qualitative research bullying in school

A Systematic Review of Research Strategies Used in Qualitative Studies on School Bullying and Victimization

Affiliations.

• 1 School of Social Work, Columbia University, New York, NY, USA [email protected].
• 2 School of Social Work, Wayne State University, Detroit, MI, USA.
• 3 Department of Social Welfare, Sungkyunkwan University, Seoul, Republic of Korea.
• 4 School of Social Service Administration, University of Chicago, Chicago, IL, USA.
• PMID: 26092753
• DOI: 10.1177/1524838015588502

School bullying and victimization are serious social problems in schools. Most empirical studies on bullying and peer victimization are quantitative and examine the prevalence of bullying, associated risk and protective factors, and negative outcomes. Conversely, there is limited qualitative research on the experiences of children and adolescents related to school bullying and victimization. We review qualitative research on school bullying and victimization published between 2004 and 2014. Twenty-four empirical research studies using qualitative methods were reviewed. We organize the findings from these studies into (1) emic, (2) context specific, (3) iterative, (4) power relations, and (5) naturalistic inquiry. We find that qualitative researchers have focused on elaborating on and explicating the experiences of bully perpetrators, victims, and bystanders in their own words. Directions for research and practice are also discussed.

Keywords: bullying; children; peer victimization; qualitative research; school.

© The Author(s) 2015.

Publication types

• Systematic Review
• Crime Victims*
• Empirical Research*
• Qualitative Research*
• Research Design
• Surveys and Questionnaires
• Young Adult

ORIGINAL RESEARCH article

The power threat meaning framework: a qualitative study of depression in adolescents and young adults.

• 1 Department of Clinical Science, Umeå University, Umeå, Sweden
• 2 Department of Nursing, Umeå University, Umeå, Sweden
• 3 Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
• 4 Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom

Introduction: Depression constitutes one of our largest global health concerns and current treatment strategies lack convincing evidence of effectiveness in youth. We suggest that this is partly due to inherent limitations of the present diagnostic paradigm that may group fundamentally different conditions together without sufficient consideration of etiology, developmental aspects, or context. Alternatives that complement the diagnostic system are available yet understudied. The Power Threat and Meaning Framework (PTMF) is one option, developed for explanatory and practical purposes. While based on scientific evidence, empirical research on the framework itself is still lacking. This qualitative study was performed to explore the experiences of adolescents and young adults with depression from the perspective of the PTMF.

Methods: We conducted semi-structured interviews with 11 Swedish individuals aged 15– 22 years, mainly female, currently enrolled in a clinical trial for major depressive disorder. Interviews were transcribed verbatim and analyzed with framework analysis informed by the PTMF.

Results: A complex multitude of adversities preceding the onset of depression was described, with a rich variety of effects, interpretations, and reactions. In total, 17 themes were identified in the four dimensions of the PTMF, highlighting the explanatory power of the framework in this context. Not all participants were able to formulate coherent narratives.

Discussion: The PTMF provides a framework for understanding the complexities, common themes, and lived experiences of young individuals with depression. This may be essential for the development of new interventions with increased precision and effectiveness in the young.

1 Introduction

Depression has become the focus of a wealth of research in recent years ( 1 ). This is appropriate as major depressive disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) ( 2 ) is predicted to soon be the largest individual contributor to the global burden of disease ( 1 , 3 ). In adolescence the prevalence of depression increases compared to childhood ( 4 , 5 ), and an early onset predicts a threefold increase in the risk of adult depression ( 6 ) as well as a sixfold increase in all-cause mortality ( 7 ). Meta-analyses conclude that available interventions for adolescent depression show some promise but lack clear evidence of efficacy ( 8 – 13 ).

The DSM-5 is based on symptom criteria that largely discounts etiology and the subjective understanding of why one is depressed, which likely contributes to its low diagnostic validity for depressive disorders in this age-group ( 14 – 17 ). A shared understanding of the causes and contributing factors is essential for therapeutic alliance, and subjective causal beliefs seem to influence help-seeking ( 18 ). An integrated individual understanding also affects compliance with treatment and ability to handle symptoms ( 19 ).

Within the body of depression research there are relatively few qualitative studies that elicit the subjective understanding of the condition, and some previous studies have focused on the lived experience of depression among adolescents ( 20 – 25 ). Some investigators have touched upon the topic of potential causes of depression ( 23 , 26 – 29 ) and its treatment ( 23 , 30 – 37 ). In summary, the etiology is described as multidimensional, often with more than one cause ( 23 , 26 – 29 ). Two studies have applied existing frameworks from psychology/social science ( 27 ) as well as physical health contexts ( 28 ) in the framing of depression. Still, no one has applied a comprehensive theoretical framework to the lived experience of depression in young people that accounts for both psychological, social, and biological factors without narrowly ascribing primacy to any single one of them.

One framework that could be used to do so is the Power Threat Meaning Framework (PTMF) ( 38 ). The PTMF is a complement/alternative to diagnosis-based practice that also aims at the identification of patterns in emotional distress, unusual experiences and troubled or troubling behavior. It is both an over-arching structure for identifying such patterns, and a meta-framework within which existing models and bodies of evidence is accommodated. The framework draws on several philosophical principles, theories, stakeholder perspectives, and scientific evidence. For example, it synthesizes the extensive literature pointing to a causal impact of relational and social adversities on human brain development and a range of emotional outcomes. The PTMF argues that distress, although enabled by and mediated by our bodies and biology, has not in any simplistic sense been shown to be caused by them. As experience is produced and perceived in contexts that are not separate from a range of socially constructed power-structures and social interactions, all imbued with personal narratives and meanings, the PTMF suggests that these aspects need to be integrated in our models to increase their explanatory power ( 38 ).

The PTMF may be relevant in the context of depression, which is often associated with profound feelings of powerlessness ( 22 , 30 ). The PTMF postulates that power is a factor that needs to be considered both in turning current epidemiological trajectories around and to increase treatment effectiveness. An augmented threat-reactivity is furthermore characteristic of adolescent depression, with amygdala hyperreactivity to emotional stimuli ( 39 ) and an increased allostatic load ( 40 ). If the perceived problems, like e.g., power-imbalances in the affected individuals’ immediate and larger relationships and surroundings ( 23 , 28 ) or subsequently activated/augmented threat reactions ( 23 ) are not addressed, it is likely that the affected individual will feel invalidated. If research is found to support the importance of including these factors, that may invite us to rethink the current interventions for depression in the young and inspire new personalized alternatives with better precision and effectiveness.

The aim of this study was to explore the experiences of adolescents and young adults with depression from the perspective of the PTMF.

2.1 Study context

The study was conducted with individuals who participated in a multi-center randomized controlled trial (RCT) ( 41 ) that investigates the effectiveness of interventions for depression at child and adolescent psychiatric outpatient clinics and youth clinics in two county councils in Northern Sweden. The trial has two phases; first, a one-armed clinical pilot ( 42 ) examining the experimental intervention called Training for Awareness Resilience and Action (TARA) ( 43 ) and second, an RCT in which participants are randomized to TARA or standard treatment, including but not limited to antidepressant medication and/or psychotherapy. The details of the RCT, including, e.g., eligibility criteria, are outlined in the openly available trial-protocol ( 41 ) and online pre-registration (clinicaltrials.gov, NCT-registration identifier: NCT04747340).

2.2 Participants

All individuals that had been enrolled in the pilot or RCT at the end of October 2022 were asked to participate in interviews and all agreed to do so (N=66). From this group, nine individuals were randomly selected and interviewed. Two additional individuals were interviewed with purposive sampling to fill remaining knowledge-gaps, resulting in a sample of 10 females and one male, median age 19 years (range 15-23, IQR 4). This extended age range is motivated by neurobiological similarities between adolescents and young adults ( 44 , 45 ) and recent calls for a new integrated youth mental health care service in this transitional age range ( 46 ). All participants had a clinical diagnosis of major depressive disorder, and the mean score on Reynolds adolescent depression self-rating scale 2 nd edition ( 47 ) was 79.64 (SD 13.02). This scale has good validity and reliability in similar clinical samples and in the Swedish language ( 48 ). All participants were Swedish citizens, one was born in the U.S.A., and six had one parent born abroad (from England, Ghambia, India, Iran, Thailand, and the U.S.A.). None reported being part of any of the official national minorities in Sweden.

TARA participants were interviewed before TARA as the intervention has components that are related to the content of the interviews, and standard treatment participants were interviewed either before, during or after treatment.

2.3 Procedure and data collection

Ethical approval was obtained from the national ethical review board, (Dnr 2020-05734 and 2021-06418-02) and all participants had provided written informed consent at the time of consenting for the clinical trial. Additional parental consent was not recommended as mandatory by the national ethical review board, and it was therefore not collected. Selected participants were contacted over the phone for more detailed information and oral consent for the interviews. Participation was voluntary and could be terminated at any time. Interviews were conducted in 2022-2023.

Three interviews were conducted by EE and two by a psychology student, all in person at the participants choice of location, most commonly in private rooms at the university or healthcare centers. Six interviews were conducted by LR through a secure online video platform. A semi-structured interview guide was used, with open-ended questions like, e.g., “I am interested in knowing more about what you think caused or contributed to your depression, what do you think?”. Follow-up questions informed by the PTMF-dimensions were asked to encourage participants to develop their narratives. For example, “Have you experienced anything that made you very scared or powerless?”, and “How did that affect you?”. More open follow-up questions, like “What other factors may have been important in your case?” were also included.

After six interviews the interview guide was modified to better probe different aspects of perceived causality and more details of treatment(s) received. Interviews lasted for 18-90 min (median 74 min) and the shortest one was ended prematurely by the participant due to an emerging painful reluctancy. All participants received a compensation equivalent to 20 Euro. Interviews were audio-recorded and transcribed verbatim.

2.4 Analysis

Data was analyzed using framework analysis ( 49 – 52 ) to elicit the participants’ experiences of depression based on the dimensions of the PTMF. Framework analysis allows researchers to both bring a pre-defined set of issues and be responsive to emerging themes.

Transcripts were read by all five analysts for familiarization, and emergent issues were discussed to get an overall understanding of the data. The text was then divided and condensed into meaning units relevant to the aim of the study, and the meaning units were coded and sorted according to the dimensions of the PTMF (Power, Threat, Meaning, and Threat Response). These steps were performed individually by EE and LR who then compared their work and adjusted as necessary. All analysts then provided input on the sorting and agreed upon the format. The codes in each dimension were then grouped, abstracted, and interpreted into themes. All analysts met regularly in reflective dialogues to discuss interpretations and finally agreed on the structure and content of the results. Analysts were familiar with the PTMF prior to the analysis. The software MAXQDA 22.8.0 (2022, VERBI software GmbH, Berlin Germany) was used, and no AI tools were applied. The Consolidated Criteria for Reporting Qualitative Research (COREQ) ( 53 ) guided this report.

The results are presented as 17 themes, all incorporated into the four dimensions of the PTMF, to describe the participants experiences of their depression. An overview of the results is presented in Table 1 . An elaboration of the results is presented in text and codes are compared within and across framework dimensions and themes. Quotations are included to illustrate themes and support analytical claims. The quotations have been translated from Swedish to English [translator’s clarifications are bracketed].

Table 1 Findings based on the PTMF-dimensions.

This dimension of the PTMF corresponds to questions like “What has happened to you?” and “How has power operated in your life?”. Participants described a range of conditions as potentially related to their depression, and our interpretation of the findings in this dimension is elaborated in the five following themes.

3.1.1 Loss or fear of loss

Loss was described as a cause for depressive symptoms, e.g., losing community or friends due to moving. Participants also expressed a loss of safety, routines and contact with close ones, e.g., due to parental divorce or the birth of a sibling. Natural changes to the body due to puberty, and diseases or injuries with sometimes permanent sequelae were said to make it hard to exercise or hang out with friends in ways that participants were used to. Participants further mentioned disappearances and deaths, sometimes violently, of family members, close friends and/or pets, and expressed fear that other loved ones would also die.

“I had five rough years where I just lost friend after friend, suicide, diseases, and even a heart attack.” (Participant 5)

3.1.2 Parental distress and lack of family support

Participants described stressful and unsafe home environments with parents who were busy and preoccupied with their own problems and who did not have the time to help them, engage with them, or even listen to them. Some parents were said to not understand participants’ feelings or the severity of their condition, and some had argued that there was no need for the participant to see a psychologist or seek help in other ways.

“Home was never really a safe place. Mom was super sick, very depressed, drank a lot, and took a lot of pills. And dad was super stressed from just taking care of her.” (Participant 2)

Some said their parents struggled with addictions, mental disorders, poverty, and physical disorders. Authoritarian parents were also described, with rigid rules that restricted the families’ and participants’ lives. Some parents were said to be angry with them for being inactive/low, and one participant was kicked out of home. Some participants assumed much responsibility at home, e.g., for siblings or even their parents when they could not cope.

3.1.3 Social exclusion and stress

Social exclusion and stress were common topics, and these were often described as persisting common parts of the participants everyday lives. The participants were often bullied in school both by students, teachers, and other school staff. Social media was also described as a stressful platform for social comparison and competition.

“And when they said all those mean things, I started to realize it myself too. I started to think that I was the problem.” (Participant 7)

Some said it was difficult to make new friends even if they wanted to, and therefore they hung out with people despite knowing they were being used by them. There were descriptions of being misunderstood and let down, and not having adults in school that could be trusted. Participants who got in conflict with teachers expressed a lack of support from their peers. Some were struggling with dyslexia, and both before and after receiving this diagnosis participants reported unfair treatment. Additionally, a pressure related to the achievement of high grades was said to come from both teachers, parents, and/or themselves. Outside school hours participants described being left behind as family members took part in social activities without them.

“I had to stay at home and the whole family went away, so I was all alone in the weekends too.” (Participant 9)

3.1.4 Abuse and harassment

Previous and ongoing domestic violence was described, including parental assaults directed to the participants themselves, other adults, siblings and/or pets. Participants described parents and/or stepparents who were aggressive and unpredictable in subjecting the participants and/or others to physical and verbal violence, silencing, withholding of information, and who made uninvited intrusive contact. Destructive romantic relationships and sexual abuse was also described, with examples of being forced to do things without consent and being physically hindered to scream for help.

“If I said no, I knew he would get angry with me, because he got angry a lot. Then it was just like if I said no, and he wanted to have sex, then it was like he just pulled my legs anyway as if I had no choice.” (Participant 5)

Participants also mentioned sexual harassment by strangers on the street, as well as close relationships in which partners and parents had made them feel stupid.

3.1.5 Invalidated by the health care system

Participants described long waiting times in health care, which contributed to feelings of being insignificant and neglected. Participants also expressed that they were not seen, diminished, and even betrayed by professionals, especially in a child- and adolescent psychiatry. Some described that when trying to explain their problems and feelings, professionals did not seem to understand the nature or severity of their condition, and at times they did not even seem interested in their story.

“Being treated by someone supposed to help you, who doesn’t even know what they’re doing or why they are there, in the end I just sat there in silence.” (Participant 4)

Participants also expressed experiences of not getting better by previous treatments, including antidepressant medication and psychotherapy, which led to feelings of invalidation and a lack of solutions or hope. Antidepressants were said to be prescribed without a treatment plan or follow-up, and participants described a shortage of information as to e.g., for how long they would continue the medication.

This dimension of the PTMF corresponds to questions like “How did that affect you?”. Participants described a variety of ways in which they were affected by being subjected to the different forms of power dynamics described in the previous section, and our interpretation of the findings in this dimension is elaborated in the four following themes.

3.2.1 Getting shocked and confused

Participants described being shocked by things that had happened to them, and this was often accompanied by a struggle to understand their situation and their feelings. Unexpected events were said to trigger disbelief and denial. Situations where participants were lacking an understanding of how they got to a particular place or situation were also described, and so was derealization and movie-like experiences. All this was said to raise more questions that mostly ended up leaving participants confused.

“Then when he passed away it was like a piece of me followed him. A piece of me that I knew, disappeared completely. Then there I was, I felt a bit empty, but then also so unreal.” (Participant 4)

3.2.2 Getting angry and frustrated

Based on being fed up with how things were, participants expressed that irritation and anger were common in their lives. Participants described quarrels, a lot of fighting and screaming, both with parents and friends. Often all persons involved were said to be irritated, which led to misunderstandings and further problems. Both overt hatred and a quieter disappointment was described.

“Everyone said I just got more and more angry, and I had to start seeing a therapist because they said I was having problems with aggression, for taking it out on other things I mean.” (Participant 7)

3.2.3 Experiencing anxiety and physical symptoms

Negative events were said to trigger fears and expectations that more negative events would occur. This led to worry, fear, social anxiety, and panic attacks that caused avoidance of triggering places and situations. A tendency to overthink and over-analyze was also described, and this was said to make it difficult to sleep or get other important things done.

“I just can’t relax; I must analyze how the person reacted. And I have trouble sleeping from having to go through the entire day before I go to sleep.” (Participant 2)

Physical symptoms like muscular tension and pain were common, and nausea, palpitations, a heaviness in the chest, shortness of breath, lumps in the throat or sense of being strangulated, hair loss, headaches, and stomachaches were described. Previous experiences were also said to have made participants more alert, sensitive, and easily triggered by things, even small insignificant sounds. One participant got really scared if someone sneezed. Participants reported that they vigilantly observed previous perpetrators, often in their home, for indicators of their current mood. If the person raised their voice, touched them, or even stayed silent it was said to indicate that more negative things were coming.

3.2.4 Feeling low and lonely

As a result of negative operations of power, participants described getting tired and low, with little or no energy to engage in their everyday lives. Things they used to enjoy were said not to feel as enjoyable. Some said it was hard to start new projects when feeling sick, leading to procrastination. Further descriptions included apathy, depression, and a deep sadness. A sense of loneliness was also common and moreover a “stuck-ness” with oneself and an inability to reach out to others.

“In the beginning I didn’t notice it much, it was more like I just didn’t have any energy to do stuff, it was no longer fun to do things I used to like.” (Participant 8)

3.3 Meaning

This dimension of the PTMF corresponds to questions like “What sense did you make of it?”. Participants described different ways of understanding their situation, and a few participants expressed that they were still struggling to make sense of the meaning of some events. Our interpretation of the findings in this dimension is elaborated in the three following themes.

3.3.1 Feeling left out

Participants sometimes interpreted their situation as if they did not belong anywhere. They described that they had nothing in common with the people around them, and therefore had a sense of not fitting in. By not understanding the social codes or themselves in relation to others, and perceiving themselves as embarrassing and in the way, participants expressed that they lost their groups and sense of community and belonging.

“I have nothing in common with them, they laugh at things I don’t understand. I mean it is like I’ve been living underneath a stone my entire life.” (Participant 11)

3.3.2 Lacking trust in others and in oneself

Participants described insecurities, doubt, and mistrust in others and in themselves. They expressed feeling such as no one could help them and therefore found it hard to rely on others. Others were said not to care. This, and the experience of losing others - which was often interpreted to mean that “goodbye means bye forever” - made some participants draw the conclusion that they were meant to be alone with their problems.

“It becomes a defense mechanism or whatever you call it. I mean the trust you have, in my case to my mom particularly. The thing is now, I can’t trust her the way I did before.” (Participant 1)

On top of that an insecurity regarding their own capability to handle things was expressed. Based on a sense of being wrong, an inability to understand and improve their situation, and not feeling good enough, some were left with a mistrust in their own feelings and thoughts. One said she could not be herself, and others said it was hard to do anything at times of uncertainty.

3.3.3 Blaming oneself

The participants expressed that they assumed responsibility for many things that had happened to them and/or their friends and family.

“I felt like a failure, inadequate. When I couldn’t fix my parents relationship, and the divorce, like, how was I gonna handle the rest of my life?” (Participant 8)

After situations of abuse a sense of self-disgust was described, and participants blamed themselves for letting perpetrators do things with them. This was also true with bullying. Seeing faults in oneself was said to result in a bad conscience and seeing oneself as a burden, and failures were described, like e.g., not being able to prevent the death of others, and not being able to explain their situation in a way that health care could understand. Others reported that they created problems out of nothing, that they just exaggerated the problem and overreacted. One said it was like they had “a ghost in the brain”, and others said that if it wasn’t for them problems wouldn’t have happened.

3.4 Threat response

This dimension of the PTMF corresponds to questions like “What did you have to do to survive?”. Participants reflected on a variety of coping strategies that they used to handle their situation, and our interpretation is elaborated in the five following themes.

3.4.1 Keeping things within and avoiding feelings

Participants described that they often handled their situation by not talking about problems, sometimes to spare their friends and family from trouble. It was also said that feelings were kept inside, often in attempts to be carefree and “happy-go-lucky “– which sometimes annoyed people around them. Some said they avoided thinking about the situation altogether, pushing things away or denying them. One said she told her parents the truth all at once and that this was not common for her.

“When I got to see a child psychiatrist, that’s when my mom really got to understand that I actually had been feeling really bad. I had not let her know about that until then.” (Participant 5)

3.4.2 Withdrawing from relationships and coping alone

Participants described isolating themselves, as sometimes it was said to be easier to be alone. Refusing to go to school, sometimes for several years, was said to negatively affect their grades. A fear of leaving home was expressed, as home was sometimes the only place where they could feel safe and in control. For some, the isolation was said to be an escape, as getting away was sometimes the only possible thing to do. Some said they hung out with others only on the internet as a way of hiding and protecting themselves.

“I stopped having contact with my friends in school. I didn’t want to talk to them, I was so ashamed, so I have stopped talking to them completely.” (Participant 6)

Participants also described things they did on their own to try to accept or improve their situation. Some reflected and made plans, others expressed a need to withdraw to spend time with their thoughts and feelings here and now. Some said they used music, movies, or physical exercise to relax and avoid rumination.

“Getting back from the walk, I have had the time to think and can handle my emotions better, like is this really my fight? No, then I don’t have to get as offended when they are the ones with problems. I can put it to the side a little.” (Participant 1)

3.4.3 Self-harming and restrictive eating

Participants expressed an urge to harm themselves in different ways, often as other strategies or means of expression were lacking. Knives, blunt objects, and tools were used to injure oneself. Some smoked large amounts of cigarettes and used alcohol and other drugs for this purpose. Participants also described being preoccupied with food and their weight, sometimes restricting their eating, and sometimes also binging as vengeance to parents who had said they ate too much.

“That [restricted eating] is something I can control, I guess the other things become less in your face when there is at least something you can control.” (Participant 10)

3.4.4 Seeking contact and support

Help seeking was described by some participants, including seeing psychologists to discuss the situation and find support. Some also described close relationships as important, and family members, teachers and friends who were described as invaluable support. To actively seek out and protect such supportive individuals was a strategy for some. Romantic relationships were sometimes also described as helpful. While some enjoyed opportunities to share their story with other young people in similar situations, others expressed a value in being surrounded by animals.

“To hear someone else [here at the youth clinic] explain that it is not all that strange that I think along these lines, it makes things easier somehow.” (Participant 3)

3.4.5 Trying to please and adapt

Participants described that they avoided conflicts in every possible way and did their best to understand others’ feelings, thoughts and needs in order to please them. Some said they tried to compensate for perceived shortcomings by making others happy and satisfied, no matter the cost, and friends were sometimes bought with money or favors. Additionally, participants said they tried to be normal and inconspicuous to fit in.

“Something that I have had to learn is to analyze everything that happens around me. To always sense what someone needs or if something is wrong, maybe even before they say they need something.” (Participant 10)

4 Discussion

This study explored the experiences of adolescents and young adults with depression from the perspective of the PTMF ( 38 ). While the PTMF is based on research, few studies have investigated it empirically in a clinical context. This is perhaps because it has a high level of complexity, with implications that challenge us to rethink key aspects of current psychiatric care and treatment.

In the present study it was feasible to apply the PTMF in the collection and analysis of data, and the dimension of “power” was clearly identified in the interviews. Data contained readily appearing and clearly traumatizing experiences that have all been previously implicated in depression in young people ( 54 – 58 ). We replicate previous findings of interpersonal problems ( 23 , 26 , 27 , 29 ) pressure ( 23 , 29 ), and loss ( 28 ) as central to adolescent depression, their common power-related denominator has however previously been largely unrecognized.

The second dimension of “threat” originally refers to what core human needs are threatened by the described negative operations of power. In our sample participants did not spontaneously identify core human needs as threatened in their responses to questions on how they were affected. Themes in this dimension reflect more autonomic stress and threat reactions. This may be due to the questions which were openly formulated. Participants were also relatively young for an analysis of their situation on this level, and potentially the current depression limited their metacognitive capacity. However, in the dimension of “meaning”, the need to belong was prominent, indicating that the ability to identify needs was present. Perhaps some experiences do cut across framework dimensions and therefore fit in more than one. It was expected that the framework would have areas of better and worse fit, as this has been described in previous framework analyses ( 49 , 52 ).

Subsequent “threat responses” or coping strategies varied in quality and some participants described self-perpetuating negative spirals, e.g., the threat reaction of isolation led to poor school performance, which in turn led to new spirals of school stress and fear of losing other things. In the analysis it was sometimes challenging to see where one chain of events ended and a new one started, and this is acknowledged by the original authors ( 38 ). Also, some participants appeared to suffer from dissociation, and some were unable to form a coherent narrative which complicated the matter. To analyze meaning, form a coherent narrative, and regulate emotions are processes that require a coordination of several high-level processes ( 59 ), and in young people with depression the fronto-limbic maturation process is delayed in comparison to healthy individuals ( 60 ). This, and the inclusions of participants that had not achieved full integration of previous traumatic experiences, can potentially explain the described difficulties. Furthermore, only negative interpretations/meanings were voiced, which may reflect the participants depressed state. The same may be true for negative views on previous therapists and interventions.

Importantly, we identified different meanings ascribed to apparently similar situations and diagnostic labels, indicating the value of personalized approaches to understand, describe, validate, and treat depression successfully. We foresee that contextual, diagnostic, and biomedical approaches to understand, describe and manage depression will complement each other and lead to improved outcomes over time.

Even within the current diagnostic paradigm, trauma informed approaches to depression treatment may be motivated in young people. In this context the PTMF may be helpful in eliciting adverse experiences that were previously obscured. As there is a growing body of evidence that suggests that difficult lives explain depression better than broken brains ( 61 , 62 ), treatment approaches that acknowledge this can potentially be more effective than interventions that primarily deal with downstream symptoms. One implication of our findings on the relevance of negative operations of power in the context of depression is that intersectional analyses of these mechanisms may be useful, both to enable individual empowerment, restored self-confidence and better life navigation skills as part of depression treatment. Policy reforms aimed to prevent depression in young people may also benefit from such analyses.

Limitations: The interviews might be considered as brief and few when trying to understand the complex phenomena behind depression. We determined the information density to be high, and the material was rich enough for analysis. Only one participant was male however, which may affect transferability. By bringing the PTFM both to the interview design and data analysis, there an almost inevitable risk of “finding” what was simply assumed a priori. To minimize this risk, we carefully searched for meaning units, codes and themes that did not fit within the PTMF, without any such findings. Also, methodological and epistemological triangulation was used by performing framework analysis ( 51 ). This allowed us to draw upon existing knowledge and yet not be limited by it, as both realist and constructionist epistemologies were applied. To our knowledge this is the first time that this approach is applied within clinical psychiatry.

Strengths include that that the study gives voice to young people with depression, a group with limited abilities and opportunities to express themselves and be fully heard. The study constitutes a real-world application of the PTMF in a diverse ethnical sample and may contribute to a paradigm shift in the way we conceptualize and address mental disorders at large.

4.1 Conclusion

In the last decades there has hardly been any pragmatic or clinically useful alternative available to DSM diagnosis-based practice, and the biomedical and pharmaceutical approach that follows from it may obscure individual needs and lead to missed opportunities for interventions to meet those needs. The PTMF provides an alternative understanding of depression in young people. It is internally coherent and compatible both with the present qualitative data and with previous studies and models of youth depression. As the negative operation of various forms of power appears to be related to the onset of depression in young people, we echo the United Nations special rapporteur: “ Mental health policies should begin to address power imbalances rather than chemical imbalances ” ( 63 ). This approach may improve our understanding of depression and inspire the development of new interventions with increased precision and effectiveness.

Author’s note

EE is a male resident in family medicine and doctoral student in child and adolescent psychiatry. LR is a female pharmacist with a PhD in clinical neuroscience. JM is a female mental health nurse and associate professor in nursing. MS is a female specialist physiotherapist and associate professor in physiotherapy. NM is a male child psychotherapist and a professor of psychological therapies with children and young people. EH is a female specialist and professor in Child and adolescent psychiatry, she developed the TARA intervention. None of the authors had any therapeutic or other relationship to any of the participants and participants were not given any specific information about the researchers. All authors had experience of qualitative research in this area.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The study was approved by the Swedish national ethical review board, (Dnr 2020-05734 and 2021-06418-02). The study was conducted in accordance with the local legislation and institutional requirements. All participants provided written informed consent. Additional parental consent for participants below 18 years of age was not recommended as mandatory by the national ethical review board.

Author contributions

EE: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Writing – original draft, Writing – review & editing. LR: Writing – original draft, Writing – review & editing, Conceptualization, Data curation, Formal analysis, Investigation, Methodology. JM: Writing – review & editing, Conceptualization, Formal analysis, Investigation, Methodology. MS: Writing – review & editing, Formal analysis. NM: Methodology, Writing – review & editing. EH: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by the County Council of the Region Västerbotten; the County Council of the Region Västernorrland, municipality of Örnsköldsvik and the Kempe foundation under grant nr. LVNFOU933598; the Swedish Society of Medicine under grant nr. SLS-935854; Lars Jacob Boëthius foundation; Fredrik and Ingrid Thurings foundation; and the Oskar-foundation. The funders had no role in the study design, data collection, analysis, interpretation, writing the report or decision to submit the article for publication.

Acknowledgments

The authors would like to thank the participants for their individual contributions to this study, Mio Negga for conducting two interviews, and Elisabeth Loisel for transcribing the recordings.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

1. Santomauro DF, Herrera AMM, Shadid J, Zheng P, Ashbaugh C, Pigott DM, et al. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet. (2021) 398:1700–12. doi: 10.1016/S0140-6736(21)02143-7

PubMed Abstract | CrossRef Full Text | Google Scholar

2. APA. Diagnostic and statistical manual of mental disorders . 5th edition. Arlington, VA, USA: American psychiatric publishing (2013).

Google Scholar

3. Lepine JP, Briley M. The increasing burden of depression. Neuropsychiatr Dis Treat . (2011) 7:3–7. doi: 10.2147/NDT

4. Avenevoli S, Swendsen J, He JP, Burstein M, Merikangas KR. Major depression in the national comorbidity survey-adolescent supplement: prevalence, correlates, and treatment. J Am Acad Child Adolesc Psychiatry . (2015) 54:37–44.e2. doi: 10.1016/j.jaac.2014.10.010

5. Lebrun-Harris LA, Ghandour RM, Kogan MD, Warren MD. Five-year trends in US children’s health and well-being, 2016-2020. JAMA Pediatr . (2022) 176:e220056. doi: 10.1001/jamapediatrics.2022.0056

6. Johnson D, Dupuis G, Piche J, Clayborne Z, Colman I. Adult mental health outcomes of adolescent depression: A systematic review. Depress Anxiety. (2018) 35:700–16. doi: 10.1002/da.2018.35.issue-8

7. Leone M, Kuja-Halkola R, Leval A, D’Onofrio BM, Larsson H, Lichtenstein P, et al. Association of youth depression with subsequent somatic diseases and premature death. JAMA Psychiatry . (2020) 78(3):302–10. doi: 10.1001/jamapsychiatry.2020.3786

CrossRef Full Text | Google Scholar

8. Cox GR, Callahan P, Churchill R, Hunot V, Merry SN, Parker AG, et al. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database Syst Rev . (2014) 11:Cd008324. doi: 10.1002/14651858.CD008324.pub3

9. Cipriani A, Zhou X, Del Giovane C, Hetrick SE, Qin B, Whittington C, et al. Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet. (2016) 388:881–90. doi: 10.1016/S0140-6736(16)30385-3

10. Zhou X, Hetrick SE, Cuijpers P, Qin B, Barth J, Whittington CJ, et al. Comparative efficacy and acceptability of psychotherapies for depression in children and adolescents: A systematic review and network meta-analysis. World Psychiatry . (2015) 14:207–22. doi: 10.1002/wps.v14.2

11. Yang L, Zhou X, Zhou C, Zhang Y, Pu J, Liu L, et al. Efficacy and acceptability of cognitive behavioral therapy for depression in children: A systematic review and meta-analysis. Acad Pediatr . (2017) 17:9–16. doi: 10.1016/j.acap.2016.08.002

12. Zhou X, Teng T, Zhang Y, Del Giovane C, Furukawa TA, Weisz JR, et al. Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis. Lancet Psychiatry . (2020) 7:581–601. doi: 10.1016/S2215-0366(20)30137-1

13. Weisz JR, Venturo-Conerly KE, Fitzpatrick OM, Frederick JA, Ng MY. What four decades of meta-analysis have taught us about youth psychotherapy and the science of research synthesis. Annu Rev Clin Psychol . (2023) 19:79–105. doi: 10.1146/annurev-clinpsy-080921-082920

14. Alexandrino-Silva C, Wang YP, Carmen Viana M, Bulhões RS, Martins SS, Andrade LH. Gender differences in symptomatic profiles of depression: results from the São Paulo Megacity Mental Health Survey. J Affect Disord . (2013) 147:355–64. doi: 10.1016/j.jad.2012.11.041

15. Blom EH, Forsman M, Yang TT, Serlachius E, Larsson JO. Latent classes of symptoms related to clinically depressed mood in adolescents. Scand J Child Adolesc Psychiatr Psychol . (2014) 2:19–28. doi: 10.21307/sjcapp-2014-004

16. BPS. Classification of behaviour and experience in relation to functional psychiatricdiagnoses: Time for a paradigm shift. In: DCP Position Statement . The British Psychological Society, Leichester (2013).

17. Manfro PH, Pereira RB, Rosa M, Cogo-Moreira H, Fisher HL, Kohrt BA, et al. Adolescent depression beyond DSM definition: a network analysis. Eur Child Adolesc Psychiatry . (2021) 32(5):881–92. doi: 10.1007/s00787-021-01908-1

18. O’Neill A, Humphrey N, Stapley E. A systematic review of qualitative research focusing on emotional distress among adolescents: perceived cause and help-seeking. Adolesc Res Review. (2023) 8:387–402. doi: 10.1007/s40894-022-00203-7

19. Nunstedt H, Nilsson K, Skärsäter I, Kylén S. Experiences of major depression: individuals’ Perspectives on the ability to understand and handle the illness. Issues Ment Health Nursing. (2012) 33:272–9. doi: 10.3109/01612840.2011.653038

20. Wisdom JP, Green CA. “Being in a funk”: teens’ efforts to understand their depressive experiences. Qual Health Res . (2004) 14:1227–38. doi: 10.1177/1049732304268657

21. Woodgate RL. Living in the shadow of fear: adolescents’ lived experience of depression. J Adv Nurs. (2006) 56:261–9. doi: 10.1111/j.1365-2648.2006.04020.x

22. Farmer TJ. The experience of major depression: adolescents’ perspectives. Issues Ment Health Nurs. (2002) 23:567–85. doi: 10.1080/01612840290052776

23. Ross E, Ali A, Toner B. Investigating issues surrounding depression in adolescent girls across Ontario: a participatory action research project. Can J Commun Ment Health . (2003) 22:55–68. doi: 10.7870/cjcmh-2003-0004

24. Midgley N, Parkinson S, Holmes J, Stapley E, Eatough V, Target M. Beyond a diagnosis: The experience of depression among clinically-referred adolescents. J Adolesc. (2015) 44:269–79. doi: 10.1016/j.adolescence.2015.08.007

25. De Mol J, D’Alcantara A, Cresti B. Agency of depressed adolescents: embodiment and social representations. Int J Qual Stud Health Well-being. (2018) 13:1564516. doi: 10.1080/17482631.2018.1564516

26. Radovic A, Gmelin T, Stein BD, Miller E. Depressed adolescents’ positive and negative use of social media. J Adolesc. (2017) 55:5–15. doi: 10.1016/j.adolescence.2016.12.002

27. Rose-Clarke K, Hassan E, Bk P, Magar J, Devakumar D, Luitel NP, et al. A cross-cultural interpersonal model of adolescent depression: A qualitative study in rural Nepal. Soc Sci Med . (1982) 2021:270. doi: 10.1016/j.socscimed.2020.113623

28. Bear HA, Krause KR, Edbrooke-Childs J, Wolpert M. Understanding the illness representations of young people with anxiety and depression: A qualitative study. Psychol Psychother. (2021) 94:1036–58. doi: 10.1111/papt.12345

29. Midgley N, Parkinson S, Holmes J, Stapley E, Eatough V, Target M. “Did I bring it on myself?” An exploratory study of the beliefs that adolescents referred to mental health services have about the causes of their depression. Eur Child Adolesc Psychiatry . (2017) 26:25–34. doi: 10.1007/s00787-016-0868-8

30. Maroun RA, Thackeray LA, Midgley N. Meaning and medication: a thematic analysis of depressed adolescents’ views and experiences of SSRI antidepressants alongside psychological therapies. BMC Psychiatry . (2018) 18:374. doi: 10.1186/s12888-018-1961-y

31. Weitkamp K, Klein E, Midgley N. The experience of depression: A qualitative study of adolescents with depression entering psychotherapy. Glob Qual Nurs Res . (2016) 3:2333393616649548. doi: 10.1177/2333393616649548

32. O’Keeffe S, Martin P, Target M, Midgley N. ‘I just stopped going’: A mixed methods investigation into types of therapy dropout in adolescents with depression. Front Psychol . (2019) 10:75. doi: 10.3389/fpsyg.2019.00075

33. Midgley N, Holmes J, Parkinson S, Stapley E, Eatough V, Target M. “Just like talking to someone about like shit in your life and stuff, and they help you”: Hopes and expectations for therapy among depressed adolescents. Psychother Res . (2016) 26:11–21. doi: 10.1080/10503307.2014.973922

34. Housby H, Thackeray L, Midgley N. What contributes to good outcomes? The perspective of young people on short-term psychoanalytic psychotherapy for depressed adolescents. PloS One . (2021) 16:e0257334. doi: 10.1371/journal.pone.0257334

35. Wilmots E, Midgley N, Thackeray L, Reynolds S, Loades M. The therapeutic relationship in Cognitive Behaviour Therapy with depressed adolescents: A qualitative study of good-outcome cases. Psychol Psychother. (2020) 93:276–91. doi: 10.1111/papt.12232

36. Herring GT, Loades ME, Higson-Sweeney N, Hards E, Reynolds S, Midgley N. The experience of cognitive behavioural therapy in depressed adolescents who are fatigued. Psychol Psychother. (2022) 95:234–55. doi: 10.1111/papt.12365

37. Reinodt S, Haglund E, Bremander A, Jarbin H, Larsson I. Adolescents’ Long-term experiences of manageability, comprehensibility, and meaningfulness of a group-based exercise intervention for depression. Int J Environ Res Public Health . (2022) 19(5):2894. doi: 10.3390/ijerph19052894

38. Johnstone LB M, Cromby J, Dillon J, Harper D, Kinderman P, Longden E, et al. The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis . Leichester: British Psychological Society (2018).

39. Yang TT, Simmons AN, Matthews SC, Tapert SF, Frank GK, Max JE, et al. Adolescents with major depression demonstrate increased amygdala activation. J Am Acad Child Adolesc Psychiatry . (2010) 49:42–51. doi: 10.1097/00004583-201001000-00008

40. National, Scientific, Council, on, the, Developing, Child. Connecting the brain to the rest of the body: early childhood development and lifelong health are deeply intertwined: working paper no. 15 (2020)Available online at: www.developingchild.harvard.edu .

41. Ekbäck E, Granåsen G, Svärling R, Blomqvist I, Henje E. Clinical effectiveness of training for awareness resilience and action online compared to standard treatment for adolescents and young adults with depression: study protocol and analysis plan for a pragmatic, multi-center randomized controlled superiority trial. Front Psychiatry . (2021) 12:674583. doi: 10.3389/fpsyt.2021.674583

42. Ekbäck E, Rådmark L, Granåsen G, Svärling R, Sörlin M, Schönbeck C, et al. Clinical effectiveness of training for awareness, resilience, and action for adolescents and young adults with depression: The pilot phase of a multicenter randomized controlled trial. Front Psychiatry . (2023) 14. doi: 10.3389/fpsyt.2023.1130035

43. Henje Blom E, Duncan LG, Ho TC, Connolly CG, LeWinn KZ, Chesney M, et al. The development of an RDoC-based treatment program for adolescent depression: “Training for Awareness, Resilience, and Action” (TARA). Front Hum Neurosci . (2014) 8:630. doi: 10.3389/fnhum.2014.00630

44. Bethlehem RAI, Seidlitz J, White SR, Vogel JW, Anderson KM, Adamson C, et al. Brain charts for the human lifespan. Nature. (2022) 604:525–33. doi: 10.1038/s41586-022-04554-y

45. Shaw P, Kabani NJ, Lerch JP, Eckstrand K, Lenroot R, Gogtay N, et al. Neurodevelopmental trajectories of the human cerebral cortex. J Neurosci . (2008) 28:3586–94. doi: 10.1523/JNEUROSCI.5309-07.2008

46. McGorry PD, Mei C, Chanen A, Hodges C, Alvarez-Jimenez M, Killackey E. Designing and scaling up integrated youth mental health care. World Psychiatry . (2022) 21:61–76. doi: 10.1002/wps.20938

47. Reynolds WM. Reynolds adolescent depression scale. In: Professional manual , 2nd edition. Psychological Assessment Resources, Odessa (FL (2002).

48. Ekbäck E, Blomqvist I, Dennhag I, Henje E. Psychometric properties of the Swedish version of the Reynolds Adolescent Depression Scale second edition (RADS-2) in a clinical sample. Nord J Psychiatry . (2022) 77(4):383–92. doi: 10.1080/08039488.2022.2128409

49. Parkinson S, Eatough V, Holmes J, Stapley E, Midgley N. Framework analysis: a worked example of a study exploring young people’s experiences of depression. Qual Res Psychol . (2016) 13:109–29. doi: 10.1080/14780887.2015.1119228

50. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol . (2013) 13:117–. doi: 10.1186/1471-2288-13-117

51. Ritchie J SL. Analyzing qualitative data, Chapter 9: Qualitative data analysis for applied policy research . Bryman BBR, editor. London and New York: Routledge (1994).

52. Goldsmith L. Using framework analysis in applied qualitative research. In: Qualitative report . (2021) 26(6):2061–76. doi: 10.46743/2160-3715/2021.5011

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

54. Kendler KS, Karkowski LM, Prescott CA. Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry . (1999) 156:837–41. doi: 10.1176/ajp.156.6.837

55. Friis RH, Wittchen HU, Pfister H, Lieb R. Life events and changes in the course of depression in young adults. Eur Psychiatry . (2002) 17:241–53. doi: 10.1016/S0924-9338(02)00682-X

56. Pine DS, Cohen P, Johnson JG, Brook JS. Adolescent life events as predictors of adult depression. J Affect Disord . (2002) 68:49–57. doi: 10.1016/S0165-0327(00)00331-1

57. Kendler KS, Hettema JM, Butera F, Gardner CO, Prescott CA. Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of onsets of major depression and generalized anxiety. Arch Gen Psychiatry . (2003) 60:789–96. doi: 10.1001/archpsyc.60.8.789

58. Andersen SL, Teicher MH. Stress, sensitive periods and maturational events in adolescent depression. Trends Neurosci . (2008) 31:183–91. doi: 10.1016/j.tins.2008.01.004

59. Ahmed SP, Bittencourt-Hewitt A, Sebastian CL. Neurocognitive bases of emotion regulation development in adolescence. Dev Cognit Neurosci . (2015) 15:11–25. doi: 10.1016/j.dcn.2015.07.006

60. Yang TT, Simmons AN, Matthews SC, Tapert SF, Frank GK, Bischoff-Grethe A, et al. Depressed adolescents demonstrate greater subgenual anterior cingulate activity. Neuroreport. (2009) 20:440–4. doi: 10.1097/WNR.0b013e3283262e10

61. Moncrieff J, Cooper RE, Stockmann T, Amendola S, Hengartner MP, Horowitz MA. Difficult lives explain depression better than broken brains. Mol Psychiatry . (2024). doi: 10.1038/s41380-024-02462-3

62. de Lacy N, Ramshaw MJ, McCauley E, Kerr KF, Kaufman J, Nathan Kutz J. Predicting individual cases of major adolescent psychiatric conditions with artificial intelligence. Transl Psychiatry . (2023) 13:314. doi: 10.1038/s41398-023-02599-9

63. Rapporteur S. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health . Geneva: United Nations General Assembly (2017).

Keywords: depression, adolescents, young adults, qualitative research, framework analysis

Citation: Ekbäck E, Rådmark L, Molin J, Strömbäck M, Midgley N and Henje E (2024) The Power Threat Meaning Framework: a qualitative study of depression in adolescents and young adults. Front. Psychiatry 15:1393066. doi: 10.3389/fpsyt.2024.1393066

Received: 28 February 2024; Accepted: 15 April 2024; Published: 01 May 2024.

Reviewed by:

Copyright © 2024 Ekbäck, Rådmark, Molin, Strömbäck, Midgley and Henje. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Erik Ekbäck, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Announcing the Recipients of the 2024 Malcolm Wiener Center Qualitative Research Grants

April 24, 2024.

In 2023, Sandra Susan Smith, faculty director of the Malcolm Wiener Center for Social Policy, launched a new research initiative that offers grants to faculty and students to support the development of qualitative research projects about social policy. We are excited to announce the 2024 Malcolm Wiener Center Qualitative Research Grant recipients. 

Faculty Recipients:

Will dobbie and crystal yang — changing opportunity: sociological mechanisms underlying growing class gaps and shrinking race gaps in economic mobility.

In this project, Dobbie, Yang, and collaborators are studying recent trends in economic mobility by race and socioeconomic class to understand the mechanisms underlying economic mobility. Building on their quantitative work that uses anonymized longitudinal data covering nearly the entire U.S. population, they will identify sites in the country that have experienced sharp changes in mobility by race and class in recent decades.  They will then conduct qualitative interviews in these sites to better understand the mechanisms underlying recent trends.

Student Recipients:

Daniel alain evrard — redistributing power navigating climate change, capitalist development, and the promise of a “just energy transition”.

Kelsey Pukelis — Dynamic Enrollment in Public Benefit Programs: Evidence from Disaster SNAP

Does taking up government benefits due to a natural disaster make a household more likely to take them up in the future? Pukelis embarks on the first systematic, mixed-methods study of the Disaster Supplemental Nutrition Assistance Program (D-SNAP) to understand mechanisms of dynamic enrollment in social safety net programs, including individual learning, group learning, and levels of stigma.

Shreya Tandon — Drivers of Intra-Household Labor Supply Complementarities and Implications for Women's Economic Opportunities: Evidence from India's Garment Sector

Tandon studies the labor supply decisions of rural-urban migrants employed in the garment manufacturing sector in India. Her research suggests that concerns about commuting safety, workplace safety, and bargaining power at work might be driving migrant couples to work together at the same factory instead of diversifying, which increases their exposure to income risk in an industry prone to export demand shocks. In future work, she aims to explore how working conditions in the garment sector shape migrant households’ labor supply decisions as well as intra-household bargaining.

Jessica Urzúa — A Collective Action Puzzle: Union Membership in “Right-to-Work” States

To better understand the potential role for unions in reducing inequality, Urzúa's project investigates workers’ motivations for contributing to collective action beyond individual financial interest, and how this may be shaped by local context.

Jessica Van Meir — The Sex Workers’ Rights Movement in Guatemala

Van Meir's dissertation focuses on the sex workers' rights movement in Latin America, asking when governments recognize sex workers as workers entitled to labor rights. Although the buying and selling of sex is not criminalized in most of Latin America, no country has passed legislation granting sex workers equal rights with other workers. Van Meir will compare two countries which have recognized a sex worker union, Colombia and Guatemala, with two which have not, Argentina and Ecuador, to understand what factors lead governments to treat people who sell sex as workers. She will conduct interviews with government officials and activists, participant observation with sex worker-led organizations, and document analysis on newspaper archives across these countries.

• Open access
• Published: 26 April 2024

Factors influencing the development of nursing professionalism: a descriptive qualitative study

• Xingyue He 1 ,
• Huili Cao 2 ,
• Linbo Li 1 ,
• Yanming Wu 1 &
• Hui Yang 1 , 3  

BMC Nursing volume  23 , Article number:  283 ( 2024 ) Cite this article

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The shortage of nurses threatens the entire healthcare system, and nursing professionalism can improve nurse retention and enhance the quality of care. However, nursing professionalism is dynamic, and the factors influencing its development are not fully understood.

A qualitative descriptive study was conducted. Using maximum variation and purposive sampling, 14 southern and northern China participants were recruited. Semi-structured interviews were conducted from May 2022 to August 2023 in face-to-face conversations in offices in the workplace or via voice calls. The interviews were transcribed verbatim and analyzed via thematic analysis.

Three main themes emerged: (1) nourishment factors: promoting early sprouting; (2) growth factors: the power of self-activation and overcoming challenges; and (3) rootedness factors: stability and upward momentum. Participants described the early acquisition of nursing professionalism as derived from personality traits, family upbringing, and school professional education, promoting the growth of nursing professionalism through self-activation and overcoming challenges, and maintaining the stable and upward development of nursing professionalism through an upward atmosphere and external motivation.

We revealed the dynamic factors that influence the development of nursing professionalism, including “nourishment factors”, “growth factors”, and “rootedness factors”. Our findings provide a foundation for future development of nursing professionalism cultivation strategies. Nursing administrators can guide the development of nurses’ professionalism from many angles according to the stage they are in, and the development of professionalism deserves more attention. In the future, we can no longer consider the development of nursing professionalism solely as the responsibility of individual nurses; the power of families, organizations, and society is indispensable to jointly promoting nursing professionalism among nurses.

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Introduction

The number of nurses leaving hospitals has been increasing, and the shortage of nurses is a significant problem faced globally [ 1 , 2 ]. According to earlier studies, professionalism improves nurses’ clinical performance [ 3 ] and positively affects their adaptability (Park et al. 2021), reducing nurses’ burnout and turnover rates. Therefore, fostering professionalism in nurses and the factors that influence the development of professionalism are essential to producing effective nurses.

Nurses comprise the largest group of healthcare providers [ 4 ]. Nurses are a vital part of the healthcare system, with 27.9 million caregivers worldwide, according to the World Health Organisation’s Global Status of Nursing Report 2020 [ 5 ]. However, an unbalanced number of nurses and patients, high work pressure, and the fact that nurses face patients’ suffering, grief, and death each day have exacerbated burnout and led to the resignation of many nurses [ 6 ]. The COVID-19 outbreak has further exposed the shortage of nursing staff, especially in low- and middle-income countries where the scarcity of nurses remains acute. The lack of nurses not only has direct negative impacts on patients but also poses a threat to the entire healthcare system.

Nursing professionalism is closely associated with nurse retention and nursing practice [ 7 , 8 , 9 ]. Nursing professionalism is defined as providing individuals care based on the principles of professionalism, caring, and altruism [ 6 ]. As a belief in the profession, nursing professionalism is a systematic view of nursing that represents the practice standards and value orientation nurses utilize [ 10 , 11 ]. According to previous research, nursing professionalism can enhance nurses’ clinical performance and positively impact their adaptability, reducing job burnout and turnover rates [ 6 ]. Furthermore, as nurses are the ones who provide “presence” care, cultivating nursing professionalism among nurses can promote interactions between nurses and patients, further improving the quality of nursing care and patient outcomes and injecting new vitality and hope into the entire healthcare system [ 12 ].

However, nursing professionalism is dynamic, and the cultural context also shapes nursing professionalism to some extent, leading to ambiguity in the factors influencing nursing professionalism. Initially perceived as mere “caregivers,” nurses have transformed into “professional practitioners,” emphasizing the nursing field’s seriousness and distinct professional characteristics [ 13 , 14 ]. Nursing professionalism is also the foundation for developing the nursing profession [ 15 ]. Focusing on the factors influencing the development of nursing professionalism is one of the essential elements in providing an optimal environment for nurses’ professional growth and development in clinical practice [ 16 ]. Although some scales, such as the Hall Professionalism Inventory (HPI) [ 17 ], Miller’s Wheel of Professionalism in Nursing (BIPN) [ 18 ], Hwang’s Nurse Professional Values Scale (NPVS) [ 19 ], and Fantahun’s Nursing Professionalism Questionnaire [ 20 ] have been used to measure factors influencing the awareness, attitudes, and behaviors, they have their limitations. They struggle to encompass professionalism’s multidimensionality and complexity fully, overlook multilayered background factors, are constrained by standardization issues, may not account for individual differences, and often fail to capture dynamic changes over time [ 21 , 22 , 23 ].Compared with quantitative research methods, qualitative research can provide insights into the “unique phenomenology and context of the individual being tested,” which can help the researcher stay close to nurses’ professional lives during the research process and understand the personal, familial, and societal factors that influence nursing professionalism [ 24 ].Additionally, the understanding of nursing professionalism varies across different cultural and social contexts. In Western countries, research on nursing professionalism tends to incorporate professionalism across the entire nursing industry. In contrast, within China, research on professionalism tends to focus more on the individual level, with less attention to the perspectives of groups or the industry [ 25 ]. Therefore, through qualitative research, we can present nursing professionalism in a deeper, more affluent, and more transparent manner. Secondly, it is more authentic to understand the factors influencing nursing professionalism by directly obtaining relevant information from the perspective of nurses through dialogue with research participants as mutual subjects.

Given these considerations, we aim to answer the question of what factors influence the development of nursing professionalism. To provide more targeted strategies and recommendations for optimizing the nursing professional environment, enhancing nurses’ job satisfaction, improving t nursing quality, and contributing sustainably to patients’ and nurses’ health and well-being.

To explore the factors influencing the development of nursing professionalism. By incorporating nurses’ perspectives, we aim to improve our understanding of professionalism as individual, family, and socio-cultural influences. With this knowledge, we can inform strategies for developing nursing professionalism.

Study design

A descriptive qualitative approach was adopted based on naturalistic inquiry [ 26 , 27 ] and analyzed using the thematic analysis method described by Braun and Clarke [ 28 ]. Semi-structured interviews were conducted between May 2022 and August 2023 with nurses in southern and northern China hospitals. Furthermore, the research findings were reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) (Supplementary Material S1 ) [ 29 ].

Participants and settings

We chose hospital nurses as study participants based on considerations of their nursing experience. Firstly, the Chinese government has implemented a policy of accountable holistic care, whereby registered nurses take on the entire cycle of a patient’s physical, mental, and spiritual care [ 30 ]. Secondly, new nurses must undergo two weeks to one month of basic training and a 12–24 month specialty rotation (for most new nurses who graduated before 2016, their training was completed by their departments). During this time, they are under the supervision of a superior nurse for holistic and responsible care [ 31 ].

We used maximum variance purposive sampling to recruit a heterogeneous sample of information-rich key participants [ 32 ]. Participant selection considered variations in role classification, years of experience, and educational levels of Chinese nurses [ 33 ]. The purposive variation allowed the discovery of Chinese nurses’ unique perceptions of nursing professionalism. Inclusion criteria: (1) registered nurses (providing direct services to patients within the unit), nurse managers (directly supervising and guiding the clinical work of registered nurses), nursing department managers (managing nurse managers throughout the hospital), with at least one year of nursing experience; (2) voluntary participation. Exclusion criteria: (1) nurses not working during the hospital’s study period (holidays, maternity leave, or sick leave); (2) refresher nurses.

Data collection

The same researcher conducted each interview to ensure consistency. Before the interviews, the interviewers systematically conducted in-depth theoretical research on relevant studies. The interviewer received guidance from professors with rich experience in qualitative research and undertook practice interviews to improve her interviewing skills. Interviewers encouraged interviewees to talk freely about their perceptions and used an interview guide (Supplementary Material S2 ), which was based on the findings of previous research on the conceptual analysis of nursing professionalism [ 6 ]. The questions were open-ended and general; ample space was left between questions to respond to interviewees’ comments. Semi-structured interviews began with a brief introduction to the topic (e.g., definition and explanation of nursing professionalism). Although the interviewer had an agenda for discussion, this format allowed the interviewee to deviate from this agenda and direct follow-up questions [ 34 ].

All interviews were conducted from May 2022 to August 2023 in face-to-face conversations in offices in the workplace or via voice calls and lasted between 35 and 94 min. Participants were asked to complete the main demographic questionnaire at the end of the interviews. The researcher recorded participants’ expressions, body language, and pauses during the interviews. Memos written by the researcher during the study were also used as analytical material.

Data analysis

For rigorous qualitative sampling and data saturation, Braun et al. [ 35 ] propose that qualitative researchers require a sample appropriate to the research questions and the theoretical aims of the study and that can provide an adequate amount of data to answer the question and analyze the issue entirely. We reached thematic saturation after 14 interviews when no new codes or themes emerged.

A thematic analysis approach was used, following the phases described by Braun and Clarke [ 28 ]. The analysis comprised six stages: (1) immersing in the data; (2) creating initial codes; (3) identifying themes; (4) reviewing; (5) defining and labeling these themes; and (6) finally, composing the analysis report. Two researchers transcribed and analyzed the textual data. In the first stage, the researchers carefully read the interview transcripts to familiarize themselves with the depth and breadth of the content. In the second stage, preliminary codes were generated based on the research questions, initial interpretation of the data, and discussion of initial emerging patterns. At this stage, ensuring that all actual data extracts were coded and organized within each code was necessary. In addition, the following principles were used as guidelines: (1) code for as many potential themes/patterns as possible; (2) code extracts of data inclusively, i.e., preserve small sections of the surrounding data when relevant; and (3) code individual extracts of data for as many different “themes” as appropriate [ 36 ]. In the third phase, the two authors analyzed the initial codes, sorted them into potential themes, and debated their meanings and emerging patterns to reach a consensus. This phase, which refocused the analysis on the broader level of themes rather than that of codes, involved sorting the different codes into potential themes. In the fourth stage, reviewing themes ensures that the data supports the themes and allows an iterative process between different levels of abstraction without losing grounding in the raw data. Finally, defining the “essence” of each theme during the development of the main themes by identifying the “story” as consistent with the data and the research question while ensuring that the themes did not overlap but still fit together in the overall “story” of the data. It told the “story” by writing analytical narratives with illustrative quotes.

This study achieved credibility by selecting a heterogeneous sample, performing member checks, and taking field notes [ 37 ]. This study ensured dependability by verifying the findings with the researchers and participants, appropriately numbering the direct quotations (e.g., DN1), and comparing the results with the previous literature. This study established confirmability via audit trails [ 38 ] and the comprehensive reporting of all research processes. This study ensured transferability by describing the data collection process and seeking a heterogeneous sample.

Fourteen participants were interviewed (the demographic information is presented in Table  1 ). The thematic analysis identifies three major themes (Fig.  1 ). These interconnected topics illuminate the growth process and factors influencing nursing professionalism. The first theme, “nourishment factors: promoting early sprouting,” includes personal traits, family upbringing, and professional education at school and emphasizes early factors influencing nursing professionalism. The second theme, “growth factors: the power of self-activation and overcoming challenges,” included self-activation and overcoming difficulties, focusing on the dual attributes of the growth process of nursing professionalism. The final theme, “rootedness factors: stability and upward momentum,” includes an upward atmosphere and external motivation and explores the factors that maintain the stability and sustainability of nursing professionalism.

Factors influencing the development of nursing professionalism

Nourishment factors: promoting early sprouting

Personal traits.

Personal traits are called “nature” [ 23 ]. There exists a close connection between personal traits and professional behavior. When nurses confront patients’ physiological and emotional needs, innate qualities like kindness and compassion predispose them to be more sensitive to patients’ suffering and needs. Nursing professionalism transcends mere task fulfillment; this inner emotional drive compels nurses to fulfill their duties and engage in nursing work out of a genuine desire and sense of responsibility, practicing the nursing mission nobly. Thus, whether individual traits align with the nursing mission profoundly influences the nursing professionalism of nurses in their work.

“At 32, I became a head nurse, full of vitality and boundless enthusiasm, particularly compassion. I have no idea where this compassion comes from.” (ND1) .

Family upbringing

Education begins in the family, and it is through family education that nurses develop an early sense of professionalism. China has a “family culture” that defines the responsibility of family education. The study participants recalled that in childhood, the “living” nature of family education shaped early professionalism, in which the concepts of “kindness” and “altruism” were acquired through interactions with family members.

“My mother was an early childhood educator, and when she told me fairy tales, it was to promote kindness. Loving others and being selfless, you can’t be a bad person. That’s what altruistic education is about.” (ND1) .

The impact of family education on the acquisition of nursing professionalism extends into adulthood. In Chinese Confucianism and collectivism, family members usually have close emotional ties, and this “strong bond” family structure promotes nurses’ understanding and care for others and their ability to be wiser and more caring in the nursing profession. This strong bonding plays a catalytic role in the emergence of nursing professionalism.

“Some nurses are very adept at expressing care, perhaps because grandparents and parents live together. Since childhood, parents have taught them how to express care.” (N4) .

School professional education

Nursing professionalism is further acquired through professional education in schools. Nursing professional education emphasizes respect and care for patients, adherence to social responsibility, and the integration of traditional Chinese oriental medical thought and Western nursing concepts, internalized into behaviors to form the concept of professional nursing spirit. Participants indicated that the virtues of dedication, responsibility, respect, and caring that permeate school professional education are incorporated by nurses into nursing practice.

“The best nursing comes from the heart. When I was administering injections, I thought about how to alleviate the patient’s pain. Later, I learned that if I entered the needle quickly, it would be less painful, so I often practiced in the operating room.” (N8) .

Other participants also shared that they felt positively guided by professional education at school, constructing a comprehensive nursing philosophy system within the educational context. They realized that nursing is a multidisciplinary field encompassing human care, social responsibility, and ethical values.

“University was my most unforgettable learning experience. I studied 36 courses here, including nursing aesthetics, literature, sociology, ethics, education, etc. I realized that the nursing work we engage in has such rich depth! has become an invaluable treasure in my nursing career.” (ND1) .

Growth factors: the power of self-activation and overcoming challenges

Self-activation, professional benefits.

Professional benefit perception refers to the advantages nurses perceive while engaging in nursing work, acknowledging that their involvement in nursing promotes their holistic personal growth [ 39 ]. Consistent with traditional perspectives, this study finds that nurses generate a sense of professional benefit through both “tangible benefits” and “spiritual benefits,” recognizing the value and significance of nursing work, thereby furthering the development of nursing professionalism.

The dynamic updating achieves “tangible benefits.” Nurses require outstanding professional competence and ongoing continuing education. Participants mentioned that nurses utilize their professional knowledge and clinical experience to save patients’ lives, and exceptional professional competence can rekindle their enthusiasm for work. Continuous and dynamic continuing education, supplementing the latest technology and knowledge in the nursing field, can generate positive professional emotions.

“There’s only one doctor on duty at night, and nurses are the first responders when we encounter emergencies. Even before the doctor arrives in the ward, I must act quickly and urgently. Every time I bring a patient back from the brink of death, I feel excited throughout the night.” (N6) . “Experience is und oubtedly important. I’ve been working for over a decade, and I undergo training every year. No one likes stagnation; we can forge ahead only by continually moving forward.” (NM3) .

Self-worth realization through “spiritual benefits.” Experiencing a sense of value in nursing practice provides nurses with positive reinforcement, enhancing nursing professionalism behavior. Moreover, as healthcare practitioners, the ability of relatives and family members to benefit from it distinguishes Chinese nurses’ unique approach to self-worth realization from nurses in other countries. This unexpected feedback, whether in material or spiritual forms, enables nurses to fulfill their sense of worth.

“Sometimes, friends and relatives ask me about hospitalization-related questions, and I am more than willing to help them.” (N2) . “ I changed my mother’s gastric tube without any complications.” (NM3) .

Professional identity

Nursing professional identity refers to nurses acknowledging their work and affirming their self-worth [ 40 ]. This study defines professional identity as a gradual “process” and a “state.”

One participant mentioned that professional identity is a psychological “process” that nurses develop and confirm their professional roles through their personal experiences. It is closely related to the individual experiences of nurses. Nurses’ gradual recognition of their work prompts them to progress and develop a positive work attitude and professionalism.

“Gradually, I discovered that being a nurse makes me realize my significance, which keeps me moving forward, time and time again.” (ND2) .

Simultaneously, as a “state,” professional identity represents the degree to which nurses identify with the nursing profession. This “state” of professional identity reflects nursing professionalism’s long-term accumulation and formation. It indicates nurses’ long-standing dedication and emotional involvement in nursing, leading to higher professional competence and a sense of responsibility in their work.

“It’s not just a job to make a living; it’s about wholeheartedly identifying with this profession, unleashing one’s potential, which results in better professional conduct.”(N5) .

Overcoming challenges

Balancing roles.

Balancing roles refers to the equilibrium individuals establish between their roles in the nursing profession, family, and organization. Nursing professional roles are inherently multifaceted, and when faced with multiple responsibilities, such as family demands and organizational tasks, nurses must balance these roles. The tension and complexity between personal and organizational roles can potentially inhibit their emotions and professional motivation. However, in China, families are tightly knit, and strong family support can help reconcile this tension.

“To be a good nursing department manager, you need strong family support. The commitment to one’s career and the dedication to family don’t always align. For instance, my job keeps me busy regarding family matters, and I have limited time to care for my children. My parents-in-law take care of them more. I do rounds every Sunday, and the phone never stops ringing, even on my days off. There’s no way around it; this is the role I’ve taken on. Family support allows me to work with peace of mind.” (ND3) .

Adaptation organization

Nurses also face challenges in adapting to organizational systems. These adaptability challenges include rapidly learning new technologies, processes, and the culture of practice in different departments. This “unfamiliarity” impedes the manifestation of nursing professionalism. Participants indicated that the inability to adapt to clinical work quickly affects new graduate nurses’ transition into practice. Initially, there is a “honeymoon period” when becoming a registered nurse, but as actual capabilities do not align with expected performance, the excitement gradually wanes.

“I didn’t know the routine procedures in ophthalmology, I couldn’t measure eye pressure, and I didn’t know how to perform eye injections. I was terrified, which brought various challenges when I started working.” (N4) .

Furthermore, nurses must adapt to the practice culture of “this is how things are done” and “it’s always been done this way” in their workplace. Due to the promotion and title system requirements in Chinese hospitals, nurses with several years of experience often need to rotate through departments such as Intensive Care Unit and emergency for a period. The differences in operations and management between different departments also frustrate these nurses during rotations. However, a certain social prestige is attached, making it challenging for the nurses from the original department to provide direct guidance to the rotating nurses, leading to isolation for the latter in new departments.

“A blank slate regarding the department’s hierarchy, administrative procedures, and so on.” (N3) . “Although there’s a set of procedures, mostly similar, it’s the slight differences that always set me apart.” (N6) .

Rootedness factors: stability and upward momentum

Upward atmosphere, peer support.

Peer support has a positive impact on nursing professionalism. Peers are individuals of the same age group who have formed a connection due to shared experiences in similar socio-cultural environments, with emotional support, mutual assistance, and understanding constituting the core elements of peer support [ 41 ]. Firstly, nursing work often involves highly stressful situations, including heavy workloads, complex patient conditions, and urgent medical cases. Peer support provides emotional support, allowing nurses to find comfort and encouragement when facing stress and difficulties. Secondly, peer support cultivates a positive work atmosphere and team spirit. In a mutually supportive, trusting, and cooperative team, nurses are more likely to experience a sense of accomplishment in their work. They feel they are not isolated but part of a united and collaborative whole. Furthermore, peer support also promotes professional development and knowledge exchange among nurses. In an open and supportive team environment, nurses are more willing to share their experiences and knowledge, learn from each other, and grow.

“The spirit influences the spirit, especially those of my age group who have left a deep impression on me with their admirable qualities in their work. It makes me reflect on my shortcomings in my work and constantly strive to improve and adjust myself.” (N2) .

Intergenerational role models

Inter-generational refers to the relationships between generations [ 42 ]. In nursing practice, inter-generational relationships exist, such as those among nurses of different ages and levels of experience. This study’s inter-generational role models include managerial role models and senior nurses.

Participants believe that managers’ professionalism influences subordinate nurses’ attitudes and performance. The professionalism of managers not only plays a guiding and leadership role in daily work but, more importantly, sets an example, inspiring and encouraging subordinate nurses who are willing to follow and inherit professionalism.

“The department’s leadership has a significant impact on professionalism. When managers have a strong sense of professionalism, the nurses they oversee follow suit. Because leadership represents the management level and higher things, it’s difficult for things at the bottom to go well if it’s not well-controlled at the top.” (N8) .

On the other hand, senior nurses, as role models within the nursing generation, also significantly impact the upward development of professionalism. Senior nurses’ rich experience and professional competence guide new nurses to maintain a rigorous attitude at work. New nurses often draw from and learn senior nurses’ work attitudes and behaviors, catalyzing the elevation of nursing professionalism.

“Senior nurses have a role model effect because new nurses learn from the older ones. If senior nurses work rigorously and new nurses make mistakes or lack a sense of dedication, they will immediately point it out. Over time, you also become more rigorous.” (NM3) .

Perceived professional respect

Societal respect for nursing work creates an atmosphere of care and emphasis on nursing. Nurses within this atmosphere become aware of the importance of nursing work and the profound significance of patient care. They are inclined to exhibit positive nursing professionalism behaviors to meet the expectations of society and the general public.

“The nursing industry has experienced the COVID-19 pandemic, and during the anti-epidemic efforts, nurses were at the forefront, risking their lives to care for patients, receiving acclaim from patients, doctors, and the public.” (N2) .

Professional respect is the manifestation of nurses’ self-acknowledgment of nursing values. It is more than an external acknowledgment; it is an internal affirmation. This mutual respect aligns nurses’ professional and societal worth, catalyzing increased potential and motivation.

External motivation

The stability of nursing professionalism relies on external resources, including the diverse support from nursing managers and the guidance of national healthcare policies. Nursing managers are the frontline leaders who interact with nurses, and their support serves as a management tool and a direct means to sustain nursing professionalism. This multifaceted support encompasses economic incentives such as compensation and reward mechanisms. It extends to non-material motivations such as career advancement opportunities, adequate staffing, modern equipment provision, and fair and equitable treatment form crucial aspects of managerial support. Providing nurses with stable external support creates a space to focus on their professional mission and responsibilities, thus maintaining the stability of nursing professionalism.

“Economic foundation determines the superstructure(spiritual world)).” (NM1) .

Furthermore, the guidance of national healthcare policies serves as a beacon for the development of the nursing profession. At the national level, healthcare policies can regulate the organization and operation of healthcare systems and services, providing nurses with a more stable and favorable working environment. This environment allows nurses to fulfill their professional roles better and maximize their value. The environmental changes brought about by policy guidance offer nurses more favorable professional conditions, effectively promoting the upward development of nursing professionalism.

“Government documents summarize the needs of our society, and nursing will continue to improve in the direction of policy guidance.” (NM3) .

Discussions

This study provides insights for understanding the factors that influence the development of nursing professionalism. We emphasize the themes of early nourishment factors that promote the emergence of nursing professionalism, growth factors associated with self-activation and overcoming challenges, and rootedness factors that stabilize upward, which reveal the dynamic factors that influence the development of nursing professionalism.

We added the early influence of personality traits, family upbringing, and school professional education in the development of nursing professionalism, which is similar to the pathway through which nurses’ foundational values are acquired [ 43 , 44 ]. Building on previous research, we highlight the sequential order of socialization in family education and school professional education, with individual socialization within the family achieving individual socialization before school professional education, emphasizing the importance of intergenerational family transmission on the development of nursing professionalism [ 45 ]. Education commences within the family, a social organization with an educational function. China values its “family culture” and emphasizes defining parental responsibilities for family education based on blood relations. It is a common folk law in China that parents are regarded as the first teachers. In addition, Chinese society promotes Confucianism, which emphasizes instilling the concept of “self-improvement” through “educational living” [ 46 ], as mentioned in our study, the interpersonal interactions such as “altruism” and “caring” arising from family interactions can help nurses establish a deeper emotional connection with their patients. Therefore, future consideration could be given to incorporating programs that foster culture and emotions into professional education. Similar studies are necessary in East Asian countries and other countries with similar cultures to broaden the results of factors influencing nursing professionalism.

The growth of nursing professionalism requires real work scenarios. Our results present the dual factors of nursing professionalism upon entering the workplace. Regarding self-activation factors, we delve into the significance of “professional identity” and, for the first time from the perspective of Chinese collectivism, explain the unique influence of “professional benefits” on nursing professionalism. Our study aligns with previous research, viewing professional identity as an ongoing “process” [ 47 ]. By developing a professional identity, nurses can exhibit “stateful” self-satisfaction and self-motivation, contributing to their job satisfaction and professionalism [ 48 ]. The “professional benefits” involve integrating rational and emotional aspects. The “tangible benefits” of professionalism and technical competence at work lead to positive experiences and emotions among nurses. Nurses voluntarily invest more passion and energy in their work [ 49 ]. In addition, what sets our results apart is how Chinese nurses obtain ‘spiritual benefits,’ which come from the convenience of medical access that their relatives enjoy due to their work. Some studies have shown that “spiritual benefits” are more apparent among nurses aged 40 and above and those with higher professional titles [ 50 ]. The accumulation of clinical experience and the harmonious interpersonal relationships achieved through medical collaboration can help family members access reliable medical resources, leading to greater professional gain. This phenomenon is closely related to the collective consciousness of Chinese nurses, revealing that people are not always “self-interested and rational”; their behavior is influenced by more complex factors such as intuition, emotions, and attitudes [ 49 ].

In terms of the challenges faced, on the one hand, we emphasized the supportive role of intergenerational relationships in nurses’ work-family conflicts. Previous studies have shown that Chinese nurses perceive nursing work as a means to fulfill family responsibilities rather than the ultimate goal, reflecting a prioritization of family over work [ 51 ]. Consequently, nurses are more likely to resign during work-family conflicts, reallocating their resources from work to family [ 52 ]. Compared with previous studies, we found that China is a highly connected society, and multi-generational households are relatively common [ 53 ]. Hence, the importance of maintaining good intergenerational relationships cannot be ignored in Chinese society and culture, substantially impacting nursing professionalism. On the other hand, we reveal the underlying reasons for the restricted development of nursing professionalism among nurses during the transition period. Newly graduated nurses face negative experiences such as incompetence, lack of preparation, exhaustion, and disappointment in their work, hindering the development of nursing professionalism, which is especially evident in departments such as obstetrics and gynecology, ophthalmology, and emergency, where teaching hours for these specialties fall significantly below those for general internal medicine and surgical nursing [ 54 ]. The educational experiences of nurses are insufficient to meet clinical demands [ 55 ]. Moreover, this is compounded by differences in the structure and content of the 12–24 month “standardized training” for new nurses that has already begun in most cities in China, further exacerbating the experience of separation of new nurses from their organizations [ 56 ]. The development of rotational nurses is often neglected, and transfer systems are a mere formality [ 57 ]. Therefore, developing nursing adaptability and creating a supportive work environment should be incorporated into the content and structure of different organizational transition programs to make a positive work environment and promote nurses’ engagement, enhancing nursing professionalism.

It is worth noting that the rootedness factor involves individual, organizational, and societal dimensions. At the personal level, peer support and intergenerational role models integrate the demonstration of actual “peers” and “role models” with nurses’ self-awareness and agency to achieve upward mobility in nursing professionalism [ 58 ]. However, while peer support offers emotional and social cognitive consistency based on age, background, and learning experiences, it may lack experiential depth [ 59 ]. In contrast, intergenerational role models involving a “superior-subordinate” relationship can initially lead to “nurturing” relationships, potentially leading to lateral violence and bullying [ 60 ]. At the organizational level, our findings highlight that professional respect in the workplace is more relevant to nurses’ professionalism than social appraisal. Professional respect is the nurses’ perception of their subjective social status within the profession and an analysis of the social value associated with the nursing profession [ 61 ]. However, nurses are not always respected, especially as insults and disregard from patients, superiors, or physicians can lead to negative emotions, professional burnout, and a desire to quit [ 62 , 63 , 64 ]. Regarding the societal dimension, providing external motivation tailored to nurses’ specific backgrounds and needs is beneficial for the stable development of nursing professionalism. Financial incentives are often considered a common strategy to improve nurses’ motivation and retention in motivation management [ 65 ]. However, the effectiveness of incentives is, more importantly, dependent on the response of nurses after implementation, and it is crucial to understand the needs and preferences of nurses in terms of incentives as well as the level of nurses’ participation in policy development, in addition to material rewards [ 66 , 67 ].Therefore, maintaining the stability of nursing professionalism is therefore complex, and nursing managers should consider ways to deepen peer support and reduce workplace bullying through “intergenerational parenting”, and should develop policies that support nurses, have zero-tolerance for disruptive behaviours, uphold the professional dignity of nurses, and ensure that their voices are heard and valued, which contributes to a more positive, fulfilling, and motivating nursing work environment.

Limitations

Given the persistently low number of men in nursing, all participants recruited for our study were female. However, considering the relatively narrow focus of the research, The purposive variation, and the richness of the generated data, the sample size was deemed sufficient to achieve our objectives. In addition, although the study results reveal dynamic influences on the development of nursing professionalism, they do not differentiate between nurses at different career stages, such as novice and expert nurses. We consider these factors as “common characteristics” for them, intertwined with each other, which can be further clarified in future research.

Conclusions

This study is an important addition to previous research in that we reveal the dynamics of factors that influence the development of nursing professionalism, including the “nourishment factor,” “growth factor,” and “rootedness factor.” Our findings provide contextual factors that can be changed during the development of nursing professionalism and lay the foundation for future strategies to foster nursing professionalism.

Relevance to clinical practice

The findings of this study have important implications for exploring the development of nursing professionalism. Nursing managers can support nurses’ professionalism from various perspectives, depending on the stage of the nurse’s life, such as valuing nurses’ family relationships, focusing on nurses in transition, listening to nurses’ voices, and creating a “magnetic nursing” work environment. These measures will not only positively impact the careers of individual nurses but will also help improve the standard and quality of health care in general. In the future, we should no longer view the development of nursing professionalism as solely the responsibility of individual nurses; the influence of family, organizations, and society is indispensable in collectively promoting the development of nurses’ nursing professionalism.

Data availability

Data used to support the findings of this study are available from the corresponding author upon request.

Abbreviations

The Hall Professionalism Inventory

Miller’s Wheel of Professionalism in Nursing

SHwang’s Nurse Professional Values Scale

The consolidated criteria for reporting qualitative research

Xiu-Yin Y, Jun-Cui R, Fang W, Nursing DJJN. Effects of Management Mode of Nursing Talent Pools on Nurse’s Professional Identity and Turnover Rate. 2018.

Meihuan X, Xiaoling F, Junyi C, Xiaowei F, Nursing DOJJNS. Impact of the two-child policy on nursing human resource management:aqualitative study. 2018.

Jang YK, Kyunghee. Professionalism and professional quality of life for oncology nurses. J Clin Nurs 2016, 25(19a20).

Marcinowicz L, Shpakou A, Piatrou S, Fejfer-Wirbal E, Dudzik A, Kalinowska P, Palubinskaya S, Wojnar D. Behavioural categories of professionalism of nurses in Poland and Belarus: a comparative survey. J Clin Nurs. 2020;29(9–10):1635–42.

Article   PubMed   Google Scholar  

State of the world’. s nursing report [ https://www.who.int/publications-detail/nursing-report ].

Cao H, Song Y, Wu Y, Du Y, He X, Chen Y, Wang Q, Yang H. What is nursing professionalism? A concept analysis. BMC Nurs. 2023;22(1):34.

Article   PubMed   PubMed Central   Google Scholar  

Rabie T. Relation between Halls’ professionalism scale and nurses’ demographic characteristics. BMC Res Notes. 2021;14(1):258.

Shen Y, Xie W, Wang X, Qu J, Zhou T, Li Y, Mao X, Hou P, Liu Y. Impact of innovative education on the professionalism of undergraduate nursing students in China. Nurse Educ Today. 2021;98:104647.

Abedin S, Khademi Z, Kamalzadeh H, Beigi Broujeni R. Characteristics of a good nurse as perceived by nurses. Nurs Ethics 2023:9697330221147895.

Xianting JU, Xiaoju F, Medicine SOJCME. The Influence of the Trinity SystemTalent Training Mode on the Professionalism of Nurses. 2018.

Kim HJ, Park D. Effects of nursing professionalism and self-efficacy on job embeddedness in nurses. Heliyon. 2023;9(6):e16991.

Park BM, Jung JJIJER, Health P. Effects of the Resilience of nurses in Long-Term Care hospitals during on job stress COVID-19 pandemic: Mediating effects of nursing professionalism. 2021, 18(19):10327-.

Ghadirian. Fataneh, Salsali, Mahvash, Cheraghi, Mohammad, Nursing AJIJo, Research M: Nursing professionalism: An evolutionary concept analysis. 2014.

Huang Y, He X, Pan H. Discussion on professionalism of a nurse. Chin J Nurs Educ 2010(9):3.

Tanaka M, Taketomi K, Yonemitsu Y, Kawamoto R. Professional behaviours and factors contributing to nursing professionalism among nurse managers. J Nurs Adm Manag. 2016;24(1):12–20.

Article   Google Scholar  

Ghadirian F, Salsali M, Cheraghi MA. Nursing professionalism: an evolutionary concept analysis. Iran J Nurs Midwifery Res. 2014;19(1):1–10.

PubMed   PubMed Central   Google Scholar  

Miller BK, Adams D, Beck LJAJ. Nursing Professionalism: A behavioral inventory for professionalism in nursing. 1994, 59(2):290–295.

Adams D, Miller BKJJPN. Professionalism in nursing behaviors of nurse practitioners. 2001, 17(4):203–210.

Hwang JI, Lou F, Han SS, Cao F, Li PJINR. Professionalism: the major factor influencing job satisfaction among Korean and Chinese nurses. 2010, 56(3):313–8.

Aregay A, Demessie A, Gebrekidan K, Abyu GJBN. A Cross Sectional Study On Factors Influencing Professionalism In Nursing Among Nurses In Mekelle Public Hospitals, North Ethiopia, 2012. 2014.

Ham YS, Kim HSJJKAFN. Comparison of factors affecting nursing professionalism perceived by nursing students anticipating graduation according to nursing Educational System. 2012, 19(3).

Tanaka M, Taketomi K, Yonemitsu Y, Kawamoto RJJNM. Professional behaviours and factors contributing to nursing professionalism among nurse managers. 2016, 24(1):12–20.

Pareek B, Batra K. Factors influencing professionalism among nurse educators: a qualitative study. J Educ Health Promotion. 2022;11:292.

Mcilveen P, Patton WJIJE, Guidance V. A critical reflection on Career Development. 2006, 6(1):15–27.

Gao R. Focusing on the Research Prospect of nurses’ professionalism from the General Research of Professionalism. Communication Vocat Educ. 2019;21:30–4.

Google Scholar  

Stannard DJaj: Essentials of Nursing Research: Appraising Evidence for Nursing Practice. 2012, 95(2):0-308.

Colorafi KJ, Evans B. Qualitative descriptive methods in Health Science Research. Herd. 2016;9(4):16–25.

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3:77–101.

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

Circular on the issuance of the Action Plan for Further Improvement of Nursing Services. (2023–2025). [ https://www.gov.cn/zhengce/zhengceku/202306/content_6887303.shtml ].

Circular on the Issuance of the Training Programme for Newly Enrolled Nurses (for Trial, Implementation.). [ http://www.nhc.gov.cn/yzygj/s3593/201602/91b5a8fa3c9a45859b036558a5073875.html ].

Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description - the poor cousin of health research? BMC Med Res Methodol. 2009;9:52.

Guo X, Xiong L, Wang Y, Li X, Wang Y, Xiao F, He J, Xiang Y, Xu C. Chinese nurses’ perceptions on toxic leadership behaviours of nurse managers: a qualitative study. J Nurs Adm Manag. 2022;30(7):3256–63.

Kelly SE. Qualitative Interviewing Techniques and Styles. In: 2010 ; 2010.

Braun V, Clarke V. Successful Qualitative Research: A Practical Guide for Beginners. 2013.

Ma D, Zhu X, Dong Y, He M, Meng X, Zhao Y, Ye Y, Sun J. It is my turn to raise her’ - decision-making regarding physical restraint in home care in China: a descriptive qualitative study. Int J Nurs Stud. 2022;134:104315.

Lincoln YS, Guba EG, Pilotta JJ. Naturalistic inquiry: Beverly Hills, CA: Sage Publications, 1985, 416 pp., $25.00 (Cloth). International Journal of Intercultural Relations 1985, 9(4):438–439.

Cutcliffe JR, McKenna HP. Expert qualitative researchers and the use of audit trails. J Adv Nurs. 2004;45(2):126–33. discussion 134 – 125.

Zhou H, Zhu Y, Zhang X, Peng J, Li Q, Wang X, Wang L, Cai X, Lan L. Psychological capital and Perceived Professional benefits: testing the Mediating role of perceived nursing work environment among Chinese nurses. J PsychoSoc Nurs Ment Health Serv. 2018;56(4):38–47.

Xu H, Xue M, Takashi E, Kitayama A, Zhu P, Liu Y. Exploring the relationship between lateral violence and nursing professionalism through the mediating effect of professional identity: a cross-sectional questionnaire study. Nurs open. 2023;10(5):3113–21.

Geyer LT, Cunningham T, Rastorguieva K, Ritenour CWM. An Abundance Mindset Approach to Support Nurse Well-Being: the feasibility of peer support. Nurse Lead 2023.

Che W. Encyclopaedia of Psychological Counselling. Zhejiang Science and Technology Publishing; 2001.

Sastrawan S, Weller-Newton J, Brand G, Malik GJNE. The development of nurses’ foundational values. 2021, 28(7–8):1244–57.

Abedin S, Khademi Z, Kamalzadeh H, Beigi Broujeni R. Characteristics of a good nurse as perceived by nurses. Nurs Ethics. 2024;31(1):79–88.

Hong M. The Basic traits of Family Education:three metaphors of Family Education. Educ Res Monthly 2023(04):90–8.

Zhang Z, Liu L. Establishing the Professional Role of parents in Family Education - the significance of the legislation on the Family Education Promotion Act. People’s Educ 2021(22):35–8.

Fitzgerald AJNF. Professional identity: A concept analysis. 2020(1).

Sheng Q, Zhang X, Wang X, Cai CJJ. The influence of experiences of involvement in the COVID-19 rescue task on the professional identity among Chinese nurses: a qualitative study. 2020(7):28.

Zhang B, Tao H, Xie M, Zhang J, Zhang M, Zhang Y. Factors associated with professional identity among ICU nurses during COVID-19: a cross-sectional study. Nurs open. 2023;10(8):5701–10.

Zhan T, Li H, Ding XJJNM. Can social support enhance sense of coherence and perceived professional benefits among Chinese registered nurses? A mediation model. 2019, 28(3).

Redding G. The Nature of Individual Attachment to the Organization: A Review of East Asian Variations. 1994.

Liu X, Yuan SJ, Ji TT, Song YL. Relationship between risk perception of COVID-19 and job withdrawal among Chinese nurses: the effect of work-family conflict and job autonomy. J Nurs Adm Manag. 2022;30(6):1931–9.

Hu W, Sze Y, Chen H, Fang XJCP. Actor–Partner analyses of the relationship between family-of-origin triangulation and marital satisfaction in Chinese couples. 2007, 24(7):2135–46.

Baharum H, Ismail A, McKenna L, Mohamed Z, Ibrahim R, Hassan NH. Success factors in adaptation of newly graduated nurses: a scoping review. BMC Nurs. 2023;22(1):125.

Shu’e, Zhang C, Ma, Dexin, Meng Y, Shi, Fengzhe, Open XJB. Impact of workplace incivility in hospitals on the work ability, career expectations and job performance of Chinese nurses: a cross-sectional survey. 2018.

Ma W, He Y, Zhao W, Xu R, Liang TJJNM. Developing and validating the transition status scale for newly graduated nurses in China. 2021.

Innes T, Calleja P. Transition support for new graduate and novice nurses in critical care settings: an integrative review of the literature. Nurse Educ Pract. 2018;30:62–72.

Liu P, Lou X, Wang Y, Hao Y, Song Y, Xu X. Exploration of the Integrated Management Mode of Gestational Diabetes Mellitus based on Social Learning Theory. Med Philosophy(B). 2017;38(07):87–90.

Tai HM, Haines TP, Canny BJ, Molloy EKJJPL. A study of medical students’ peer learning on clinical placements: What they have taught themselves to do. 2014(1).

Anderson LB, Morgan MJCQ. An Examination of Nurses’ Intergenerational Communicative Experiences in the Workplace. Do Nurses Eat Their Young? 2016:1–25.

Shi X, Li Y, Zhang C. Correlation among job-esteem,job burnout and turnover intention in nurses employee turnover. Chin Nurs Res. 2021;35(15):2654–60.

Fereshteh N, Masoud F-K et al. Fazlollah, Ahmadi, Asghar, Dalvandi, Mehdi, Nursing RJ : Human dignity and professional reputation under threat: Iranian Nurses’ experiences of workplace violence. 2016.

Arnetz J, Hamblin LE, Sudan. Sukhesh, Occupational BJJo, Medicine. Organizational Determinants of Workplace Violence Against Hospital Workers; 2018.

Bambi S, Guazzini A, Felippis CD, Lucchini A. Rasero LJAb-mAP: preventing workplace incivility, lateral violence and bullying between nurses. A narrative literature review. 2017, 88(5-S):39–47.

Ditlopo P, Blaauw D, Rispel L, Thomas S, Bidwell PJGHA. Policy implementation and financial incentives for nurses in South Africa: a case study on the occupation-specific dispensation. 2013, 6(1):138–46.

Okyere E, Ward PR, Marfoh K, Mwanri L. Incentives management among health workers in primary health-care facilities: addressing important issues in rural Ghana. Journal of health organization and management 2022, ahead-of-print(ahead-of-print).

Rasheed SP, Younas A, Mehdi F. Challenges, extent of involvement, and the impact of nurses’ involvement in politics and policy making in in last two decades: an integrative review. J Nurs Scholarship: Official Publication Sigma Theta Tau Int Honor Soc Nurs. 2020;52(4):446–55.

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Acknowledgements

The authors would like to express their gratitude to all participating nurses.

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School of Nursing, Shanxi Medical University, Taiyuan, 030001, China

Xingyue He, Ya Mao, Linbo Li, Yanming Wu & Hui Yang

Department of Nursing, Linfen Hospital Affiliated to Shanxi Medical University (Linfen People’s Hospital), Linfen, 041000, China

Department of Nursing, The First Hospital of Shanxi Medical University, Taiyuan, 030001, China

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XYH, YM, and HLC were responsible for the study’s inception, study design, and data collection. All authors analyzed the data. XYH wrote the first draft of the manuscript, LBL, YMW, and HY reviewed the manuscript, and HY finalized the final version. All authors reviewed and approved the manuscript prior to submission.

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Correspondence to Hui Yang .

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All methods were performed in accordance with the relevant guidelines and regulations of the declaration of Helsinki (ethical approval and consent to participate). The aims and methods of the project were explained to all participants, and necessary assurance was given to them about the anonymity and confidentiality of their information and audio files. Informed consent was taken from all participants. The participants had the right to withdraw from the study during or at any other time. Ethical approval was obtained from the ethics committee of The First Hospital of Shanxi Medical University (Ref. 201811049RIND).

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He, X., Mao, Y., Cao, H. et al. Factors influencing the development of nursing professionalism: a descriptive qualitative study. BMC Nurs 23 , 283 (2024). https://doi.org/10.1186/s12912-024-01945-6

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Received : 03 March 2024

Accepted : 17 April 2024

Published : 26 April 2024

DOI : https://doi.org/10.1186/s12912-024-01945-6

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