qualitative research proposal in nursing

Designing a Research Proposal in Qualitative Research

• First Online: 27 October 2022

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• Md. Ismail Hossain 4 ,
• Nafiul Mehedi 4 &
• Iftakhar Ahmad 4  

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The chapter discusses designing a research proposal in qualitative research. The main objective is to outline the major components of a qualitative research proposal with example(s) so that the students and novice scholars easily get an understanding of a qualitative proposal. The chapter highlights the major components of a qualitative research proposal and discusses the steps involved in designing a proposal. In each step, an example is given with some essential tips. Following these steps and tips, a novice researcher can easily prepare a qualitative research proposal. Readers, especially undergraduate and master’s students, might use this as a guideline while preparing a thesis proposal. After reading this chapter, they can easily prepare a qualitative proposal.

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Hossain, M.I., Mehedi, N., Ahmad, I. (2022). Designing a Research Proposal in Qualitative Research. 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_18

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A Practical Guide to Writing Quantitative and Qualitative Research Questions and Hypotheses in Scholarly Articles

Edward barroga.

1 Department of General Education, Graduate School of Nursing Science, St. Luke’s International University, Tokyo, Japan.

Glafera Janet Matanguihan

2 Department of Biological Sciences, Messiah University, Mechanicsburg, PA, USA.

The development of research questions and the subsequent hypotheses are prerequisites to defining the main research purpose and specific objectives of a study. Consequently, these objectives determine the study design and research outcome. The development of research questions is a process based on knowledge of current trends, cutting-edge studies, and technological advances in the research field. Excellent research questions are focused and require a comprehensive literature search and in-depth understanding of the problem being investigated. Initially, research questions may be written as descriptive questions which could be developed into inferential questions. These questions must be specific and concise to provide a clear foundation for developing hypotheses. Hypotheses are more formal predictions about the research outcomes. These specify the possible results that may or may not be expected regarding the relationship between groups. Thus, research questions and hypotheses clarify the main purpose and specific objectives of the study, which in turn dictate the design of the study, its direction, and outcome. Studies developed from good research questions and hypotheses will have trustworthy outcomes with wide-ranging social and health implications.

INTRODUCTION

Scientific research is usually initiated by posing evidenced-based research questions which are then explicitly restated as hypotheses. 1 , 2 The hypotheses provide directions to guide the study, solutions, explanations, and expected results. 3 , 4 Both research questions and hypotheses are essentially formulated based on conventional theories and real-world processes, which allow the inception of novel studies and the ethical testing of ideas. 5 , 6

It is crucial to have knowledge of both quantitative and qualitative research 2 as both types of research involve writing research questions and hypotheses. 7 However, these crucial elements of research are sometimes overlooked; if not overlooked, then framed without the forethought and meticulous attention it needs. Planning and careful consideration are needed when developing quantitative or qualitative research, particularly when conceptualizing research questions and hypotheses. 4

There is a continuing need to support researchers in the creation of innovative research questions and hypotheses, as well as for journal articles that carefully review these elements. 1 When research questions and hypotheses are not carefully thought of, unethical studies and poor outcomes usually ensue. Carefully formulated research questions and hypotheses define well-founded objectives, which in turn determine the appropriate design, course, and outcome of the study. This article then aims to discuss in detail the various aspects of crafting research questions and hypotheses, with the goal of guiding researchers as they develop their own. Examples from the authors and peer-reviewed scientific articles in the healthcare field are provided to illustrate key points.

DEFINITIONS AND RELATIONSHIP OF RESEARCH QUESTIONS AND HYPOTHESES

A research question is what a study aims to answer after data analysis and interpretation. The answer is written in length in the discussion section of the paper. Thus, the research question gives a preview of the different parts and variables of the study meant to address the problem posed in the research question. 1 An excellent research question clarifies the research writing while facilitating understanding of the research topic, objective, scope, and limitations of the study. 5

On the other hand, a research hypothesis is an educated statement of an expected outcome. This statement is based on background research and current knowledge. 8 , 9 The research hypothesis makes a specific prediction about a new phenomenon 10 or a formal statement on the expected relationship between an independent variable and a dependent variable. 3 , 11 It provides a tentative answer to the research question to be tested or explored. 4

Hypotheses employ reasoning to predict a theory-based outcome. 10 These can also be developed from theories by focusing on components of theories that have not yet been observed. 10 The validity of hypotheses is often based on the testability of the prediction made in a reproducible experiment. 8

Conversely, hypotheses can also be rephrased as research questions. Several hypotheses based on existing theories and knowledge may be needed to answer a research question. Developing ethical research questions and hypotheses creates a research design that has logical relationships among variables. These relationships serve as a solid foundation for the conduct of the study. 4 , 11 Haphazardly constructed research questions can result in poorly formulated hypotheses and improper study designs, leading to unreliable results. Thus, the formulations of relevant research questions and verifiable hypotheses are crucial when beginning research. 12

CHARACTERISTICS OF GOOD RESEARCH QUESTIONS AND HYPOTHESES

Excellent research questions are specific and focused. These integrate collective data and observations to confirm or refute the subsequent hypotheses. Well-constructed hypotheses are based on previous reports and verify the research context. These are realistic, in-depth, sufficiently complex, and reproducible. More importantly, these hypotheses can be addressed and tested. 13

There are several characteristics of well-developed hypotheses. Good hypotheses are 1) empirically testable 7 , 10 , 11 , 13 ; 2) backed by preliminary evidence 9 ; 3) testable by ethical research 7 , 9 ; 4) based on original ideas 9 ; 5) have evidenced-based logical reasoning 10 ; and 6) can be predicted. 11 Good hypotheses can infer ethical and positive implications, indicating the presence of a relationship or effect relevant to the research theme. 7 , 11 These are initially developed from a general theory and branch into specific hypotheses by deductive reasoning. In the absence of a theory to base the hypotheses, inductive reasoning based on specific observations or findings form more general hypotheses. 10

TYPES OF RESEARCH QUESTIONS AND HYPOTHESES

Research questions and hypotheses are developed according to the type of research, which can be broadly classified into quantitative and qualitative research. We provide a summary of the types of research questions and hypotheses under quantitative and qualitative research categories in Table 1 .

Research questions in quantitative research

In quantitative research, research questions inquire about the relationships among variables being investigated and are usually framed at the start of the study. These are precise and typically linked to the subject population, dependent and independent variables, and research design. 1 Research questions may also attempt to describe the behavior of a population in relation to one or more variables, or describe the characteristics of variables to be measured ( descriptive research questions ). 1 , 5 , 14 These questions may also aim to discover differences between groups within the context of an outcome variable ( comparative research questions ), 1 , 5 , 14 or elucidate trends and interactions among variables ( relationship research questions ). 1 , 5 We provide examples of descriptive, comparative, and relationship research questions in quantitative research in Table 2 .

Hypotheses in quantitative research

In quantitative research, hypotheses predict the expected relationships among variables. 15 Relationships among variables that can be predicted include 1) between a single dependent variable and a single independent variable ( simple hypothesis ) or 2) between two or more independent and dependent variables ( complex hypothesis ). 4 , 11 Hypotheses may also specify the expected direction to be followed and imply an intellectual commitment to a particular outcome ( directional hypothesis ) 4 . On the other hand, hypotheses may not predict the exact direction and are used in the absence of a theory, or when findings contradict previous studies ( non-directional hypothesis ). 4 In addition, hypotheses can 1) define interdependency between variables ( associative hypothesis ), 4 2) propose an effect on the dependent variable from manipulation of the independent variable ( causal hypothesis ), 4 3) state a negative relationship between two variables ( null hypothesis ), 4 , 11 , 15 4) replace the working hypothesis if rejected ( alternative hypothesis ), 15 explain the relationship of phenomena to possibly generate a theory ( working hypothesis ), 11 5) involve quantifiable variables that can be tested statistically ( statistical hypothesis ), 11 6) or express a relationship whose interlinks can be verified logically ( logical hypothesis ). 11 We provide examples of simple, complex, directional, non-directional, associative, causal, null, alternative, working, statistical, and logical hypotheses in quantitative research, as well as the definition of quantitative hypothesis-testing research in Table 3 .

Research questions in qualitative research

Unlike research questions in quantitative research, research questions in qualitative research are usually continuously reviewed and reformulated. The central question and associated subquestions are stated more than the hypotheses. 15 The central question broadly explores a complex set of factors surrounding the central phenomenon, aiming to present the varied perspectives of participants. 15

There are varied goals for which qualitative research questions are developed. These questions can function in several ways, such as to 1) identify and describe existing conditions ( contextual research question s); 2) describe a phenomenon ( descriptive research questions ); 3) assess the effectiveness of existing methods, protocols, theories, or procedures ( evaluation research questions ); 4) examine a phenomenon or analyze the reasons or relationships between subjects or phenomena ( explanatory research questions ); or 5) focus on unknown aspects of a particular topic ( exploratory research questions ). 5 In addition, some qualitative research questions provide new ideas for the development of theories and actions ( generative research questions ) or advance specific ideologies of a position ( ideological research questions ). 1 Other qualitative research questions may build on a body of existing literature and become working guidelines ( ethnographic research questions ). Research questions may also be broadly stated without specific reference to the existing literature or a typology of questions ( phenomenological research questions ), may be directed towards generating a theory of some process ( grounded theory questions ), or may address a description of the case and the emerging themes ( qualitative case study questions ). 15 We provide examples of contextual, descriptive, evaluation, explanatory, exploratory, generative, ideological, ethnographic, phenomenological, grounded theory, and qualitative case study research questions in qualitative research in Table 4 , and the definition of qualitative hypothesis-generating research in Table 5 .

Qualitative studies usually pose at least one central research question and several subquestions starting with How or What . These research questions use exploratory verbs such as explore or describe . These also focus on one central phenomenon of interest, and may mention the participants and research site. 15

Hypotheses in qualitative research

Hypotheses in qualitative research are stated in the form of a clear statement concerning the problem to be investigated. Unlike in quantitative research where hypotheses are usually developed to be tested, qualitative research can lead to both hypothesis-testing and hypothesis-generating outcomes. 2 When studies require both quantitative and qualitative research questions, this suggests an integrative process between both research methods wherein a single mixed-methods research question can be developed. 1

FRAMEWORKS FOR DEVELOPING RESEARCH QUESTIONS AND HYPOTHESES

Research questions followed by hypotheses should be developed before the start of the study. 1 , 12 , 14 It is crucial to develop feasible research questions on a topic that is interesting to both the researcher and the scientific community. This can be achieved by a meticulous review of previous and current studies to establish a novel topic. Specific areas are subsequently focused on to generate ethical research questions. The relevance of the research questions is evaluated in terms of clarity of the resulting data, specificity of the methodology, objectivity of the outcome, depth of the research, and impact of the study. 1 , 5 These aspects constitute the FINER criteria (i.e., Feasible, Interesting, Novel, Ethical, and Relevant). 1 Clarity and effectiveness are achieved if research questions meet the FINER criteria. In addition to the FINER criteria, Ratan et al. described focus, complexity, novelty, feasibility, and measurability for evaluating the effectiveness of research questions. 14

The PICOT and PEO frameworks are also used when developing research questions. 1 The following elements are addressed in these frameworks, PICOT: P-population/patients/problem, I-intervention or indicator being studied, C-comparison group, O-outcome of interest, and T-timeframe of the study; PEO: P-population being studied, E-exposure to preexisting conditions, and O-outcome of interest. 1 Research questions are also considered good if these meet the “FINERMAPS” framework: Feasible, Interesting, Novel, Ethical, Relevant, Manageable, Appropriate, Potential value/publishable, and Systematic. 14

As we indicated earlier, research questions and hypotheses that are not carefully formulated result in unethical studies or poor outcomes. To illustrate this, we provide some examples of ambiguous research question and hypotheses that result in unclear and weak research objectives in quantitative research ( Table 6 ) 16 and qualitative research ( Table 7 ) 17 , and how to transform these ambiguous research question(s) and hypothesis(es) into clear and good statements.

a These statements were composed for comparison and illustrative purposes only.

b These statements are direct quotes from Higashihara and Horiuchi. 16

a This statement is a direct quote from Shimoda et al. 17

The other statements were composed for comparison and illustrative purposes only.

CONSTRUCTING RESEARCH QUESTIONS AND HYPOTHESES

To construct effective research questions and hypotheses, it is very important to 1) clarify the background and 2) identify the research problem at the outset of the research, within a specific timeframe. 9 Then, 3) review or conduct preliminary research to collect all available knowledge about the possible research questions by studying theories and previous studies. 18 Afterwards, 4) construct research questions to investigate the research problem. Identify variables to be accessed from the research questions 4 and make operational definitions of constructs from the research problem and questions. Thereafter, 5) construct specific deductive or inductive predictions in the form of hypotheses. 4 Finally, 6) state the study aims . This general flow for constructing effective research questions and hypotheses prior to conducting research is shown in Fig. 1 .

Research questions are used more frequently in qualitative research than objectives or hypotheses. 3 These questions seek to discover, understand, explore or describe experiences by asking “What” or “How.” The questions are open-ended to elicit a description rather than to relate variables or compare groups. The questions are continually reviewed, reformulated, and changed during the qualitative study. 3 Research questions are also used more frequently in survey projects than hypotheses in experiments in quantitative research to compare variables and their relationships.

Hypotheses are constructed based on the variables identified and as an if-then statement, following the template, ‘If a specific action is taken, then a certain outcome is expected.’ At this stage, some ideas regarding expectations from the research to be conducted must be drawn. 18 Then, the variables to be manipulated (independent) and influenced (dependent) are defined. 4 Thereafter, the hypothesis is stated and refined, and reproducible data tailored to the hypothesis are identified, collected, and analyzed. 4 The hypotheses must be testable and specific, 18 and should describe the variables and their relationships, the specific group being studied, and the predicted research outcome. 18 Hypotheses construction involves a testable proposition to be deduced from theory, and independent and dependent variables to be separated and measured separately. 3 Therefore, good hypotheses must be based on good research questions constructed at the start of a study or trial. 12

In summary, research questions are constructed after establishing the background of the study. Hypotheses are then developed based on the research questions. Thus, it is crucial to have excellent research questions to generate superior hypotheses. In turn, these would determine the research objectives and the design of the study, and ultimately, the outcome of the research. 12 Algorithms for building research questions and hypotheses are shown in Fig. 2 for quantitative research and in Fig. 3 for qualitative research.

EXAMPLES OF RESEARCH QUESTIONS FROM PUBLISHED ARTICLES

• EXAMPLE 1. Descriptive research question (quantitative research)
• - Presents research variables to be assessed (distinct phenotypes and subphenotypes)
• “BACKGROUND: Since COVID-19 was identified, its clinical and biological heterogeneity has been recognized. Identifying COVID-19 phenotypes might help guide basic, clinical, and translational research efforts.
• RESEARCH QUESTION: Does the clinical spectrum of patients with COVID-19 contain distinct phenotypes and subphenotypes? ” 19
• EXAMPLE 2. Relationship research question (quantitative research)
• - Shows interactions between dependent variable (static postural control) and independent variable (peripheral visual field loss)
• “Background: Integration of visual, vestibular, and proprioceptive sensations contributes to postural control. People with peripheral visual field loss have serious postural instability. However, the directional specificity of postural stability and sensory reweighting caused by gradual peripheral visual field loss remain unclear.
• Research question: What are the effects of peripheral visual field loss on static postural control ?” 20
• EXAMPLE 3. Comparative research question (quantitative research)
• - Clarifies the difference among groups with an outcome variable (patients enrolled in COMPERA with moderate PH or severe PH in COPD) and another group without the outcome variable (patients with idiopathic pulmonary arterial hypertension (IPAH))
• “BACKGROUND: Pulmonary hypertension (PH) in COPD is a poorly investigated clinical condition.
• RESEARCH QUESTION: Which factors determine the outcome of PH in COPD?
• STUDY DESIGN AND METHODS: We analyzed the characteristics and outcome of patients enrolled in the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) with moderate or severe PH in COPD as defined during the 6th PH World Symposium who received medical therapy for PH and compared them with patients with idiopathic pulmonary arterial hypertension (IPAH) .” 21
• EXAMPLE 4. Exploratory research question (qualitative research)
• - Explores areas that have not been fully investigated (perspectives of families and children who receive care in clinic-based child obesity treatment) to have a deeper understanding of the research problem
• “Problem: Interventions for children with obesity lead to only modest improvements in BMI and long-term outcomes, and data are limited on the perspectives of families of children with obesity in clinic-based treatment. This scoping review seeks to answer the question: What is known about the perspectives of families and children who receive care in clinic-based child obesity treatment? This review aims to explore the scope of perspectives reported by families of children with obesity who have received individualized outpatient clinic-based obesity treatment.” 22
• EXAMPLE 5. Relationship research question (quantitative research)
• - Defines interactions between dependent variable (use of ankle strategies) and independent variable (changes in muscle tone)
• “Background: To maintain an upright standing posture against external disturbances, the human body mainly employs two types of postural control strategies: “ankle strategy” and “hip strategy.” While it has been reported that the magnitude of the disturbance alters the use of postural control strategies, it has not been elucidated how the level of muscle tone, one of the crucial parameters of bodily function, determines the use of each strategy. We have previously confirmed using forward dynamics simulations of human musculoskeletal models that an increased muscle tone promotes the use of ankle strategies. The objective of the present study was to experimentally evaluate a hypothesis: an increased muscle tone promotes the use of ankle strategies. Research question: Do changes in the muscle tone affect the use of ankle strategies ?” 23

EXAMPLES OF HYPOTHESES IN PUBLISHED ARTICLES

• EXAMPLE 1. Working hypothesis (quantitative research)
• - A hypothesis that is initially accepted for further research to produce a feasible theory
• “As fever may have benefit in shortening the duration of viral illness, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response when taken during the early stages of COVID-19 illness .” 24
• “In conclusion, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response . The difference in perceived safety of these agents in COVID-19 illness could be related to the more potent efficacy to reduce fever with ibuprofen compared to acetaminophen. Compelling data on the benefit of fever warrant further research and review to determine when to treat or withhold ibuprofen for early stage fever for COVID-19 and other related viral illnesses .” 24
• EXAMPLE 2. Exploratory hypothesis (qualitative research)
• - Explores particular areas deeper to clarify subjective experience and develop a formal hypothesis potentially testable in a future quantitative approach
• “We hypothesized that when thinking about a past experience of help-seeking, a self distancing prompt would cause increased help-seeking intentions and more favorable help-seeking outcome expectations .” 25
• “Conclusion
• Although a priori hypotheses were not supported, further research is warranted as results indicate the potential for using self-distancing approaches to increasing help-seeking among some people with depressive symptomatology.” 25
• EXAMPLE 3. Hypothesis-generating research to establish a framework for hypothesis testing (qualitative research)
• “We hypothesize that compassionate care is beneficial for patients (better outcomes), healthcare systems and payers (lower costs), and healthcare providers (lower burnout). ” 26
• Compassionomics is the branch of knowledge and scientific study of the effects of compassionate healthcare. Our main hypotheses are that compassionate healthcare is beneficial for (1) patients, by improving clinical outcomes, (2) healthcare systems and payers, by supporting financial sustainability, and (3) HCPs, by lowering burnout and promoting resilience and well-being. The purpose of this paper is to establish a scientific framework for testing the hypotheses above . If these hypotheses are confirmed through rigorous research, compassionomics will belong in the science of evidence-based medicine, with major implications for all healthcare domains.” 26
• EXAMPLE 4. Statistical hypothesis (quantitative research)
• - An assumption is made about the relationship among several population characteristics ( gender differences in sociodemographic and clinical characteristics of adults with ADHD ). Validity is tested by statistical experiment or analysis ( chi-square test, Students t-test, and logistic regression analysis)
• “Our research investigated gender differences in sociodemographic and clinical characteristics of adults with ADHD in a Japanese clinical sample. Due to unique Japanese cultural ideals and expectations of women's behavior that are in opposition to ADHD symptoms, we hypothesized that women with ADHD experience more difficulties and present more dysfunctions than men . We tested the following hypotheses: first, women with ADHD have more comorbidities than men with ADHD; second, women with ADHD experience more social hardships than men, such as having less full-time employment and being more likely to be divorced.” 27
• “Statistical Analysis
• ( text omitted ) Between-gender comparisons were made using the chi-squared test for categorical variables and Students t-test for continuous variables…( text omitted ). A logistic regression analysis was performed for employment status, marital status, and comorbidity to evaluate the independent effects of gender on these dependent variables.” 27

EXAMPLES OF HYPOTHESIS AS WRITTEN IN PUBLISHED ARTICLES IN RELATION TO OTHER PARTS

• EXAMPLE 1. Background, hypotheses, and aims are provided
• “Pregnant women need skilled care during pregnancy and childbirth, but that skilled care is often delayed in some countries …( text omitted ). The focused antenatal care (FANC) model of WHO recommends that nurses provide information or counseling to all pregnant women …( text omitted ). Job aids are visual support materials that provide the right kind of information using graphics and words in a simple and yet effective manner. When nurses are not highly trained or have many work details to attend to, these job aids can serve as a content reminder for the nurses and can be used for educating their patients (Jennings, Yebadokpo, Affo, & Agbogbe, 2010) ( text omitted ). Importantly, additional evidence is needed to confirm how job aids can further improve the quality of ANC counseling by health workers in maternal care …( text omitted )” 28
• “ This has led us to hypothesize that the quality of ANC counseling would be better if supported by job aids. Consequently, a better quality of ANC counseling is expected to produce higher levels of awareness concerning the danger signs of pregnancy and a more favorable impression of the caring behavior of nurses .” 28
• “This study aimed to examine the differences in the responses of pregnant women to a job aid-supported intervention during ANC visit in terms of 1) their understanding of the danger signs of pregnancy and 2) their impression of the caring behaviors of nurses to pregnant women in rural Tanzania.” 28
• EXAMPLE 2. Background, hypotheses, and aims are provided
• “We conducted a two-arm randomized controlled trial (RCT) to evaluate and compare changes in salivary cortisol and oxytocin levels of first-time pregnant women between experimental and control groups. The women in the experimental group touched and held an infant for 30 min (experimental intervention protocol), whereas those in the control group watched a DVD movie of an infant (control intervention protocol). The primary outcome was salivary cortisol level and the secondary outcome was salivary oxytocin level.” 29
• “ We hypothesize that at 30 min after touching and holding an infant, the salivary cortisol level will significantly decrease and the salivary oxytocin level will increase in the experimental group compared with the control group .” 29
• EXAMPLE 3. Background, aim, and hypothesis are provided
• “In countries where the maternal mortality ratio remains high, antenatal education to increase Birth Preparedness and Complication Readiness (BPCR) is considered one of the top priorities [1]. BPCR includes birth plans during the antenatal period, such as the birthplace, birth attendant, transportation, health facility for complications, expenses, and birth materials, as well as family coordination to achieve such birth plans. In Tanzania, although increasing, only about half of all pregnant women attend an antenatal clinic more than four times [4]. Moreover, the information provided during antenatal care (ANC) is insufficient. In the resource-poor settings, antenatal group education is a potential approach because of the limited time for individual counseling at antenatal clinics.” 30
• “This study aimed to evaluate an antenatal group education program among pregnant women and their families with respect to birth-preparedness and maternal and infant outcomes in rural villages of Tanzania.” 30
• “ The study hypothesis was if Tanzanian pregnant women and their families received a family-oriented antenatal group education, they would (1) have a higher level of BPCR, (2) attend antenatal clinic four or more times, (3) give birth in a health facility, (4) have less complications of women at birth, and (5) have less complications and deaths of infants than those who did not receive the education .” 30

Research questions and hypotheses are crucial components to any type of research, whether quantitative or qualitative. These questions should be developed at the very beginning of the study. Excellent research questions lead to superior hypotheses, which, like a compass, set the direction of research, and can often determine the successful conduct of the study. Many research studies have floundered because the development of research questions and subsequent hypotheses was not given the thought and meticulous attention needed. The development of research questions and hypotheses is an iterative process based on extensive knowledge of the literature and insightful grasp of the knowledge gap. Focused, concise, and specific research questions provide a strong foundation for constructing hypotheses which serve as formal predictions about the research outcomes. Research questions and hypotheses are crucial elements of research that should not be overlooked. They should be carefully thought of and constructed when planning research. This avoids unethical studies and poor outcomes by defining well-founded objectives that determine the design, course, and outcome of the study.

Disclosure: The authors have no potential conflicts of interest to disclose.

Author Contributions:

• Conceptualization: Barroga E, Matanguihan GJ.
• Methodology: Barroga E, Matanguihan GJ.
• Writing - original draft: Barroga E, Matanguihan GJ.
• Writing - review & editing: Barroga E, Matanguihan GJ.

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The qualitative research proposal

Affiliation.

• 1 School of Nursing Science, North-West University, South Africa. [email protected]
• PMID: 19653539
• DOI: 10.4102/curationis.v31i4.1062

Qualitative research in the health sciences has had to overcome many prejudices and a number of misunderstandings, but today qualitative research is as acceptable as quantitative research designs and is widely funded and published. Writing the proposal of a qualitative study, however, can be a challenging feat, due to the emergent nature of the qualitative research design and the description of the methodology as a process. Even today, many sub-standard proposals at post-graduate evaluation committees and application proposals to be considered for funding are still seen. This problem has led the researcher to develop a framework to guide the qualitative researcher in writing the proposal of a qualitative study based on the following research questions: (i) What is the process of writing a qualitative research proposal? and (ii) What does the structure and layout of a qualitative proposal look like? The purpose of this article is to discuss the process of writing the qualitative research proposal, as well as describe the structure and layout of a qualitative research proposal. The process of writing a qualitative research proposal is discussed with regards to the most important questions that need to be answered in your research proposal with consideration of the guidelines of being practical, being persuasive, making broader links, aiming for crystal clarity and planning before you write. While the structure of the qualitative research proposal is discussed with regards to the key sections of the proposal, namely the cover page, abstract, introduction, review of the literature, research problem and research questions, research purpose and objectives, research paradigm, research design, research method, ethical considerations, dissemination plan, budget and appendices.

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• Correspondence to Kate Seers RCN Research Institute, School of Health & Social Studies, University of Warwick, Coventry, CV4 7AL, Warwick, UK; kate.seers{at}warwick.ac.uk

https://doi.org/10.1136/ebnurs.2011.100352

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Good qualitative research uses a systematic and rigorous approach that aims to answer questions concerned with what something is like (such as a patient experience), what people think or feel about something that has happened, and it may address why something has happened as it has. Qualitative data often takes the form of words or text and can include images.

Qualitative research covers a very broad range of philosophical underpinnings and methodological approaches. Each has its own particular way of approaching all stages of the research process, including analysis, and has its own terms and techniques, but there are some common threads that run across most of these approaches. This Research Made Simple piece will focus on some of these common threads in the analysis of qualitative research.

So you have collected all your qualitative data – you may have a pile of interview transcripts, field-notes, documents and notes from observation. The process of analysis is described by Richards and Morse 1 as one of transformation and interpretation.

It is easy to be overwhelmed by the volume of data – novice qualitative researchers are sometimes told not to worry and the themes will emerge from the data. This suggests some sort of epiphany, (which is how it happens sometimes!) but generally it comes from detailed work and reflection on the data and what it is telling you. There is sometimes a fine line between being immersed in the data and drowning in it!

A first step is to sort and organise the data, by coding it in some way. For example, you could read through a transcript, and identify that in one paragraph a patient is talking about two things; first is fear of surgery and second is fear of unrelieved pain. The codes for this paragraph could be ‘fear of surgery’ and ‘fear of pain’. In other areas of the transcript fear may arise again, and perhaps these codes will be merged into a category titled ‘fear’. Other concerns may emerge in this and other transcripts and perhaps best be represented by the theme ‘lack of control’. Themes are thus more abstract concepts, reflecting your interpretation of patterns across your data. So from codes, categories can be formed, and from categories, more encompassing themes are developed to describe the data in a form which summarises it, yet retains the richness, depth and context of the original data. Using quotations to illustrate categories and themes helps keep the analysis firmly grounded in the data. You need to constantly ask yourself ‘what is happening here?’ as you code and move from codes, to categories and themes, making sure you have data to support your decisions. Analysis inevitably involves subjective choices, and it is important to document what you have done and why, so a clear audit trail is provided. The coding example above describes codes inductively coming from the data. Some researchers may use a coding framework derived from, for example, the literature, their research questions or interview prompts, (Ritchie and Spencer 2 ) or a combination of both approaches.

Qualitative data, such as transcripts from an interview, are often routed in the interaction between the participant and the researcher. Reflecting on how you, as a researcher, may have influenced both the data collected and the analysis is an important part of the analysis.

As well as keeping your brain very much in gear, you need to be really organised. You may use highlighting pens and paper to keep track of your analysis, or use qualitative software to manage your data (such as NVivio or Atlas Ti). These programmes help you organise your data – you still have to do all the hard work to analyse it! Whatever you choose, it is important that you can trace your data back from themes to categories to codes. There is nothing more frustrating than looking for that illustrative patient quote, and not being able to find it.

If your qualitative data are part of a mixed methods study, (has both quantitative and qualitative data) careful thought has to be given to how you will analyse and present findings. Refer to O’Caithain et al 3 for more details.

There are many books and papers on qualitative analysis, a very few of which are listed below. 4 , – , 6 Working with someone with qualitative expertise is also invaluable, as you can read about it, but doing it really brings it alive.

• Richards L ,
• Ritchie J ,
• O'Cathain ,
• Bradley EH ,
• Huberman AM

Competing interests None.

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Getting started with qualitative research: developing a research proposal, cristina g vivar lecturer, department of community nursing and maternal & child health care, school of nursing, university of navarra, spain, and a doctoral student, nursing studies, school of health in social science, university of edinburgh, uk, anne mcqueen senior lecturer, nursing studies, school of health in social science, university of edinburgh, uk, dorothy a whyte honorary fellow, nursing studies, school of health in social science, university of edinburgh, uk, navidad canga armayor lecturer, head of department of community nursing and maternal & child health care, school of nursing, university of navarra, spain.

The aim of this article is to illustrate in detail important issues that research beginners may have to deal with during the design of a qualitative research proposal in nursing and health care. Cristina Vivar has developed a 17-step process to describe the development of a qualitative research project. This process can serve as an easy way to start research and to ensure a comprehensive and thorough proposal.

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How to Write a Nursing Research Proposal Topics | Guide & Examples [Updated]

Rachel andel rn, bsn.

• July 24, 2023
• Nursing Writing Guides

Nursing research proposal topics can vary greatly, depending on the type of research you’re looking to conduct.

Whether you are interested in studying public health issues or improving patient care through innovative research methods, something on this list likely appeals to you.

Here’s a guide on writing a nursing research proposal and nursing research proposal topics , DNP research proposal topics, current nursing research proposal topics, and nursing research examples.

Working on a Nursing Research Proposal?

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How to Write a Nursing Research Proposal

A nursing research proposal serves as a blueprint for conducting studies that address important clinical questions, explore innovative interventions, and contribute to the overall body of nursing knowledge. 

To create a strong nursing research proposal, there are several key considerations that nursing students must take into account, which include;

• Defining a clear and concise research question addresses an important nursing knowledge gap.
• Selecting an appropriate research design and methodology that aligns with the research question and objectives.
• Ensuring ethical considerations are addressed and appropriate measures are in place to protect the rights and welfare of participants.
• Determining an appropriate sample size and recruitment strategy to ensure adequate statistical power and generalizability of findings.
• Developing a detailed data analysis plan that aligns with the research design and objectives.
• Consider dissemination and knowledge translation strategies to ensure research findings reach the intended audience and positively impact nursing practice.

Key components of a Nursing Research Proposa l

When creating a nursing research proposal, including all the components contributing to a comprehensive and well-structured document is crucial.

Understanding these components will ensure that your proposal is clear and organized and addresses the necessary aspects of your research endeavor. 

Problem Statement

• It should provide a clear description of a problem that will be solved.
• It shows the gap between the current situation and the future goal to improve it.

Research Question

• The research question forms the foundation of your nursing research proposal. It is a concise and focused statement that outlines the main objective of your research.
• Your research question should be specific, measurable, attainable, relevant, and time-bound (SMART), enabling you to address a particular problem or gap in the existing literature.

Study Design

• The study design section outlines the methodology and approach you will employ to conduct your research.
• It includes details on the type of study, such as quantitative, qualitative, or mixed methods, and explains how data will be collected, analyzed, and interpreted.
• The study design should align with your research question and ensure the validity and reliability of your findings.

Methodology

• The methodology component of your nursing research proposal describes the specific techniques and procedures you will use to gather data.
• This may include surveys, interviews, observations, or systematic reviews.
• Clearly outlining your methodology ensures transparency and allows others to reproduce your study if needed.

Sample Size Determination

• Determining an appropriate sample size is crucial in nursing research to ensure your findings’ statistical power and representativeness.
• This section will explain how you calculated the required sample size based on the research question, study design, and expected effect size.
• It is essential to consider factors such as the population size, confidence level, and desired margin of error.

Ethical Considerations

• Ethical considerations play a vital role in nursing research.
• This component addresses the protection and well-being of participants, safeguarding their privacy and confidentiality, and the potential risks and benefits associated with the study.
• Ethical considerations also involve obtaining informed consent from participants and ensuring compliance with institutional review boards or ethical committees.

Nursing Research Proposal Outline

List of Nursing research proposal topics

• Racial and ethnic disparities in nursing care
• The impact of technology on nursing care
• Prevalence and determinants of burnout in nurses
• Quality of life for people with chronic illnesses served by nurses
• Effectiveness of nurse-led interventions for short-term weight loss in adults
• Nursing home adjusted Living Experience Surveys: measuring resident satisfaction and quality of life
• Identification and characterization of health disparities among LGBT elders in long-term care facilities
• Role of nurses in the early detection and management of cancer diagnosis
• Effects of delegation on nurse burnout, patient safety, and coordination of care
• The use of technology in home health care: a study of patient and nurse perspectives11. The impact of nurse staffing on patient safety
• Effectiveness of Nurse-led interventions for promoting healthy physical Activity in hospitalized patients.
• The role of nurses in the development and implementation of evidence-based pain management guidelines
• Effectiveness of patient-centred communication interventions to reduce bed sores in nursing home residents
• Identification and characterization of best practices for providing hospice care
• Nurse-led stress reduction interventions for long-term care staff
• Nurses’ perceptions of work-life balance: a qualitative study
• Development and evaluation of a web-based tool to support caregiver adherence to oral health care guidelines among long-term care residents
• Effects of sleep deprivation on nurses’ cognitive performance, satisfaction with work, and daytime sleepiness
• A study exploring the  association between nurse  staffing levels and rates of infection in a university hospital setting
• A qualitative study exploring how  nurses manage  transitions from inpatient to outpatient settings
• The use of  social media by nurses in an acute hospital  setting
• Nurses’ experiences with burnout: a cross-sectional study
• Nurse preparedness for pandemic influenza: an examination of the role of  professional development
• The use of telehealth in long-term  care settings:  a study of nurses’ experiences
• Nurses’ experiences with  chronic pain:  a qualitative study
• The impact of the Affordable Care Act on the workforce and nursing
• Nursing care plans  for patients with dementia: a systematic review
• Implementation of evidence-based interventions for preventing  falls in older adults  living in long-term care facilities
• Nurse staffing and  quality of patient care:  a cross-sectional study
• Use of  social media  by nurses during preoperative assessment
• Nurses’ perceptions of resident safety in an acute hospital setting: a qualitative study
• The effects of nurse staffing on patient satisfaction and outcomes in an acute hospital setting
• A comparative study investigating the use of videoconferencing  among nurses  in different specialties
• A qualitative study exploring how  nurse educators use technology to engage students in online learning  environments
• Examining the effect on patient safety when using electronic health records to order medications on off-hours
• Nurse staffing, work demands, and burnout in neonatal intensive care units 38. Factors that predict nurses’ decision to leave their jobs
• Effects of nurse-led interventions to improve care for  veterans with chronic pain
• The use of wearable technology in hospitals: a systematic review
• Review and assessment of technologies used to support nurses during surgery
• Nursing care plans  for patients with cancer: a systematic review
• Nurse-led interventions to prevent falls in older adults living in  long-term care facilities:  a systematic review
• The use of electronic health records to inform clinical decision making: a systematic review
• Implementation of evidence-based interventions to  improve patient  safety in hospitals
• A qualitative study exploring how nurses use technology in the workplace
• Factors influencing  nurse satisfaction  with their work and workplace culture
• Identification and assessment of best practices for preoperative  patient communication in the surgical setting
• Effectiveness of nurse-led stress reduction interventions on nurses’ burnout
• Nurse staffing, workload, and burnout in intensive care units: a cross-sectional study
• There are many other nursing research proposal  topics that can be explored in order to improve patient care .

Some additional potential nursing research proposal topics include:

• Assessing the effectiveness of nurse-led interventions for reducing readmissions among hospitalized patients
• Evaluating the impact of nurse call patterns on patient safety
• Analyzing the influence of nurse staffing levels on patient outcomes
• Determining the best methods for measuring patient satisfaction with nurse care
• Studying the  factors influencing  nurse decision making
• Investigating the feasibility and  effectiveness of using remote patient monitoring technology to improve patient care

DNP Research proposal topics

There are countless  nursing research  proposal topics that could be explored in a doctoral or post-doctoral program. Below is a list of some DNP Research proposal topics consider:

• Investigating the feasibility and effectiveness of using remote patient monitoring technology to improve patient care
• The effect of sleep deprivation on nurses
• The use of technology in nursing care
• Investigating the relationship between patient satisfaction and nurse retention
• Studying nutrition-related issues in the context of nursing
• Assessing the impact  of patient satisfaction on nurse recruitment and retention
• The relationship between patient satisfaction and nurse retention
• Investigating the feasibility of using remote patient monitoring technology in healthcare settings
• Evaluating the impact of patient satisfaction on nurse retention
• Research the best methods for measuring patient satisfaction with nurse care
• Studying the feasibility of using remote patient monitoring technology in healthcare settings

Check out the additional DNP Research proposal topics as suggested by a Nursing Instructor

• Nursing research  on dementia care
• Nursing research on neonatal intensive care unit (NICU) management
• Nursing research on palliative care
• Nursing research on wound healing and reconstruction 5.  Nursing research on pediatric health  nursing
• Nursing research on geriatric care
• Nursing research on pharmacology for nursing
• Nursing research on infection control in the acute care setting
• Nursing research on nutrition for nursing
• The  Effect of Health Education on Patient Outcomes
• Development and Evaluation of Nursing Intervention  Programs
• Assessment of Patient Satisfaction with Nursing Services
• Advocating for  Improved Patient-Nurse Communication
• Assessing the Effectiveness of Interventions to Address Nurses’ Burnout
• Investigating the Relationship between Nurse workload and Patient outcomes7. Evaluating the Impact of Technology on Nursing Care
• Investigating the Relationship between Professionalism and Patient Outcomes
• Studying Nutrition-Related Issues in the Context of Nursing
• Evaluating Patient-Nurse Interactions in the Context of Home Health Services

The list of DNP Research proposal topics above should guide you in creating a Research proposal.

Current Nursing research proposal topics

Nursing research proposal topics  can vary greatly, depending on the type of research you’re looking to conduct. Some common topics include:

• The effects of sleep deprivation on nurses
• The effect of patient communication skills on nurses’ outcomes
• How to improve patient safety in nursing care
• How to reduce readmissions among hospitalized patients
• Study the feasibility of using remote patient monitoring technology in healthcare settings
• Evaluate the impact of patient satisfaction on nurse recruitment and retention
• Evaluate the impact of nurse staffing levels on patient outcomes
• Research the feasibility of using remote patient monitoring technology in healthcare  settings
• Research the impact of patient satisfaction on nurse recruitment and retention
• Opioid use in the elderly
• Preterm birth and neonatal care
• Mobile health technology in nursing
• Nursing home  quality improvement
• The impact of social media on nursing

Nursing research proposal topics can vary greatly, so it’s important to select a  topic that is of interest to you and that will help you to improve patient care .

Nursing research proposal writing tips

When  preparing your nursing  research proposal, it’s important to keep the following tips in mind:

• Be organized

Planning and organizing your data will make your research proposal more concise and easier to read. Start by identifying the specific question you want to answer, and then list all the relevant sources that you consulted in order to reach your conclusions. Use headings and subheadings to help organize your information, and be sure to include detailed citations for all sources used.

• Use effective writing techniques

To produce a well-written research proposal, use effective writing techniques such as strong thesis statements , clear language, and well-organized data. You should also make use of persuasive arguments, vivid descriptions, and concrete  examples in order to make your case for the proposed study .

• Include references

In order for your nursing research proposal to be accepted, it  must include references  from reliable sources that support your findings. Always cite the source where you obtained the data presented in your proposal, as well as any other sourcesthat you used in order to support your arguments.

• Make sure your proposal is properly formatted

Your nursing research proposal should be properly formatted and error-free in order to be accepted for review. Always use the correct style and grammar when writing, and make sure all data is properly referenced. avoid using excessive jargon or acronyms, and try to keep your presentation as concise as possible.

• Submit your proposal well in advance of the deadline

The sooner you submit your proposal, the better chance you have of being accepted for review. Make sure to follow the submission guidelines outlined by the journal you are submitting to, as well as the submission system specific to that journal .

Nursing Research Proposal Examples

• Evidence-Based Practice Project Proposal Research Design Comparison
• Evidence-Based Practice Project Proposal Presentation
• Evidence-Based Practice Project Proposal: Organizational Culture and Readiness
• Project Proposal Identification of Nursing Practice Problem Assignment
• EBP Proposal – Section E: Duck’s Change Curve Model
• Capstone Project Change Proposal Presentation
• Draft Proposal Development 1 Part 2 of Chapter 1
• Evidence-Based Practice Proposal – Complete Proposal – Sample Project
• Evidence-Based Practice Proposal – Evaluation of Process – Solved Essay
• Evidence Based Practice Proposal: Implementation Plan – Solved Essay
• Evidence-Based Proposal – Solved Essay
• Benchmark – Community Teaching Plan: Community Teaching Work Plan Proposal Example – Solved Essay
• Evidence-Based Practice Project Proposal

In this article, we will provide you with some  ideas for nursing research proposal topics  that can be used in any discipline. Whether you are interested in studying public  health issues or improving patient care  through innovative research methods, there is likely something on this list that appeals to you. So get started on your Nursing Research Proposal now by placing an order with us.

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What is qualitative research? Approaches, methods, and examples

Published 19 Jul 2024

Students in social sciences frequently seek to understand how people feel, think, and behave in specific situations or relationships that evolve over time. To achieve this, they employ various techniques and data collection methods in qualitative research allowing for a deeper exploration of human experiences. Participant observation, in-depth interviews, and other qualitative methods are commonly used to gather rich, detailed data to uncover key aspects of social behavior and relationships. What is qualitative research? This article will answer this question and guide you through the essentials of this methodology, including data collection techniques and analytical approaches.

Qualitative research definition and significance 

This inquiry method is helpful for learners interested in how to conduct research . It focuses on understanding human behavior, experiences, and social phenomena from the perspective of those involved. What does qualitative mean? It uses non-numerical data, such as interviews, observations, and textual analysis, to understand people’s feelings, thoughts, and actions.

Where and when is it used?

Qualitative analysis is crucial in education, healthcare, social sciences, marketing, and business. It helps gain detailed insights into behaviors, experiences, and cultural phenomena. This approach is fundamental during exploratory phases, for understanding complex issues, and when context-specific insights are required. By focusing on depth over breadth, this approach is often employed when researchers seek to explore complex issues, understand the context of a phenomenon, or investigate things that are not easily quantifiable. It uncovers rich, nuanced data essential for developing theories and evaluating programs.

Why is qualitative research important in academia?

• It sheds light on complex phenomena and human experiences that quantitative methods may overlook.
• This method offers contextual understanding by studying subjects in their natural environments, which is crucial for grasping real-world complexities.
• It adapts flexibly to evolving study findings and allows for adjusting approaches as new ideas emerge.
• It collects rich, detailed data through interviews, observations, and analysis, offering a comprehensive view of the exploration topic.
• Qualitative research studies focus on new or less explored areas, helping to identify key variables and generate hypotheses for further study.
• This approach focuses on understanding individuals' perspectives, motivations, and emotions, essential in fields like sociology, psychology, and education.
• It supports theory development by providing empirical data that can create new theories and frameworks (you may read about “ What is a conceptual framework ?” and learn about other frameworks on the EduBirdie website).
• It improves practices in fields such as education and healthcare by offering insights into practitioners' and clients' needs and experiences.

The difference between qualitative and quantitative studies

Now that you know the answer to “Why is qualitative data important?”, let’s consider how this method differs from quantitative. Both studies represent two main types of research methods. The qualitative approach focuses on understanding behaviors, experiences, and perspectives using interviews, observations, and analyzing texts. These studies are based on reflexivity and aim to explore complexities and contexts, often generating new ideas or theories. Researchers analyze data to find patterns and themes, clarifying the details. However, findings demonstrated in the results section of a research paper may not apply broadly because they often use small, specific groups rather than large, random samples.

Quantitative studies, on the other hand, emphasize numerical data and statistical analysis to measure variables and relationships. They use methods such as surveys, experiments, or analyzing existing data to collect structured information. The goal is quantifying phenomena, testing hypotheses, and determining correlations or causes. Statistical methods are used to analyze data, identifying patterns and significance. Quantitative studies produce results that can be applied to larger populations, providing generalizable findings. However, they may lack the detailed context that qualitative methods offer.

The approaches to qualitative research 

To better understand the answer to “What is qualitative research?”, it’s necessary to consider various approaches within this methodology, each with its unique focus, implications, and functions. 

1. Phenomenology.

This theory aims to understand and describe the lived experiences of individuals regarding a particular phenomenon. 

Peculiarities:

• Focuses on personal experiences and perceptions.
• Seeks to uncover the essence of a phenomenon.
• Uses in-depth interviews and first-person accounts.

Example: Studying the experiences of people living with chronic illness to understand how it affects their daily lives.

2. Ethnography.

The approach involves immersive, long-term observation and participation in particular cultural or social contexts. 

• Provides a deep understanding of cultural practices and social interactions.
• Involves participant observation and fieldwork.
• Researchers often live within the community they are studying.

Example: Observing and participating in the daily life of a rural village to understand its social structure and cultural practices.

3. Grounded theory.

This approach seeks to develop a research paper problem statement and theories based on participant data.

• Focuses on creating new theories rather than analyzing existing ones.
• Uses a systematic process of data collection and analysis.
• Involves constant comparison and coding of data.

Example: Developing a theory on how people cope with job loss by interviewing and analyzing the experiences of unemployed individuals.

4. Case study.

Case studies involve an in-depth examination of a single case or a small number of cases.

• Provides detailed, holistic insights.
• Can involve individuals, groups, organizations, or events.
• Uses multiple data sources such as interviews, observations, and documents.

Example: One of the qualitative research examples is analyzing a specific company’s approach to innovation to understand its success factors.

5. Narrative research.

This methodology focuses on the stories and personal interpretations of individuals.

• Emphasizes the chronological sequence and context of events.
• Seeks to understand how people make sense of their experiences.
• Uses interviews, diaries, and autobiographies.

Example: Collecting and analyzing the life stories of veterans to understand their experiences during and after military service.

6. Action research.

This theoretical model involves a collaborative approach in which researchers and participants work together to solve a problem or improve a situation.

• Aims for practical outcomes and improvements.
• Involves cycles of planning, acting, observing, and reflecting.
• Often used in educational, organizational, and community settings.

Example: Teachers collaborating with researchers to develop and test new teaching approaches to improve student engagement.

7. Discourse analysis.

It examines language use in texts, conversations, and other forms of communication.

• Focuses on how language shapes social reality and power dynamics.
• Analyzes speech, written texts, and media content.
• Explores the underlying meanings and implications of language.

Example: Analyzing political speeches to understand how leaders construct and convey their messages to the public.

Each of these examples of qualitative research offers unique tools and perspectives, enabling researchers to delve deeply into complex issues and gain a rich understanding of the issue they study.

Qualitative research methods

Various techniques exist to explore phenomena in depth and understand the complexities of human behavior, experiences, and social interactions. Some key methodologies that are commonly used in different sciences include several approaches.

Unstructured interviews;

These are informal and open-ended, designed to capture detailed narratives without imposing preconceived notions. Researchers typically start with a broad question and encourage interviewees to share their stories freely.

Semi-structured interviews;

They involve a core set of questions that allow researchers to explore topics deeply, adapting their inquiries based on responses received. This method of qualitative research design aims to gather rich, descriptive information, such as understanding what qualities make a good teacher.

Open questionnaire surveys;

They differ from closed-ended surveys in that they seek opinions and descriptions through open-ended questions. They allow for gathering diverse viewpoints from a larger group than one-on-one interviews would permit.

Observation;

It relies on researchers' skills to observe and interpret unbiased behaviors or activities. For instance, in education research, observation might track how students stay focused and manage distractions, recorded through field notes taken during or shortly after the observation.

Keeping logs and diaries;

This involves participants or researchers documenting daily activities or study contexts. Participants might record their social interactions or exercise routines, giving detailed data for later analysis. Researchers may also maintain diaries to document study contexts, helping to explain findings and other information sources.

All types of qualitative research have their strengths for gathering detailed information and exploring the social, cultural, and psychological aspects of exploration topics. Learners often use several methods (triangulation) to confirm their findings and deepen their understanding of complex subjects. If you need assistance choosing the most appropriate method to explore, feel free to contact our website, as we offer essays for sale and support with academic papers. 

Advantages and disadvantages of the qualitative research methodology

This approach has unique strengths, making it valuable in many sciences. One of the primary advantages of qualitative research is its ability to capture participants' voices and perspectives accurately. It is highly adaptable, allowing researchers to modify the technique as new questions and ideas arise. This flexibility allows researchers to investigate new ideas and trends without being limited to set methods from the start. While this approach has many strengths, it also has significant drawbacks. A research paper writer faces practical and theoretical limitations when analyzing and interpreting data. Let’s consider all the pros and cons of this methodology in detail.

Strengths of qualitative research:

• Adaptability: Data gathering and analysis can be adjusted as new patterns or ideas develop, ensuring the study remains relevant and responsive.
• Real-world contexts: Research often occurs in natural conditions, providing a more authentic understanding of phenomena and describing the particularities of human behavior and interactions.
• Rich insights: Detailed analysis of people’s feelings, perceptions, and experiences can be useful for designing, testing, or developing systems, products, and services.
• Innovation: Open-ended responses allow experts to discover new problems or opportunities, leading to innovative ideas and approaches.

Limitations of qualitative research:

• Unpredictability: Real-world conditions often introduce uncontrolled factors, making this approach less reliable and difficult to replicate.
• Bias: The qualitative method relies heavily on the researcher’s viewpoint, leading to subjective interpretations. This makes it challenging to replicate studies and achieve consistent results.
• Limited applicability: Small, specific samples give detailed information but limit the ability to generalize findings to a broader population. Conclusions about the qualitative research topics may be biased and not representative of the wider population.
• Time and effort: Analyzing qualitative data is time-consuming and labor-intensive. While software can help, much of the analysis must be done manually, requiring significant effort and expertise.

So, qualitative methodology offers significant benefits, such as adaptability, real-world context, rich insights, and fostering innovation. However, it also presents challenges like unpredictability, bias, limited applicability, or time- and labor-intensive. Understanding these pros and cons helps researchers make informed decisions about when and how to effectively utilize various types of qualitative research designs in their studies.

Final thoughts

Qualitative research provides a valuable understanding of complicated human experiences and social situations, making it a strong tool in various areas of study. Despite its challenges, such as unreliability, subjectivity, and limited generalizability, its strengths in flexibility, natural settings, and generating meaningful insights make it an essential approach. If you are one of the students looking to incorporate qualitative methodology into their academic papers, EduBirdie is here to help. Our experts can guide you through the process, ensuring your work is thorough, credible, and impactful.

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• Credits required for PhD: 61-62
• Dissertation credits: 30
• Minimum of 91 credits total

** Sequencing of concentration courses, advanced methods and residencies are flexible depending on students' needs and resource availability. Note: There are five concentration courses in addition to an advanced methods course. Concentration courses may be taken in spring/summer.

*** University Residency requirement met (two successive semesters of at least six graduate credits).

^ Research residency is to be done over two semesters. Both must be completed before Proposal Defense. Satisfactory completion requires that students meet the core research competencies as outlined in the student handbook. Sequencing based on availability of research mentor.

^^ Pilot study must be done prior to Dissertation Proposal Defense. Note: There is one pilot study conducted over two semesters and separate from the Research Residency.

^^^ Teaching Residency is to be done during one semester and must be completed before a student can graduate from the program. Successful completion requires that students meet the teaching competencies as outlined in the student handbook. Program may be completed in less time if concentration, electives or residencies are completed in the spring/summer semester or if students elect more credits each term.

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• Students have a seven-year time limit to complete all requirements for the PhD. The time limit does not stop with a Leave of Absence. A student whose PhD. time limit has expired is regarded by the Graduate School as automatically terminated from the program unless the department submits an appropriately justified request for a time extension and the Graduate School approves that request.
• 90 graduate credits beyond the baccalaureate degree are required: 60 in coursework and 30 in dissertation research and preparation. Transferred credits may not be used to reduce the minimum requirement of 30 credits of coursework, excluding dissertation, that must be earned at WSU.

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The qualitative research proposal

2008, Curationis

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This seminar covers on qualitative methods in the social sciences. It is structured as a survey course, exposing students to a range of issues, rather than intensive training in a single approach. The purpose of the seminar is twofold: First, to provide participants with a broad sense of qualitative research methods, a better understanding of how to design and carry out research, an awareness of the different logics and trade-offs that distinguish methodologies and methods, and an improved capacity to read and evaluate diverse qualitative social science research. Second, to write a dissertation proposal that will be competitive for various external dissertation fellowship funders—such as NSF, Fulbright, SSRC, etc.—and defensible before one’s dissertation committee.

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• Published: 09 July 2024

Navigating end-of-life decision-making in nursing: a systematic review of ethical challenges and palliative care practices

• Majed Awad Alanazi 1 ,
• Marwa Mamdouh Shaban 2 ,
• Osama Mohamed Elsayed Ramadan 1 ,
• Mohammed Elsayed Zaky 1 ,
• Huda Hamdy Mohammed 3 ,
• Fatma Gomaa Mohamed Amer 2 &
• Mostafa Shaban 1  

BMC Nursing volume  23 , Article number:  467 ( 2024 ) Cite this article

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This systematic review aimed to synthesize evidence on the ethical dilemma’s nurses encounter in end-of-life care and effective palliative care practices. The objectives were to understand key ethical issues, evaluate communication and decision-making strategies, and identify approaches to support nurses and patients.

A comprehensive search of major databases was conducted according to the PRISMA guidelines. Studies directly relating to nursing ethics, challenges in end-of-life decision-making, and palliative care practices were included. The risk of bias was assessed using ROBVIS-II. Data on ethical issues, palliative interventions, and outcomes was extracted and analyzed thematically.

22 studies met the inclusion criteria. Key themes that emerged were: (1) Effective communication and involving patients in decision-making are essential but complex. (2) Nurses face dilemmas around balancing autonomy, beneficence and relational issues. (3) Integrating palliative care principles enhances symptom management and aligns care with patient values. (4) Education and organizational support are needed to equip nurses with skills and coping strategies.

Navigating end-of-life care requires addressing interconnected ethical, communication and support needs. While studies provided insights, further research is required on cultural competence training, standardized education programs and longitudinal evaluations.

Peer Review reports

Introduction

End-of-life decision-making presents complex ethical challenges for patients, families, and healthcare providers. As medical technologies advance, patients are living longer with serious illness, and end-of-life care planning is becoming increasingly important [ 1 ]. Palliative care practices aim to improve quality of life for patients with serious illness through pain and symptom management, while also providing support for difficult medical decisions near the end of life [ 2 ]. This review aimed to provide background on key ethical issues in end-of-life decision-making and summarize evidence on communication strategies, advance care planning interventions, and palliative care models to support patients and families navigating this difficult process.

A fundamental ethical principle in end-of-life care is respect for patient autonomy – the idea that patients have the right to make their own healthcare decisions consistent with their values and priorities [ 3 ]. However, many factors can impede patient autonomy. These include acute changes in decision-making capacity from illness progression, family/provider conflicts about appropriate goals of care, and racial/ethnic/cultural differences in end-of-life decision-making norms [ 4 ]. Surrogate decision makers for incapacitated patients may struggle to balance substituted judgment (making decisions aligned with the patient’s known preferences) and best interest standards (choosing options that seem to maximize benefit and minimize harm based on available evidence) [ 5 , 6 ]. Palliative sedation is an ethically accepted practice aimed at relieving intractable suffering in end-of-life care without hastening death. With competent practices, the risk of death due to palliative sedation is highly unlikely, aligning with the ethical principle of non-maleficence [ 7 ]. The goal is always to relieve suffering while maintaining patient dignity [ 8 ].

Clear communication and conflict resolution strategies are needed to address these ethical complexities [ 9 ]. Various communication models aim to support truly shared decision-making near the end of life [ 10 ]. Principle-based approaches emphasize upholding patient autonomy through informed consent. Welfare-based models focus more on determining objective best interests by balancing benefits and burdens of treatment options [ 11 ]. Relationship-based perspectives highlight the importance of shared deliberation, surfacing unspoken needs and sustaining family relationships [ 12 ]. Evidence suggests relationship-based approaches may have advantages in end-of-life communication, as they allow space for emotional catharsis and subtle negotiation of values while still respecting patient priorities [ 13 ].

Numerous structured communication interventions also show promise for improving the quality of end-of-life conversations and reducing conflict in diverse care settings ranging from ICUs to nursing homes [ 14 ]. For example, the VitalTalk model uses role-play and feedback to train clinicians in core communication skills to promote goal-concordant care for seriously ill patients [ 15 ]. However, major communication challenges often persist near the end of life, especially regarding conveying prognosis and explaining care limitations for patients with severely compromised health [ 16 ]. Cultural factors further complicate communication norms, as some patients and families from non-Western backgrounds may believe discussing death directly can be harmful or show disrespect. More research is needed to adapt end-of-life communication training approaches to cultural contexts [ 17 ].

Advance care planning represents another vital component of ethical end-of-life care, providing a process for patients to document preferences to guide treatment decisions in the event of future incapacity [ 18 ]. However, studies suggest fewer than one third of American adults have completed any kind of advance directive. Key barriers include difficulty contemplating one’s own mortality, lack of public awareness, time constraints with healthcare providers, and concerns that advance directives may undermine hope or be misinterpreted later [ 19 ]. A range of advance care planning interventions have shown promise in increasing documentation of patient preferences and care aligned with patient values and goals [ 20 ]. Notable examples include video-based decision aids to assist completion of living wills and Portable Medical Orders (POLST) forms, which provide specific medical orders for compromised patients [ 21 ].

Research finds POLST forms are substantially more effective than traditional, more vague living wills on their own in ensuring patient preferences such as DNR orders are actually honored [ 22 ]. However, additional research is needed on cultural differences in values and preferences around advance care planning, as well as dissemination strategies to increase access to POLST paradigm programs [ 23 ]. Further study should also explore potential ethical downsides of POLST forms, including concerns regarding self-determination if patients feel pressured into unwanted orders, or possible over-emphasis on technical treatment options rather than eliciting patient values and priorities [ 24 ].

In addition to advance care planning, palliative care models aim to improve quality of life and provide multifaceted support for patients and families facing serious illness through comprehensive symptom management, psychological and spiritual care, and coordination of goals and values with treatment options across care settings [ 25 ]. The End of Life Nursing Education Consortium (ELNEC) provides comprehensive training and resources for nurses to deliver quality end-of-life care. ELNEC’s curriculum includes critical aspects such as pain management, ethical issues, cultural competence, and communication strategies, which are essential for enhancing nurses’ competencies in palliative care [ 26 ]. Numerous studies demonstrate benefits of early, integrated palliative care provided alongside disease treatment for conditions like advanced cancer. These benefits include improvements in quality of life, reduced rates of depression, more appropriate referrals to hospice, and even survival gains for certain cancer patients [ 27 , 28 ]. However, major access barriers persist. Significant racial, ethnic, and rural disparities remain in utilization of specialist palliative care and hospice services [ 29 ].

Novel models like home-based palliative care programs may help increase access for underserved populations, while telehealth options can also extend services to remote areas [ 30 ]. However, more research is needed on potential technological barriers and privacy risks of virtual palliative care. Additionally, palliative care historically has focused predominantly on cancer populations, while evidence on optimal models tailored to other terminal illnesses like end-stage organ failure and neurodegenerative conditions remains limited [ 31 ]. For example, nursing homes have some of the highest death rates yet variable integration of palliative care principles. Quality of end-of-life care in nursing homes depends heavily on staff education in symptom management, nursing home resources, and state regulatory policies on palliative approaches [ 32 ]. As nursing homes disproportionately serve minorities already at high risk for undertreatment of pain and other symptoms, enhancing palliative care in this setting could help address care disparities [ 33 ]. More implementation research should investigate multifaceted strategies to integrate palliative care principles into nursing homes, such as staff skills training, facility culture changes, and policy initiatives [ 34 ].

Looking beyond current practices, recent studies have addressed many of the complexities surrounding end-of-life care, including ethical decision-making, communication strategies, and cultural competence. These advancements highlight the need for continuous updates and adaptations in palliative care practices [ 35 ]. . Although early outpatient specialty palliative care reduces ICU admissions at the end of life, further study is needed to clarify net impacts on healthcare spending across multiple settings, which could inform policies on coverage and payment incentives for palliative care [ 36 ]. Many nurses also report feeling unprepared and overwhelmed when discussing end-of-life preferences and providing care to seriously ill patients [ 37 ]. Investigating associations between palliative care integration and clinician stress, career satisfaction, and retention may highlight benefits to healthcare staff as well as patients [ 38 ].

Finally, robust evidence on cultural competence interventions is needed to address significant disparities in access to and experiences with end-of-life care among minority groups [ 39 ]. Racial and ethnic minorities are less likely to complete advance directives, more likely to prefer life-prolonging measures at end of life, and report lower quality end-of-life care compared to white Americans [ 40 ]. Culturally tailored advance care planning and communication approaches could help reduce these disparities. Diversifying the palliative care and hospice workforce is also critical to bringing cultural humility to end-of-life services [ 41 ].

Delivering ethical, patient-centered end-of-life care requires aligning treatments with patient values and goals through skillful communication and informed advance care planning, which must account for cultural factors [ 42 ]. Evidence-based palliative care models integrate physical comfort and holistic support with shared decision-making grounded in patient priorities. However, major gaps remain in access to quality end-of-life care [ 43 ]. Further research on communication interventions, advance directive dissemination, palliative care integration across diverse settings and populations, impacts on costs and clinicians, and reducing disparities can help support patients and families navigating high-quality, ethical care through this challenging yet inevitable phase of the healthcare journey [ 44 ].

Despite extensive research on ethical decision-making and palliative care practices, significant gaps remain. Firstly, there is a lack of comprehensive understanding of how cultural differences impact end-of-life decision-making, particularly in non-Western contexts. Secondly, the integration of palliative care principles into various healthcare settings, especially in regions with limited access to specialized palliative care services, requires further exploration. Thirdly, there is a need for more targeted education and training programs to equip nurses with the skills necessary to navigate complex ethical dilemmas and provide culturally competent care. This systematic review aims to address these knowledge gaps by synthesizing current evidence on ethical challenges and palliative care practices, identifying effective communication and decision-making strategies, and proposing areas for future research to enhance end-of-life care for diverse populations.

Search strategy and selection criteria

This systematic review strictly adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, ensuring adherence to the highest standards of rigor and transparency. Following the PRISMA Protocols (PRISMA-P) statement, we developed a detailed research protocol, which was registered with PROSPERO (CRD42024513767), demonstrating our commitment to methodological precision and integrity.

Our literature search strategy was designed to be comprehensive, spanning multiple prestigious databases: Embase.com (Scopus), Medline ALL (Ovid), CINHAL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (Wiley), and Google Scholar. This approach aims to encompass the breadth and depth of existing research on end-of-life decision-making and palliative care practices within nursing. The last search, conducted on 17-1-2024 (which started from 2000 to 2024), We have revised our search terms to include the correct MeSH terms such as ‘Terminal Care,’ ‘Palliative Medicine,’ ‘Hospice and Palliative Care Nursing,’ ‘Ethics,’ and ‘Hospice Care.’ This ensures a more robust methodological approach.

Keywords and search terms were chosen to capture the complexities of ethical dilemmas nurses face in end-of-life care, strategies for addressing these challenges, and the implementation of palliative care practices. This targeted search strategy aimed to comprehensively review literature on the ethical dimensions of end-of-life care decision-making in nursing, including the perspectives, experiences, and practices of nursing professionals in various healthcare settings (Table  1 ).

The selection criteria for studies included in this review will focus on qualitative, quantitative, and mixed-methods research that directly addresses ethical challenges and palliative care practices in nursing, with particular emphasis on studies that offer insights into effective communication, decision-making processes, and the application of ethical principles in end-of-life care. Priority will be given to peer-reviewed articles, guidelines, and consensus statements that contribute significantly to understanding and improving ethical decision-making and palliative care practices in nursing.

Eligibility criteria for screening

Following the removal of duplicates from our search output, we conducted a preliminary screening of titles and abstracts, leading to a thorough evaluation of full-text articles. Our inclusion criteria were designed to identify publications such as original research articles, and clinical trials involving human subjects. The primary focus was on studies that addressed ethical challenges and palliative care practices in the nursing domain, specifically within the context of end-of-life decision-making. We sought research that provided insights into ethical dilemmas, strategies for navigating these challenges, approaches to palliative care, and the role of nurses in managing end-of-life care. This included studies that examined the effectiveness of communication strategies, decision-making processes, advance care planning, and the impact of ethical training on nursing practice. We prioritized studies that offered comparative analyses of different ethical approaches, palliative care models, and interventions aimed at supporting nurses and patients through the end-of-life care journey. The key outcomes of interest were improvements in ethical decision-making, patient-nurse relationships, quality of end-of-life care, and nurse well-being.

Exclusion criteria were applied to case reports, case series, publications only available as abstracts, letters, editorials, and conference materials, as well as studies conducted on animals or in vitro. We also excluded research not explicitly focusing on nursing practices related to end-of-life care or ethical challenges, studies that did not implement specific interventions aimed at improving palliative care or ethical decision-making in nursing, and those lacking in-depth methodological detail. Research that adhered strictly to existing ethical or palliative care guidelines without introducing novel approaches, as well as studies without control groups or insufficient data for meaningful analysis, were omitted. Additionally, studies failing to offer new insights into ethical or palliative care practices in nursing or published in languages other than English without accessible translations were disregarded. These exclusion criteria ensured our systematic review concentrated on pertinent, high-caliber research that significantly advances understanding of ethical and palliative care practices in nursing, particularly at the end of life, thereby aligning our investigation with the broader research objectives and contributing to the existing literature on this critical topic.

We began with an initial pool of 4962 records identified through database searches. After deduplication, 3574 records remained for screening. We screened all these records and excluded 2489 based on titles and abstracts, leaving 1085 articles for full-text eligibility assessment. Upon detailed review, we excluded 745 articles for being not retrieved leaving 340 studies were assessed for eligibility, resulting in 22 studies being included in the final review [ 16 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ]. Each of these 22 studies was accounted for in our report, ensuring a comprehensive and transparent documentation of our systematic review process. as shown in Fig.  1 .

the extraction table of the included studies

Data extraction

The review process involved two independent reviewers who screened titles and abstracts, followed by a full-text review of potentially eligible studies. Discrepancies were resolved through discussion or consultation with a third reviewer .The data extraction phase was a critical component of our systematic review, which centered on exploring ethical challenges and palliative care practices in nursing, particularly in the context of end-of-life decision-making. The main objective during this stage was to systematically collect and consolidate essential information from the selected studies, focusing on how ethical dilemmas and palliative care interventions are navigated and implemented by nurses in end-of-life care scenarios.

The extraction process involved a thorough examination of each study, with particular attention to several key aspects:

Study Characteristics : We gathered detailed information on the study’s design, setting, population, and sample size. This was vital for contextualizing the research, ensuring its relevance to our review, and assessing its contribution to the field of nursing ethics and palliative care.

Ethical Challenges and Palliative Care Interventions : We meticulously documented the nature of ethical dilemmas encountered by nurses, the strategies employed to address these challenges, and the specifics of palliative care interventions. This included descriptions of decision-making processes, communication techniques, advanced care planning measures, and any educational or support frameworks designed to facilitate ethical and palliative care in nursing.

Outcome Measures : Our data extraction also focused on identifying and noting the outcomes used to evaluate the impact of ethical and palliative care interventions on patients, nurses, and the healthcare system. These outcomes included measures of decision-making efficacy, quality of end-of-life care, patient and nurse satisfaction, psychological well-being of healthcare professionals, and any reported challenges or adverse events associated with implementing ethical decisions or palliative care practices.

In cases where data were missing, unclear, or incomplete, efforts were made to contact the original authors for additional information, thus ensuring the accuracy and completeness of our dataset.

Additionally, we scrutinized studies for potential overlaps in study populations to prevent data duplication in our analysis. Direct communication with authors was initiated when there was any uncertainty regarding the study cohorts, which played a crucial role in maintaining the integrity and reliability of our data extraction process. This detailed and diligent approach allowed us to develop a solid foundation for our systematic review, ultimately leading to meaningful insights into the ethical challenges and palliative care practices in nursing, especially at the end of life.

Quality assessment

In our systematic review examining ethical challenges and palliative care practices in nursing, particularly focusing on end-of-life decision-making, we underscored the imperative of assessing the methodological quality and risk of bias in the included studies. This step is vital to affirm the reliability and relevance of our findings, thereby establishing a solid basis for recommendations regarding ethical and palliative care strategies in the nursing profession.

For the evaluation of study quality, we adopted a structured methodology by utilizing the ROBVIS-II tool, an enhancement over its predecessor designed to more accurately assess the risk of bias in non-randomized studies of interventions. The choice of the ROBVIS-II tool was informed by its comprehensive capability to scrutinize various dimensions of bias, making it particularly suitable for our review’s emphasis on ethical dilemmas and palliative care approaches in the context of nursing care for end-of-life patients. While the ROBVIS-II tool was used for non-randomized clinical trials, we utilized the Joanna Briggs Institute (JBI) critical appraisal tools for qualitative studies and the Cochrane Risk of Bias tool for randomized controlled trials.

Each selected study underwent an independent assessment to meticulously explore critical dimensions such as study design, selection and categorization of participants, adherence to ethical and palliative care protocols, methods for measuring outcomes, and handling of potential confounders and missing data. This detailed scrutiny was crucial in appraising the methodological robustness of the studies and pinpointing any possible biases that could affect the conclusions drawn.

To ensure the objectivity and fairness of our assessments, we rigorously addressed any discrepancies encountered during the review process. Conflicts or uncertainties regarding the quality or risk of bias of the studies were resolved through a process of consensus-building. This involved comprehensive discussions among the members of our review team, fostering a collaborative effort that culminated in a unanimous agreement on the evaluations of the studies’ quality. This approach not only reinforced the integrity of our quality assessment process but also enhanced the credibility of our systematic review’s findings on navigating ethical challenges and implementing palliative care practices in nursing at the end of life.

Data analysis

In this extensive systematic review, which examines ethical challenges and palliative care practices in nursing at the end of life, we adopted a rigorous data analysis methodology that combines both narrative synthesis and thematic analysis. This dual approach is essential for a nuanced understanding of the complex ethical dilemma’s nurses face and the effectiveness of palliative care strategies. Below is a detailed description of how each analytical method was utilized in our study:

Narrative Synthesis : This method formed the cornerstone of our data analysis, enabling a comprehensive and systematic review of the literature [ 26 ]. Through narrative synthesis, we meticulously evaluated the ethical challenges encountered in nursing practices, particularly in end-of-life care, and the various palliative care approaches employed. This process allowed for a deep dive into the complexities and subtleties of ethical decision-making and palliative care in nursing, facilitating an understanding of the impact of different strategies on patient care, nurse-patient relationships, and overall care quality. The narrative synthesis provided a structured narrative that highlighted key patterns, gaps in the literature, and potential areas for future inquiry. It enabled us to collate and interpret findings on the effectiveness of communication strategies, the role of advanced care planning, and the impacts of ethical education and support systems on nursing practice.

Thematic Analysis : Complementing the narrative synthesis, thematic analysis was crucial for identifying recurring themes across the studies included in our review. This qualitative technique delved into the ethical and palliative care practices within nursing, uncovering central themes such as ethical dilemmas, strategies for managing moral distress, approaches to enhancing communication with patients and families, and the integration of palliative care principles into nursing education and practice. By focusing on these themes, we explored the intricacies involved in navigating ethical challenges and implementing palliative care practices. Thematic analysis shed light on the various dimensions of end-of-life care, including the barriers to and facilitators of effective ethical decision-making and palliative care, the importance of cultural competence, and the need for interprofessional collaboration. This analytical approach enhanced our comprehension of how ethical challenges and palliative care practices are approached in nursing, emphasizing the significance of tailored interventions, ongoing education, and organizational support in improving end-of-life care.

Together, narrative synthesis and thematic analysis provided a robust framework for our systematic review, offering deep insights into the ethical challenges and palliative care practices in nursing. This combined approach enabled a rich exploration of the literature, contributing to a comprehensive understanding of the current state of knowledge and identifying avenues for future research in this critical area of nursing practice.

Risk of bias

The Risk of Bias assessment of the studies listed in Fig.  2 shows a spectrum of concerns across different areas. For instance, the study by Agarwal, R. and Epstein, A.S. (2018) raises some concerns due to a high bias in the deviation from the intended intervention. In contrast, the studies by Kuosmanen et al., (2021), Lim and Kim, (2021), Peggy Kalowes (2015), Filip et al., (2022), Elisabeth Diehl et al., (2021), and Tomasz Brzostek et al. (2008) consistently show low bias in all categories, indicating a robust methodological approach.

Rebecca J Anderson et al., (2019) and Jane Elizabeth Seymour, Christine Ingleton (1999) have high bias in the measurement of outcomes, which may affect the reliability of their results. The studies by Petersen, Breakwell, Callahan (2014), Pablo Hernández-Marrero et al. (2018), Aura Alexandra et al., (2020), Linda Heino et al., (2021), and David Kenneth Wright et al., (2021) show some concerns in more than one category, but not to a degree as high as some others.

The majority of studies maintain a low bias in the selection of reported results, suggesting that reporting bias is less of a concern in this collection of studies. However, there are sporadic concerns with randomization, intended interventions, and outcome measurements that indicate areas for improvement. Overall, the studies exhibit a variable risk of bias, with many showing a good methodological quality but with some studies indicating areas that could potentially influence the outcomes and interpretations of the research.

Risk of bias of the included studies

Main outcomes

Based on the data extracted from the studies (Table S1 ), we can elaborate on the four identified themes with comprehensive paragraphs incorporating all relevant studies:

1- Ethical Challenges in Practice :

Autonomy : Ethical dilemmas related to patient autonomy were a prominent theme. Studies by Filip et al. (2022) and Pablo Hernández-Marrero et al. (2018) highlighted challenges in respecting patient autonomy, particularly when patients’ wishes were unclear or when surrogate decision-makers were involved. These studies underscored the importance of clear communication and advance care planning to ensure that patient preferences are respected. Additionally, decisions around providing or withholding hydration and nutrition presented significant ethical tensions, balancing patient comfort and autonomy with medical best practices.

Beneficence and Nonmaleficence : The ethical implications of practices potentially hastening death, such as palliative sedation, were extensively discussed. Studies emphasized that competent palliative sedation practices aim solely at relieving intractable symptoms without the intention of hastening death (Deborah HL Muldrew et al., 2018). Nurses also faced dilemmas in balancing the benefits and harms of interventions, striving to maximize patient comfort while avoiding unnecessary suffering.

Justice : Issues related to equitable access to palliative care services were significant, especially for marginalized and underserved populations. Studies reflected on the ethical intricacies of ensuring fair access to high-quality end-of-life care, highlighting the need for policies and practices that promote justice in healthcare.

2- Communication and Decision-Making :

Communication Strategies : Effective communication is a cornerstone in end-of-life care, facilitating shared decision-making and honoring patient autonomy. The studies by Kuosmanen et al. (2021), Agarwal & Epstein (2018), and Rebecca J Anderson et al. (2019) all highlighted the importance of involving patients in decision-making processes with a strong emphasis on clear communication and understanding patient values. These studies suggested that open communication and interdisciplinary teamwork are prerequisites for meaningful participation in care decisions.

Interventions : Specific communication interventions, such as training programs and structured communication models, were highlighted for their role in improving end-of-life discussions. Lim and Kim (2021) pointed towards the need for improved ethics education to enhance moral sensitivity and ethical decision-making abilities. Emma Lundin & Tove E. Godskesen (2021) and Elisabeth Diehl et al. (2021) underscored the communication barriers that exist, particularly in the care of residents with dementia, suggesting the development of better communication training programs. Together, these studies advocated for interventions to optimize communication strategies and patient education, aiming to enhance shared decision-making in palliative care settings.

3- Integration of Palliative Care Principles and Practices :

Communication Strategies : The integration of palliative care principles into nursing practice is crucial for improving the quality of end-of-life care. Studies by Peggy Kalowes (2015), Terrah L. et al. (2010), and Aura Alexandra et al. (2020) discussed the role of nurses in leading conversations about disease trajectory and goals of care, managing family effects, culture, spirituality, communication, and ethics. These studies emphasized the need for consistent communication and early involvement in palliative care to better manage symptoms and family dynamics.

Nursing Leadership : Nursing leadership was highlighted as essential in facilitating palliative care principles and advocating for improved guidelines and support systems. The utility of prognostic tools and the importance of flexibility in care plans were underscored, emphasizing the role of nurses in integrating palliative care principles into practice and ensuring that care aligns with patient values and priorities.

4- Educational and Organizational Support :

Interventions for Nurse Development : Education and organizational support are pivotal in equipping nurses to manage the complexities of end-of-life care. Studies such as those by Linda Heino et al. (2021), Wassiem Abu Hatoum & Daniel Sperling (2022), Yuanfei Liu et al. (2023), and David Kenneth Wright et al. (2021) discussed the roles and attitudes of nurses regarding palliative sedation, shared decision-making, and coping with ethical conflict. These studies called for more research on the impact of various educational and support interventions, evaluation of standardized training, and the exploration of cultural differences and organizational factors in end-of-life care.

Clarifying Practices : It is important to note that palliative care and Medical Assistance in Dying (MAID) are distinct practices. The primary focus of palliative care is on symptom management and improving the quality of life for patients with serious illnesses, with no intention to hasten death. In contrast, MAID involves intentionally ending a patient’s life at their request to relieve suffering. These practices are fundamentally different, and conflating them could lead to misunderstandings about the goals and ethical principles underlying each approach. This distinction is crucial for developing appropriate educational and organizational support for nurses.

The findings of this systematic review highlight the multifaceted and complex ethical challenges that nurses encounter in providing end-of-life care. By synthesizing the evidence from diverse studies, four overarching themes emerge: the centrality of communication and decision-making, the ethical dilemmas inherent in end-of-life care practice, the integration of palliative care principles, and the need for educational and organizational support. These themes underscore the interdependent nature of ethical issues, palliative care practices, and the pivotal role of nurses in navigating this intricate terrain.

Communication and Decision-Making:

Effective communication is a foundational element in ensuring patient autonomy and shared decision-making in end-of-life care. Several studies in this review emphasize the importance of involving patients in decision-making processes, highlighting the need for clear communication and an understanding of patient values [ 67 , 68 , 69 ]. Kuosmanen et al. [ 55 ]assert that interdisciplinary teamwork, open communication, and a positive patient-healthcare professional relationship are prerequisites for meaningful participation in care decisions. Rebecca J Anderson et al. [ 16 ] offer insights into communication strategies, such as highlighting deterioration, involving patients in decision-making, tailoring information, and maintaining honesty and clarity. These findings resonate with the work of Lim and Kim [ 70 ], who advocate for improved ethics education and support services to enhance nurses’ moral sensitivity and ethical decision-making abilities in end-of-life care.

The reviewed studies underscore the need for nurses to be equipped with effective communication skills and decision-making frameworks to navigate the complexities of end-of-life care. Agarwal and Epstein [ 54 ]emphasize the importance of advance care planning (ACP) in supporting patient autonomy and suggest that nurses can facilitate ACP and primary palliative care to promote informed decision-making. Emma Lundin and Tove E. Godskesen [ 64 ] and Elisabeth Diehl et al. [ 46 ] highlight the communication barriers that exist, particularly in caring for residents with dementia, advocating for the development of better communication training programs and enhanced team collaboration.

These findings collectively reinforce the pivotal role of communication in facilitating shared decision-making and honoring patient autonomy in end-of-life care. They also highlight the need for interventions to optimize communication strategies, patient education, and the integration of ethical principles into nursing practice.

Ethical Challenges in Practice:

End-of-life care is inherently fraught with ethical dilemmas, and nurses frequently face complex decisions that involve balancing principles of autonomy, beneficence, nonmaleficence, and justice [ 71 , 72 , 73 , 74 ]. Filip et al. [ 52 ]and Pablo Hernández-Marrero et al. [ 75 ] delve into the ethical decision-making involved in end-of-life care, underscoring the value of patient autonomy and the relational and organizational challenges that arise, particularly in nursing home settings. Deborah HL Muldrew et al. [ 63 ] reveal that relational issues, especially those involving residents and families, are among the most frequent and distressing ethical challenges encountered by nurses in nursing homes.

These studies reflect the intricate ethical landscape that nurses navigate, highlighting the need for nurses to be equipped with robust ethical decision-making frameworks and support systems. Petersen, Breakwell, and Callahan [ 59 ] emphasize the importance of integrating palliative care principles and ethical considerations into nursing practice, particularly in orthopedic settings, where end-of-life care may be overlooked. These findings underscore the significance of providing multidisciplinary education and fostering organizational cultures that prioritize ethical decision-making in end-of-life care across diverse healthcare settings [ 76 , 77 ].

Integration of Palliative Care Principles and Practices:

The integration of palliative care principles into nursing practice is crucial for improving the quality of end-of-life care and addressing ethical challenges [ 78 , 79 ]. Studies by Peggy Kalowes [ 45 ], Terrah L. et al. [ 47 ], and Aura Alexandra et al. [ 58 ] discuss the pivotal role of nurses in leading conversations about disease trajectories, goals of care, managing family dynamics, addressing cultural and spiritual needs, and anticipating end-of-life issues. These studies highlight the importance of consistent communication, early involvement in palliative care, and the utility of prognostic tools and flexible care plans to better manage symptoms and support families.

The findings underscore the significance of nurses embracing their leadership role in facilitating palliative care principles and advocating for improved guidelines, support systems, and organizational cultures that prioritize holistic, patient-centered care. By incorporating palliative care principles into their practice, nurses can better navigate ethical dilemmas, enhance communication, and ensure that care aligns with patients’ values and priorities throughout the end-of-life journey.

Educational and Organizational Support:

Equipping nurses with the necessary knowledge, skills, and support is pivotal in addressing the ethical challenges and complexities of end-of-life care [ 80 , 81 ]. Several studies highlight the need for developing training programs, increasing interprofessional shared decision-making, and providing emotional and practical support for nurses [ 82 , 83 , 84 ].

Linda Heino et al. [ 56 ] and Wassiem Abu Hatoum and Daniel Sperling [ 60 ] emphasize the importance of educational interventions and interprofessional shared decision-making in enhancing nurses’ competencies and practices related to palliative sedation and end-of-life care for patients with end-stage renal disease (ESRD). David Kenneth Wright et al. [ 65 ]underscore the need for support and recognition of the moral identity work that palliative care nurses undergo when navigating the intersection of palliative care and medical assistance in dying (MAID).

Additionally, studies by Yuanfei Liu et al. [ 62 ] and Rajkumar Cheluvappa and Selwyn Selvendran [ 66 ] explore the coping strategies and perspectives of nurses in intensive care settings, highlighting the need for training programs and interventions to address the ethical conflicts and challenges encountered in these contexts.

These findings emphasize the importance of comprehensive educational initiatives, organizational support systems, and the fostering of collaborative, interdisciplinary approaches to equip nurses with the necessary competencies and coping mechanisms to navigate the ethical complexities of end-of-life care [ 85 ]. Furthermore, the studies suggest the need for longitudinal research to evaluate the impact of standardized training programs, organizational changes, and multidisciplinary interventions in enhancing ethical decision-making and palliative care practices across diverse healthcare settings [ 86 , 87 ].

While the reviewed studies provide valuable insights into ethical challenges and palliative care practices, it is essential to acknowledge the role of cultural factors and address the disparities that exist in accessing and experiencing end-of-life care. Several authors, including Rebecca J Anderson et al. [ 16 ], Agarwal and Epstein [ 54 ], and Tomasz Brzostek et al. [ 61 ], underscore the influence of cultural beliefs, norms, and values on perceptions of end-of-life care, decision-making processes, and attitudes towards concepts such as euthanasia.

Tomasz Brzostek et al. [ 61 ] highlight the influence of personal philosophy of life and the importance of legal frameworks in shaping attitudes towards euthanasia among nurses. These findings emphasize the need for culturally sensitive approaches that respect diverse perspectives and belief systems while promoting ethical decision-making and patient-centered care.

Furthermore, studies such as Jane Elizabeth Seymour and Christine Ingleton [ 48 ] draw attention to the unique ethical challenges that arise in qualitative research involving critically ill individuals, informal carers, and healthcare staff in palliative care settings. They emphasize the importance of adopting a holistic and context-based approach, maintaining a non-judgmental attitude, practicing transparent communication, and fostering collaboration between researchers and participants.

To address the disparities and ensure equitable access to quality end-of-life care, there is a pressing need for further research on cultural competence interventions and strategies to bridge the gap between different cultural and socioeconomic backgrounds [ 88 , 89 ]. Diversifying the palliative care and hospice workforce and promoting cultural humility in end-of-life services can contribute to reducing these disparities and enhancing the overall quality of care [ 90 , 91 ].

Limitation of the study

This review has several limitations that should be considered when interpreting the findings. First, there is potential publication bias, as we included only published studies, which may skew the results towards positive findings. Second, our review was restricted to studies published in English, potentially overlooking relevant research in other languages. Third, we excluded grey literature, such as conference abstracts, theses, and reports, which may contain valuable insights. Additionally, the included studies varied in their design, context, and quality, which could affect the generalizability of our conclusions. These limitations highlight the need for cautious interpretation and underscore the importance of further research to address these gaps.

Future research directions

While this systematic review provides valuable insights, it also highlights several areas that warrant further investigation. Several authors, including Rebecca J Anderson et al. [ 1 ], Emma Lundin and Tove E. Godskesen [ 21 ], and Linda Heino et al. [ 13 ], emphasize the need for more research on communication strategies, cultural influences, and the experiences of healthcare professionals in different settings.

Additionally, longitudinal studies exploring the evolution of ethical reflections and practices in the context of MAID and palliative care, as suggested by David Kenneth Wright et al. [ 22 ], can deepen our understanding of the complex interplay between these domains.

Furthermore, researchers such as Michael G. Cohen et al. [ 8 ] and Rajkumar Cheluvappa and Selwyn Selvendran [ 23 ] call for evaluating the impact of standardized training programs, organizational changes, and multidisciplinary meetings on ethical decision-making and palliative care practices.

Moreover, comparative studies examining cultural variations in ethical considerations, as proposed by Jane Elizabeth Seymour and Christine Ingleton [ 5 ], and investigating the experiences and perspectives of healthcare staff in palliative care research can contribute to a more comprehensive understanding of this multifaceted issue.

Moral distress, defined as the psychological discomfort experienced when constrained from acting on one’s ethical beliefs, is a prevalent issue among nurses in end-of-life care. Addressing this distress is crucial for supporting nurses’ well-being and ethical practice [ 92 , 93 ]. Future research should explore interventions to mitigate moral distress and its impact on nursing practice.

Future research should focus on several key areas to enhance our understanding and practice of palliative care in nursing. First, developing culturally tailored communication training programs is essential to address the diverse needs of patients and families from different backgrounds. Second, evaluating the long-term impacts of standardized palliative care education can provide insights into the sustainability and effectiveness of these programs. Third, exploring ethical decision-making frameworks in diverse clinical settings will help identify best practices and potential areas for improvement. Additionally, there is a need for longitudinal studies to assess the effectiveness of interventions aimed at reducing moral distress among nurses, which can significantly impact their well-being and quality of care. Further research should also investigate strategies to integrate palliative care principles across various healthcare settings, ensuring that all patients receive comprehensive, compassionate care at the end of life.

This systematic review illuminates the intricate ethical challenges and palliative care practices that nurses encounter in end-of-life care. The four overarching themes – communication and decision-making, ethical challenges in practice, integration of palliative care principles, and educational and organizational support – highlight the interdependence of these elements and the pivotal role of nurses in navigating this complex terrain.

Addressing the ethical dilemmas in palliative care requires a multifaceted and targeted approach that encompasses education, communication, and systemic integration. This review highlights the complexity of ethical challenges faced by nurses, including issues related to patient autonomy, beneficence, nonmaleficence, and justice. To effectively navigate these challenges, several key strategies should be implemented.

First, developing and implementing culturally tailored communication training programs for healthcare providers is essential. These programs should focus on enhancing communication skills that respect and incorporate the cultural and personal values of patients and their families, thereby improving shared decision-making and ensuring that care aligns with patient preferences.

Second, evaluating the long-term impacts of standardized palliative care education on nursing practice is crucial. By assessing these programs over time, we can determine their effectiveness in enhancing nurses’ abilities to handle ethical dilemmas and improve patient outcomes. Continuous education and training in ethical decision-making, communication strategies, and palliative care principles are necessary to equip nurses with the skills required to provide high-quality end-of-life care.

Third, creating ethical decision-making frameworks that can be applied across diverse clinical settings will provide nurses with structured guidance to navigate complex ethical issues. These frameworks should be adaptable to various contexts, ensuring that nurses can make informed and consistent ethical decisions regardless of the setting.

Fourth, conducting longitudinal studies to assess the effectiveness of interventions aimed at reducing moral distress among nurses is imperative. Moral distress, which arises when nurses are unable to act according to their ethical beliefs, can lead to burnout and negatively impact patient care. Interventions designed to alleviate moral distress, such as support groups, counseling services, and resilience training, should be evaluated for their long-term benefits.

Finally, integrating palliative care principles more comprehensively into various healthcare settings will ensure that all patients receive holistic, compassionate care. This integration involves incorporating palliative care into routine clinical practice, enhancing access to palliative care services, and promoting interdisciplinary collaboration. By embedding palliative care principles throughout healthcare systems, we can ensure that end-of-life care is patient-centered, ethically sound, and focused on improving quality of life.

In conclusion, addressing the ethical dilemmas in palliative care requires a comprehensive approach that includes targeted education, effective communication, ethical frameworks, support for nurses, and systemic integration of palliative care principles. By implementing these strategies, we can enhance the ability of nurses to navigate ethical challenges and provide compassionate, high-quality care to patients at the end of life. Further research and continued efforts are needed to refine these approaches and ensure their successful implementation across diverse healthcare settings.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

Appreciation is given to all faculty members of the Department of Rheumatology and Rehabilitation, School of Medicine, Qasr Al-Ainy, Cairo University for their help to conduct this research., and special thanks to Dr.Reem Hamdy: Professor of Immunology, Rheumatology, and Rehabilitation, Qasr Al-Ainy Faculty of Medicine, for her valuable guidance and support.

No funding support was received for this study.

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Majed Awad Alanazi, Osama Mohamed Elsayed Ramadan, Mohammed Elsayed Zaky & Mostafa Shaban

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MAA, MMS, OMER, MEZ, HHM, FGMA, and MS collectively contributed to the conception, design, data acquisition, analysis, and interpretation of this study. MAA led the drafting and critical revision of the manuscript for important intellectual content, ensuring final approval of the version to be published. MMS and FGMA provided significant input in the study design and data analysis, contributing to the drafting and revision of the manuscript. OMER, MEZ, and MS were instrumental in data collection, analysis, and interpretation, playing a key role in manuscript preparation and revision. HHM, as a PhD candidate, brought critical insights into data interpretation and contributed substantially to the manuscript’s drafting and refinement.

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Alanazi, M.A., Shaban, M.M., Ramadan, O.M.E. et al. Navigating end-of-life decision-making in nursing: a systematic review of ethical challenges and palliative care practices. BMC Nurs 23 , 467 (2024). https://doi.org/10.1186/s12912-024-02087-5

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Received : 20 February 2024

Accepted : 11 June 2024

Published : 09 July 2024

DOI : https://doi.org/10.1186/s12912-024-02087-5

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