qualitative research key informant interviews

Key Informant Interviews: An In-Depth Guide for Researchers

Frankline kibuacha | feb. 02, 2024 | 8 min. read.

What are Key Informant Interviews?

Key Informant Interviews (KIIs) are specialized qualitative interviews conducted with individuals (key informants) recognized for their insider knowledge or unique perspectives on a specific topic. This method is distinct in its focus on depth rather than breadth, targeting information-rich sources.

Unlike surveys that seek quantitative data or focus groups that explore group dynamics, KIIs delve deeply into individual perspectives, offering a granular understanding of complex issues.

KIIs are invaluable for gaining insights into trends, motivations, perceptions, and experiences. They are particularly effective in sectors where in-depth, expert knowledge is crucial, such as public health, policy development, and market analysis.

The Importance of Key Informant Interviews in Research

Key Informant Interviews (KIIs) play a pivotal role in qualitative research, offering a depth of understanding often unattainable through other methods. Their significance in various research settings can be elaborated as follows:

Access to Specialized Knowledge and Expert Insights: KIIs enable researchers to tap into the wealth of knowledge possessed by experts in specific fields. This is especially crucial in areas where specialized insights are vital to understanding complex issues. For instance, interviews with healthcare professionals in public health research can uncover nuances in patient care practices that surveys may not reveal.
Understanding Context and Nuance: One of the primary strengths of KIIs is their ability to capture the context and nuances around a subject matter. Unlike quantitative methods that offer breadth, KIIs provide depth, uncovering the ‘why’ and ‘how’ behind observable trends. This depth is invaluable in fields like policy analysis, where understanding the rationale behind decisions can inform more effective policy development.
Flexibility and Adaptability: KIIs offer unmatched flexibility, allowing researchers to explore new lines of inquiry as they emerge during the interview. This adaptability is critical in exploratory research or when dealing with emerging issues, where predefined survey questions might miss important aspects.
Identifying Hidden or Sensitive Issues: Given their expertise and experience, key informants can provide insights into sensitive or hidden issues that might not be readily disclosed through other methodologies. In contexts such as humanitarian work or conflict research, KIIs can reveal underlying problems or needs that are not visible on the surface.
Enhancing Other Research Findings: KIIs can complement and improve findings from quantitative research. They add depth to the statistical data by providing qualitative insights, offering a more comprehensive view of the research topic.
Case Studies Illustrating Impact: Real-world examples further illustrate the impact of KIIs. For example, in environmental research, KIIs with local community leaders and environmental experts have been instrumental in understanding the impact of climate change at a local level, leading to more targeted and effective conservation strategies.

Key Informant Interviews are an indispensable tool in the researcher’s toolkit. They provide a level of detail and understanding crucial for fully grasping complex issues, influencing policy, and informing comprehensive and effective solutions.

Methodology and Best Practices for Key Informant Interviews

Effective Key Informant Interviews require a well-thought-out methodology and adherence to best practices. This section outlines the key steps and considerations for maximizing the value of KIIs.

Criteria for Selection: The selection of key informants is a critical step. Ideal candidates are those who have in-depth knowledge or experience relevant to the research topic. This could include industry experts, community leaders, or individuals with unique experiences pertinent to the study.
Diversity and Representation: It’s essential to ensure diversity in selecting informants. This includes diversity in profession, demographic characteristics, and perspectives to obtain a well-rounded understanding of the issue.
Recruitment Strategies: Effective recruitment may involve formal invitations, leveraging professional networks, or recommendations from other experts in the field. It’s crucial to clearly communicate the purpose of the research and the informant’s role.
Balancing Structure and Flexibility: While having a structured set of questions to guide the interview is important, flexibility is key. Researchers should be prepared to explore interesting avenues that emerge during the conversation.
Question Types : A mix of open-ended questions (to explore opinions and experiences) and more specific questions (to gather detailed information) is recommended. Avoid leading questions to minimize bias.
Piloting Questions: Before conducting the interviews, it’s advisable to pilot the questions with a small group to ensure they are clear and elicit the desired information.
Building Rapport: The initial part of the interview should focus on building rapport with the informant. This can be achieved through a friendly demeanor, active listening, and genuine interest in the informant’s perspectives.
Interview Techniques: Effective techniques include probing for details, paraphrasing to check understanding, and managing the pace of the interview. Non-verbal cues play a significant role in creating a comfortable environment.
Recording and Note-Taking: It’s essential to accurately record the interviews, subject to the informant’s consent. This can be done through audio recordings or detailed note-taking. Clear, concise, and accurate notes are vital for accurate data analysis.
Informed Consent: Informants should be fully informed about the purpose of the research, how their information will be used, and their rights, including the right to withdraw from the interview at any point.
Confidentiality and Anonymity: Researchers must respect the confidentiality of the information provided and ensure anonymity if the informant requests it.
Cultural Sensitivity: It is crucial to be culturally sensitive and respectful of the informant’s background and beliefs, especially when dealing with sensitive topics.
Debriefing and Reflection: After each interview, a debriefing session can be helpful for the research team to discuss initial impressions and insights.
Data Management: Organizing and securely storing interview data is crucial for analysis and future reference.

Challenges and Solutions in Key Informant Interviews

Key Informant Interviews, while invaluable in qualitative research, present unique challenges. Addressing these effectively is crucial for the integrity and utility of the data collected.

Solution: Employing multiple interviewers and informants can provide diverse viewpoints, reducing individual bias. Establishing a clear, structured interview framework helps maintain objectivity. Regular team discussions can also aid in identifying and mitigating biases.
Solution: Developing a detailed interview guide ensures consistency across interviews. Validity can be enhanced through careful selection of informants based on their expertise and through cross-verification of data with other sources.
Solution: Flexibility in scheduling and using technology for remote interviews can alleviate logistical issues. Building rapport with informants beforehand can also ease scheduling difficulties. It is also important to have backup interviewees, for instance, someone in the same department with the same knowledge as the primary informant.
Solution: Employing culturally aware and, where necessary, multilingual interviewers can mitigate these issues. Researching cultural norms and using interpreters when needed is also helpful.
Solution : KIIs typically involve a small group of respondents, so your best bet is to attain a sample that is well knowledgeable of the topic at hand.
Solution: Utilizing qualitative data analysis software can streamline coding and thematic analysis, reducing time and subjective biases. Engaging multiple team members in the analysis can provide a balance of perspectives.

While Key Informant Interviews pose specific challenges, these can be effectively addressed through careful planning, methodological rigor, and cultural sensitivity. Overcoming these challenges ensures the integrity and value of the insights gained from this qualitative research method.

Analyzing and Utilizing Data from Key Informant Interviews

Analyzing and utilizing data gathered from KIIs are as crucial as the interview process itself. This phase transforms raw, qualitative data into meaningful insights that can guide decision-making and policy formulation. It is worth noting that, due to their typically small sample sizes and qualitative nature, KIIs are almost never quantified.

Transcribing Interviews: The first step is to transcribe the interviews verbatim. This process involves converting audio recordings into written text, capturing every word, and noting critical non-verbal cues.
Data Cleaning: Transcripts should be reviewed and cleaned for clarity and accuracy. This includes removing irrelevant sections, correcting errors, and anonymizing data if required.
Thematic Analysis: One of the most common approaches is thematic analysis, which involves identifying patterns and themes within the interview data. This process starts with reading through the transcripts multiple times to gain a deep understanding of the content.
Coding: Coding involves labeling text segments with tags that summarize their content. This could be done manually or with the help of qualitative data analysis software. Initial codes are generated and then refined and grouped into broader themes.
Interpreting Themes: Once themes are identified, the next step is to interpret them in the context of the research objectives. This involves understanding how these themes contribute to answering the research questions and what new insights they offer.
Cross-Verification with Other Data Sources: To enhance the validity of the findings, it’s essential to cross-verify the insights from KIIs with other data sources, such as surveys, literature reviews, or observational studies.
Triangulation: This process involves using multiple data sources or methods to corroborate the findings. Triangulation strengthens the credibility of the research conclusions.
Developing Recommendations: The insights derived from KIIs should be translated into actionable recommendations. This involves considering how the findings can inform policy, influence strategies, or guide practical interventions.
Reporting Findings: When reporting findings, it’s essential to present the data in a way that is accessible and understandable to the intended audience. This could include using quotes from informants to illustrate points, creating visual representations of themes, or developing case studies.
Subjectivity: One of the challenges in analyzing qualitative data is the inherent subjectivity. It’s crucial to approach data interpretation with an awareness of potential biases and strive for objectivity.
Complexity of Data: Qualitative data from KIIs can be complex and multifaceted. Researchers need to be methodical in their approach to ensure that the richness of the data is fully explored and understood.

In a nutshell, analyzing and utilizing data from Key Informant Interviews require meticulous attention to detail, rigorous methodological approaches, and a careful balance between subjective interpretation and objective analysis.

When to Use Key Informant Interviews in Research

Understanding when to utilize Key Informant Interviews (KIIs) is crucial for researchers to gather in-depth qualitative data effectively. KIIs are particularly advantageous in specific research contexts:

Exploring Complex or Sensitive Issues: KIIs are ideal when researching topics that are complex, nuanced, or sensitive. They provide a safe environment for informants to share detailed insights and personal experiences that might not be captured through other methods.
Gaining Expert Perspectives: When a study requires expert opinions or specialized knowledge, KIIs are an excellent choice. They allow researchers to tap into the wealth of experience and expertise of individuals who are well-versed in the subject matter.
Developing or Refining Hypotheses: In the early stages of research, especially when hypotheses are being developed or refined, KIIs can offer valuable insights that inform the direction and focus of the study.
Understanding Contextual and Cultural Dynamics: When research involves understanding the cultural or contextual nuances of a topic, KIIs with local experts or community leaders can provide depth and context that other methods may miss.
Policy Development and Evaluation: For policy-oriented research, KIIs with policymakers, stakeholders, and those affected by the policy can provide insights into both the impact of existing policies and considerations for future policy development.
Market Research and Consumer Insights: In market research , KIIs with industry experts, consumers, or other stakeholders can uncover trends, motivations, and attitudes that inform marketing strategies and product development.
When Quantitative Data Needs Qualitative Support: KIIs are also valuable when quantitative data requires qualitative insights for a more comprehensive understanding. They can explain the ‘why’ behind the numbers, adding depth to quantitative findings.
Resource-Limited Settings: In settings where resources for large-scale surveys are limited, KIIs can provide significant insights without the need for extensive logistics and infrastructure.

The decision to use KIIs should be guided by the research objectives, the nature of the research question, and the context in which the study is conducted. When used appropriately, KIIs can be a powerful tool in the researcher’s arsenal, providing nuanced insights that are vital for in-depth understanding and informed decision-making.

Master Key Informant Interviews with GeoPoll

Key Informant Interviews (KIIs) stand as an indispensable qualitative research tool, adept at uncovering deep insights and nuanced understandings in a wide array of research settings. From exploring complex and sensitive issues to refining hypotheses and informing policy decisions, KIIs offer a unique avenue for accessing expert knowledge and contextual information that other methods might miss.

This guide has journeyed through the intricacies of KIIs, highlighting their importance, methodology, challenges, solutions, and ideal usage scenarios. The careful planning, ethical considerations, and skilled execution required for effective KIIs underscore the need for experienced researchers and methodologists.

GeoPoll, with its vast experience and expertise in conducting KIIs across diverse sectors and regions, is uniquely positioned to help you leverage this powerful research method. Our seasoned professionals are adept at navigating the complexities of KIIs, ensuring that each interview is methodologically sound and rich in valuable insights. We offer a full spectrum of services, from designing the interview guide and selecting key informants to conducting the interviews and analyzing the data.

Contact us for further information on how Key Informant Interviews can enrich your specific research endeavors and how we can support you.

The International Marketing Research Process : A Guide

GeoPoll Report: A Guide To Conducting Research in Emerging Markets

Key Informants’ Interviews

First Online: 27 October 2022

Cite this chapter

qualitative research key informant interviews

Salma Akhter 4

3204 Accesses

4 Citations

This chapter provides a short description of the key informant interview (KII), an important data collection method in qualitative research. Then, the chapter explains the suitability of this method in qualitative research. The chapter discusses the selection process of key informants with the roles of researcher and interviewer. The chapter gives important guidelines of the steps to conduct KII. The chapter also provides some guidelines about the data process, data presentation, and data analysis strategies of KII. The chapter ends with a description of the advantages and disadvantages of KII.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save.

Get 10 units per month
Download Article/Chapter or eBook
1 Unit = 1 Article or 1 Chapter
Cancel anytime
Available as PDF
Read on any device
Instant download
Own it forever
Available as EPUB and PDF
Compact, lightweight edition
Dispatched in 3 to 5 business days
Free shipping worldwide - see info
Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Interviewing in Qualitative Research

Methodological Framework

Qualitative Interviewing

Adams, A., & Cox, A. L. (2008). Questionnaires, in-depth interviews and focus groups. In P. Cairns & A. L. Cox (Eds.), Research methods for human computer interaction (pp. 17–34). Cambridge University Press.

Chapter Google Scholar

Ali, M., David, M. K., & Lai, L. C. (2014). Using the Key Informants Interviews (KIIs) technique: A social sciences study with Malaysian and Pakistani respondents. Man and Society , 24 , 131–148

Google Scholar

Bailey, C. A. (2017). A guide to qualitative field research. The Pine Forge Press series in research methods and statistics . Pine Forge Press. A Sage Publications Company.

Bryman, A. (2004). Social research methods , (2nd ed). Oxford university Press.

Douglas, J. (1985). Creating interviewing . Sage.

Henn, M., Weinstein, M., & Foard, N. (2006). A short introduction to social research . Sage Publications: California, USA.

Jones, C. (1993). Qualitative interviewing. In G. Allan, C. Skinner (Eds), Handbook for Research students in the social sciences . The Falmer Press: London.

Kumar, K. (1989). Conducting Key Informant Interviews in Developing Countries, A.I.D. Program Design and Evaluation Methodology Report No. 13, Center for Development Information and Evaluation, A.I.D, December 1989

Kvale, S. (1996). Interviews: An introduction to qualitative research interviewing . Sage Publications.

Lavrakas, Paul J., 2008, Encyclopaedia of Survey research Methods, Sage Publications.

Mack, N., Woodsong, C., Macqueen, K. M., Guest, G., & Namey, E. (2005). Qualitative research methods overview. Qualitative research methods: A data collector’s field guide , 1–12, Family Health International, USAID.

Marshall, M. N. (1996). The key informant technique, Family Practice , 13 (1), Oxford University Press.

Maxwell, J. (1996). Qualitative research design: An interactive approach, applied social research methods series . Vol. 41, Sage publication: Thousand Oaks, USA.

McKenna, S. A., & Main, D. S. (2013). The role and influence of key informants in community-engaged research: A critical perspective. Action Research . SAGE.

Needs assessment techniques. Using key informant interviews . Retrieved from. http://ppa.aces.uiuc.edu/pdf_files/Informant1.PDF

Neuman, W., & Lawrence. (1997). Social research methods. Qualitative and quantitative approaches (3rd ed), Allyn and Bacon: USA.

Oklahoma's Official Website. Key informant interview guidance document . Retrieved from. https://www.ok.gov/odmhsas/documents/Key%20Informant%20Interview%20Guidance%20Doc_Draft.pdf

Pact Inc. (2014). Field guide for evaluation: How to develop an effective terms of reference, Washington DC. Retrieved from. https://www.betterevaluation.org/sites/default/files/Field%20Guide%20for%20Evaluation_Final.pdf

Parsons, J., (2008). A Key Informant. Blackwell encyclopaedia of sociology, 2007 , Sage publications.

Punch, KF. (2001). Introduction to social research. Qualitative and quantitative approaches , Sage Publications: London.

Richardson, M. (1994). Writing: A method of inquiry. In N. K. Denzin, & Y. S. Lincoln (Eds), Handbook of qualitative research (pp. 516–529). Sage: Thousand Oaks, CA, USA.

Ritchie, J. & Lewis, J. (Eds.). (2013). Qualitative research practice: A guide for social science students and researchers . Sage.

Sanjari, M., Bahramnezhad, F., Fomani, F. K., Shoghi, M., & Cheraghi, M. A. (2014). Ethical challenges of researchers in qualitative studies: The necessity to develop a specific guideline. Journal of Medical Ethics and History of Medicine , 7 , 14.

Sofaer, S. (2002). Qualitative research matters. International Journal for Quality in Health Care, 18 (4), 329–336, International Society for Quality in health care and Oxford University Press.

Thakur, D. (2005). Research Methodology in Social Sciences . Deep and Deep Publications Pvt Ltd.

The center for substance abuse prevention’s northeast center for the application of prevention technologies. (2004). Key informant interviews , (NECAPT, 2004 Education Development Center, Inc.

Turney, L. & Pocknee, C. (2005). Virtual Focus Groups. New Frontiers in Research.

UCLA centre for health policy research, Key informant interviews .

University of Illinois Extension Service-Office of Program Planning and Assessment.

USAID centre for Development Information and Evaluation. (1996). Performance monitoring and evaluation TIPS . No. 2. Retrieved from. http://pdf.usaid.gov/pdf_docs/PNABS541.pdf

Washington University. Conducting key informant interviews guide. Key informant interview handbook . courses.washington.edu.

World Health organization (WHO). (2003). Description of the key informant survey . Retrieved from. http://www.who.int/evidence/KI-Survey

Download references

Author information

Authors and affiliations.

Department of Sociology, University of Dhaka, Dhaka, 1000, Bangladesh

Salma Akhter

You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Salma Akhter .

Editor information

Editors and affiliations.

Centre for Family and Child Studies, Research Institute of Humanities and Social Sciences, University of Sharjah, Sharjah, United Arab Emirates

M. Rezaul Islam

Department of Development Studies, University of Dhaka, Dhaka, Bangladesh

Niaz Ahmed Khan

Department of Social Work, School of Humanities, University of Johannesburg, Johannesburg, South Africa

Rajendra Baikady

Rights and permissions

Reprints and permissions

Copyright information

About this chapter

Akhter, S. (2022). Key Informants’ Interviews. 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_27

Download citation

DOI : https://doi.org/10.1007/978-981-19-5441-2_27

Published : 27 October 2022

Publisher Name : Springer, Singapore

Print ISBN : 978-981-19-5219-7

Online ISBN : 978-981-19-5441-2

eBook Packages : Social Sciences Social Sciences (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Publish with us

Policies and ethics

Find a journal
Track your research

This website may not work correctly because your browser is out of date. Please update your browser .

Key informant interviews

Key informant interviews involve interviewing people who have particularly informed perspectives on an aspect of the program being evaluated.

Key informant interviews are "qualitative, in-depth interviews of 15 to 35 people selected for their first-hand knowledge about a topic of interest. The interviews are loosely structured, relying on a list of issues to be discussed. Key informant interviews resemble a conversation among acquaintances, allowing a free flow of ideas and information. Interviewers frame questions spontaneously, probe for information and take notes, which are elaborated on later" (USAID 1996).

USAID (1996) lists a number of situations in which key informant interviews are useful:

When decision-making can be achieved through qualitative and descriptive information.
When it is important to gain an understanding of the perspectives, behaviour and motivations of customers and partners of an activity or project in order to explain the shortcomings and successes of an activity.
When generating recommendations is the key purpose.
In order to interpret quantitative data by interviewing key informants about the how and why of the quantitative findings.
In order to help frame the issues that are relevant before designing a quantitative study.

Advantages to this method include:

They are an affordable way to gain a big picture idea of a situation.

The information gathered comes from people who have relevant knowledge and insight.

They allow for new and unanticipated issues and ideas to emerge.

Limitations to this method include:

There is a potential for the interviewer to unwittingly influence the responses given by informants.

There is a potential bias if informants are not selected with care.

Systematic analysis of a large amount of qualitative data can be time-consuming.

The validity of the data can sometimes be difficult to prove.

Advice for using this method

When formulating study questions, limit the amount to five or fewer.

The interview should allow for free discussion by informants however, interviewers should be aware of what questions to ask and topics that should be covered.

When preparing a guide for interview topics, items are usually limited to 12 items so as to allow for in-depth discussion. It is sometimes useful to prepare different guides for different groups of informants.

When selecting key informants, it is often a good idea to start with a smaller amount as initially unplanned informants are often added. The total number generally is no more than 35.

In selecting key informants, make sure to include a wide range of perspectives and points of view, including selecting from different groups of key stakeholders.

See Interviews for more general advice on interviewing.

This USAID document advises how to conduct and apply the rapid appraisal technique known as key informant interviews.

Pact, Inc. (2014), Field Guide for Evaluation: How to Develop an Effective Terms of Reference. Washington.

USAID Center for Development Information and Evaluation (1996) Conducting Key Informant Interviews Performance Monitoring & Evaluation TIPS . Washington DC, USAID. Retrieved from http://pdf.usaid.gov/pdf_docs/PNABS541.pdf via USAID

'Key informant interviews' is referenced in:

52 weeks of BetterEvaluation: Week 4: Including unintended impacts

Framework/Guide

Communication for Development (C4D) : C4D Hub: Check the results support causal attribution (strategy 2)
Communication for Development (C4D) : C4D Hub: Investigate possible alternative explanations (strategy 3)
Communication for Development (C4D) : C4D: Collect and/or retrieve data (methods)
Communication for Development (C4D) : C4D: Identify potential unintended results
Rainbow Framework : Collect and/ or retrieve data
Rainbow Framework : Identify potential unintended results
Footprint evaluation
Sustained and Emerging Impacts Evaluation (SEIE)

What’s the Difference Between Key Informant Interviews and In-Depth Interviews?

Key Informant Interviews vs In-Depth Interviews

Years ago, in the burgeoning field of cultural anthropology, ethnographers began discreetly observing research subjects from within a community. It was a novel approach; instead of bringing subjects to them in a controlled setting, researchers would immerse themselves within a group, asking questions and conversing with individual subjects with the hope of uncovering key pieces of information. They believed that observing people in their native environment would provide critical details that might be lost if they were removed from it. They also felt that by going straight to the source they were gathering truly “expert” opinions.

Many disciplines use derivatives of this type of study today. Market researchers call it key informant interviewing . The key informant interview is a type of qualitative in-depth interview. Both types, key informant and in-depth interviews, forgo preconceived questions to instead focus on the dynamic flow of conversation between researcher and participant(s). But depending on their resources, as well as the type of data needed, companies often choose one method over the other. Take a look at some of the key differences between key informant interviews and in-depth interviews:

Key informants are experts. Thus, researchers only use key informant interviews when they can secure a participant with unique knowledge of a topic. In-depth interviews can be with anyone.

Companies looking for ways to fix a problem should probably choose in-depth interviews. If they want to identify a potential problem, they might consider key informant ones. In-depth interviews aim to uncover information about an issue that has already come up. The topics of dialogue during them reflect a company’s desire to explore a particular subject. Yes, dynamic interaction between the interviewer and participant can and should direct some of the conversation, but the nature of the interview is to gather specific data. Key informant interviews, on the other hand, are designed to explore a topic before digging for the details. It’s often the first step: researching what needs to be researched!

Key informant interviews frequently take less time to administer than standard in-depth interviews. This is because there are typically fewer “experts” to interview as compared to the general public (from which a sample of participants might be chosen for in-depth interviews).

Oftentimes, key informants are not truly representative of a population. They are knowledgeable, but that knowledge might not translate well in the real world. Market researchers need to be mindful of this when choosing their key informants.

The way data is uncovered, processed and analyzed directly impacts the quality of results rendered. Without careful consideration of what needs to be uncovered, as well as the type of methodologies needed to uncover it, companies often needlessly waste time and money, getting nothing but subpar information in return for their efforts. Contact our co-CEO Colson Steber at Qlarity Access to learn if in-depth interviews, including key informant ones, could be the lynchpin your company needs to get ahead of competition, increase ROI and connect with your consumers.

An Introduction to In-Depth Interviews

Oftentimes, one of the first things companies do when starting a large-scale market research...

In-Depth Interviews: Data Collection Advantages and Disadvantages

In-depth interviews are a qualitative data collection method that involves direct, one-on-one...

Four Actionable Tips to Improve Your In-Depth Interviews

In-depth interviews are an excellent source of primary data for researchers looking to answer more...

Stay In The Loop

Subscribe to our blog today to get the latest posts delivered straight to your inbox. Don’t miss a beat in the ever-evolving arena of market research.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings
My Bibliography
Collections
Citation manager

Save citation to file

Email citation, add to collections.

Create a new collection
Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

Search in PubMed
Search in NLM Catalog
Add to Search

Using Qualitative Comparative Analysis of Key Informant Interviews in Health Services Research: Enhancing a Study of Adjuvant Therapy Use in Breast Cancer Care

Affiliation.

1 *Department of Family Medicine, College of Medicine †Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH ‡Departments of Health Evidence and Policy and Medicine, Mount Sinai School of Medicine, New York, NY.
PMID: 26908085
PMCID: PMC4792771
DOI: 10.1097/MLR.0000000000000503

Background: Qualitative comparative analysis (QCA) is a methodology created to address causal complexity in social sciences research by preserving the objectivity of quantitative data analysis without losing detail inherent in qualitative research. However, its use in health services research (HSR) is limited, and questions remain about its application in this context.

Objective: To explore the strengths and weaknesses of using QCA for HSR.

Research design: Using data from semistructured interviews conducted as part of a multiple case study about adjuvant treatment underuse among underserved breast cancer patients, findings were compared using qualitative approaches with and without QCA to identify strengths, challenges, and opportunities presented by QCA.

Subjects: Ninety administrative and clinical key informants interviewed across 10 NYC area safety net hospitals.

Measures: Transcribed interviews were coded by 3 investigators using an iterative and interactive approach. Codes were calibrated for QCA, as well as examined using qualitative analysis without QCA.

Results: Relative to traditional qualitative analysis, QCA strengths include: (1) addressing causal complexity, (2) results presentation as pathways as opposed to a list, (3) identification of necessary conditions, (4) the option of fuzzy-set calibrations, and (5) QCA-specific parameters of fit that allow researchers to compare outcome pathways. Weaknesses include: (1) few guidelines and examples exist for calibrating interview data, (2) not designed to create predictive models, and (3) unidirectionality.

Conclusions: Through its presentation of results as pathways, QCA can highlight factors most important for production of an outcome. This strength can yield unique benefits for HSR not available through other methods.

PubMed Disclaimer

Publication types

Search in MeSH

Grants and funding

R01 CA149025/CA/NCI NIH HHS/United States
R01-CA149025/CA/NCI NIH HHS/United States

LinkOut - more resources

Full text sources.

Europe PubMed Central
Ingenta plc
Ovid Technologies, Inc.
PubMed Central
Wolters Kluwer

Other Literature Sources

scite Smart Citations
Genetic Alliance

Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

Advanced Search
Journal List
Sage Choice
PMC10666509

Key Informants in Applied Qualitative Health Research

Manisha pahwa.

1 Health Policy PhD Program, McMaster University, Hamilton, ON, Canada

2 Occupational Cancer Research Centre, Cancer Care Ontario, Ontario Health, Toronto, ON, Canada

Alice Cavanagh

3 Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

Meredith Vanstone

4 Department of Family Medicine, McMaster University, Hamilton, ON, Canada

Identifying and recruiting key informants is a widely used sampling strategy in applied qualitative health research. Key informants were first conceptualized within ethnography, but there is little methodological guidance about how to use this technique outside of that research tradition. The objective of this article is to offer practical suggestions about how existing methods for data collection with key informants could be translated to methodologies commonly used in applied qualitative health research. This article delineates how key informants could be conceptualized and sampled and how data sufficiency can be approached. The article prompts deeper consideration of the politics of representation and epistemic power that are inherent to the use of key informants in applied qualitative health research.

Introduction

Enrolling key informants is common in many applied qualitative health research studies. Although the “key informant technique” originated in ethnographic anthropology, key ( Tremblay, 1957 ) informants are now commonly integrated into data collection strategies in diverse research methodologies. However, there is a dearth of methodological guidance for qualitative researchers working outside ethnographic traditions. As a result, many applied qualitative health researchers describe using “key informants” without explaining how they defined this role, how they conceptualized the value of information provided by these participants, and how they made decisions about identifying, sampling, and judging the sufficiency of data. This methodological gap also poses an important challenge to readers seeking to appraise the credibility and transferability of findings to other contexts or populations.

In this article, we synthesize existing methodological guidance about sampling and collecting data from key informants to offer practical suggestions about how to incorporate this technique into methodologies commonly used in applied qualitative health research. Our analysis is conceptual, looking to literature outside anthropology about the use of key informants in qualitative research. We synthesized this knowledge through our own scholarly lenses formed by conducting applied qualitative health research with key informants and non-key informants in the fields of medical education and health policy. We lean both on established methodologies (e.g., interpretive description, grounded theory, and case study) and methodological guidance established outside of formal methodologies (e.g., qualitative description, methodological guidance on sampling, and data sufficiency). Our intention is that the principles we highlight here will be adapted by researchers for congruency to the paradigm, methodology, topic, and content of their individual projects.

Using key informants within qualitative traditions outside of anthropology requires adaptation, as the philosophical assumptions and methodological traditions of anthropology do not directly translate to many methodologies used more commonly for applied qualitative health research. However, this work is worthwhile, as the incorporation of key informants can be a helpful addition to the methodological toolkit of the applied qualitative health researcher. A key informant sampling approach can be flexible and assist in building thoughtful linkages to existing knowledge and the experiential knowledge of the research team ( Neergaard et al., 2009 ). Doing this work rigorously requires careful application to the study-specific theoretical foundation, methodology, and methods. The current article provides a foundation for researchers to develop a study-specific rigorous approach to incorporating key informants consistent with their chosen methodology.

Conceptualizing the Key Informant

Traditionally, key informants were engaged in anthropological research to provide “relatively complete ethnographical description of the social and cultural patterns” of their group ( Tremblay, 1957 ). Key informants have been used for both qualitative and quantitative data collection, offering value through their ability to articulate observed social relationships to the researcher ( Hughes & Preski, 1997 ; Seidler, 1974 ). Key informants are selected due to their ability to help the researcher understand cultural patterns, often providing background information that is inaccessible, implicit, or inefficient to identify through document reviews or other partial accounts ( Marshall, 1996 ; Poggie Jr, 1972 ).

The term “key” evokes ideas both about the crucial importance of the informant and about their capacity to unlock or grant access to a hitherto inaccessible phenomenon. The term “informant” gestures toward the researcher’s naive position relative to research participants’ embedded knowledge or insider experience of an issue at hand ( Morse, 1991 ); it also reflects an assumption that the subject of the research is complex or inaccessible enough to necessitate interpretation by a knowledgeable member of an in-group. Contrasted with research with participants who are not framed as key informants, insight and knowledge generated from key informant interviews is often framed as “more objective” or given more weight when interpreting results ( Lokot, 2021 ). Research designs that integrate data collection with both “regular” study participants and key informants frequently reflect these tacit hierarchical assumptions.

Key informants provide high level perspectives and comparative insights on issues or questions under study. This contrasts with the scope of insight attributed to other groups of qualitative interviewees, who are more often recruited to provide data rooted in their own lived experiences, or about their personal opinions, and beliefs. In some studies, this distinction is clear: the key informant may contribute knowledge of history, policy, and organizational interaction while the participant contributing lived experience speaks about their experiences embedded within that historical event or affected by the policy. For example, key informants may speak about the implementation, scale-up, and history of public funding for a new prenatal testing technology ( Van Schendel et al., 2017 ), while participants with personal experience of that technology may speak about that experience to offer opinions, beliefs, and attitudes ( Vanstone et al., 2015 ).

In some types of studies, the distinction is less clear. For example, in a study about patients’ post-operative experiences, an experienced nurse or surgeon might be sought as a key informant for their perceived ability to draw on and synthesize observations and insights gleaned from their professional practice. A hospital administrator might be engaged as a key informant to offer insight on typical lengths of stay and rehabilitation resources. A home care aide might offer key informant perspectives on how living spaces might be adapted and home services arranged to facilitate post-operative recovery. The knowledge each of these key informants contributes is based on their professional work (observations, data, and formal training) with many patients undergoing and recovering from the procedure in question. Accordingly, they may offer insights different from a patient or family caregiver, who would be able to speak more directly to the lived experience of anticipating, undergoing, and recovering from that surgery in their own social and medical context.

To further illustrate this difference between participants who share their own lived experience, each of the types of key informants mentioned above might be engaged to share their personal lived experience in response to a different question—perhaps about navigating complexity and uncertainty during a surgery for the surgeons ( Cristancho et al., 2013 ), making decisions about implementing a new clinical program in a hospital unit they oversee for the administrators ( Swinton et al., 2021 ), or grieving after client death for home care aides ( Tsui et al., 2019 ). The difference here is whether the research question requires participants to draw on their personal experiences or offer comment based on accumulated expertise based on a synthesis of different forms of knowledge, experience, and observation of others’ experiences.

Qualities of “good” key informants have been posited to include:

(1) Community role: “unique access” to, or experience of, the phenomena of research interest by virtue of a profession or social position ( Hughes & Preski, 1997 ; Tremblay, 1957 ).
(2) Knowledge: ability to “meaningfully” synthesize their experiences and to offer rich, reflexive insights ( Marshall, 1996 ; Payne & Payne, 2004 ; Tremblay, 1957 ).
(3) Willingness to engage with researchers: “relative ease” to be recruited to participate in research ( Bernard, 2017 ; Tremblay, 1957 ).
(4) Capacity to communicate “intelligibility” to the researcher ( Pelto & Pelto, 1978 ; Tremblay, 1957 ).
(5) Impartiality: biases should be “minimal” and well-known to researchers ( Tremblay, 1957 ).

When selecting key informants and interpreting their data, it is important to remember that their perspectives are still the situated, partial perspectives inherent to qualitative data. Accordingly, drawbacks of key informant data relate to concerns about the partial and subjective view of phenomena under study that can be elicited from stakeholders, particularly as sampling strategies for key informant studies have yet to be subject to extensive methodological discussion. This form of subjectivity can be perceived as a source of bias that negatively impacts the rigor and trustworthiness of study results ( Hughes & Preski, 1997 ; Lokot, 2021 ; Payne & Payne, 2004 ) but can be mitigated by transparent reporting in publication, alongside a frank and fair discussion of the above considerations that guide the identification and recruitment of participants.

What Knowledge Are They Representing?

Key informants are used in applied qualitative health research shaped by a diverse range of epistemological paradigms ( Creswell, 2007 ). In positivist paradigms for inquiry, key informants are often presented as being able to reveal something about “the actual nature of the … domains on which they are reporting” [emphasis ours] provided they are asked the right questions ( Poggie Jr, 1972 ), they are sufficiently unbiased ( Tremblay, 1957 ), or their biases are accounted for by researchers ( Bernard et al., 1984 ; Poggie Jr, 1972 ). In interpretive paradigms, key informants may be framed as co-constructing knowledge with researchers ( Morse, 1991 ), where the subjectivity of individuals in both groups shapes the process and products of research inquiry.

In research conducted in either positivist or interpretive paradigms, considerations related to how key informants are identified, and knowledge claims that researchers seek to make, ultimately reflect and can reify or disrupt social and political power relations ( Lokot, 2021 ; Soucy, 2000 ). Since key informants are identified on the basis of expertise relevant to a subject of study, the cultural norms, attitudes, and values that shape perceptions of expertise and experience play a foundational role in shaping researcher considerations about who is authoritative or insightful ( Soucy, 2000 ). This invokes questions about epistemic injustice and what Fricker describes as the implications of prejudice entrenched in social and political economies of credibility ( Fricker, 2009 ). When individual people or communities of people are not recognized or regarded in their capacity as knowers, they are subject to testimonial and hermeneutical injustice that hampers the perception of their expressions as credible and denies them the “interpretive resources” that provide them with architecture to make sense of their experiences in and of the world.

For example, a feminist perspective offers insight on key informants useful to any qualitative researcher, encouraging researchers to critically inquire about why individuals are assumed to be “key” and to whom. Those choosing to engage with their research from a feminist or critical perspective may further consider the under recognition of vested interests that are sometimes, potentially often and invisibly, enmeshed with the power and privilege of key informants. If such interests are not recognnised, qualitaitve research can contribute to the problematic power constructs and relationships that give rise to the identification of key informants and the reproduction of epistemic injustice. These issues can be mitigated by approaches that give communities of “ordinary” people voices and by recognizing the limits of key informant interviews in qualitative research ( Lokot, 2021 ).

How Have Key Informants Been Used in Applied Qualitative Health Research?

Key informants have been used widely in a range of applied qualitative health research methodologies including grounded theory, interpretive description, and qualitative description. Key informants have been referred to as informants, experts, stakeholders, and “key knowledgeables” ( Patton, 2014 ). In applied qualitative health research, key informants nearly always refer to a group sampled by virtue of their professional role or expertise using conventional sampling strategies ( Bailey et al., 2012 ; Hodges et al., 2011 ; Van Melle et al., 2014 ). Key informants in applied qualitative health research have included healthcare providers, policymakers, scientists, community leaders, and educators, among others, situated in clinical practice, government, academia, community organizations, or other places that are believed to contribute to their contextual, overarching, and comparative perspectives on an issue.

For example, key informants who occupy social and professional roles have been used in community-engaged research on health promotion ( McKenna & Main, 2013 ); senior health ministry officials were identified as key informants for a study on health system priorities in Canada ( Abelson et al., 2017 ); and individuals in the ministry of health and nongovernmental or civil society organizations were considered key informants about the use of routine health information systems in malaria, tuberculosis, and HIV programming in Senegal ( Muhoza et al., 2021 ).

Typically, key informants are engaged because they provide high level insight or understanding on the phenomena of interest, often through participating in interviews, focus groups, or deliberative methods. Key informants have also been used to probe about how an issue is thought of or acted upon in clinical practice or policy, as well as for understanding how debates on a topic within the field are navigated by its members.

Working With Key Informants

In practical terms, designing a study that solicits and makes use of data gathered from key informants necessitates a clear understanding of how epistemological, methodological, and analytical considerations align. In the following sections, we highlight some of the practical concerns that researchers adapting key informant technique must address. We make a distinction between intrinsically and extrinsically bound projects. By “intrinsically bound” we mean projects about a specific group of people (e.g., policy-making staff within a specific organization and an identifiable healthcare delivery team). By “extrinsically bound” we mean projects about a phenomenon where the boundaries of who may have relevant data to contribute are not as clear and where participants will not necessarily have any interaction with each other, live or work in the same jurisdiction, or participate in the same culture or social groups. Table 1 summarizes these ideas.

How to Operationalize a Reflexive and Transparent Approach in the Building and Reporting of a Key Informant Strategy.

	Key considerations	Things to avoid
Choosing a methodology	Strive for clear congruence of the epistemological, methodological, and interpretive aspects of research.	Selecting a methodology which is philosophically opposed to the use of key informants as you conceptualize them; importing methodological concepts from ethnography into a disparate methodological tradition.
Defining relevant key informants	First, conceptualize your key informants: Be clear about why you are choosing a key informant strategy and how you differentiate these participants from other types of participants. Ask who is considered to be a key informant and why?	Avoid listing roles or attributes of potential key informants without justification.
	Second, define the boundaries of phenomenon under study: Who is in, who is out, and why?	Ensure you have boundaries for the study and eligible KI participants, which are not overly wide or permeable.
	If combining with other types of participants, consider what different weight might be given to the comments made by different KIs by virtue of their perspective?
Identifying and recruiting key informants	Choose KIs strategically, considering their ability to provide insight about both the group and phenomenon of study ( ).	Relying solely on snowball sampling, which may recruit only those with aligned perspectives on the issue.
	Use an accessible and transparent way to recruit key informants to your study.
	Ensure that you are employing strategies to identify and recruit “less visible” potential KIs who are not already known to you or existing participants.
Collecting data	It will be important to acknowledge the expertise of the key informant and not be overly restrictive in the questions asked of this person. Instead, define the scope of the inquiry in order to give the informant a sense of the boundaries of the study. Within these boundaries, the key informant should be encouraged to speak freely about what they see as relevant and important, with the interviewer drawing the conversation back if it veers outside of the boundaries of the scope of the inquiry. This unstructured approach acknowledges the expertise of the key informant and the likelihood that they may identify points of importance or relevance unrecognized by the researcher ( ).	Use data collection techniques which encourage the KI to understand your desire that they speak from beyond their personal experience, to help identify overarching patterns or features of the phenomenon under study.
Analyzing KI data	Follow the analytic guidance of your methodology, paying careful attention to the epistemic assumptions you hold about what kind of information KIs are providing.	Avoid treating data from KIs and other types of participants in the same way, if both types are included in the project.
Determining data sufficiency	Identify your strategy for determining data sufficiency. Will this be driven by convenience, access, or connections?	Traditional ways of considering data sufficiency when participants are speaking only about personal experience are unlikely to be rigorous when used with key informants.
	Consider how you will approach the challenge of identifying participants who are unwilling or unable to participate and the implications this has for data sufficiency.
Returning findings/credibility	Incorporating efforts to return the findings and elicit KI response on your interpretation may yield particularly rich insights that will increase the credibility of your study.	Be alert to different opinions in the field and have a plan to work with conflicting opinions or accounts within your participating KIs.

What Sampling Strategies Could Be Used?

As with any sampling strategy, it is important to begin by defining participant eligibility criteria. First, researchers should ask themselves how they will differentiate key informants from other types of participants. Is employment in a particular organization sufficient or do key informants need to have a particular level of experience or role within that organization? What characteristics will indicate the likelihood that a key informant can speak about the broader organization of a phenomenon, rather than just their personal experience interacting with the issue? These characteristics will be operationalized into eligibility criteria. When using a key informant strategy, eligibility criteria commonly describe particular roles, experience levels, organizations, or jurisdictions. They may also describe involvement with the particular policy, program, or intervention under study. For example, in their study of Canadian policy makers’ perspectives on setting objectives for health systems, Abelson and colleagues defined the eligibility of their key informants as those with particular forms of knowledge as exemplified through professional role and duration of tenure in that role ( Abelson et al., 2017 ).

After defining eligibility criteria, researchers must identify a sampling strategy to assist them in choosing who to speak to from among the available pool of key informants. Key informant strategies fit with non-probabilistic, non-representative approaches to purposive sampling, and there are a variety of sampling options that researchers may choose from within this approach.

In intrinsically bound research studies, a complete target population approach may be appropriate ( Patton, 2014 ). This approach seeks to sample everyone within the group of interest, for instance, a particular workplace in a case study or individuals involved with the origination or implementation of a particular policy, where there are only a small number of individuals with relevant expertise.

Quota sampling strategies define different categories of theoretical or analytic interest for purposive sampling, and participants are selected to fill categories ( Patton, 2014 ). In qualitative research, quota sampling is not used for representativeness nor to achieve a specific quantity of participants, but rather to ensure that theoretically relevant perspectives are included in the data. A key informant quota sampling strategy would emphasize breadth, purpose, and variety in key informant participants. This could be done by identifying multiple factors of interest related to, for example, role, organization, experience, geography, domain, or sector of work and then seeking key informants who fit in each of these domains.

Snowball sampling, sometimes known as chain referral sampling, is a purposive sampling strategy that is useful when individuals in the group of interest are not necessarily known to the researcher and may be hard to reach ( Parker et al., 2019 ). Snowball sampling asks existing participants to identify new potential participants. This can be very useful with key informants, who may be knowledgeable about others who have similar roles or interests in their field. As colleagues or people known to each other professionally, a snowball approach may also help with purposive sampling. For example, an initial participant could be asked to identify another key informant in a similar role but with a different form of expertise, conflicting perspective, or working in a specific jurisdiction or organization, as warranted by the purpose of the study. A snowball sampling strategy may also help with recruitment, as the contact is more likely to be known to the target participant than the researcher.

Key informants may also be identified with a theoretical sampling approach, such as that associated with grounded theory ( Glaser & Strauss, 2017 ). This is typically an approach to sampling that incorporates insights from analysis of preliminary data. These emerging insights may indicate particular features of relevance or gap, which the researcher uses to select additional participants.

When using a methodology that encourages iteration between data collection and analysis, multiple sampling strategies may be combined. For instance, the categories in a quota sampling strategy may evolve theoretically. Snowball sampling may assist in filling those quotas. A maximum variation or convenience sampling approach might be used to elicit the initial set of data that will inform a subsequent theoretical sample ( Emmel, 2013 ). In Pahwa’s qualitative description study about ethical and social values toward lung cancer screening with low dose computed tomography in Canada, maximum variation sampling was initially used to sample key informants who were scientists, clinicians, and policymakers currently engaged in Canadian lung cancer screening activities ( Pahwa, 2023 ). These individuals were identified through review of published scientific papers and reports, lung cancer screening study websites, and personal knowledge of key experts and influential figures in the field. As initial key informant interviews were conducted and analytic categories developed, Pahwa used theoretical and snowball sampling to identify subsequent key informants who could be invited to the study to speak about themes or ideas in need of further perspectives, explanation, or articulation. Snowball sampling was particularly useful for identifying policymakers whose identities were not as evidently available in the public sphere on scientific publications or policy reports.

Identifying and Recruiting Key Informants

In an intrinsically bound study, the sampling strategy is likely to point to specific individuals who can then be recruited into the study as key informants. In extrinsically bound studies, identifying eligibility criteria for key informant participants may still leave a need to identify particular individuals from among those who meet the criteria. Additional layers of methodological planning are required to choose who to recruit from among eligible individuals.

For example, in Cavanagh’s extrinsically bound study of physician roles in the provision of care to those who have experienced intimate partner violence, she wished to sample key informants who were stakeholders in the provision of this care ( Cavanagh, 2022 ). She used a quota sampling strategy to identify that she was interested in, for example, speaking with someone who made macro-level policy about intimate partner violence at a provincial or national level. To fill this category, she needed to identify particular individuals and choose who to approach. She did this by employing a variety of tactics to identify potential individuals, looking at publicly available information through published white paper or policy reports, talking to experts in the field, and searching LinkedIn profiles to identify who may currently or previously have held a relevant position. Snowball sampling was also very useful here, as initial participants were often aware of other experts in their field and could suggest and sometimes help recruit other informants.

Once potential individuals are identified, the researcher must choose who to approach. There are many considerations here. Most methodological guidance encourages researchers to think strategically, considering the ability of individuals to provide insight about the group and phenomenon of study ( Tremblay, 1957 ). At this point, it will be important to be very clear about relevance. What are the boundaries of your phenomenon? With key informant sampling, it can be tempting to move outside of typical temporal or geographical bounds. A policymaker in Ireland might have insight on the roles of Canadian physicians in caring for people who have experienced intimate partner violence, or a scientist in the United States might have perspectives about the ethical principles involved with lung cancer screening programs in Canada, it is true. But without a clear rationale for reaching that far, it will be difficult to make an argument for the comprehensiveness and sufficiency of your sample, so make judicious decisions about defining boundaries and reaching beyond them.

As the project continues, think about the evolving sample. What areas of affinity and conflict are present in the existing sample? What gaps may exist? Some of this work may be possible to do during the planning phases of the project, consulting with collaborators who have expert knowledge of the field. Other work in this area will come during data analysis, as initial data indicates potential theoretically relevant areas that need to be investigated to provide a comprehensive view on the phenomenon ( Charmaz, 2014 ).

Reflexivity is important in this stage. Consider how your own identities, networks, and assumptions shaped the way you defined, identified, and recruited key informants. An audit trail can help document these important research decisions ( White et al., 2012 ). This documentation can be a catalyst for reflexive conversation among the research team about who was not invited or who did not respond to invitations, what knowledge or perspectives may not be represented, and what information provided by key informants may be expressed or influenced by vested interests. Documenting and reporting these processes can assist in facilitating the confirmability and trustworthiness of the project, providing much needed transparency. It can also invite critical discussion of the limitations of how key informants were conceptualized, identified, and sampled, as well as of the information collected from key informants.

Accounting for Data Sufficiency

Accounting for data sufficiency is one of the most under-developed aspects of existing methodological guidance about key informant sampling. Feasibility constraints are particularly acute in key informant research. Unlike other types of qualitative research, where pools of potential participants are very large, key informant groups can be quite small. They may also be hard to reach, busy, and have professional, organizational, cultural, or legal constraints on information they can share with researchers. While feasibility limitations to recruitment are real, they do not diminish the need for rigorous ways to establish data sufficiency.

In an intrinsically bound project where the researcher has invited participation from all eligible individuals via a target sampling approach ( Patton, 2014 ), it may be sufficient to describe that all were invited, and all volunteers were included ( Khalid et al., 2019 ). The researcher could increase credibility by offering comment on any common characteristics noted about those who declined to participate, and on the influence that may have on the data represented in the research. Depending on the methodological approach used, there may be other ways the researcher could enhance the credibility of a limited sample, perhaps by including other forms of data (e.g., documents and observation) where it is methodologically appropriate to do so.

In intrinsically bound studies, regardless of whether or not a target sampling approach is used, we may borrow from Robert Yin’s conceptualization of data sufficiency within case study research. According to Yin, data sufficiency is related to the “completeness” of the data needed to understand the case ( Yin, 2017 ). Yin suggests this can be done by establishing of “converging lines of inquiry” or identifying consistency across data from multiple sources. Others understand this as a form of triangulation ( Flick, 2018 ).

In an extrinsically bound project, determining and justifying data sufficiency becomes more complex. Common qualitative data sufficiency constructs like saturation will often be insufficient, due to a mismatch between underlying assumptions of the study and the key informant technique. Saunders and colleagues describe four different ways that saturation is defined ( Saunders et al., 2018 ). When defined as information redundancy, saturation is inconsistent with key informant sampling because it doesn’t recognize that key informants are speaking beyond their personal experience, providing an overview of the organization of a phenomenon. Accordingly, each key informant may contribute a very different perspective that is not intended to overlap. Redundancy may therefore not be possible and also may not be needed to offer assurance that relevant perspectives are incorporated. When incorporated during data analysis, achieving thematic saturation does not assure the researcher that relevant divergent perspectives have been adequately incorporated.

If methodologically congruent, researchers may choose to adopt Malterud and colleagues’ proposal of information power as a model for determining data sufficiency ( Malterud et al., 2016 ). Information power is useful for planning what resources will be needed for a study related to the anticipated number of participants, which will have implications for transcription, participant honoraria, and researcher time. However, information power must be continuously evaluated during data analysis. This model posits that data sufficiency rests on whether there is specific information to answer the question and offers five items that may influence the level of information required: study aim, sample specificity, use of established theory, quality of dialogue, and analysis strategy ( Malterud et al., 2016 ). These items are inter-related and influence each other. For example, a study of expert perspectives on which barriers and resources affect the ability of adolescent and young adult cancer survivors to return to education or work used the theory of information power to inform their judgment of data sufficiency, judging 15 key informants to be sufficient on the basis of strong dialogue, the use of an underlying theory, and the use of a cross-case analysis strategy ( Pedersen et al., 2018 ). Key informant data may reach information power because this model of data sufficiency accounts for participants speaking beyond their personal (specific) experiences who are likely to offer strong and sophisticated dialogue with the researcher, although in analysis the researcher would need to explore the meaning and basis of this perspective.

Ethical Considerations

There are particular ethical considerations when using key informants, many of which are related to the unethical nature of conducting methodologically weak research. In relation to sampling, researchers may reflect upon who are they conceptualizing as a key informant and inviting to the research and why? How are they being invited to the study? Importantly, who is not being invited and what are the possible implications of the eligibility criteria for participation and the reproduction of certain forms of power, privilege, and knowledge?

Key informants who already have epistemic power are often readily identifiable to the researcher from published studies or existing knowledge of who is influential in the field. Key informants who have relatively less influence, perhaps due to a dissenting or critical stance on a topic, may be more challenging for an outsider researcher to identify. These critical voices risk being excluded from the research. Researchers may consider the potential implications of including and excluding key informants on reproducing epistemic injustice in the analysis and interpretation of study results, particularly with respect to whose ideational power is amplified, whose vested interests are being mobilized through the research and given credibility in the research, and why.

For topics where there is contention or debate, key informants are often engaged on issues that involve a struggle for epistemic power among themselves. The researcher is thus tasked with negotiating and producing meaning from ideational or knowledge conflict. They may notice that in the desire of key informants to give voice to their ideas, certain types of evidence or knowledge (of which they may have a stake in producing), and the mandates of institutions and interest groups to whom they are affiliated are promoted. It is also important for the researcher to acknowledge that epistemic communities and epistemic power are not monolithic and fixed in time and space; these are continuously changing and sometimes reinventing themselves as political priorities and knowledge paradigms shift, evolve, or emerge.

Researcher positionality may impact how key informants are sampled in a study. Researchers who are part of the in-group at the outset of the research may depend to some extent on sampling key informants with whom they share a personal connection, invariably invoking their personal reputations during participant recruitment. In these situations, it is vital that the researcher be transparent about their positionality and subjectivity and be reflexive and conscientious about their power, power dynamics, and the situated relatedness of the researcher and key informant in the field. Researchers who do not have an “in” at the outset of the research also need to be reflexive about power and relationships as these are equally relevant, albeit usually in the inverse direction (i.e., key informants holding power over researchers). The process of researchers possibly gaining an “in” as the research progresses, through gaining insider knowledge or even becoming part of the in-group, also needs to be reflected upon and articulated by the researcher through the overlapping lenses of positionality, power, and access.

The implications of these ethical considerations are many and dependent on the paradigm each researcher is working within. Feminist and critical researchers will be well familiar with these topics and likely already prepared to include an analysis of which voices are amplified, who is absent, and who may be silenced in a particular analysis. Researchers working in other paradigms may find these considerations less familiar and may choose to incorporate these considerations into their sampling and recruitment strategy, in order to ensure that less-resourced, less-established perspectives are all included.

Worked Examples: Key Informant Conceptualization and Sampling in Two Methodologies

Example 1 : Pahwa engaged key informants via one-on-one semi-structured interviews in a qualitative description study about ethical and social values toward lung cancer screening with low dose computed tomography in Canadian jurisdictions ( Pahwa, 2023 ). The aim of this research was to understand what key informants perceived as the ethical issues associated with lung cancer screening in Canada and to observe their processes of navigating these ethical issues from their distinct place in lung cancer screening research, clinical practice, or policy. The methodology, qualitative description ( Sandelowski, 2000 ), was selected to stay close to the spoken words and ideas or meaning ascribed to them by key informants as elicited in interviews. The interpretation of results was subject to a low level of inference to provide a comprehensive description of subjective facts of the phenomenon, lung cancer screening ethics, in everyday terms. Epistemologically, this study was carried out from a pragmatic position, permitting a slight degree of interpretive inference within the descriptive aim required by the methodology. Key informants were conceptualized as scientists, clinicians, or policymakers who influence lung cancer screening in Canada. Key informants were expected to possess sufficient knowledge about the design, benefits, harms, and objectives of lung cancer screening, and the willingness and capacity to communicate with Pahwa about their perspectives on ethical aspects. Impartiality was relatively more challenging for Pahwa to estimate at the outset of the research, although biases were sometimes deduced as key informant interviews were conducted. This study was justified as a KI study because insights on the ethical aspects of lung cancer screening in Canada were not possible to attain from the literature or interviews with other types of research participants.

Example 2 : Cavanagh conducted unstructured interviews with key informants for an extrinsically bounded interpretive description study exploring stakeholder priorities and perspectives about medical training related to intimate partner violence (IPV) ( Cavanagh, 2022 ). The primary goal of this study was to draw on expertise of stakeholders outside of medicine to generate training recommendations to enhance physicians’ clinical practice related to IPV in the future. Interpretive description, a methodology developed by nursing scholars, was chosen in view of its alignment with the study goal of developing insights with practical applications to medical education ( Thorne et al., 1997 ). Data analysis proceeded concurrently with data collection, incorporating constant comparison, member-checking, and other methodologically specific strategies for assessing credibility and validity of new findings. Epistemologically, interpretive description is rooted in constructivist and interpretivist paradigms, producing findings that claim to represent and interpret phenomena of clinical interest. Key informants were conceptualized as stakeholders doing professional and/or advocacy work related to IPV in fields outside of medicine that meant they would have uniquely informed perspectives on improving medical care for people affected by IPV. Participants were initially identified using quota, theoretical, and snowball sampling strategies; in the course of interviews, participants were asked directly to comment on aspects of their positionality that shaped their perspectives, and were also asked to suggest prospective participants whose informed perspectives were likely different from their own. The use of key informants in this study was justified as the goal of this study was to generate recommendations drawing on the unique access and insights of experts seldom included in medical education research.

Key informants are an oft used and powerful tool in applied qualitative health research. In this article, we have offered parameters that qualitative researchers may use to thoughtfully and deliberately incorporate key informants into individual research projects. This includes consideration of how key informants could be conceptualized, a critical perspective on what knowledge key informants represent, and methodological questions to guide decisions about how key informants could be sampled, identified, and recruited and how data sufficiency could be formulated. The worked examples from health policy and medical education research, two areas within applied qualitative health research, bring to vision the congruence between why key informants were engaged, how they were conceptualized, and what methods were used to collect data. This article addresses a methodological gap in the qualitative health research literature about key informants, providing flexible suggestions that can be adapted to many qualitative methodologies to increase comfort with designing a rigorous key informant strategy. Beyond these implications for designing research, we also highlight the need for additional critical research that elaborates on the specific epistemic and ethical complexities inherent to the use of key informants in qualitative health research.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by the Canada Research Chairs Program (Ethical Complexity in Primary Care).

Manisha Pahwa https://orcid.org/0000-0002-9131-8721

Meredith Vanstone https://orcid.org/0000-0002-7347-6259

Open access
Published: 20 August 2024

Exploring healthcare workers’ perceptions of child health research at Kamuzu Central Hospital, Malawi: an interpretative phenomenological analysis

Myness Kasanda Ndambo 1 , 2 ,
Tuntufye Brighton Ndambo 3 &
Lucinda Manda-Taylor 1 , 2

Human Resources for Health volume 22 , Article number: 57 ( 2024 ) Cite this article

Metrics details

Children’s health is a global public health priority and a determinant of development and sustainability. Its effective delivery and further improvements require constant and dedicated research on children, especially by child healthcare workers (HCWs). Studies have shown a high involvement of child HCWs from developed countries in child health research, with an under-representation from the global south in authorship and leadership in international collaborations. To our knowledge, there is very little literature on challenges faced by child HCWs in Malawi in conducting child health research. We sought to explore the lived experiences of child HCWs at Kamuzu Central Hospital (KCH) in Malawi by examining their perceptions of child health research and assessing the availability of child health research opportunities.

From July 2023 to August 2023, we conducted five key informant interviews with purposively sampled policymakers and 20 in-depth interviews with child HCWs at KCH. The interviews were conducted in English, audio-recorded, and transcribed verbatim. We utilised interpretative phenomenological analysis by reviewing initial transcripts for familiarity, generating codes manually, and refining them into broader themes through comparisons and iterative processes.

The analysis revealed three main themes on perceptions of child HCWs at KCH in child health research. These are (i) perceived motivation and challenges for engaging in child health research, (ii) perceptions of resource availability and research opportunities at KCH, and (iii) perceptions of gaps in research training and participation among child HCWs.

Conclusions

Our study has uncovered critical factors influencing the low participation of child HCWs in child health research at KCH. Lack of collaboration, limited financial opportunities, and non-research-based training were the key barriers to participation in child health research among child HCWs at KCH. We advocate for the inclusion of child HCWs at all stages of collaborative health research, transparency on funding opportunities for child health research, and inclusion of research in the training of HCWs. These initiatives can strengthen the participation of child HCWs in child health research and ultimately enhance child health outcomes in Malawi.

Peer Review reports

Children’s health is a global public health priority and a determinant of development and sustainability [ 1 , 2 , 3 ]. Studies show a significant improvement in children’s health as evidenced by a sustained reduction in global child mortality from 12.7 to 5.7 million between 1990 and 2015. Child health research has significantly reduced mortality and morbidity [ 1 , 4 , 5 , 6 , 7 ]. Despite the reduction, estimated 16,000 children worldwide continue to die daily due to preventable causes [ 8 ]. Most of these deaths are clustered in developing countries [ 9 , 10 , 11 ] and comprise preventable infectious diseases [ 12 , 13 ]. Despite the higher burden of child mortality in developing countries, research in child health is dominated by researchers from developed countries [ 2 , 12 , 14 , 15 , 16 ].

Participation in child health research is one of the glaring inequalities between the developed and the developing world [ 17 , 18 ]. Previous studies have reported an under-representation in research by health professionals from the developing world in authorship and leadership in international collaborative research [ 18 ]. For instance, a global literature search on HIV/AIDs reported high dominance by North America and Western and Central Europe in scientific productions [ 18 ]. The study also showed low levels of leadership by Africans in international collaborative HIV/AIDS research [ 18 ]. It is argued that the absence of infrastructure and inadequate funding exacerbates the low participation in research leadership and authorship in the global south [ 19 , 20 , 21 ].

Africans do not take the leading roles in studies and authorship because of inadequate methodological skills in research design, analytical skills, and language problems (English), which hinder them in writing publications [ 18 ]. A study in Malawi on research experience among health professionals reported that all participants (100%) indicated a willingness to be trained in research, 3 (5.3%) had ever written a journal article, 23 (40.4%) had ever participated in research projects, and 18 (31.6%) had been trained in research methods [ 22 ].

Research has further shown that limitations of child health research in different areas result in gaps that cause physicians to extrapolate from adult studies, implement interventions that may not have been adequately evaluated, and even give out medications that may be potentially harmful to children or culturally and socially unacceptable [ 12 ].

Like other developing countries, Malawi needs medical treatments that reflect biological and non-biological variations [ 12 , 23 ] to make evidence-based decisions on the most efficient and cost-effective interventions [ 24 ]. In support, the Government of Malawi emphasises the need to conduct health research on child health [ 25 ]. The Malawi National Health Policy II points to insufficient capacity in research, among others, as a serious challenge that affects service delivery [ 26 , 27 ]. However, to our knowledge, there needs to be more literature on the perspectives of child healthcare workers (HCWs) at Kamuzu Central Hospital (KCH) in Malawi in conducting child health research. Therefore, this study sought to explore child HCWs’ experiences conducting child health research at KCH, assessing their perspectives and the availability of research opportunities at both delivery and policy levels.

Study design and setting

We applied interpretative phenomenological analysis (IPA), a qualitative research approach that investigates how individuals make sense of their lived experiences [ 28 , 29 , 30 , 31 , 32 , 33 ], to examine how child HCWs perceive their research experiences. IPA is suitable when more knowledge of the explored phenomenon is needed.

Key Informant Interviews (KIIs) and Individual In-Depth Interviews (IDIs) generated detailed descriptions of child HCWs' experiences in conducting child health research at KCH, a tertiary hospital with a well-established paediatric section in Lilongwe, Malawi (Fig. 1 ). KCH is a primary site for child health studies, making it suitable for exploring child HCWs' research experiences. Policymakers are also at Lilongwe's Ministry of Health (MoH) Headquarters.

Map showing the study area

Recruitment

We purposively [ 34 ] sampled 20 HCWs involved in child healthcare delivery and five policymakers responsible for the paediatric section at KCH. Previous research has shown that at least six IDIs are enough to reach saturation [ 35 ]. Being an IPA approach, 25 participants were more than enough to get detailed research perceptions without targeting saturation [ 29 ]. Policymakers included health directors, managers, and a coordinator in the child health space. HCWs included doctors, clinicians, nurses, pharmacists, lab technicians, and biomedical engineers. The principal investigator (MKN) and the unit leader at the KCH paediatric unit compiled a list of prospective participants. MKN contacted them to explain the study before sending consent forms and planning for interviews. All contacted participants agreed to participate.

Data collection

MKN collected data using the same interview guide for both categories from July 2023 to August 2023. The interview guide was developed in English (Supplementary Information 1) and pre-tested by MKN at Area 25 Health Centre in Lilongwe to five purposively sampled HCWs involved in child healthcare delivery. The pre-test results assisted in refining the questions for clarity. The interview guide included questions on perceptions of child health research in Malawi, the importance of child health research, child HCWs’ current capacity in research, and the availability of research opportunities among child HCWs.

The IDIs provided a detailed exploration of everyone’s perspective [ 36 ], and KIIs created room for triangulation of results. Participants were explained the study, and MKN obtained signed informed consent. All participants were identified using numbers. MKN conducted interviews in English and audio-taped to make sure that everything was captured. All participants were professional HCWs who had gone up to tertiary education level and were conversant with English. Participants were interviewed in their offices for confidentiality and to create a safe environment to explain their perceptions freely. The interviews lasted 30–45 min, and we provided lunch allowances to all the participants. MKN took notes and summarised key points after every interview for validation [ 30 ].

Data analysis

The recordings were transcribed verbatim in English by MKN. TBN listened to all recordings and cross-checked the verbatim transcription. Using IPA, we analysed data flexibly in five steps described by Smith et al. [ 29 ]. Firstly, MKN was immersed in the data set by repeatedly reading the transcripts while stepping into the participants’ shoes as deeply as possible to note the initial thoughts, observations, and responses concerning the research objectives [ 37 ]. Secondly, MKN developed a codebook examining codes related to general perceptions of child health research.

Thirdly, LMT and TBN checked the codebook for validation by independently reading the first two transcripts line by line and identifying emerging codes to ensure coding reliability and consistency. The researchers regrouped for a final codebook through a consensus process by looking at commonalities and differences [ 38 ]. The final codebook was agreed upon by the joint consensus of all authors [ 38 , 39 ]. Fourthly, MKN coded all transcripts manually using the validated codebook by grouping similar excerpts in a Word document for easy immersion/familiarisation with the data through repeatedly and active reading [ 40 ]. Fifthly, all authors regrouped again and identified relationships between codes. The frequently identified codes were merged, and themes were generated from these codes. Throughout these steps, we focused on participants’ interpretations of their experiences in research. This manuscript comprises summaries, interpretations, and quotes from participants’ excerpts.

Ethical considerations

The College of Medicine Research Ethics Committee (COMREC) [P.06/23-0089] approved this study. Before data collection, we obtained written informed consent from all participants. We maintained confidentiality and anonymity by allocating numbers and transcripts to the participants. Each participant was informed about voluntary participation and the option to withdraw at any stage without repercussions. This study was conducted per the Declaration of Helsinki guidelines and regulations [ 41 ].

Reflexivity

We were mindful of our prior experiences and preconceptions shaped by our backgrounds in health research [ 31 , 32 , 33 , 37 , 42 ]. As researchers immersed in data collection, transcription, and analysis, we acknowledged that our understanding could influence interpretations. Through ongoing reflexive practices, such as team discussions and journaling, we recognised the subjectivity of our perspectives [ 31 , 32 , 33 , 37 , 42 ].

MKN played a pivotal role throughout the study, engaging in data collection, transcription, and leading the analysis, which enabled nuanced interpretations of HCWs' participation in child health research [ 43 ]. Our collective experience in qualitative research shaped our analytical stance and guided the emphasis on certain themes. By acknowledging our positionality and the iterative nature of our interpretations, we aimed to enhance the transparency and rigour of our study [ 43 ]. Reflexivity enriched our understanding and guided the interpretation and presentation of findings.

There were more female participants in the HCW category (60%) but one female participant in the policymaker category (20%) (Table 1 ). Most participants in the HCW category were aged between 25 and 34 years (65%), with most policymakers being above 45 years old (60%). All the nurses were females. Two doctors in the HCW group have a publication each, a pharmacist has two publications, and the publications for all the policymakers who participated in the KIIs add up to 104.

Participants in this study reported low involvement in research. Three key themes emerged from the transcripts. These are (i) perceived motivation and challenges for engaging in child health research, (ii) perceptions of resource availability and research opportunities at KCH, and (iii) perceptions of gaps in research training and participation among child HCWs. The themes are discussed below.

Perceived motivation and challenges for engaging in child health research

Participants reported some intrinsic professional motivation and multifaceted challenges for engaging in child health research. A willingness to better understand child health issues was reported as a strong motivator among child HCWs at KCH to engage in child health research.

“We know that part of our job is to look at the progress of the diseases and how the evolution has been for many years… looking at the fact that medicine is dynamic…all the changes that are happening in terms of vaccines, medicines, and all the changes, make everybody who works in the pediatric department to have that feeling and need to do more research. So yes, the willingness is there.” ID1 18, Doctor “Research that can tell us about the changing epidemiology of the disease would be paramount, and that should be very well documented and disseminated through the layers for implementation purposes to influence decision making that is still not happening... emerging conditions like Non Communcable Dseases (NCDs) in children...” KII 04, Policymaker

Child HCWs and policymakers expressed that financial incentives influence their motivation for engaging in research. Participants associate research with significant economic gains despite the struggles researchers have to go through to secure grants.

“…research comes with a lot of resources, so some can be used to improve the lives of the people conducting research.” IDI 10, Clinical Administrator “There is freedom of money in research if you find a grant. I know you have to struggle to find a grant, but after the struggle, there’s something you can benefit from. Healthcare workers do not know that research has some monetary benefits.” KII 04, Policymaker

However, other participants showed reluctance to engage in research due to various barriers within their environment, as explained below.

“…People are not oriented on how they can conduct research in children… in our lab, we generate data, so we expect that people will come to ask what they have noted, but only a few have come to ask us for data... So, it just shows that people are not interested in the data.” IDI 05, Lab Technician “Most of us get discouraged because we do not see the results of most studies happening here.” 1D1 19, Pediatric nurse

Policymakers emphasised the need for increased research initiatives to empower child HCWs to research in their respective hospital settings.

“The effort of research itself is low… We need to move in a direction where you can wake up and start writing a research question independently. It is something that needs to be pushed.” KII 04, Policymaker

Participants highlighted the limited involvement of nursing professionals in research, attributing it to insufficient capacity. Nurses reported that, unlike medical professionals, they are mostly overlooked in child health research.

“Most of us, especially nurses, are quiet. We are not active, unwilling, and do not participate more compared to the other side of medical, like the clinicians and the other team. Most of us are not experienced in research. So, with a lack of knowledge and expertise in research, we are not active compared to the other team.” IDI 01, Palliative nurse “No, in nursing, no. In pediatric? I have never heard of it, but the medical ones, like the doctors, are the ones who do that. For us, it is just continued professional development (CPD). Maybe because I am a junior, I don’t know much, but I have worked here for four years.” 1DI 20, Pediatric nurse

Some participants attributed their limited involvement in research to their busy clinical schedules, as outlined below.

“We don’t have time... doing normal clinical work is a lot of burden, and then there is the administration, clinical work, and teaching. … You need to formulate a time frame for research. People are torn between sitting behind their laptops and working on research or seeing patients. So the patient always takes precedence.” IDI 10, Clinical Administrator ” Research needs time, and for health professionals in Government hospitals, there is so much pressure for work, so we prioritise seeing clients over doing research. … We are so much interested in doing research, especially in medical equipment for neonates, children, and all that, but what limits us is the time factor.” IDI 16, Biomedical Engineer

In addition to time constraints, female nurses link their limited participation in research to gender roles, which hinder their ability to pursue research opportunities outside of their working hours.

“Women are too busy than men in our culture. Males find a lot of information on the Internet on how to conduct research. For females, we come to work and are busy with our daily routine; we go back home, are tired with the kids, and go to bed ...” IDI 19, Pediatric nurse.

These findings underscore the importance of addressing these barriers and enhancing support for child HCWs and policymakers to foster a conducive environment for research in child health.

Perceptions of resource availability and research opportunities at KCH

In this study, we were keen to understand the available research opportunities for child HCWs at KCH. Participants reported that research is not a priority in the annual budget at KCH, with only a small portion allocated for research activities. Child HCWs indicated that these funds often get diverted into clinical expenditures, leaving little-to-no resources available for research endeavours.

“Government policy demands every institution to allocate 1-2% of the annual funding to research, but in most cases, this money is not available for research …maybe the priority is on the clinical part of treating the patients. So, if I am interested in doing a study, I have to find funding to conduct it even though it will benefit the hospital.” IDI 05, Pharmacist.

Participants, therefore, emphasised the need for institutional support, including allocating a budget line specifically for research to minimise the diversion of funds from research to service delivery and encourage child HCWs to engage in research activities.

“They should allocate a certain amount for research because if they can, it will have its budget line within the hospital that the hospital cannot tap from for other expenses... That would make people interested in research because they would know there are already some funds I can utilise elsewhere.” IDI 05, Pharmacist

Child HCWs expressed concerns about limited funding opportunities for research, advocating for funders to be more open to supporting new researchers. They suggested that funders should allow new researchers to participate in grant writing competitions and allocate grants to encourage early career researchers.

“Funders should be more open to new people writing grants. The case of looking for proven records and experience. Where do you get the experience if you are starting? Give new people some small grants and see how they handle that...” IDI 10, Clinical Administrator

These sentiments were echoed by policymakers who admitted that, as a country, very little money is allocated for research.

“As a country, we are not investing in research in terms of money. People can have ideas, but we do not expect them to take the little money from their pockets. ” KII 04, Policymaker

Child HCWs highlighted the challenge of securing external funding for research projects due to the need for more institutional support and resources. The theme exposes the systemic challenges child HCWs face at KCH in pursuing research opportunities, including inadequate funding and competing priorities within the healthcare system.

Perceptions of gaps in research training and participation among child HCWs

Participants expressed a clear need for more emphasis on research training to address capability gaps among HCWs.

“…if we were exposed to training … I think I can be confident enough to research on my own and develop some manuscripts for publication.” 1D1 19, Pediatric Nurse “When someone is doing a study, we ask for our involvement to get mentored. But how involved are we? They have already developed a concept, done everything, and now they are on data collection; that is when we are involved. So, I would say our involvement should start from conceptualisation.” IDI 03, Nurse Administrator

Participants expressed inadequate training and capacity-building opportunities among HCWs, hindering their ability to engage in research activities effectively.

“I would say the opportunities are limited; if we had such opportunities, we have the team of people that are always willing to work in research, to do more research, but such opportunities are minimal…we need some sort of training here and there...” IDI 05, Pharmacist “I wouldn’t say there is any training in the department or at a hospital level to enhance someone’s progress with research. We get interested in doing research, but at the hospital level, there are no training and capacity-building activities.” 1DI 18, Doctor

Participants highlighted the need for more exposure to research training due to the absence of research concepts in clinical, medical, and nursing education curricula. They suggested incorporating research concepts into CPD programs as a potential solution to bridge this gap.

We underwent medical training and internship and were introduced to research concepts when we started working. It is a new concept to us, so it becomes a challenge... Again, it should be part of CPD. We do CPD as professionals, but mostly, it’s the same things that we do in the hospitals. I have never seen research being part of it.” ID1 18, Doctor

Policymakers acknowledged the importance of incorporating child HCWs into technical working group meetings to expose them to research gaps in the health system.

“I think it is about including them in our technical working groups; that is when they will be open and be exposed to implementation arrangements. They will also be motivated to say this is the area we can do something on.” KII 01, Policymaker

There was a perceived need to strengthen collaborations with stakeholders in various areas of healthcare to improve child HCWs' participation in research.

“…People should know that who is there in this area. We have people specialising in child health, but where are they? Do we know them? Why? They are somewhere in an organisation where we can’t even access them. But why do we have people specialising in child health? They are the ones who are supposed to be in the forefront...” IDI 03, Nurse Administrator

The results under this theme describe the multifaceted gaps that hinder child HCWs’ engagement in research activities and the importance of addressing these gaps through enhanced researcher involvement, training and capacity-building opportunities, policy support on health education curriculum, and improved collaboration with stakeholders.

This study offers valuable insights into the perceptions of child HCWs at KCH regarding child health research. Despite a general willingness among child HCWs to engage in research, participation still needs to improve due to various challenges.

A significant challenge identified was the need for more research capacity among child HCWs at KCH. Our study identified that child HCWs at KCH have a low drive to engage in child health research due to a lack of research training during their studies. This is in contrast to Tanzania, where a similar study found that over half of the participants had received research training at a university or medical college [ 44 ], which may result in regional differences in research capacity among child HCWs in sub-Saharan Africa. These disparities could impact research outcomes and the effectiveness of child health interventions in different countries. We recommend urgent reforms in the clinical education curriculum in Malawi to incorporate research training and bridge this gap.

Our findings highlight a significant involvement gap in research collaboration practices at KCH, where child HCWs are mainly involved in data collection rather than other processes, such as developing protocols, data analysis, and manuscript writing. The challenge is further exacerbated by the absence of a dedicated child health department within the Ministry of Health to foster collaboration and ownership of child health initiatives. In addition to advocating for establishing a standalone child health department to improve stakeholder collaboration and child health outcomes [ 45 , 46 ], we also advocate for a comprehensive engagement approach for child HCWs in research from conceptualisation to report writing. Collaboration between academic and research institutions can provide cost-effective training and expertise sharing, as recommended by the previous studies [ 44 , 47 , 48 , 49 ].

Gender constraints were also identified as a significant challenge for participation in research among female child HCWs at KCH. While male child HCWs have taken the initiative to self-train in research during their spare time using the internet, female child HCWs lack such opportunities due to household gender roles which fill their non-professional work time. Similar findings from other African countries have been reported [ 44 , 50 ]. Policymakers are urged to implement strategies to empower female child HCWs, including early involvement in research processes and creating supportive environments conducive to research engagement. Additionally, KCH child HCWs face significant time constraints due to heavy workloads, similar to findings from both African and developed countries [ 50 , 51 , 52 , 53 , 54 , 55 ]. To address this, we recommend allocating protected research time within the hospital, supported by increased human resources and integration of research into duty rosters.

Financial constraints were another significant challenge to research participation at KCH as the annual budget needs to prioritise research. This highlights the need for a dedicated budget line for research to ensure adequate funding. Lack of financial resources limits the ability to conduct research and affects the quality and scope of studies. With sufficient funding, procuring materials, compensating participants, and covering other essential expenses is easier. Prior research has also identified insufficient finances as a barrier to African research [ 44 , 47 ], indicating a broader systemic issue. Addressing this financial gap is crucial to fostering a research culture, building capacity among child HCWs, and improving healthcare outcomes through evidence-based practices. Enhanced funding mechanisms from governmental and non-governmental sources are needed to overcome these obstacles and promote a research-oriented healthcare environment.

Limitations

This is the first study to explore HCW experiences in child health research at KCH in Malawi. Our child HCW sample had more females, while the Policymaker sample included only one female, potentially introducing gender bias. Interpretative Phenomenological Analysis (IPA) allowed for detailed and nuanced perceptions of child health research at KCH. However, a qualitative study cannot establish causality, and the sample from a single hospital in central Malawi may limit generalizability. Despite this, the identified barriers and recommendations likely apply to all government hospitals in Malawi, as they share common health education institutions and policies. Further research involving multiple sites and more balanced gender representation is needed to validate and extend these findings.

Our study has identified crucial factors contributing to the low participation of child HCWs in child health research at KCH. We found notable gaps in research participation among child HCWs at KCH, including a lack of collaboration, limited financial opportunities, and non-research-based training. Some child HCWs expressed a strong research interest, but challenges at both individual and institutional levels hinder engagement. We advocate for targeted capacity-building interventions to address these challenges and promote a culture of research excellence. Prioritising these initiatives can foster a conducive environment for child health research and enhance outcomes in Malawi.

Availability of data and materials

The dataset generated and analysed during the current study is not publicly available. Even without identifiers such as names, the dataset could hold identifiable participant information in aggregate form due to some narratives in the transcripts with participants sampled in a single district. The pediatric department at KCH is a small section. With potential identifiers in the transcript narratives, we believe it would be ethically inappropriate to publicly share the data that could reveal our participants’ identities if read by someone within the district or KCH. The dataset or part of it could be available from the corresponding author at a reasonable request with permission from KCH. No datasets were generated or analysed during the current study.

Abbreviations

Healthcare Workers

Ministry of Health

Kamuzu Central Hospital

Human Immunodeficiency Virus

Acquired Immunodeficiency Syndrome

College of Medicine Research Ethics Committee

Key Informant Interview

Individual In-depth Interviews

Hanifiha M, Ghanbari A, Keykhaei M, Saeedi Moghaddam S, Rezaei N, Pasha Zanous M, et al. Global, regional, and national burden and quality of care index in children and adolescents: a systematic analysis for the global burden of disease study 1990–2017. PLoS ONE. 2022. https://doi.org/10.1371/journal.pone.0267596 .

Article PubMed PubMed Central Google Scholar

Khan MI, Memon ZA, Bhutta ZA. Challenges and opportunities in conducting research in developing countries. Pediatr Epidemiol. 2017. https://doi.org/10.1159/000481323 .

Article Google Scholar

Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet. 2015;385:430–40. https://doi.org/10.1016/S0140-6736(14)61698-6 .

Article PubMed Google Scholar

Requejo JH, Bhutta ZA. The post-2015 agenda: staying the course in maternal and child survival. Arch Dis Child. 2015;100(suppl 1):S76–81. https://doi.org/10.1136/archdischild-2013-305737 .

The World Health Organisation. Child health research. A foundation for improving child health. https://apps.who.int/iris/bitstream/handle/10665/68359/WHO_FCH_CAH_02.3.pdf;jsessionid=8860E98FB42246C4A3869DD54B713910?sequence=1

Lang T, Siribaddana S. Clinical trials have gone global: is this a good thing? PLoS Med. 2012. https://doi.org/10.1371/journal.pmed.1001228 .

Mbuagbaw L, Thabane L, Ongolo-Zogo P, Lang T. The challenges and opportunities of conducting a clinical trial in a low-resource setting: the case of the Cameroon mobile phone SMS (CAMPS) trial, an investigator-initiated trial. Trials. 2011;12:1. https://doi.org/10.1186/1745-6215-12-145 .

Khodaee GH, Khademi G, Saeidi M. Under-five mortality in the world (1900–2015). Int J Pediatr. 2015;3:1093–5. https://doi.org/10.22038/ijp.2015.6078 .

Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht J. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet. 2003;362:233–41. https://doi.org/10.1016/S0140-6736(03)13917-7 .

Reiner RC Jr, Olsen HE, Ikeda CT, Echko MM, Ballestreros KE, Manguerra H, et al. Diseases, injuries, and risk factors in child and adolescent health, 1990 to 2017: findings from the global burden of diseases, injuries, and risk factors 2017 study. JAMA Pediatr. 2019. https://doi.org/10.1001/jamapediatrics.2019.0337 .

Dabis F, Orne-Gliemann J, Perez F, Leroy V, Newell ML, Coutsoudis A, et al. Working group on women and child health. Improving child health: the role of research. BMJ. 2002;324(7351):1444–7. https://doi.org/10.1136/bmj.324.7351.1444 .

Article CAS PubMed PubMed Central Google Scholar

Alemayehu C, Mitchell G, Nikles J. Barriers for conducting clinical trials in developing countries—a systematic review. Int J Equity Health. 2018;17:37. https://doi.org/10.1186/s12939-018-0748-6 .

Murray CJ, Lopez AD. Global comparative assessments in the health sector: disease burden, expenditures and intervention packages. 1994. https://www.ncbi.nlm.nih.gov/books/NBK209104/ .

Orne-Gliemann J, Perez F, Leroy V, Newell ML, Dabis F. A decade of child health research in developing countries. Sante. 2003;13:69–75.

PubMed Google Scholar

Røttingen JA, Regmi S, Eide M, Young AJ, Viergever RF, Ardal C, et al. Mapping of available health research and development data: what’s there, what’s missing, and what role is there for a global observatory? Lancet. 2013;382(9900):1286–307. https://doi.org/10.1016/S0140-6736(13)61046-6 .

Moon S, Bermudez J, Hoen E. Innovation and access to medicines for neglected populations: could a treaty address a broken pharmaceutical R&D system? PLoS Med. 2012;9: e1001218. https://doi.org/10.1371/journal.pmed.1001218 .

Chu KM, Jayaraman S, Kyamanywa P, Ntakiyiruta G. Building research capacity in Africa: equity and global health collaborations. PLoS Med. 2014;11(3): e1001612. https://doi.org/10.1371/journal.pmed.1001612 .

González-Alcaide G, Menchi-Elanzi M, Nacarapa E, Ramos-Rincón JM. HIV/AIDS research in Africa and the Middle East: participation and equity in North-South collaborations and relationships. Glob Health. 2020;16:83. https://doi.org/10.1186/s12992-020-00609-9 .

Zakumumpa H, Bennett S, Ssengooba F. Leveraging the lessons learned from financing HIV programs to advance the universal health coverage (UHC) agenda in the East African community. Glob Health Res Policy. 2019;4:27. https://doi.org/10.1186/s41256-019-0118-y .

Langer A, Díaz-Olavarrieta C, Berdichevsky K, Villar J. Why is research from developing countries underrepresented in international health literature, and what can be done about it? Bull World Health Organ. 2004;82:802–3.

PubMed PubMed Central Google Scholar

Smith E, Hunt M, Master Z. Authorship ethics in global health research partnerships between researchers from low or middle-income countries and high-income countries. BMC Med Ethics. 2014;15:42. https://doi.org/10.1186/1472-6939-15-42 .

Muula AS, Misiri H, Chimalizeni Y, Mpando D, Phiri C, Nyaka A. Access to continued professional education among health workers in Blantyre, Malawi. Afr Health Sci. 2004;4(3):182–4.

WHO Expert Committee. Guidelines for Good Clinical Practice (GCP) for trials on pharmaceutical products and the use of essential drugs. Sixth report of the WHO expert committee. Geneva: WHO Technical Report Series; 1995. https://www.femh-irb.org/content_pages/files_add/doc_arb/I01_9712011000.pdf .

McMichael C, Waters E, Volmink J. Evidence-based public health: what does it offer developing countries? J Public Health. 2005;27:215–21. https://doi.org/10.1093/PubMed/fdi024 .

Ministry of Health. (2012). National Health Research Agenda 2012–2016. file:///C:/Users/HP/Downloads/Malawi%20National-Health-Research-Agenda.pdf.

Masefield SC, Msosa A, Grugel J. Challenges to effective governance in a low-income healthcare system: a qualitative study of stakeholder perceptions in Malawi. BMC Health Serv Res. 2020;20:1142. https://doi.org/10.1186/s12913-020-06002-x .

Government of the Republic of Malawi. Health Sector Strategic Plan II 2017–2022. Towards universal health coverage. Lilongwe: Ministry of Health; 2017. https://www.healthdatacollaborative.org/fileadmin/uploads/hdc/Documents/Country_documents/HSSP_II_Final_HQ_complete_file.pdf.pdf

Sihre HK, Gill P, Lindenmeyer A, McGuiness M, Berrisford G, Jankovic J, et al. Understanding the lived experiences of severe postnatal psychiatric illnesses in English speaking South Asian women, living in the UK: a qualitative study protocol. BMJ Open. 2019. https://doi.org/10.1136/bmjopen-2018-025928 .

Smith JA, Fieldsend M. Interpretative phenomenological analysis. In: Camic PM, editor. Qualitative research in psychology: expanding perspectives in methodology and design (2nd ed.). Washington: American Psychological Association; 2021. p. 147–66. https://doi.org/10.1037/0000252-008 .

Chapter Google Scholar

Pietkiewicz I, Smith JA. A practical guide to using interpretative phenomenological analysis in qualitative research psychology. Psychol J. 2014;20:7–14. https://doi.org/10.14691/CPPJ.20.1.7 .

Heidegger M. Introduction to phenomenological research. Indiana University Press. 2005.

Rodriguez A, Smith J. Phenomenology as a healthcare research method. Evid Based Nurs. 2018;21(4):96–8. https://doi.org/10.1136/eb-2018-102990 .

Crotty M. Phenomenology and nursing research. Melbourne: Churchill Livingstone; 1996.

Google Scholar

Tongco MDC. Purposive sampling as a tool for informant selection. Ethnobot Res Appl. 2007;5:147–58.

Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18:59–82. https://doi.org/10.1177/1525822X05279903 .

Ritchie J, Lewis J. Qualitative research practice: a guide for social science students and researchers—Google Books. 2013

Heidegger M. Being and time (J. Macquarrie, & E. Robinson, Trans.). Oxford, UK & Cambridge, USA: Blackwell Publishers Ltd; 1962 (Original work published 1927).

Burnard P, Gill P, Stewart K, Treasure E, Chadwick B. Analysing and presenting qualitative data. Br Dent J. 2008;204(8):429–32. https://doi.org/10.1038/SJ.bdj.2008.292 .

Article CAS PubMed Google Scholar

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. https://doi.org/10.1093/intqhc/mzm042 .

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa .

World Medical Association. Declaration of Helsinki. Brazil: The World Medical Association, Inc. 2013. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ .

Olmos-Vega FM, Stalmeijer RE, Varpio L, Kahlke R. A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Med Teach. 2022. https://doi.org/10.1080/0142159X.2022.2057287 .

Mills J, Bonner A, Francis K. The development of constructivist grounded theory. Int J Qual Methods. 2006;5:25–35. https://doi.org/10.1177/160940690600500103 .

Kengia JT, Kalolo A, Barash D, Chwa C, Hayirli TC, Kapologwe NA, et al. Research capacity, motivators and barriers to conducting research among healthcare providers in Tanzania’s public health system: a mixed methods study. Hum Resour Health. 2023;21(1):73. https://doi.org/10.1186/s12960-023-00858-w .

Franzen SRP, Chandler C, Lang T. Health research capacity development in low and middle-income countries: reality or rhetoric? A systematic meta-narrative review of the qualitative literature. BMJ Open. 2017;7: e012332. https://doi.org/10.1136/bmjopen-2016-012332 .

Gureje O, Seedat S, Kola L, Appiah-Poku J, Othieno C, Harris B, et al. Partnership for mental health development in sub-Saharan Africa (PaM-D): a collaborative initiative for research and capacity building. Epidemiol Psychiatr Sci. 2019;28:389–96. https://doi.org/10.1017/S2045796018000707 .

Sun C, Dlamini PS, Maimbolwa MC, Changala Lukwesa Mukonka C, Nyamakura R, Omoni G, et al. Success stories: overcoming barriers to research in southern and eastern African countries. Clin Nurs Res. 2017;26:399–418. https://doi.org/10.1177/1054773817718935 .

Thomson DR, Semakula M, Hirschhorn LR, Murray M, Ndahindwa V, Manzi A, et al. Applied statistical training to strengthen analysis and health research capacity in Rwanda. Health Res Policy Syst. 2016;14:73. https://doi.org/10.1186/s12961-016-0144-x .

Bates I, Boyd A, Smith H, Cole DC. A practical and systematic approach to organisational capacity strengthening for research in the health sector in Africa. Health Res Policy Syst. 2014;12:11. https://doi.org/10.1186/1478-4505-12-11 .

Pascal Iloh GU, Amadi AN, Iro OK, Agboola SM, Aguocha GU, Chukwuonye ME. Attitude, practice orientation, benefits and barriers towards health research and publications among medical practitioners in Abia State, Nigeria: a cross-sectional study. Niger J Clin Pract. 2020;23:129–37. https://doi.org/10.4103/njcp.njcp_284_18 .

Corchon S, Portillo MC, Watson R, Saracíbar M. Nursing research capacity building in a Spanish hospital: an intervention study. J Clin Nurs. 2011;20(17–18):2479–89. https://doi.org/10.1111/j.1365-2702.2011.03744.x .

Gulland A. Doctors cite lack of time as greatest barrier to research. Br Med J. 2016. https://doi.org/10.1136/bmj.i1488 .

Habineza H, Nsanzabaganwa C, Nyirimanzi N, Umuhoza C, Cartledge K, Conard C, et al. Perceived attitudes of the importance and barriers to research amongst Rwandan interns and pediatric residents—a cross-sectional study. BMC Med Educ. 2019;19:4. https://doi.org/10.1186/s12909-018-1425-6 .

Golenko X, Pager S, Holden L. A thematic analysis of the role of the organisation in building allied health research capacity: a senior managers’ perspective. BMC Health Serv Res. 2012;12:276. https://doi.org/10.1186/1472-6963-12-276 .

Pager S, Holden L, Golenko X. Motivators, enablers, and barriers to building allied health research capacity. J Multidiscip Healthc. 2012;5:53–9. https://doi.org/10.2147/JMDH.S27638 .

Download references

Acknowledgements

The authors are grateful to the Management and Staff at Kamuzu Central Hospital (KCH), the Management and Staff of the KCH pediatric section, and all HCWs who participated in the study. The authors acknowledge the International Child Health Group for the financial support. The authors recognise the Ministry of Health and all Policymakers who participated in the study. Last but not least, the authors appreciate the staff members at the Training and Research Unit of Excellence for their administrative support throughout the study.

This study was supported by the International Child Health Group (ICHG), UK (ICHG Project No. ICHG835/537044). The funding body had no role in the study’s design, data collection, analysis, interpretation of data, or manuscript write-up.

Author information

Authors and affiliations.

School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi

Myness Kasanda Ndambo & Lucinda Manda-Taylor

Training and Research Unit of Excellence (TRUE), Kufa Road, Mandala, P. O. Box 30538, Blantyre, 3, Malawi

Department of Civic Education, Ministry of Local Government, Unity and Culture, Lilongwe, Malawi

Tuntufye Brighton Ndambo

You can also search for this author in PubMed Google Scholar

Contributions

MKN, TBN, and LMT conceptualised and designed the study. MKN collected and analysed data with TBN. MKN drafted the manuscript. TBN and LMT reviewed the manuscript, provided input, and suggested additions and changes. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Myness Kasanda Ndambo .

Ethics declarations

Ethics approval and consent to participate.

The College of Medicine Research Ethics Committee (COMREC) approved the study [Protocol No. P.06/23-0089]. Before data collection, we obtained written informed consent from all participants. We maintained confidentiality and anonymity by allocating numbers to the participant transcripts. The information letter informed participants of their choice to participate and the option to withdraw at any stage of the research process. This study was conducted per the Declaration of Helsinki guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1. interview guide for policymakers and child healthcare workers., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ .

Reprints and permissions

About this article

Cite this article.

Ndambo, M.K., Ndambo, T.B. & Manda-Taylor, L. Exploring healthcare workers’ perceptions of child health research at Kamuzu Central Hospital, Malawi: an interpretative phenomenological analysis. Hum Resour Health 22 , 57 (2024). https://doi.org/10.1186/s12960-024-00938-5

Download citation

Received : 08 April 2024

Accepted : 22 July 2024

Published : 20 August 2024

DOI : https://doi.org/10.1186/s12960-024-00938-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Child health
Child health research
Interpretative phenomenological analysis
Healthcare workers

Human Resources for Health

ISSN: 1478-4491

Submission enquiries: Access here and click Contact Us
General enquiries: [email protected]

Extract insights from Customer & Employee Interviews. At Scale.

Narrative analysis interview transcript techniques for qualitative research.

Home » Narrative analysis interview transcript techniques for qualitative research

Understanding the Storytelling Analysis Method opens doors to rich insights in qualitative research. This method emphasizes the significance of narratives, providing researchers with techniques to analyze interview transcripts effectively. By focusing on the stories participants share, researchers can uncover deeper meanings and themes within the data collected.

Through the storytelling analysis, researchers gain a comprehensive understanding of individual experiences. This method allows for a nuanced examination of interview transcripts, revealing the underlying emotions and motivations of participants. Ultimately, the Storytelling Analysis Method enriches qualitative research, making it vital for those seeking to grasp the complexities of human narratives.

The Fundamentals of Narrative Analysis

Narrative analysis serves as a vital framework in qualitative research, offering insights into how individuals construct meaning through their stories. The storytelling analysis method focuses on the narrative structures people use, revealing their values and beliefs. This approach recognizes that narratives are not just a sequence of events; they embody the person’s experiences, emotions, and cultural backgrounds, making them rich sources of qualitative data.

Understanding the fundamentals involves several key elements. First, the context of the story significantly shapes its meaning. Researchers must consider where, when, and why the story is told. Second, participants’ perspectives provide essential insights into their lived experiences. By analyzing everything from word choice to the story's tone, researchers can uncover underlying themes and patterns. Lastly, the process of storytelling itself, including how stories are framed, may influence participants' emotional and cognitive responses. Engaging deeply with narrative analysis enhances the quality and depth of qualitative research.

The Storytelling Analysis Method: Key Principles

The Storytelling Analysis Method revolves around understanding narratives that people share during interviews. By focusing on these narratives, researchers can uncover deeper insights and emotions that lie beneath surface-level responses. This approach considers storytelling as a fundamental human experience, emphasizing the importance of context, characters, and events within each tale.

Key principles of the Storytelling Analysis Method include identifying core themes, assessing emotional undertones, and examining narrative structures. Firstly, identifying core themes allows researchers to condense complex stories into central ideas that reflect participants' experiences. Next, assessing emotional undertones enables a deeper understanding of feelings that accompany those stories, revealing participant motivations and impacts. Finally, examining narrative structures provides insight into how participants organize their experiences, which can highlight significant turning points or resolutions in their narratives. By applying these principles, researchers can enhance their qualitative analysis, leading to richer conclusions and recommendations.

Advantages of Using Narrative Analysis in Qualitative Research

Utilizing the Storytelling Analysis Method in qualitative research offers several key advantages that enrich the research process. First, it provides a rich context for understanding participants' experiences and perspectives. By focusing on narratives, researchers can capture the nuances of human behavior and emotions, allowing for a deeper comprehension of complex social phenomena. This method emphasizes the interconnectedness of individual stories, which can reveal broader societal patterns and themes.

Second, narrative analysis encourages active engagement between the researcher and participants. This approach fosters a collaborative environment, where storytelling serves as a tool for dialogue and reflection. Engaging with participants in this way can lead to unexpected insights, enhancing the overall quality of the research. Consequently, by prioritizing narrative, researchers not only gather information but also build trust and rapport with those they study. Thus, the Storytelling Analysis Method proves invaluable in producing rich, meaningful qualitative data.

Techniques for Conducting Narrative Analysis

Conducting narrative analysis requires a structured approach to ensure that the richness of stories is preserved while uncovering deeper insights. One effective method is the Storytelling Analysis Method, which emphasizes understanding the context and the emotions behind participants' narratives.

To begin, identify key themes that emerge from interview transcripts. This helps in categorizing the stories according to prevalent topics. Following this, analyze the structure of each narrative. Look at how participants sequence their stories and the significance they attach to different events. Lastly, consider the language used, as it often reveals underlying emotions and cultural nuances. By focusing on these elements, researchers can derive meaningful interpretations from narratives and effectively highlight the broader implications of participants' experiences.

Preparing and Managing Interview Transcripts

Preparing and managing interview transcripts is essential for effective narrative analysis. The first step is organizing the transcripts systematically. This allows researchers to access the information quickly. One useful technique in storytelling analysis is to categorize transcripts based on themes or participant demographics. Creating a structured format helps in identifying trends and patterns in the narrative.

Next, consider the importance of accurate transcription. High-quality transcripts facilitate a clearer understanding of the content. Utilize audio recording tools and transcription software to capture every detail precisely. After transcription, editing is crucial to eliminate errors and enhance readability. Research teams should maintain a clear version control system to track amendments and ensure consistency in data interpretation. Such meticulous preparation not only streamlines analysis but also enriches the overall research process by providing a reliable foundation for storytelling analysis.

Coding Transcripts Using the Storytelling Analysis Method

The Storytelling Analysis Method emphasizes the importance of narrative coherence in qualitative research. To effectively code transcripts using this approach, researchers begin by identifying key themes that emerge from participants' stories. Each transcript should be meticulously reviewed, allowing for the extraction of unique insights and contextual elements that represent respondents' experiences.

One recommended process involves three essential steps. First, familiarize yourself with the stories shared during the interviews, noting patterns and recurring motifs. Next, categorize these themes into broader narrative arcs that reflect the essence of participants’ journeys. Lastly, it’s crucial to validate the findings by revisiting the original transcripts, ensuring that the identified narratives resonate authentically with the respondents' voices. By employing the Storytelling Analysis Method this way, researchers can reveal deeper meanings and create a more compelling understanding of the qualitative data.

Conclusion: The Power of the Storytelling Analysis Method

The Storytelling Analysis Method highlights the transformative role narratives play in qualitative research. By examining personal stories, researchers unlock insights into the experiences, values, and beliefs of participants. This method allows for a deeper understanding of social dynamics, providing context that mere statistics cannot convey.

Additionally, utilizing storytelling not only enriches the data but also fosters a connection between researchers and subjects. As stories unfold, they reveal patterns and themes that can inform future decisions. The power of the Storytelling Analysis Method lies in its ability to humanize data, making the research process more engaging and impactful.

Turn interviews into actionable insights

On this Page

How to Develop a Research Hypothesis Effectively

You may also like, ai ml use cases for business innovation.

Top Companies Using AI in 2024

Ai computer program solutions for businesses.

Unlock Insights from Interviews 10x faster

Request demo
Get started for free

Open access
Published: 21 August 2024

Facilitators and barriers to evidence adoption for central venous catheters post-insertion maintenance in oncology nurses: a multi-center mixed methods study

Funa Yang 1 ,
Ka Yan Ho 2 ,
Katherine Ka Wai Lam 2 ,
Ting Mao 2 ,
Yan Wen 3 ,
Liqing Li 4 ,
Xiuxiu Yang 5 ,
Na Xiao 6 ,
Yanling Gao 7 ,
Xiaoxia Xu 1 ,
Frances-Kam-Yuet Wong 2 ,
Hongying Shi 8 &
Lanwei Guo 9

BMC Nursing volume 23 , Article number: 581 ( 2024 ) Cite this article

Metrics details

The post-insertion maintenance of central venous catheters(CVCs)is a common, vital procedure undertaken by nurses. Existing literature lacks a comprehensive review of evidence adoption for CVCs post-insertion maintenance specifically within the oncology context. This investigation assessed evidence-based practice by oncology nurses in the care of CVCs, elucidating facilitators and obstacles to this adoption process.

This was a sequential explanatory mixed methods study, executed from May 2022 to April 2023, adhering to the GRAMMS checklist. The study commenced with a cross-sectional study through clinical observation that scrutinized the adoption of scientific evidence for CVC maintenance, analyzing 1314 records from five hospitals in China. Subsequently, a semi-structured, in-depth interview with nurses based on the i-PARIHS framework was conducted to ascertain facilitators and barriers to evidence adoption for CVCs post-insertion maintenance. Fifteen nurses were recruited through purposive sampling. Descriptive statistics were used to summarize quantitative data, while content analysis was used to analyze qualitative data.

An overall compliance rate of 90.0% was observed; however, two domains exhibited a lower adoption rate of less than 80%, namely disinfection of infusion connector and disinfection of skin and catheter. Three barriers and two facilitators were discerned from the interviews. Barriers encompassed (1) difficulty in accessing the evidence, (2) lack of involvement from nurse specialists, and (3) challenges from internal and external environments. Facilitators comprised (1) the positive attitudes of specialist nurses toward evidence application, and (2) the formation of a team specializing in intravenous therapy within hospitals.

There exists a significant opportunity to improve the adoption of evidence-based practices for CVC maintenance. Considering the identified barriers and facilitators, targeted interventions should be conceived and implemented at the organizational level to augment oncology evidence-based practice, especially the clinical evidence pertinent to infection control protocols.

Trial registration

This investigation was sanctioned by the Medical Ethics Committee of Henan Cancer Hospital (Number 2023-KY-0014).

Peer Review reports

Catheter technology has evolved to accommodate the multifaceted medical necessities of disparate patient populations [ 1 ]. Central venous catheters (CVCs) instruments essential for chemotherapy, parenteral nutrition, hemodynamic monitoring, and other interventions, are often inserted into oncology patients [ 2 , 3 ]. This insertion disrupts skin integrity, thereby heightening the susceptibility of patients to infections. Concurrently, the immunosuppression engendered by chemotherapy and radiotherapy [ 4 , 5 ], amplifies the risk for CVC-associated complications, such as bloodstream infection, thrombosis, and catheter malfunction [ 3 ]. The estimated incidence of CVC-related infections in oncology patients ranges from 0.5 to10 per 1000 CVC-days [ 6 , 7 ], with variations in the incidence of CVC-associated thrombi ranging from 27 to 66%, when assessed by routine screening venography [ 3 , 8 ]. Unforeseen catheter removal necessitated by these complications, can induce anxiety, pain, helplessness, and apprehension regarding subsequent catheter injection [ 9 ].

Post-insertion management is pivotal in circumventing catheter-related complications, including infections, thromboses, and mechanical injuries. Numerous institutions and regulatory bodies have promulgated recommendations and guidelines to mitigate these complications [ 10 , 11 , 12 ]. Despite the critical nature of adherence to these protocols in clinical environments, compliance among healthcare professionals is frequently suboptimal, as evidenced by studies indicating merely 60% adherence to guidelines pertaining to CVC post-insertion management [ 13 ]. Remarkably, no extant research has reviewed nursing compliance for post-insertion management of CVCs within the context of Chinese oncology patients.

Evidence-based practice, a cornerstone of clinical care across various countries, including China, demands a progressive and time-consuming adoption process by healthcare professionals. Existing literature underscores a temporal span of 17 years for research findings to be integrated into clinical routines [ 14 ], with only half eventually achieving widespread acceptance [ 15 ]. Evidence-based nursing emphasizes that nurses should not only identify and implement best practices for patients, but also integrate these practices with their clinical experience [ 16 ]. This paradigm emphasizes that nurses should synergize best-evidence practice with clinical experience, ensuring that implementation is a confluence of optimal evidence and consideration of patient’s unique situation, medical requirements, resource accessibility, environmental conditions, collaborative dynamics, and potential hindrances [ 17 , 18 ].

Examined through the lens of implementation science, the adoption of clinical practice guidelines for CVCs encounters various challenges and obstructions. These include the inherent complexity of the evidence, the multifaceted nature of the healthcare environment, financial constraints, personnel receptivity, and organizational policies [ 19 , 20 , 21 ]. Ascertaining facilitators and barriers to evidence adoption for CVCs post-insertion maintenance represents an essential and foundational step in transmuting optimal evidence into tangible clinical practice. In this context, the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) framework serves as a prominent model in implementation science, illustrating pathways for successful guideline promotion and assimilation within clinical settings, by focusing on innovation, recipients of change and context, as well as facilitation impacts [ 22 , 23 ].

The i-PARIHS framework was employed to navigate our qualitative interview, delineating the facilitators and barriers to compliance with the evidence-based practice in post-insertion maintenance for CVCs within oncological contexts. This framework, multi-dimensional in its construct, elucidates the modalities through which successful promotion and implementation of guidelines may transpire in clinical environments [ 24 ]. Within the i-PARIHS framework, four core components are instrumental for translating evidence into practice. These components are encapsulated in the framework’s core conceptual equation: SI = Facn(I + R + C) (SI: Successful Implementation of evidence; Facn: Facilitation; I: Innovation; R: Recipients; C: Context) [ 25 ]. Within this equation, ‘innovation’ encompasses not only the intervention itself, but also the underlying evidence informing it. ‘Recipients’ denote those individuals or collectives affected by or exerting influence over the implementation process, while ‘context’ integrates both the internal and external environmental variables. Additionally, ‘facilitation’ alludes to specific elements that may expedite the translation of evidence-based practice [ 25 , 26 , 27 ]. The successful implementation of evidence into clinical practice is conceptualized as a resultant synthesis of innovation, recipients, context, and facilitation [ 27 ]. In oncology nursing, the i-PARIHS framework can assist cancer nurses in exploring the determinants of evidence-based nursing and integrating the best evidence or innovations into clinical settings, enabling cancer nurses to deliver high-quality supportive cancer care through facilitating factors such as multidisciplinary cooperation and resource integration. For example, Roberts et al [ 28 ] conducted a descriptive mixed method in supportive cancer care and evaluated the utility of the i-PARIHS framework for introducing patient-reported outcome measures into oncology patients. In the qualitative segment of this investigation, we sought to harness the i-PARIHS framework to dissect the nuanced interplay of these components, thereby enriching our comprehension of the implementation dynamics governing post-insertion management for CVCs within oncological settings.

Presently, literature is deficient in studies investigating the adoption of scientific evidence in post-insertion management for CVCs within the Chinese oncology nursing community. Moreover, few have applied the i-PARIHS framework for evaluation purposes [ 25 , 29 , 30 ]. To redress this scholarly deficiency, the present study endeavored to appraise the adoption of scientific evidence in post-insertion management for CVCs by oncology nurses in China. Crucially, we harnessed the i-PARIHS framework to delineate facilitators and barriers to evidence adoption for CVCs post-insertion maintenance, employing qualitative interviews, as an exemplary method to garner profound insights into these influential factors.

This investigation comprised a sequential explanatory mixed-methods study spanning multiple centers, conducted between May 2022 to April 2023. It commenced with a cross-sectional study from May 2022 to January 2023, followed by a qualitative study from February 2023 to April 2023. In the qualitative phase, a deductive method based on the i-PARIHS framework was used to explore barriers and facilitators to evidence adoption for CVCs post-insertion maintenance. Compliance with the GRAMMS checklist was maintained throughout the process.

Sample and sampling

The parallel mixed methods sampling [ 31 ] and purposive sampling strategy were used to select suitable participants, the informants of the interview were a subset of the quantitative study. For the quantitative part, nurses who fulfilled this inclusion criteria were included: caring patients having an established cancer diagnosis with a CVC, defined as a catheter introduced into the internal jugular vein, subclavian vein, or femoral vein. Regarding the qualitative study, the inclusion criteria for informants were: (1) involvement in the observation study; (2) completion of national or provincial specialized intravenous nurse training courses (exceeding 3 months) and attainment of corresponding qualifications; (3) registration as nurses delivering intravenous therapy for a period surpassing 5 years post-qualification; (4) direct care provision to cancer patients; and (5) voluntary participation in the interviews with informed consent. Exclusion criteria were applied to nurses who had resigned from hospital settings. Data saturation was realized upon conducting interviews with 15 informants.

Setting and data collection

The investigation encompassed oncology wards across five hospitals in China, namely Henan Cancer Hospital, Zhengzhou Central Hospital, Luohe Central Hospital, Sanmenxia Central Hospital, and Pingdingshan Hospital. Each of these tertiary-level hospitals housed approximately 1000–3000 beds. All CVCs within these institutions were positioned by designated venous catheterization centers following a uniform protocol. Additionally, oncology ward nurses underwent specific training on the post-insertion management of CVCs.

In the quantitative phase, to assess the evidence adoption for CVCs post-insertion maintenance within oncology wards, an audit team was formed, which comprised five nursing managers and ten intravenous therapy nurse specialists from five research centers. The audit members were from different parts of different organizations and had no working relationship with the nurses being evaluated. The research team also devised an audit checklist to scrutinize the adoption of scientific evidence in the post-insertion management of CVCs and conducted clinical observation. The audit checklist encompassed 30 items, stratified into 10 distinct domains: (1) hand hygiene, (2) assessment, (3) infusion connector disinfection, (4) infusion connector replacement, (5) infusion device replacement, (6) confirmation of in-situ catheter, (7) catheter and skin disinfection, (8) catheter dressing and fixation, (9) flushing, and (10) catheter covering. Supplementary file 1 delineates the checklist in detail. All participating oncology nurses were subsequently assessed through clinical observation utilizing this checklist to ascertain their adherence to scientific evidence in post-insertion management. Audit criteria were dichotomized, with “yes” signifying compliance with recommended practice, and “no” indicating deviation therefrom. The evaluation commenced with the audit team screening the medical records of all patients within the oncology wards. Upon identification of patients diagnosed with cancer and inserted with CVC, a designated audit member came to the ward to appraise the adherence to scientific evidence in post-insertion management of CVCs by the patient’s primary nurse, utilizing the checklist via clinical observation.

In the qualitative phase, a series of in-depth semi-structured interviews were administered by the first author, who was a nursing manager and hailed from different departments with the informants. All informants will be informed of the quantitative findings before the interview to ensure the continuity of the two research phases. The interviews were conducted either face-to-face in a meeting room of the informants’ ward or online (e.g. WeChat video calls or Tencent conferences), contingent upon the informants’ preference. A semi-structured interview guide was meticulously crafted by researchers predicated upon the i-PARIHS framework and the findings in the quantitative phase. This guide was subsequently pilot-tested on two intravenous therapy nurse specialists. Supplementary file 2 elucidates the guiding inquiries of the finalized semi-structured interview guide. Before acquiring written consent, the informants were thoroughly apprised of the study’s purpose and content. All interviews were diligently audio-recorded, with individual durations averaging 45 min, and ranging from 32 to 56 min.

Data analysis

Quantitative data analysis.

Quantitative data procured from the cross-sectional study were analyzed using IBM SPSS v26.0. Descriptive statistics were deployed, where continuous variables were elucidated by means and standard deviations, and categorical variables by frequencies and percentages. The sample size calculation adhered to the audit checklist’s item count, guided by the formula [ 32 ]: n=[Max(number of items)×(10 ∼ 15)]×[1+(10% ∼ 15%)]. With the checklist comprising 30 items and an anticipated attrition rate of 15%, the minimal requisite sample size amounted to 518.

Qualitative data analysis

The qualitative data stemming from the interviews were scrutinized through content analysis, supported by Nvivo 10. Preliminary to the analysis, audio recordings were verbatim transcribed. A six-phase coding process was diligently followed [ 33 ]: (a) data familiarization; (b) initial code generation; (c) thematic code search; (d) theme review; (e) theme definition and naming; and (f) final analysis production. To obviate subjective bias, interview transcripts were separately coded by two researchers, well-versed in qualitative research. The data analysis employed a deductive reasoning process based on the four components of the i-PARIHS framework, including innovation, recipients, context, and facilitation. Similar codes were categorized, and interrelated categories were amalgamated to discern major themes. Subsequent dialogue and revision by the two coding researchers and the first author led to a consensus, culminating in the translation of the codebook into English by the first author.

Ethical considerations

This investigation was sanctioned by the Medical Ethics Committee of Henan Cancer Hospital (Number 2023-KY-0014). All participants were apprised that their involvement was voluntary, with strict confidentiality maintained concerning personal information, accessible solely by the research team. Moreover, adherence to the principles of the Helsinki Declaration was stringently upheld. In this study, our targeted participants were nurses who have provided care for patients with a confirmed cancer diagnosis with CVCs. Therefore, patients were not involved in the study. Screening of the patient’s medical records was solely to facilitate the identification of eligible nurses, which would not involve any personal information about patients. Informed consent to participate was obtained from all the participants.

Rigorous in the quantitative part was upheld by multiple strategies. Firstly, the developmental process of checklists allowed wide input from diverse sources regarding the checklist content [ 34 , 35 ]. To ensure board sources of input to the checklist content, our team exhaustively examined pertinent evidence-based practice guidelines, expert opinions, and national and local health policies endorsed by various professional entities, including the Infusion Nursing Society [ 11 ], National Health Commission [ 36 , 37 ], National Institute of Hospital Administration [ 38 ], Chinese Nursing Association [ 12 ]. The checklist further embodied salient recommendations for CVC management as stipulated by the NICE guideline [ 39 ]. The research team extracted, collated, and integrated the evidence on CVC maintenance therein into a preliminary checklist. In addition, expert testing was employed to ensure the feasibility. Two CVC specialists from the Intravenous Infusion Therapy of the Chinese Nursing Association appraised and refined the items to validate the checklist’s feasibility, and the final checklist was formed. Secondly, the audit members were thoroughly briefed regarding the study’s objectives, content, and procedures to ensure comprehension. Besides, comprehensive training was provided to all audit members on the checklist to evaluate the assimilation of scientific evidence in post-insertion management of CVCs, thereby enhancing inter-rater reliability.

To uphold the rigor in the qualitative part, we adhered to the criteria outlined by Guba and Lincoln [ 40 ]. Credibility was promoted by having a researcher with extensive experience in conducting qualitative research to conduct the interviews. A concerted effort to mitigate recall bias and errors through field notes and recording equipment to capture the interview process. Subsequent verbatim transcription in Mandarin was conducted within 24 h of the interviews to ensure the accuracy of the findings. Interview transcripts were separately coded by two researchers, well-versed in qualitative research. Similar codes were categorized, and interrelated categories were amalgamated to discern major themes. Dialogue and revision by the two coding researchers and the first author led to a consensus. Additionally, throughout the interview process, the interviewer adopted empathetic techniques, including a non-judgmental stance, honoring all responses, fostering a supportive environment for the informants to divulge their emotions, and keen observation of salient non-verbal cues such as facial expressions, gestures, postures, and eye contact. To ensure transferability, purposive sampling was used to maximize the diversity of the informants in characteristics such as age, education level, and years of experience. To procure rich data and invaluable insights into informants’ experiences, informants were reassured that they could articulate their perspectives without fear of judgment or reprisal. Regular consultations were held to assess the data, allowing the researchers to understand the data and avoid potential misinterpretations. To enhance both dependability and confirmability, triangulation was employed to ensure that the results aligned with informants’ perceptions and experiences. Three supplementary intravenous therapy nurse specialists were enlisted to validate the findings. Their eligibility was aligned with those in the qualitative interviews. Initial engagements involved inviting the three specialists to review a thematic representation of our preliminary findings, with clarifications furnished by the interviewer. Subsequently, these specialists were encouraged to query and feedback on the tentative results and to reflect and notate comments. Transcripts were then examined employing qualitative methodologies congruent with phenomenological design. Following this process, concurrence was reached within our research team that the nurse specialists’ evaluations substantiated our delineated themes, subthemes, and interpretations.

Cross-sectional study

Background characteristics of nurses evaluated for the adoption of scientific evidence for post-insertion management of cvcs.

During the designated study period, 1314 nurses were included in the evaluation. Table 1 delineates the demographic and professional characteristics of the participants. A significant majority of the participants, 96.3% were female, the mean tenure of working experience stood at 8.3 years, 51.3% of participants possessed a college degree, 40.6% were classified as primary nurses, and a substantial 92.4% originated from departments specializing in medical oncology, surgical oncology, or radiotherapy oncology.

Adoption of scientific evidence in post-insertion management for CVCs

Table 2 encapsulates the adoption of scientific evidence for post-insertion management of CVCs by oncology nurses. A total of 1,314 field observations were conducted by the evaluation team throughout the study. The cumulative adoption rate was calculated at 90.0%. Within the evaluation checklist’s 10 categories, half were found to have adoption rates less than 90%, including hand hygiene, preoperative assessment, infusion connector disinfection, confirmation of in-situ catheter, and skin and catheter disinfection. Specifically, two categories exhibited a lower adoption rate of less than 80%, namely disinfection of infusion connector and disinfection of skin and catheter. Furthermore, of the 30 checklist items, 14 recommendations were identified with an adoption rate falling below 90%, including specific practices related to disinfection, blood flow management, and post-transfusion procedures. Four items that achieved less than an 80% adoption rate were the disinfection of the infusion connector, skin, and catheter.

Qualitative study

Background characteristics of the informants.

Table 3 delineates the demographic attributes of the informants who partook in the interviews. Among them, the mean age was 34.0 years, with 14 females and 9 holding a bachelor’s degree. Additionally, 12 had served in the specialized role of a CVC nurse for more than 11 years.

Barriers to compliance

Through an analysis of the semi-structured interviews, three barriers were discerned that may hinder the adoption of scientific evidence in post-insertion management for CVCs within oncology settings, mapping to three components of i-PARIHS framework of innovation, recipient, and context, shown in Table 4 .

Theme 1: Difficulty in accessing the evidence (Innovation)

Subtheme 1: insufficiency of training on research skills for appraisal and synthesis of evidence.

Concurrent with the evolution of evidence-based practice, the proliferation of high-quality evidence continues to unfold. A significant proportion of informants recognized the critical role of evidence-based practice in patient outcomes, they concurred that accessing high-quality evidence constitutes the preliminary stage of evidence-based practice. The informants expressed a keen motivation to acquire knowledge on optimal post-insertion management strategies for CVCs. Nonetheless, they were confronted with a paucity of training on research, resulting in uncertainty regarding where to locate evidence and how to evaluate its quality amidst an expanding volume of available evidence. The evidence at hand was occasionally disjointed or even contradictory, thereby posing challenges to the informants in synthesizing it to guide their clinical practice. As articulated by one informant:

“The landscape of evidence concerning post-insertion management for CVCs is in a constant state of flux. Regrettably , my knowledge remains anchored to guidelines published several years prior. Although I aspire to familiarize myself with the most current guidelines , I am at a loss as to where to obtain them.” (N.5).

Another informant stressed the need for institutional support, stating:

“ It would be beneficial if the hospital could facilitate research training or directly identify and disseminate the pertinent guidelines. We could then integrate these guidelines into our practice. ” (N.7).

Yet another shared a similar sentiment, remarking:

“With the myriad of evidence available for post-insertion management , I often encounter fragmented evidence across various channels , such as WeChat accounts. Lacking training in research , I find myself uncertain of the reliability of these pieces of evidence and , consequently , refrain from applying them.” (N.9).

Subtheme 2. Clinical applicability of evidence

The informants predominantly emphasized that the clinical applicability of evidence was a decisive factor influencing the feasibility of implementation. Specifically, they stressed that the evidence must be aligned with patient needs and seamlessly integrated into clinical environments. Certain occurrences, such as blood oozing at the puncture site after coughing, rendered some recommendations impracticable. Without careful adaptation, the direct application of recommended practices could present frontline nurses with considerable obstacles, leading to a loss of motivation. An informant in the semi-structured interview highlighted this, stating:

“According to the latest guidelines for CVC care , immediate replacement is mandated in cases of exudation. Yet , it is common for patients to cough after surgery , thus , blood oozing is inevitable. The consequent necessity to repeatedly change dressings not only escalates the nursing workload but also meets with disapproval from patients. Therefore , this recommendation is virtually infeasible to implement.” (N.8).

Another informant expressed similar concerns, saying:

“Changes to workflows , such as methods of catheter disinfection , changed after implementing the new practice. The initial adaptation was challenging. Regular training and reinforcement are imperative to secure compliance. Additionally , a flowchart could serve to elucidate the procedures involved in executing the new practice.” (N.10).

One more informant also noted:

“The guideline prescribes a specific area for disinfection , yet the suitability of this may vary depending on the anatomical location of CVC insertion. Thus , the stipulated size of the disinfection area is often impractical in a clinical context. Adhering to it rigidly would augment the complexity of our operations.” (N.6).

Subtheme 3: sustainability in applying the evidence

The interviews revealed that although training on post-insertion maintenance for CVCs had been conducted within hospitals and oncology departments, the sustenance and enhancement of its application were predominantly contingent on nursing managers. A glaring absence of corresponding policies and oversight mechanisms to encourage compliance with post-insertion management in oncology settings was evident. Furthermore, there was a notable deficiency in understanding the potential adverse health ramifications for patients should the post-insertion management for CVCs not be adhered to. The absence of prompt feedback on post-insertion management consequently attenuated the nurses’ impetus to integrate evidence into practice. As elucidated by an informant:

“Our superiors mandated the implementation of post-insertion management for CVCs. However , compliance was fleeting , as the emphasis was not sustained. Consequently , we reverted to our original practices.” (N.7).

Another informant expressed a similar sentiment, stating:

“It (post-insertion management for CVCs) only lasted for a period of time and then we stopped. Indeed , we have relied on our established practices for an extensive duration without encountering complications.” (N.3).

Yet another informant suggested an enhancement in oversight, remarking:

“The monitoring framework for post-insertion management necessitates reform. Specifically , integration with our extant monitoring system is advisable to preclude redundancy in workflow and diminish workload. Additionally , reciprocal monitoring between nurses on day and night shifts could more adeptly pinpoint issues with CVCs.” (N.11).

Theme 2: lack of involvement from nurse specialists (recipients)

Subtheme 1. absence of participation in the evidence-translation process.

Some informants disclosed their exclusion from the process of crafting hospital regulations and workflows. Consequently, these specialists were impeded from conveying their insights and strategies to nursing managers, who occupied roles pivotal to policy development. This rendered them incapable of refining post-insertion maintenance for CVCs in alignment with the most judicious evidence. As articulated by an informant as an intravenous treatment nurse specialist:

“The hospital mandated adherence to their newest guideline for post-insertion management for CVCs. However , discerning a distinction between this purported latest iteration and the current version is elusive , given our non-involvement in the guideline’s development.” (N.1).

This perspective was reiterated by another nurse specialist, who lamented:

“While the utilization of the best evidence is commendable , I find myself perplexed. We are marginalized during the policymaking process for CVC management. Those responsible for the guideline’s formulation lack the pertinent expertise.” (N.13).

Subtheme 2. Insufficiency of nurse specialists to oversee the quality of care

A prevalent sentiment among the informants was the inadequate presence of intravenous treatment nurse specialists within their institutions. This scarcity hindered the provision of sufficient oversight for less-experienced nurses, thereby posing challenges to the maintenance of care quality in post-insertion management. During a semi-structured interview, an informant expressed the dilemma succinctly:

“My responsibilities preclude devoting sufficient time to ensuring the proper execution of post-insertion management for CVCs within my ward , given the sheer magnitude of routine tasks. My ability to focus on this particular issue (post-insertion management) is consequently constrained.” (N.7).

Another informant lamented the challenges inherent in the singular role of intravenous therapy nurse specialist within the ward:

“I stand as the sole intravenous therapy nurse specialist in our ward , and the daily completion of routine tasks forces me into overtime to supervise juniors and instruct them on post-insertion management. My capacity to focus on this task (post-insertion management) is thus compromised.” (N.15).

Additionally, another informant articulated the distractions that impede the care process:

“While engaged in post-insertion management , my focus is incessantly diverted by other routine tasks. Consequently , I find myself unable to concentrate fully on the care process , resulting in certain steps being inadvertently overlooked.” (N.14).

Subtheme 3. Difficulty in achieving consensus with medical staff

Several informants elucidated that the domain of intravenous therapy was heavily influenced by medical staff, a fact that emerged as a major barrier to changing the current practice of post-insertion management. The tendency of doctors to concentrate exclusively on insertion procedures, neglecting post-insertion maintenance, exacerbates this issue. Correspondingly, the specialized expertise of nurses in providing post-insertion management often goes unrecognized in the formulation of hospital policies. Therefore, achieving consensus on necessary alterations to post-insertion maintenance based on the evidence proves arduous. For instance, an informant conveyed:

“My involvement in the management team is dictated by my professional role , yet I have remained excluded from the development of hospital-wide policies , focusing solely on managing my department. This is because doctors dominated the hospital management team.” (N.3).

Another informant resonated with this sentiment, emphasizing:

“To effect meaningful changes to post-insertion management for CVCs , the endorsement of doctors , particularly department heads , is indispensable. Their support would considerably facilitate the integration of novel practices.” (N.2).

Furthermore, an informant pointed out the doctors’ lack of concern:

“While numerous physicians elect to insert CVCs into cancer patients for the administration of chemotherapy , their attentiveness to post-insertion management is minimal , sometimes even diminishing its significance.” (N.9).

Theme 3: challenges from internal and external environments (context)

Subtheme 1 inadequate atmosphere for internal change.

The majority of informants, having participated in assorted programs aimed at amending current practices, observed a discernible lack of vigor in the climate for change within hospitals. This tepidity failed to galvanize frontline nurses to embrace new methodologies, especially as their primary focus was anchored on patient safety. As long as existing practices yielded improvements in patient outcomes without adverse events, nurses exhibited little motivation to explore innovations. At the managerial echelon, the informants noted an absence of multidisciplinary collaboration in enhancing post-insertion management for CVCs, coupled with a deficient incentive structure for change. Even among intravenous therapy nurse specialists, consensus on the mission to promote the adoption of best practices remained elusive. An informant elaborated:

“Nurses are more concerned about patients’ safety. They are more conservative about innovations. The implementation of a broad-scale program to alter current practices is inherently intricate , encompassing various facets and necessitating extensive communication and coordination with diverse stakeholders.” (N.4).

Another informant articulated a nuanced observation, stating:

“We have discerned that the standards of post-insertion management leave much to be desired. This deficiency is not amenable to superficial remedies; it mandates that nursing leaders devise systematic strategies to sustain change and galvanize universal participation.” (N.10).

Further elaboration was provided by another informant, who commented on the cultural constraints within the hospital:

“Our hospital gets our own culture. The senior staff do not advocate for changing our practices according to scientific evidence as long as the current practices bring benefits to patients.” (N.12).

Subtheme 2 paucity of external support

A consensus among informants underscored the significance of support from nursing managers and leaders in enhancing post-insertion maintenance for CVCs. Their guiding policies shape the procedural approach; however, several informants expressed concerns that this managerial support, though overtly positive, lacked substantial backing in terms of regular training and resource allocation. Moreover, the incorporation of the best available evidence in post-insertion management for CVCs necessitates specific materials such as connectors and disinfectants. This requirement might burden the department’s budget, thereby hindering effective adoption. In the interview, one informant mentioned:

“Things are not so simple. The hospital (department) does not provide necessary equipment for post-insertion management , such as special kit sets. This complicated the whole process. It is very difficult for us to work.” (N.7).

Another informant, specializing in intravenous therapy, expressed the desire for more conducive working conditions:

“As an intravenous therapy nurse specialist , I yearn for the hospital to allocate space for work focused on service enhancement. At present , I am still tasked with routine duties. Specialists ought to be entrusted with more complex responsibilities. Allotting more time to these intricate tasks , rather than routine work , would undoubtedly elevate the quality of post-insertion management for CVCs.” (N.6).

Further insights were provided by another informant, who suggested:

“Should the hospital initiate a dedicated nursing clinic for intravenous infusion , or foster opportunities for intellectual discourse , it would facilitate the acquisition of skills in post-insertion management , thereby augmenting the overall quality of nursing care.” (N.8).

Facilitators of compliance

Two facilitative elements were identified in the quest for compliance with post-insertion maintenance for CVCs, shown in Table 4 .

Theme 1: positive attitudes of specialist nurses toward evidence application

Most informants asserted that their professional identity can be enhanced through the adoption of evidence-based practice. Specifically, by altering the existing protocols on CVC management, the informants perceived a greater recognition and appreciation of their contributions by nursing leaders, colleagues, patients, and patients’ families. This affirmation of their professional identity consequently augmented their sense of self-worth. The informants also posited that the promotion of evidence-based practice could demonstrate to other nurses that their professional growth was not confined to administrative roles but extended to specialized patient care. An informant elucidated:

“After completing my specialist training , I returned to my hospital to contribute to the development of CVC management guidelines. Now , everyone who encounters problems in CVC management , they will seek for my advice.” (N.10).

Additional insights were provided by other informants:

“Everyone acknowledges my work and my passion. It is a kind of achievement.” (N.11). “Nurse specialists in intravenous therapy serve not merely as practitioners performing injections and infusions but also as educators and facilitators , imparting advanced knowledge to peers and patients , and assuming leadership within the department.” (N.2).

Theme 2: formation of a team specializing in intravenous therapy within hospitals

The informants indicated that their hospitals had instituted professional teams to oversee post-insertion maintenance for CVCs. Particularly after receiving specialization, these nurses are empowered to scrutinize care quality and impart relevant training to their colleagues. When frontline nurses are tasked with post-insertion maintenance for CVCs, these trained specialists can offer guidance and feedback, thereby enhancing the quality of care. An informant shared during a semi-structured interview:

“Having worked only a few years , I began to acquire knowledge about CVC management through a training course at my hospital. This instruction has greatly expanded my understanding and skills.” (N.4).

Another informant reflected on the specialized care required for cancer patients:

“Cancer patients represent a unique cohort , exhibiting a wide variation in medical conditions. When I encounter complexities in providing CVC care , I often consult the professional group on intravenous therapy. The guidance from nurse specialists is invariably insightful and greatly facilitates my practice.” (N.6).

The deployment of CVCs is linked with catheter-associated complications in oncology patients, which may culminate in extended hospital stays and augmented morbidity and mortality rates, thereby constituting a substantial menace to patient safety and escalating healthcare expenditures. In China, nurses are exempted from inserting CVCs but are mandated to administer post-insertion maintenance. Evidence implementation in post-insertion maintenance for CVCs is imperative for nurses engaged in oncological settings to mitigate the aforementioned perils and ramifications [ 41 ].

The quantitative findings in the present research revealed an overall adoption rate of 90.0% concerning evidence adoption in post-insertion maintenance for CVCs in oncology environments. The high rate of evidence adoption was potentially influenced by the inclusion of oncology patients rendered immunocompromised through radiotherapy and chemotherapy. This, in turn, necessitates heightened attention by oncology nurses to infection control protocols during all aspects of CVC management. Although this figure was promising, this study also revealed that there was still room for improvement in the current practice to achieve the expected targets of evidence-based practice. We found that 14 out of 30 practices enumerated in the evaluation checklist did not achieve 90% adoption rate among oncology nurses. These findings were consistent with studies in the West demonstrating unsatisfactory compliance rates in post-insertion management for CVCs [ 42 , 43 ]. Notably, the poorest adoption (< 80%) of evidence-based practices were primarily related to infection control, particularly the disinfection of infusion connector, skin, and catheter, which are associated with complications of catheter-related bloodstream infections and deserve to be heeded. The quantitative data provided more precise information on identifying the weak and critical segment of post-insertion maintenance for CVCs. As in any evidence implementation project, evaluating the pivotal clinical questions and identifying the key segments is crucial for promoting evidence-based clinical translation and implementation [ 44 ]. Consequently, the results highlighted a clear and effective avenue for improvement, which is developing targeted and addressed implementation strategies for disinfection control in the future to enhance the quality of post-insertion maintenance for CVCs in China.

One feature of this study is the continuity and consistency of the quantitative and qualitative research. All informants were a subset of the quantitative phase and involved in the quantitative study before providing their specifically targeted insights and opinions. The outcomes of the clinical observation serve to delineate the specific challenges, laying the groundwork for an in-depth analysis of hindrances and further devising targeted strategies for amelioration [ 45 ]. Additionally, successful evidence implementation is regarded as an outcome resulting from the quality and type of innovation, the characteristics of context, recipients who are influenced or implement the innovation, and how the innovation is facilitated [ 46 ]. Guided by the i-PARIHS framework, the qualitative dialogues were deductively reasoned into four key elements of the clinical implementation of evidence, including innovation, recipients, context, and facilitation [ 47 ]. Facilitators and barriers to adopting scientific evidence in post-insertion maintenance for CVCs among oncology nurses were further clarified using this framework.

The qualitative data identified the difficulty in accessing the evidence was a main barrier to evidence practice in CVCs post-insertion maintenance, mapping to the innovation in the i-PARHIS framework. Knowledge deficit in the evidence may result in low compliance with CVCs maintenance [ 48 ]. In the field of CVCs post-insertion maintenance, the large amount of evidence published does not represent an increase in nurses’ knowledge. Continuous training is necessary to promote best practices in CVC maintenance, not just in knowledge and key points in each procedure, but in the ability to appraise and synthesize evidence. Of the identified barriers to innovation, the clinical applicability of evidence was persistently mentioned by informants, which emphasized that the evidence should be modified, tailored, or refined to fit local context or needs [ 49 ]. Especially some evidence practices related to infection control, e.g. suggested size of the disinfected area, naturally dried waiting after disinfection, seemed hard to apply in clinical operations with workload. Continuous monitoring and periodic revisions to post-insertion management protocols for CVCs are essential to ensure clinical applicability [ 50 ]. Additionally, nurses were concerned with the increased budget resulting from the evidence-based practices related to the inflection control measures. For instance, the cost of a recommended disinfectant, i.e. chlorhexidine gluconate alcohol is 3 to 4 times more expensive than general disinfectants. Therefore, facilitators should be preoccupied with evidence that may increase clinical costs and develop strategies in advance to ensure the sustainability of CVC maintenance evidence application. At the same time, these phenomena were the possible reasons for the quantitative results that most infection control measures in post-insertion management failed to achieve at least 80% adoption rates.

Nurses are the major recipients, responsible for evidence adoption for CVCs post-insertion maintenance. Fortunately, all informants in our qualitative study manifested a positive attitude toward adopting scientific evidence in post-insertion management for CVCs. This is significant, as delineated by Ferrara et al [ 42 , 51 ], attitudes of healthcare workers were crucial to promote adherence to guidelines. Notwithstanding the positive attitudes of our informants, they did mention the difficulties in participating in the evidence-translation process and hospital policymaking, thus hindering the adoption of evidence in post-insertion management for CVCs. This phenomenon is particularly pronounced in China, attributing to medical dominance. Relative to the medical profession, nursing is a comparatively nascent discipline [ 52 ]. Furthermore, a conventional societal perception prevails that nurses are subordinate to physicians, possessing diminished autonomy within healthcare environments [ 53 ]. This perception, combined with an inherently hierarchical structure, diminishes nurses’ participation in policymaking, resulting in their perspectives on post-insertion management for CVCs being marginalized within hospital policy. Encouraging multidisciplinary involvement will provide more opportunities and facilities for specialist nurses to be better involved in addressing such situations. It would be beneficial to expand the scope of involvement by working more closely with the medical team, organizational managers, and patients, who are all key stakeholders in promoting evidence-based practice for CVC maintenance [ 54 ]. One potential approach is the establishment of nurse-led multidisciplinary teams for CVC or the creation of specialist clinics, which can facilitate communication and collaboration with the medical teams and utilize the professional value of specialist nurses.

Aligning with the i-PARIHS framework, the context includes the external and internal environment or organizational culture [ 25 ]. Workload as a barrier should be mentioned, especially since the research settings in this study are tertiary public hospitals with more than 1000 beds. Previous systematic reviews [ 55 ] explicitly indicated that a lower nurse-to-patient ratio was associated with an increased risk of healthcare-associated infections, which was the single significant predictor for bloodstream infections related to CVCs [ 48 ]. The correlation between workload and catheter infection control is also indirectly illustrated considering the low infection control implementation rate in this study’s quantitative results. Moreover, a lack of CVC-maintained required materials, such as CVC maintenance kits and chlorhexidine gluconate alcohol, can also decrease compliance with evidence-based practice. This perspective is consistent with another study from China [ 56 ], which focused on implementation strategies for CVC maintenance in pediatric intensive care units. External support and negotiation from the medical insurance finance, healthcare organization, materials supply department, and nursing department, cannot be ignored. Financial allocations should be strategically increased to avail the necessary human resources and materials for implementing evidence-based practices in CVC management, e.g. purchasing recommended disinfectants or materials. Furthermore, a positive culture can promote the application of innovation, thereby facilitating change [ 56 ]. Within the internal culture, another finding in the study was that managers or frontline specialist nurses were more conservative towards the change and emphasized priority on patient safety. These are misconceptions about change and safety, need to be reversed by the implementation facilitator by creating an adequate atmosphere for change through best-evidence training, demonstration of excellent practice, and performance or moral incentives.

The significance of identifying facilitators is to enhance the facilitators in implementation strategies to increase the uptake of evidence-based clinical innovations [ 57 ]. Two main facilitators of evidence practice for CVC maintenance emerged in this present study. Informants indicated the positive attitudes of specialist nurses toward evidence application, as well as constituting a specialized team focused on CVCs within all research sites, had the potential efficacy in promoting evidence practice for CVC maintenance. Previous literature also supported the effectiveness of such professional teams in enhancing evidence adoption in various clinical practices and settings [ 58 , 59 ]. Nevertheless, a consideration warranting scrutiny is that forming such professional teams necessitates professional training, iteration of knowledge and concept, and communication with and support from management to better leverage the influence of the academic team in the hospital. Consequently, further investigations and well-developed operational mechanisms are warranted to leverage the role of professional teams comprehensively in evidence-based practice.

Strengths and limitations

To our best understanding, this was the first study that adopted a sequential explanatory mixed method based on the i-PARIHS, an implementation science framework, to scrutinize the integration of scientific evidence in post-insertion maintenance for CVCs and identify facilitators and barriers to the evidence adoption within oncological settings in China. An additional virtue pertains to the expansive scale of the research, executed across five medical centers and encompassing 1,314 clinical observations. Such a voluminous dataset conferred robustness and precision in the estimation. Notwithstanding these strengths, certain limitations must also be acknowledged. Firstly, the trustworthiness of the quantitative data from the cross-sectional study might be compromised as the audit checklist did not undergo a psychometric properties test notwithstanding some evidence suggesting that it might not be necessary for the audit checklist [ 34 , 35 ]. Secondly, we did not apply advanced statistical methods to analyze the data as the current analysis could achieve the study objectives. However, advanced statistical methods may be useful to verify some identified facilitators and barriers in evidence adoption, and hence future studies are recommended to do so. Thirdly, this study was conducted in hospitals in China. Due to the difference in organizational structures and cultural beliefs between China and Western countries, which might affect the generalizability of findings in overseas. Fourthly, the semi-structured interviews were conducted by a nurse manager, which might affect the willingness and perceptions of informants to share their opinions due to power imbalance. Lastly, this study adopted different methods, i.e., face-to-face and online platforms to conduct interviews. There might be differences in the study results due to the interview techniques.

Conclusions

This research has bridged an existing gap in the literature, unearthing that the aggregate adoption rate of evidence in post-insertion management for CVCs by nurses within the oncology setting stood at 90.0%. Among all the advocated practices, infection control protocols were the least adopted. Employing the i-PARIHS framework, we identified two facilitators, including the positive attitudes of specialist nurses to evidence application and formation of a team specializing in intravenous therapy within all sites; as well as three barriers mapping to three elements in the i-PARIHS framework, including difficulty in accessing the evidence, lack of involvement from nurse specialists and challenges from internal and external environments. Stemming from these recognized facilitators and obstructions, tailored interventions must be strategized and instituted at an organizational stratum to enhance the execution of the guideline, with particular emphasis on the clinical evidence pertinent to infection control.

Data availability

The datasets used or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Central Venous Catheters

Integrated Promoting Action on Research Implementation in Health Services

Jamshidi R. Central venous catheters: indications, techniques, and complications. Semin Pediatr Surg. 2019;28(1):26–32.

PubMed Google Scholar

van den Bosch CH, van Woensel J, van de Wetering MD. Prophylactic antibiotics for preventing gram-positive infections associated with long-term central venous catheters in adults and children receiving treatment for cancer. Cochrane Database Syst Rev. 2021;10(10):Cd003295.

Schiffer CA, Mangu PB, Wade JC, Camp-Sorrell D, Cope DG, El-Rayes BF, Gorman M, Ligibel J, Mansfield P, Levine M. Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncology: Official J Am Soc Clin Oncol. 2013;31(10):1357–70.

Google Scholar

Zitvogel L, Apetoh L, Ghiringhelli F, Kroemer G. Immunological aspects of cancer chemotherapy. Nat Rev Immunol. 2008;8(1):59–73.

CAS PubMed Google Scholar

Chen DS, Mellman I. Oncology meets immunology: the cancer-immunity cycle. Immunity. 2013;39(1):1–10.

Böll B, Schalk E, Buchheidt D, Hasenkamp J, Kiehl M, Kiderlen TR, Kochanek M, Koldehoff M, Kostrewa P, Claßen AY, et al. Central venous catheter-related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol. 2021;100(1):239–59.

Sun Y, Bao Z, Guo Y, Yuan X. Positive effect of care bundles on patients with central venous catheter insertions at a tertiary hospital in Beijing, China. J Int Med Res. 2020;48(7):300060520942113.

Verso M, Agnelli G. Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncology: Official J Am Soc Clin Oncol. 2003;21(19):3665–75.

Pan M, Meng A, Yin R, Zhi X, Du S, Shi R, Zhu P, Cheng F, Sun M, Li C, Fang H. Nursing interventions to reduce peripherally inserted central catheter occlusion for Cancer patients: a systematic review of literature. Cancer Nurs. 2019;42(6):E49–58.

Llapa-Rodríguez EO, Oliveira JKA, Melo FC, Silva GGD, Mattos MCT, Macieira VP Jr. Insertion of central vascular catheter: adherence to infection prevention bundle. Revista brasileira de enfermagem. 2019;72(3):774–9.

Gorski LA, Hadaway L, Hagle ME, Broadhurst D, Clare S, Kleidon T, Meyer BM, Nickel B, Rowley S, Sharpe E, Alexander M. Infusion Therapy Standards of Practice, 8th Edition. Journal of infusion nursing: the official publication of the Infusion Nurses Society 2021, 44(1S Suppl 1):S1-s224.

Sun Hong CL, Guo Caixia Y, Qiaofang L, Xuying Z, Gaiting M, Zanhong C, Ying X, Hong. Feng Bilong, Wang Lei: Expert consensus on venous catheter maintenance/Intravenous Therapy Committee of Chinese Nursing Association. Chin J Nurs. 2019;54(9):1334–42.

Lin FF, Murphy N, Martinez A, Marshall A. An audit of central venous catheter insertion and management practices in an Australian tertiary intensive care unit: a quality improvement project. Intensive Crit Care Nurs. 2022;70:103217.

Elliott JH, Turner T, Clavisi O, Thomas J, Higgins JP, Mavergames C, Gruen RL. Living systematic reviews: an emerging opportunity to narrow the evidence-practice gap. PLoS Med. 2014;11(2):e1001603.

PubMed PubMed Central Google Scholar

Ayatollahi H, Zeraatkar K. Factors influencing the success of knowledge management process in health care organisations: a literature review. Health Info Libr J. 2020;37(2):98–117.

Chen Q, Halili X, Castro AR, Zhao J, Chen W, Li Z, Tang S, Wang H. Differences in evidence-based nursing practice competencies of clinical and academic nurses in China and opportunities for complementary collaborations: a cross-sectional study. J Clin Nurs 2022.

Nilsen P, Bernhardsson S. Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC Health Serv Res. 2019;19(1):189.

Dryden-Palmer KD, Parshuram CS, Berta WB. Context, complexity and process in the implementation of evidence-based innovation: a realist informed review. BMC Health Serv Res. 2020;20(1):81.

CAS PubMed PubMed Central Google Scholar

Ridde V, Pérez D, Robert E. Using implementation science theories and frameworks in global health. BMJ Global Health. 2020;5(4):e002269.

Pfadenhauer LM, Gerhardus A, Mozygemba K, Lysdahl KB, Booth A, Hofmann B, Wahlster P, Polus S, Burns J, Brereton L, Rehfuess E. Making sense of complexity in context and implementation: the context and implementation of Complex interventions (CICI) framework. Implement Science: IS. 2017;12(1):21.

Lin CC, Xu X. A Leap from evidence to practice: implementation science in Cancer nursing. Cancer Nurs. 2019;42(4):259–60.

Byrnes A, Young A, Mudge A, Banks M, Clark D, Bauer J. Prospective application of an implementation framework to improve postoperative nutrition care processes: evaluation of a mixed methods implementation study. Nutr Dietetics: J Dietitians Association Australia. 2018;75(4):353–62.

Yakovchenko V, Bolton RE, Drainoni ML, Gifford AL. Primary care provider perceptions and experiences of implementing hepatitis C virus birth cohort testing: a qualitative formative evaluation. BMC Health Serv Res. 2019;19(1):236.

Elam ME, Louis CJ, Brindle ME, Woodson J, Greece JA. Using i-PARIHS to assess implementation of the Surgical Safety Checklist: an international qualitative study. BMC Health Serv Res. 2022;22(1):1284.

Cao S, Gu M, Feng M, Jia Y, Zhao Y, Chen S, Zhu L, Bo S, Zhao Q. Implementation of evidence in preventing medical device-related pressure injury in ICU patients using the i-PARIHS framework. J Nurs Adm Manag. 2022;30(1):318–27.

Peel NM, Hornby-Turner YC, Osborne SR, Henderson A, Hubbard RE, Gray LC. Implementation and evaluation of a standardized nurse-administered Assessment of Functional and Psychosocial issues for patients in Acute Care. Worldviews evidence-based Nurs. 2021;18(3):161–9.

Alostaz Z, Rose L, Mehta S, Johnston L, Dale C. Physical restraint practices in an adult intensive care unit: a prospective observational study. J Clin Nurs 2022.

Roberts NA, Janda M, Stover AM, Alexander KE, Wyld D, Mudge A, Group IPPiCPISW. The utility of the implementation science framework Integrated Promoting Action on Research Implementation in Health Services(i-PARIHS) and the facilitator role for introducing patient-reported outcome measures (PROMs) in a medical oncology outpatient department. Qual Life Res. 2021;30:3063–71.

Gu Y, Hu Y, Zhang H, Fu W, Yang Y, Latour JM. Implementation of an evidence-based Guideline of Enteral Nutrition for infants with congenital heart disease: a controlled before-and-after study. Pediatr Crit care Medicine: J Soc Crit Care Med World Federation Pediatr Intensive Crit Care Soc. 2020;21(6):e369–77.

Qin X, Yu P, Li H, Hu Y, Li X, Wang Q, Lin L, Tian L. Integrating the best evidence into nursing of venous thromboembolism in ICU patients using the i-PARIHS framework. PLoS ONE. 2020;15(8):e0237342.

Creswell JW, Clark VLP. Designing and conducting mixed methods research. Sage; 2017.

Jianhua W. Practical Medical Research Methods: Beijing. People’s Health Publishing Company; 2003.

Braun VaC V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101.

Van de Velde S, Kunnamo I, Roshanov P, Kortteisto T, Aertgeerts B, Vandvik PO, Flottorp S. The GUIDES checklist: development of a tool to improve the successful use of guideline-based computerised clinical decision support. Implement Sci. 2018;13:1–12.

Burian BK, Clebone A, Dismukes K, Ruskin KJ. More than a tick box: medical checklist development, design, and use. Anesth Analgesia. 2018;126(1):223–32.

WS/T 433–. 2013, Operating Standards for Intravenous Treatment Nursing Techniques[S] [ http://www.nhc.gov.cn/wjw/pjl/201412/806fe9a7171e4cf584c0d40ed093dfa7.shtml ].

National Health Commission of the People’s Republic of China. Guidelines for the prevention and control of vascular catheter-related infections issued by the General Office of the National Health Commission(2021 Edition). [ http://www.nhc.gov.cn/yzygj/s7659/202103/dad04cf7992e472d9de1fe6847797e49.shtml ].

National Institute of Hospital Administration. Quality Control Toolkit for Preventing Intravascular Catheter-Related Bloodstream Infections (Trial Version) [ https://niha.org.cn/prod-api/web/normal/downloadDetail/853 ]

Macmillan T, Pennington M, Summers JA, Goddard K, Zala D, Herz N, Peacock JL, Keevil S, Chalkidou A. SecurAcath for securing peripherally inserted Central catheters: a NICE Medical Technology Guidance. Appl Health Econ Health Policy. 2018;16(6):779–91.

Cope DG. Methods and meanings: credibility and trustworthiness of qualitative research. In: Oncology nursing forum: 2014 ; 2014.

Panepinto R, Harris J, Wellette J. A review of best practices related to Intravenous Line Management for nurses. Nurs Clin N Am. 2021;56(3):389–99.

Ferrara P, Albano L. The adherence to guidelines for preventing CVC-related infections: a survey among Italian health-care workers. BMC Infect Dis. 2018;18(1):606.

Dedunska K, Dyk D. Prevention of central venous catheter-associated bloodstream infections: a questionnaire evaluating the knowledge of the selected 11 evidence-based guidelines by Polish nurses. Am J Infect Control. 2015;43(12):1368–71.

Moullin JC, Dickson KS, Stadnick NA, Albers B, Nilsen P, Broder-Fingert S, Mukasa B, Aarons GA. Ten recommendations for using implementation frameworks in research and practice. Implement Sci Commun. 2020;1:1–12.

Wan GY, Yuan H, Xue H, Li HQ, Hu HY, Zhang XY. Assessment of compliance with oral nutritional supplementation and exploration of barriers and facilitators for patients after gastrectomy: a mixed-methods study. J Adv Nurs. 2021;77(6):2845–59.

Balbale SN, Hill JN, Guihan M, Hogan TP, Cameron KA, Goldstein B, Evans CT. Evaluating implementation of methicillin-resistant Staphylococcus aureus (MRSA) prevention guidelines in spinal cord injury centers using the PARIHS framework: a mixed methods study. Implement Science: IS. 2015;10:130.

Duan Y, Iaconi A, Wang J, Perez JS, Song Y, Chamberlain SA, Shrestha S, Choroschun K, Hoben M, Beeber A, et al. Conceptual and relational advances of the PARIHS and i-PARIHS frameworks over the last decade: a critical interpretive synthesis. Implement Science: IS. 2022;17(1):78.

Matlab AA, Al-Hussami MO, Alkaid Albqoor M. Knowledge and compliance to prevention of central line-associated blood stream infections among registered nurses in Jordan. J Infect Prev. 2022;23(4):133–41.

Gillespie BM, Latimer S, Walker RM, McInnes E, Moore Z, Eskes AM, Li Z, Schoonhoven L, Boorman RJ, Chaboyer W. The quality and clinical applicability of recommendations in pressure injury guidelines: a systematic review of clinical practice guidelines. Int J Nurs Stud. 2021;115:103857.

Parker V, Giles M, King J, Bantawa K. Barriers and facilitators to implementation of a multifaceted nurse-led intervention in acute care hospitals aimed at reducing indwelling urinary catheter use: a qualitative study. J Clin Nurs. 2020;29(15–16):3042–53.

Ferrara P, Stromillo L, Albano L. Awareness, attitudes, and practices toward Meningococcal B Vaccine among pediatricians in Italy. Med (Kaunas Lithuania) 2018, 54(6).

Frachel RR. A new profession: the evolution of public health nursing. Public Health Nurs (Boston Mass). 1988;5(2):86–90.

CAS Google Scholar

Freund T, Everett C, Griffiths P, Hudon C, Naccarella L, Laurant M. Skill mix, roles and remuneration in the primary care workforce: who are the healthcare professionals in the primary care teams across the world? Int J Nurs Stud. 2015;52(3):727–43.

Eisman AB, Quanbeck A, Bounthavong M, Panattoni L, Glasgow RE. Implementation science issues in understanding, collecting, and using cost estimates: a multi-stakeholder perspective. Implement Sci. 2021;16(1):75.

Mitchell BG, Gardner A, Stone PW, Hall L, Pogorzelska-Maziarz M. Hospital staffing and health care–associated infections: a systematic review of the literature. Joint Comm J Qual Patient Saf. 2018;44(10):613–22.

Wang W, Fu Q, Shen W, Xu Y, Wang L, Chun X, Shi Y, Lin J, Zhao Y, Gu Y. Using the i-PARIHS theoretical framework to develop evidence implementation strategies for central venous catheter maintenance: a multi-site quality improvement project. JBI Evid Implement. 2024;22(2):195–204.

Bauer MS, Kirchner J. Implementation science: what is it and why should I care? Psychiatry Res. 2020;283:112376.

Hammarskjöld F, Berg S, Hanberger H, Taxbro K, Malmvall BE. Sustained low incidence of central venous catheter-related infections over six years in a Swedish hospital with an active central venous catheter team. Am J Infect Control. 2014;42(2):122–8.

Ferreira JDN, Dos Santos KB, Siqueira EC, Gomes EP, Martini L, Fraga JBP, Lima MAM, Poveda VB. Central venous catheter insertion in adult patients: a best practice implementation project. JBI Evid Implement. 2020;19(3):296–305.

Download references

Acknowledgements

We would like to sincerely thank the participants and those who facilitated the research in the study.

The research was supported by the Soft Science Key Project of the Science and Technology Tackling Program of Henan Provincial Health Commission (RKX202301003).

Author information

Authors and affiliations.

Nursing Department, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Henan, China

Funa Yang & Xiaoxia Xu

School of Nursing, Hong Kong Polytechnic University, Hong Kong, China

Ka Yan Ho, Katherine Ka Wai Lam, Qi Liu, Ting Mao & Frances-Kam-Yuet Wong

Nursing Department, Luohe Central Hospital, Henan, China

Department of Critical Care Medicine, Zhengzhou Central Hospital, Henan, China

Nursing Department, Sanmenxia Central Hospital, Henan, China

Xiuxiu Yang

Department of Anorectal Surgery, Pingdingshan First People’s Hospital, Henan, China

Chinese-Western Medicine Combined Department, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Henan, China

Yanling Gao

Office of the Dean, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Henan, China

Hongying Shi

Department of Clinical Research Management, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Henan, China

You can also search for this author in PubMed Google Scholar

Contributions

FNY, KYHo, LWG designed the study. FNY, QL conducted the literature search and wrote the initial proposal. FNY, KYHo, TM analyzed the data and interpretation of data. FNY and KYH drafted the manuscript. YW, LQ L, XXY, NX, YLG contributed to the data collection process. XXX, HYS, LWG, FKYW, KKWL reviewed and provided expert opinions. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Lanwei Guo .

Ethics declarations

Ethics approval and consent to participate.

This investigation was sanctioned by the Medical Ethics Committee of Henan Cancer Hospital (Number 2023-KY-0014). Informed consent to participate was obtained from all the participants in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, rights and permissions.

Reprints and permissions

About this article

Cite this article.

Yang, F., Ho, K.Y., Lam, K.K.W. et al. Facilitators and barriers to evidence adoption for central venous catheters post-insertion maintenance in oncology nurses: a multi-center mixed methods study. BMC Nurs 23 , 581 (2024). https://doi.org/10.1186/s12912-024-02242-y

Download citation

Received : 08 January 2024

Accepted : 07 August 2024

Published : 21 August 2024

DOI : https://doi.org/10.1186/s12912-024-02242-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Central venous catheters
Evidence-based practice
Facilitators
Oncology nursing

BMC Nursing

ISSN: 1472-6955

General enquiries: [email protected]

COMMENTS

Key Informant Interviews: An In-Depth Guide for Researchers
Key Informant Interviews (KIIs) stand as an indispensable qualitative research tool, adept at uncovering deep insights and nuanced understandings in a wide array of research settings. From exploring complex and sensitive issues to refining hypotheses and informing policy decisions, KIIs offer a unique avenue for accessing expert knowledge and ...
Key Informants in Applied Qualitative Health Research
Enrolling key informants is common in many applied qualitative health research studies. Although the "key informant technique" originated in ethnographic anthropology, key (Tremblay, 1957) informants are now commonly integrated into data collection strategies in diverse research methodologies.However, there is a dearth of methodological guidance for qualitative researchers working outside ...
Key Informants' Interviews
The term key informant is usually associated with qualitative research. Key informant interview is interviewing knowledgeable persons as an important part of the method of investigation (Blackwell Encyclopaedia of Sociology, 2018). Key informant interviews are in-depth interviews to capture participants' perspectives on the research topic.
PDF Key Informants' Interviews
The term key informant is usually associated with qualitative research. Key infor-mant interview is interviewing knowledgeable persons as an important part of the method of investigation (Blackwell Encyclopaedia of Sociology, 2018). Key infor-mant interviews are in-depth interviews to capture participants' perspectives on the research topic.
Key Informants in Applied Qualitative Health Research
Key informants have been used widely in a range of applied qualitative health research methodologies in-cluding grounded theory, interpretive description, and qualitative description. Key informants have been referred to as informants, experts, stakeholders, and key. ". knowledgeables (Patton, 2014). In applied qualitative.
Key informant interviews
Key informant interviews are "qualitative, in-depth interviews of 15 to 35 people selected for their first-hand knowledge about a topic of interest. The interviews are loosely structured, relying on a list of issues to be discussed. Key informant interviews resemble a conversation among acquaintances, allowing a free flow of ideas and information.
The Key Informant Technique in Qualitative Research
The main purpose of the case in this research context is to set out in practical detail the social and analytical processes required of the researcher when adopting the key informant technique. The key informant technique, often referred to as the in-depth interview, is characteristic of interpretative qualitative research and ethnographic ...
Whose Voices? Whose Knowledge? A Feminist Analysis of the Value of Key
Key informant interviews are a stalwart of qualitative research, particularly policy-focused research. So ubiquitous is this research method that it is sometimes taken for granted that key informants indeed have important knowledge and value.
Key Informants' Interviews
Key Informants' Interviews. October 2022. DOI: 10.1007/978-981-19-5441-2_27. In book: Principles of Social Research Methodology (pp.389-403) Authors: Salma Akhter. University of Dhaka. To read ...
PDF Ucla Center for Health Policy Research
4.9 Conduct key informant interviews 4.10 Compile and organize key informant interview data 4.1 Gather and review existing data Collect and review existing research data and reports before determining what additional information needs to be collected from key informants, as the information you are looking for may already exist.
PDF Key Informant Interviews
THP-OEPP Key Informant Interviews [August 2012] 1 Key Informant Interviews Outcome Evaluation Pilot Project (OEPP) ... in-depth interviews are used to gather qualitative information that can provide an enhanced ... (having valuable knowledge about your research topic) and the interviewer is considered the student. As a researcher, you will ...
PDF CONDUCTING KEY INFORMANT INTERVIEWS
Steps in Conducting the Interviews. Step 1. Formulate study questions. These relate to specific concerns of the study. Study questions generally should be limited to five or fewer. Step 2. Prepare a short interview guide. Key informant interviews do not use rigid ques- tionnaires, which inhibit free discussion.
PDF III. Key informant interviews
a problem, especially for policy-oriented research (Lokot, 2021, p. 3). Interviews—whether referred to as KIIs, expert interviews, or in-depth interviews (terms used interchangeably for the purposes of this discussion)—can uncover detailed infor - mation, personal beliefs, and individual motivations, including on sensitive topics.
(PDF) 02. Key Informant Survey/Interview (KIS)
The key informant interview is a type of qualitative in-depth interview. It is one of several rapid, low-. cost modes o f qualitative data collection that can be used for assessing and management ...
How many key informants are enough? Analysing the validity of the
A number of 4-6 key informant interviews are recommended in the community ... In qualitative research, the concept of data saturation refers to the point in data collection when no new information arises from subsequent data collection efforts [8, 9]. Studies examining the number of qualitative interviews required to reach data ...
What's the Difference Between Key Informant Interviews and In-Depth
The key informant interview is a type of qualitative in-depth interview. Both types, key informant and in-depth interviews, forgo preconceived questions to instead focus on the dynamic flow of conversation between researcher and participant(s). But depending on their resources, as well as the type of data needed, companies often choose one ...
Key Informant Interviews
Key informant interviews are in-depth qualitative interviews of a small number of individuals (15-35) with direct knowledge or experience about a particular topic. The goal of conducting key informant interviews is to obtain descriptions of insights, perceptions, and experiences from a wide range of people.
(PDF) Using the Key Informants Interviews (KIIs) Technique: A Social
This chapter provides a short description of the key informant interview (KII), an important data collection method in qualitative research. Then, the chapter explains the suitability of this ...
Using Qualitative Comparative Analysis of Key Informant Interviews in
Background: Qualitative comparative analysis (QCA) is a methodology created to address causal complexity in social sciences research by preserving the objectivity of quantitative data analysis without losing detail inherent in qualitative research. However, its use in health services research (HSR) is limited, and questions remain about its application in this context.
Key Informants in Applied Qualitative Health Research
Introduction. Enrolling key informants is common in many applied qualitative health research studies. Although the "key informant technique" originated in ethnographic anthropology, key (Tremblay, 1957) informants are now commonly integrated into data collection strategies in diverse research methodologies.However, there is a dearth of methodological guidance for qualitative researchers ...
Whose Voices? Whose Knowledge? A Feminist Analysis of the Value of Key
Key informant interviews are a stalwart of qualitative research, particularly policy-focused research. So ubiquitous is this research method that it is sometimes taken for granted that key informants indeed have important knowledge and value.
Key informant interviews.
Citation. Gilchrist, V. J. (1992). Key informant interviews. In B. F. Crabtree & W. L. Miller (Eds.), Doing qualitative research (pp. 70-89). Sage Publications, Inc.
Exploring healthcare workers' perceptions of child health research at
Key Informant Interviews (KIIs) and Individual In-Depth Interviews (IDIs) generated detailed descriptions of child HCWs' experiences in conducting child health research at KCH, a tertiary hospital with a well-established paediatric section in Lilongwe, Malawi (Fig. 1). KCH is a primary site for child health studies, making it suitable for ...
The establishment, persistence, and scaling of marine ...
It draws on a document review of the grey and scientific literature, and in-depth qualitative field work carried out in four coastal districts on mainland Tanzania. The field work involved 15 key informant interviews, 12 focus groups discussion, and participant observation, documenting the perceptions of resource users.
PDF Conducting Key Informant Interviews
Steps in Conducting the Interviews. Step 1. Formulate study questions. These relate to specific concerns of the study. Study questions generally should be limited to five or fewer. Step 2. Prepare a short interview guide. Key informant interviews do not use rigid ques-tionnaires, which inhibit free discussion.
Narrative analysis interview transcript techniques for qualitative research
This method allows for a nuanced examination of interview transcripts, revealing the underlying emotions and motivations of participants. Ultimately, the Storytelling Analysis Method enriches qualitative research, making it vital for those seeking to grasp the complexities of human narratives. The Fundamentals of Narrative Analysis
Facilitators and barriers to evidence adoption for central venous
In the qualitative phase, a series of in-depth semi-structured interviews were administered by the first author, who was a nursing manager and hailed from different departments with the informants. All informants will be informed of the quantitative findings before the interview to ensure the continuity of the two research phases.

Key Informant Interviews: An In-Depth Guide for Researchers

What are Key Informant Interviews?

The Importance of Key Informant Interviews in Research

Methodology and Best Practices for Key Informant Interviews

Challenges and Solutions in Key Informant Interviews

Analyzing and Utilizing Data from Key Informant Interviews

When to Use Key Informant Interviews in Research

Master Key Informant Interviews with GeoPoll

Key Informants’ Interviews

Cite this chapter

Access this chapter

Similar content being viewed by others

Interviewing in Qualitative Research

Methodological Framework

Qualitative Interviewing

Author information

Corresponding author

Editor information

Rights and permissions

Copyright information

About this chapter

Download citation

Share this chapter

Key informant interviews

Advice for using this method

'Key informant interviews' is referenced in:

Framework/Guide

What’s the Difference Between Key Informant Interviews and In-Depth Interviews?

An Introduction to In-Depth Interviews

In-Depth Interviews: Data Collection Advantages and Disadvantages

Four Actionable Tips to Improve Your In-Depth Interviews

Stay In The Loop

Save citation to file

Add to My Bibliography

Using Qualitative Comparative Analysis of Key Informant Interviews in Health Services Research: Enhancing a Study of Adjuvant Therapy Use in Breast Cancer Care

Similar articles

Publication types

Grants and funding

LinkOut - more resources

Other Literature Sources

Key Informants in Applied Qualitative Health Research

Alice Cavanagh

Meredith Vanstone

Introduction

Conceptualizing the Key Informant

What Knowledge Are They Representing?

How Have Key Informants Been Used in Applied Qualitative Health Research?

Working With Key Informants

What Sampling Strategies Could Be Used?

Identifying and Recruiting Key Informants

Accounting for Data Sufficiency

Ethical Considerations

Worked Examples: Key Informant Conceptualization and Sampling in Two Methodologies

Exploring healthcare workers’ perceptions of child health research at Kamuzu Central Hospital, Malawi: an interpretative phenomenological analysis

Conclusions

Study design and setting

Recruitment

Data collection

Data analysis

Ethical considerations

Reflexivity

Perceived motivation and challenges for engaging in child health research

Perceptions of resource availability and research opportunities at KCH

Perceptions of gaps in research training and participation among child HCWs

Limitations

Availability of data and materials

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Competing interests

Additional information

Supplementary Information

About this article

Share this article

Human Resources for Health

Extract insights from Customer & Employee Interviews. At Scale.