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• Inductive vs. Deductive Research Approach | Steps & Examples

Inductive vs. Deductive Research Approach | Steps & Examples

Published on April 18, 2019 by Raimo Streefkerk . Revised on June 22, 2023.

The main difference between inductive and deductive reasoning is that inductive reasoning aims at developing a theory while deductive reasoning aims at testing an existing theory .

In other words, inductive reasoning moves from specific observations to broad generalizations . Deductive reasoning works the other way around.

Both approaches are used in various types of research , and it’s not uncommon to combine them in your work.

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Inductive research approach, deductive research approach, combining inductive and deductive research, other interesting articles, frequently asked questions about inductive vs deductive reasoning.

When there is little to no existing literature on a topic, it is common to perform inductive research , because there is no theory to test. The inductive approach consists of three stages:

• A low-cost airline flight is delayed
• Dogs A and B have fleas
• Elephants depend on water to exist
• Another 20 flights from low-cost airlines are delayed
• All observed dogs have fleas
• All observed animals depend on water to exist
• Low cost airlines always have delays
• All dogs have fleas
• All biological life depends on water to exist

Limitations of an inductive approach

A conclusion drawn on the basis of an inductive method can never be fully proven. However, it can be invalidated.

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When conducting deductive research , you always start with a theory. This is usually the result of inductive research. Reasoning deductively means testing these theories. Remember that if there is no theory yet, you cannot conduct deductive research.

The deductive research approach consists of four stages:

• If passengers fly with a low cost airline, then they will always experience delays
• All pet dogs in my apartment building have fleas
• All land mammals depend on water to exist
• Collect flight data of low-cost airlines
• Test all dogs in the building for fleas
• Study all land mammal species to see if they depend on water
• 5 out of 100 flights of low-cost airlines are not delayed
• 10 out of 20 dogs didn’t have fleas
• All land mammal species depend on water
• 5 out of 100 flights of low-cost airlines are not delayed = reject hypothesis
• 10 out of 20 dogs didn’t have fleas = reject hypothesis
• All land mammal species depend on water = support hypothesis

Limitations of a deductive approach

The conclusions of deductive reasoning can only be true if all the premises set in the inductive study are true and the terms are clear.

• All dogs have fleas (premise)
• Benno is a dog (premise)
• Benno has fleas (conclusion)

Many scientists conducting a larger research project begin with an inductive study. This helps them develop a relevant research topic and construct a strong working theory. The inductive study is followed up with deductive research to confirm or invalidate the conclusion. This can help you formulate a more structured project, and better mitigate the risk of research bias creeping into your work.

Remember that both inductive and deductive approaches are at risk for research biases, particularly confirmation bias and cognitive bias , so it’s important to be aware while you conduct your research.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Chi square goodness of fit test
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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Inductive reasoning is a bottom-up approach, while deductive reasoning is top-down.

Inductive reasoning takes you from the specific to the general, while in deductive reasoning, you make inferences by going from general premises to specific conclusions.

Inductive reasoning is a method of drawing conclusions by going from the specific to the general. It’s usually contrasted with deductive reasoning, where you proceed from general information to specific conclusions.

Inductive reasoning is also called inductive logic or bottom-up reasoning.

Deductive reasoning is a logical approach where you progress from general ideas to specific conclusions. It’s often contrasted with inductive reasoning , where you start with specific observations and form general conclusions.

Deductive reasoning is also called deductive logic.

Exploratory research aims to explore the main aspects of an under-researched problem, while explanatory research aims to explain the causes and consequences of a well-defined problem.

Explanatory research is used to investigate how or why a phenomenon occurs. Therefore, this type of research is often one of the first stages in the research process , serving as a jumping-off point for future research.

Exploratory research is often used when the issue you’re studying is new or when the data collection process is challenging for some reason.

You can use exploratory research if you have a general idea or a specific question that you want to study but there is no preexisting knowledge or paradigm with which to study it.

A research project is an academic, scientific, or professional undertaking to answer a research question . Research projects can take many forms, such as qualitative or quantitative , descriptive , longitudinal , experimental , or correlational . What kind of research approach you choose will depend on your topic.

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Analyzing and Interpreting Qualitative Research After the Interview

• Charles Vanover - University of South Florida, USA
• Paul Mihas - The University of North Carolina at Chapel Hill, USA
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This text provides comprehensive coverage of the key methods for analyzing, interpreting, and writing up qualitative research in a single volume, and drawing on the expertise of major names in the field. Covering all the steps in the process of analyzing, interpreting, and presenting findings in qualitative research, the authors utilize a consistent chapter structure that provides novice and seasoned researchers with pragmatic, “how-to” strategies. Each chapter introduces the method; uses one of the authors' own research projects as a case study of the method described; shows how the specific analytic method can be used in other types of studies; and concludes with questions and activities to prompt class discussion or personal study.

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This book is a great addition to the library of qualitative books for use with graduate students. Each chapter has examples to use and offers the nuance and complexities that are inherent in qualitative inquiry.

As an instructor of qualitative research courses, I know this text will be immediately useful for my students. Each chapter calls to mind a student who could benefit from its contents. The whole book is written in a way that’s accessible and down-to-earth and it will appeal to graduate students especially; I’ve picked up some new techniques, as well.

A complete guide for qualitative researchers – emerging or experienced. New ways to think about the vital role of qualitative studies!

The chapter authors provide clear, practical, and vibrant examples of their strategies. Individually, each chapter gives care to how the authors have used the strategy in the past. Collectively, the chapters provide a wealth of unique and innovative analysis approaches for all qualitative researchers to consider.

Change of focus in course design.

This was a great supplemental text to use in the Qualitative Research foundations course. This supplemented the main text by providing great detail about the "after" of the interview. Many of my students faced challenges in the coding and analyzing, especially during covid, and virtual interviews, so this was a great almost manual for them to have.

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107: Deductive Qualitative Analysis: Evaluating, Expanding, and Refining Theory

Stephen Fife; Jacob Gossner; Nathalie Saltikoff

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Authors: Stephen Fife, Jacob Gossner

Presider: Nathalie Saltikoff

Summary The advancement of Family Science requires the examination of current theories and the re-examination of previously published findings, whether quantitative or qualitative. Until recently, qualitative researchers have lacked a systematic way to combine inductive and deductive analysis in exploring the applicability of previous findings and existing theory to new samples. Deductive qualitative analysis (DQA) is a qualitative methodology suited to theory testing and refinement that combines deduction and induction to examine evidence that supports, contradicts, expands, or refines theory. We explore two applications of this methodology and offer suggestions for maintaining rigor and trustworthiness of analysis.

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2.3: Inductive or Deductive? Two Different Approaches

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Learning Objectives

• Describe the inductive approach to research, and provide examples of inductive research.
• Describe the deductive approach to research, and provide examples of deductive research.
• Describe the ways that inductive and deductive approaches may be complementary.

Theories structure and inform sociological research. So, too, does research structure and inform theory. The reciprocal relationship between theory and research often becomes evident to students new to these topics when they consider the relationships between theory and research in inductive and deductive approaches to research. In both cases, theory is crucial. But the relationship between theory and research differs for each approach. Inductive and deductive approaches to research are quite different, but they can also be complementary. Let’s start by looking at each one and how they differ from one another. Then we’ll move on to thinking about how they complement one another.

Inductive Approaches and Some Examples

In an inductive approach to research, a researcher begins by collecting data that is relevant to his or her topic of interest. Once a substantial amount of data have been collected, the researcher will then take a breather from data collection, stepping back to get a bird’s eye view of her data. At this stage, the researcher looks for patterns in the data, working to develop a theory that could explain those patterns. Thus when researchers take an inductive approach, they start with a set of observations and then they move from those particular experiences to a more general set of propositions about those experiences. In other words, they move from data to theory, or from the specific to the general. Figure 2.5 outlines the steps involved with an inductive approach to research.

Figure 2.5 Inductive Research

There are many good examples of inductive research, but we’ll look at just a few here. One fascinating recent study in which the researchers took an inductive approach was Katherine Allen, Christine Kaestle, and Abbie Goldberg’s study (2011)Allen, K. R., Kaestle, C. E., & Goldberg, A. E. (2011). More than just a punctuation mark: How boys and young men learn about menstruation. Journal of Family Issues, 32 , 129–156. of how boys and young men learn about menstruation. To understand this process, Allen and her colleagues analyzed the written narratives of 23 young men in which the men described how they learned about menstruation, what they thought of it when they first learned about it, and what they think of it now. By looking for patterns across all 23 men’s narratives, the researchers were able to develop a general theory of how boys and young men learn about this aspect of girls’ and women’s biology. They conclude that sisters play an important role in boys’ early understanding of menstruation, that menstruation makes boys feel somewhat separated from girls, and that as they enter young adulthood and form romantic relationships, young men develop more mature attitudes about menstruation.

In another inductive study, Kristin Ferguson and colleagues (Ferguson, Kim, & McCoy, 2011)Ferguson, K. M., Kim, M. A., & McCoy, S. (2011). Enhancing empowerment and leadership among homeless youth in agency and community settings: A grounded theory approach. Child and Adolescent Social Work Journal, 28 , 1–22. analyzed empirical data to better understand how best to meet the needs of young people who are homeless. The authors analyzed data from focus groups with 20 young people at a homeless shelter. From these data they developed a set of recommendations for those interested in applied interventions that serve homeless youth. The researchers also developed hypotheses for people who might wish to conduct further investigation of the topic. Though Ferguson and her colleagues did not test the hypotheses that they developed from their analysis, their study ends where most deductive investigations begin: with a set of testable hypotheses.

Deductive Approaches and Some Examples

Researchers taking a deductive approach take the steps described earlier for inductive research and reverse their order. They start with a social theory that they find compelling and then test its implications with data. That is, they move from a more general level to a more specific one. A deductive approach to research is the one that people typically associate with scientific investigation. The researcher studies what others have done, reads existing theories of whatever phenomenon he or she is studying, and then tests hypotheses that emerge from those theories. Figure 2.6 outlines the steps involved with a deductive approach to research.

Figure 2.6 Deductive Research

While not all researchers follow a deductive approach, as you have seen in the preceding discussion, many do, and there are a number of excellent recent examples of deductive research. We’ll take a look at a couple of those next.

In a study of US law enforcement responses to hate crimes, Ryan King and colleagues (King, Messner, & Baller, 2009)King, R. D., Messner, S. F., & Baller, R. D. (2009). Contemporary hate crimes, law enforcement, and the legacy of racial violence. American Sociological Review, 74 , 291–315.hypothesized that law enforcement’s response would be less vigorous in areas of the country that had a stronger history of racial violence. The authors developed their hypothesis from their reading of prior research and theories on the topic. Next, they tested the hypothesis by analyzing data on states’ lynching histories and hate crime responses. Overall, the authors found support for their hypothesis.

In another recent deductive study, Melissa Milkie and Catharine Warner (2011)Milkie, M. A., & Warner, C. H. (2011). Classroom learning environments and the mental health of first grade children. Journal of Health and Social Behavior, 52 , 4–22. studied the effects of different classroom environments on first graders’ mental health. Based on prior research and theory, Milkie and Warner hypothesized that negative classroom features, such as a lack of basic supplies and even heat, would be associated with emotional and behavioral problems in children. The researchers found support for their hypothesis, demonstrating that policymakers should probably be paying more attention to the mental health outcomes of children’s school experiences, just as they track academic outcomes (American Sociological Association, 2011).The American Sociological Association wrote a press release on Milkie and Warner’s findings: American Sociological Association. (2011). Study: Negative classroom environment adversely affects children’s mental health. Retrieved from asanet.org/press/Negative_Cla...tal_Health.cfm

Complementary Approaches?

While inductive and deductive approaches to research seem quite different, they can actually be rather complementary. In some cases, researchers will plan for their research to include multiple components, one inductive and the other deductive. In other cases, a researcher might begin a study with the plan to only conduct either inductive or deductive research, but then he or she discovers along the way that the other approach is needed to help illuminate findings. Here is an example of each such case.

In the case of my collaborative research on sexual harassment, we began the study knowing that we would like to take both a deductive and an inductive approach in our work. We therefore administered a quantitative survey, the responses to which we could analyze in order to test hypotheses, and also conducted qualitative interviews with a number of the survey participants. The survey data were well suited to a deductive approach; we could analyze those data to test hypotheses that were generated based on theories of harassment. The interview data were well suited to an inductive approach; we looked for patterns across the interviews and then tried to make sense of those patterns by theorizing about them.

For one paper (Uggen & Blackstone, 2004),Uggen, C., & Blackstone, A. (2004). Sexual harassment as a gendered expression of power. American Sociological Review, 69 , 64–92. we began with a prominent feminist theory of the sexual harassment of adult women and developed a set of hypotheses outlining how we expected the theory to apply in the case of younger women’s and men’s harassment experiences. We then tested our hypotheses by analyzing the survey data. In general, we found support for the theory that posited that the current gender system, in which heteronormative men wield the most power in the workplace, explained workplace sexual harassment—not just of adult women but of younger women and men as well. In a more recent paper (Blackstone, Houle, & Uggen, 2006),Blackstone, A., Houle, J., & Uggen, C. “At the time I thought it was great”: Age, experience, and workers’ perceptions of sexual harassment. Presented at the 2006 meetings of the American Sociological Association. Currently under review. we did not hypothesize about what we might find but instead inductively analyzed the interview data, looking for patterns that might tell us something about how or whether workers’ perceptions of harassment change as they age and gain workplace experience. From this analysis, we determined that workers’ perceptions of harassment did indeed shift as they gained experience and that their later definitions of harassment were more stringent than those they held during adolescence. Overall, our desire to understand young workers’ harassment experiences fully—in terms of their objective workplace experiences, their perceptions of those experiences, and their stories of their experiences—led us to adopt both deductive and inductive approaches in the work.

Researchers may not always set out to employ both approaches in their work but sometimes find that their use of one approach leads them to the other. One such example is described eloquently in Russell Schutt’s Investigating the Social World (2006).Schutt, R. K. (2006). Investigating the social world: The process and practice of research . Thousand Oaks, CA: Pine Forge Press. As Schutt describes, researchers Lawrence Sherman and Richard Berk (1984)Sherman, L. W., & Berk, R. A. (1984). The specific deterrent effects of arrest for domestic assault. American Sociological Review, 49 , 261–272. conducted an experiment to test two competing theories of the effects of punishment on deterring deviance (in this case, domestic violence). Specifically, Sherman and Berk hypothesized that deterrence theory would provide a better explanation of the effects of arresting accused batterers than labeling theory . Deterrence theory predicts that arresting an accused spouse batterer will reduce future incidents of violence. Conversely, labeling theory predicts that arresting accused spouse batterers will increase future incidents. Figure 2.7 summarizes the two competing theories and the predictions that Sherman and Berk set out to test.

Figure 2.7 Predicting the Effects of Arrest on Future Spouse Battery

Sherman and Berk found, after conducting an experiment with the help of local police in one city, that arrest did in fact deter future incidents of violence, thus supporting their hypothesis that deterrence theory would better predict the effect of arrest. After conducting this research, they and other researchers went on to conduct similar experimentsThe researchers did what’s called replication. We’ll learn more about replication in Chapter 3. in six additional cities (Berk, Campbell, Klap, & Western, 1992; Pate & Hamilton, 1992; Sherman & Smith, 1992).Berk, R., Campbell, A., Klap, R., & Western, B. (1992). The deterrent effect of arrest in incidents of domestic violence: A Bayesian analysis of four field experiments. American Sociological Review, 57 , 698–708; Pate, A., & Hamilton, E. (1992). Formal and informal deterrents to domestic violence: The Dade county spouse assault experiment. American Sociological Review, 57 , 691–697; Sherman, L., & Smith, D. (1992). Crime, punishment, and stake in conformity: Legal and informal control of domestic violence. American Sociological Review, 57 , 680–690. Results from these follow-up studies were mixed. In some cases, arrest deterred future incidents of violence. In other cases, it did not. This left the researchers with new data that they needed to explain. The researchers therefore took an inductive approach in an effort to make sense of their latest empirical observations. The new studies revealed that arrest seemed to have a deterrent effect for those who were married and employed but that it led to increased offenses for those who were unmarried and unemployed. Researchers thus turned to control theory, which predicts that having some stake in conformity through the social ties provided by marriage and employment, as the better explanation.

Figure 2.8 Predicting the Effects of Arrest on Future Spouse Battery: A New Theory

What the Sherman and Berk research, along with the follow-up studies, shows us is that we might start with a deductive approach to research, but then, if confronted by new data that we must make sense of, we may move to an inductive approach. Russell Schutt depicts this process quite nicely in his text, and I’ve adapted his depiction here, in Figure 2.9.

KEY TAKEAWAYS

• The inductive approach involves beginning with a set of empirical observations, seeking patterns in those observations, and then theorizing about those patterns.
• The deductive approach involves beginning with a theory, developing hypotheses from that theory, and then collecting and analyzing data to test those hypotheses.
• Inductive and deductive approaches to research can be employed together for a more complete understanding of the topic that a researcher is studying.
• Though researchers don’t always set out to use both inductive and deductive strategies in their work, they sometimes find that new questions arise in the course of an investigation that can best be answered by employing both approaches.

Monty Python and Holy Grail :

(click to see video)

Do the townspeople take an inductive or deductive approach to determine whether the woman in question is a witch? What are some of the different sources of knowledge (recall Chapter 1) they rely on?

• Think about how you could approach a study of the relationship between gender and driving over the speed limit. How could you learn about this relationship using an inductive approach? What would a study of the same relationship look like if examined using a deductive approach? Try the same thing with any topic of your choice. How might you study the topic inductively? Deductively?

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Inductive and Deductive Approaches

• Watching now: Chapter 1: Overview of Inductive and Deductive Approaches in Qualitative Research Start time: 00:00:00 End time: 00:04:37

Video Type: Tutorial

(2018). Inductive and deductive approaches [Video]. Sage Research Methods. https:// doi. org/10.4135/9781529625271

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An overview of inductive and deductive approaches in qualitative research, including examples.

Chapter 1: Overview of Inductive and Deductive Approaches in Qualitative Research

• Start time: 00:00:00
• End time: 00:04:37
• Product: Sage Research Methods Video: Qualitative and Mixed Methods
• Type of Content: Tutorial
• Title: Inductive and Deductive Approaches
• Publisher: Scholarsight Technologies Private Limited
• Series: Theoretical Foundations of Qualitative Research
• Publication year: 2018
• Online pub date: December 02, 2022
• Discipline: Sociology , Communication and Media Studies , History , Public Health , Criminology and Criminal Justice , Counseling and Psychotherapy , Psychology , Health , Education , Social Policy and Public Policy , Social Work , Political Science and International Relations , Geography , Business and Management , Anthropology , Nursing
• Methods: Qualitative measures , Induction , Deduction
• Duration: 00:04:37
• DOI: https:// doi. org/10.4135/9781529625271
• Keywords: deductive reasoning , inductive reasoning , qualitative research methods Show all Show less
• Online ISBN: 9781529625271 Copyright: © Scholarsight Technologies Private Limited. MAXQDA software is the registered trademark of VERBE Gmbh. Any other brand mentioned in examples belong to respective owners. Examples are for demonstration and learning purposes only. More information Less information

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1-2 The Nature of Evidence: Inductive and Deductive Reasoning

Renate Kahlke; Jonathan Sherbino; and Sandra Monteiro

Different philosophies of science (Chapter 1-1) inform different approaches to research, characterized by different goals, assumptions, and types of data. In this chapter, we discuss how post-positivist, interpretivist, constructivist, and critical philosophies form a foundation for two broad approaches to generating knowledge: quantitative and qualitative research. There are several often-discussed distinctions between these two approaches, stemming from their philosophical roots, specifically, a commitment to objectivity versus subjective interpretation, numbers versus words, generalizability versus transferability, and deductive versus inductive reasoning. While these distinctions often distinguish qualitative and quantitative research, there are always exceptions. These exceptions demonstrate that quantitative and qualitative research approaches have more in common than what superficial descriptions imply.

Key Points of the Chapter

By the end of this chapter the learner should be able to:

• Describe quantitative research methodologies
• Describe qualitative research methodologies
• Compare and contrast these two approaches to interpreting data

Rayna (they/their) stared at the blinking cursor on her screen. They had been recently invited to revise and resubmit their first qualitative research manuscript. Most of the editor and reviewer comments had been relatively easy to handle, but when Rayna reached Reviewer 2’s comments, they were caught off guard. The reviewer acknowledged that they came from a quantitative background, but then went on to write: “I am worried about the generalizability of this study, with a sample of only 25 residents. Wouldn’t it be better to do a survey to get more perspectives?”

Rayna hadn’t seen any other qualitative studies talk about generalizability, so they weren’t entirely sure how to address this comment. Maybe the study won’t be valuable if the results aren’t generalizable! Reviewer 2 might be right that the sample size is too small! They immediately panic-email one of their co-authors:

Hi Rayna, We get these kinds of reviews all the time. Don’t worry, it’s not a flaw in your study. That said, I think we can build our field’s knowledge about qualitative research approaches by explaining some of these concepts. Start with the one by Monteiro et al. and then read the one by Wright and colleagues. These are both good primers and will give you some language to help respond to this reviewer.

With a sigh of relief, Rayna reads through the attached papers (1-8) and continues her mission to craft a response.

Deeper Dive on this Concept

Qualitative and quantitative research are often talked about as two different ways of thinking and generating knowledge. We contrast a reliance on words with a reliance on numbers, a focus on subjectivity with a focus on objectivity. And to some extent these approaches are different, in precisely the ways described. However, many experienced researchers on both sides of the line will tell you that these differences only go so far.

Drawing on Chapter 1-1, there are different philosophies of science that inform researchers and their research products. Generally, quantitative research is associated with post-positivism; researchers seek to be objective and reduce their bias in order to ensure that their results are as close as possible to the truth. Post-positivists, unlike positivists, acknowledge that a singular truth is impossible to define. However, truth can be defined within a spectrum of probability. Quantitative researchers generate and test hypotheses to make conclusions about a theory they have developed. They conduct experiments that generate numerical data that  define the extent to which an observation is “true.” The strength of the numerical data  suggests whether the observation can be generalized beyond the study population. This process is called deductive reasoning because it starts with a general theory that narrows to a hypothesis that is tested against observations that support (or refute) the theory.

Qualitative researchers, on the other hand, tend to be guided by interpretivism, constructivism, critical theory or other perspectives that value subjectivity. These analytic approaches do not address bias because bias assumes a misrepresentation of “truth” during collection or analysis of data. Subjectivity emphasizes the position and perspective assumed during analysis, articulating that there is no external objective truth, uninformed by context. ( See Chapter 1-1 .) Qualitative methods seek to deeply understand a phenomenon, using the rich meaning provided by words, symbols, traditions, structures, identity constructs and power dynamics (as opposed to simply numbers). Rather than testing a hypothesis, they generate knowledge by inductively generating new insights or theory (i.e. observations are collected and analyzed to build a theory). These insights are contextual, not universal.  Qualitative researchers translate their results within a rich description of context so that readers can assess the similarities and differences between contexts and determine the extent to which the study results are transferable to their setting.

While these distinctions can be helpful in distinguishing quantitative and qualitative research broadly, they also create false divisions. The relationships between these two approaches are more complex, and nuances are important to bear in mind, even for novices, lest we exacerbate hierarchies and divisions between different types of knowledge and evidence.

As an example, the interpretation of quantitative results is not always clear and obvious – findings do not always support or refute a hypothesis. Thus, both qualitative and quantitative researchers need to be attentive to their data. While quantitative research is generally thought to be deductive, quantitative researchers often do a bit of inductive reasoning to find meaning in data that hold surprises. Conversely, qualitative data are stereotypically analyzed inductively, making meaning from the data rather than proving a hypothesis. However, many qualitative researchers apply existing theories or theoretical frameworks, testing the relevance of existing theory in a new context or seeking to explain their data using an existing framework. These approaches are often characterized as deductive qualitative work.

As another example, quantitative researchers use numbers, but these numbers aren’t always meaningful without words. In surveys, interpretation of numerical responses may not be possible without analyzing them alongside free-text responses. And while qualitative researchers rarely use numbers, they do need to think through the frequency with which certain themes appear in their dataset. An idea that only appears once in a qualitative study may have great value to the analysis, but it is also important that researchers acknowledge the views that are most prevalent in a given qualitative dataset.

Key Takeaways

• Quantitative research is generally associated with post-positivism. Since researchers seek to get as close to ‘the truth’, as they can, they value objectivity and seek generalizable results. They generate hypotheses and use deductive reasoning and numerical data numbers to prove or disprove their hypotheses. Replicating patterns of data to validate theories and interpretations is one way to evaluate ‘the truth’.
• Qualitative research is generally associated with worldviews that value subjectivity. Since qualitative researchers seek to understand the interaction between person, place, history, power, gender and other elements of context, they value subjectivity (e.g. interpretivism, constructivism, critical theory). Qualitative research does not seek generalizability of findings (i.e. a universal, decontextualized result), rather it produces results that are inextricably linked to the context of the data and analysis. Data tend to take the form of words, rather than numbers, and are analyzed inductively.
• Qualitative and quantitative research are not opposites. Qualitative and quantitative research are often marked by a set of apparently clear distinctions, but there are always nuances and exceptions. Thus, these approaches should be understood as complementary, rather than diametrically opposed.

Vignette Conclusion

Rayna smiled and read over their paper once more. They had included an explanation of qualitative research, and how it’s about depth of information and nuance of experience. The depth of data generated per participant is significant, therefore fewer people are typically recruited in qualitative studies.  Rayna also articulated that while the interpretivist approach she used for analysis isn’t focused on generalizing the results beyond a specific context, they were able to make an argument for how the results can transfer to other, similar contexts. Cal provided a bunch of margin comments in her responses to the reviews, highlighting how savvy Rayna had been in addressing the concerns of Reviewer 2 without betraying their epistemic roots. The editor certainly was right – adding more justification and explanation had made the paper stronger, and would likely help others grow to better understand qualitative work. Now the only challenge left was figuring out how to upload the revised documents to the journal submission portal…

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Sandra Monteiro is an Associate Professor within the Department of Medicine, Division of Education and Innovation, Faculty of Health Sciences, McMaster University. She holds a joint appointment within the Department of   Health Research Methods, Evidence, and Impact ,  Faculty of Health Sciences, McMaster University.

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Inductive and/or Deductive Research Designs

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This chapter aims to introduce the readers, especially the Bangladeshi undergraduate and postgraduate students to some fundamental considerations of inductive and deductive research designs. The deductive approach refers to testing a theory, where the researcher builds up a theory or hypotheses and plans a research stratagem to examine the formulated theory. On the contrary, the inductive approach intends to construct a theory, where the researcher begins by gathering data to establish a theory. In the beginning, a researcher must clarify which approach he/she will follow in his/her research work. The chapter discusses basic concepts, characteristics, steps and examples of inductive and deductive research designs. Here, also a comparison between inductive and deductive research designs is shown. It concludes with a look at how both inductive and deductive designs are used comprehensively to constitute a clearer image of research work.

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Haque, M.S. (2022). Inductive and/or Deductive Research Designs. In: Islam, M.R., Khan, N.A., Baikady, R. (eds) Principles of Social Research Methodology. Springer, Singapore. https://doi.org/10.1007/978-981-19-5441-2_5

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Qualitative Research Journal

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Article publication date: 31 October 2018

Issue publication date: 15 November 2018

The purpose of this paper is to explain the rationale for choosing the qualitative approach to research human resources practices, namely, recruitment and selection, training and development, performance management, rewards management, employee communication and participation, diversity management and work and life balance using deductive and inductive approaches to analyse data. The paper adopts an emic perspective that favours the study of transfer of human resource management practices from the point of view of employees and host country managers in subsidiaries of western multinational enterprises in Ghana.

Design/methodology/approach

Despite the numerous examples of qualitative methods of data generation, little is known particularly to the novice researcher about how to analyse qualitative data. This paper develops a model to explain in a systematic manner how to methodically analyse qualitative data using both deductive and inductive approaches.

The deductive and inductive approaches provide a comprehensive approach in analysing qualitative data. The process involves immersing oneself in the data reading and digesting in order to make sense of the whole set of data and to understand what is going on.

Originality/value

This paper fills a serious gap in qualitative data analysis which is deemed complex and challenging with limited attention in the methodological literature particularly in a developing country context, Ghana.

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Azungah, T. (2018), "Qualitative research: deductive and inductive approaches to data analysis", Qualitative Research Journal , Vol. 18 No. 4, pp. 383-400. https://doi.org/10.1108/QRJ-D-18-00035

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Answers to the most commonly asked questions here

Deductive Approach (Deductive Reasoning)

A deductive approach is concerned with “developing a hypothesis (or hypotheses) based on existing theory, and then designing a research strategy to test the hypothesis” [1]

It has been stated that “deductive means reasoning from the particular to the general. If a causal relationship or link seems to be implied by a particular theory or case example, it might be true in many cases. A deductive design might test to see if this relationship or link did obtain on more general circumstances” [2] .

Deductive approach can be explained by the means of hypotheses, which can be derived from the propositions of the theory. In other words, deductive approach is concerned with deducting conclusions from premises or propositions.

Deduction begins with an expected pattern “that is tested against observations, whereas induction begins with observations and seeks to find a pattern within them” [3] .

Advantages of Deductive Approach

Deductive approach offers the following advantages:

• Possibility to explain causal relationships between concepts and variables
• Possibility to measure concepts quantitatively
• Possibility to generalize research findings to a certain extent

Alternative to deductive approach is  inductive approach.  The table below guides the choice of specific approach depending on circumstances:

Choice between deductive and inductive approaches

Deductive research approach explores a known theory or phenomenon and tests if that theory is valid in given circumstances. It has been noted that “the deductive approach follows the path of logic most closely. The reasoning starts with a theory and leads to a new hypothesis. This hypothesis is put to the test by confronting it with observations that either lead to a confirmation or a rejection of the hypothesis” [4] .

Moreover, deductive reasoning can be explained as “reasoning from the general to the particular” [5] , whereas inductive reasoning is the opposite. In other words, deductive approach involves formulation of hypotheses and their subjection to testing during the research process, while inductive studies do not deal with hypotheses in any ways.

Application of Deductive Approach (Deductive Reasoning) in Business Research

In studies with deductive approach, the researcher formulates a set of hypotheses at the start of the research. Then, relevant research methods are chosen and applied to test the hypotheses to prove them right or wrong.

Generally, studies using deductive approach follow the following stages:

• Deducing  hypothesis from theory.
• Formulating  hypothesis in operational terms and proposing relationships between two specific variables
• Testing  hypothesis with the application of relevant method(s). These are quantitative methods such as regression and correlation analysis, mean, mode and median and others.
• Examining  the outcome of the test, and thus confirming or rejecting the theory. When analysing the outcome of tests, it is important to compare research findings with the literature review findings.
• Modifying  theory in instances when hypothesis is not confirmed.

My e-book,  The Ultimate Guide to Writing a Dissertation in Business Studies: a step by step assistance  contains discussions of theory and application of research approaches. The e-book also explains all stages of the  research process  starting from the  selection of the research area  to writing personal reflection. Important elements of dissertations such as  research philosophy ,   research design ,  methods of data collection ,   data analysis  and   sampling   are explained in this e-book in simple words.

John Dudovskiy

[1] Wilson, J. (2010) “Essentials of Business Research: A Guide to Doing Your Research Project” SAGE Publications, p.7

[2] Gulati, PM, 2009, Research Management: Fundamental and Applied Research, Global India Publications, p.42

[3] Babbie, E. R. (2010) “The Practice of Social Research” Cengage Learning, p.52

[4] Snieder, R. & Larner, K. (2009) “The Art of Being a Scientist: A Guide for Graduate Students and their Mentors”, Cambridge University Press, p.16

[5] Pelissier, R. (2008) “Business Research Made Easy” Juta & Co., p.3

• Open access
• Published: 28 March 2024

Nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents– a qualitative study

• Rachel Gilbert 1 &
• Daniela Lillekroken   ORCID: orcid.org/0000-0002-7463-8977 1  

BMC Nursing volume  23 , Article number:  216 ( 2024 ) Cite this article

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Over the years, caring has been explained in various ways, thus presenting various meanings to different people. Caring is central to nursing discipline and care ethics have always had an important place in nursing ethics discussions. In the literature, Joan Tronto’s theory of ethics of care is mostly discussed at the personal level, but there are still a few studies that address its influence on caring within the nursing context, especially during the provision of end-of-life care. This study aims to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

This study has a qualitative descriptive design. Data were collected by conducting five individual interviews and one focus group during a seven-month period between April 2022 and September 2022. Nine nurses employed at four Norwegian nursing homes were the participants in this study. Data were analysed by employing a qualitative deductive content analysis method.

The content analysis generated five categories that were labelled similar to Tronto’s five phases of the care process: (i) caring about, (ii) caring for, (iii) care giving, (iv) care receiving and (v) caring with. The findings revealed that nurses’ autonomy more or less influences the decision-making care process at all five phases, demonstrating that the Tronto’s theory contributes to greater reflectiveness around what may constitute ‘good’ end-of-life care.

Conclusions

Tronto’s care ethics is useful for understanding end-of-life care practice in nursing homes. Tronto’s care ethics provides a framework for an in-depth analysis of the asymmetric relationships that may or may not exist between nurses and nursing home residents and their next-of-kin. This can help nurses see and understand the moral dimension of end-of-life care provided to nursing home residents during their final days. Moreover, it helps handle moral responsibility around end-of-life care issues, providing a more complex picture of what ‘good’ end-of-life care should be.

Peer Review reports

In recent decades, improving end-of-life care has become a global priority [ 1 ]. The proportion of older residents dying in nursing homes is rising across the world [ 2 ], resulting in a significant need to improve the quality of end-of-life care provided to residents. Therefore, throughout the world, nursing homes are becoming increasingly important as end-of-life care facilities [ 3 ]. As the largest professional group in healthcare [ 4 ], nurses primarily engage in direct care activities [ 5 ] and patient communication [ 6 ] positioning them in close proximity to patients. This proximity affords them the opportunity to serve as information brokers and mediators in end-of-life decision-making [ 7 ]. They also develop trusting relationships with residents and their next-of-kin, relationships that may be beneficial for the assessment of residents and their next-of-kin’s needs [ 8 ]. Moreover, nurses have the opportunity to gain a unique perspective that allows them to become aware of if and when a resident is not responding to a treatment [ 9 ].

When caring for residents in their critical end-of-life stage, nurses form a direct and intense bond with the resident’s next-of-kin, hence nurses become central to end-of-life care provision and decision-making in nursing homes [ 10 ]. The degree of residents and their next-of-kin involvement in the decision-making process in practice remains a question [ 11 ]. Results from a study conducted in six European countries [ 12 ], demonstrate that, in long-term care facilities, too many care providers are often involved, resulting in difficulties in reaching a consensus in care. Although nurses believe that their involvement is beneficial to residents and families, there is a need for more empirical evidence of these benefits at the end-of-life stage. However, the question of who should be responsible for making decisions is still difficult to answer [ 13 ]. One study exploring nurse’s involvement in end-of-life decisions revealed that nurses experience ethical problems and uncertainty about the end-of-life care needs of residents [ 14 ]. Another study [ 10 ] reported patients being hesitant to discuss end-of‐life issues with their next-of-kin, resulting in nurses taking over; thus, discussing end-of-life issues became their responsibility. A study conducted in several nursing homes from the UK demonstrated that ethical issues associated with palliative care occurred most frequently during decision-making, causing greater distress among care providers [ 15 ].

Previous research has revealed that there are some conflicts over end-of-life care that consume nurses’ time and attention at the resident’s end-of-life period [ 16 ]. The findings from a meta-synthesis presenting nurses’ perspectives dealing with ethical dilemmas and ethical problems in end-of-life care revealed that nurses are deeply involved with patients as human beings and display an inner responsibility to fight for their best interests and wishes in end-of-life care [ 17 ].

Within the Norwegian context, several studies have explored nurses’ experiences with ethical dilemmas when providing end-of-life care in nursing homes. One study describing nurses’ ethical dilemmas concerning limitation of life-prolonging treatment suggested that there are several disagreements between the next-of-kin’s wishes and what the resident may want or between the wishes of the next-of-kin and what the staff consider to be right [ 18 ]. Another study revealed that nurses provide ‘more of everything’ and ‘are left to dealing with everything on their own’ during the end-of-life care process [ 19 ] (p.13) . Several studies aiming to explore end-of-life decision-making in nursing homes revealed that nurses experience challenges in protecting the patient’s autonomy regarding issues of life-prolonging treatment, hydration, nutrition and hospitalisation [ 20 , 21 , 22 ]. Other studies conducted in the same context have described that nurses perceive ethical problems as a burden and as barriers to decision-making in end-of-life care [ 8 , 23 ].

Nursing, as a practice, is fundamentally grounded in moral values. The nurse-patient relationship, central to nursing care provision, holds ethical importance and significance. It is crucial to recognise that the context within which nurses practice can both shape and be shaped by nursing’s moral values. These values collectively constitute what can be termed the ethical dimension of nursing [ 24 ]. Nursing ethos and practices are rooted in ethical values and principles; therefore, one of the position statements of the International Council of Nurses [ 25 ] refers to nurses’ role in providing care to dying patients and their families as an inherent part of the International Classification for Nursing Practice [ 26 ] (e.g., dignity, autonomy, privacy and dignified dying). Furthermore, ethical competence is recognised as an essential element of nursing practice [ 27 ], and it should be considered from the following viewpoints: ethical decision-making, ethical sensitivity, ethical knowledge and ethical reflection.

The term ‘end-of-life care’ is often used interchangeably with various terms such as terminal care, hospice care, or palliative care. End-of life care is defined as care ‘to assist persons who are facing imminent or distant death to have the best quality of life possible till the end of their life regardless of their medical diagnosis, health conditions, or ages’ [ 28 ] (p.613) . From this perspective, professional autonomy is an important feature of nurses’ professionalism [ 29 ]. Professional autonomy can be defined based on two elements: independence in decision-making and the ability to use competence, which is underpinned by three themes: shared leadership, professional skills, inter- and intraprofessional collaboration and a healthy work environment [ 30 ].

As presented earlier, research studies have reported that nurses experience a range of difficulties or shortcomings during the decision-making process; therefore, autonomous practice is essential for safe and quality care [ 31 ]. Moreover, autonomous practice is particularly important for the moral dimension in end-of-life care, where nurses may need to assume more responsibility in the sense of defining and giving support to matters that are at risk of not respecting ethical principles or fulfilling their ethical, legal and professional duties towards the residents they care for.

To the best of the researchers’ knowledge, little is known about nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents; therefore, the aim of this study is to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

Theoretical framework

Joan Tronto is an American political philosopher and one of the most influential care ethicists. Her theory of the ethics of care [ 32 , 33 , 34 ] has been chosen as the present study’s theoretical framework. The ethics of care is a feminist-based ethical theory, focusing on caring as a moral attitude and a sensitive and supportive response of the nurse to the situation and circumstances of a vulnerable human being who is in need of help [ 33 , 34 , 35 ]. In this sense, nurses’ caring behaviour has the character of a means—helping to reach the goal of nursing practice—which here entails providing competent end-of-life care.

Thinking about the process of care, in her early works [ 32 , 33 , 34 ], Tronto proposes four different phases of caring and four elements of care. Although the phases may be interchangeable and often overlap with each other, the elements of care are fundamental to demonstrate caring. The phases of caring involve cognitive, emotional and action strategies.

The first phase of caring is caring about , which involves the nurse’s recognition of being in need of care and includes concern, worry about someone or something. In this phase, the element of care is attentiveness, which entails the detection of the patient and/or family need.

The second phase is caring for , which implies nurses taking responsibility for the caring process. In this phase, responsibility is the element of care and requires nurses to take responsibility to meet a need that has been identified.

The third phase is care giving , which encompasses the actual physical work of providing care and requires direct engagement with care. The element of care in this phase is competence, which involves nurses having the knowledge, skills and values necessary to meet the goals of care.

The fourth phase is care receiving , which involves an evaluation of how well the care giving meets the caring needs. In this phase, responsiveness is the element of care and requires the nurse to assess whether the care provided has met the patient/next-of-kin care needs. This phase helps preserve the patient–nurse relationship, which is a distinctive aspect of the ethics of care [ 36 ].

In 2013, Tronto [ 35 ] updated the ethics of care by adding a fifth phase of caring— caring with —which is the common thread weaving among the four phases. When care is responded to through care receiving and new needs are identified, nurses return to the first phase and begin again. The care elements in this phase are trust and solidarity. Within a healthcare context, trust builds as patients and nurses realise that they can rely on each other to participate in their care and care activities. Solidarity occurs when patients, next-of-kin, nurses and others (i.e., ward leaders, institutional management) engage in these processes of care together rather than alone.

To the best of our knowledge, these five phases of caring and their elements of caring have never been interpreted within the context of end-of-life care. The ethics of care framework offers a context-specific way of understanding how nurses’ professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents, revealing similarities with Tronto’s five phases, which has motivated choosing her theory.

Aim of the study

The present study aims to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

The current study has a qualitative descriptive design using five individual interviews and one focus group to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

Setting and participants

The setting for the study was four nursing homes located in different municipalities from the South-Eastern region of Norway. Nursing homes in Norway are usually public assisted living facilities and offer all-inclusive accommodation to dependent individuals on a temporary or permanent basis [ 37 ]. The provision of care in the Norwegian nursing homes is regulated by the ‘Regulation of Quality of Care’ [ 38 ], aiming to improve nursing home residents’ quality of life by offering quality care that meets residents’ fundamental physiological and psychosocial needs and to support their individual autonomy through the provision of daily nursing care and activities tailored to their specific needs, and, when the time comes, a dignified end-of-life care in safe milieu.

End-of-life care is usually planned and provided by nurses having a post graduate diploma in either palliative nursing or oncology nursing– often holding an expert role, hence ensuring that the provision of end-of-life care meets the quality criteria and the resident’s needs and preferences [ 39 ].

To obtain rich information to answer the research question, it was important to involve participants familiar with the topic of study and who had experience working in nursing homes and providing end-of-life care to residents; therefore, a purposive sample was chosen. In this study, a heterogeneous sampling was employed, which involved including participants from different nursing homes with varying lengths of employment and diverse experiences in providing end-of-life care to residents. This approach was chosen to gather data rich in information [ 40 ]. Furthermore, when recruiting participants, the first author was guided by Malterud et al.’s [ 41 ] pragmatic principle, suggesting that the more ‘information power’ the participants provided, the smaller the sample size needed to be, and vice versa. Therefore, the sample size was not determined by saturation but instead by the number of participants who agreed to participate. However, participants were chosen because they had particular characteristics such as experience and roles which would enable understanding how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

The inclusion criteria for the participants were as follows: (i) to be a registered nurse, (ii) had a minimum work experience of two years employed at a nursing home, and (iii) had clinical experience with end-of-life/palliative care. To recruit participants, the first author sent a formal application with information about the study to four nursing homes. After approval had been given, the participants were asked and recruited by the leadership from each nursing home. The participants were then contacted by the first author by e-mail and scheduled a time for meeting and conducting the interviews.

Ten nurses from four different nursing homes were invited to participate, but only nine agreed. The participants were all women, aged between 27 and 65 and their work experience ranged from 4 to 21 years. Two participants had specialist education in palliative care, and one was currently engaged in a master’s degree in nursing science. Characteristics of the participants are presented in Table  1 :

Data collection methods

Data were collected through five semistructured individual and one focus group interviews. Both authors conducted the interviews together. The study was carried out between April and September 2022. Due to the insecurity related to the situation caused by the post-SARS-CoV-2 virus pandemic and concerns about potential new social distancing regulations imposed by the Norwegian government, four participants from the same nursing home opted for a focus group interview format. This decision was motivated by a desire to mitigate the potential negative impact that distancing regulations might have on data collection. The interviews were guided by an interview guide developed after reviewing relevant literature on end-of-life care and ethical dilemmas. The development of the interview guide consisted of five phases: (i) identifying the prerequisites for using semi-structured interviews; (ii) retrieving and using previous knowledge; (iii) formulating the preliminary semi-structured interview guide; (iv) pilot testing the interview guide; and (v) presenting the complete semistructured interview guide [ 42 ]. The interview guide was developed by both authors prior to the onset of the project and consisted of two demographic questions and eight main open-ended questions. The interview guide underwent initial testing with a colleague employed at the same nursing home as the first author. After the pilot phase in phase four, minor language revisions were made to specific questions to bolster the credibility of the interview process and ensure the collection of comprehensive and accurate data. The same interview guide was used to conduct individual interviews and focus group (Table  2 ).

The interviews were all conducted in a quiet room at a nursing home. Each interview lasted between 30 and 60 min and were digitally recorded. The individual interviews were transcribed verbatim by the first author. The focus group interview was transcribed by the second author.

Ethical perspectives

Prior to the onset of the data collection, ethical approval and permission to conduct the study were sought from the Norwegian Agency for Shared Services in Education and Research (Sikt/Ref. number 360,657) and from each leader of the nursing home. The study was conducted in accordance with the principles of the Declaration of Helsinki of the World Medical Association [ 43 ]: informed consent, consequences and confidentiality. The participants received written information about the aim of the study, how the researcher would ensure their confidentiality and, if they chose to withdraw from the study, their withdrawal would not have any negative consequences for their employment at nursing homes. Data were anonymised, and the digital records of the interviews were stored safely on a password-protected personal computer. The transcripts were stored in a locked cabinet in accordance with the existing rules and regulations for research data storage at Oslo Metropolitan University. The participants did not receive any financial or other benefits from participating in the study. Written consent was obtained prior to data collection, but verbal consent was also provided before each interview. None of the participants withdrew from the study.

Data analysis

The data were analysed by employing a qualitative deductive content analysis, as described by Kyngäs and Kaakinen [ 44 ]. Both researchers independently conducted the data analysis manually. The empirical data consisted of 63 pages (34,727 words) of transcripts from both individual and focus group interviews. The deductive content analysis was performed in three steps: (i) preparation, (ii) organisation and (iii) reporting of the results.

During the first step—preparation—each researcher, individually, read the transcripts several times to get an overview of the data and select units of analysis by searching for recurring codes and meanings and to carefully compare the similarities and differences between coded data. These codes were labelled independently by both researchers and placed into an analysis matrix.

During the next step—organisation—the researchers met and discussed and then compared and revised the labels several times until they agreed about the preliminary findings. During the interpretative process towards developing an understanding of the empirical data, the content of the labels referred to nurses’ perceptions about how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents, revealing similarities with the five phases of Tronto’s theory of ethics of care [ 32 , 33 ], thus assigning them to the five phases of the theory. Following this final refinement, one main category and five categories, each supported by several subcategories, were identified, as presented in Table  3 .

Reporting the results was the last step in the analysis. To enhance the understanding of the study’s findings, the findings are presented with supporting excerpts from the participants.

In qualitative studies, trustworthiness is the main parameter for appraising the rigour of the study [ 45 ]. To enhance the trustworthiness of the study, four criteria—credibility, transferability, dependability and confirmability, as described by Lincoln and Guba [ 46 ]—were applied.

To support credibility, a detailed description of the sample and the sampling process was provided. Furthermore, the interview guide and the questions that the participants were asked during the interviews are made available to the readers. Moreover, although the data were collected from five individual interviews and one focus group, triangulation of two data collection methods allowed researchers to ensure that the study is based on diverse perceptions and experiences, strengthening the credibility and impact of the study’s findings [ 47 ].

Detailed information about the sample and setting supports the assessment of the transferability of the findings. In this way, the readers can recognise and evaluate whether the findings would be applicable to similar contexts with a similar sample. Quotes from the participants’ statements are given to support the findings. Each quote ends with a number representing the code that each nurse was given before conducting the interviews (i.e., Participant in interview 1, PI1 or participant 6 in focus group interview, P6FG).

To increase dependability, the same interview guide was used to ask all participants the same questions. Dependability was also increased by the researchers reading and analysing the interviews independently and then checking the consistency of the data analysis technique with each other and discussing the analytical process until a consensus was reached.

To enhance confirmability, excerpts from the participants’ statements were included when presenting the findings, thus verifying the concordance of findings with the raw data. This demonstrates that the data were not based on preconceived notions.

Trustworthiness was also supported by member checking, meaning that the researchers sent the participants the transcripts of the interviews immediately after data collection; then, the interviews were transcribed. The participants were asked to review the transcripts and check the accuracy of the data; hence, they had the opportunity to add, remove or clarify their statements. Only one participant answered this request, stating that the transcripts were accurate, and she did not have any further comments. Despite encountering a suboptimal response from participants, the authors remain confident in the trustworthiness of the study. Rich data, derived from a combination of individual and focus group interviews, yielded diverse and nuanced responses from participants, reinforcing the credibility of the findings.

Reflexivity is the researcher’s reflection on their position during the research process [ 48 ]. Both researchers have clinical experience in providing end-of-life care to nursing home residents. Therefore, it was critical to be aware of the impact that their clinical backgrounds might have on the research process from information seeking during the analysis of data and discussion of the findings. To avoid early interpretation of the data, the researchers were aware of their preunderstanding and tried to put it on hold. Both authors engaged in discussions regarding apprehensions and reflections, actively participating in the triangulation process throughout the study to prevent potential bias during data collection, analysis, and interpretation. The theoretical framework was brought in the end of the analysis process, which helped label the emerged findings.

The analysis of the empirical data combined with an ethical reflection helped researchers to identify and understand the moral dimension of nurses’ experiences with end-of-life care provided to nursing home residents. During the analysis, an overarching category emerged– ‘The moral dimension of the provision of end-of life care’– describing nurses’ perceptions about how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. The participants agreed that end-of-life care is a care process that undergoes several phases, with each phase having its own ethical quality or its own element of care, here according to Tronto’s moral qualities [ 34 ]. In the following section, the findings are described using Tronto’s identified moral qualities for each of the five phases of the care process [ 32 , 33 , 34 , 35 ].

Caring about—being attentive

For the participants, being autonomous was perceived as a feature that increased their awareness of the resident’s caring needs during their last days of life. The participants agreed that the caring process involves paying attention, listening and recognising residents’ unspoken needs. Moreover, it implies nurses being able to make autonomous decisions when deciding which needs to care about at one particular moment.

The participants agreed that the core values of providing end-of-life care were to alleviate suffering, maintain dignity and provide comfort care. The participants perceived caring about as having sufficient knowledge, along with the experience and autonomy in practice, as well as providing comprehensive end-of-life care for residents. For the participants, caring about during the end-of-life process means them being present and dedicated. This implies nurses carefully observing, autonomously acting, and making decisions based on their judgements, and thus, they can decide and choose their course of action promptly based on resident’s condition or side effects. Moreover, caring about involved participants being attentive to perceiving the residents’ needs when the residents could no longer articulate themselves. The participants expressed their worries about resident’s bodily deterioration, leading them to lose their ability to express needs, as shown by the following quote:

There is not much communication when residents go into their last stage of life. Well… some of them are consciously until their death, but most are sedated; therefore, it is necessary to use your knowledge and experience to assess not only their needs for food and liquids or bodily hygiene, but also, we have to monitor their response to pain killers and other medication, and if it’s too much or too little, we need to do what’s needed to reduce or increase the medication and not let them suffer (PI3).

Some of the participants expressed that attentiveness to the residents’ care needs was a skill based on their clinical gaze developed during their careers. Other participants discussed that building a close relationship with the residents while they still could walk and talk was a precondition that helped them develop a clinical gaze, hence facilitating the nurses’ being attentive. Attentiveness allowed the participants to do what was needed when knowing the residents’ needs during the provision of end-of-life care. This may be interpreted as the moral or ethical quality of caring about during the end-of-life caring process, as demonstrated by the following statement:

We have time to know the resident before their health condition worsens… We previously knew what they wanted and how they wanted… their stay at nursing home gives us the opportunity to know their preferences and needs. Morally, we are obliged to provide the same quality of care they received when they could express themselves (PI4).

Caring for—taking responsibility

According to several participants, another phase within the end-of-life caring process was taking responsibility to care for. The participants agreed that monitoring the residents in their last days implies assuming responsibility. Assuming responsibility was perceived as an autonomous caring activity. They also discussed taking this responsibility seriously, which is a moral dimension of the end-of-life caring process and, ultimately, of the nursing profession. Usually, this responsibility was taken by a nurse, but it also involved other healthcare personnel or even next-of-kin. Among these responsibilities, the participants mentioned that the end-of-life caring process included not only caring for the resident’s physiological and psychosocial needs, but also assigning permanent healthcare personnel to continuously monitor the resident. Although the participants were aware that they share responsibilities for the caring process, ‘who does what…’, they ultimately had the overall responsibility for the whole end-of-life caring process.

Another responsibility included communication, which included listening, providing information, and supporting the residents’ next-of-kin. One of the participants expressed this as follows:

When I observe that the resident’s health worsens, I inform the next-of-kin and invite the spouse or the children to a meeting together with the responsible doctor and I, and we inform the next-of-kin what they might expect. The end-of-life care is not only about the resident and their last days, but also is to care for their next-of-kin to meet their needs and to overcome guilt feelings, anger or sadness.… (PI1).

Another way to care for patients was to deliberately increase opportunities to exercise autonomy during the caring process. For instance, the focus group participants discussed issues around advanced life support during the resident’s last days of life. Being prepared and having knowledge were the preconditions that gave them the authority to identify and make decisions about residents’ needs in here-and-now moments, hence exercising their autonomy. Some participants shared their experiences with controversies between next-of-kins’ and nurses’ assessments of what is the best care for the residents during their last days of life. Therefore, the importance of taking the initiative to discuss and clarify the resident’s needs and preferences was emphasised during the focus group interview, as shown in the following quote:

Some next-of-kins express wishes for advance life support and hospitalisation for their loved ones… and sometimes, to meet their needs, we try this, but the resident is suffering. The resident comes back to us after one or two days… To avoid this, clear guidelines, and a dialogue between the resident, their next-of-kin and us at the very beginning [when the resident enters the nursing home] is important… I think that minimalising the occurrence of difficult or conflictual situations and relieving the sufferance is care for both resident and their next-of-kin (P8FG).

Care giving—knowing what, why, how and when

During the interviews, the participants also discussed the caregiving process and provided concrete examples of what their caregiving encompassed. Spending extra time with the resident, choosing to be in the room and holding their hand to maintain physical contact was perceived as an autonomous caring act and a deliberate choice. One participant described this as follows:

For me, it is important that the dying person feels or hears that I am here with him or her… how he or she feels in these moments matters to me. I do it because I want to do it.… (PI5).

Other participants said that being autonomous when they actually provided caregiving to residents helped them make continuous assessments based on knowledge about what , how , how much , when and why to care. Knowledge and skills were decisive factors in providing competent care and making autonomous decisions during the caregiving phase; hence, competence was perceived as a moral dimension of caregiving. One of the participants said the following:

Caregiving at end-of-life is not only about giving morphine according to the doctor’s prescription… it involves all the judgements you have to make, all the skills you have… from preventing the occurrence of bedsores to knowing when to stop feeding but preventing thirst… think about all this knowledge and experience you must have to be able to make autonomous bedside judgements about when , why and so on.… (PI2).

Care giving at the end-of-life was described as all the necessary activities a nurse does to provide comfort and compassionate care to a dying resident. Among these activities, providing fundamental care and keeping residents comfortable and free of pain were seen as parts of the caregiving process. Moreover, adequate pain relief and symptom management were described as the moral dimension of care giving at this stage of end-of-life care, as one of the participants from the focus group interview said:

You cannot be passive when you see that the resident is suffering. I cannot go home and think that I should have done one or the other. It is against the nurses’ code of ethics and my personal moral and ethical principles. You have to act… I have to do what is needed… first thing first… pain relief and then personal hygiene! (P9FG)

Some of the participants mentioned some challenges they encountered during the care giving process. They said that care giving implies also standing in demanding situations. The lack of healthcare personnel with necessary knowledge or formal palliative care education or handling ethical dilemmas was seen as demanding situations that influenced the provision of care giving. Most of the participants felt that they were alone during the decision-making processes, which increased their awareness of their professional autonomy:

Sometimes, during weekends or evenings, I am the only nurse among the healthcare staff, and I have an overall responsibility for all nursing home residents. I have to prioritise who gets my attention and who needs me the most. Things can happen, regardless of whether it is Friday evening or weekend. I have to make a decision and do what is needed: to be with the dying resident and to support his or her next-of-kin in that moment. (PI5)

Care receiving—assessing caregiving

Several participants stated that, during the care-giving process, it was important to assess how the resident receive the care provided at the end-of-life stage. This was possible by monitoring the resident’s state of being but to also assess the outcomes of their care giving activities. They also reflected on their assessments and how they subsequently dealt with those assessments.

All the participants were confident in their knowledge and with their care giving at the end-of-life stage. They were aware that their care activities had consequences for the residents’ physiological and psychosocial needs. The assessment of the resident’s state of being was made by nurses listening, observing and interpreting resident’s response to care giving as signs of comfort or discomfort. One of the participants explained this as follows:

When providing personal care, if the resident presents any signs that can be interpreted as discomfort, I think that priority number one is me not causing more pain or suffering. However, I also understand that this person needs more pain killers, so I have to make sure that this person receives adequate medicine. (PI5)

Some participants also discussed the importance of assessing their care giving activities. They mentioned the importance of their assessments of the benefits of all care giving against the burden of all interventions and treatments. Their professional autonomy allowed them to make decisions about how to eschew care giving that was inappropriately and burdensome and choose the best comforting care for the resident. The participants stated that knowledge and experience were important in making such decisions, and their professional autonomy facilitated making choices of the best and less burdensome care giving. One of the participants said the following:

We have to assess whether the care giving provided meets the resident’s needs or not, whether the care comforts or perceives it as a burden and how the resident responds to this provision of care. (PI4)

During the interviews, some of the participants revealed a feeling of guilt when assessing that care giving altered the resident’s state of being, thus leading to new needs for care. They also discussed that the moral obligation and intention to relieve the suffering of the resident should override the foreseen but unintended harmful effects of care giving, including medication or other care interventions. One of the participants shared her experience as follows:

I still remember the attitude some of us had for a while ago… too much or too often morphine depresses the respiration and leads to death… I was struggling with feelings of guilt and even moral distress when I observed residents were still suffering because the medication they received had little or maybe no effect. I called the doctor and explained the situation… usually, the experienced doctors listen to us… and he [the doctor] prescribed more morphine.… (PI3).

Documentation of the response to care giving was also an issue discussed during the interviews. Some participants emphasised the importance of keeping detailed reports for a proper assessment of the care giving and medication and its outcomes. All reports were digitally written. Informal discussions between nurses and next-of-kin were also documented, especially when next-of-kin evaluated the care their loved ones received. The participants indicated that the more written information there was, the better. One participant acknowledged the following:

There is no such thing as ‘too much information’… being open about the morphine’s side effects and what to expect in the next hours or days is important for them [next-of-kin]. It helps them understand that end-of-life care is a process, not a quick fix procedure. (PI5)

Caring with—It is a teamwork process

During the interviews, most of the participants reflected upon the end-of-life caring process and its occurrence within the context of care in nursing home. The participants discussed that end-of-life care is not only about the responsibilities nurses have towards residents and their next-of-kin, but also the responsibilities of others who may influence the caring process. They perceived the caring process as an interplay between residents, next-of-kin, and themselves, along with how they relate to each other, which influences the caring process. However, as several participants asserted, this process did not occur in a vacuum: it occurred within an organisational context, which then influenced the caring process from the very beginning. One participant emphasised the importance of stable healthcare personnel within a caring organisation:

High staff turnover does not facilitate good end-of-life caregiving. Both residents and their next-of-kin need continuity and predictability in caring for and among healthcare personnel. They need somebody they know and trust… being exposed to new people every day increases their stress levels. (PI1)

Other participants discussed the importance of the leadership style and how the leader’s support influenced the culture of end-of-life care at the ward. The participants revealed that, within a caring context where their natural potential was enhanced through an enabling leadership style, they felt that they could provide competent and compassionate end-of-life care. One of the participants from the focus group stated that a positive leadership style supports nurses’ professional autonomy, thus helping them control the caring process, to have independence and to increase their ability to make clinical decisions and competent judgements regarding resident’s end-of-life care. One participant shared her experience as follows:

My leader gives me the freedom to make decisions when it comes to deciding what is best for the resident… She [the leader] enables me to be autonomous during the caring process, and this makes me aware of what and how to care.… (PI2).

The participants from the focus group interview also discussed how the nursing home’s caring culture influences care practice. They perceived the nursing home’s caring culture as positive, enabling good end-of-life care but also defective and an obstacle to care. They emphasised the importance of providing dignifying end-of-life care for residents. During the focus group interview, two of the participants engaged in a dialogue:

End-of-life care is providing care to the most vulnerable people, and it should be dignified… To do so, I have to provide care in a ‘caring room’ filled with dignity. (P7FG) Although next-of-kin and I have different perspectives of what good end-of-life care might be, we care together, we are a caring team which ensures in our own way that the resident receives competent care.… Yes, you [P7] mentioned this ‘caring room’… maybe we should open the door more often into this room and invite next-of-kin. (P6FG)

The aim of the present study was to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. In the following, we discuss these perceptions in relation to Tronto’s [ 32 , 35 ] ethics of care framework and other supporting literature. To identify the moral dimension of these perceptions, we have related them to the moral qualities corresponding to each phase of the care process, as described by Tronto [ 33 , 35 ].

In the first phase of the care process—caring about—the participants discussed the importance of being attentive to which type of care needs to be provided, which is the moral quality of the first phase of care. Similar to findings from another study [ 49 ], findings from the present study revealed that some participants perceived autonomous practice as carrying out actions based on their decisions. Caring about entails detecting the resident’s needs, hence obliging nurses to ‘do something’ [ 50 ]. This particular skill was seen as an autonomous caring activity, that is, the nurses’ deliberate choice of putting on hold their self-interest and/or agenda and ‘a capacity genuinely to understand the perspective of the other in need’ [ 35 ] (p.34) , here nursing home resident.

In Tronto’s view [ 33 ], nurses’ attentiveness contributes to building up a caring relationship with a patient. The findings from the current study reveal that nurses perceived the provision of competent and compassionate end-of-life care as a result of their clinical gaze developed through certain activities, attitudes and knowledge of the patient, and through mutual relationships between the residents, next-of-kin and them. These results are supported by findings from previous studies that emphasise the importance of the nurse’s past experiences with the resident [ 51 ] and the significance of developing a good relationship with the resident and their next-of-kin [ 8 , 23 , 52 , 53 , 54 ] to provide adequate care. Moreover, similar to findings from other studies [ 55 , 56 ], the present study reveal that, to respond to the resident’s end-of-life care needs, nurses must bring not only their professional knowledge, clinical experience and ability to work autonomously but even ethical sensitivity. These findings enforce Gastman’s [ 50 ] view on caring, in which caring should respond to the patient’s care needs. This involves nurses having empathy, capacity of judgement and the ability to see what is required in a specific situation (here, end-of-life care), which, according to Gastmans [ 50 ], is inherent in the moral dimension of nursing practice.

The second phase of care—caring for—refers to nurses taking on the burden of meeting the needs identified in the first phase, that is, caring about. There was no ambiguity, and the participants had no doubts regarding who had the responsibility for the provision of end-of-life care to nursing home residents. The nurses’ responsibility was seen as a moral dimension of care. In line with Pursio et al.’s study [ 30 ], the present findings indicate that the freedom to make patient care decisions and work independently has a positive impact on the moral dimension of end-of-life care for nursing home residents. However, nurses’ work was not only about meeting residents’ needs, but also to create a safe milieu, a communicative space together with each other and with the resident’s next-of-kin, thus sharing power and control over the care process. Similar findings are displayed in an integrative literature review [ 53 ], demonstrating that a positive culture of collaborative and reciprocal relationships, a willingness to engage and become engaged and nurses communicating with intent to share and support rather than inform all lead to facilitating decision-making in nursing homes. According to Tronto [ 35 ], to facilitate end-of-life decision-making, nurses must take the initiative to allocate responsibilities; otherwise, the nurses withdraw themselves from their responsibility. By exercising their professional autonomy to assign responsibilities, nurses strive to mitigate the power imbalance among residents, their next-of-kin, and themselves, thereby preventing the occurrence of potential power struggles in their relationships [ 34 ]. This proactive approach helps prevent the emergence of end-of-life care dilemmas that could undermine the moral dimension of end-of-life care.

The third phase of care—care giving—requires, according to Tronto [ 35 ], the moral quality of nurses’ competence, meaning nurses directly engaging with care. The findings revealed that the nurses provided end-of-life care, and to do so, they needed to have competence, which implies the nurses having the knowledge, skills and values necessary to know what, why, how and when to provide end-of-life adequately. In addition, good end-of-life care requires the competence to individualise care—to provide competent care based on the resident’s physical, psychological, cultural and spiritual needs [ 57 ] while considering the resident’s context of care. Nurses’ competence is crucial for their autonomy; however, to effectively utilize their competence, nurses must be capable of assessing care needs and responding promptly [ 30 ]. Otherwise, delays in assessing residents’ care needs could undermine the moral dimension of end-of-life care. To provide individualised competent care, it is necessary that nurses make continuous assessments. As the findings reveal, the nurses were concerned with providing competent care, that is, adequate pain management. If the care provided was incompetent and led to more pain for the resident, the nurses perceived psychological distress—a state of being that resulted in response to a variety of moral events—leading to the nurses feeling anger, frustration, guilt, powerlessness and stress [ 58 ]. According to Tronto [ 34 ] (p.17) , ‘incompetent care is not only a technical problem, but a moral one’; however, as the findings reveal, the provision of competent care also depends on the nurses’ ability to prioritise decision-making when standing alone. Although nurses’ professional autonomy enabled them to make decisions and choose the right what , how , how much , when , and why , the lack of adequately educated healthcare personnel make the decision-making process a technical problem, which could weaken the moral dimension of end-of -life care.

The fourth phase—care receiving—involves the moral quality responsiveness. This means nurses being responsive to the reaction of the nursing home residents to end-of-life care process. As the findings have revealed, nursing home residents are vulnerable to nurses’ act of care or lack of care. According to Gastmans [ 59 ], care is a reciprocal practice that occurs within the framework of a relationship between the care provider (nurse) and care receiver (resident). The reciprocity consists of nurses assessing that the care provided actually meets the resident’s needs for pain management and other physiological and spiritual needs. The nurses had to make autonomous end-of-life care decisions to meet the resident’s needs. This involved the nurse’s attention to care giving to not be perceived as power abuse, which could have negative consequences for the moral dimension of end-of-life care provision.

According to Tronto [ 33 ], vulnerability may lead to unequal relationships where power abuse may occur. Nursing home residents are in a vulnerable position because they rely on nurses’ competence and ability to alleviate suffering and assess and reassess the residents’ responsiveness to pain management. To avoid an unequal relationship between resident and nurse, nurses must assess whether the care provided is competent or incompetent. Besides assessing and documenting the care provided and its outcomes, informal discussions between the resident’s next-of-kin and nurses were also assessed as important for next-of-kin perceiving a balanced power and equal position within the relationship. However, because each end-of-life act of care may alter the resident’s state of being, responsiveness requires more attentiveness [ 34 ]. Nurses must therefore meet the resident’s new needs for care with compassion and a commitment to maintaining the highest quality of life throughout the evolving stages of the resident’s end-of-life journey.

The final phase of care—caring with—requires that solidarity and trust are the foundation of all care giving to meet caring needs [ 35 ]. The moral quality of this caring phase is solidarity. The findings from the present study suggest that the nurses felt solidarity with both the residents and their leaders. The nurses felt that they were given the support and freedom to act autonomously when making decisions regarding end-of-life care, but similar to findings from a previous study [ 22 ], they also recognised the impact that organisational factors, such as leadership and care culture, may have on the justice and equality of the care provided when they prioritise care to whom needed it the most. Similar to findings from another study [ 49 ], participants in the present study described autonomy as the ability to make independent decisions and prioritise care for those who needed it most. However, according to Tronto [ 35 ], all nurses have a responsibility to help determine how care activities and responsibilities should be allocated. Residents, their next-of-kin and other healthcare personnel may have different views on how they may perceive appropriate, compassionate and dignified end-of-life care [ 20 , 21 ].Therefore, it is important to have transparency in nurse–resident–next-of-kin relations if the element of power within the relationship should be replaced by trust. Otherwise, the nurses’ autonomy may negatively influence the moral dimension of end-of-life care provided to nursing home residents. By opening the door of the “caring room” and inviting next-of-kin to participate in the care process, nurses may contribute to a greater reflectiveness around what may constitute ‘good’ end-of-life care.

Strengths and limitations

One of the strengths of the study is the use of Joan Tronto’s theory of the ethics of care [ 32 , 34 , 35 ] and its five phases and elements of care to discuss the study’s findings. This allows a deeper understanding of how nurses’ professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. Another strength lies in the utilisation of two distinct methods of data collection: individual and focus group interviews. These approaches provided diverse datasets that shed light on various aspects of how nurses’ professional autonomy impacts the moral dimension of end-of-life care. Furthermore, the inclusion of participants with varying work experiences from four nursing homes enhances the richness and depth of the data generated from the interviews, further strengthening the quality of the study. Member checking ensures that the researcher’s interpretations accurately reflect the participants’ experiences and perspectives, thereby enhancing the validity of the study. This practice can be considered one of the methodological strengths of the study.

The current study has also some limitations that need to be considered. First, a limitation may be related to the size of the participant sample. The sample consisted of only nine nurses, a number that may be seen as a limitation in data collection. To challenge this limitation, the researchers posed follow-up questions during the interviews, thus offering the participants the opportunity to provide rich descriptions of their experiences with end-of-life care. Even though the sample consisted of only nine nurses, these participants reflected on and described their everyday work experiences. The participants’ rich descriptions were evaluated as possessing sufficient information power [ 41 ], thereby enhancing the overall quality of dialogues during interviews– a notable strength.

Second, the findings are limited to these nine participants and their personal work experiences in four different Norwegian nursing homes. This means that the sample is small and context dependent, which may limit the transferability and generalisability of the findings.

A third limitation pertains to the potential influence of the chosen theoretical framework on researchers’ preunderstanding during data analysis. To avoid bias, the theoretical framework was introduced at the end of the data analyses and after the coding process was conducted. The theoretical framework contributed to situating the knowledge from the empirical data into theoretical knowledge and vice versa. However, to be certain about interpretations and knowing that the qualitative nature of the study cannot completely exclude the impact of the preunderstanding on the analysis of the data, both researchers were aware of their theoretical preunderstanding and tried not to make conclusions beforehand.

The ethics of care framework provides opportunities for nurses to analyse their own caring activities during the provision of end-of-life care to nursing home residents. The exploration of the moral dimension of the provision of end-of-life care, utilising Tronto’s theory, revealed that moral qualities, such as attentiveness, responsibility, competence, responsiveness, and solidarity are influenced to a certain extent by nurses’ autonomy. What is crucial for the provision of competent end-of-life care is the nurses’ awareness of acting properly in accordance with the moral qualities to each of the phases of caring. Therefore, to provide competent end-of-life care nurses must be attentive to residents’ care needs, take on the responsibility for the care provided to ensure that residents’ needs are met, provide competent care based on knowledge, skills and values and assess how residents respond to the care provided. In other words, this is the basic nursing process in action, and this problem-solving approach is needed for the provision of competent end-of-life care.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Oslo Metropolitan University.

Abbreviations

Participant in interview [number of the individual interview

Participant [number] in Focus Group interview

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Acknowledgements

We would like to express gratitude to the nurses who participated in this study, thereby contributing to the data collection. Additionally, we extend our thanks to the Oslo Metropolitan University Library for granting approval and for their support in covering the publication fee of this article.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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D.L. contributed to the study conception, data collection, and analysis, and wrote the main manuscript text. R.G. was involved in data collection, analysis, reflection, and manuscript writing. D.L. was responsible for administrative work related to journal submission and was also involved in reviewing and editing the manuscript. R.G. and D.L. have read and approved the manuscript before submission.

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The Norwegian Agency for Shared Services in Education and Research approved the study protocol (Sikt/Ref. number 360657) and concluded that the study was not subject to the Norwegian Health Research Act (LOV-2008-06-20-44; https://lovdata.no/dokument/NL/lov/2008-06-20-44 ). An English version of the Norwegian Health Research Act can be found at: https://www.uib.no/en/med/81598/norwegian-health-research-act . This study does not aim to get insight into participants’ health status, sexuality, ethnicity, and political affiliation (sensitive information), therefore, no additional approval from a local ethics committee or institutional review board (IRB) was necessary to be obtained to conduct the study. This study was performed according to principles outlined in the Declaration of Helsinki, and in accordance with Oslo Metropolitan University’s guidelines and regulations. Data were kept confidential and used only for this research purpose. The researchers provided verbal and written information about the study. Informed consent was obtained from all participants prior data collection.

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Gilbert, R., Lillekroken, D. Nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents– a qualitative study. BMC Nurs 23 , 216 (2024). https://doi.org/10.1186/s12912-024-01865-5

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• End-of-life
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Using the consolidated Framework for Implementation Research to integrate innovation recipients’ perspectives into the implementation of a digital version of the spinal cord injury health maintenance tool: a qualitative analysis

• John A Bourke 1 , 2 , 3 ,
• K. Anne Sinnott Jerram 1 , 2 ,
• Mohit Arora 1 , 2 ,
• Ashley Craig 1 , 2 &
• James W Middleton 1 , 2 , 4 , 5  

BMC Health Services Research volume  24 , Article number:  390 ( 2024 ) Cite this article

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Despite advances in managing secondary health complications after spinal cord injury (SCI), challenges remain in developing targeted community health strategies. In response, the SCI Health Maintenance Tool (SCI-HMT) was developed between 2018 and 2023 in NSW, Australia to support people with SCI and their general practitioners (GPs) to promote better community self-management. Successful implementation of innovations such as the SCI-HMT are determined by a range of contextual factors, including the perspectives of the innovation recipients for whom the innovation is intended to benefit, who are rarely included in the implementation process. During the digitizing of the booklet version of the SCI-HMT into a website and App, we used the Consolidated Framework for Implementation Research (CFIR) as a tool to guide collection and analysis of qualitative data from a range of innovation recipients to promote equity and to inform actionable findings designed to improve the implementation of the SCI-HMT.

Data from twenty-three innovation recipients in the development phase of the SCI-HMT were coded to the five CFIR domains to inform a semi-structured interview guide. This interview guide was used to prospectively explore the barriers and facilitators to planned implementation of the digital SCI-HMT with six health professionals and four people with SCI. A team including researchers and innovation recipients then interpreted these data to produce a reflective statement matched to each domain. Each reflective statement prefaced an actionable finding, defined as alterations that can be made to a program to improve its adoption into practice.

Five reflective statements synthesizing all participant data and linked to an actionable finding to improve the implementation plan were created. Using the CFIR to guide our research emphasized how partnership is the key theme connecting all implementation facilitators, for example ensuring that the tone, scope, content and presentation of the SCI-HMT balanced the needs of innovation recipients alongside the provision of evidence-based clinical information.

Conclusions

Understanding recipient perspectives is an essential contextual factor to consider when developing implementation strategies for healthcare innovations. The revised CFIR provided an effective, systematic method to understand, integrate and value recipient perspectives in the development of an implementation strategy for the SCI-HMT.

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Injury to the spinal cord can occur through traumatic causes (e.g., falls or motor vehicle accidents) or from non-traumatic disease or disorder (e.g., tumours or infections) [ 1 ]. The onset of a spinal cord injury (SCI) is often sudden, yet the consequences are lifelong. The impact of a SCI is devastating, with effects on sensory and motor function, bladder and bowel function, sexual function, level of independence, community participation and quality of life [ 2 ]. In order to maintain good health, wellbeing and productivity in society, people with SCI must develop self-management skills and behaviours to manage their newly acquired chronic health condition [ 3 ]. Given the increasing emphasis on primary health care and community management of chronic health conditions, like SCI, there is a growing responsibility on all parties to promote good health practices and minimize the risks of common health complications in their communities.

To address this need, the Spinal Cord Injury Health Maintenance Tool (SCI-HMT) was co-designed between 2018 and 2023 with people living with SCI and their General Practitioners (GPs) in NSW, Australia [ 4 ] The aim of the SCI-HMT is to support self-management of the most common and arguably avoidable potentially life-threatening complications associated with SCI, such as mental health crises, autonomic dysreflexia, kidney infections and pressure injuries. The SCI-HMT provides comprehensible information with resources about the six highest priority health areas related to SCI (as indicated by people with SCI and GPs) and was developed over two phases. Phase 1 focused on developing a booklet version and Phase 2 focused on digitizing this content into a website and smartphone app [ 4 , 5 ].

Enabling the successful implementation of evidence-based innovations such as the SCI-HMT is inevitably influenced by contextual factors: those dynamic and diverse array of forces within real-world settings working for or against implementation efforts [ 6 ]. Contextual factors often include background environmental elements in which an intervention is situated, for example (but not limited to) demographics, clinical environments, organisational culture, legislation, and cultural norms [ 7 ]. Understanding the wider context is necessary to identify and potentially mitigate various challenges to the successful implementation of those innovations. Such work is the focus of determinant frameworks, which focus on categorising or classing groups of contextual determinants that are thought to predict or demonstrate an effect on implementation effectiveness to better understand factors that might influence implementation outcomes [ 8 ].

One of the most highly cited determinant frameworks is the Consolidated Framework for Implementation Research (CFIR) [ 9 ], which is often posited as an ideal framework for pre-implementation preparation. Originally published in 2009, the CFIR has recently been subject to an update by its original authors, which included a literature review, survey of users, and the creation of an outcome addendum [ 10 , 11 ]. A key contribution from this revision was the need for a greater focus on the place of innovation recipients, defined as the constituency for whom the innovation is being designed to benefit; for example, patients receiving treatment, students receiving a learning activity. Traditionally, innovation recipients are rarely positioned as key decision-makers or innovation implementers [ 8 ], and as a consequence, have not often been included in the application of research using frameworks, such as the CFIR [ 11 ].

Such power imbalances within the intersection of healthcare and research, particularly between those receiving and delivering such services and those designing such services, have been widely reported [ 12 , 13 ]. There are concerted efforts within health service development, health research and health research funding, to rectify this power imbalance [ 14 , 15 ]. Importantly, such efforts to promote increased equitable population impact are now being explicitly discussed within the implementation science literature. For example, Damschroder et al. [ 11 ] has recently argued for researchers to use the CFIR to collect data from innovation recipients, and that, ultimately, “equitable population impact is only possible when recipients are integrally involved in implementation and all key constituencies share power and make decisions together” (p. 7). Indeed, increased equity between key constituencies and partnering with innovation recipients promotes the likelihood of sustainable adoption of an innovation [ 4 , 12 , 14 ].

There is a paucity of work using the updated CFIR to include and understand innovation recipients’ perspectives. To address this gap, this paper reports on a process of using the CFIR to guide the collection of qualitative data from a range of innovation recipients within a wider co-design mixed methods study examining the development and implementation of SCI-HMT. The innovation recipients in our research are people living with SCI and GPs. Guided by the CFIR domains (shown in the supplementary material), we used reflexive thematic analysis [ 16 ]to summarize data into reflective summaries, which served to inform actionable findings designed to improve implementation of the SCI-HMT.

The procedure for this research is multi-stepped and is summarized in Fig.  1 . First, we mapped retrospective qualitative data collected during the development of the SCI-HMT [ 4 ] against the five domains of the CFIR in order to create a semi-structured interview guide (Step 1). Then, we used this interview guide to collect prospective data from health professionals and people with SCI during the development of the digital version of the SCI-HMT (Step 2) to identify implementation barriers and facilitators. This enabled us to interpret a reflective summary statement for each CFIR domain. Lastly, we developed an actionable finding for each domain summary. The first (RESP/18/212) and second phase (2019/ETH13961) of the project received ethical approval from The Northern Sydney Local Health District Human Research Ethics Committee. The reporting of this study was conducted in line with the consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [ 17 ]. All methods were performed in accordance with the relevant guidelines and regulations.

Procedure of synthesising datasets to inform reflective statements and actionable findings. a Two health professionals had a SCI (one being JAB); b Two co-design researchers had a SCI (one being JAB)

Step one: retrospective data collection and analysis

We began by retrospectively analyzing the data set (interview and focus group transcripts) from the previously reported qualitative study from the development phase of the SCI-HMT [ 4 ]. This analysis was undertaken by two team members (KASJ and MA). KASJ has a background in co-design research. Transcript data were uploaded into NVivo software (Version 12: QSR International Pty Ltd) and a directed content analysis approach [ 18 ] was applied to analyze categorized data a priori according to the original 2009 CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process of implementation) described by Damschroder et al. [ 9 ]. This categorized data were summarized and informed the specific questions of a semi-structured interview guide. The final output of step one was an interview guide with context-specific questions arranged according to the CFIR domains (see supplementary file 1). The interview was tested with two people with SCI and one health professional.

Step two: prospective data collection and analysis

In the second step, semi-structured interviews were conducted by KASJ (with MA as observer) with consenting healthcare professionals who had previously contributed to the development of the SCI-HMT. Healthcare professionals included GPs, Nurse Consultants, Specialist Physiotherapists, along with Health Researchers (one being JAB). In addition, a focus group was conducted with consenting individuals with SCI who had contributed to the SCI-HMT design and development phase. The interview schedule designed in step one above guided data collection in all interviews and the focus group.

The focus group and interviews were conducted online, audio recorded, transcribed verbatim and uploaded to NVivo software (Version 12: QSR International Pty Ltd). All data were subject to reflexive, inductive and deductive thematic analysis [ 16 , 19 ] to better understand participants’ perspectives regarding the potential implementation of the SCI-HMT. First, one team member (KASJ) read transcripts and began a deductive analysis whereby data were organized into CFIR domains-specific dataset. Second, KASJ and JAB analyzed this domain-specific dataset to inductively interpret a reflective statement which served to summarise all participant responses to each domain. The final output of step two was a reflective summary statement for each CFIR domain.

Step three: data synthesis

In the third step we aimed to co-create an actionable finding (defined as tangible alteration that can be made to a program, in this case the SCI-HMT [ 20 ]) based on each domain-specific reflective statement. To achieve this, three codesign researchers (KAS and JAB with one person with SCI from Step 2 (deidentified)) focused on operationalising each reflective statement into a recommended modification for the digital version of the SCI-HMT. This was an iterative process guided by the specific CFIR domain and construct definitions, which we deemed salient and relevant to each reflective statement (see Table  2 for example). Data synthesis involved line by line analysis, group discussion, and repeated refinement of actionable findings. A draft synthesis was shared with SCI-HMT developers (JWM and MA) and refinement continued until consensus was agreed on. The final outputs of step three were an actionable finding related to each reflective statement for each CFIR domain.

The characteristics of both the retrospective and prospective study participants are shown in Table  1 . The retrospective data included data from a total of 23 people: 19 people with SCI and four GPs. Of the 19 people with SCI, 12 participated in semi-structured interviews, seven participated in the first focus group, and four returned to the second focus group. In step 2, four people with SCI participated in a focus group and six healthcare professionals participated in one-on-one semi-structured interviews. Two of the healthcare professionals (a GP and a registrar) had lived experience of SCI, as did one researcher (JAB). All interviews and focus groups were conducted either online or in-person and ranged in length between 60 and 120 min.

In our overall synthesis, we actively interpreted five reflective statements based on the updated CFIR domain and construct definitions by Damschroder et al. [ 11 ]. Table  2 provides a summary of how we linked the updated CFIR domain and construct definitions to the reflective statements. We demonstrate this process of co-creation below, including illustrative quotes from participants. Importantly, we guide readers to the actionable findings related to each reflective statement in Table  2 . Each actionable statement represents an alteration that can be made to a program to improve its adoption into practice.

Participants acknowledged that self-management is a major undertaking and very demanding, as one person with SCI said, “ we need to be informed without being terrified and overwhelmed”. Participants felt the HMT could indeed be adapted, tailored, refined, or reinvented to meet local needs. For example, another person with SCI remarked:

“Education needs to be from the get-go but in bite sized pieces from all quarters when readiness is most apparent… at all time points , [not just as a] a newbie tool or for people with [long-term impairment] ” (person with SCI_02).

Therefore, the SCI-HMT had to balance complexity of content while still being accessible and engaging, and required input from both experts in the field and those with lived experience of SCI, for example, a clinical nurse specialist suggested:

“it’s essential [the SCI-HMT] is written by experts in the field as well as with collaboration with people who have had a, you know, the lived experience of SCI” (healthcare professional_03).

Furthermore, the points of contact with healthcare for a person with SCI can be challenging to navigate and the SCI-HMT has the potential to facilitate a smoother engagement process and improve communication between people with SCI and healthcare services. As a GP suggested:

“we need a tool like this to link to that pathway model in primary health care , [the SCI-HMT] it’s a great tool, something that everyone can read and everyone’s reading the same thing” (healthcare professional_05).

Participants highlighted that the ability of the SCI-HMT to facilitate effective communication was very much dependent on the delivery format. The idea of digitizing the SCI-HMT garnered equal support from people with SCI and health care professionals, with one participant with SCI deeming it to be “ essential” ( person with SCI_01) and a health professional suggesting a “digitalized version will be an advantage for most people” (healthcare professional_02).

Outer setting

There was strong interest expressed by both people with SCI and healthcare professionals in using the SCI-HMT. The fundamental premise was that knowledge is power and the SCI-HMT would have strong utility in post-acute rehabilitation services, as well as primary care. As a person with SCI said,

“ we need to leave the [spinal unit] to return to the community with sufficient knowledge, and to know the value of that knowledge and then need to ensure primary healthcare provider [s] are best informed” (person with SCI_04).

The value of the SCI-HMT in facilitating clear and effective communication and shared decision-making between healthcare professionals and people with SCI was also highlighted, as shown by the remarks of an acute nurse specialist:

“I think this tool is really helpful for the consumer and the GP to work together to prioritize particular tests that a patient might need and what the regularity of that is” (healthcare professional_03).

Engaging with SCI peer support networks to promote the SCI-HMT was considered crucial, as one person with SCI emphasized when asked how the SCI-HMT might be best executed in the community, “…peers, peers and peers” (person with SCI_01). Furthermore, the layering of content made possible in the digitalized version will allow for the issue of approachability in terms of readiness for change, as another person with SCI said:

“[putting content into a digital format] is essential and required and there is a need to put summarized content in an App with links to further web-based information… it’s not likely to be accessed otherwise” (person with SCI_02).

Inner setting

Participants acknowledged that self-management of health and well-being is substantial and demanding. It was suggested that the scope, tone, and complexity of the SCI-HMT, while necessary, could potentially be resisted by people with SCI if they felt overwhelmed, as one person with SCI described:

“a manual that is really long and wordy, like, it’s [a] health metric… they maybe lack the health literacy to, to consume the content then yes, it would impede their readiness for [self-management]” (person with SCI_02).

Having support from their GPs was considered essential, and the HMT could enable GP’s, who are under time pressure, to provide more effective health and advice to their patients, as one GP said:

“We GP’s are time poor, if you realize then when you’re time poor you look quickly to say oh this is a patient tool - how can I best use this?” (healthcare professional_05).

Furthermore, health professional skills may be best used with the synthesis of self-reported symptoms, behaviors, or observations. A particular strength of a digitized version would be its ability to facilitate more streamlined communication between a person with SCI and their primary healthcare providers developing healthcare plans, as an acute nurse specialist reflected, “ I think that a digitalized version is essential with links to primary healthcare plans” (healthcare professional_03).

Efficient communication with thorough assessment is essential to ensure serious health issues are not missed, as findings reinforce that the SCI-HMT is an educational tool, not a replacement for healthcare services, as a clinical nurse specialist commented, “ remember, things will go wrong– people end up very sick and in acute care “ (healthcare professional_02).

The SCI-HMT has the potential to provide a pathway to a ‘hope for better than now’ , a hope to ‘remain well’ and a hope to ‘be happy’ , as the informant with SCI (04) declared, “self-management is a long game, if you’re keeping well, you’ve got that possibility of a good life… of happiness”. Participants with SCI felt the tool needed to be genuine and

“acknowledge the huge amount of adjustment required, recognizing that dealing with SCI issues is required to survive and live a good life” (person with SCI_04).

However, there is a risk that an individual is completely overwhelmed by the scale of the SCI-HMT content and the requirement for lifelong vigilance. Careful attention and planning were paid to layering the information accordingly to support self-management as a ‘long game’, which one person with SCI reflected in following:

“the first 2–3 year [period] is probably the toughest to get your head around the learning stuff, because you’ve got to a stage where you’re levelling out, and you’ve kind of made these promises to yourself and then you realize that there’s no quick fix” (person with SCI_01).

It was decided that this could be achieved by providing concrete examples and anecdotes from people with SCI illustrating that a meaningful, healthy life is possible, and that good health is the bedrock of a good life with SCI.

There was universal agreement that the SCI-HMT is aspirational and that it has the potential to improve knowledge and understanding for people with SCI, their families, community workers/carers and primary healthcare professionals, as a GP remarked:

“[different groups] could just read it and realize, ‘Ahh, OK that’s what that means… when you’re doing catheters. That’s what you mean when you’re talking about bladder and bowel function or skin care” (healthcare professional_04).

Despite the SCI-HMT providing an abundance of information and resources to support self-management, participants identified four gaps: (i) the priority issue of sexuality, including pleasure and identity, as one person with SCI remarked:

“ sexuality is one of the biggest issues that people with SCI often might not speak about that often cause you know it’s awkward for them. So yeah, I think that’s a that’s a serious issue” (person with SCI_03).

(ii) consideration of the taboo nature of bladder and bowel topics for indigenous people, (iii) urgent need to ensure links for SCI-HMT care plans are compatible with patient management systems, and (iv) exercise and leisure as a standalone topic taking account of effects of physical activity, including impact on mental health and wellbeing but more especially for fun.

To ensure longevity of the SCI-HMT, maintaining a partnership between people with SCI, SCI community groups and both primary and tertiary health services is required for liaison with the relevant professional bodies, care agencies, funders, policy makers and tertiary care settings to ensure ongoing education and promotion of SCI-HMT is maintained. For example, delivery of ongoing training of healthcare professionals to both increase the knowledge base of primary healthcare providers in relation to SCI, and to promote use of the tools and resources through health communities. As a community nurse specialist suggested:

“ improving knowledge in the health community… would require digital links to clinical/health management platforms” (healthcare professional_02).

In a similar vein, a GP suggested:

“ our common GP body would have continuing education requirements… especially if it’s online, in particular for the rural, rural doctors who you know, might find it hard to get into the city” (healthcare professional_04).

The successful implementation of evidence-based innovations into practice is dependent on a wide array of dynamic and active contextual factors, including the perspectives of the recipients who are destined to use such innovations. Indeed, the recently updated CFIR has called for innovation recipient perspectives to be a priority when considering contextual factors [ 10 , 11 ]. Understanding and including the perspectives of those the innovation is being designed to benefit can promote increased equity and validation of recipient populations, and potentially increase the adoption and sustainability of innovations.

In this paper, we have presented research using the recently updated CFIR to guide the collection of innovation recipients’ perspectives (including people with SCI and GPs working in the community) regarding the potential implementation barriers and facilitators of the digital version of the SCI-HMT. Collected data were synthesized to inform actionable findings– tangible ways in which the SCI-HMT could be modified according of the domains of the CFIR (e.g., see Keith et al. [ 20 ]). It is important to note that we conducted this research using the original domains of the CFIR [ 9 ] prior to Damschroder et al. publishing the updated CFIR [ 11 ]. However, in our analysis we were able to align our findings to the revised CFIR domains and constructs, as Damschroder [ 11 ] suggests, constructs can “be mapped back to the original CFIR to ensure longitudinal consistency” (p. 13).

One of the most poignant findings from our analyses was the need to ensure the content of the SCI-HMT balanced scientific evidence and clinical expertise with lived experience knowledge. This balance of clinical and experiential knowledge demonstrated genuine regard for lived experience knowledge, and created a more accessible, engaging, useable platform. For example, in the innovation and individual domains, the need to include lived experience quotes was immediately apparent once the perspective of people with SCI was included. It was highlighted that while the SCI-HMT will prove useful to many parties at various stages along the continuum of care following onset of SCI, there will be those individuals that are overwhelmed by the scale of the content. That said, the layering of information facilitated by the digitalized version is intended to provide an ease of navigation through the SCI-HMT and enable a far greater sense of control over personal health and wellbeing. Further, despite concerns regarding e-literacy the digitalized version of the SCI-HMT is seen as imperative for accessibility given the wide geographic diversity and recent COVID pandemic [ 21 ]. While there will be people who are challenged by the technology, the universally acceptable use of the internet is seen as less of a barrier than printed material.

The concept of partnership was also apparent within the data analysis focusing on the outer and inner setting domains. In the outer setting domain, our findings emphasized the importance of engaging with SCI community groups, as well as primary and tertiary care providers to maximize uptake at all points in time from the phase of subacute rehabilitation onwards. While the SCI-HMT is intended for use across the continuum of care from post-acute rehabilitation onwards, it may be that certain modules are more relevant at different times, and could serve as key resources during the hand over between acute care, inpatient rehabilitation and community reintegration.

Likewise, findings regarding the inner setting highlighted the necessity of a productive partnership between GPs and individuals with SCI to address the substantial demands of long-term self-management of health and well-being following SCI. Indeed, support is crucial, especially when self-management is the focus. This is particularly so in individuals living with complex disability following survival after illness or injury [ 22 ], where health literacy has been found to be a primary determinant of successful health and wellbeing outcomes [ 23 ]. For people with SCI, this tool potentially holds the most appeal when an individual is ready and has strong partnerships and supportive communication. This can enable potential red flags to be recognized earlier allowing timely intervention to avert health crises, promoting individual well-being, and reducing unnecessary demands on health services.

While the SCI-HMT is an educational tool and not meant to replace health services, findings suggest the current structure would lead nicely to having the conversation with a range of likely support people, including SCI peers, friends and family, GP, community nurses, carers or via on-line support services. The findings within the process domain underscored the importance of ongoing partnership between innovation implementers and a broad array of innovation recipients (e.g., individuals with SCI, healthcare professionals, family, funding agencies and policy-makers). This emphasis on partnership also addresses recent discussions regarding equity and the CFIR. For example, Damschroder et al. [ 11 ] suggests that innovation recipients are too often not included in the CFIR process, as the CFIR is primarily seen as a tool intended “to collect data from individuals who have power and/or influence over implementation outcomes” (p. 5).

Finally, we feel that our inclusion of innovation recipients’ perspectives presented in this article begins to address the notion of equity in implementation, whereby the inclusion of recipient perspectives in research using the CFIR both validates, and increases, the likelihood of sustainable adoption of evidence-based innovations, such as the SCI-HMT. We have used the CFIR in a pragmatic way with an emphasis on meaningful engagement between the innovation recipients and the research team, heeding the call from Damschroder et al. [ 11 ], who recently argued for researchers to use the CFIR to collect data from innovation recipients. Adopting this approach enabled us to give voice to innovation recipient perspectives and subsequently ensure that the tone, scope, content and presentation of the SCI-HMT balanced the needs of innovation recipients alongside the provision of evidence-based clinical information.

Our research is not without limitations. While our study was successful in identifying a number of potential barriers and facilitators to the implementation of the SCI-HMT, we did not test any implementation strategies to impact determinants, mechanisms, or outcomes. This will be the focus of future research on this project, which will investigate the impact of implementation strategies on outcomes. Focus will be given to the context-mechanism configurations which give rise to particular outcomes for different groups in certain circumstances [ 7 , 24 ]. A second potential concern is the relatively small sample size of participants that may not allow for saturation and generalizability of the findings. However, both the significant impact of secondary health complications for people with SCI and the desire for a health maintenance tool have been established in Australia [ 2 , 4 ]. The aim our study reported in this article was to achieve context-specific knowledge of a small sample that shares a particular mutual experience and represents a perspective, rather than a population [ 25 , 26 ]. We feel our findings can stimulate discussion and debate regarding participant-informed approaches to implementation of the SCI-HMT, which can then be subject to larger-sample studies to determine their generalisability, that is, their external validity. Notably, future research could examine the interaction between certain demographic differences (e.g., gender) of people with SCI and potential barriers and facilitators to the implementation of the SCI-HMT. Future research could also include the perspectives of other allied health professionals working in the community, such as occupational therapists. Lastly, while our research gave significant priority to recipient viewpoints, research in this space would benefit for ensuring innovation recipients are engaged as genuine partners throughout the entire research process from conceptualization to implementation.

Employing the CFIR provided an effective, systematic method for identifying recipient perspectives regarding the implementation of a digital health maintenance tool for people living with SCI. Findings emphasized the need to balance clinical and lived experience perspectives when designing an implementation strategy and facilitating strong partnerships with necessary stakeholders to maximise the uptake of SCI-HMT into practice. Ongoing testing will monitor the uptake and implementation of this innovation, specifically focusing on how the SCI-HMT works for different users, in different contexts, at different stages and times of the rehabilitation journey.

Data availability

The datasets supporting the conclusions of this article are available available upon request and with permission gained from the project Steering Committee.

Abbreviations

spinal cord injury

HMT-Spinal Cord Injury Health Maintenance Tool

Consolidated Framework for Implementation Research

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Acknowledgements

Authors of this study would like to thank all the consumers with SCI and healthcare professionals for their invaluable contribution to this project. Their participation and insights have been instrumental in shaping the development of the SCI-HMT. The team also acknowledges the support and guidance provided by the members of the Project Steering Committee, as well as the partner organisations, including NSW Agency for Clinical Innovation, and icare NSW. Author would also like to acknowledge the informant group with lived experience, whose perspectives have enriched our understanding and informed the development of SCI-HMT.

The SCI Wellness project was a collaborative project between John Walsh Centre for Rehabilitation Research at The University of Sydney and Royal Rehab. Both organizations provided in-kind support to the project. Additionally, the University of Sydney and Royal Rehab received research funding from Insurance and Care NSW (icare NSW) to undertake the SCI Wellness Project. icare NSW do not take direct responsibility for any of the following: study design, data collection, drafting of the manuscript, or decision to publish.

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John A Bourke, K. Anne Sinnott Jerram, Mohit Arora, Ashley Craig & James W Middleton

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John A Bourke

Royal Rehab, Ryde, NSW, Australia

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Project conceptualization: KASJ, MA, JWM; project methodology: JWM, MA, KASJ, JAB; data collection: KASJ and MA; data analysis: KASJ, JAB, MA, JWM; writing—original draft preparation: JAB; writing—review and editing: JAB, KASJ, JWM, MA, AC; funding acquisition: JWM, MA. All authors contributed to the revision of the paper and approved the final submitted version.

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The first (RESP/18/212) and second phase (2019/ETH13961) of the project received ethical approval from The Northern Sydney Local Health District Human Research Ethics Committee. All participants provided informed, written consent. All data were to be retained for 7 years (23rd May 2030).

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Competing interests

MA part salary (from Dec 2018 to Dec 2023), KASJ part salary (July 2021 to Dec 2023) and JAB part salary (Jan 2022 to Aug 2022) was paid from the grant monies. Other authors declare no conflicts of interest.

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Bourke, J.A., Jerram, K.A.S., Arora, M. et al. Using the consolidated Framework for Implementation Research to integrate innovation recipients’ perspectives into the implementation of a digital version of the spinal cord injury health maintenance tool: a qualitative analysis. BMC Health Serv Res 24 , 390 (2024). https://doi.org/10.1186/s12913-024-10847-x

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Received : 14 August 2023

Accepted : 11 March 2024

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DOI : https://doi.org/10.1186/s12913-024-10847-x

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