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• Ethical Considerations in Research | Types & Examples

Ethical Considerations in Research | Types & Examples

Published on October 18, 2021 by Pritha Bhandari . Revised on May 9, 2024.

Ethical considerations in research are a set of principles that guide your research designs and practices. Scientists and researchers must always adhere to a certain code of conduct when collecting data from people.

The goals of human research often include understanding real-life phenomena, studying effective treatments, investigating behaviors, and improving lives in other ways. What you decide to research and how you conduct that research involve key ethical considerations.

These considerations work to

• protect the rights of research participants
• enhance research validity
• maintain scientific or academic integrity

Table of contents

Why do research ethics matter, getting ethical approval for your study, types of ethical issues, voluntary participation, informed consent, confidentiality, potential for harm, results communication, examples of ethical failures, other interesting articles, frequently asked questions about research ethics.

Research ethics matter for scientific integrity, human rights and dignity, and collaboration between science and society. These principles make sure that participation in studies is voluntary, informed, and safe for research subjects.

You’ll balance pursuing important research objectives with using ethical research methods and procedures. It’s always necessary to prevent permanent or excessive harm to participants, whether inadvertent or not.

Defying research ethics will also lower the credibility of your research because it’s hard for others to trust your data if your methods are morally questionable.

Even if a research idea is valuable to society, it doesn’t justify violating the human rights or dignity of your study participants.

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Before you start any study involving data collection with people, you’ll submit your research proposal to an institutional review board (IRB) .

An IRB is a committee that checks whether your research aims and research design are ethically acceptable and follow your institution’s code of conduct. They check that your research materials and procedures are up to code.

If successful, you’ll receive IRB approval, and you can begin collecting data according to the approved procedures. If you want to make any changes to your procedures or materials, you’ll need to submit a modification application to the IRB for approval.

If unsuccessful, you may be asked to re-submit with modifications or your research proposal may receive a rejection. To get IRB approval, it’s important to explicitly note how you’ll tackle each of the ethical issues that may arise in your study.

There are several ethical issues you should always pay attention to in your research design, and these issues can overlap with each other.

You’ll usually outline ways you’ll deal with each issue in your research proposal if you plan to collect data from participants.

Voluntary participation means that all research subjects are free to choose to participate without any pressure or coercion.

All participants are able to withdraw from, or leave, the study at any point without feeling an obligation to continue. Your participants don’t need to provide a reason for leaving the study.

It’s important to make it clear to participants that there are no negative consequences or repercussions to their refusal to participate. After all, they’re taking the time to help you in the research process , so you should respect their decisions without trying to change their minds.

Voluntary participation is an ethical principle protected by international law and many scientific codes of conduct.

Take special care to ensure there’s no pressure on participants when you’re working with vulnerable groups of people who may find it hard to stop the study even when they want to.

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Informed consent refers to a situation in which all potential participants receive and understand all the information they need to decide whether they want to participate. This includes information about the study’s benefits, risks, funding, and institutional approval.

You make sure to provide all potential participants with all the relevant information about

• what the study is about
• the risks and benefits of taking part
• how long the study will take
• your supervisor’s contact information and the institution’s approval number

Usually, you’ll provide participants with a text for them to read and ask them if they have any questions. If they agree to participate, they can sign or initial the consent form. Note that this may not be sufficient for informed consent when you work with particularly vulnerable groups of people.

If you’re collecting data from people with low literacy, make sure to verbally explain the consent form to them before they agree to participate.

For participants with very limited English proficiency, you should always translate the study materials or work with an interpreter so they have all the information in their first language.

In research with children, you’ll often need informed permission for their participation from their parents or guardians. Although children cannot give informed consent, it’s best to also ask for their assent (agreement) to participate, depending on their age and maturity level.

Anonymity means that you don’t know who the participants are and you can’t link any individual participant to their data.

You can only guarantee anonymity by not collecting any personally identifying information—for example, names, phone numbers, email addresses, IP addresses, physical characteristics, photos, and videos.

In many cases, it may be impossible to truly anonymize data collection . For example, data collected in person or by phone cannot be considered fully anonymous because some personal identifiers (demographic information or phone numbers) are impossible to hide.

You’ll also need to collect some identifying information if you give your participants the option to withdraw their data at a later stage.

Data pseudonymization is an alternative method where you replace identifying information about participants with pseudonymous, or fake, identifiers. The data can still be linked to participants but it’s harder to do so because you separate personal information from the study data.

Confidentiality means that you know who the participants are, but you remove all identifying information from your report.

All participants have a right to privacy, so you should protect their personal data for as long as you store or use it. Even when you can’t collect data anonymously, you should secure confidentiality whenever you can.

Some research designs aren’t conducive to confidentiality, but it’s important to make all attempts and inform participants of the risks involved.

As a researcher, you have to consider all possible sources of harm to participants. Harm can come in many different forms.

• Psychological harm: Sensitive questions or tasks may trigger negative emotions such as shame or anxiety.
• Social harm: Participation can involve social risks, public embarrassment, or stigma.
• Physical harm: Pain or injury can result from the study procedures.
• Legal harm: Reporting sensitive data could lead to legal risks or a breach of privacy.

It’s best to consider every possible source of harm in your study as well as concrete ways to mitigate them. Involve your supervisor to discuss steps for harm reduction.

Make sure to disclose all possible risks of harm to participants before the study to get informed consent. If there is a risk of harm, prepare to provide participants with resources or counseling or medical services if needed.

Some of these questions may bring up negative emotions, so you inform participants about the sensitive nature of the survey and assure them that their responses will be confidential.

The way you communicate your research results can sometimes involve ethical issues. Good science communication is honest, reliable, and credible. It’s best to make your results as transparent as possible.

Take steps to actively avoid plagiarism and research misconduct wherever possible.

Plagiarism means submitting others’ works as your own. Although it can be unintentional, copying someone else’s work without proper credit amounts to stealing. It’s an ethical problem in research communication because you may benefit by harming other researchers.

Self-plagiarism is when you republish or re-submit parts of your own papers or reports without properly citing your original work.

This is problematic because you may benefit from presenting your ideas as new and original even though they’ve already been published elsewhere in the past. You may also be infringing on your previous publisher’s copyright, violating an ethical code, or wasting time and resources by doing so.

In extreme cases of self-plagiarism, entire datasets or papers are sometimes duplicated. These are major ethical violations because they can skew research findings if taken as original data.

You notice that two published studies have similar characteristics even though they are from different years. Their sample sizes, locations, treatments, and results are highly similar, and the studies share one author in common.

Research misconduct

Research misconduct means making up or falsifying data, manipulating data analyses, or misrepresenting results in research reports. It’s a form of academic fraud.

These actions are committed intentionally and can have serious consequences; research misconduct is not a simple mistake or a point of disagreement about data analyses.

Research misconduct is a serious ethical issue because it can undermine academic integrity and institutional credibility. It leads to a waste of funding and resources that could have been used for alternative research.

Later investigations revealed that they fabricated and manipulated their data to show a nonexistent link between vaccines and autism. Wakefield also neglected to disclose important conflicts of interest, and his medical license was taken away.

This fraudulent work sparked vaccine hesitancy among parents and caregivers. The rate of MMR vaccinations in children fell sharply, and measles outbreaks became more common due to a lack of herd immunity.

Research scandals with ethical failures are littered throughout history, but some took place not that long ago.

Some scientists in positions of power have historically mistreated or even abused research participants to investigate research problems at any cost. These participants were prisoners, under their care, or otherwise trusted them to treat them with dignity.

To demonstrate the importance of research ethics, we’ll briefly review two research studies that violated human rights in modern history.

These experiments were inhumane and resulted in trauma, permanent disabilities, or death in many cases.

After some Nazi doctors were put on trial for their crimes, the Nuremberg Code of research ethics for human experimentation was developed in 1947 to establish a new standard for human experimentation in medical research.

In reality, the actual goal was to study the effects of the disease when left untreated, and the researchers never informed participants about their diagnoses or the research aims.

Although participants experienced severe health problems, including blindness and other complications, the researchers only pretended to provide medical care.

When treatment became possible in 1943, 11 years after the study began, none of the participants were offered it, despite their health conditions and high risk of death.

Ethical failures like these resulted in severe harm to participants, wasted resources, and lower trust in science and scientists. This is why all research institutions have strict ethical guidelines for performing research.

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

• Normal distribution
• Measures of central tendency
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Thematic analysis
• Cohort study
• Peer review
• Ethnography

Research bias

• Implicit bias
• Cognitive bias
• Conformity bias
• Hawthorne effect
• Availability heuristic
• Attrition bias
• Social desirability bias

Ethical considerations in research are a set of principles that guide your research designs and practices. These principles include voluntary participation, informed consent, anonymity, confidentiality, potential for harm, and results communication.

Scientists and researchers must always adhere to a certain code of conduct when collecting data from others .

These considerations protect the rights of research participants, enhance research validity , and maintain scientific integrity.

Research ethics matter for scientific integrity, human rights and dignity, and collaboration between science and society. These principles make sure that participation in studies is voluntary, informed, and safe.

Anonymity means you don’t know who the participants are, while confidentiality means you know who they are but remove identifying information from your research report. Both are important ethical considerations .

You can only guarantee anonymity by not collecting any personally identifying information—for example, names, phone numbers, email addresses, IP addresses, physical characteristics, photos, or videos.

You can keep data confidential by using aggregate information in your research report, so that you only refer to groups of participants rather than individuals.

These actions are committed intentionally and can have serious consequences; research misconduct is not a simple mistake or a point of disagreement but a serious ethical failure.

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Statistics for the Public Good

Ethical considerations associated with Qualitative Research methods

Introduction.

This high-level guidance has been developed by the UK Statistics Authority’s Centre for Applied Data Ethics (CADE), and the UK Government Data Quality Hub (DQHub), based at the Office for National Statistics (ONS). The guidance can be used as a practical resource to help researchers identify different ethical issues when conducting qualitative research.  

This guidance is not exhaustive but aims to support researchers navigating the ethical issues surrounding qualitative research projects (particularly in relation to primary data collection). It brings together existing literature on qualitative research methods and their ethical concerns. Links to further resources are provided if you would like to read about aspects in more detail.  

The guidance has been created for researchers using qualitative methods within the ONS . However, the ethical considerations discussed, and the mitigations for these, can be more widely applied to all types of qualitative research.  

The guidance is divided into several parts.    

• An introduction to qualitative research and why ethics matters in this space.   
• An overview of some of the ethical considerations associated with qualitative research methods, and some potential mitigations for these issues. This includes an overview of some of the qualitative methods used within the ONS.  
• An ethics checklist which summarises the main points covered in this guidance.    
• A list of helpful links to further resources.   

Ethical Issues in Research

• Living reference work entry
• First Online: 05 March 2021
• Cite this living reference work entry

• Juwel Rana 2 , 3 , 4 ,
• Segufta Dilshad 2 &
• Md. Ali Ahsan 5  

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The most important human endeavor is the striving for morality in our actions. Our inner balance and even our very existence depend on it. Only morality in our actions can give beauty and dignity to life – Albert Einstein.

Ethics ; Methodology ; Mixed-method research ; Observation ; Qualitative research ; Quantitative research ; Research ; Research design ; Research ethics

Ethics is a set of standards, a code, or value system, worked out from human reason and experience, by which free human actions are determined as ultimately right or wrong, good, or evil. If acting agrees with these standards, it is ethical, otherwise unethical.

Scientific research refers to a persistent exercise towards producing new knowledge to unveil a new stream of ideas in academia for humankind.

Research ethics refer to some of the genres that researchers follow to protect the rights in developing research strategies and building a trusted relationship between the...

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Bulmer M (1982) Social Research Ethics: An Examination of the Merits of Covert Participant Observation. Holmes & Meier Publishers

Google Scholar  

Butler I (2002) A Code of Ethics for Social Work and Social Care Research. Br J Soc Work [Internet]. 32(2):239–48. Available from: https://doi.org/10.1093/bjsw/32.2.239

Fisher CB, Anushko AE (2008) The SAGE Handbook of Social Research Methods [Internet]. London: SAGE Publications Ltd; p. 95–109. Available from: https://methods.sagepub.com/book/the-sage-handbook-of-socialresearch-methods

Hill J, Wright LT (2001) A qualitative research agenda for small to medium-sized enterprises. Mark Intell Plan 19(6):432–443

Homan R (1991) The ethics of social research. Addison-Wesley Longman Limited

Israel M, Hay I (2006) Research ethics for social scientists. Sage

Kimmel AJ (1988) Ethics and values in applied social research. 1st ed. SAGE Publications Inc

Orb A, Eisenhauer L, Wynaden D (2001) Ethics in qualitative research. J Nurs Scholarsh 33(1):93–96

Principles of research ethics [Internet]. Lund Research Ltd. 2012 [cited 2020 Dec 15]. Available from: https://dissertation.laerd.com/principles-of-research-ethics.php

Robley LR (1995) The ethics of qualitative nursing research. J Prof Nurs 11(1):45–48

Wiles R, Charles V, Crow G, Heath S (2006) Researching researchers: lessons for research ethics. Qual Res. 6(3):283–99

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Department of Public Health, School of Health and Life Sciences, North South University, Dhaka, Bangladesh

Juwel Rana & Segufta Dilshad

Department of Biostatistics and Epidemiology, School of Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA

Department of Research and Innovation, South Asia Institute for Social Transformation (SAIST), Dhaka, Bangladesh

Space and Environment Research Center (SERC), Rajshahi, Bangladesh

Md. Ali Ahsan

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Correspondence to Juwel Rana .

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Florida Atlantic University, Boca Raton, FL, USA

Ali Farazmand

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Rana, J., Dilshad, S., Ahsan, M.A. (2021). Ethical Issues in Research. In: Farazmand, A. (eds) Global Encyclopedia of Public Administration, Public Policy, and Governance. Springer, Cham. https://doi.org/10.1007/978-3-319-31816-5_462-1

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DOI : https://doi.org/10.1007/978-3-319-31816-5_462-1

Received : 01 February 2021

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Ethics in Qualitative Research Controversies and Contexts

• Martyn Hammersley - The Open University, UK
• Anna Traianou - Goldsmiths, University of London, UK
• Description

All researchers need to think about research ethics, and for a variety of reasons it is an increasingly important part of research methods training. Ethics in Qualitative Research explores this field and presents a distinctive perspective; one that is at odds with the assumptions underpinning ethical regulation, but also with the views of many qualitative researchers today.

Martyn Hammersley and Anna Traianou emphasize the difficult and controversial character of ethical issues, and examine the philosophical assumptions involved, the social contexts in which key ethical principles arise, and their implications for research practice.

The authors argue that the starting point for any discussion of research ethics must be the values intrinsic to research, above all the commitment to knowledge-production. However, the pursuit of inquiry is rightly constrained by external values, and the book focuses on three of these: minimizing harm, respecting autonomy, and protecting privacy. These values are shown to be far from unequivocal in character, often in conflict with one another, or with the commitments of research, and always subject to situational interpretation and practical judgment.

It is argued that in the present challenging times it is essential that qualitative researchers think clearly about, and stand up for, their principles.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

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As a former Masters student and novice qualitative researcher, had I had more insight into the complexities around ethics detailed in this book before entering the field I may well have been better equipped to deal with some of the more problematic issues I encountered. Chloe Roberts Action Learning: Research & Practice

What is ethical acting in qualitative research, what want to say it when you act ethical or unethical, and just imagine that how solid are questions at the heart of this book. The introduction is also immediately announced that answering these questions is not easy and that the answers given by the authors are controversial. Such a statement makes me curious and will read something very new in the hope you go with the book to get started. (Translation).

Very useful on the ethics course to encourage critique and reflection on ethical issues in qualitative research and to support the students in developing ethical awareness

Martyn Hammersley and Anna Traianou have set out to examine some important underlying assumptions and concepts in ethics in qualitative research. Starting with a historical context for the ever increasing ethical requirements in research since the mid 20thC, the authors then set the tone and tenor of the discussion by raising the debate around the perceived purpose of research ethics. They invoke the moral dimension of research aims and outcomes, differentiating between the ethical requirements of research within an institutional context together with the morality of differing research design in various populations and from a range of perspectives. This is an informative and thought-provoking text that will appeal to postgraduate students keen to use qualitative methods as well as experienced researchers, wanting to revisit and re-examine some important ethical debates.

Excellent and thought provoking text which challenges mainstream beliefs around ethics in qualitative research. Would cause you to challenge your core understanding on principles associated with certain aspects relating to qualitative research. Particularly liked the synopsis of chapters in the summary section too. Useful if you are re-visiting the text after a break away.

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Quantitative and qualitative research methods: Considerations and issues in qualitative research

• CC BY-NC-SA 4.0

• The Maldives National University

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This paper revisits the role of quantitative and qualitative methods in visualization research in the context of advancements in artificial intelligence (AI). The focus is on how we can bridge between the different methods in an integrated process of analyzing user study data. To this end, a process model of - potentially iterated - semantic enrichment and transformation of data is proposed. This joint perspective of data and semantics facilitates the integration of quantitative and qualitative methods. The model is motivated by examples of own prior work, especially in the area of eye tracking user studies and coding data-rich observations. Finally, there is a discussion of open issues and research opportunities in the interplay between AI, human analyst, and qualitative and quantitative methods for visualization research.

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Managing “socially admitted” patients in hospital: a qualitative study of health care providers’ perceptions

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Background: Emergency departments are a last resort for some socially vulnerable patients without an acute medical illness (colloquially known as “socially admitted” patients), resulting in their occupation of hospital beds typically designated for patients requiring acute medical care. In this study, we aimed to explore the perceptions of health care providers regarding patients admitted as “social admissions.”

Methods: This qualitative study was informed by grounded theory and involved semistructured interviews at a Nova Scotia tertiary care centre. From October 2022 to July 2023, we interviewed eligible participants, including any health care clinician or administrator who worked directly with “socially admitted” patients. Virtual or in-person individual interviews were audio-recorded and transcribed, then independently and iteratively coded. We mapped themes on the 5 domains of the Quintuple Aim conceptual framework.

Results: We interviewed 20 nurses, physicians, administrators, and social workers. Most identified as female ( n = 11) and White ( n = 13), and were in their mid to late career ( n = 13). We categorized 9 themes into 5 domains: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes). Participants described experiences caring for “socially admitted” patients, perceptions and assumptions underlying “social” presentations, system barriers to care delivery, and suggestions of potential solutions.

Interpretation: Health care providers viewed “socially admitted” patients as needing enhanced care but identified individual, institutional, and system challenges that impeded its realization. Examining perceptions of the people who care for “socially admitted” patients offers insights to guide clinicians and policy-makers in caring for socially vulnerable patients.

See related editorial at www.cmaj.ca/lookup/doi/10.1503/cmaj.240577

Emergency departments have become a destination of last resort for some patients who are made vulnerable by social circumstances, resulting in their occupying hospital beds typically designated for people with acute medical issues. 1 “Social admission” is a colloquial, nondiagnostic label used to describe a person for whom no acute medical issues are recognized to be contributing to their seeking health care. However, many health care providers understand that patients who are admitted for social reasons face challenges such as a breakdown of care supports or an inability of the patient or family to cope with the demands of living at home. 2 These patients often have lengthy stays in emergency departments or hospital wards, and frequently encounter barriers (e.g., housing or home support) delaying safe discharge from hospital. The colloquial terms “failure to cope,” “acopia,” “orphan patient,” or “home care impossible,” among others, are sometimes used to refer to these patients. 3 – 5 Such terminology can be stigmatizing because it indicates a value judgment that patients require admission solely on “social” grounds, sometimes failing to account for underlying medical complexity. 6

The “social admission” phenomenon is an under-researched area in health care. These patients, often categorized by health care providers as not being acutely ill, experience in-hospital death rates as high as 22.2%–34.9%. 7 , 8 Explanations may include under-triaging in the emergency department owing to poor recognition of atypical clinical presentations and delays in timely assessments. 5 Patients may be misdiagnosed or develop acute illness during their hospital stay. In 2 international studies, by the end of hospitalization, an admission diagnosis of “acopia” was no longer the discharge diagnosis in 88%–92.5% of cases. 7 , 9 Diagnoses of falls, delirium, and mobility problems were common, but sepsis was initially undiagnosed in almost one-third of these patients. 7 This raises questions about health care providers’ awareness of atypical presentations and decision-making for “social” presentations, which often require a nuanced understanding of both medical and social care needs.

Health care providers face challenges providing high-quality care to this patient population across Canada 1 , 10 and internationally. 1 , 4 , 10 – 13 “Social admissions” may account for as many as 1 in 10 patients (0.57%–9.3%) presenting to the emergency department and 1 in 25 admissions to hospital, with increasing prevalence with age. 14 A survey from Wales showed that 51.8% of hospital physicians consider that they frequently care for these patients, encountering them several times per week. 15

Since “social admission” is a nondiagnostic label, its definition varies across regions and health care systems, meaning no guidelines exist to standardize approaches to meet medical or social care needs. Qualitative data evaluating how health care providers perceive and care for these patients are lacking. Therefore, we aimed to explore the perceptions of health care providers regarding patients admitted as “social admissions.”

Study design

This qualitative study was informed by constructivist grounded theory, which uses inductive analysis of data collected from participants to generate new theories. 16 , 17 We conducted semistructured interviews with clinicians and health care administrators between October 2022 and July 2023. Given that little is known about “social admissions,” grounded theory was best suited to our objective to generate an explanatory theory about this phenomenon. 17

The research team included qualitative methods experts, geriatric medicine specialists, clinician scientists, primary care and emergency department clinicians, and members with administrative leadership roles. We also included nursing students, medical students, and internal medicine residents of diverse backgrounds.

We reported this study using the Consolidated Criteria for Reporting Qualitative Research Checklist (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content ). 18

Setting and participants

Studying “social admissions” can be challenging because of the variability in terminology and admission policies across different jurisdictions. 19 The Orphan Patient Policy is a standardized “social admission” pathway used at the Queen Elizabeth II Health Sciences Centre, a tertiary care centre in Halifax, Nova Scotia. Halifax is the provincial capital and the largest city in the Atlantic region of Canada. In Nova Scotia, health care is provided through a publicly funded health care system.

Since March 2012, any patient, regardless of age or living situation, can be admitted to the Queen Elizabeth II Health Sciences Centre under the Orphan Patient Policy if they have undergone a medical assessment by a physician in the emergency department, are determined to have no acute or new medical conditions, and have been seen by a social worker or discharge planning nurse to exhaust all home care options. Inability to return home includes situations of homelessness, unavailable community supports, or waiting for transitions to long-term care. These patients are admitted to the first available inpatient bed, based on a rotating roster of all hospital admission services (e.g., medicine, psychiatry, surgery, subspecialty medicine or surgery, and hospitalist). The admitting service and its allied health care team become responsible for the patient’s care and disposition, with the expectation that discharge planning is the primary issue. Although these patients are locally called “orphan patients,” we use the terminology “social admission” throughout this paper.

Eligible participants included any clinical provider or administrator who worked directly with “socially admitted” patients. To identify potential participants for our study, we held initial interviews with hospital nursing bed flow managers who are responsible for administering the Orphan Patient Policy.

To recruit participants, we used snowball sampling: we emailed each health care provider or department that had been recommended by the initial interviewees (i.e., the nursing bed flow managers), and those suggested by study participants during their interviews or by key knowledge users with whom we shared preliminary findings (see Data analysis). Preliminary analyses also informed recruitment, and we used purposive and theoretical sampling 20 , 21 to ensure that the perspectives of multiple health care professionals within the “social admission” care pathway were included, with the aim of data saturation. We approached several departments and individuals who declined to participate or did not respond to our requests for interviews. These included recreation therapy, physiotherapy, occupational therapy, some administrative positions, and several subspecialty medicine divisions.

Data collection

The interview guide (Appendix 2a, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content ) was based on our literature review of “social admissions” 14 and informed by our chart reviews of more than 350 “social admissions” in Nova Scotia (unpublished data, 2021). The entire research team gave input on the interview guide through several iterative processes: multiple meetings to develop the guide, a pilot test with non-author colleagues, and a meeting after all interviewers had conducted at least 1 interview to discuss whether the guide was robust enough to elicit the information we were seeking. We revised the interview guide wording for clarity and understanding, and we added 2 major questions (interview guide questions 7 and 8) and several prompting questions.

Experienced qualitative researchers (C.S. and E.G.M.) provided training. We held 2 group and 1 individual interactive training and practice sessions, which provided methodological context, and practical approaches and techniques in qualitative interviewing. One research team member (J.C.M., L.E., G.A., or M.K.) administered individual interviews. Interviews occurred virtually (via Microsoft Teams) or in person in quiet rooms on hospital wards or participants’ offices. After interviews were completed, we contacted participants by email to provide self-identified demographic data. The survey was voluntary and anonymous, and participants selected from predefined categories or supplied free text for sex, gender, ethnicity, role, and profession (Appendix 2b).

Interviews were audio-recorded and transcribed verbatim. For additional rigour and contextualization during analysis, interviewers kept detailed field notes of their reflections during the interviews.

Data analysis

Data collection and analysis occurred simultaneously. All participants were invited to review their transcripts before analysis (1 participant opted to). We used Dedoose software for data coding and organization.

Two team members independently coded interview transcripts using an inductive approach. 16 , 17 Throughout the initial coding process, the coders (J.C.M., C.S., G.A., and M.K.) met regularly to refine, merge and expand codes, come to consensus about any disagreements and interpretations, add context to certain transcripts with their field notes from the interviews, and identify additional participants suggested by the participants. Using constant comparative and selective coding processes, 16 , 17 we generated categories and subcategories to form themes to reflect participants’ perspectives on “social admissions.”

We used several strategies to ensure rigour and trustworthiness throughout the research process. As per the grounded theory approach, we incorporated reflexivity into our analytic process and acknowledged our dual roles as researchers and health care providers delivering care. Most members of the research team were affiliated with the research site and possessed an in-depth understanding of the local context and providers involved in “social admission” care. This intimate understanding enabled us to add context to the findings. However, we also challenged our preconceptions and biases by recruiting participants with diverse experiences and perspectives, and scheduling regular meetings among research team members to triangulate findings with our internal chart review, knowledge user feedback, and data analysis. 22

We put participant narratives at the forefront by presenting the data (from preliminary interviews and after completion of interviews) to engaged key knowledge users within our hospital and university network (e.g., experienced researchers, clinicians, social workers, and administrators) in a variety of settings (e.g., individual communications, small group sessions, or internal department presentations). The knowledge users provided feedback and suggested further participants. The data were also triangulated with findings from our recent literature review. 14

After data saturation was achieved, we mapped our findings on the Quintuple Aim conceptual framework at the suggestion of a knowledge user and as per consensus with the research group. 23 , 24 This framework adequately organized and contextualized our findings and is a well-known approach to optimizing health system performance and defines 5 fundamental domains (definitions in Appendix 1) for transforming health care: enhance patient experience, better population health, optimize cost of care, improve care team well-being, and advance health equity. 23 , 24

Ethics approval

Nova Scotia Health granted institutional research ethics approval (REB no. 1027628).

We conducted 20 interviews (9 in person and 11 virtual) among hospital administrators and clinicians ( Table 1 ). Clinicians were nurses (charge, discharge planning, and inpatient), physicians (residents and staff physicians), and social workers, representing the following services: emergency department, internal medicine, medical subspecialties (cardiology, neurology, and geriatric medicine), psychiatry, hospitalist, and surgical specialties (orthopedics, general surgery, cardiovascular surgery, and vascular surgery). Administrators included nursing bed managers and directors of hospital divisions and long-term care. The mean interview length was 38 (range 16–76) minutes.

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Demographic information of hospital administrators and clinicians who were interviewed

We categorized 9 themes into each of the 5 domains of the Quintuple Aim framework as shown in Figure 1 : patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes for addressing “social admissions”). Additional illustrative quotations are presented in Appendix 3, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content .

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Domains (in the circle) and themes (outside the circle) using the Quintuple Aim framework. 23 , 24

Patient experience

Participants’ description of patients.

Participants provided diverse descriptions of these patients ( Table 2 ). One cited financial precarity as a key problem faced by these patients. Another highlighted recurrent health care system interactions as being important. Some mentioned these patients had a mix of medical, mental health, and social problems. Most equated “social admissions” with older patients or those who were cognitively impaired. Some deemed them the most frail, vulnerable, or complex cases. Few considered that “socially admitted” patients had no medical conditions involved (Appendix 3) or that the medical conditions could wholly be managed at a primary care level.

Descriptions and illustrative quotations of the patient description and provision of care themes in the patient experience domain

Provision of care

Participants described “socially admitted” patients as receiving passive and hands-off care, contrasting this with active approaches for medical and surgical cases. Participants reported that patients, especially those who were older or confused, often received limited attention and workup, leaving their needs unaddressed ( Table 2 ). The approach to care was characterized by patients being left in their beds, being the last person rounded on by the care team, and not being chosen to participate in rehabilitative programs or exercises. In short, these patients’ care needs were the last in the queue of nursing and physician priorities. Beyond direct provision of care, participants identified that hospital programs (e.g., recreation therapy) benefitting these patients had been discontinued or under-resourced (Appendix 3). Almost all clinical participants considered their ward was not the place to care for these patients.

Care team well-being

Moral distress.

Health care providers described their roles as acute care or sub-specialized experts but said they felt helpless when they were unable to provide care for “socially admitted” patients, who often had complex, unrecognized, or chronic health issues. They often stated that better care should be offered yet described challenges when caring for “socially admitted” patients. These included a lack of appropriate training, struggles to arrange suitable care, and resistance when attempting to involve other services, allied health care, or social work, leading to delays in appropriate management ( Table 3 ). As articulated by 1 participant (HC605): “I think that’s a lot to ask of different providers who may not have that skill set. So, sometimes I think it does cause, you know, moral distress and challenge for people sometimes, which then gets perhaps articulated as being ‘they shouldn’t be here.’” Many reported feeling negative toward the policy and labelling of these patients, and acknowledged it was used primarily to communicate with other health care providers. One participant suggested the policy prevented blame on clinicians for “admitting this [patient]” (HC840).

Descriptions and illustrative quotations of the moral distress and hierarchy of care themes in the care team well-being domain

Hierarchy of care

Participants highlighted a hierarchy in health care, prioritizing acute care patients over “social admissions.” One participant reflected on how hospitals rely on pathways with these patients not fitting into a clear “slot,” representing individuals not well differentiated, individuals with complexity, or individuals with issues that are not specialty specific. Consequently, “social admissions” were passed down the hierarchy, from physicians to residents, and sometimes to nursing assistants, implying they were less worthy of routine medical attention ( Table 3 ).

Health equity

Stigma and missed opportunities.

The term “social admission” led to incorrect assumptions about medical needs and cognitive abilities. Beliefs about behaviours were noted by several participants. These assumptions were propagated as early as handovers from paramedics to emergency nursing teams ( Table 4 ). Participants highlighted instances where these patients were not medically stable and emphasized that social stressors did not exempt patients from becoming medically ill during the admission. The label was reported to be an impediment to opportunities to look for underlying treatable medical issues, compounded by the need to make timely decisions because of pressures to free up beds.

Descriptions and illustrative quotations of the stigma and missed opportunities, and prejudices themes in the health equity domain

Ageist beliefs underpinned assumptions about capacity, especially for older “socially admitted” patients. Some participants recognized that these patients could not effectively advocate for themselves, and others pointed out that older patients were often assumed to be cognitively or functionally impaired, and decisions were made without them. Participants provided examples of premature capacity determinations made without proper medical evaluation or consultation ( Table 4 ). One participant described the invisibility of these patients, especially for women and minorities, and another noted how the care of “socially admitted” patients is undermined by negative attitudes similar to those encountered by individuals with substance use disorders (Appendix 3).

Cost of care

Wait-lists and scarcity of alternatives.

Inadequate community support often resulted in emergency department visits and hospital admissions, with the perception that hospitals are the safest place. Participants noted lengthy wait-lists for community services like home care, physiotherapy, or occupational therapy, which led to deconditioning ( Table 5 ). The transition to long-term care was described as “abysmal,” leaving patients in challenging situations for extended periods. Admissions were a “last resort” after all other options were exhausted, with patients and families struggling to access necessary care. The lack of alternatives contributed to participants’ distress when caring for “socially admitted” patients (Appendix 3).

Description and illustrative quotations of the wait-list and scarcity of alternatives theme in the cost of care domain

Population health

Factors leading to vulnerability.

Participants identified many issues that were associated with the “social admission” label, particularly for patients with cognitive impairment ( Table 6 ). These included physical barriers (e.g., inaccessible homes), homelessness, and financial challenges. Social isolation left individuals unsupported, managing alone until emergencies, such as falls, catalyzed hospital admission. The inability to advocate for oneself was also a common observation.

Descriptions and illustrative quotations of factors leading to vulnerability and system changes for addressing “social admission” themes in the population health domain

System changes for addressing “social admissions”

Participants identified systemic barriers that they considered disadvantaged “socially admitted” patients. Participants were concerned that the health care system is currently in crisis (e.g., with a lack of primary care and home support), and emergency departments cannot function as intended, causing the acute care system to become the community system or “the [inter]mediate pathway between community and long-term care” ( Table 6 ). Some called for specialized seniors’ care teams to address the unique needs of older adults. Participants emphasized the importance of understanding these patients’ situations holistically, with a multidisciplinary approach to assess medical history, social factors, and available resources; several examples of ideal approaches were shared. The system’s focus on individuals with higher functioning left “socially admitted” patients underserved, with emphases on services that are “organized from a provider lens, not from a patient-need lens” (HC605).

• Interpretation

We sought to understand how health care providers perceive patients labelled as “socially admitted” in hospital, and we identified 9 key themes across the Quintuple Aim framework. 23 , 24 The themes in the patient experience domain highlighted inconsistent definitions and passive care approaches for these patients, who are often seen as low priority in hospital. Under the care team well-being domain, themes of moral distress and hierarchy of care showed the challenges and dilemmas faced by health care providers. Issues of stigma (e.g., “they have dementia”), prejudices (e.g., ageism), wait-lists, and scarcity of alternatives underscored systemic challenges under the health equity and cost of care domains. Finally, factors leading to vulnerability and potential system changes were described by participants as ways to better the health of this population.

Our findings highlight the potential adverse effects on care when patients are labelled as “socially admitted” (or as “orphan patients” in the study hospital), such as incorrect assumptions about medical needs and cognitive abilities, which impedes opportunities to look for treatable medical issues. Despite a “social admission” pathway ostensibly designed to ensure there are no acute or new medical issues, patients were still perceived as having “multiple comorbidities” or being “the most frail … the most complex” ( Table 2 ). This finding is in keeping with the results of a case–control study (in London, Ontario), in which medical comorbidity played a minimal role in the label of a “failure to cope” admission among adults aged 70 years or older. Instead, recent failed discharge from hospital was significantly associated with a “social admission” label, leading the authors to suggest blame was an important part of the use of this label in a system that prizes efficiency. 3 This supports the viewpoint that it is more a system’s failure to cope than the patient’s. 10

Our findings also demonstrate possible negative impacts on health care providers not addressed in previous research. Although similar patient populations (“failure to thrive” or “failure to cope”) in British Columbia 25 and Ontario, 3 and “acopia” admissions in the United Kingdom and Australia, 7 , 9 have been researched, these studies did not consider the insights of providers directly caring for these patients. We highlight some structures (e.g., propagation of the label early in care) or cultures (e.g., ageism) in our health care systems, leading to system and individual tensions caring for “socially admitted” patients, especially in the context of few readily available alternatives. We observed that participants frequently reported feeling conflicted defining, prioritizing, and managing this patient population, yet unequivocally considered these patients deserved care — albeit care delivered by someone else. This latter finding contrasts with a survey of physicians in Wales in which two-thirds (62.7%) considered patients labelled as “social admissions/acopia” were a burden on national health resources, with 44.8% of physicians admitted to feeling that these patients were a burden on their time. 15

Despite considering that “socially admitted” patients were deserving of care, our participants recounted how care was passed down to less-senior members of the health care team. This pattern of downgrading care can lead to situations in which “socially admitted” patients are looked after by team members who possess minimal experience recognizing evolving medical presentations or lack the authority to advocate strongly for clinical reassessments when needed. The implication that the care of “social admissions” should be delegated to others reflects an implicit attitude of hierarchy and detachment from the needs associated with this patient population. Not being able to provide the care that is warranted while at the same time believing that the needed care is beneath the care they provide is in keeping with cognitive dissonance literature in medicine (i.e., holding 2 or more inconsistent beliefs or behaving in a way that is inconsistent with core beliefs). 26 Cognitive dissonance can trigger negative emotions and subsequent defensive reactions resulting in fault finding in others (e.g., blaming “social admissions”), reinforced commitment to wrong actions (e.g., propagating labels), and overlooked medical errors, 26 , 27 offering some explanations for understanding how stigma and hierarchies of care can lead to missed acute medical illnesses (e.g., sepsis, malignancy, and strokes) in previous “social admission” populations. 5 , 7 , 9

Existing literature indicates that “social admission” labelling may harm patients. 14 Our findings suggest that the use of this label appears to have little benefit for the health care providers who care for this patient population. Moreover, no evidence exists to date that “social admissions” labelling or pathways help the health care system. Therefore, re-evaluating an approach to caring for “socially admitted” patients is imperative, and this may include abandoning the nondiagnostic label.

Better support for this patient population may be achieved through enhanced policies that propose feasible solutions to support these patients. To achieve this, further steps are required to define “social admissions,” and to highlight the importance and scope of the issues surrounding the patient population captured under this label. 28 However, we found inconsistencies in how “social admissions” are described, which adds to the challenge in developing effective policies for these patients, and in comparing similar presentations across Canada. 29 Developing a consistent definition for “social admissions” may also prompt clinical specialties to claim responsibility for this population, as champions are key to raising issues for prioritization in health care. 30

“Social admissions” can be considered a “wicked problem” with no single easy solution. 31 A previously proposed ecological approach can guide clinicians in managing “social” presentations. 2 , 32 Participants in our study made suggestions about community- and institutional-level solutions such as home care and primary care teams that support social integration, more multidisciplinary care teams in and out of the hospital, and “geriatrizing” acute care. These suggestions reflect many of the same calls for action made by previous scholars and advocates, 33 , 34 and are similar to solutions proposed by the National Institute on Ageing’s “Ageing in the Right Place” report. 35 Scholars in France have proposed a societal-level solution involving the procedural and financial restructuring of ultraspecialized medicine, coupled with a revival of historic values combining medicine and social work to address the needs of an increasingly frail and socially complex population. 36

Limitations

Our study was conducted in a single tertiary health centre in Nova Scotia, where “socially admitted” patients are admitted under an institution-specific Orphan Patient Policy, which likely limits the generalizability of our findings. Our participants were mainly White and female, which also limits the generalizability to other settings across the country and internationally. Furthermore, the participant sample did not include recreational therapists, volunteers, physiotherapists, or occupational therapists. In the study centre, recreation and volunteer programs had been discontinued or reduced following the COVID-19 pandemic, and there were no occupational or physiotherapists specifically assigned to this patient population. Another limitation of our study is that some interviewers had prior acquaintance with the participants they interviewed. This familiarity may introduce bias in the data collection and interpretation, although this should be balanced with constructivist grounded theory’s emphasis on researchers as co-participants in the research process.

Our research draws attention to health care providers’ challenges in managing care for “socially admitted” patients, and to perceptions regarding “social” presentations, perceived system barriers and resource shortages, and some potential solutions for better patient care. Overall, no consensus emerged as to what constitutes a “social admission” (who are the patients labelled as “socially admitted”?) or ownership for “social admissions” (who cares for these patients?), and participants reported inconsistencies in care delivered for such patients (how to care for “socially admitted” patients). To improve the patient experience and alleviate the moral distress of staff who care for “socially admitted” patients in hospital, the inherent structures of our health care system, such as hierarchies and stigmatization, should be reformed to better address the needs of patients with increasingly complex social problems who present to hospitals.

Competing interests: Jasmine Mah receives scholarships supporting her PhD research from the Department of Medicine at Dalhousie University, Dalhousie Medical Research Foundation, Dr. Patrick Madore Traineeship, and the Pierre Elliott Trudeau Foundation. Kenneth Rockwood has asserted copyright of the Clinical Frailty Scale through Dalhousie University’s Industry, Liaison, and Innovation Office. In addition to academic and hospital appointments, Kenneth Rockwood is cofounder of Ardea Outcomes, which (as DGI Clinical) in the last 3 years has contracts with pharmaceutical and device manufacturers (Danone, Hollister, INmune, Novartis, Takeda) on individualized outcome measurement. In 2020, he attended an advisory board meeting with Nutricia on dementia and chaired a Scientific Workshop & Technical Review Panel on frailty for the Singapore National Research Foundation. He is associate director of the Canadian Consortium on Neurodegeneration in Aging, itself funded by the Canadian Institutes for Health Research, the Alzheimer Society of Canada, and several other charities. He holds the Kathryn Allen Weldon Chair in Alzheimer Research, funded by the Dalhousie Medical Research Foundation. Kenneth Rockwood also reports personal fees from Ardea Outcomes, the Chinese Medical Association, Wake Forest University Medical School Centre, the University of Nebraska Omaha, the Australia and New Zealand Society for Geriatric Medicine, Atria Institute, Fraser Health Authority, McMaster University, and EpiPharma. In addition, Dr. Rockwood has licensed the Clinical Frailty Scale to Enanta Pharmaceuticals, Synairgen Research, Faraday Pharmaceuticals, KCR S.A., Icosavax, BioAge Labs, Biotest AG, Qu Biologics, AstraZeneca UK, Cellcolabs AB, Pfizer, W.L. Gore & Associates, pending to Cook Research Incorporated, Renibus Therapeutics, and, as part of Ardea Outcomes, has a pending patent for Electronic Goal Attainment Scaling. He also reports permission for the Pictorial Fit-Frail Scale licensed to Congenica. Use of both the Clinical Frailty Scale and Pictorial Fit-Frail Scale is free for education, research, and nonprofit health care with completion of a permission agreement stipulating users will not change, charge for, or commercialize the scales. For-profit entities pay a licensing fee, 15% of which is is retained by the Dalhousie University Office of Commercialization and Industry Engagement. The remainder of the licence fees are donated to the Dalhousie Medical Research Foundation. Melissa Andrew reports grants from Sanofi, grants and support to attend meetings from GSK, grants from Pfizer, grants from Canadian Frailty Network, personal fees from Sanofi, personal fees from Pfizer, personal fees from Seqirus, grants from Merck, grants from Public Health Agency of Canada, and grants from Canadian Institutes of Health Research, outside the submitted work. Dr. Andrew is a volunteer board member for the Alzheimer Society of Nova Scotia and the National Advisory Committee on Immunization. Sheliza Khan declares leadership in the patient flow department at Queen Elizabeth II Hospital. No other competing interests were declared.

This article has been peer reviewed.

Contributors: Jasmine Mah and Christie Stilwell contributed equally as co–first authors. Jasmine Mah contributed to the conceptualization and design, procurement of data, analysis of data, drafting of the original manuscript, and review of the manuscript. Christie Stilwell and Emily Marshall contributed to the conceptualization and design, analysis of data, drafting of the original manuscript, and review of the manuscript. Madeline Kubiseski and Gaurav Arora contributed to the conceptualization and design, procurement of data, analysis of data, and review of the manuscript. Karen Nicholls, Sheliza Khan, Jonathan Veinot, Lucy Eum, Susan Freter, Katalin Koller, Maia von Maltzahn, Kenneth Rockwood, Samuel Searle, and Melissa Andrew contributed to the conceptualization and design, analysis of data, and drafting of the original manuscript or review of manuscript drafts. All authors approved the final version to be published and agreed to be accountable for its accuracy and integrity.

Data sharing: Anonymized data from our study may be available on request. Interested parties are encouraged to contact the lead author via email to access these data or to obtain a copy of the Orphan Patient Policy. The data will be shared under terms that ensure the protection of participant privacy and compliance with relevant data protection regulations.

Funding: This study is supported by Nova Scotia Health, through a grant from the Nova Scotia Health Research Fund. Nova Scotia Health is the provincial health authority.

• Accepted March 5, 2024.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

• Luther RA ,
• Richardson L ,
• Andrew MK ,
• Burrell A ,
• Chahine S ,
• Rutschmann OT ,
• Chevalley T ,
• Zumwald C ,
• Rippingale C
• Bielawska C ,
• Murphy PJ ,
• Campbell SG
• Searle SD ,
• Chattopadhyay I
• Sainsbury P ,
• Furlong KR ,
• O’Donnell K ,
• Farrell A ,
• Strauss A ,
• Cooper LA ,
• Itchhaporia D
• Harmon-Jones E ,
• Shiffman J ,
• Sinskey JL ,
• Margolis RD ,
• Bronfenbrenner U
• Reuben DB ,
• Auerbach J ,
• ↵ Ageing in the right place: supporting older Canadians to live where they want . Toronto : National Institute on Ageing, Toronto Metropolitan University 2022 : 1 – 148 . Available: https://static1.squarespace.com/static/5c2fa7b03917eed9b5a436d8/t/638e0857c959d1546d9f6f3a/1670252637242/AIRP+Report+Final2022-.pdf ( accessed 2023 Dec. 18 ).

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Qualitative Methods in Health Care Research

Vishnu renjith.

School of Nursing and Midwifery, Royal College of Surgeons Ireland - Bahrain (RCSI Bahrain), Al Sayh Muharraq Governorate, Bahrain

Renjulal Yesodharan

1 Department of Mental Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Judith A. Noronha

2 Department of OBG Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Elissa Ladd

3 School of Nursing, MGH Institute of Health Professions, Boston, USA

Anice George

4 Department of Child Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Healthcare research is a systematic inquiry intended to generate robust evidence about important issues in the fields of medicine and healthcare. Qualitative research has ample possibilities within the arena of healthcare research. This article aims to inform healthcare professionals regarding qualitative research, its significance, and applicability in the field of healthcare. A wide variety of phenomena that cannot be explained using the quantitative approach can be explored and conveyed using a qualitative method. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research. The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes. In health research, these methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

Introduction

Healthcare research is a systematic inquiry intended to generate trustworthy evidence about issues in the field of medicine and healthcare. The three principal approaches to health research are the quantitative, the qualitative, and the mixed methods approach. The quantitative research method uses data, which are measures of values and counts and are often described using statistical methods which in turn aids the researcher to draw inferences. Qualitative research incorporates the recording, interpreting, and analyzing of non-numeric data with an attempt to uncover the deeper meanings of human experiences and behaviors. Mixed methods research, the third methodological approach, involves collection and analysis of both qualitative and quantitative information with an objective to solve different but related questions, or at times the same questions.[ 1 , 2 ]

In healthcare, qualitative research is widely used to understand patterns of health behaviors, describe lived experiences, develop behavioral theories, explore healthcare needs, and design interventions.[ 1 , 2 , 3 ] Because of its ample applications in healthcare, there has been a tremendous increase in the number of health research studies undertaken using qualitative methodology.[ 4 , 5 ] This article discusses qualitative research methods, their significance, and applicability in the arena of healthcare.

Qualitative Research

Diverse academic and non-academic disciplines utilize qualitative research as a method of inquiry to understand human behavior and experiences.[ 6 , 7 ] According to Munhall, “Qualitative research involves broadly stated questions about human experiences and realities, studied through sustained contact with the individual in their natural environments and producing rich, descriptive data that will help us to understand those individual's experiences.”[ 8 ]

Significance of Qualitative Research

The qualitative method of inquiry examines the 'how' and 'why' of decision making, rather than the 'when,' 'what,' and 'where.'[ 7 ] Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena and make sense of the complex reality. Health interventions, explanatory health models, and medical-social theories could be developed as an outcome of qualitative research.[ 9 ] Understanding the richness and complexity of human behavior is the crux of qualitative research.

Differences between Quantitative and Qualitative Research

The quantitative and qualitative forms of inquiry vary based on their underlying objectives. They are in no way opposed to each other; instead, these two methods are like two sides of a coin. The critical differences between quantitative and qualitative research are summarized in Table 1 .[ 1 , 10 , 11 ]

Differences between quantitative and qualitative research

Qualitative Research Questions and Purpose Statements

Qualitative questions are exploratory and are open-ended. A well-formulated study question forms the basis for developing a protocol, guides the selection of design, and data collection methods. Qualitative research questions generally involve two parts, a central question and related subquestions. The central question is directed towards the primary phenomenon under study, whereas the subquestions explore the subareas of focus. It is advised not to have more than five to seven subquestions. A commonly used framework for designing a qualitative research question is the 'PCO framework' wherein, P stands for the population under study, C stands for the context of exploration, and O stands for the outcome/s of interest.[ 12 ] The PCO framework guides researchers in crafting a focused study question.

Example: In the question, “What are the experiences of mothers on parenting children with Thalassemia?”, the population is “mothers of children with Thalassemia,” the context is “parenting children with Thalassemia,” and the outcome of interest is “experiences.”

The purpose statement specifies the broad focus of the study, identifies the approach, and provides direction for the overall goal of the study. The major components of a purpose statement include the central phenomenon under investigation, the study design and the population of interest. Qualitative research does not require a-priori hypothesis.[ 13 , 14 , 15 ]

Example: Borimnejad et al . undertook a qualitative research on the lived experiences of women suffering from vitiligo. The purpose of this study was, “to explore lived experiences of women suffering from vitiligo using a hermeneutic phenomenological approach.” [ 16 ]

Review of the Literature

In quantitative research, the researchers do an extensive review of scientific literature prior to the commencement of the study. However, in qualitative research, only a minimal literature search is conducted at the beginning of the study. This is to ensure that the researcher is not influenced by the existing understanding of the phenomenon under the study. The minimal literature review will help the researchers to avoid the conceptual pollution of the phenomenon being studied. Nonetheless, an extensive review of the literature is conducted after data collection and analysis.[ 15 ]

Reflexivity

Reflexivity refers to critical self-appraisal about one's own biases, values, preferences, and preconceptions about the phenomenon under investigation. Maintaining a reflexive diary/journal is a widely recognized way to foster reflexivity. According to Creswell, “Reflexivity increases the credibility of the study by enhancing more neutral interpretations.”[ 7 ]

Types of Qualitative Research Designs

The qualitative research approach encompasses a wide array of research designs. The words such as types, traditions, designs, strategies of inquiry, varieties, and methods are used interchangeably. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research.[ 1 , 7 , 10 ]

Narrative research

Narrative research focuses on exploring the life of an individual and is ideally suited to tell the stories of individual experiences.[ 17 ] The purpose of narrative research is to utilize 'story telling' as a method in communicating an individual's experience to a larger audience.[ 18 ] The roots of narrative inquiry extend to humanities including anthropology, literature, psychology, education, history, and sociology. Narrative research encompasses the study of individual experiences and learning the significance of those experiences. The data collection procedures include mainly interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences through “re-storying of stories” and developing themes usually in chronological order of events. Rolls and Payne argued that narrative research is a valuable approach in health care research, to gain deeper insight into patient's experiences.[ 19 ]

Example: Karlsson et al . undertook a narrative inquiry to “explore how people with Alzheimer's disease present their life story.” Data were collected from nine participants. They were asked to describe about their life experiences from childhood to adulthood, then to current life and their views about the future life. [ 20 ]

Phenomenological research

Phenomenology is a philosophical tradition developed by German philosopher Edmond Husserl. His student Martin Heidegger did further developments in this methodology. It defines the 'essence' of individual's experiences regarding a certain phenomenon.[ 1 ] The methodology has its origin from philosophy, psychology, and education. The purpose of qualitative research is to understand the people's everyday life experiences and reduce it into the central meaning or the 'essence of the experience'.[ 21 , 22 ] The unit of analysis of phenomenology is the individuals who have had similar experiences of the phenomenon. Interviews with individuals are mainly considered for the data collection, though, documents and observations are also useful. Data analysis includes identification of significant meaning elements, textural description (what was experienced), structural description (how was it experienced), and description of 'essence' of experience.[ 1 , 7 , 21 ] The phenomenological approach is further divided into descriptive and interpretive phenomenology. Descriptive phenomenology focuses on the understanding of the essence of experiences and is best suited in situations that need to describe the lived phenomenon. Hermeneutic phenomenology or Interpretive phenomenology moves beyond the description to uncover the meanings that are not explicitly evident. The researcher tries to interpret the phenomenon, based on their judgment rather than just describing it.[ 7 , 21 , 22 , 23 , 24 ]

Example: A phenomenological study conducted by Cornelio et al . aimed at describing the lived experiences of mothers in parenting children with leukemia. Data from ten mothers were collected using in-depth semi-structured interviews and were analyzed using Husserl's method of phenomenology. Themes such as “pivotal moment in life”, “the experience of being with a seriously ill child”, “having to keep distance with the relatives”, “overcoming the financial and social commitments”, “responding to challenges”, “experience of faith as being key to survival”, “health concerns of the present and future”, and “optimism” were derived. The researchers reported the essence of the study as “chronic illness such as leukemia in children results in a negative impact on the child and on the mother.” [ 25 ]

Grounded Theory Research

Grounded theory has its base in sociology and propagated by two sociologists, Barney Glaser, and Anselm Strauss.[ 26 ] The primary purpose of grounded theory is to discover or generate theory in the context of the social process being studied. The major difference between grounded theory and other approaches lies in its emphasis on theory generation and development. The name grounded theory comes from its ability to induce a theory grounded in the reality of study participants.[ 7 , 27 ] Data collection in grounded theory research involves recording interviews from many individuals until data saturation. Constant comparative analysis, theoretical sampling, theoretical coding, and theoretical saturation are unique features of grounded theory research.[ 26 , 27 , 28 ] Data analysis includes analyzing data through 'open coding,' 'axial coding,' and 'selective coding.'[ 1 , 7 ] Open coding is the first level of abstraction, and it refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory.[ 1 , 7 ] Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings. Strauss and Corbin highlights that “the value of the grounded theory lies not only in its ability to generate a theory but also to ground that theory in the data.”[ 27 ]

Example: Williams et al . conducted a grounded theory research to explore the nature of relationship between the sense of self and the eating disorders. Data were collected form 11 women with a lifetime history of Anorexia Nervosa and were analyzed using the grounded theory methodology. Analysis led to the development of a theoretical framework on the nature of the relationship between the self and Anorexia Nervosa. [ 29 ]

Ethnographic research

Ethnography has its base in anthropology, where the anthropologists used it for understanding the culture-specific knowledge and behaviors. In health sciences research, ethnography focuses on narrating and interpreting the health behaviors of a culture-sharing group. 'Culture-sharing group' in an ethnography represents any 'group of people who share common meanings, customs or experiences.' In health research, it could be a group of physicians working in rural care, a group of medical students, or it could be a group of patients who receive home-based rehabilitation. To understand the cultural patterns, researchers primarily observe the individuals or group of individuals for a prolonged period of time.[ 1 , 7 , 30 ] The scope of ethnography can be broad or narrow depending on the aim. The study of more general cultural groups is termed as macro-ethnography, whereas micro-ethnography focuses on more narrowly defined cultures. Ethnography is usually conducted in a single setting. Ethnographers collect data using a variety of methods such as observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group with emic and etic perspectives. When the researcher reports the views of the participants it is called emic perspectives and when the researcher reports his or her views about the culture, the term is called etic.[ 7 ]

Example: The aim of the ethnographic study by LeBaron et al . was to explore the barriers to opioid availability and cancer pain management in India. The researchers collected data from fifty-nine participants using in-depth semi-structured interviews, participant observation, and document review. The researchers identified significant barriers by open coding and thematic analysis of the formal interview. [ 31 ]

Historical research

Historical research is the “systematic collection, critical evaluation, and interpretation of historical evidence”.[ 1 ] The purpose of historical research is to gain insights from the past and involves interpreting past events in the light of the present. The data for historical research are usually collected from primary and secondary sources. The primary source mainly includes diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The data gathered from these various sources are synthesized and reported as biographical narratives or developmental perspectives in chronological order. The ideas are interpreted in terms of the historical context and significance. The written report describes 'what happened', 'how it happened', 'why it happened', and its significance and implications to current clinical practice.[ 1 , 10 ]

Example: Lubold (2019) analyzed the breastfeeding trends in three countries (Sweden, Ireland, and the United States) using a historical qualitative method. Through analysis of historical data, the researcher found that strong family policies, adherence to international recommendations and adoption of baby-friendly hospital initiative could greatly enhance the breastfeeding rates. [ 32 ]

Case study research

Case study research focuses on the description and in-depth analysis of the case(s) or issues illustrated by the case(s). The design has its origin from psychology, law, and medicine. Case studies are best suited for the understanding of case(s), thus reducing the unit of analysis into studying an event, a program, an activity or an illness. Observations, one to one interviews, artifacts, and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived. A written case study report includes a detailed description of one or more cases.[ 7 , 10 ]

Example: Perceptions of poststroke sexuality in a woman of childbearing age was explored using a qualitative case study approach by Beal and Millenbrunch. Semi structured interview was conducted with a 36- year mother of two children with a history of Acute ischemic stroke. The data were analyzed using an inductive approach. The authors concluded that “stroke during childbearing years may affect a woman's perception of herself as a sexual being and her ability to carry out gender roles”. [ 33 ]

Sampling in Qualitative Research

Qualitative researchers widely use non-probability sampling techniques such as purposive sampling, convenience sampling, quota sampling, snowball sampling, homogeneous sampling, maximum variation sampling, extreme (deviant) case sampling, typical case sampling, and intensity sampling. The selection of a sampling technique depends on the nature and needs of the study.[ 34 , 35 , 36 , 37 , 38 , 39 , 40 ] The four widely used sampling techniques are convenience sampling, purposive sampling, snowball sampling, and intensity sampling.

Convenience sampling

It is otherwise called accidental sampling, where the researchers collect data from the subjects who are selected based on accessibility, geographical proximity, ease, speed, and or low cost.[ 34 ] Convenience sampling offers a significant benefit of convenience but often accompanies the issues of sample representation.

Purposive sampling

Purposive or purposeful sampling is a widely used sampling technique.[ 35 ] It involves identifying a population based on already established sampling criteria and then selecting subjects who fulfill that criteria to increase the credibility. However, choosing information-rich cases is the key to determine the power and logic of purposive sampling in a qualitative study.[ 1 ]

Snowball sampling

The method is also known as 'chain referral sampling' or 'network sampling.' The sampling starts by having a few initial participants, and the researcher relies on these early participants to identify additional study participants. It is best adopted when the researcher wishes to study the stigmatized group, or in cases, where findings of participants are likely to be difficult by ordinary means. Respondent ridden sampling is an improvised version of snowball sampling used to find out the participant from a hard-to-find or hard-to-study population.[ 37 , 38 ]

Intensity sampling

The process of identifying information-rich cases that manifest the phenomenon of interest is referred to as intensity sampling. It requires prior information, and considerable judgment about the phenomenon of interest and the researcher should do some preliminary investigations to determine the nature of the variation. Intensity sampling will be done once the researcher identifies the variation across the cases (extreme, average and intense) and picks the intense cases from them.[ 40 ]

Deciding the Sample Size

A-priori sample size calculation is not undertaken in the case of qualitative research. Researchers collect the data from as many participants as possible until they reach the point of data saturation. Data saturation or the point of redundancy is the stage where the researcher no longer sees or hears any new information. Data saturation gives the idea that the researcher has captured all possible information about the phenomenon of interest. Since no further information is being uncovered as redundancy is achieved, at this point the data collection can be stopped. The objective here is to get an overall picture of the chronicle of the phenomenon under the study rather than generalization.[ 1 , 7 , 41 ]

Data Collection in Qualitative Research

The various strategies used for data collection in qualitative research includes in-depth interviews (individual or group), focus group discussions (FGDs), participant observation, narrative life history, document analysis, audio materials, videos or video footage, text analysis, and simple observation. Among all these, the three popular methods are the FGDs, one to one in-depth interviews and the participant observation.

FGDs are useful in eliciting data from a group of individuals. They are normally built around a specific topic and are considered as the best approach to gather data on an entire range of responses to a topic.[ 42 Group size in an FGD ranges from 6 to 12. Depending upon the nature of participants, FGDs could be homogeneous or heterogeneous.[ 1 , 14 ] One to one in-depth interviews are best suited to obtain individuals' life histories, lived experiences, perceptions, and views, particularly while exporting topics of sensitive nature. In-depth interviews can be structured, unstructured, or semi-structured. However, semi-structured interviews are widely used in qualitative research. Participant observations are suitable for gathering data regarding naturally occurring behaviors.[ 1 ]

Data Analysis in Qualitative Research

Various strategies are employed by researchers to analyze data in qualitative research. Data analytic strategies differ according to the type of inquiry. A general content analysis approach is described herewith. Data analysis begins by transcription of the interview data. The researcher carefully reads data and gets a sense of the whole. Once the researcher is familiarized with the data, the researcher strives to identify small meaning units called the 'codes.' The codes are then grouped based on their shared concepts to form the primary categories. Based on the relationship between the primary categories, they are then clustered into secondary categories. The next step involves the identification of themes and interpretation to make meaning out of data. In the results section of the manuscript, the researcher describes the key findings/themes that emerged. The themes can be supported by participants' quotes. The analytical framework used should be explained in sufficient detail, and the analytic framework must be well referenced. The study findings are usually represented in a schematic form for better conceptualization.[ 1 , 7 ] Even though the overall analytical process remains the same across different qualitative designs, each design such as phenomenology, ethnography, and grounded theory has design specific analytical procedures, the details of which are out of the scope of this article.

Computer-Assisted Qualitative Data Analysis Software (CAQDAS)

Until recently, qualitative analysis was done either manually or with the help of a spreadsheet application. Currently, there are various software programs available which aid researchers to manage qualitative data. CAQDAS is basically data management tools and cannot analyze the qualitative data as it lacks the ability to think, reflect, and conceptualize. Nonetheless, CAQDAS helps researchers to manage, shape, and make sense of unstructured information. Open Code, MAXQDA, NVivo, Atlas.ti, and Hyper Research are some of the widely used qualitative data analysis software.[ 14 , 43 ]

Reporting Guidelines

Consolidated Criteria for Reporting Qualitative Research (COREQ) is the widely used reporting guideline for qualitative research. This 32-item checklist assists researchers in reporting all the major aspects related to the study. The three major domains of COREQ are the 'research team and reflexivity', 'study design', and 'analysis and findings'.[ 44 , 45 ]

Critical Appraisal of Qualitative Research

Various scales are available to critical appraisal of qualitative research. The widely used one is the Critical Appraisal Skills Program (CASP) Qualitative Checklist developed by CASP network, UK. This 10-item checklist evaluates the quality of the study under areas such as aims, methodology, research design, ethical considerations, data collection, data analysis, and findings.[ 46 ]

Ethical Issues in Qualitative Research

A qualitative study must be undertaken by grounding it in the principles of bioethics such as beneficence, non-maleficence, autonomy, and justice. Protecting the participants is of utmost importance, and the greatest care has to be taken while collecting data from a vulnerable research population. The researcher must respect individuals, families, and communities and must make sure that the participants are not identifiable by their quotations that the researchers include when publishing the data. Consent for audio/video recordings must be obtained. Approval to be in FGDs must be obtained from the participants. Researchers must ensure the confidentiality and anonymity of the transcripts/audio-video records/photographs/other data collected as a part of the study. The researchers must confirm their role as advocates and proceed in the best interest of all participants.[ 42 , 47 , 48 ]

Rigor in Qualitative Research

The demonstration of rigor or quality in the conduct of the study is essential for every research method. However, the criteria used to evaluate the rigor of quantitative studies are not be appropriate for qualitative methods. Lincoln and Guba (1985) first outlined the criteria for evaluating the qualitative research often referred to as “standards of trustworthiness of qualitative research”.[ 49 ] The four components of the criteria are credibility, transferability, dependability, and confirmability.

Credibility refers to confidence in the 'truth value' of the data and its interpretation. It is used to establish that the findings are true, credible and believable. Credibility is similar to the internal validity in quantitative research.[ 1 , 50 , 51 ] The second criterion to establish the trustworthiness of the qualitative research is transferability, Transferability refers to the degree to which the qualitative results are applicability to other settings, population or contexts. This is analogous to the external validity in quantitative research.[ 1 , 50 , 51 ] Lincoln and Guba recommend authors provide enough details so that the users will be able to evaluate the applicability of data in other contexts.[ 49 ] The criterion of dependability refers to the assumption of repeatability or replicability of the study findings and is similar to that of reliability in quantitative research. The dependability question is 'Whether the study findings be repeated of the study is replicated with the same (similar) cohort of participants, data coders, and context?'[ 1 , 50 , 51 ] Confirmability, the fourth criteria is analogous to the objectivity of the study and refers the degree to which the study findings could be confirmed or corroborated by others. To ensure confirmability the data should directly reflect the participants' experiences and not the bias, motivations, or imaginations of the inquirer.[ 1 , 50 , 51 ] Qualitative researchers should ensure that the study is conducted with enough rigor and should report the measures undertaken to enhance the trustworthiness of the study.

Conclusions

Qualitative research studies are being widely acknowledged and recognized in health care practice. This overview illustrates various qualitative methods and shows how these methods can be used to generate evidence that informs clinical practice. Qualitative research helps to understand the patterns of health behaviors, describe illness experiences, design health interventions, and develop healthcare theories. The ultimate strength of the qualitative research approach lies in the richness of the data and the descriptions and depth of exploration it makes. Hence, qualitative methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

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