• CASP Subquestions
Note . The CASP questions are adapted from “10 questions to help you make sense of qualitative research,” by Critical Appraisal Skills Programme, 2013, retrieved from http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf . Its license can be found at http://creativecommons.org/licenses/by-nc-sa/3.0/
Once articles were assessed by the two authors independently, all three authors discussed and reconciled our assessment. No articles were excluded based on CASP results; rather, results were used to depict the general adequacy (or rigor) of all 55 articles meeting inclusion criteria for our systematic review. In addition, the CASP was included to enhance our examination of the relationship between the methods and the usefulness of the findings documented in each of the QD articles included in this review.
To further assess each of the 55 articles, data were extracted on: (a) research objectives, (b) design justification, (c) theoretical or philosophical framework, (d) sampling and sample size, (e) data collection and data sources, (f) data analysis, and (g) presentation of findings (see Table 2 ). We discussed extracted data and identified common and unique features in the articles included in our systematic review. Findings are described in detail below and in Table 3 .
Elements for Data Extraction
Elements | Data Extraction |
---|---|
Research objectives | • Verbs used in objectives or aims |
• Focuses of study | |
Design justification | • If the article cited references for qualitative description |
• If the article offered rationale to choose qualitative description | |
• References cited | |
• Rationale reported | |
Theoretical or philosophical frameworks | • If the article has theoretical or philosophical frameworks for study |
• Theoretical or philosophical frameworks reported | |
• How the frameworks were used in data collection and analysis | |
Sampling and sample sizes | • Sampling strategies (e.g., purposeful sampling, maximum variation) |
• Sample size | |
Data collection and sources | • Data collection techniques (e.g., individual or focus-group interviews, interview guide, surveys, field notes) |
Data analysis | • Data analysis techniques (e.g., qualitative content analysis, thematic analysis, constant comparison) |
• If data saturation was achieved | |
Presentation of findings | • Statement of findings |
• Consistency with research objectives |
Data Extraction and Analysis Results
Authors Country | Research Objectives | Design justification | Theoretical/ philosophical frameworks | Sampling/ sample size | Data collection and data sources | Data analysis | Findings |
---|---|---|---|---|---|---|---|
• USA | • Explore • Responses to communication strategies | • (-) Reference • (-) Rationale | Not reported (NR) | • Purposive sampling/ maximum variation • 32 family members | • Interviews • Observations • Review of daily flow sheet • Demographics | • Inductive and deductive qualitative content analysis • (-) Data saturation | Five themes about family members’ perceptions of nursing communication approaches |
• Sweden | • Describe • Experiences of using guidelines in daily practice | • (-) Reference • (+) Rationale • Part of a research program | NR | • Unspecified • 8 care providers | • Semistructured, individual interviews • Interview guide | • Qualitative content analysis • (-) Data saturation | One theme and seven subthemes about care providers’ experiences of using guidelines in daily practice |
• USA | • Examine • Culturally specific views of processes and causes of midlife weight gain | • (-) Reference • (-) Rationale | Health belief model and Kleiman’s explanatory model | • Unspecified • 19 adults | • Semistructured, individual interview | • Conventional content analysis • (-) Data saturation | Three main categories (from the model) and eight subthemes about causes of weight gain in midlife |
• Iran | • Explore • Factors initiating responsibility among medical trainees | • (-) Reference • (+) Rationale | NR | • Convenience, snowball, and maximum variation sampling • 15 trainees and other professionals | • Semistructured, individual interview • Interview guide | • Conventional content analysis • Constant comparison • (+) Data saturation | Two themes and individual and non- individual-based factors per theme |
• Iran | • Explore • Factors related to job satisfaction and dissatisfaction | • (-) Reference • (-) Rationale | NR | • Convenience sampling • 85 nurses | • Semistructured focus group interviews • Interview guide | • Thematic analysis • (+) Data saturation | Three main themes and associated factors regarding job satisfaction and dissatisfaction |
• Norway | • Describe • Perceptions on simulation-based team training | • (-) Reference • (-) Rationale | NR | • Strategic sampling • 18 registered nurses | • Semistructured individual interviews | • Inductive content analysis • (-) Data saturation | One main category, three categories, and six sub- categories regarding nurses’ perceptions on simulation-based team training |
• USA | • Determine • Barriers and supports for attending college and nursing school | • (-) Reference • (-) Rationale | NR | • Unspecified • 45 students | • Focus-group interviews • Using Photovoice and SHOWeD | • Constant comparison • (-) Data saturation | Five themes about facilitators and barriers |
• USA | • Explore • Reasons for choosing home birth and birth experiences | • (-) Reference • (-) Rationale | NR | • Purposeful sampling • 20 women | • Semistructured focus-group interviews • Interview guide • Field notes | • Qualitative content analysis • (+) Data saturation | Five common themes and concepts about reasons for choosing home birth based on their birth experiences |
• New Zealand | • Explore • Normal fetal activity related to hunger and satiation | • (+) Reference • (+) Rationale • • Denzin & Lincoln (2011) | NR | • Purposive sampling • 19 pregnant women | • Semistructured individual interviews • Open-ended questions | • Inductive qualitative content analysis • Descriptive statistical analysis • (+) Data saturation | Four patterns regarding fetal activities in relation to meal anticipation, maternal hunger, maternal meal consummation, and maternal satiety |
• Italy | • Explore, describe, and compare • perceptions of nursing caring | • (+) Reference • (-) Rationale • | NR | • Purposive sampling • 20 nurses and 20 patients | • Semistructured individual interviews • Interview guide • Field notes during interviews | • Unspecified various analytic strategies including constant comparison • (-) Data saturation | Nursing caring from both patients’ and nurses’ perspectives – a summary of data in visible caring and invisible caring |
• Hong Kong | • Address • How to reduce coronary heart disease risks | • (+) Reference • (+) Rationale • Secondary analysis • • | NR | • Convenience and snowball sampling • 105 patients | • Focus-group interviews • Interview guide | • Content analysis • (+) Data saturation | Four categories about patients’ abilities to reduce coronary heart disease |
• Taiwan | • Explore • Reasons for young–old people not killing themselves | • (-) Reference • (-) Rationale | NR | • Convenience sampling • 31 older adults | • Semistructured individual interviews • Interview guide • Observation with memos/reflective journal | • Content analysis • (+) Data saturation | Six themes regarding reasons for not committing to suicide |
• USA | • Explore • Neonatal intensive care unit experiences | • (+) Reference • (+) Rationale • | NR | • Purposive sampling and convenience sample • 15 mothers | • Semistructured individual interviews • Interview guide | • Qualitative content analysis • (+) Data saturation | Four themes about participants’ experiences of neonatal intensive care unit |
• Colombia | • Investigate • Barriers/facilitators to implementing evidence-based nursing | • (+) Reference • (-) Rationale • | Ottawa model for research use: knowledge translation framework | • Convenience sampling • 13 nursing professionals | • Semistructured individual interviews • Interview guide | • Inductive qualitative content analysis • Constant comparison • (-) Data saturation | Four main barriers and potential facilitators to evidence-based nursing |
• Australia | • Explore • Perceptions and utilization of diaries | • (+) Reference • (-) Rationale • | NR | • Unspecified • 19 patients and families | • Responses to open-ended questions on survey | • Unspecified analysis strategy • (-) Data saturation | Five themes regarding perceptions on use of diaries and descriptive statistics using frequencies of utilization |
• USA | • Explore • Knowledge, attitudes, and beliefs about sexual consent | • (-) Reference • (-) Rationale • Part of a larger mixed-method study | Theory of planned behavior | • Purposive sampling • snowball sampling • 26 women | • Semistructured focus-group interviews • Interview guide | • Content analysis • (+) Data saturation | Three main categories and subthemes regarding sexual consent |
• Sweden | • Describe • Experiences of knowledge development in wound management | • (+) Reference • (+) Rationale: weak • | NR | • Purposive sampling • 16 district nurses | • Individual interviews • Interview guide | • Qualitative content analysis • (-) Data saturation | Three categories and eleven sub-categories about knowledge development experiences in wound management |
• USA | • Describe • Parental-pain journey, beliefs about pain, and attitudes/behaviors related to children’s responses | • (+) Reference • (+) Rationale • • • Part of a larger mixed methods study | NR | • Purposive sampling • 9 parents | • Individual interviews • One open- ended question | • Qualitative content analysis • (+) Data saturation | Two main themes, categories, and subcategories about parents’ experiences of observing children’s pain |
• USA | • Describe • Challenges and barriers in providing culturally competent care | • (+) Reference • (+) Rationale • • Secondary analysis | NR | • Stratified sampling • 253 nurses | • Written responses to 2 open-ended questions on survey | • Thematic analysis • (-) Data saturation | Three themes regarding challenges/barriers |
• Denmark | • Describe • Experiences of childbirth | • (-) Reference • (-) Rationale • A substudy | NR | • Purposive sampling with maximum variation • Partners of 10 women | • Semistructured, individual interviews • Interview guide | • Thematic analysis • (+) Data saturation | Three themes and four subthemes about partners’ experiences of women’s childbirth |
• Australia | • Explore • Perceptions about medical nutrition and hydration at the end of life | • (+) Reference • (+) Rationale • | NR | • Purposeful sampling • 10 nurses | • Focus-group interviews | • “analyzed thematically” • (-) Data saturation | One main theme and four subthemes regarding nurses’ perceptions on EOL- related medical nutrition and hydration |
• USA | • Describe • Reasons for leaving a home visiting program early | • (-) Reference • (-) Rationale | NR | • Convenience sample • 32 mothers, nurses, and nurse supervisors | • Semistructured, individual interviews • Focus-group interviews • Interview guide | • Inductive content analysis • Constant comparison approach • (+) Data saturation | Three sets of reasons for leaving a home visiting program |
• Sweden | • Explore and describe • Beliefs and attitudes around the decision for a caesarean section | • (+) Reference • (+) Rationale • • | NR | • Unspecified • 21 males | • Individual telephone interviews | • Thematic analysis • Constant comparison approach • (-) Data saturation | Two themes and subthemes in relation to the research objective |
• Taiwan | • Explore • Illness experiences of early onset of knee osteoarthritis | • (+) Reference • (+) Rationale • • • Part of a large research series | NR | • Purposive sampling • 17 adults | • Semistructured, Individual interviews • Interview guide • Memo/field notes (observations) | • Inductive content analysis • (+) Data saturation | Three major themes and nine subthemes regarding experiences of early onset-knee osteoarthritis |
• Australia | • Explore • Perceptions about bedside handover (new model) by nurses | • (+) Reference • (+) Rationale • • | NR | • Purposive sampling • 30 patients | • Semistructured, individual interviews • Interview guide | • Thematic content analysis • (-) Data analysis | Two dominant themes and related subthemes regarding patients’ thoughts about nurses’ bedside handover |
• Sweden | • Identify • Patterns in learning when living with diabetes | • (-) Reference • (-) Rationale | NR | • Purposive sampling with variations in age and sex • 13 participants | • Semistructured, individual interviews (3 times over 3 years) | • analysis process • Inductive qualitative content analysis • (-) Data saturation | Five main patterns of learning when living with diabetes for three years following diagnosis |
• Canada | • Evaluate • Book chat intervention based on a novel | • (-) Reference • (-) Rationale • Part of a larger research project | NR | • Unspecified • 11 long-term- care staff | • Questionnaire with two open- ended questions | • Thematic content analysis • (-) Data saturation | Five themes (positive comments) about the book chat with brief description |
• Taiwan | • Explore • Facilitators and barriers to implementing smoking- cessation counseling services | • (-) Reference • (-) Rationale | NR | • Unspecified • 16 nurse- counselors | • Semistructured individual interviews • Interview guide | • Inductive content analysis • Constant comparison • (-) Data saturation | Two themes and eight subthemes about facilitators and barriers described using 2-4 quotations per subtheme |
• USA | • Identify • Educational strategies to manage disruptive behavior | • (-) Reference • (-) Rationale • Part of a larger study | NR | • Unspecified • 9 nurses | • Semistructured, individual interviews • Interview guide | • Content analysis procedures • (-) Data saturation | Two main themes regarding education strategies for nurse educators |
• USA | • Explore • Experiences of difficulty resolving patient- related concerns | • (-) Reference • (-) Rationale • Secondary analysis | NR | • Unspecified • 1932 physician, nursing, and midwifery professionals | • E-mail survey with multiple- choice and free- text responses | • Inductive thematic analysis • Descriptive statistics • (-) Data saturation | One overarching theme and four subthemes about professionals’ experiences of difficulty resolving patient-related concerns |
• Singapore | • Explicate • Experience of quality of life for older adults | • (+) Reference • (+) Rationale • | Parse’s human becoming paradigm | • Unspecified • 10 elderly residents | • Individual interviews • Interview questions presented (Parse) | • Unspecified analysis techniques • (-) Data saturation | Three themes presented using both participants’ language and the researcher’s language |
• China | • Explore • Perspectives on learning about caring | • (-) Reference • (-) Rationale | NR | • Purposeful sampling • 20 nursing students | • Focus-group interviews • Interview guide | • Conventional content analysis • (-) Data saturation | Four categories and associated subcategories about facilitators and challenges to learning about caring |
• Poland | • Describe and assess • Components of the patient–nurse relationship and pediatric-ward amenities | • (+) Reference • (-) Rationale • | NR | • Purposeful, maximum variation sampling • 26 parents or caregivers and 22 children | • Individual interviews | • Qualitative content analysis • (-) Data saturation | Five main topics described from the perspectives of children and parents |
• Canada | • Evaluate • Acceptability and feasibility of hand-massage therapy | • (-) Reference • (-) Rationale • Secondary to a RCT | Focused on feasibility and acceptability | • Unspecified • 40 patients | • Semistructured, individual interviews • Field notes • Video recording | • Thematic analysis for acceptability • Quantitative ratings of video items for feasibility • (-) Data analysis | Summary of data focusing on predetermined indicators of acceptability and descriptive statistics to present feasibility |
• USA | • Understand • Challenges occurring during transitions of care | • (+) Reference • (+) Rationale • • Part of a larger study | NR | • Convenience sample • 22 nurses | • Focus groups • Interview guide | • Qualitative content analysis methods • (+) Data analysis | Three themes about challenges regarding transitions of care: |
• Canada | • Understand • Factors that influence nurses’ retention in their current job | • (-) Reference • (-) Rationale | NR | • Purposeful sampling • 41 nurses | • Focus-group interviews • Interview guide | • Directed content analysis • (+) Data saturation | Nurses’ reasons to stay and leave their current job |
• Australia | • Extend • Understanding of caregivers’ views on advance care planning | • (+) Reference • (+) Rationale • • Grounded theory overtone | NR | • Theoretical sampling • 18 caregivers | • Semistructured focus group and individual interviews • Interview guide • Vignette technique | • Inductive, cyclic, and constant comparative analysis • (-) Data analysis | Three themes regarding caregivers’ perceptions on advance care planning |
• USA | • Describe • Outcomes older adults with epilepsy hope to achieve in management | • (-) Reference • (-) Rationale | NR | • Unspecified • 20 patients | • Individual interview | • Conventional content analysis • (-) Data saturation | Six main themes and associated subthemes regarding what older adults hoped to achieve in management of their epilepsy |
• The Netherlands | • Gain • Experience of personal dignity and factors influencing it | • (+) Reference • (-) Rationale • | Model of dignity in illness | • Maximum variation sampling • 30 nursing home residents | • Individual interviews • Interview guide | • Thematic analysis • Constant comparison • (+) Data saturation | The threatening effect of illness and three domains being threatened by illness in relation to participants’ experiences of personal dignity |
• USA | • Identify and describe • Needs in mental health services and “ideal” program | • (+) Reference • (+) Rationale • • There is a primary study | NR | • Unspecified • 52 family members | • Semistructured, individual and focus-group interviews | • “Standard content analytic procedures” with case-ordered meta-matrix • (-) Data saturation | Two main topics – (a) intervention modalities that would fit family members’ needs in mental health services and (b) topics that programs should address |
• USA | • “What are the perceptions of staff nurses regarding palliative care…?” | • (-) Reference • (-) Rationale | NR | • Purposive, convenience sampling • 18 nurses | • Semistructured and focus-group interviews • Interview guide | • Ritchie and Spencer’s framework for data analysis • (-) Data saturation | Five thematic categories and associated subcategories about nurses’ perceptions of palliative care |
• Canada | • Describe • Experience of caring for a relative with dementia | • (+) Reference • (+) Rationale • Sandelowski ( ; ) • Secondary analysis • Phenomenological overtone | NR | • Purposive sampling • 11 bereaved family members | • Individual interviews • 27 transcripts from the primary study | • Unspecified • (-) Data saturation | Five major themes regarding the journey with dementia from the time prior to diagnosis and into bereavement |
• Canada | • Describe Experience of fetal fibronectin testing | • (+) Reference • (+) Rationale • • | NR | • Unspecified • 17 women | • Semistructured individual interviews • Interview guide | • Conventional content analysis • (+) Data saturation | One overarching theme, three themes, and six subthemes about women’s experiences of fetal fibronectin testing |
• New Zealand | • Explore • Role of nurses in providing palliative and end-of-life care | • (+) Reference • (+) Rationale • • Part of a larger study | NR | • Purposeful sampling • 21 nurses | • Semistructured individual interviews | • Thematic analysis • (-) Data saturation | Three themes about practice nurses’ experiences in providing palliative and end-of-life care |
• Brazil | • Understand • Experience with postnatal depression | • (+) Reference • (-) Rationale • | NR | • Purposeful, criterion sampling • 15 women with postnatal depression | • Minimally structured, individual interviews | • Thematic analysis • (+) Data saturation | Two themes – women’s “bad thoughts” and their four types of responses to fear of harm (with frequencies) |
• Australia | • Understand • Experience of peripherally inserted central catheter insertion | • (+) Reference • (+) Rationale • | NR | • Purposeful sampling • 10 patients | • Semistructured, individual interviews • Interview guide | • Thematic analysis • (+) Data saturation | Four themes regarding patients’ experiences of peripherally inserted central catheter insertion |
• USA | • Discover • Context, values, and background meaning of cultural competency | • (+) Reference • (+) Rationale • | Focused on cultural competence | • Purposive, maximum variation, and network • 20 experts | • Semistructured, individual interviews | • Within-case and across-case analysis • (-) Data saturation | Three themes regarding cultural competency |
• USA | • Explore and describe • Cancer experience | • (+) Reference • (+) Rationale • | NR | • Unspecified • 15 patients | • Longitudinal individual interviews (4 time points) • 40 interviews | • Inductive content analysis • (-) Data saturation | Processes and themes about adolescent identify work and cancer identify work across the illness trajectory |
• Sweden | • Explore • Experiences of giving support to patients during the transition | • (-) Reference • (-) Rationale | Focused on support and transition | • Unspecified (but likely purposeful sampling) • 8 nurses | • Semistructured Individual interviews • Interview guide | • Content analysis • (-) Data saturation | One theme, three main categories, and eight associated categories |
• Taiwan | • Describe • Process of women’s recovery from stillbirth | • (+) Reference • (+) Rationale • | NR | • Purposeful sampling • 21 women | • Individual interview techniques | • Inductive analytic approaches ( ) • (+) Data saturation | Three stages (themes) regarding the recovery process of Taiwanese women with stillbirth |
• Iran | • Describe • Perspectives of causes of medication errors | • (+) Reference • (+) Rationale • | NR | • Purposeful sampling • 24 nursing students | • Focus-group interviews • Observations with notes | • Content analysis • (-) Data saturation | Two main themes about nursing students’ perceptions on causes of medication errors |
• Iran | • Explore • Image of nursing | • (-) Reference • (-) Rationale | NR | • Purposeful sampling • 18 male nurses | • Semistructured individual, interviews • Field notes | • Content analysis • (-) Data saturation | Two main views (themes) on nursing presented with subthemes per view |
• Spain | • Ascertain • Barriers to sexual expression | • (-) Reference • (-) Rationale | NR | • Maximum variation • 100 staff and residents | • Semistructured, individual interview | • Content analysis • (-) Data saturation | 40% of participants without identification of barriers and 60% with seven most cited barriers to sexual expression in the long-term care setting |
• Canada | • Explore • Perceptions of empowerment in academic nursing environments | • (+) Reference • (+) Rationale • Sandelowski ( , ) | Theories of structural power in organizations and psychological empowerment | • Unspecified • 8 clinical instructors | • Semistructured, individual • interview guide | • Unspecified (but used pre-determined concepts) • (+) Data saturation | Structural empowerment and psychological empowerment described using predetermined concepts |
• China | • Investigate • Meaning of life and health experience with chronic illness | • (+) Reference • (+) Rationale • Sandelowski ( , ) | Positive health philosophy | • Purposive, convenience sampling • 11 patients | • Individual interviews • Observations of daily behavior with field notes | • Thematic analysis • (-) Data saturation | Four themes regarding the meaning of life and health when living with chronic illnesses |
Note . NR = not reported
Justification for use of a QD design was evident in close to half (47.3%) of the 55 publications. While most researchers clearly described recruitment strategies (80%) and data collection methods (100%), justification for how the study setting was selected was only identified in 38.2% of the articles and almost 75% of the articles did not include any reason for the choice of data collection methods (e.g., focus-group interviews). In the vast majority (90.9%) of the articles, researchers did not explain their involvement and positionality during the process of recruitment and data collection or during data analysis (63.6%). Ethical standards were reported in greater than 89% of all articles and most articles included an in-depth description of data analysis (83.6%) and development of categories or themes (92.7%). Finally, all researchers clearly stated their findings in relation to research questions/objectives. Researchers of 83.3% of the articles discussed the credibility of their findings (see Table 1 ).
In statements of study objectives and/or questions, the most frequently used verbs were “explore” ( n = 22) and “describe” ( n = 17). Researchers also used “identify” ( n = 3), “understand” ( n = 4), or “investigate” ( n = 2). Most articles focused on participants’ experiences related to certain phenomena ( n = 18), facilitators/challenges/factors/reasons ( n = 14), perceptions about specific care/nursing practice/interventions ( n = 11), and knowledge/attitudes/beliefs ( n = 3).
A total of 30 articles included references for QD. The most frequently cited references ( n = 23) were “Whatever happened to qualitative description?” ( Sandelowski, 2000 ) and “What’s in a name? Qualitative description revisited” ( Sandelowski, 2010 ). Other references cited included “Qualitative description – the poor cousin of health research?” ( Neergaard et al., 2009 ), “Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research” ( Pope & Mays, 1995 ), and general research textbooks ( Polit & Beck, 2004 , 2012 ).
In 26 articles (and not necessarily the same as those citing specific references to QD), researchers provided a rationale for selecting QD. Most researchers chose QD because this approach aims to produce a straight description and comprehensive summary of the phenomenon of interest using participants’ language and staying close to the data (or using low inference).
Authors of two articles distinctly stated a QD design, yet also acknowledged grounded-theory or phenomenological overtones by adopting some techniques from these qualitative traditions ( Michael, O'Callaghan, Baird, Hiscock, & Clayton, 2014 ; Peacock, Hammond-Collins, & Forbes, 2014 ). For example, Michael et al. (2014 , p. 1066) reported:
The research used a qualitative descriptive design with grounded theory overtones ( Sandelowski, 2000 ). We sought to provide a comprehensive summary of participants’ views through theoretical sampling; multiple data sources (focus groups [FGs] and interviews); inductive, cyclic, and constant comparative analysis; and condensation of data into thematic representations ( Corbin & Strauss, 1990 , 2008 ).
Authors of four additional articles included language suggestive of a grounded-theory or phenomenological tradition, e.g., by employing a constant comparison technique or translating themes stated in participants’ language into the primary language of the researchers during data analysis ( Asemani et al., 2014 ; Li, Lee, Chen, Jeng, & Chen, 2014 ; Ma, 2014 ; Soule, 2014 ). Additionally, Li et al. (2014) specifically reported use of a grounded-theory approach.
In most (n = 48) articles, researchers did not specify any theoretical or philosophical framework. Of those articles in which a framework or philosophical stance was included, the authors of five articles described the framework as guiding the development of an interview guide ( Al-Zadjali, Keller, Larkey, & Evans, 2014 ; DeBruyn, Ochoa-Marin, & Semenic, 2014 ; Fantasia, Sutherland, Fontenot, & Ierardi, 2014 ; Ma, 2014 ; Wiens, Babenko-Mould, & Iwasiw, 2014 ). In two articles, data analysis was described as including key concepts of a framework being used as pre-determined codes or categories ( Al-Zadjali et al., 2014 ; Wiens et al., 2014 ). Oosterveld-Vlug et al. (2014) and Zhang, Shan, and Jiang (2014) discussed a conceptual model and underlying philosophy in detail in the background or discussion section, although the model and philosophy were not described as being used in developing interview questions or analyzing data.
In 38 of the 55 articles, researchers reported ‘purposeful sampling’ or some derivation of purposeful sampling such as convenience ( n = 10), maximum variation ( n = 8), snowball ( n = 3), and theoretical sampling ( n = 1). In three instances ( Asemani et al., 2014 ; Chan & Lopez, 2014 ; Soule, 2014 ), multiple sampling strategies were described, for example, a combination of snowball, convenience, and maximum variation sampling. In articles where maximum variation sampling was employed, “variation” referred to seeking diversity in participants’ demographics ( n = 7; e.g., age, gender, and education level), while one article did not include details regarding how their maximum variation sampling strategy was operationalized ( Marcinowicz, Abramowicz, Zarzycka, Abramowicz, & Konstantynowicz, 2014 ). Authors of 17 articles did not specify their sampling techniques.
Sample sizes ranged from 8 to 1,932 with nine studies in the 8–10 participant range and 24 studies in the 11–20 participant range. The participant range of 21–30 and 31–50 was reported in eight articles each. Six studies included more than 50 participants. Two of these articles depicted quite large sample sizes (N=253, Hart & Mareno, 2014 ; N=1,932, Lyndon et al., 2014 ) and the authors of these articles described the use of survey instruments and analysis of responses to open-ended questions. This was in contrast to studies with smaller sample sizes where individual interviews and focus groups were more commonly employed.
In a majority of studies, researchers collected data through individual ( n = 39) and/or focus-group ( n = 14) interviews that were semistructured. Most researchers reported that interviews were audiotaped ( n = 51) and interview guides were described as the primary data collection tool in 29 of the 51 studies. In some cases, researchers also described additional data sources, for example, taking memos or field notes during participant observation sessions or as a way to reflect their thoughts about interviews ( n = 10). Written responses to open-ended questions in survey questionnaires were another type of data source in a small number of studies ( n = 4).
The analysis strategy most commonly used in the QD studies included in this review was qualitative content analysis ( n = 30). Among the studies where this technique was used, most researchers described an inductive approach; researchers of two studies analyzed data both inductively and deductively. Thematic analysis was adopted in 14 studies and the constant comparison technique in 10 studies. In nine studies, researchers employed multiple techniques to analyze data including qualitative content analysis with constant comparison ( Asemani et al., 2014 ; DeBruyn et al., 2014 ; Holland, Christensen, Shone, Kearney, & Kitzman, 2014 ; Li et al., 2014 ) and thematic analysis with constant comparison ( Johansson, Hildingsson, & Fenwick, 2014 ; Oosterveld-Vlug et al., 2014 ). In addition, five teams conducted descriptive statistical analysis using both quantitative and qualitative data and counting the frequencies of codes/themes ( Ewens, Chapman, Tulloch, & Hendricks, 2014 ; Miller, 2014 ; Santos, Sandelowski, & Gualda, 2014 ; Villar, Celdran, Faba, & Serrat, 2014 ) or targeted events through video monitoring ( Martorella, Boitor, Michaud, & Gelinas, 2014 ). Tseng, Chen, and Wang (2014) cited Thorne, Reimer Kirkham, and O’Flynn-Magee (2004)’s interpretive description as the inductive analytic approach. In five out of 55 articles, researchers did not specifically name their analysis strategies, despite including descriptions about procedural aspects of data analysis. Researchers of 20 studies reported that data saturation for their themes was achieved.
Researchers described participants’ experiences of health care, interventions, or illnesses in 18 articles and presented straightforward, focused, detailed descriptions of facilitators, challenges, factors, reasons, and causes in 15 articles. Participants’ perceptions of specific care, interventions, or programs were described in detail in 11 articles. All researchers presented their findings with extensive descriptions including themes or categories. In 25 of 55 articles, figures or tables were also presented to illustrate or summarize the findings. In addition, the authors of three articles summarized, organized, and described their data using key concepts of conceptual models ( Al-Zadjali et al., 2014 ; Oosterveld-Vlug et al., 2014 ; Wiens et al., 2014 ). Martorella et al. (2014) assessed acceptability and feasibility of hand massage therapy and arranged their findings in relation to pre-determined indicators of acceptability and feasibility. In one longitudinal QD study ( Kneck, Fagerberg, Eriksson, & Lundman, 2014 ), the researchers presented the findings as several key patterns of learning for persons living with diabetes; in another longitudinal QD study ( Stegenga & Macpherson, 2014 ), findings were presented as processes and themes regarding patients’ identity work across the cancer trajectory. In another two studies, the researchers described and compared themes or categories from two different perspectives, such as patients and nurses ( Canzan, Heilemann, Saiani, Mortari, & Ambrosi, 2014 ) or parents and children ( Marcinowicz et al., 2014 ). Additionally, Ma (2014) reported themes using both participants’ language and the researcher’s language.
In this systematic review, we examined and reported specific characteristics of methods and findings reported in journal articles self-identified as QD and published during one calendar year. To accomplish this we identified 55 articles that met inclusion criteria, performed a quality appraisal following CASP guidelines, and extracted and analyzed data focusing on QD features. In general, three primary findings emerged. First, despite inconsistencies, most QD publications had the characteristics that were originally observed by Sandelowski (2000) and summarized by other limited available QD literature. Next, there are no clear boundaries in methods used in the QD studies included in this review; in a number of studies, researchers adopted and combined techniques originating from other qualitative traditions to obtain rich data and increase their understanding of the phenomenon under investigation. Finally, justification for how QD was chosen and why it would be an appropriate fit for a particular study is an area in need of increased attention.
In general, the overall characteristics were consistent with design features of QD studies described in the literature ( Neergaard et al., 2009 ; Sandelowski, 2000 , 2010 ; Vaismoradi et al., 2013 ). For example, many authors reported that study objectives were to describe or explore participants’ experiences and factors related to certain phenomena, events, or interventions. In most cases, these authors cited Sandelowski (2000) as a reference for this particular characteristic. It was rare that theoretical or philosophical frameworks were identified, which also is consistent with descriptions of QD. In most studies, researchers used purposeful sampling and its derivative sampling techniques, collected data through interviews, and analyzed data using qualitative content analysis or thematic analysis. Moreover, all researchers presented focused or comprehensive, descriptive summaries of data including themes or categories answering their research questions. These characteristics do not indicate that there are correct ways to do QD studies; rather, they demonstrate how others designed and produced QD studies.
In several studies, researchers combined techniques that originated from other qualitative traditions for sampling, data collection, and analysis. This flexibility or variability, a key feature of recently published QD studies, may indicate that there are no clear boundaries in designing QD studies. Sandelowski (2010) articulated: “in the actual world of research practice, methods bleed into each other; they are so much messier than textbook depictions” (p. 81). Hammersley (2007) also observed:
“We are not so much faced with a set of clearly differentiated qualitative approaches as with a complex landscape of variable practice in which the inhabitants use a range of labels (‘ethnography’, ‘discourse analysis’, ‘life history work’, narrative study’, ……, and so on) in diverse and open-ended ways in order to characterize their orientation, and probably do this somewhat differently across audiences and occasions” (p. 293).
This concept of having no clear boundaries in methods when designing a QD study should enable researchers to obtain rich data and produce a comprehensive summary of data through various data collection and analysis approaches to answer their research questions. For example, using an ethnographical approach (e.g., participant observation) in data collection for a QD study may facilitate an in-depth description of participants’ nonverbal expressions and interactions with others and their environment as well as situations or events in which researchers are interested ( Kawulich, 2005 ). One example found in our review is that Adams et al. (2014) explored family members’ responses to nursing communication strategies for patients in intensive care units (ICUs). In this study, researchers conducted interviews with family members, observed interactions between healthcare providers, patients, and family members in ICUs, attended ICU rounds and family meetings, and took field notes about their observations and reflections. Accordingly, the variability in methods provided Adams and colleagues (2014) with many different aspects of data that were then used to complement participants’ interviews (i.e., data triangulation). Moreover, by using a constant comparison technique in addition to qualitative content analysis or thematic analysis in QD studies, researchers compare each case with others looking for similarities and differences as well as reasoning why differences exist, to generate more general understanding of phenomena of interest ( Thorne, 2000 ). In fact, this constant comparison analysis is compatible with qualitative content analysis and thematic analysis and we found several examples of using this approach in studies we reviewed ( Asemani et al., 2014 ; DeBruyn et al., 2014 ; Holland et al., 2014 ; Johansson et al., 2014 ; Li et al., 2014 ; Oosterveld-Vlug et al., 2014 ).
However, this flexibility or variability in methods of QD studies may cause readers’ as well as researchers’ confusion in designing and often labeling qualitative studies ( Neergaard et al., 2009 ). Especially, it could be difficult for scholars unfamiliar with qualitative studies to differentiate QD studies with “hues, tones, and textures” of qualitative traditions ( Sandelowski, 2000 , p. 337) from grounded theory, phenomenological, and ethnographical research. In fact, the major difference is in the presentation of the findings (or outcomes of qualitative research) ( Neergaard et al., 2009 ; Sandelowski, 2000 ). The final products of grounded theory, phenomenological, and ethnographical research are a generation of a theory, a description of the meaning or essence of people’s lived experience, and an in-depth, narrative description about certain culture, respectively, through researchers’ intensive/deep interpretations, reflections, and/or transformation of data ( Streubert & Carpenter, 2011 ). In contrast, QD studies result in “a rich, straight description” of experiences, perceptions, or events using language from the collected data ( Neergaard et al., 2009 ) through low-inference (or data-near) interpretations during data analysis ( Sandelowski, 2000 , 2010 ). This feature is consistent with our finding regarding presentation of findings: in all QD articles included in this systematic review, the researchers presented focused or comprehensive, descriptive summaries to their research questions.
Finally, an explanation or justification of why a QD approach was chosen or appropriate for the study aims was not found in more than half of studies in the sample. While other qualitative approaches, including grounded theory, phenomenology, ethnography, and narrative analysis, are used to better understand people’s thoughts, behaviors, and situations regarding certain phenomena ( Sullivan-Bolyai et al., 2005 ), as noted above, the results will likely read differently than those for a QD study ( Carter & Little, 2007 ). Therefore, it is important that researchers accurately label and justify their choices of approach, particularly for studies focused on participants’ experiences, which could be addressed with other qualitative traditions. Justifying one’s research epistemology, methodology, and methods allows readers to evaluate these choices for internal consistency, provides context to assist in understanding the findings, and contributes to the transparency of choices, all of which enhance the rigor of the study ( Carter & Little, 2007 ; Wu, Thompson, Aroian, McQuaid, & Deatrick, 2016 ).
Use of the CASP tool drew our attention to the credibility and usefulness of the findings of the QD studies included in this review. Although justification for study design and methods was lacking in many articles, most authors reported techniques of recruitment, data collection, and analysis that appeared. Internal consistencies among study objectives, methods, and findings were achieved in most studies, increasing readers’ confidence that the findings of these studies are credible and useful in understanding under-explored phenomenon of interest.
In summary, our findings support the notion that many scholars employ QD and include a variety of commonly observed characteristics in their study design and subsequent publications. Based on our review, we found that QD as a scholarly approach allows flexibility as research questions and study findings emerge. We encourage authors to provide as many details as possible regarding how QD was chosen for a particular study as well as details regarding methods to facilitate readers’ understanding and evaluation of the study design and rigor. We acknowledge the challenge of strict word limitation with submissions to print journals; potential solutions include collaboration with journal editors and staff to consider creative use of charts or tables, or using more citations and less text in background sections so that methods sections are robust.
Several limitations of this review deserve mention. First, only articles where researchers explicitly stated in the main body of the article that a QD design was employed were included. In contrast, articles labeled as QD in only the title or abstract, or without their research design named were not examined due to the lack of certainty that the researchers actually carried out a QD study. As a result, we may have excluded some studies where a QD design was followed. Second, only one database was searched and therefore we did not identify or describe potential studies following a QD approach that were published in non-PubMed databases. Third, our review is limited by reliance on what was included in the published version of a study. In some cases, this may have been a result of word limits or specific styles imposed by journals, or inconsistent reporting preferences of authors and may have limited our ability to appraise the general adequacy with the CASP tool and examine specific characteristics of these studies.
A systematic review was conducted by examining QD research articles focused on nursing-related phenomena and published in one calendar year. Current patterns include some characteristics of QD studies consistent with the previous observations described in the literature, a focus on the flexibility or variability of methods in QD studies, and a need for increased explanations of why QD was an appropriate label for a particular study. Based on these findings, recommendations include encouragement to authors to provide as many details as possible regarding the methods of their QD study. In this way, readers can thoroughly consider and examine if the methods used were effective and reasonable in producing credible and useful findings.
This work was supported in part by the John A. Hartford Foundation’s National Hartford Centers of Gerontological Nursing Excellence Award Program.
Hyejin Kim is a Ruth L. Kirschstein NRSA Predoctoral Fellow (F31NR015702) and 2013–2015 National Hartford Centers of Gerontological Nursing Excellence Patricia G. Archbold Scholar. Justine Sefcik is a Ruth L. Kirschstein Predoctoral Fellow (F31NR015693) through the National Institutes of Health, National Institute of Nursing Research.
Conflict of Interest Statement
The Authors declare that there is no conflict of interest.
Hyejin Kim, MSN, CRNP, Doctoral Candidate, University of Pennsylvania School of Nursing.
Justine S. Sefcik, MS, RN, Doctoral Candidate, University of Pennsylvania School of Nursing.
Christine Bradway, PhD, CRNP, FAAN, Associate Professor of Gerontological Nursing, University of Pennsylvania School of Nursing.
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Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing
* E-mail: [email protected]
Affiliation Institute for Health and Care Improvement, York St John University, York, United Kingdom
Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Software, Supervision, Writing – original draft, Writing – review & editing
Affiliation School of Medical and Health Sciences, Bangor University, Bangor, United Kingdom
Roles Conceptualization, Data curation, Funding acquisition, Investigation, Writing – review & editing
Affiliation Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, United Kingdom
Roles Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Writing – review & editing
Affiliations Institute for Health and Care Improvement, York St John University, York, United Kingdom, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, United Kingdom
Roles Data curation, Investigation, Writing – original draft, Writing – review & editing
Affiliation College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, United Kingdom
Roles Data curation, Investigation, Writing – review & editing
People with severe mental illness engage in considerably less physical activity than those without. They also experience premature mortality of around 10–25 years. A large proportion of these premature deaths are attributed to modifiable behaviours, including physical activity. The inpatient environment provides an opportunity to support people to become more physically active; however, there is limited evidence on which interventions are most successful and what contextual factors affect their delivery. A scoping review was conducted to help understand the extent and type of evidence in this area and identify research gaps. We included studies of physical activity correlates and interventions in adult inpatient mental health services published in peer-reviewed journals. Reviews, meta-analyses, and papers focusing on eating disorder populations were excluded. We searched the MEDLINE, CINAHL, PsycINFO, ASSIA and Web of Science databases for relevant studies published in English. We extracted data on study design, participant characteristics, intervention and control conditions, key findings, and research recommendations. We used a descriptive analytical approach and results are presented in tables and figures. Of 27,286 unique records screened, 210 reports from 182 studies were included. Sixty-one studies reported on correlates of physical activity, and 139 studies reported on physical activity interventions. Most intervention studies used a single-group, pre-post design (40%) and included fewer than 100 participants (86%). Ninety percent of interventions delivered physical activity directly to participants, and 50% included group-based sessions. The duration, type, frequency and intensity of sessions varied. Mental health was the most commonly reported outcome (64%), whereas physical activity was rarely an outcome (13%). Overall, there is a modest but growing body of research on physical activity in adult users of inpatient mental health services. More high-quality trials are needed to advance the field, and future research should target neglected intervention types, outcomes, populations and settings.
Citation: Tew GA, Peckham E, Ker S, Smith J, Hodgson P, Machaczek KK, et al. (2024) Physical activity in adult users of inpatient mental health services: A scoping review. PLoS ONE 19(8): e0301857. https://doi.org/10.1371/journal.pone.0301857
Editor: Maher Abdelraheim Titi, King Saud University Medical City, SAUDI ARABIA
Received: November 4, 2023; Accepted: March 22, 2024; Published: August 19, 2024
Copyright: © 2024 Tew et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting information files.
Funding: This study was supported by Research Capability Funding from Tees Esk and Wear Valleys NHS Trust The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
People who use mental health services, including people with severe mental illness (SMI), depression, anxiety or stress disorders and people with alcohol and substance use disorders, experience worse health outcomes and a shortened life expectancy when compared to people without these disorders (10–25 years for SMI, 7–20 years for anxiety/stress disorders and alcohol and substance use disorders) [ 1 – 4 ]. Much of this reduced life expectancy is due to modifiable risk factors such as engaging in health risk behaviours, one of which is physical inactivity [ 5 – 7 ]; and it has been reported that between 70 and 75% of people with schizophrenia do not meet public health targets for physical activity [ 8 ]. Yet, physical activity interventions have been shown to improve cardiometabolic health outcomes in people with mental illnesses and improve symptoms of depression, cognitive function, feelings of isolation, and quality of life [ 9 – 11 ].
Insufficient physical activity and excessive sedentary behaviour in people receiving care for SMI have been observed in both community and inpatient settings [ 12 , 13 ]. However, the majority of intervention studies have recruited people receiving care in community and outpatient settings, and less research has been done in inpatient settings [ 14 ]. While some of the reasons for insufficient physical activity and excessive sedentary behaviour are common across both inpatient and community settings, such as the sedative effects of psychotropic medicine [ 15 ] and mental health symptoms (lack of motivation, anhedonia, fatigue and negative body image) [ 13 ], there are some unique barriers presented by inpatient settings. For example, lack of appropriate facilities, lack of suitably trained staff to support physical activity, and restrictions on leave for people detained under mental health legislation all contribute to decreased opportunities for physical activity in inpatient settings [ 16 – 19 ]. However, inpatient physical activity programmes provide an opportunity to improve patients’ physical and mental health. For this reason, it is important to have an up-to-date understanding of the literature on this topic.
The scope of inpatient physical activity research is broad, including quantitative or qualitative research such as randomised controlled trials (RCTs) of physical activity interventions or interviews with service users exploring their perceptions of physical activity. Studies have also explored correlates of physical activity or been more intervention focused. Qualitative studies have examined the views of patients, carers or healthcare professionals, or a particular subpopulation of patients. Recent reviews regarding inpatient physical activity have focused on tightly defined inclusion criteria leading to the inclusion of specific sets of studies, such as RCTs. One systematic review and meta-analysis [ 14 ] explored the benefits of, adherence to, and safety of physical activity interventions delivered in inpatient mental health settings. This review and meta-analysis also investigated trials that supported sustaining physical activity after patient discharge and discussed patient feedback on physical activity interventions [ 14 ]. In addition, two reviews focused on physical activity interventions for inpatients in secure forensic settings. The first of these reviews investigated the effectiveness of physical activity programmes for inpatients in secure forensic settings on various health outcomes [ 20 ]. The second paper used the scoping review methodology to explore and synthesise the literature on physical activity interventions for inpatients in secure mental health settings [ 21 ]. [ 14 , 20 , 21 ] A broader review of inpatient physical activity research, that considers all inpatient settings and quantitative and qualitative evidence would be advantageous to understand the current state of the literature and inform future research. A scoping review is a suitable way of achieving this [ 22 ]. Understanding and mapping the available evidence on physical activity in inpatient settings, including qualitative and quantitative research, is important due to their complementary nature. They answer different questions about physical activity. For example, quantitative research can shed light on cause-and-effect relationships between various factors associated with physical activity, while qualitative research can tell us why this is the case. A scoping review also provides a means to determine whether there is scope and a need for a systematic review of a particular type or in a specific area of literature, and to identify gaps in the existing research base that could be filled by future primary research [ 22 ]. The overall aim of this scoping review was therefore to understand the extent and type of evidence regarding physical activity in adult users of inpatient mental health services. This included study designs used, primary conditions of participants, types of outcomes assessed, correlates of physical activity explored, intervention characteristics, outcomes, and research recommendations.
This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews [ 23 ] and reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMAScR) [ 24 ]. A protocol was prepared in advance and published in the Open Science Framework [ 25 ].
We included studies pertaining to adult (≥18 years) users of inpatient mental health services. This included studies where psychiatric inpatients were the participants and studies where other stakeholders were involved (e.g., healthcare professionals giving their views regarding services for psychiatric inpatients). Studies focusing on learning disability populations were included whereas those focusing on eating disorder populations were excluded because of the unique requirement to carefully manage energy input/output in these populations. “Inpatient Setting” was defined as mental health care facilities which provide continuous care for a period of over 24 hours. This included psychiatric hospitals, separate inpatient units of a general hospital, residential treatment centres, and the prison service. Outpatient and community living participant-based studies were not included. There were no limits on the country of origin.
The phenomenon of interest was physical activity. Physical activity has been defined as any bodily movement produced by skeletal muscles and requiring energy expenditure [ 26 ]. Exercise is a subset of physical activity that has been defined as any structured and repetitive physical activity that has an objective of improving or maintaining physical fitness [ 26 ]. To address the aims of the review we took a broad view of physical activity and included studies that had focused on supervised exercise or promotion of self-managed physical activity.
This scoping review included experimental and quasi-experimental study designs such as RCTs, non-randomised controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies were included. This review also considered descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion. Qualitative studies that utilised various methodologies (e.g., phenomenology, grounded theory, ethnography, action research) were also considered. Literature reviews and meta-analyses were used to identify primary studies, but were excluded from data analysis. Conference abstracts and opinion papers were also excluded.
The search strategy targeted peer-reviewed publications. A pilot search of the MEDLINE database was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe them were employed to develop a full search strategy for the MEDLINE, CINAHL, PsycINFO, ASSIA and Web of Science databases ( S1 File ). The search strategy, including all identified keywords and index terms, was adapted for each included database and/or information source. The database searches were conducted on October 31, 2022 and updated on October 24, 2023. The reference list of all included sources of evidence, and those of any review articles or meta-analyses, were screened for additional studies. We also conducted forward citation tracking of included studies using Google Scholar. We only included studies that were published in English language from 2007 onwards. The latter relates to amendments in the 1983 Mental Health Act that were made in 2007; prior studies may have employed different clinical practices and patient populations.
Following the search, all identified citations were collated and uploaded into Covidence [ 27 ], and duplicates were removed. After a pilot test, the titles and abstracts were screened by pairs of independent reviewers against the eligibility criteria for the review. Potentially relevant sources were retrieved in full and assessed in detail against the eligibility criteria by pairs of independent reviewers. The reasons for excluding sources of evidence in full text that did not meet the eligibility criteria were documented. Any disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion or with the aid of additional reviewers.
Data were extracted from papers included in the scoping review by pairs of independent reviewers using a data extraction form ( S2 File ) developed by the reviewers in Covidence [ 27 ], which was based on the JBI template extraction tool [ 28 ]. The form was piloted on twenty papers to ensure it was fit for purpose.
The extracted data encompassed specific details about the participants, concept, context, study methods, key findings relevant to the review questions, and research recommendations. Any disagreements between the reviewers were resolved through discussion or with the aid of an additional reviewer. Due to limited timescales and resources, we did not contact any authors to request missing or additional data.
A descriptive analytical approach was used to summarise the included studies’ contextual, process and outcome-related data [ 29 , 30 ]. This approach was undertaken to map the key concepts and available evidence, synthesise existing research findings, and identify research gaps. Extracted data were organised in Microsoft Excel. Physical activity correlates were categorised based on the Socio-Ecological Model [ 31 – 33 ]. This model was chosen as it considers the multifaceted and interactive effects of various factors (e.g., interpersonal, organisational and community), which characterise the delivery of physical activity interventions for people with SMI. Themes for research recommendations were derived inductively following review of original quotes by two independent reviewers. The analysis was reported in accordance with the synthesis without meta-analysis (SWiM) guideline [ 34 ], with data presented in tables and figures where appropriate.
Fig 1 shows the PRISMA flow diagram. The database searches yielded 35,278 records. After removing duplicates, we screened 27,040 records, from which we reviewed 280 full-text reports, and finally included 132 reports. Later, we reviewed a further 246 full-text reports that were identified from review articles or the forward and backward citations of included reports. This resulted in a further 78 reports being included. Together, 210 reports from 182 studies were included in the review. The complete reference list of included reports can be found in S3 File .
https://doi.org/10.1371/journal.pone.0301857.g001
Sixty-one (34%) studies reported on correlates of physical activity, 139 (76%) studies reported on physical activity interventions, and 19 (10%) studies reported on both physical activity correlates and interventions.
Of the 61 studies on correlates of physical activity, 43 (70%) studies reported on quantitative data (28 observational studies, 15 interventional studies) and 22 (36%) studies reported on qualitative data (14 observational studies, 8 interventional studies) ( Table 1 ). Sample sizes varied by study type, with observational quantitative studies including the largest samples. The majority of studies were conducted in Europe (62%), with most of the remainder originating from Australasia (16%) and Asia (11%). The three most common settings were psychiatric hospitals (39%), forensic/secure settings (23%), and ‘mixed’ settings (16%).
https://doi.org/10.1371/journal.pone.0301857.t001
Of the 139 studies on interventions ( Table 2 ), 57 (41%) studies used a single-group, pre-post design and 57 (41%) studies were RCTs. The majority of studies included fewer than 100 participants (86%) and were conducted in Europe (47%) and within a psychiatric hospital (45%). The most common study populations included people with schizophrenia or related psychotic disorders (35%) and a mixture of diagnoses (20%). Mental health was the most commonly reported outcome (64%), whereas physical activity (13%) and quality of life (16%) were rarely reported outcomes ( Table 2 ).
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Fourteen (10%) of the intervention studies were qualitative studies. All 14 studies collected qualitative data from service users who had participated in the intervention; seven studies (50%) also collected data from healthcare staff, and one study (7%) also collected data from family members. Most studies (71%) used one-to-one interviews to collect data. Other methods included observations (n = 2), evaluation forms (n = 2), document analysis (n = 1) and focus groups (n = 1).
Tables 3 and 4 summarise the physical activity correlates examined or highlighted in quantitative and qualitative studies, respectively. A broad range of individual, interpersonal, environmental and organisational correlates was reported regarding inpatient physical activity, whereas no wider societal factors were highlighted. ‘Health status’ and ‘medication side effects’ were the most commonly reported demographic and biological factors in both quantitative (23% and 21%, respectively) and qualitative (55% and 23%, respectively) studies. ‘Self-motivation’ was the most common factor in the ‘psychological, cognitive and emotional’ category (37% quantitative, 45% qualitative). Factors were less frequently reported in the ‘behavioural’ and ‘social and cultural’ categories, but ‘physical activity enjoyment’ (7% quantitative, 5% qualitative) and ‘social support’ (26% quantitative, 41% qualitative) were the most common factors, respectively. ‘Access to equipment and facilities’ (28% quantitative) and ‘environment restrictions’ (23% quantitative, 32% qualitative) were commonly cited physical environment factors. ‘Staff capacity’ (33% quantitative, 82% qualitative) and ‘staff capability’ (51% quantitative, 59% qualitative) were among the top-ranking organisational factors.
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Table 5 summarises the themes of research recommendations from the studies of physical activity correlates. Twenty-two (36%) of the 61 studies included research recommendations, which we grouped according to whether they were related to the research topic, research methods, or patient involvement.
https://doi.org/10.1371/journal.pone.0301857.t005
The components of physical activity interventions are summarised in Table 2 . Most interventions delivered physical activity directly to participants (90%) and in group-based sessions (50%). Most physical activity interventions included structured exercise (34.5%) such as aerobic and/or resistance training, or a variety of physical activities (24%). Fewer studies considered sport- or dance-based interventions (7% and 6%, respectively). The duration, frequency and intensity of sessions varied (see Table 2 ). Most interventions were delivered by health and/or exercise professionals, but few studies assessed interventions for staff. There was also very little evidence on environmental interventions with only one study exploring an environmental intervention.
Table 6 summarises the themes of the findings from the 14 qualitative studies, which we grouped under the headings of ‘perceptions of the intervention’ and ‘factors influencing intervention delivery and participation’. Beneficial psychosocial effects of interventions were reported in most studies (79%), such as participants feeling more relaxed, happier and calmer. Several studies reported on a range of personal and environmental factors that might influence participation in physical activity. Examples of personal factors included perceived health benefits, social support, medication side effects, confinement in a locked facility, and the availability of trained staff. Environmental factors included physical space and facilities.
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Table 7 summarises the themes of research recommendations from the studies of physical activity interventions. Forty-nine (35%) of the 139 studies included research recommendations, which we grouped according to whether they were related to the research topic or research methods. The most commonly reported research topic-related recommendation was to investigate other physical activity interventions (11.5%), such as different modes of exercise or different behaviour change strategies. The most commonly reported research methods-related recommendations were longer follow-up periods (12%), investigating other outcomes (11.5%), and larger sample sizes (11%).
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This scoping review shows that a wide range of research has been published regarding physical activity and adult users of inpatient mental health services since 2007.
Forty-three quantitative studies explored correlates of physical activity. Organisational factors and psychological, cognitive and emotional factors were the top two domains cited ( Table 3 ). Within these, four out of the top five factors were organisational factors: staff capability, staff capacity, staff attitudes to physical activity, and access to equipment, while self-motivation was the second most highly cited correlate of physical activity overall. Similar findings were observed among the 22 qualitative studies that reported on correlates, with the addition of social support. There was also more emphasis on stigma, health, value of health and funding for physical activity programmes in the qualitative studies. Overall, a broad range of correlates have been reported.
One hundred and thirty-nine interventional studies were identified; only eight of these were larger-scale RCTs with 100 or more participants, and long-term follow-up was rare with only six out of the 57 RCTs (11%) having a follow up of 6 months or more. We did not identify any studies that included an economic evaluation, and there were few replications, suggesting that it would be challenging to evaluate the clinical and cost-effectiveness of physical activity interventions within the current evidence.
In terms of intervention design, the majority of studies explored an intervention that involved delivering physical activity (81%) rather than promoting physical activity (8%); 9% used a mixed model of both delivering and promoting physical activity. Interventions were mainly limited to the period of inpatient stay. The type of physical activity delivered was generally some form of structured exercise or physical recreation targeting individuals. However, descriptions of the interventions were often incomplete, and interventions appeared to lack systematic development. For example, within the 57 RCTs, only two interventions were described as being based on a specific theory [ 70 , 71 ], and only one [ 72 ]made reference to the Medical Research Council’s guidance on developing and evaluating complex interventions [ 73 ]. There was a notable lack of research on environmental interventions and interventions targeting healthcare professionals. In the current review, and elsewhere [ 74 ], we have observed that the reporting of interventions is often inadequate. Since adequate reporting of interventions is central to interpreting study findings and translating effective interventions into practice, we recommend that researchers use relevant reporting guidelines, such as TIDieR [ 75 ], when writing study reports.
Research has been conducted in a wide range of countries, including both high-income and low- and middle-income countries. However, the majority of studies were conducted in European psychiatric inpatient settings. Given the fact that forensic settings are likely to have a more stable population, in terms of patients’ length of stay, than some other inpatient settings, where patients may stay only a few days, surprisingly few RCTs have been conducted in forensic settings (n = 1).
Outcomes collected were mainly mental or physical health-related and the primary outcome was often not clearly stated. In many studies more than one mental or physical health outcome was examined, with some of the outcomes being positive and others neutral or negative, leading to difficulty interpreting the study results. It is important that studies, especially RCTs, clearly state their primary outcome from the outset to avoid cherry-picking results. Physical activity and health-related quality of life were rarely included as outcomes; the lack of physical activity outcomes suggests that increasing levels of physical activity was not the primary objective of many of the studies.
This current review differed in scope from the earlier papers [ 14 , 20 , 21 ] in that it encompassed varied settings (all adult inpatient mental health settings) and clinical populations (not only patients with serious mental illness but also those who receive care on inpatient mental health wards, e.g., those with dementia). In this way, it offered a systematically developed map of research available on physical activity interventions in adult users of inpatient mental health services. It also differed in its purpose and methods from previous studies [ 14 , 20 ]. For example, it included qualitative studies, which facilitated the identification of contextual factors that may influence the implementation and delivery of physical activity interventions in adult inpatient mental health settings.
This review encompasses a wide range of articles and was conducted rigorously and systematically following a predefined protocol and existing guidance for scoping reviews. It provides a comprehensive overview of the extent and type of research on physical activity in inpatient mental health services and identifies important gaps in the literature.
Although a systematic search was conducted, some eligible articles might have been missed. The review is also limited to English language articles and does not include grey literature. Although a scoping review was appropriate to meet the objectives of this study, it is subject to limitations that are typical of this approach. For example, it did not permit a quality assessment of the included studies. It was also limited in its capacity to conclude what factors affect participation in physical activity among adult users of inpatient mental health services, what interventions are effective, and what themes recur in the qualitative literature.
A 2018 meta-review of the evidence on physical activity as a treatment for SMI made several research recommendations [ 9 ], the following of which are relevant for research in relation to the inpatient context:
In addition, we believe that more research is needed to develop and test interventions that span the transition from inpatient to community settings. For example, it would be useful to study longer-term outcomes, such as the impact of physical activity programmes on rates of readmission to inpatient mental health facilities. Finally, this scoping review has identified sets of articles that could be collated for quantitative or qualitative systematic reviews of physical activity in inpatient mental health services. Researchers conducting such reviews should consider the quality of the studies, which was beyond the scope of this review, and to consider the variety of populations represented in these studies.
In conclusion, this scoping review summarised the extent and type of research on physical activity in adult users of inpatient mental health services. We identified a modest volume of evidence regarding correlates of physical activity. A broad range of individual, interpersonal, environmental and organisational correlates have been reported, but more studies with a longitudinal design are needed to determine how these and other factors are associated. We also found a large number of studies reporting on the outcomes of specific physical activity interventions. Most interventions targeted service users and involved the delivery of physical activity sessions rather than self-management interventions. There were very few large-scale RCTs and most studies did not include physical activity or quality of life outcomes. The findings of this review will help guide further primary research that is needed to guide clinical practice and policy.
S1 file. search strategy..
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COMMENTS
A descriptive study design is a research method that observes and describes the behaviour of subjects from a scientific viewpoint with regard to variables of a situation (Sharma, 2019). Here, the ...
As discussed earlier, common research methods for descriptive research include surveys, case studies, observational studies, cross-sectional studies, and longitudinal studies. Design your study: Plan the details of your study, including the sampling strategy, data collection methods, and data analysis plan.
Descriptive research methods. Descriptive research is usually defined as a type of quantitative research, though qualitative research can also be used for descriptive purposes. The research design should be carefully developed to ensure that the results are valid and reliable.. Surveys. Survey research allows you to gather large volumes of data that can be analyzed for frequencies, averages ...
INTRODUCTION. In our previous article in this series, [ 1] we introduced the concept of "study designs"- as "the set of methods and procedures used to collect and analyze data on variables specified in a particular research question.". Study designs are primarily of two types - observational and interventional, with the former being ...
Descriptive research is a methodological approach that seeks to depict the characteristics of a phenomenon or subject under investigation. In scientific inquiry, it serves as a foundational tool for researchers aiming to observe, record, and analyze the intricate details of a particular topic. This method provides a rich and detailed account ...
Author Affiliation: Senior Nurse Scientist and Clinical Nurse Specialist, Office of Nursing Research & Innovation, Nursing Institute, Cleveland Clinic, Ohio. The author reports no conflicts of interest. Correspondence: Sandra L. Siedlecki, PhD, RN, APRN-CNS, 3271 Stillwater Dr, Medina, OH 44256 ([email protected]).
The length and complexity of describing the research design in your paper can vary considerably, ... Descriptive Research Design, September 26, 2008; Erickson, G. Scott. "Descriptive Research Design." In New Methods of Market Research and Analysis. (Northampton, MA: Edward Elgar Publishing, 2017), pp. 51-77; Sahin, Sagufta, and Jayanta Mete. "A ...
As such, descriptive design is great for¹: Case reports and surveys: Descriptive research is a valuable tool for in-depth examination of uncommon diseases and other unique occurrences. In the context of surveys, it can help researchers meticulously analyse extensive datasets. A survey conducted to measure the changes in the levels of customer ...
SUBMIT PAPER. Close Add email alerts. You are adding the following journal to your email alerts. New content; Journal of Pediatric Hematology/Oncology Nursing: Create email alert. Restricted access. Other. First published October 1993. Research Design: Descriptive Research. Helen L. Dulock, RN, DNS View all authors and affiliations. Volume 10 ...
Descriptive research methods. Descriptive research is usually defined as a type of quantitative research, though qualitative research can also be used for descriptive purposes. The research design should be carefully developed to ensure that the results are valid and reliable.. Surveys. Survey research allows you to gather large volumes of data that can be analysed for frequencies, averages ...
Some characteristics of descriptive research are: Quantitativeness. Descriptive research uses a quantitative research method by collecting quantifiable information to be used for statistical analysis of the population sample. This is very common when dealing with research in the physical sciences. Qualitativeness.
Abstract. Descriptive research is a study of status and is widely used in education, nutrition, epidemiology, and the behavioral sciences. Its value is based on the premise that problems can be solved and practices improved through observation, analysis, and description. The most common descriptive research method is the survey, which includes ...
Descriptive research design. Descriptive research design uses a range of both qualitative research and quantitative data (although quantitative research is the primary research method) to gather information to make accurate predictions about a particular problem or hypothesis. As a survey method, descriptive research designs will help ...
In a descriptive research design, the researcher can choose to be either a complete observer, an observer as a participant, a participant as an observer, or a full participant. For example, in a supermarket, a researcher can from afar monitor and track the customers' selection and purchasing trends. This offers a more in-depth insight into ...
A descriptive research design was used to observe and describe the characteristics of the sample ... This paper designs and optimizes the flow of university crisis management and early warning ...
Benefits of Descriptive Research: Limitations of Descriptive Research: Rich Data: Provides a comprehensive and detailed profile of the subject or issue through rich data, offering a thorough understanding (Gresham, 2016). Lack of Control: Cannot control variables or external factors, potentially influencing the accuracy and reliability of the data. Basis for Further Research: Helps to identify ...
Descriptive research design is a powerful tool used by scientists and researchers to gather information about a particular group or phenomenon. This type of research provides a detailed and accurate picture of the characteristics and behaviors of a particular population or subject. ... Research paper retractions represent a critical event in ...
Qualitative Research as a Descriptive-Interpretive Process 4 ... so qualitative designs using inter-views and other in-depth data-gathering procedures offer exciting, nimble, and useful research approaches. Indeed, the number and variety of qualitative approaches that have been developed is remarkable. We remember Bill Stiles saying (quoting
Qualitative descriptive designs are common in nursing and healthcare research due to their inherent simplicity, flexibility and utility in diverse healthcare contexts. However, the application of descriptive research is sometimes critiqued in terms of scientific rigor. Inconsistency in decision making within the research process coupled with a ...
Research describing or defining a particular phenomenon, often through patterns. Book Chapters. Descriptive Research Design
Abstract. This chapter presents two of the most prominent approaches to the design of descriptive research in music education. Simply creating depictions of music teaching and learning experiences that are organized and illustrative of the variation that can exist in any given setting is a worthwhile scientific endeavor in and of itself.
The nonexperimental designs are descriptive, descriptive comparative, and correlation, whereas the experimental designs are quasi-experimental and experimental.2 The purpose of this article is to discuss the use and utility of quantitative descriptive designs and descriptive methods and to explain procedures for defining variables, collecting ...
Descriptive Research Design. This is a theory-based design, where the researcher is primarily interested in describing. ... It is one of the first statements made in any research paper and, as ...
Qualitative description (QD) is a label used in qualitative research for studies which are descriptive in nature, particularly for examining health care and nursing-related phenomena (Polit & Beck, 2009, 2014).QD is a widely cited research tradition and has been identified as important and appropriate for research questions focused on discovering the who, what, and where of events or ...
We extracted data on study design, participant characteristics, intervention and control conditions, key findings, and research recommendations. We used a descriptive analytical approach and results are presented in tables and figures. Of 27,286 unique records screened, 210 reports from 182 studies were included.