research has the primary purpose of expanding the existing knowledge base through new discoveries, while applied research aims to solve a real problem. Descriptive research attempts to factually present comparisons and interpretations of findings based on analyses of the characteristics, progression, or relationships of a certain phenomenon by manipulating the variables or controlling the conditions. Experimental or analytical research attempts to identify causal relationships between variables through experiments by arbitrarily manipulating the variables or controlling the conditions [ 3 ]. In addition, research can be quantitative or qualitative, depending on the data collection and analytical methods. Quantitative research relies on statistical analyses of quantitative data obtained primarily through investigation and experiment, while qualitative research uses specific methodologies to analyze qualitative data obtained through participant observations and in-depth interviews. However, as these types of research are not polar opposites and the criteria for classifying research types are unclear, there is some degree of methodological overlap.

What is more important than differentiating types of research is identifying the appropriate type of research to gain a better understanding of specific questions and improve problems encountered by people in life. An appropriate research type or methodology is essential to apply findings reliably. However, quantitative research based on the philosophical ideas of empiricism and positivism has been the mainstay in the field of healthcare, with academic advancement achieved through the application of various statistical techniques to quantitative data [ 4 ]. In particular, there has been a tendency to treat complicated statistical techniques as more scientific and superior, with few qualitative studies in not only clinical medicine, but also primary care and social medicine, which are relatively strongly influenced by the social sciences [ 5 , 6 ].

Quantitative and qualitative research use different ways of exploring various social phenomena. Both research methodologies can be applied individually or in combination based on the research topic, with mixed quantitative and qualitative research methodologies becoming more widespread in recent years [ 7 ]. Applying these 2 methods through a virtuous cycle of integration from a complementary perspective can provide a more accurate understanding of human phenomena and solutions to real-world problems.

This review aimed to provide a proper understanding of qualitative research to assist researchers in selecting the appropriate research methodology. Specifically, this review examined the characteristics of quantitative and qualitative research, the applicability of qualitative research, and the data sources collected and analyzed in qualitative research.

COMPARISON OF QUALITATIVE AND QUANTITATIVE RESEARCH

A clearer understanding of qualitative research can be obtained by comparing qualitative and quantitative research, with which people are generally familiar [ 8 , 9 ]. Quantitative research focuses on testing the validity of hypotheses established by the researcher to identify the causal relationships of a specific phenomenon and discovering laws to predict that phenomenon ( Table 1 ). Therefore, it emphasizes controlling the influence of variables that may interfere with the process of identifying causality and laws. In contrast, qualitative research aims to discover and explore new hypotheses or theories based on a deep understanding of the meaning of a specific phenomenon. As such, qualitative research attempts to accept various environmental factors naturally. In quantitative research, importance is placed on the researcher acting as an outsider to take an objective view by keeping a certain distance from the research subject. In contrast, qualitative research encourages looking inside the research subjects to understand them deeply, while also emphasizing the need for researchers to take an intersubjective view that is formed and shared based on a mutual understanding with the research subjects.

Comparison of methodological characteristics between quantitative research and qualitative research

The data used in quantitative research can be expressed as numerical values, and data accumulated through questionnaire surveys and tests are often used in analyses. In contrast, qualitative research uses narrative data with words and images collected through participant observations, in-depth interviews, and focus group discussions used in the analyses. Quantitative research data are measured repeatedly to enhance their reliability, while the analyses of such data focus on superficial aspects of the phenomenon of interest. Qualitative research instead focuses on obtaining deep and rich data and aims to identify the specific contents, dynamics, and processes inherent within the phenomenon and situation.

There are clear distinctions in the advantages, disadvantages, and goals of quantitative and qualitative research. On one hand, quantitative research has the advantages of reliability and generalizability of the findings, and advances in data collection and analysis methods have increased reliability and generalizability. However, quantitative research presents difficulties with an in-depth analysis of dynamic phenomena that cannot be expressed by numbers alone and interpreting the results analyzed in terms numbers. On the other hand, qualitative research has the advantage of validity, which refers to how accurately or appropriately a phenomenon was measured. However, qualitative research also has the disadvantage of weak generalizability, which determines whether an observed phenomenon applies to other cases.

APPLICATIONS OF QUALITATIVE RESEARCH AND ITS USEFULNESS IN THE HEALTHCARE FIELD

Qualitative research cannot be the solution to all problems. A specific methodology should not be applied to all situations. Therefore, researchers need to have a good understanding of the applicability of qualitative research. Generally, qualitative research is applicable in following cases: (1) when an exploratory approach is required on a topic that is not well known, (2) when something cannot be explained fully with quantitative research, (3) when it is necessary to newly present a specific view on a research topic that is difficult to explain with existing views, (4) when it is inappropriate to present the rationale or theoretical proposition for designing hypotheses, as in quantitative research, and (5) when conducting research that requires detailed descriptive writing with literary expressions [ 7 ]. In particular, qualitative research is useful for opening new fields of research, such as important topics that have not been previously examined or whose significance has not been recognized. Moreover, qualitative research is advantageous for examining known topics from a fresh perspective.

In the healthcare field, qualitative research is conducted on various topics considering its characteristics and strengths. Quantitative research, which focuses on hypothesis validation, such as the superiority of specific treatments or the effectiveness of specific policies, and the generalization of findings, has been the primary research methodology in the field of healthcare. Qualitative research has been mostly applied for studies such as subjective disease experiences and attitudes with respect to health-related patient quality of life [ 10 - 12 ], experiences and perceptions regarding the use of healthcare services [ 13 - 15 ], and assessments of the quality of care [ 16 , 17 ]. Moreover, qualitative research has focused on vulnerable populations, such as the elderly, children, disabled [ 18 - 20 ], minorities, and socially underprivileged with specific experiences [ 21 , 22 ].

For instance, patient safety is considered a pillar of quality of care, which is an aspect of healthcare with increasing international interest. The ultimate goal of patient safety research should be the improvement of patient safety, for which it is necessary to identify the root causes of potential errors and adverse events. In such cases, qualitative rather than quantitative research is often required. It is also important to identify whether there are any barriers when applying measures for enhancing patient safety to clinical practice. To identify such barriers, qualitative research is necessary to observe healthcare workers directly applying the solutions step-by-step during each process, determine whether there are difficulties in applying the solutions to relevant stakeholders, and ask how to improve the process if there are difficulties.

Patient safety is a very broad topic, and patient safety issues could be categorized into preventing, recognizing, and responding to patient safety issues based on related metrics [ 23 ]. Responding to issues that pertain to the handling of patient safety incidents that have already occurred has received relatively less interest than other categories of research on this topic, particularly in Korea. Until 2017, almost no research was conducted on the experiences of and difficulties faced by patients and healthcare workers who have been involved in patient safety incidents. This topic can be investigated using qualitative research.

A study in Korea investigated the physical and mental suffering experienced during the process of accepting disability and medical litigation by a patient who became disabled due to medical malpractice [ 21 ]. Another qualitative case study was conducted with participants who lost a family member due to a medical accident and identified psychological suffering due to the incident, as well as secondary psychological suffering during the medical litigation process, which increased the expandability of qualitative research findings [ 24 ]. A quantitative study based on these findings confirmed that people who experienced patient safety incidents had negative responses after the incidents and a high likelihood of sleep or eating disorders, depending on their responses [ 25 ].

A study that applied the grounded theory to examine the second victim phenomenon, referring to healthcare workers who have experienced patient safety incidents, and presented the response stages experienced by second victims demonstrated the strength of qualitative research [ 26 ]. Subsequently, other studies used questionnaire surveys on physicians and nurses to quantify the physical, mental, and work-related difficulties experienced by second victims [ 27 , 28 ]. As such, qualitative research alone can produce significant findings; however, combining quantitative and qualitative research produces a synergistic effect. In the healthcare field, which remains unfamiliar with qualitative research, combining these 2 methodologies could both enhance the validity of research findings and facilitate open discussions with other researchers [ 29 ].

In addition, qualitative research has been used for diverse sub-topics, including the experiences of patients and guardians with respect to various diseases (such as cancer, myocardial infarction, chronic obstructive pulmonary disease, depression, falls, and dementia), awareness of treatment for diabetes and hypertension, the experiences of physicians and nurses when they come in contact with medical staff, awareness of community health environments, experiences of medical service utilization by the general public in medically vulnerable areas, the general public’s awareness of vaccination policies, the health issues of people with special types of employment (such as delivery and call center workers), and the unmet healthcare needs of persons with vision or hearing impairment.

GENERAL WORKFLOW OF QUALITATIVE RESEARCH

Rather than focusing on deriving objective information, qualitative research aims to discern the quality of a specific phenomenon, obtaining answers to “why” and “how” questions. Qualitative research aims to collect data multi-dimensionally and provide in-depth explanations of the phenomenon being researched. Ultimately, the purpose of qualitative research is set to help researchers gain an understanding of the research topic and reveal the implications of the research findings. Therefore, qualitative research is generally conducted in the following order: (1) selection of a research topic and question, (2) selection of a theoretical framework and methods, (3) literature analysis, (4) selection of the research participants (or participation target) and data collection methods, (5) data analysis and description of findings, and (6) research validation ( Figure 1 ) [ 30 ]. However, unlike quantitative research, in which hypothesis setting and testing take place unidirectionally, a major characteristic of qualitative research is that the process is reversible and research methods can be modified. In other words, the research topic and question could change during the literature analysis process, and theoretical and analytical methods could change during the data collection process.

General workflow of qualitative research.

Selection of a Research Topic and Question

As with any research, the first step in qualitative research is the selection of a research topic and question. Qualitative researchers can select a research topic based on their interests from daily life as a researcher, their interests in issues within the healthcare field, and ideas from the literature, such as academic journals. The research question represents a more specific aspect of the research topic. Before specifically starting to conduct research based on a research topic, the researcher should clarify what is being researched and determine what research would be desirable. When selecting a research topic and question, the research should ask: is the research executable, are the research topic and question worth researching, and is this a research question that a researcher would want to research?

Selection of Theoretical Framework and Methods

A theoretical framework refers to the thoughts or attitudes that a researcher has about the phenomenon being researched. Selecting the theoretical framework first could help qualitative researchers not only in selecting the research purpose and problem, but also in carrying out various processes, including an exploration of the precedent literature and research, selection of the data type to be collected, data analysis, and description of findings. In qualitative research, theoretical frameworks are based on philosophical ideas, which affect the selection of specific qualitative research methods. Representative qualitative research methods include the grounded theory, which is suitable for achieving the goal of developing a theory that can explain the processes involved in the phenomenon being researched; ethnographic study, which is suitable for research topics that attempt to identify and interpret the culture of a specific group; phenomenology, which is suitable for research topics that attempt to identify the nature of research participants’ experiences or the phenomenon being researched; case studies, which aim to gain an in-depth understanding of a case that has unique characteristics and can be differentiated from other cases; action research, which aims to find solutions to problems faced by research participants, with the researchers taking the same position as the participants; and narrative research, which is suitable for research topics that attempt to interpret the entire life or individual experiences contained within the stories of research participants. Other methodologies include photovoice research, consensual qualitative research, and auto-ethnographic research.

Literature Analysis

Literature analysis results can be helpful in specifically selecting the research problem, theoretical framework, and research methods. The literature analysis process compels qualitative researchers to contemplate the new knowledge that their research will add to the academic field. A comprehensive literature analysis is encouraged both in qualitative and quantitative research, and if the prior literature related to the subject to be studied is insufficient, it is sometimes evaluated as having low research potential or research value. Some have claimed that a formal literature review should not be performed before the collection of field data, as it could create bias, thereby interfering with the investigation. However, as the qualitative research process is cyclic rather than unidirectional, the majority believes that a literature review can be performed at any time. Moreover, an ethical review prior to starting the research is a requirement; therefore, the research protocol must be prepared and submitted for review and approval prior to conducting the research. To prepare research protocols, the existing literature must be analyzed at least to a certain degree. Nonetheless, qualitative researchers must keep in mind that their emotions, bias, and expectations may interject themselves during the literature review process and should strive to minimize any bias to ensure the validity of the research.

Selection of the Research Participants and Data Collection Methods

The subjects of qualitative research are not necessarily humans. It is more important to find the research subject(s) from which the most in-depth answers to the research problem can be obtained. However, the subjects in most qualitative studies are humans, as most research question focus on humans. Therefore, it is important to obtain research participants with sufficient knowledge, experience, and attitudes to provide the most appropriate answers to the research question. Quantitative research, which views generalizability as a key research goal, emphasizes the selection of research participants (i.e., the research sample that can represent the study’s population of interest), whereas qualitative research emphasizes finding research participants who can best describe and demonstrate the phenomenon of interest.

In qualitative research, the participant selection method is referred to as purposeful sampling (or purposive sampling), which can be divided into various types. Sampling methods have various advantages, disadvantages, and characteristics. For instance, unique sampling (extreme case sampling) has the advantage of being able to obtain interesting research findings by researching phenomena that have previously received little or no interest, and the disadvantage of deriving research findings that are interesting to only some readers if the research is conducted on an overly unique situation. Maximum variation sampling, also referred to as theoretical sampling, is commonly used in qualitative research based on the grounded theory. Selecting the appropriate participant sampling method that suits the purpose of research is crucial ( Table 2 ).

Sampling methods of selecting research participants in qualitative research

Once the researcher has decided how to select study participants, the data collection methods must be determined. Just as with participant sampling, various data collection methods are available, all of which have various advantages and disadvantages; therefore, the method must be selected based on the research question and circumstances. Unlike quantitative research, which usually uses a single data source and data collection method, the use of multiple data sources and data collection methods is encouraged in qualitative research [ 30 ]. Using a single data source and data collection method could cause data collection to be skewed by researcher bias; therefore, using multiple data sources and data collection methods is ideal. In qualitative research, the following data types are commonly used: (1) interview data obtained through one-on-one in-depth interviews and focus group discussions, (2) observational data from various observation levels, (3) documented data collected from personal or public documents, and (4) image data, such as photographs and videos.

Interview data are the most commonly used data source in qualitative research [ 31 ]. In qualitative research, an interview refers to communication that takes place based on a clear sense of purpose of acquiring certain information, unlike conversations that typically take place in daily life. The level of data acquired through interviews varies significantly depending on the researcher’s personal qualifications and abilities, as well as his or her level of interest and knowledge regarding the research topic. Therefore, interviewers must be trained to go beyond simply identifying the clearly expressed experiences of research participants to exploring their inner experiences and emotions [ 32 ]. Interview data can be classified based on the level of structuralization of the data collection method, sample size, and interview method. The characteristics of each type of interview are given in Table 3 .

Detailed types of interview methods according to the characteristics of in-depth interviews and focus group discussion

Observations, which represent a key data collection method in anthropology, refer to a series of actions taken by the researcher in search of a deep understanding by systematically examining the appearances of research participants that take place in natural situations [ 33 ]. Observations can be categorized as participant and non-participant, insider and outsider, disguised and undisguised, short- and long-term, and structured and unstructured. However, a line cannot be drawn clearly to differentiate these categories, and the degree of each varies along a single spectrum. Therefore, it is necessary for a qualitative researcher to select the appropriate data collection method based on the circumstances and characteristics of the research topic.

Various types of document data can be used in qualitative research. Personal documents include diaries, letters, and autobiographies, while public documents include legal documents, public announcements, and civil documents. Online documents include emails and blog or bulletin board postings, while other documents include graffiti. All these document types may be used as data sources in qualitative research. In addition, image data acquired by the research participant or researcher, such as photographs and videos, serve as useful data sources in qualitative research. Such data sources are relatively objective and easily accessible, while they contain a significant amount of qualitative meaning despite the low acquisition cost. While some data may have been collected for research purposes, other data may not have been originally produced for research. Therefore, the researcher must not distort the original information contained in the data source and must verify the accuracy and authenticity of the data source in advance [ 30 ].

This review examined the characteristics of qualitative research to help researchers select the appropriate qualitative research methodology and identify situations suitable for qualitative research in the healthcare field. In addition, this paper analyzed the selection of the research topic and problem, selection of the theoretical framework and methods, literature analysis, and selection of the research participants and data collection methods. A forthcoming paper will discuss more specific details regarding other qualitative research methodologies, such as data analysis, description of findings, and research validation. This review can contribute to the more active use of qualitative research in the healthcare field, and the findings are expected to instill a proper understanding of qualitative research in researchers who review and judge qualitative research reports and papers.

Ethics Statement

Since this study used secondary data source, we did not seek approval from the institutional review board. We also did not have to ask for the consent of the participants.

Acknowledgments

CONFLICT OF INTEREST

The authors have no conflicts of interest associated with the material presented in this paper.

AUTHOR CONTRIBUTIONS

Conceptualization: Pyo J, Lee W, Choi EY, Jang SG, Ock M. Data curation: Pyo J, Ock M. Formal analysis: Pyo J, Ock M. Funding acquisition: None. Validation: Lee W, Choi EY, Jang SG. Writing - original draft: Pyo J, Ock M. Writing - review & editing: Pyo J, Lee W, Choi EY, Jang SG, Ock M.

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Research Article

Professional regulation in the digital era: A qualitative case study of three professions in Ontario, Canada

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada

Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

Affiliations Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada, School of Sociological and Anthropological Studies, University of Ottawa, Ottawa, Ontario, Canada

Roles Data curation, Formal analysis, Writing – review & editing

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

Affiliation Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada

Roles Validation, Writing – review & editing

Affiliation School of Nursing, University of Northern British Columbia, Prince George, British Columbia, Canada

Roles Conceptualization, Visualization, Writing – review & editing

Affiliation Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

Roles Conceptualization, Formal analysis, Validation, Writing – review & editing

Affiliation Department of Sociology, Western University, London, Ontario, Canada

• Kathleen Leslie, 
• Sophia Myles, 
• Abeer A. Alraja, 
• Patrick Chiu, 
• Catharine J. Schiller, 
• Sioban Nelson, 
• Tracey L. Adams

• Published: May 10, 2024
• https://doi.org/10.1371/journal.pone.0303192
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Technology is transforming service delivery and practice in many regulated professions, altering required skills, scopes of practice, and the organization of professional work. Professional regulators face considerable pressure to facilitate technology-enabled work while adapting to digital changes in their practices and procedures. However, our understanding of how regulators are responding to technology-driven risks and the impact of technology on regulatory policy is limited. To examine the impact of technology and digitalization on regulation, we conducted an exploratory case study of the regulatory bodies for nursing, law, and social work in Ontario, Canada. Data were collected over two phases. First, we collected documents from the regulators’ websites and regulatory consortiums. Second, we conducted key informant interviews with two representatives from each regulator. Data were thematically analyzed to explore the impact of technological change on regulatory activities and policies and to compare how regulatory structure and field shape this impact. Five themes were identified in our analysis: balancing efficiency potential with risks of certain technological advances; the potential for improving regulation through data analytics; considering how to regulate a technologically competent workforce; recalibrating pandemic emergency measures involving technology; and contemplating the future of technology on regulatory policy and practice. Regulators face ongoing challenges with providing equity-based approaches to regulating virtual practice, ensuring practitioners are technologically competent, and leveraging regulatory data to inform decision-making. Policymakers and regulators across Canada and internationally should prioritize risk-balanced policies, guidelines, and practice standards to support professional practice in the digital era.

Citation: Leslie K, Myles S, Alraja AA, Chiu P, Schiller CJ, Nelson S, et al. (2024) Professional regulation in the digital era: A qualitative case study of three professions in Ontario, Canada. PLoS ONE 19(5): e0303192. https://doi.org/10.1371/journal.pone.0303192

Editor: Sascha Köpke, University Hospital Cologne: Uniklinik Koln, GERMANY

Received: December 15, 2023; Accepted: April 20, 2024; Published: May 10, 2024

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

Data Availability: The minimum data needed to replicate the study are within the paper and its Supporting information files. However, the raw interview transcripts cannot be made publicly available for ethical reasons because they may contain identifiable or sensitive data. Excerpts from interviews are presented in the paper and additional excerpts can be made available upon reasonable request to the Athabasca University Research Ethics Board (email: [email protected] , phone: 780.213.2033).

Funding: This project was funded by an Insight Development Grant (File # 430-2021-00407) from the Social Sciences and Humanities Research Council of Canada (Principal Investigator KL). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Funder URL: https://www.sshrc-crsh.gc.ca/ .

Competing interests: The authors have declared that no competing interests exist.

Introduction

Technology is rapidly transforming service delivery across regulated professions, altering required skills, scopes of practice, and the organization of professional work [ 1 – 5 ]. Regulatory bodies that govern these professions are under immense pressure to adapt their practices and procedures to facilitate technology-enabled work, while also upholding their mandate to protect the public interest. This urgency has been magnified by the COVID-19 pandemic, which expedited the shift towards virtual practice [ 6 – 8 ] and the scrutiny of professionals’ social media behaviour [ 9 , 10 ]. Regulators must evolve alongside technological advancements to mitigate emerging risks and ensure that new technologies do not negatively impact professional practice or services provided to the public.

Research exploring the impact of digitalization, artificial intelligence (AI), and other technological changes on professional work is emerging [ 11 – 15 ]. This literature has explored the interplay between traditional professional practice and digital innovation [ 16 , 17 ], the organizational changes induced by digital development [ 13 , 15 , 18 , 19 ], and the emerging digital competencies required by professionals [ 20 , 21 ]. Our previous research has also identified challenges that accompany the expansion of virtual practice, including uncertainty about professional standards, breaches of privacy law and other legal requirements, and concerns about equity and professional ethics [ 6 , 22 , 23 ]. Furthermore, while AI technology has the potential to deliver more efficient and data-driven professional services, the associated risks are just beginning to be explored [ 24 , 25 ]. Notably, the burgeoning use of AI raises issues around privacy, equity, and the integrity of professional practice, all of which have implications for professional regulators. Already there are cases where regulators have needed to respond to the inappropriate use of AI in professional practice [ 26 ]. Technology with the potential to profoundly affect professional practice calls for regulatory practices that are responsive to the changing sociotechnical landscape, including the associated risks, inequities, and uncertainties.

Despite emerging research on digitalization’s impact on professional work, our understanding of how regulatory bodies are responding to technology-driven risks and opportunities remains limited. Responses to these challenges have varied, with some regulators imposing a duty of technological competence [ 27 ], while others have refrained from setting formal tech-centric standards. Standards for virtual practice also vary significantly between regulators, even for the same profession [ 6 ]. In addition to how regulators are working to support registrants in the digital era, regulators may be adopting technology to improve their own regulatory practices. To varying extents, professional regulators are digitizing processes related to registration, complaints management, continuing competence, and discipline. However, the way that professional regulators may be using technology to enhance their own work has received little research attention.

This research aims to address these research gaps by examining how regulatory practices and policies are evolving in response to digitalization, and how regulators can support professionals through significant workplace changes while upholding the public interest. Building on our team’s recent work, including a knowledge synthesis of existing academic and grey literature [ 22 , 23 ] and a review of regulatory guidance around virtual care [ 6 ], this study provides foundational insights into the challenges and opportunities of regulating in a digital era. Understanding these challenges and opportunities can inform professional regulators across various sectors and jurisdictions and guide the development of risk-appropriate policies, guidelines, and standards for modern professional regulation.

We aimed to examine the impact of technology and digitalization on three regulatory bodies in Ontario, Canada through a qualitative comparative case study approach. Our specific objectives were to:

• Explore approaches and policies that these regulators have enacted to address the challenges and opportunities presented by the digital era;
• Describe the effects of technological change on regulatory activities at these regulatory bodies; and
• Compare the regulatory responses to technological change across these regulators.

Our study was guided by Yin’s [ 28 ] structured approach to exploratory case study research, which is well suited to understanding new or less studied areas where the researcher has little or no control over the phenomenon of interest. Case study designs in professional regulatory research can produce comprehensive analyses for examining regulatory reforms and innovations [ 29 ]. In this study, we compared how three professional regulators in Ontario, Canada approached regulating in the public interest in the digital era.

Participants

Participating regulators were the Ontario College of Social Workers and Social Service Workers (OCSW), the Law Society of Ontario (LSO), and the College of Nurses of Ontario (CNO). As an exploratory case study, we sought a variety of professional sectors; law, nursing, and social work offered a diversity of regulatory and professional contexts. These three regulators are each under separate legislative frameworks but share the common context of a single jurisdiction of Ontario. Further, the nature of the professional work being regulated is different, and we expected that technology may be impacting these different work contexts in unique ways. In this way, we could distinguish between issues specific to each regulatory body and cross-cutting themes present across the professional, legislative, and workforce factors that vary between them. Our selection of these three regulatory bodies was thus aimed at achieving what Flyvbjerg [ 30 ] called maximum variation in case study research and is appropriate for exploratory work that can be built upon by examining other professions in more jurisdictions in future projects. A brief description of these regulatory bodies is provided in Table 1 .

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Data collection

We conducted data collection over two phases. The first phase involved gathering publicly available documents relevant to our research objectives and the second phase involved semi-structured interviews. We started with documents to gain a foundational understanding of how technology intersected with regulatory policy and practice for these three professions, and our interviews provided further insight and contextualization to deepen our understanding.

In the first phase, we identified relevant documents by searching regulators’ websites. We conducted our initial searches between May 2022 and September 2022, reviewing documents back to 2015. The date of 2015 was chosen to capture pre-COVID responses while being feasible given our research funding timeline. We also anticipated limited applicability and availability of older regulatory documents given the rapid change of technology in the past decade. The search was updated in January 2023.

We searched each regulator’s website for keywords based on concepts that fit with our research objectives (e.g., digital, tele*, virtual, tech*) and then specific documents were reviewed in full, including minutes from council meetings, regulatory publications for registrants and the public such as newsletters, and strategic plans. We reviewed each retrieved document for references to other regulatory documents, webpages, or resources that were directly relevant to the impact of technology on the regulator’s policies or practices. In this iterative way, we retrieved regulatory updates and news releases; frequently-asked-questions; policies and policy briefs; council briefing reports and minutes; and practice statements, standards, directives, guidance, and guidelines. We identified 34 documents (nine from the CNO, 15 from the LSO, and ten from the OCSW; see S1 File ) that met our inclusion criteria of relating to our research objectives and being published between 2015 and 2022. Document information was organized in a spreadsheet and copies of all included documents were saved as PDFs to keep a record in case websites changed during analysis. These documents allowed us to identify pivotal milestones and policies related to regulatory responses to technology that were used to inform the development of our interview guide. All documents were publicly available.

In the second phase, we emailed the executive director or registrar from each of the three regulators to explain the study and request an interview with individuals familiar with the regulator’s response to technology and relevant policies and practices. Each executive director agreed to an interview and designated two individuals (total n = 6) from their regulatory body to participate and with whom the research team communicated directly by email. Our sampling strategy was purposive and required study participants to have knowledge about the impact of technology on regulatory practice and policy at their organization, appropriate for our case study research design.

We developed a semi-structured interview guide and shared this with our participants prior to the interview (see S2 File ). The semi-structured interview guide was developed collaboratively by the research team based on our previous research in the field, our recent scoping review on a similar topic, and our preliminary analysis of the Phase 1 documents. The first author (KL, she/her) is an early career researcher with experience conducting qualitative interviews in regulatory research who was supported by senior career qualitative researchers (TLA, SN). Interviews were conducted between 1 January 2023 and 31 March 2023 by the first author (KL), and at least one other research team member attended and took detailed notes (TLA, AA, SM). At the beginning of each interview, the first author (KL) provided participants with background information and reiterated the study purpose and objectives. Interviews were conducted by videoconference software (Microsoft Teams) and lasted approximately 60 minutes. Each interview was recorded and transcribed verbatim.

Data analysis

Following data collection, we analyzed all data (documents, interview transcripts, and field notes) using thematic data analysis [ 31 , 32 ]. In this flexible but rigourous approach to data analysis, the researchers play a key role in knowledge production through prolonged engagement with the data [ 32 ]. Three research team members (KL, AA, SM) independently read all documents, transcripts, and field notes to develop a coding framework, using the categories and concepts from the documents and semi-structured interview guide as a basis. Two research team members (KL, PC) with experience in qualitative data analysis and regulatory research then coded all transcripts independently by hand using colour-coded highlighting. KL and PC collaborated throughout regular discussions to develop themes. Extracts from transcripts were brought together for each theme as it was developed, and information from the documents was used to augment and triangulate these findings. As results were developed for each regulator, we compared and contrasted findings across the cases to identify themes and develop rich descriptions. Finally, we returned to the original transcripts and audio recordings to ensure the identified themes and selected quotes accurately reflected the data. We also identified documentary data from Phase 1 that could be included to support the findings and add context, depth, and breadth to the interview data. Findings were regularly reviewed and refined with the research team throughout the analysis.

Trustworthiness

To ensure the credibility of our findings, we used a multifaceted approach. Data collection and analysis were carried out in a systematic way, including extensive engagement with the transcripts and generating a careful audit trail. Using multiple data sources provides enhanced validity with our findings supported by more than one source of evidence [ 28 , 33 ]. We met regularly as a research team to discuss and verify our analysis; we included thick descriptions of our findings and verbatim quotes to support each theme. The diversity of our team, which includes research and clinical backgrounds in professional regulation, political science, nursing, law, and sociology, provided a range of analytical perspectives to aid in interpreting results. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) [ 34 ] to guide the transparent reporting of our methods and findings (see S3 File ).

Ethical considerations

The Athabasca University Research Ethics Board approved the study (File #24794). Each regulatory body contacted agreed to participate and informed written consent was obtained from all interview participants. No one withdrew their participation and only participants and research team members were present during the interviews. The study posed minimal risk to participants as they provided information in their professional capacity and no personal information was collected. To protect participant confidentiality, quotes in the findings are attributed to the regulatory bodies and the professions they represent without using names or position titles. As each regulator represents a single case, we have not differentiated between participants representing the same regulator.

While some research team members are members of the profession of participating regulators, they do not have established relationships with interviewees (prior to study commencement or since study completion), and interviewees were aware of the principal investigator’s (KL) background as a registered nurse and lawyer.

We identified five themes in our analysis of the interview and document data: 1) balancing efficiency potential with risks of certain technological advances; 2) the potential for improving regulation through data analytics; 3) considering how to regulate a technologically competent workforce; 4) recalibrating pandemic emergency measures involving technology; and 5) contemplating the future of technology on regulatory policy and practice. Descriptions of these themes, along with illustrative regulatory responses and quotes, are provided in Table 2 . We also review these themes in detail below, providing context from regulatory documents and quotes from interview transcripts. Quotations have been very lightly edited for grammar.

https://doi.org/10.1371/journal.pone.0303192.t002

Theme 1: Balancing efficiency potential with risks of technological advances

Participants recognized that technological advances may enable regulators to work more efficiently; however, they believed the risks associated with new technologies necessitated a cautious approach. This caution meant that many changes were incorporated slowly, and participants emphasized that even seemingly simple changes, such as online registration processes, were being approached carefully. A participant from the LSO noted that “historically, we’ve been very paper-based, so people would fill out paper applications and they would mail those into us” but the pandemic “accelerated changes that were being considered prior to that, and certainly desired prior to that, and so the application process has moved online.” Similarly, a participant from OCSW described their desire to move away from printing out physical certificates for all registrants, noting “we’re hoping we can transition out of it because it’s a very manual, expensive process that we do across the board for everyone.” However, the potential efficiency gain of digital certificates also came with risk, with the participant noting “then technology comes into play, because how do we ensure that it’s not fraudulent? … There’s always the ability to tamper with it” (OCSW).

Participants also discussed the importance of carefully considering the contexts in which technology should be used to facilitate regulatory operations. Participants from all three regulatory bodies discussed opportunities to automate tasks to free up staff and to improve their response times to registrants, especially for low-risk activities. For example, inquiries related to registration renewals are often straightforward and may not require human interaction. Participants from the CNO and OCSW discussed how technology can create opportunities for registrants to better engage with regulatory bodies and increase the accessibility of standards and guidelines at the point of care.

At the same time, all participants emphasized the need to consider the full context of each situation to assess the appropriate use of technology. One commonality between regulators was the recognition that not everything should be digitalized because regulation also involves a relational component. This requirement for human interaction is especially relevant when dealing with registrants and the public in higher-stakes situations (e.g., investigations and discipline processes). A participant from OCSW noted that technological interactions were appropriate for the “benign stuff” such as registration renewals, but that “there is a balance and if a regulator wants to be sort of relevant, they have to ensure that they are meeting that sort of human need.” A participant from the LSO responded similarly:

I think , probably the answer is that where processes that don’t really require a human touch , so for instance , handing an application in–we can eliminate the human touch there and move those types of things increasingly online . But I think maintaining those sorts of areas where having someone to talk to where you’re having an ethical issue , having a CPD program that you can attend that speaks specifically to your practice area and there are other colleagues there as well , those types of things . I think , that’s probably–to my mind at least–where the balance is . You beef up those areas where [human interaction] is important , and you try to gain those efficiencies in areas where perhaps it’s not so important that you do something in person ( LSO )

Participants’ responses highlighted the value regulators place on using a risk-based approach to carefully assess the suitability and feasibility of integrating technology into regulatory processes: “I think increasingly, as we try to move into new areas with technology, that ensuring that we’re approaching things from a risk-based perspective is very important” (LSO).

The potential of technology to improve efficiency was valued by participants who noted the complexity and resource-intensity of regulatory processes were increasing; however, the risk-adverse nature of regulation meant currently these gains have not yet been fully realized as participants focused more on the potential efficiency gains, should risks be appropriately managed.

Theme 2: The potential for improving regulation through data analytics

In addition to potential efficiency gains, participants highlighted where data could be leveraged to guide decision-making and potentially improve regulatory processes and outcomes. Similar to the cautious approach regulators were taking to the incorporation of new technologies more generally, the discussion of data analytics focused primarily on potential, rather than realized, benefits.

Participants from the CNO discussed the development of a new Insights Engine [ 35 ] that focused on data analytics but was in the very early stages of being used. This new system is meant to provide “more real-time data” that would allow the regulator to “specifically tag pieces of information…where they are coming from, from whom, and that informs how we also develop resources for members” (CNO). A CNO participant noted that the regulator had “lots and lots of data inputs” but these were “not accessible in a way that is as meaningful as we would like them to be in order to drive…our projects or the things that we need to improve or change.” The CNO participant described this as important not only to inform decision-making but to “prioritize our projects, where we kind of put our resources and our people, kind of focus our work so I think that will make us more efficient.”

A participant from the OCSW also noted a change in their current data systems that could, in the future, support data analytics for decision-making:

We’re changing over from our current legacy software into a new CRM [customer relationship management system] this year…we are hoping [the new CRM] will be able to mine the data in that way and be able to identify trends . So even when we’re looking at complaints , registrants , investigations or even something simple like [continuing competence program] completion rates . We have a pretty high completion rate , but let’s say we do have a situation where we have lower completion rates , we can look to see if there are certain regions that have individuals that are not participating as much or things like that . Currently , we can’t do that as simply , but in a future state , we’d want to . So , we have the questions we want to ask . ( OCSW )

In addition to regulators’ plans to use data analytics to improve regulation, we also heard that regulators were using existing data to identify practitioners at risk. As a participant from the LSO noted, “I think we always use data that’s available to us to sort of assess risk and try to get ahead of things and understand where problems exist”. For example, existing data have “clearly shown for many years that the sole practitioners are at the highest risk of being the subject of complaints” and “the causes of this are usually skills-related, not knowledge of the law” (LSO). Using this data, the regulator developed a new competence framework to support the implementation of a practice essentials course to support sole practitioners; at the time of our data collection, this was almost ready to be rolled out.

Theme 3: Considering how to regulate a technologically competent workforce

Beyond considering how to incorporate technology to improve regulatory operations, participants also discussed how to support and regulate their registrants in an increasingly digitalized world. Participants from all three regulatory bodies discussed the factors that have influenced their regulatory approaches as technology changes how their registrants practiced. Participants discussed the importance of assessing the most appropriate level of regulation to balance their mandate of protecting the public while ensuring that they do not create barriers in practice. This is sometimes termed right touch or risk-based regulation.

One key consideration was the legislative framework under which regulatory bodies operate and how this impacted regulators’ ability to respond nimbly. A participant from the LSO described their broad bylaw-making power under the Law Society Act and the way it allowed the regulator “quite a bit of flexibility…[to] be fairly nimble when we need to be…basically to allow access to justice to continue when no one could meet in person” during the pandemic. For example, the LSO facilitated emergency Orders in Council to allow virtual execution and witnessing of wills [ 36 ] provided legislative interpretation regarding virtual client identification [ 37 ], and guided registrants about requirements for virtual notarizing and commissioning [ 38 ].

Other factors influencing regulators’ decision-making included their existing strategies for modernizing standards and the influence of collaborative work between regulators. Participants from the CNO highlighted pre-pandemic work that was done in collaboration with other regulators to develop guidelines and competencies for compassion in the digital healthcare age. This work informed their ongoing reforms for technology-enabled practice and virtual care as the regulator worked to modernize practice standards [ 39 ].

Similarly, a participant from the LSO spoke about the influence of the Federation of Law Societies of Canada on discussions around technological competence. In 2019, this Federation added commentary to the duty of competency in its Model Code of Professional Conduct; this commentary required lawyers to have an understanding of and ability to use technology relevant to the nature and area of the lawyer’s practice and responsibility [ 40 ]. The commentary further required that lawyers understand the risks and benefits associated with relevant technology. Different legal regulators across Canada began to adopt this duty of technological competence, and the LSO adopted it in 2022. As one LSO participant described:

In general , we try and stay fairly close to [the model code] , certainly with the basics , because , you know , that’s what a national model code is supposed to do . And in this one , we were actually slow to adopt it because we had a technological taskforce…And then we also had a competence taskforce—the competence taskforce was intended to look at if our competence standards and programs were suitable for the next 20 years…the tech competence requirement was part of that report…So that was the impetus for this particular change to our rules . ( LSO )

An important element of this commentary to the competence rule is that legal professionals must understand technology relevant to their area of practice. One participant from the LSO discussed the importance of this approach given the nuances in different law practice areas. This participant noted that the regulator was not assessing technological competence because “depending on practice area, it’s often not entirely clear how we would assess it anyway” since some areas of legal practice required uses of very specific technologies (e.g., the Ontario Teranet system to transfer title in real estate law) “whereas there are other areas of law where, in theory at least, you could probably still get by with a typewriter and dictaphone” (LSO).

In contrast to the LSO’s specific inclusion of technology in its commentary to the duty of competence, the OCSW and CNO described how their current standards were broad enough to generally cover technological competence. The Council of the OCSW specifically decided not to adopt the model technology guidelines for social work published by the Association of Social Work Boards in 2015 [ 41 ], opting “instead to produce resources to help support members in their practice and to apply those standards to technology or any other issue” (OCSW). One participant from the OCSW described how this decision was made:

I think one of the convincing reasons for that was the current edition of our standards of practice refers to diskettes , which is such a great example of why you don’t want standards of practice to be too specific , because they’ll be out of date before the ink dries , I guess . And so I think that has been the approach that our college has taken—that technology competence and technology really doesn’t warrant its own standalone standard because it applies to other standards such as record keeping boundaries , competence and integrity , and confidentiality . ( OCSW )

Despite differences in approaches to technological competence, participants from all three regulatory bodies spoke about their role in supporting their registrants’ professional practice by developing guidance around technology and virtual practice. In deciding what practice resources were needed, regulators responded based on registrant inquiries and the level of perceived risk. For example, a participant from the LSO discussed how they use inquiries from their practice management helpline to inform their continuing professional development offerings and regulatory resources.

Participants from the OCSW discussed how they encourage registrants to identify learning needs associated with technology when completing their continuing professional development program. Our review of OCSW newsletters showed ongoing encouragement of members to review resources on topics such as using communication technology in practice, selecting online platforms for virtual services, and practice standard considerations for navigating COVID-19 [ 42 – 46 ]. Participants from the OCSW also highlighted measures they took to ensure social workers from other Canadian jurisdictions were registered with OCSW before providing virtual services to clients in Ontario. This enabled the regulator to address issues related to professional conduct since “we can’t minimize the risks involved in electronic practice—they’re huge…so it is probably extra important that those people be registered in Ontario” (OCSW).

In developing practice support and guidance, participants discussed whether they had a role in providing guidance on specific technologies. There were differences in perspectives between regulators. For example, participants from the CNO discussed that it was not within their mandate to endorse or provide guidance on specific technologies:

Questions about which [technology platform] I should be using—we don’t regulate that , right ? We don’t say one thing is better than the other . We don’t endorse certain products . So that also becomes a challenge as well , what do we tell them in order to assess what is appropriate ? It goes back to your accountabilities . Does it meet those standards that you’re obligated to follow in order to assess whether this application or technology is appropriate and is safe for you to use ? ( CNO )

Participants from the LSO spoke about their technology resource centre [ 47 ] that provided guidance on selecting technology for practice, technology use, data protection, cybersecurity, cloud computing, and working remotely. While this was a departure from the level of guidance provided historically, this participant felt it was necessary to guide legal professionals on what was required to meet the standard of professional competence.

We’ve also tried to sort of help people along , in terms of what was created at the Technology Resource Centre…that was sort of a bit of a departure for us , because we got into really looking at specific products and…even suggesting to people that these are products that you can use in certain areas to help facilitate your practice . And traditionally , that hadn’t been our approach . Our approach was much more of satisfy yourself—go out there and see what’s out there kind of approach . So , we’ve tried to help nudge people in the right direction and give them a better idea of what we mean by technological competence . But that has certainly been a challenge . ( LSO )

Thus, while all three regulators operate within the same province, their approach to regulating a technologically competent workforce differed, creating differences in standards and resources provided to registrants regarding technology.

Theme 4: Recalibrating pandemic emergency measures involving technology

In many ways, the COVID-19 pandemic accelerated the use of virtual technologies and impacted various aspects of regulatory operations, including entry-to-practice, registration, continuing competence, and complaints and discipline proceedings. Different perspectives emerged about whether specific regulatory functions should remain virtual or return to pre-pandemic in-person norms. A recurring theme was the need to strike a balance between both modalities.

I think through all of this , whether it’s hearings or discipline or entry to practice , I think there’s increasingly this feeling that… some form of hybrid is probably where the sweet spot is , and I think we need to figure out where that is , and figure out what’s going to stay online , what’s going to stay remote and what should be in-person . And I suspect it’ll take some time to really figure that out . ( LSO )

Since a core function of regulatory bodies is to ensure that applicants meet the required entry-to-practice competencies, regulators found themselves grappling with the consequences of changes to the delivery of education and practicums during the pandemic. Participants from the CNO discussed how the lack of evidence on the outcomes of simulated clinical experiences created challenges for ensuring graduates were prepared competently:

Is there a break point in terms of safety ? And there is research out there [but] none of it is conclusive . There certainly are some jurisdictions that have gone the route of saying , you know , 50% of your clinical can be simulation . We haven’t designated a percentage yet . ( CNO )

Participants from the LSO also experienced challenges as education, placements and articling shifted online. In some cases, applicants were called to the bar after completing their legal education and training remotely. While these changes were necessary due to the pandemic, participants discussed the need to re-assess to determine the best approach going forward.

The pandemic also meant that some regulators shifted to online entry-to-practice exams, but this raised risks related to the security of exams and the appropriateness of the testing environment. The CNO did not adopt remote proctoring and participants noted they “weren’t comfortable at the time with the kind of research that’s out there in terms of security and the whole process around remote proctoring. And we are well aware that there are other regulators—both nursing and outside of nursing—that are doing it. So it’s something we’re exploring” (CNO). The LSO was one of the regulators that adopted remote proctoring and experienced an “exam cheating scandal…where we received information and materials to suggest that there had been cheating involved in some of our licensing examinations…And we’re now no longer doing testing online.” While the OCSW does not currently require an entry-to-practice exam, participants spoke about their interest in exploring how digitalization might impact future exam requirements that were being considered.

In considering the use of technology to increase efficiencies during the licensure process, one participant from the LSO identified the need to attend to equity considerations:

I think the other place where you really see that tension playing out is in the equity space … for , particularly , students who are going through the licensing process . If you are in one of these marginalized groups , you can … face more barriers , you can become more anxious about dealing with what feels like the behemoth , the impersonal behemoth , of the Law Society … So that’s a tension and because efficiency is highly valued … I think , how we are trying to deal with that is to have a personal engagement as needed . The trick is to determine when it’s needed . I don’t think it’s hard to find a sympathetic ear actually at the Law Society , but to know when that intervention is required—that’s , I think , the real challenge . ( LSO )

In addition to changes to entry-to-practice and registration/licensure, regulators’ investigation, discipline, and conduct processes were significantly disrupted by the pandemic as many of these shifted from in-person to virtual formats. This shift to virtual formats provided some advantages that participants described, such as “levelling the playing field” (CNO) for those who lived far from the regulatory body and potentially easing anxiety to facilitate more open conversations.

Participants from the CNO and LSO highlighted the potential negative consequences of virtual hearings such as increased ‘Zoom fatigue’, perceptions of informality, and barriers for individuals who live in areas with unreliable internet access. A participant from the CNO mentioned concerns about whether virtual hearings would have the same level of seriousness as an in-person meeting. These concerns were shared by those at the LSO:

When you walk into a courtroom , and you see that the judge sitting up there and there’s a sense of formality to it , versus getting on a Zoom call with a bunch of heads from shoulders up . That may not feel like you’re getting the same hearing that you might have in person . So , I think there’s definitely a balance there . ( LSO )

In general, regulators seemed to be striving for a balanced approach to post-pandemic recalibrations. Advantages, disadvantages, and risks associated with in-person and virtual modalities are becoming clearer and are helping inform this recalibration process.

Theme 5: Contemplating the future of technology in regulatory policy and practice

Participants described their curiosity in wanting to learn more about the impact on public protection as technologies like AI continue to evolve and become more commonplace. Participants described specific areas they were watching to learn more about how technology was impacting professional practice, such as how the therapeutic relationship might “look different when practicing in a more technological environment” (CNO). A participant from the LSO was interested in exploring “whether virtual proceedings have impacted incarceration rates, and release versus bail, or other outcomes” and whether digital products such as online “will kits” help people in the way they are intended.

Participants highlighted opportunities for increased collaboration between regulators to streamline and harmonize processes and to share data to support evidence-based regulatory policy across professions. For example, one participant from the CNO said “I think there’s always been that collaboration amongst different regulators, but having data, I think, provides this objective piece as well, which I think will be helpful for sure.” A participant from the OCSW described the importance of working together given the similarities in regulatory functions and services, especially across health profession regulators:

In essence , even though we’re regulating different professions , we’re all regulating . So , when you’re thinking of technology and the use of social media and some of the expectations we have from our professionals , specifically health , it would be good if those regulatory bodies could come together and say , you know , here’s the spectrum of our expectations . Here’s how we’ve been monitoring this spectrum . Let’s talk about it as a unit…We may be regulating different professionals , but we’re all running organizations . The operations of each of these organizations are extremely similar and overlap . ( OCSW )

A participant from OCSW expressed a desire for regulation to become more forward-thinking around technology: “Often regulators are sort of the last ones around the corner with a lot of the updates……there’s no reason the regulator can’t be the cutting edge in some of this.” One more innovative approach to staying on top of technological changes was the LSO’s Access to Innovation program which created a regulatory sandbox for innovative technological legal services [ 48 ]. While, at the time of our interview, this sandbox did not yet have evaluation data available, this way of providing a safe space to support innovative technology is meant to provide insight into new risks and opportunities related to technology.

Technology can potentially revolutionize professional work and the regulation of that work. However, technological change has simultaneously created tensions around the application of AI, data analytics, technological competence, social media use, and other dimensions of professional practice and regulation [ 49 ]. The results of our study have underscored the wide-ranging implications of technology on regulatory practices, with changes to entry-to-practice and registration/licensing, practice standards and guidance, practitioner support, continuing professional development, and disciplinary practices and procedures. Regulators are grappling with how to respond to technological changes in the practice of the professionals they regulate, while simultaneously experiencing technologically mediated changes to internal processes.

Concerns about risk may slow progress

Our findings illustrate that regulators are in the early stages of exploring the opportunities and risks that technology has on daily operations. Although regulators from different sectors have adopted technology at varied paces, the literature suggests that many have begun exploring the potential value of technology, including AI, in supporting regulatory operations and decision-making [ 50 – 55 ]. Regulation is becoming increasingly complex and resource-intensive, and our findings suggest that participants are hopeful that integrating technology into regulatory operations will provide a means to enhance efficiency. While participants noted that there are areas where technology can be integrated more easily, they also highlighted the importance of carefully studying the impacts of technology on functions that carry a greater risk of producing undesirable outcomes. This finding aligns with research by van der Gaag et al. that found regulators were concerned that AI could introduce errors and biases, jeopardize public trust, and perpetuate systemic inequities [ 56 ]. Our participants noted a need to take a risk-based approach to the advantages and disadvantages of adopting technology to support decision-making. While risk aversion may be necessary for higher-stakes regulatory processes, it may slow progress in adopting technological enhancements that could drive needed efficiency gains in increasingly resource-constrained environments.

Ensuring an equity-based approach to virtual practice and processes

The rapid expansion of virtual services influenced our participants’ responses to regulating technology use among professionals. In the context of the health and social care sectors, the pandemic accelerated the proliferation of virtual care options. In the context of law, evidence from before the pandemic suggests that, increasingly, lawyers are operating virtual legal offices rather than those of traditional brick-and-mortar [ 57 ]. Technology use in practice raises important questions about privacy, confidentiality, boundaries, informed consent, continuity of services, and new complexities for addressing malpractice and complaints [ 6 , 57 – 59 ]. While our participants discussed that technology does not necessarily require the development of unique standards of practice, this is an area that regulators will be required to re-evaluate as new risks and challenges emerge.

The introduction of virtual practice also raises unique equity concerns, potentially expanding access but in unequal ways [ 60 ]. Regulators have a role in ensuring that regulatory decisions do not perpetuate systemic inequities [ 61 ]. Our previous research on for-profit virtual care in Canada found that equity has not been adequately considered within standards from medical regulators [ 6 , 22 ]. Equity considerations must be embedded in regulatory decision-making as technology continues to evolve, and many of these considerations apply to regulatory policies and practices (e.g., virtual discipline hearings) as well as regulating virtual practice.

Our participants also described varied approaches to virtual training experiences and entry-to-practice exams, and this was an area where participants noted disparate approaches were common even across regulators in the same field. A growing body of literature across various professions suggests that there are advantages and lessons to be learned from virtual training models, including virtual reality. More evidence is needed to support informed regulatory decision-making in this evolving area of technology-enabled training and assessing entry-to-practice competency. For nursing, social work, and law, training usually requires hands-on, practical experience that may be difficult to gain in a virtual or simulated setting; however, there may be advantages to innovative virtual training models [ 62 ]. There may also be lessons that can be learned from professions, such as paramedicine, that use training via virtual reality to help establish competence [ 63 – 65 ].

Varied approaches to ensuring technologically competent professionals

As regulators work to strike a balanced approach for enabling professionals to deliver virtual services, practitioners themselves must build technological competence. As discussed by our participants, regulators expect registrants to have the required knowledge and skills related to technology but the approaches regulators have taken to ensure that registrants have this competence differed. Scholars have explored the knowledge needs and competencies that members of their professions require to function in an increasingly digitalized world [ 59 , 66 , 67 ]. As discussed by our participants, technological competence will look different depending on each practice setting. However, with growing interprofessional collaboration, regulators within and across sectors have an opportunity to work together to share evidence and explore how competencies can be harmonized to ensure greater consistency amongst professionals.

Aside from being competent in using technology to deliver professional services, social media introduces implications for how regulated professionals interact with the public to maintain public trust. Many professional regulators have developed standards of practice to outline responsibilities and accountabilities due to increased complaints and findings of unprofessional conduct centred on inappropriate social media use [ 9 , 68 – 71 ]. High-profile conduct cases have sparked considerable debate about the need to balance professionals’ freedom of expression and speech with their obligations to maintain public trust. Social media can be a powerful platform for fostering professional networks, continuing education, and advocacy to encourage system improvements. At the same time, it can potentially cause significant social harm. Regulators will continue to need to evaluate how they approach registrants who use social media in ways that push the boundaries of conventional views of professionalism.

Opportunities to leverage regulatory data

Participants discussed the opportunities that technology can bring in facilitating better use of regulatory data to inform decision-making, though many challenges–including adequate knowledge and resources, addressing privacy concerns, and ensuring data platform interoperability–remain to realize this potential. Beyond the use of data analytics to inform internal regulatory policies and processes, regulators have an opportunity to leverage data to inform broader social goals such as workforce planning. Within the health and social care sectors, the importance of standardized health workforce data for integrated workforce planning has been recognized by scholars [ 72 – 74 ] and has become a priority for federal, provincial, and territorial governments in Canada [ 75 – 77 ]. Promising practices exist in other jurisdictions such as the United States and Australia where national databases and datasets are used, and Canada has recently announced pan-Canadian databases for physician and nursing data [ 75 , 78 ]. These data support inter-jurisdictional labour mobility and awareness of registration status and malpractice or disciplinary histories. The collection of standardized data can also provide meaningful input on issues such as the mental health of the workforce, a priority mentioned by all our participants. In addition, equity must be a priority, and the collection of enhanced demographic data could facilitate better understanding of the diversity of the workforce and the inequities that exist to inform policy and research needs.

Limitations and future research

The transferability of these findings should be interpreted carefully when applying to other regulatory contexts within and outside of Canada. Our participant sample was small and meant to provide foundational insights into how regulators are navigating an increasingly digitalized world. Members of our team are currently engaged in two funded research projects that build on this foundational work, one that expands the current study to survey and interview regulators across Canada, and one examining whether ethical codes and guidelines from regulators provide sufficient guidance for practitioners when they encounter challenges related to technology in practice. The implications of technology on professional regulation will require monitoring and evaluation over time to examine how technological innovations impact all facets of regulation and professional work.

Our case study explored how three Ontario professional regulators operating within different legislative frameworks are navigating technology in the digital era. Cross-sectoral participants provided theoretical and pragmatic insights for regulating in the digital era and the role regulators can and should play in digitally enabled professional practice. These insights provided an understanding of how these regulatory bodies are responding to the challenges of upholding their mandate to regulate in the public interest during rapid digital evolution. Our analysis identified five themes: balancing efficiency potential with risks of certain technological advances; the potential for improving regulation through data analytics; considering how to regulate a technologically competent workforce; recalibrating pandemic emergency measures involving technology; and contemplating the future of technology on regulatory policy and practice. Regulators will continue to grapple with considerations about technology used to facilitate regulatory functions, balancing consumer demands amid emerging risks posed by technology, producing technologically competent workforces, and informing workforce planning via regulatory data. Policymakers and regulators across Canada and internationally should prioritize risk-balanced policies, guidelines, and practice standards for modern professional regulation.

Supporting information

S1 file. description of regulatory documents..

https://doi.org/10.1371/journal.pone.0303192.s001

S2 File. Semi-structured interview guide.

https://doi.org/10.1371/journal.pone.0303192.s002

S3 File. COREQ checklist.

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

https://doi.org/10.1371/journal.pone.0303192.s003

Acknowledgments

We gratefully acknowledge and thank our interview participants for generously sharing their time and insights with us.

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• Volume 21, Issue 3
• Data collection in qualitative research
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• David Barrett 1 ,
• http://orcid.org/0000-0003-1130-5603 Alison Twycross 2
• 1 Faculty of Health Sciences , University of Hull , Hull , UK
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr David Barrett, Faculty of Health Sciences, University of Hull, Hull HU6 7RX, UK; D.I.Barrett{at}hull.ac.uk

https://doi.org/10.1136/eb-2018-102939

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

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

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

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

Example of an interview schedule 3

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

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

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

When managing pain in children what is your overall aim?

Whose responsibility is pain management?

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

What involvement do children have in their pain management?

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

What would help you manage pain better?

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

Focus groups

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

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

Observation

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

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

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

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

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Commissioned; internally peer reviewed.

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