importance of semi structured interviews in research

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6 Semi-structured interviewing

• Published: June 2005
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This chapter presents a guide to conducting effective semi-structured interviews. It discusses the nature of semi-structured interviews and why they should be used, as well as preparation, the logistics of conducting the interview, and reflexivity.

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Semi-Structured Interviews in Qualitative Research

Unveiling insights of semi-structured interviews in qualitative research, the methods for nuanced understanding and robust data analysis.

Qualitative research explores the rich complexities of human experiences, perceptions, and meanings. In the research area, semi-structured interviews emerge as a versatile method to gather in-depth insights from participants. Unlike rigidly structured interviews, semi-structured interviews provide a flexible framework that combines predetermined questions with the freedom to explore emergent topics and probe deeper into participants’ thoughts and experiences. This article aims to show the purpose, benefits, and best practices of utilizing semi-structured interviews in qualitative research. By understanding how this approach facilitates a nuanced exploration of research questions, researchers can harness its potential to capture the multifaceted nature of human phenomena and gain rich and meaningful data that enhances the understanding of diverse social, psychological, and cultural phenomena.

What Are Semi-structured Interviews In Qualitative Research?

A semi-structured interview is a qualitative research method that combines aspects of both structured and unstructured interviews. In a semi-structured interview, the researcher prepares a set of predetermined questions or topics to guide the conversation with the participant, but there is also room for flexibility and follow-up questions based on the participant’s responses. This allows for a more conversational and exploratory approach, enabling the researcher to delve deeper into specific areas of interest and capture detailed and nuanced information.

Also read: What’s the Difference: Qualitative vs Quantitative Research?

Semi-structured interviews enable researchers to explore participants’ perspectives, experiences, and perceptions in-depth. They can uncover rich narratives, personal insights, and contextual details that may not emerge in more standardized interview formats. The open-ended nature of semi-structured interviews allows for a holistic understanding of the research topic and captures the complexity of human experiences.

The Purpose Of Semi-Structured Interviews

Semi-structured interviews serve as a dynamic means of collecting qualitative data, allowing researchers to engage in a conversation with participants while maintaining a certain level of flexibility. These interviews enable researchers to explore research questions, delve into participants’ perspectives, and gain a comprehensive understanding of the studied phenomena. The purpose of semi-structured interviews extends beyond factual information; it aims to uncover participants’ perceptions, beliefs, values, and emotions, providing valuable insights into their subjective experiences.

When To Use A Semi-Structured Interview?

When conducting qualitative research, the decision to use a semi-structured interview approach is influenced by various factors. Semi-structured interviews are particularly suitable when exploring complex and multifaceted topics that require full understanding. They are valuable when researchers aim to capture participants’ perspectives, experiences, and narratives in a flexible and open-ended manner. Semi-structured interviews are effective when the research objectives involve exploring diverse viewpoints, identifying patterns and themes, and gaining insights into individuals’ thoughts and emotions. Additionally, this approach is advantageous when researchers seek to establish rapport and build a collaborative relationship with participants, as it allows for meaningful and interactive conversations. The use of semi-structured interviews empowers researchers to investigate the richness of participants’ experiences while maintaining a level of versatility and adaptability in data collection.

Benefits Of Semi-Structured Interviews

Flexibility and Adaptability: Semi-structured interviews offer a balance between structure and flexibility, allowing researchers to adapt their questioning based on participant responses. This approach enables researchers to examine specific areas of interest, explore unexpected avenues, and capture nuanced information that may not emerge in rigidly structured interviews.

Participant-Centered Approach: Semi-structured interviews place participants at the center of the research process, valuing their perspectives and experiences. By creating a conversational and comfortable atmosphere, researchers can foster trust and rapport, encouraging participants to share their thoughts openly. This approach facilitates a collaborative and co-constructed knowledge-building process, capturing the complexity of participants’ lived experiences.

In-Depth Exploration: Through semi-structured interviews, researchers can delve deeply into participants’ narratives, unraveling intricate details and uncovering hidden meanings. The open-ended nature of these interviews allows for rich descriptions, personal anecdotes, and contextual insights, enabling researchers to gain a comprehensive understanding of the research topic.

Disadvantages Of Semi-Structured Interviews

While semi-structured interviews offer several benefits, it is important to consider their potential disadvantages in qualitative research. One disadvantage is the possibility of interviewer bias or influence. As the interviewer plays an active role in guiding the interview, their personal biases, assumptions, or interpretations may inadvertently shape the participants’ responses. This can compromise the objectivity of the data collected. Another challenge is the time-consuming nature of semi-structured interviews. Conducting interviews, transcribing, and analyzing the data can be a lengthy process, requiring substantial time and resources.

Also read: A Problem Called Sampling Bias

Additionally, the quality of the data obtained may depend on the interviewer’s skills and experience in conducting interviews and eliciting rich responses from participants. If the interviewer lacks proper training or expertise, the quality and depth of the data collected may be compromised. Lastly, the open-ended nature of semi-structured interviews may lead to a vast amount of qualitative data that can be challenging to analyze and interpret, requiring careful attention and rigorous analysis techniques.

Key Considerations For Conducting Semi-Structured Interviews

After confirming that a semi-structured interview aligns with the research topic, the following sequential steps are used to prepare and conduct a semi-structured interview:

Step 1: Define The Objective And Research Scope

Begin by clarifying the purpose of the semi-structured interview and why it is the most suitable research method for the study. Consider the specific knowledge or insights that are intended to be gained through the interview process.

Step 2: Develop Well-Designed Interview Questions

Craft the interview questions to be open-ended, simple, and concise. Take care with the choice of words, particularly when discussing sensitive topics. Ensure that the questions allow for participants to provide detailed and nuanced responses.

Step 3: Identify The Target Group(s) For The Interview

Determine the specific population or groups to engage with during the semi-structured interview. Depending on the size of the target group, utilize random or stratified sampling techniques to select a representative sample. Alternatively, if the group is small, the interview may be with all potential participants.

Step 4: Plan The Logistics Of The Interview

Decide on the details of how, when, and where the interview will take place. Obtain consent from participants and provide them with advance notice of the interview date, time, and location. Choose an environment conducive to open and comfortable communication.

Step 5: Conduct The Interviews

Initiate the interviews by engaging in a casual conversation to establish rapport and build trust with the participants. During face-to-face interviews, actively listen to respondents, paying attention to their non-verbal cues such as body language, gestures, and vocal changes. Maintain a non-judgmental, empathetic, and friendly demeanor throughout the interview process.

Step 6: Transcribe The Interview Recordings

Transcribe the audio or video recordings of the semi-structured interviews. Transcription converts spoken content into written form, aiding in data analysis. Seek appropriate resources or tools to assist you in effectively transcribing the interviews.

Step 7: Code And Categorize The Data

Next, analyze the data collected from the semi-structured interviews. Coding involves carefully examining the transcribed data to identify recurring patterns, themes, and categories. This process helps in organizing and making sense of the information obtained. Consider using specialized coding interview software to streamline this task.

Also read: Mastering Analysis: The Role of Codebook Qualitative Research

Step 8: Analyze The Coded Data

Once the coding process is complete, analyze the coded data to gain meaningful insights. Utilize qualitative data analysis tools, such as Delve, to explore the data more deeply and uncover valuable findings. Draw connections between themes and patterns to develop a comprehensive understanding of the interview outcomes.

Step 9: Present Findings In A Research Paper Or Report

Transform the analysis into a coherent narrative by presenting the results in a research paper or report. Communicate the story behind the data, emphasizing key insights and supporting evidence. Structure the paper to effectively convey the significance and implications of findings in relation to research objectives.

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Qualitative Interviewing

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• First Online: 13 January 2019
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• Sally Nathan 2 ,
• Christy Newman 3 &
• Kari Lancaster 3  

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Qualitative interviewing is a foundational method in qualitative research and is widely used in health research and the social sciences. Both qualitative semi-structured and in-depth unstructured interviews use verbal communication, mostly in face-to-face interactions, to collect data about the attitudes, beliefs, and experiences of participants. Interviews are an accessible, often affordable, and effective method to understand the socially situated world of research participants. The approach is typically informed by an interpretive framework where the data collected is not viewed as evidence of the truth or reality of a situation or experience but rather a context-bound subjective insight from the participants. The researcher needs to be open to new insights and to privilege the participant’s experience in data collection. The data from qualitative interviews is not generalizable, but its exploratory nature permits the collection of rich data which can answer questions about which little is already known. This chapter introduces the reader to qualitative interviewing, the range of traditions within which interviewing is utilized as a method, and highlights the advantages and some of the challenges and misconceptions in its application. The chapter also provides practical guidance on planning and conducting interview studies. Three case examples are presented to highlight the benefits and risks in the use of interviewing with different participants, providing situated insights as well as advice about how to go about learning to interview if you are a novice.

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Interviews in the social sciences

Interviewing in Qualitative Research

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Nathan, S., Newman, C., Lancaster, K. (2019). Qualitative Interviewing. In: Liamputtong, P. (eds) Handbook of Research Methods in Health Social Sciences. Springer, Singapore. https://doi.org/10.1007/978-981-10-5251-4_77

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Qualitative research method-interviewing and observation

Shazia jamshed.

Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia

Buckley and Chiang define research methodology as “a strategy or architectural design by which the researcher maps out an approach to problem-finding or problem-solving.”[ 1 ] According to Crotty, research methodology is a comprehensive strategy ‘that silhouettes our choice and use of specific methods relating them to the anticipated outcomes,[ 2 ] but the choice of research methodology is based upon the type and features of the research problem.[ 3 ] According to Johnson et al . mixed method research is “a class of research where the researcher mixes or combines quantitative and qualitative research techniques, methods, approaches, theories and or language into a single study.[ 4 ] In order to have diverse opinions and views, qualitative findings need to be supplemented with quantitative results.[ 5 ] Therefore, these research methodologies are considered to be complementary to each other rather than incompatible to each other.[ 6 ]

Qualitative research methodology is considered to be suitable when the researcher or the investigator either investigates new field of study or intends to ascertain and theorize prominent issues.[ 6 , 7 ] There are many qualitative methods which are developed to have an in depth and extensive understanding of the issues by means of their textual interpretation and the most common types are interviewing and observation.[ 7 ]

Interviewing

This is the most common format of data collection in qualitative research. According to Oakley, qualitative interview is a type of framework in which the practices and standards be not only recorded, but also achieved, challenged and as well as reinforced.[ 8 ] As no research interview lacks structure[ 9 ] most of the qualitative research interviews are either semi-structured, lightly structured or in-depth.[ 9 ] Unstructured interviews are generally suggested in conducting long-term field work and allow respondents to let them express in their own ways and pace, with minimal hold on respondents’ responses.[ 10 ]

Pioneers of ethnography developed the use of unstructured interviews with local key informants that is., by collecting the data through observation and record field notes as well as to involve themselves with study participants. To be precise, unstructured interview resembles a conversation more than an interview and is always thought to be a “controlled conversation,” which is skewed towards the interests of the interviewer.[ 11 ] Non-directive interviews, form of unstructured interviews are aimed to gather in-depth information and usually do not have pre-planned set of questions.[ 11 ] Another type of the unstructured interview is the focused interview in which the interviewer is well aware of the respondent and in times of deviating away from the main issue the interviewer generally refocuses the respondent towards key subject.[ 11 ] Another type of the unstructured interview is an informal, conversational interview, based on unplanned set of questions that are generated instantaneously during the interview.[ 11 ]

In contrast, semi-structured interviews are those in-depth interviews where the respondents have to answer preset open-ended questions and thus are widely employed by different healthcare professionals in their research. Semi-structured, in-depth interviews are utilized extensively as interviewing format possibly with an individual or sometimes even with a group.[ 6 ] These types of interviews are conducted once only, with an individual or with a group and generally cover the duration of 30 min to more than an hour.[ 12 ] Semi-structured interviews are based on semi-structured interview guide, which is a schematic presentation of questions or topics and need to be explored by the interviewer.[ 12 ] To achieve optimum use of interview time, interview guides serve the useful purpose of exploring many respondents more systematically and comprehensively as well as to keep the interview focused on the desired line of action.[ 12 ] The questions in the interview guide comprise of the core question and many associated questions related to the central question, which in turn, improve further through pilot testing of the interview guide.[ 7 ] In order to have the interview data captured more effectively, recording of the interviews is considered an appropriate choice but sometimes a matter of controversy among the researcher and the respondent. Hand written notes during the interview are relatively unreliable, and the researcher might miss some key points. The recording of the interview makes it easier for the researcher to focus on the interview content and the verbal prompts and thus enables the transcriptionist to generate “verbatim transcript” of the interview.

Similarly, in focus groups, invited groups of people are interviewed in a discussion setting in the presence of the session moderator and generally these discussions last for 90 min.[ 7 ] Like every research technique having its own merits and demerits, group discussions have some intrinsic worth of expressing the opinions openly by the participants. On the contrary in these types of discussion settings, limited issues can be focused, and this may lead to the generation of fewer initiatives and suggestions about research topic.

Observation

Observation is a type of qualitative research method which not only included participant's observation, but also covered ethnography and research work in the field. In the observational research design, multiple study sites are involved. Observational data can be integrated as auxiliary or confirmatory research.[ 11 ]

Research can be visualized and perceived as painstaking methodical efforts to examine, investigate as well as restructure the realities, theories and applications. Research methods reflect the approach to tackling the research problem. Depending upon the need, research method could be either an amalgam of both qualitative and quantitative or qualitative or quantitative independently. By adopting qualitative methodology, a prospective researcher is going to fine-tune the pre-conceived notions as well as extrapolate the thought process, analyzing and estimating the issues from an in-depth perspective. This could be carried out by one-to-one interviews or as issue-directed discussions. Observational methods are, sometimes, supplemental means for corroborating research findings.

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• Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

• P. Gill 1 &
• J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

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Determinants of behaviour and their efficacy as targets of behavioural change interventions

Principal component analysis

Interviews in the social sciences

Introduction.

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

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Gill, P., Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J 225 , 668–672 (2018). https://doi.org/10.1038/sj.bdj.2018.815

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Issue Date : 12 October 2018

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• Volume 7, Issue 2
• Semistructured interviewing in primary care research: a balance of relationship and rigour
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• http://orcid.org/0000-0002-2660-3358 Melissa DeJonckheere 1 and
• Lisa M Vaughn 2 , 3
• 1 Department of Family Medicine , University of Michigan , Ann Arbor , Michigan , USA
• 2 Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , Ohio , USA
• 3 Division of Emergency Medicine , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
• Correspondence to Dr Melissa DeJonckheere; mdejonck{at}med.umich.edu

Semistructured in-depth interviews are commonly used in qualitative research and are the most frequent qualitative data source in health services research. This method typically consists of a dialogue between researcher and participant, guided by a flexible interview protocol and supplemented by follow-up questions, probes and comments. The method allows the researcher to collect open-ended data, to explore participant thoughts, feelings and beliefs about a particular topic and to delve deeply into personal and sometimes sensitive issues. The purpose of this article was to identify and describe the essential skills to designing and conducting semistructured interviews in family medicine and primary care research settings. We reviewed the literature on semistructured interviewing to identify key skills and components for using this method in family medicine and primary care research settings. Overall, semistructured interviewing requires both a relational focus and practice in the skills of facilitation. Skills include: (1) determining the purpose and scope of the study; (2) identifying participants; (3) considering ethical issues; (4) planning logistical aspects; (5) developing the interview guide; (6) establishing trust and rapport; (7) conducting the interview; (8) memoing and reflection; (9) analysing the data; (10) demonstrating the trustworthiness of the research; and (11) presenting findings in a paper or report. Semistructured interviews provide an effective and feasible research method for family physicians to conduct in primary care research settings. Researchers using semistructured interviews for data collection should take on a relational focus and consider the skills of interviewing to ensure quality. Semistructured interviewing can be a powerful tool for family physicians, primary care providers and other health services researchers to use to understand the thoughts, beliefs and experiences of individuals. Despite the utility, semistructured interviews can be intimidating and challenging for researchers not familiar with qualitative approaches. In order to elucidate this method, we provide practical guidance for researchers, including novice researchers and those with few resources, to use semistructured interviewing as a data collection strategy. We provide recommendations for the essential steps to follow in order to best implement semistructured interviews in family medicine and primary care research settings.

• qualitative research

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https://doi.org/10.1136/fmch-2018-000057

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Introduction

Semistructured interviews can be used by family medicine researchers in clinical settings or academic settings even with few resources. In contrast to large-scale epidemiological studies, or even surveys, a family medicine researcher can conduct a highly meaningful project with interviews with as few as 8–12 participants. For example, Chang and her colleagues, all family physicians, conducted semistructured interviews with 10 providers to understand their perspectives on weight gain in pregnant patients. 1 The interviewers asked questions about providers’ overall perceptions on weight gain, their clinical approach to weight gain during pregnancy and challenges when managing weight gain among pregnant patients. Additional examples conducted by or with family physicians or in primary care settings are summarised in table 1 . 1–6

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Examples of research articles using semistructured interviews in primary care research

From our perspective as seasoned qualitative researchers, conducting effective semistructured interviews requires: (1) a relational focus, including active engagement and curiosity, and (2) practice in the skills of interviewing. First, a relational focus emphasises the unique relationship between interviewer and interviewee. To obtain quality data, interviews should not be conducted with a transactional question-answer approach but rather should be unfolding, iterative interactions between the interviewer and interviewee. Second, interview skills can be learnt. Some of us will naturally be more comfortable and skilful at conducting interviews but all aspects of interviews are learnable and through practice and feedback will improve. Throughout this article, we highlight strategies to balance relationship and rigour when conducting semistructured interviews in primary care and the healthcare setting.

Qualitative research interviews are ‘attempts to understand the world from the subjects’ point of view, to unfold the meaning of peoples’ experiences, to uncover their lived world prior to scientific explanations’ (p 1). 7 Qualitative research interviews unfold as an interviewer asks questions of the interviewee in order to gather subjective information about a particular topic or experience. Though the definitions and purposes of qualitative research interviews vary slightly in the literature, there is common emphasis on the experiences of interviewees and the ways in which the interviewee perceives the world (see table 2 for summary of definitions from seminal texts).

Definitions of qualitative interviews

The most common type of interview used in qualitative research and the healthcare context is semistructured interview. 8 Figure 1 highlights the key features of this data collection method, which is guided by a list of topics or questions with follow-up questions, probes and comments. Typically, the sequencing and wording of the questions are modified by the interviewer to best fit the interviewee and interview context. Semistructured interviews can be conducted in multiple ways (ie, face to face, telephone, text/email, individual, group, brief, in-depth), each of which have advantages and disadvantages. We will focus on the most common form of semistructured interviews within qualitative research—individual, face-to-face, in-depth interviews.

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Key characteristics of semistructured interviews.

Purpose of semistructured interviews

The overall purpose of using semistructured interviews for data collection is to gather information from key informants who have personal experiences, attitudes, perceptions and beliefs related to the topic of interest. Researchers can use semistructured interviews to collect new, exploratory data related to a research topic, triangulate other data sources or validate findings through member checking (respondent feedback about research results). 9 If using a mixed methods approach, semistructured interviews can also be used in a qualitative phase to explore new concepts to generate hypotheses or explain results from a quantitative phase that tests hypotheses. Semistructured interviews are an effective method for data collection when the researcher wants: (1) to collect qualitative, open-ended data; (2) to explore participant thoughts, feelings and beliefs about a particular topic; and (3) to delve deeply into personal and sometimes sensitive issues.

Designing and conducting semistructured interviews

In the following section, we provide recommendations for the steps required to carefully design and conduct semistructured interviews with emphasis on applications in family medicine and primary care research (see table 3 ).

Steps to designing and conducting semistructured interviews

Steps for designing and conducting semistructured interviews

Step 1: determining the purpose and scope of the study.

The purpose of the study is the primary objective of your project and may be based on an anecdotal experience, a review of the literature or previous research finding. The purpose is developed in response to an identified gap or problem that needs to be addressed.

Research questions are the driving force of a study because they are associated with every other aspect of the design. They should be succinct and clearly indicate that you are using a qualitative approach. Qualitative research questions typically start with ‘What’, ‘How’ or ‘Why’ and focus on the exploration of a single concept based on participant perspectives. 10

Step 2: identifying participants

After deciding on the purpose of the study and research question(s), the next step is to determine who will provide the best information to answer the research question. Good interviewees are those who are available, willing to be interviewed and have lived experiences and knowledge about the topic of interest. 11 12 Working with gatekeepers or informants to get access to potential participants can be extremely helpful as they are trusted sources that control access to the target sample.

Sampling strategies are influenced by the research question and the purpose of the study. Unlike quantitative studies, statistical representativeness is not the goal of qualitative research. There is no calculation of statistical power and the goal is not a large sample size. Instead, qualitative approaches seek an in-depth and detailed understanding and typically use purposeful sampling. See the study of Hatch for a summary of various types of purposeful sampling that can be used for interview studies. 12

‘How many participants are needed?’ The most common answer is, ‘it depends’—it depends on the purpose of the study, what kind of study is planned and what questions the study is trying to answer. 12–14 One common standard in qualitative sample sizes is reaching thematic saturation, which refers to the point at which no new thematic information is gathered from participants. Malterud and colleagues discuss the concept of information power , or a qualitative equivalent to statistical power, to determine how many interviews should be collected in a study. They suggest that the size of a sample should depend on the aim, homogeneity of the sample, theory, interview quality and analytic strategy. 14

Step 3: considering ethical issues

An ethical attitude should be present from the very beginning of the research project even before you decide who to interview. 15 This ethical attitude should incorporate respect, sensitivity and tact towards participants throughout the research process. Because semistructured interviewing often requires the participant to reveal sensitive and personal information directly to the interviewer, it is important to consider the power imbalance between the researcher and the participant. In healthcare settings, the interviewer or researcher may be a part of the patient’s healthcare team or have contact with the healthcare team. The researchers should ensure the interviewee that their participation and answers will not influence the care they receive or their relationship with their providers. Other issues to consider include: reducing the risk of harm; protecting the interviewee’s information; adequately informing interviewees about the study purpose and format; and reducing the risk of exploitation. 10

Step 4: planning logistical aspects

Careful planning particularly around the technical aspects of interviews can be the difference between a great interview and a not so great interview. During the preparation phase, the researcher will need to plan and make decisions about the best ways to contact potential interviewees, obtain informed consent, arrange interview times and locations convenient for both participant and researcher, and test recording equipment. Although many experienced researchers have found themselves conducting interviews in less than ideal locations, the interview location should avoid (or at least minimise) interruptions and be appropriate for the interview (quiet, private and able to get a clear recording). 16 For some research projects, the participants’ homes may make sense as the best interview location. 16

Initial contacts can be made through telephone or email and followed up with more details so the individual can make an informed decision about whether they wish to be interviewed. Potential participants should know what to expect in terms of length of time, purpose of the study, why they have been selected and who will be there. In addition, participants should be informed that they can refuse to answer questions or can withdraw from the study at any time, including during the interview itself.

Audio recording the interview is recommended so that the interviewer can concentrate on the interview and build rapport rather than being distracted with extensive note taking 16 (see table 4 for audio-recording tips). Participants should be informed that audio recording is used for data collection and that they can refuse to be audio recorded should they prefer.

Suggestions for successful audio recording of interviews

Most researchers will want to have interviews transcribed verbatim from the audio recording. This allows you to refer to the exact words of participants during the analysis. Although it is possible to conduct analyses from the audio recordings themselves or from notes, it is not ideal. However, transcription can be extremely time consuming and, if not done yourself, can be costly.

In the planning phase of research, you will want to consider whether qualitative research software (eg, NVivo, ATLAS.ti, MAXQDA, Dedoose, and so on) will be used to assist with organising, managing and analysis. While these tools are helpful in the management of qualitative data, it is important to consider your research budget, the cost of the software and the learning curve associated with using a new system.

Step 5: developing the interview guide

Semistructured interviews include a short list of ‘guiding’ questions that are supplemented by follow-up and probing questions that are dependent on the interviewee’s responses. 8 17 All questions should be open ended, neutral, clear and avoid leading language. In addition, questions should use familiar language and avoid jargon.

Most interviews will start with an easy, context-setting question before moving to more difficult or in-depth questions. 17 Table 5 gives details of the types of guiding questions including ‘grand tour’ questions, 18 core questions and planned and unplanned follow-up questions.

Questions and prompts in semistructured interviewing

To illustrate, online supplementary appendix A presents a sample interview guide from our study of weight gain during pregnancy among young women. We start with the prompt, ‘Tell me about how your pregnancy has been so far’ to initiate conversation about their thoughts and feelings during pregnancy. The subsequent questions will elicit responses to help answer our research question about young women’s perspectives related to weight gain during pregnancy.

Supplemental material

After developing the guiding questions, it is important to pilot test the interview. Having a good sense of the guide helps you to pace the interview (and not run out of time), use a conversational tone and make necessary adjustments to the questions.

Like all qualitative research, interviewing is iterative in nature—data collection and analysis occur simultaneously, which may result in changes to the guiding questions as the study progresses. Questions that are not effective may be replaced with other questions and additional probes can be added to explore new topics that are introduced by participants in previous interviews. 10

Step 6: establishing trust and rapport

Interviews are a special form of relationship, where the interviewer and interviewee converse about important and often personal topics. The interviewer must build rapport quickly by listening attentively and respectfully to the information shared by the interviewee. 19 As the interview progresses, the interviewer must continue to demonstrate respect, encourage the interviewee to share their perspectives and acknowledge the sensitive nature of the conversation. 20

To establish rapport, it is important to be authentic and open to the interviewee’s point of view. It is possible that the participants you recruit for your study will have preconceived notions about research, which may include mistrust. As a result, it is important to describe why you are conducting the research and how their participation is meaningful. In an interview relationship, the interviewee is the expert and should be treated as such—you are relying on the interviewee to enhance your understanding and add to your research. Small behaviours that can enhance rapport include: dressing professionally but not overly formal; avoiding jargon or slang; and using a normal conversational tone. Because interviewees will be discussing their experience, having some awareness of contextual or cultural factors that may influence their perspectives may be helpful as background knowledge.

Step 7: conducting the interview

Location and set-up.

The interview should have already been scheduled at a convenient time and location for the interviewee. The location should be private, ideally with a closed door, rather than a public place. It is helpful if there is a room where you can speak privately without interruption, and where it is quiet enough to hear and audio record the interview. Within the interview space, Josselson 15 suggests an arrangement with a comfortable distance between the interviewer and interviewee with a low table in between for the recorder and any materials (consent forms, questionnaires, water, and so on).

Beginning the interview

Many interviewers start with chatting to break the ice and attempt to establish commonalities, rapport and trust. Most interviews will need to begin with a brief explanation of the research study, consent/assent procedures, rationale for talking to that particular interviewee and description of the interview format and agenda. 11 It can also be helpful if the interviewer shares a little about who they are and why they are interested in the topic. The recording equipment should have already been tested thoroughly but interviewers may want to double-check that the audio equipment is working and remind participants about the reason for recording.

Interviewer stance

During the interview, the interviewer should adopt a friendly and non-judgemental attitude. You will want to maintain a warm and conversational tone, rather than a rote, question-answer approach. It is important to recognise the potential power differential as a researcher. Conveying a sense of being in the interview together and that you as the interviewer are a person just like the interviewee can help ease any discomfort. 15

Active listening

During a face-to-face interview, there is an opportunity to observe social and non-verbal cues of the interviewee. These cues may come in the form of voice, body language, gestures and intonation, and can supplement the interviewee’s verbal response and can give clues to the interviewer about the process of the interview. 21 Listening is the key to successful interviewing. 22 Listening should be ‘attentive, empathic, nonjudgmental, listening in order to invite, and engender talk’ 15 15 (p 66). Silence, nods, smiles and utterances can also encourage further elaboration from the interviewee.

Continuing the interview

As the interview progresses, the interviewer can repeat the words used by the interviewee, use planned and unplanned follow-up questions that invite further clarification, exploration or elaboration. As DiCicco-Bloom and Crabtree 10 explain: ‘Throughout the interview, the goal of the interviewer is to encourage the interviewee to share as much information as possible, unselfconsciously and in his or her own words’ (p 317). Some interviewees are more forthcoming and will offer many details of their experiences without much probing required. Others will require prompting and follow-up to elicit sufficient detail.

As a result, follow-up questions are equally important to the core questions in a semistructured interview. Prompts encourage people to continue talking and they can elicit more details needed to understand the topic. Examples of verbal probes are repeating the participant’s words, summarising the main idea or expressing interest with verbal agreement. 8 11 See table 6 for probing techniques and example probes we have used in our own interviewing.

Probing techniques for semistructured interviews (modified from Bernard 30 )

Step 8: memoing and reflection

After an interview, it is essential for the interviewer to begin to reflect on both the process and the content of the interview. During the actual interview, it can be difficult to take notes or begin reflecting. Even if you think you will remember a particular moment, you likely will not be able to recall each moment with sufficient detail. Therefore, interviewers should always record memos —notes about what you are learning from the data. 23 24 There are different approaches to recording memos: you can reflect on several specific ideas, or create a running list of thoughts. Memos are also useful for improving the quality of subsequent interviews.

Step 9: analysing the data

The data analysis strategy should also be developed during planning stages because analysis occurs concurrently with data collection. 25 The researcher will take notes, modify the data collection procedures and write reflective memos throughout the data collection process. This begins the process of data analysis.

The data analysis strategy used in your study will depend on your research question and qualitative design—see the study of Creswell for an overview of major qualitative approaches. 26 The general process for analysing and interpreting most interviews involves reviewing the data (in the form of transcripts, audio recordings or detailed notes), applying descriptive codes to the data and condensing and categorising codes to look for patterns. 24 27 These patterns can exist within a single interview or across multiple interviews depending on the research question and design. Qualitative computer software programs can be used to help organise and manage interview data.

Step 10: demonstrating the trustworthiness of the research

Similar to validity and reliability, qualitative research can be assessed on trustworthiness. 9 28 There are several criteria used to establish trustworthiness: credibility (whether the findings accurately and fairly represent the data), transferability (whether the findings can be applied to other settings and contexts), confirmability (whether the findings are biased by the researcher) and dependability (whether the findings are consistent and sustainable over time).

Step 11: presenting findings in a paper or report

When presenting the results of interview analysis, researchers will often report themes or narratives that describe the broad range of experiences evidenced in the data. This involves providing an in-depth description of participant perspectives and being sure to include multiple perspectives. 12 In interview research, the participant words are your data. Presenting findings in a report requires the integration of quotes into a more traditional written format.

Conclusions

Though semistructured interviews are often an effective way to collect open-ended data, there are some disadvantages as well. One common problem with interviewing is that not all interviewees make great participants. 12 29 Some individuals are hard to engage in conversation or may be reluctant to share about sensitive or personal topics. Difficulty interviewing some participants can affect experienced and novice interviewers. Some common problems include not doing a good job of probing or asking for follow-up questions, failure to actively listen, not having a well-developed interview guide with open-ended questions and asking questions in an insensitive way. Outside of pitfalls during the actual interview, other problems with semistructured interviewing may be underestimating the resources required to recruit participants, interview, transcribe and analyse the data.

Despite their limitations, semistructured interviews can be a productive way to collect open-ended data from participants. In our research, we have interviewed children and adolescents about their stress experiences and coping behaviours, young women about their thoughts and behaviours during pregnancy, practitioners about the care they provide to patients and countless other key informants about health-related topics. Because the intent is to understand participant experiences, the possible research topics are endless.

Due to the close relationships family physicians have with their patients, the unique settings in which they work, and in their advocacy, semistructured interviews are an attractive approach for family medicine researchers, even if working in a setting with limited research resources. When seeking to balance both the relational focus of interviewing and the necessary rigour of research, we recommend: prioritising listening over talking; using clear language and avoiding jargon; and deeply engaging in the interview process by actively listening, expressing empathy, demonstrating openness to the participant’s worldview and thanking the participant for helping you to understand their experience.

Further Reading

Edwards R, & Holland J. (2013). What is qualitative interviewing?: A&C Black.

Josselson R. Interviewing for qualitative inquiry: A relational approach. Guilford Press, 2013.

Kvale S. InterViews: An Introduction to Qualitative Research Interviewing. SAGE, London, 1996.

Pope C, & Mays N. (Eds). (2006). Qualitative research in health care.

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Contributors Both authors contributed equally to this work.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; internally peer reviewed.

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• Open access
• Published: 22 May 2024

Preparedness for a first clinical placement in nursing: a descriptive qualitative study

• Philippa H. M. Marriott 1 ,
• Jennifer M. Weller-Newton 2   nAff3 &
• Katharine J. Reid 4  

BMC Nursing volume  23 , Article number:  345 ( 2024 ) Cite this article

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A first clinical placement for nursing students is a challenging period involving translation of theoretical knowledge and development of an identity within the healthcare setting; it is often a time of emotional vulnerability. It can be a pivotal moment for ambivalent nursing students to decide whether to continue their professional training. To date, student expectations prior to their first clinical placement have been explored in advance of the experience or gathered following the placement experience. However, there is a significant gap in understanding how nursing students’ perspectives about their first clinical placement might change or remain consistent following their placement experiences. Thus, the study aimed to explore first-year nursing students’ emotional responses towards and perceptions of their preparedness for their first clinical placement and to examine whether initial perceptions remain consistent or change during the placement experience.

The research utilised a pre-post qualitative descriptive design. Six focus groups were undertaken before the first clinical placement (with up to four participants in each group) and follow-up individual interviews ( n  = 10) were undertaken towards the end of the first clinical placement with first-year entry-to-practice postgraduate nursing students. Data were analysed thematically.

Three main themes emerged: (1) adjusting and managing a raft of feelings, encapsulating participants’ feelings about learning in a new environment and progressing from academia to clinical practice; (2) sinking or swimming, comprising students’ expectations before their first clinical placement and how these perceptions are altered through their clinical placement experience; and (3) navigating placement, describing relationships between healthcare staff, patients, and peers.

Conclusions

This unique study of first-year postgraduate entry-to-practice nursing students’ perspectives of their first clinical placement adds to the extant knowledge. By examining student experience prior to and during their first clinical placement experience, it is possible to explore the consistency and change in students’ narratives over the course of an impactful experience. Researching the narratives of nursing students embarking on their first clinical placement provides tertiary education institutions with insights into preparing students for this critical experience.

Peer Review reports

First clinical placements enable nursing students to develop their professional identity through initial socialisation, and where successful, first clinical placement experiences can motivate nursing students to persist with their studies [ 1 , 2 , 3 , 4 ]. Where the transition from the tertiary environment to learning in the healthcare workplace is turbulent, it may impact nursing students’ learning, their confidence and potentially increase attrition rates from educational programs [ 2 , 5 , 6 ]. Attrition from preregistration nursing courses is a global concern, with the COVID-19 pandemic further straining the nursing workforce; thus, the supply of nursing professionals is unlikely to meet demand [ 7 ]. The COVID-19 pandemic has also impacted nursing education, with student nurses augmenting the diminishing nursing workforce [ 7 , 8 ].

The first clinical placement often triggers immense anxiety and fear for nursing students [ 9 , 10 ]. Research suggests that among nursing students, anxiety arises from perceived knowledge deficiencies, role ambiguity, the working environment, caring for ‘real’ people, potentially causing harm, exposure to nudity and death, and ‘not fitting in’ [ 2 , 3 , 11 ]. These stressors are reported internationally and often relate to inadequate preparation for entering the clinical environment [ 2 , 10 , 12 ]. Previous research suggests that high anxiety before the first clinical placement can be related to factors likely to affect patient outcomes, such as self-confidence and efficacy [ 13 ]. High anxiety during clinical placement may impair students’ capacity to learn, thus compromising the value of the clinical environment for learning [ 10 ].

The first clinical placement often occurs soon after commencing nursing training and can challenge students’ beliefs, philosophies, and preconceived ideas about nursing. An experience of cultural or ‘reality’ shock often arises when entering the healthcare setting, creating dissonance between reality and expectations [ 6 , 14 ]. These experiences may be exacerbated by tertiary education providers teaching of ‘ideal’ clinical practice [ 2 , 6 ]. The perceived distance between theoretical knowledge and what is expected in a healthcare placement, as opposed to what occurs on clinical placement, has been well documented as the theory-practice gap or an experience of cognitive dissonance [ 2 , 3 ].

Given the pivotal role of the first clinical placement in nursing students’ trajectories to nursing practice, it is important to understand students’ experiences and to explore how the placement experience shapes initial perceptions. Existing research focusses almost entirely either on describing nursing students’ projected emotions and perceptions prior to undertaking a first clinical placement [ 3 ] or examines student perceptions of reflecting on a completed first placement [ 15 ]. We wished to examine consistency and change in student perception of their first clinical placement by tracking their experiences longitudinally. We focused on a first clinical placement undertaken in a Master of Nursing Science. This two-year postgraduate qualification provides entry-to-practice nursing training for students who have completed any undergraduate qualification. The first clinical placement component of the course aimed to orient students to the clinical environment, support students to acquire skills and develop their clinical reasoning through experiential learning with experienced nursing mentors.

This paper makes a significant contribution to understanding how nursing students’ perceptions might develop over time because of their clinical placement experiences. Our research addresses a further gap in the existing literature, by focusing on students completing an accelerated postgraduate two-year entry-to-practice degree open to students with any prior undergraduate degree. Thus, the current research aimed to understand nursing students’ emotional responses and expectations and their perceptions of preparedness before attending their first clinical placement and to contrast these initial perceptions with their end-of-placement perspectives.

Study design

A descriptive qualitative study was undertaken, utilising a pre- and post-design for data collection. Focus groups with first-year postgraduate entry-to-practice nursing students were conducted before the first clinical placement, with individual semi-structured interviews undertaken during the first clinical placement.

Setting and participants

All first-year students enrolled in the two-year Master of Nursing Science program ( n  = 190) at a tertiary institution in Melbourne, Australia, were eligible to participate. There were no exclusion criteria. At the time of this study, students were enrolled in a semester-long subject focused on nursing assessment and care. They studied the theoretical underpinnings of nursing and science, theoretical and practical nursing clinical skills and Indigenous health over the first six weeks of the course. Students completed a preclinical assessment as a hurdle before commencing a three-week clinical placement in a hospital setting, a subacute or acute environment. Overall, the clinical placement aimed to provide opportunities for experiential learning, skill acquisition, development of clinical reasoning skills and professional socialisation [ 16 , 17 ].

In total, sixteen students participated voluntarily in a focus group of between 60 and 90 min duration; ten of these students also participated in individual interviews of between 30 and 60 min duration, a number sufficient to reach data saturation. Table  1 shows the questions used in the focus groups conducted before clinical placement commenced and the questions for the semi-structured interview questions conducted during clinical placement. Study participants’ undergraduate qualifications included bachelor’s degrees in science, arts and business. A small number of participants had previous healthcare experience (e.g. as healthcare assistants). The participants attended clinical placement in the Melbourne metropolitan, Victorian regional and rural hospital locations.

Data collection

The study comprised two phases. The first phase comprised six focus groups prior to the first clinical placement, and the second phase comprised ten individual semi-structured interviews towards the end of the first clinical placement. Focus groups (with a maximum of four participants) and individual interviews were conducted by the lead author online via Zoom and were audio-recorded. Capping group size to a relatively small number considered diversity of perceptions and opportunities for participants to share their insights and to confirm or contradict their peers, particularly in the online environment [ 18 , 19 ].

Focus groups and interview questions were developed with reference to relevant literature, piloted with volunteer final-year nursing students, and then verified with the coauthors. All focus groups and interviewees received the same structured questions (Table  1 ) to ensure consistency and to facilitate comparison across the placement experience in the development of themes. Selective probing of interviewees’ responses for clarification to gain in-depth responses was undertaken. Nonverbal cues, impressions, or observations were noted.

The lead author was a registered nurse who had a clinical teaching role within the nursing department and was responsible for coordinating clinical placement experiences. To ensure rigour during the data collection process, the lead author maintained a reflective account, exploring her experiences of the discussions, reflecting on her interactions with participants as a researcher and as a clinical educator, and identifying areas for improvement (for instance allowing participants to tell their stories with fewer prompts). These reflections in conjunction with regular discussion with the other authors throughout the data collection period, aided in identifying any researcher biases, feelings and thoughts that possibly influenced the research [ 20 ].

To maintain rigour during the data analysis phase, we adhered to a systematic process involving input from all authors to code the data and to identify, refine and describe the themes and subthemes reported in this work. This comprehensive analytic process, reported in detail in the following section, was designed to ensure that the findings arising from this research were derived from a rigorous approach to analysing the data.

Data analysis

Focus groups and interviews were transcribed using the online transcription service Otter ( https://otter.ai/ ) and then checked and anonymised by the first author. Preliminary data analysis was carried out simultaneously by the first author using thematic content analysis proposed by Braun and Clarke [ 21 ] using NVivo 12 software [ 22 ]. All three authors undertook a detailed reading of the first three transcripts from both the focus groups and interviews and independently identified major themes. This preliminary coding was used as the basis of a discussion session to identify common themes between authors, to clarify sources of disagreement and to establish guidelines for further coding. Subsequent coding of the complete data set by the lead author identified a total of 533 descriptive codes; no descriptive code was duplicated across the themes. Initially, the descriptive codes were grouped into major themes identified from the literature, but with further analysis, themes emerged that were unique to the current study.

The research team met frequently during data analysis to discuss the initial descriptive codes, to confirm the major themes and subthemes, to revise themes on which there was disagreement and to identify any additional themes. Samples of quotes were reviewed by the second and third authors to decide whether these quotes were representative of the identified themes. The process occurred iteratively to refine the thematic categories, to discuss the definitions of each theme and to identify exemplar quotes.

Ethical considerations

The lead author was a clinical teacher and the clinical placement coordinator in the nursing department at the time of the study. Potential risks of perceived coercion and power imbalances were identified because of the lead author’s dual roles as an academic and as a researcher. To manage these potential risks, an academic staff member who was not part of the research study informed students about the study during a face-to-face lecture and ensured that all participants received a plain language statement identifying the lead author’s role and how perceived conflicts of interest would be managed. These included the lead author not undertaking any teaching or assessment role for the duration of the study and ensuring that placement allocations were completed prior to undertaking recruitment for the study. All students who participated in the study provided informed written consent. No financial or other incentives were offered. Approval to conduct the study was granted by the University of Melbourne Human Research Ethics Committee (Ethics ID 1955997.1).

Three main themes emerged describing students’ feelings and perceptions of their first clinical placement. In presenting the findings, before or during has been assigned to participants’ quotes to clarify the timing of students’ perspectives related to the clinical placement.

Major theme 1: Adjusting and managing a raft of feelings

The first theme encompassed the many positive and negative feelings about work-integrated learning expressed by participants before and during their clinical placement. Positive feelings before clinical placement were expressed by participants who were comfortable with the unknown and cautiously optimistic.

I am ready to just go with the flow, roll with the punches (Participant [P]1 before).

Overwhelmingly, however, the majority of feelings and thoughts anticipating the first clinical placement were negatively oriented. Students who expressed feelings of fear, anxiety, lack of knowledge, lack of preparedness, uncertainty about nursing as a career, or strong concerns about being a burden were all classified as conveying negative feelings. These negative feelings were categorised into four subthemes.

Subtheme 1.1 I don’t have enough knowledge

All participants expressed some concerns and anxiety before their first clinical placement. These encompassed concerns about knowledge inadequacy and were linked to a perception of under preparedness. Participants’ fears related to harming patients, responsibility for managing ‘real’ people, medication administration, and incomplete understanding of the language and communication skills within a healthcare setting. Anxiety for many participants merged with the logistics and management of their life during the clinical placement.

I’m scared that they will assume that I have more knowledge than I do (P3 before). I feel quite similar with P10, especially when she said fear of unknown and fear that she might do something wrong (P9 before).

Subtheme 1.2 Worry about judgment, being seen through that lens

Participants voiced concerns that they would be judged negatively by patients or healthcare staff because they perceived that the student nurse belonged to specific social groups related to their cultural background, ethnicity or gender. Affiliation with these groups contributed to students’ sense of self or identity, with students often describing such groups as a community. Before the clinical placement, participants worried that such judgements would impact the support they received on placement and their ability to deliver patient care.

Some older patients might prefer to have nurses from their own background, their own ethnicity, how they would react to me, or if racism is involved (P10 before). I just don’t want to reinforce like, whatever negative perceptions people might have of that community (P16 before).

Participants’ concerns prior to the first clinical placement about judgement or poor treatment because of patients’ preconceived ideas about specific ethnic groups did not eventuate.

I mean, it didn’t really feel like very much of a thing once I was actually there. It is one of those things you stress about, and it does not really amount to anything (P16 during).

Some students’ placement experiences revealed the positive benefits of their cultural background to enhancing patient care. One student affirmed that the placement experience reinforced their commitment to nursing and that this was related to their ability to communicate with patients whose first language was not English.

Yeah, definitely. Like, I can speak a few dialects. You know, I can actually see a difference with a lot of the non-English speaking background people. As soon as you, as soon as they’re aware that you’re trying and you’re trying to speak your language, they, they just open up. Yeah, yes. And it improves the care (P10 during).

However, a perceived lack of judgement was sometimes attributed to wearing the full personal protective equipment required during the COVID-19 pandemic, which meant that their personal features were largely obscured. For this reason, it was more difficult for patients to make assumptions or attributions about students’ ethnic or gender identity based on their appearance.

People tend to assume and call us all girls, which was irritating. It was mostly just because all of us were so covered up, no one could see anyone’s faces (P16 during).

Subtheme 1.3 Is nursing really for me?

Prior to their first clinical placement experience, many participants expressed ambivalence about a nursing career and anticipated that undertaking clinical placement could determine their suitability for the profession. Once exposed to clinical placement, the majority of students were completely committed to their chosen profession, with a minority remaining ambivalent or, in rare cases, choosing to leave the course. Not yet achieving full commitment to a nursing career was related to not wishing to work in the ward they had for their clinical placement, while remaining open to trying different specialities.

I didn’t have an actual idea of what I wanted to do after arts, this wasn’t something that I was aiming towards specifically (P14 before). I think I’m still not 100%, but enough to go on, that I’m happy to continue the course as best as I can (P11 during).

Subtheme 1.4 Being a burden

Before clinical placement, participants had concerns about being burdensome and how this would affect their clinical placement experiences.

If we end up being a burden to them, an extra responsibility for them on top of their day, then we might not be treated as well (P10 before).

A sense of burden remained a theme during the clinical placement for participants for the first five to seven days, after which most participants acknowledged that their role became more active. As students contributed more productively to their placement, their feelings of being a burden reduced.

Major theme 2: Sinking or swimming

The second major theme, sinking or swimming, described participants’ expectations about a successful placement experience and identified themes related to students’ successes (‘swimming’) or difficulties (‘sinking’) during their placement experience. Prior to clinical placement, without a realistic preview of what the experience might entail, participants were uncertain of their role, hoped for ‘nice’ supervising nurses and anticipated an observational role that would keep them afloat.

I will focus on what I want to learn and see if that coincides with what is expected, I guess (P15 before).

During the clinical placement, the reality was very different, with a sense of sinking. Participants discovered, some with shock, that they were expected to participate actively in the healthcare team.

I got the sense that they were not going to muck around, and, you know, they’re ‘gonna’ use the free labour that came with me (P1 during).

Adding to the confusion about the expected placement experience, participants believed that healthcare staff were unclear about students’ scope of practice for a postgraduate entry-to-practice degree, creating misalignment between students’ and supervising nurses’ expectations.

It seems to me like the educators don’t really seem to have a clear picture of what the scope is, and what is actually required or expected of us (P10 during).

In exploring perceived expectations of the clinical placement and the modifying effect of placement on initial expectations, three subthemes were identified: translation to practice is overwhelming, trying to find the rhythm or jigsaw pieces, and individual agency.

Subtheme 2.1 Translation to practice is overwhelming

Before clinical placement, participants described concerns about insufficient knowledge to enable them to engage effectively with the placement experience.

If I am doing an assessment understanding what are those indications and why I would be doing it or not doing it at a certain time (P1 before).

Integrating and applying theoretical content while navigating an unfamiliar clinical environment created a significant gap between theory and practice during clinical placement. As the clinical placement experience proceeded and initial fears dissipated, students became more aware of applying their theoretical knowledge in the clinical context.

We’re learning all this theory and clinical stuff, but then we don’t really have a realistic idea of what it’s like until we’re kind of thrown into it for three weeks (P10 during).

Subtheme 2.2 Trying to find the rhythm or the jigsaw pieces

Before clinical placement, participants described learning theory and clinical skills with contextual unfamiliarity. They had the jigsaw pieces but did not know how to assemble it; they had the music but did not know the final song. When discussing their expectations about clinical placement, the small number of participants with a healthcare background (e.g. as healthcare assistants) proposed realistic answers, whereas others struggled to answer or cited stories from friends or television. With a lack of context, feelings of unpreparedness were exacerbated. Once in the clinical environment, participants further emphasised that they could not identify what they needed to know to successfully prepare for clinical placement.

It was never really pieced together. We’ve learned bits and pieces, and then we’re putting it together ourselves (P8 during). On this course I feel it was this is how you do it, but I did not know how it was supposed to be played, I did not know the rhythm (P4 during).

Subtheme 2.3 Individual agency

Participants’ individual agency, their attitude, self-efficacy, and self-motivation affected their clinical placement experiences. Participant perceptions in advance of the clinical placement experience remained consistent with their perspectives following clinical placement. Before clinical placement, participants who were highly motivated to learn exhibited a growth mindset [ 23 ] and planned to be proactive in delivering patient care. During their clinical placement, initially positive students remained positive and optimistic about their future. Participants who believed that their first clinical placement role would be largely observational and were less proactive about applying their knowledge and skills identified boredom and a lack of learning opportunities on clinical placement.

A shadowing position, we don’t have enough skills and authority to do any work, not do any worthwhile skills (P3 before). I thought it would be a lot busier, because we’re limited with our scope, so there’s not much we can do, it’s just a bit slower than I thought (P12 during).

Individual agency appears to influence a successful first clinical placement; other factors may also be implicated but were not the focus of this study. Further research exploring the relationships between students’ age, life experience, resilience, individual agency, and the use of coping strategies during a first clinical placement would be useful.

Major theme 3: The reality of navigating placement relationships

The third main theme emphasised the reality of navigating clinical placement relationships and explored students’ relationships with healthcare staff, patients, and peers. Before clinical placement, many participants, especially those with healthcare backgrounds, expressed fears about relationships with supervising nurses. They perceived that the dynamics of the team and the healthcare workplace might influence the support they received. Several participants were nervous about attending placement on their own without peers for support, especially if the experience was challenging. Participants identified expectations of being mistreated, believing that it was unavoidable, and prepared themselves to not take it personally.

For me it’s where we’re going to land, are we going to be in a supportive, kind of nurturing environment, or is it just kind of sink or swim? (P5 before). If you don’t really trust them, you’re nervous the entire time and you’ll be like what if I get it wrong (P16 before).

Despite these concerns, students strongly emphasised the value of relationships during their first clinical placement, with these perceptions unchanged by their clinical placement experience. Where relationships were positive, participants felt empowered to be autonomous, and their self-confidence increased.

You get that that instant reaction from the patients. And that makes you feel more confident. So that really got me through the first week (P14 during). I felt like I was intruding, then as I started to build a bit of rapport with the people, and they saw that I was around, I don’t feel that as much now (P1 during).

Such development hinged on the receptiveness and support of supervising nurses, the team on the ward, and patients and could be hindered by poor relationships.

He was the old-style buddy nurse in his fifties, every time I questioned him, he would go ssshh, just listen, no questions, it was very stressful (P10 during). It depends whether the buddy sees us as an extra pair of hands, or we’re learners (P11 during).

Where students experienced poor behaviour from supervising nurses, they described a range of emotional responses to these interactions and also coping strategies including avoiding unfriendly staff and actively seeking out those who were more inclusive.

If they weren’t very nice, it wouldn’t be very enjoyable and if they didn’t trust you, then it would be a bit frustrating, that like I can do this, but you won’t let me (P12 during). If another nurse was not nice to me, and I was their buddy, I would literally just not buddy with them and go and follow whoever was nice to me (P4 during).

Relationships with peers were equally important; students on clinical placement with peers valued the shared experience. In contrast, students who attended clinical placement alone at a regional or rural hospital felt disconnected from the opportunities that learning with peers afforded.

Our research explored the emotional responses and perceptions of preparedness of postgraduate entry-to-practice nursing students prior to and during their first clinical placement. In this study, we described how the perceptions of nursing students remained consistent or were modified by their clinical placement experiences. Our analysis of students’ experiences identified three major themes: adjusting and managing a raft of feelings; sinking or swimming; and the reality of navigating placement relationships. We captured similar themes identified in the literature; however, our study also identified novel aspects of nursing students’ experiences of their first clinical placement.

The key theme, adjusting and managing a raft of feelings, which encapsulates anxiety before clinical placement, is consistent with previous research. This theme included concerns in communicating with healthcare staff and managing registered nurses’ negative attitudes and expectations, in addition to an academic workload [ 11 , 24 ]. Concerns not previously identified in the literature included a fear of judgement or discrimination by healthcare staff or patients that might impact the reputation of marginalised communities. Fortunately, these initial fears largely dissipated during clinical placement. Some students discovered that a diverse cultural background was an asset during their clinical placement. Although these initial fears were ameliorated by clinical placement experiences, evidence of such fears before clinical placement is concerning. Further research to identify appropriate support for nursing students from culturally diverse or marginalised communities is warranted. For example, a Finnish study highlighted the importance of mentoring culturally diverse students, creating a pedagogical atmosphere during clinical placement and integrating cultural diversity into nursing education [ 25 ].

Preclinical expectations of being mistreated can be viewed as an unavoidable phenomenon for nursing students [ 26 ]. The existing literature highlights power imbalances and hierarchical differences within the healthcare system, where student nurses may be marginalised, disrespected, and ignored [ 9 , 27 , 28 ]. During their clinical placement, students in our study reported unintentional incivility by supervising nurses: feeling not wanted, ignored, or asked to remain quiet by supervising nurses who were unfriendly or highly critical. These findings were similar to those of Thomas et al.’s [ 29 ] UK study and were particularly heightened at the beginning of clinical placement. Several students acknowledged that nursing staff fatigue from a high turnover of students on their ward and the COVID-19 pandemic could be contributing factors. In response to such incivility, students reported decreased self-confidence and described becoming quiet and withdrawing from active participation with their patients. Students oriented their behaviour towards repetitive low-level tasks, aiming to please and help their supervising nurse, to the detriment of learning opportunities. Fortunately, these incidents did not appear to impact nursing students’ overall experience of clinical placement. Indeed, students found positive experiences with different supervising nurses and their own self-reflection assisted with coping. Other active strategies to combat incivility identified in the current study that were also identified by Thomas et al. [ 29 ] included avoiding nurses who were uncivil, asking to work with nurses who were ‘nice’ to them, and seeking out support from other staff as a coping strategy. The nursing students in our study were undertaking a postgraduate entry-to-practice qualification and already had an undergraduate degree. The likely greater levels of experience and maturity of this cohort may influence their resilience when working with unsupportive supervising nurses and identifying strategies to manage challenging situations.

The theory-practice gap emerged in the theme of sinking or swimming. A theory-practice gap describes the perceived dissonance between theoretical knowledge and expectations for the first clinical placement, as opposed to the reality of the experience, and has been reported in previous studies (see, for instance, 24 , 30 , 31 , 32 ). Existing research has shown that when the first clinical placement does not meet inexperienced student nurses’ expectations, a disconnect between theory and practice occurs, creating feelings of being lost and insecure within the new environment, potentially impacting students’ motivation and risk of attrition [ 19 , 33 ]. The current study identified further areas exacerbating the theory-practice gap. Before the clinical placement, students without a healthcare background lacked context for their learning. They lacked understanding of nurses’ shift work and were apprehensive about applying clinical skills learned in the classroom. Hence, some students were uncertain if they were prepared for their first clinical placement or even how to prepare, which increased their anxiety. Prior research has demonstrated that applying theoretical knowledge more seamlessly during clinical placement was supported when students knew what to expect [ 6 ]. For instance, a Canadian study exposed students as observers to the healthcare setting before starting clinical placement, enabling early theory to practice connections that minimised misconceptions and false assumptions during clinical placement [ 34 ].

In the current study, the theory-practice gap was further exacerbated during clinical placement, where healthcare staff were confused about students’ scope of practice and the course learning objectives and expectations in a postgraduate entry-to-practice nursing qualification. The central booking system for clinical placements classifies first-year nursing students who participated in this study as equivalent to second-year undergraduate nursing students. Such a classification could create a misalignment between clinical educators’ expectations and their delivery of education versus students’ actual learning needs and capacity [ 3 , 31 ]. Additional communication to healthcare partners is warranted to enhance understanding of the scope of practice and expectations of a first-year postgraduate entry-to-practice nursing student. Educating and empowering students to communicate their learning needs within their scope of practice is also required.

Our research identified a link between students’ personality traits or individual agency and their first clinical placement experience. The importance of a positive orientation towards learning and the nursing profession in preparedness for clinical placement has been highlighted in previous studies [ 31 ]. Students’ experience of their first clinical placement in our study appeared to be strongly influenced by their mindset [ 23 ]. Some students demonstrated motivation to learn, were happy to ‘roll with the punches’, yet remain active in their learning requirements, whereas others perceived their role as observational and expected supervising nurses to provide learning opportunities. Students who anticipated a passive learning approach prior to their first clinical placement reported boredom, limited activity, and lack of opportunities during their first clinical placement. These students could have a lowered sense of self-efficacy, which may lead to a greater risk of doubt, stress, and reduced commitment to the profession [ 35 ]. Self-efficacy theory explores self-perceived confidence and competence around people’s beliefs in their ability to influence events, which is associated with motivation and is key to nursing students progressing in their career path confidently [ 35 , 36 ]. In the current study, students who actively engaged in their learning process used strategies such as self-reflection and sought support from clinical educators, peers and family. Such active approaches to learning appeared to increase their resilience and motivation to learn as they progressed in their first clinical placement.

Important relationships with supervising nurses, peers, or patients were highlighted in the theme of the reality of navigating placement relationships. This theme links with previous research findings about belongingness. Belongingness is a fundamental human need and impacts students’ behaviour, emotions, cognitive processes, overall well-being, and socialisation into the profession [ 37 , 38 ]. Nursing students who experience belongingness feel part of a team and are more likely to report positive experiences. Several students in the current study described how feeling part of a team improved self-confidence and empowered work-integrated learning. Nonetheless, compared with previous literature (see for instance, 2), working as a team and belongingness were infrequent themes. Such infrequency could be related to the short duration of the clinical placement. In shorter clinical placements, nursing students learn a range of technical skills but have less time to develop teamwork skills and experience socialisation to the profession [ 29 , 39 ].

Positive relationships with supervising nurses appeared fundamental to students’ experiences. Previous research has shown that in wards with safe psycho-social climates, where the culture tolerates mistakes, regarding them as learning opportunities, a pedagogical atmosphere prevails [ 25 , 39 ]. Whereas, if nursing students experience insolent behaviours or incivility, this not only impacts learning it can also affect career progression [ 26 ]. Participants who felt safe asking questions were given responsibility, had autonomy to conduct skills within their scope of practice and thrived in their learning. This finding aligns with previous research affirming that a welcoming and supportive clinical placement environment, where staff are caring, approachable and helpful, enables student nurses to flourish [ 36 , 40 , 41 , 42 ]. Related research highlights that students’ perception of a good clinical placement is linked to participation within the community and instructor behaviour over the quality of the clinical environment and opportunities [ 27 , 28 ]. Over a decade ago, a large European study found that the single most important element for students’ clinical learning was the supervisory relationship [ 39 ]. In our study, students identified how supervising nurses impacted their emotions and this was critical to their experience of clinical placement, rather than how effective they were in their teaching, delivery of feedback, or their knowledge base.

Students’ relationships with patients were similarly important for a successful clinical placement. Before the clinical placement, students expressed anxiety and fears in communicating and interacting with patients, particularly if they were dying or acutely unwell, which is reflective of the literature [ 2 , 10 , 11 ]. However, during clinical placement, relationships with patients positively impacted nursing students’ experiences, especially at the beginning when they felt particularly vulnerable in a new environment. Towards the end of clinical placement, feelings of incompetence, nervousness and uncertainty had subsided. Students were more active in patient care, which increased self-confidence, empowerment, and independence, in turn further improving relationships with patients and creating a positive feedback loop [ 36 , 42 , 43 ].

Limitations

This study involved participants from one university and a single course, thus limiting the generalisability of the results. Thus, verification of the major themes identified in this research in future studies is needed. Nonetheless, the purpose of this study was to explore in detail the way in which the experiences of clinical placement for student nurses modified initial emotional responses towards undertaking placement and their perceptions of preparedness. Participants in this study undertook their clinical placement in a variety of different hospital wards in different specialties, which contributed to the rigour of the study in identifying similar themes in nursing students’ experiences across diverse placement contexts.

This study explored the narratives of first-year nursing students undertaking a postgraduate entry-to-practice qualification on their preparedness for clinical placement. Exploring students’ changing perspectives before and during the clinical placement adds to extant knowledge about nursing students’ emotional responses and perceptions of preparedness. Our research highlighted the role that preplacement emotions and expectations may have in shaping nursing students’ clinical placement experiences. Emerging themes from this study highlighted the importance students placed on relationships with peers, patients, and supervising nurses. Significant anxiety and other negative emotions experienced by nursing students prior to the first clinical placement suggests that further research is needed to explore the impact of contextual learning to scaffold students’ transition to the clinical environment. The findings of this research also have significant implications for educational practice. Additional educational support for nursing students prior to entering the clinical environment for the first time might include developing students’ understanding of the clinical environment, such as through increasing students’ understanding of the different roles of nurses in the clinical context through pre-recorded interviews with nurses. Modified approaches to simulated teaching prior to the first clinical placement would also be useful to increase the emphasis on students applying their learning in a team-based, student-led context, rather than emphasising discrete clinical skill competencies. Finally, increasing contact between students and university-based educators throughout the placement would provide further opportunities for students to debrief, to receive support and to manage some of the negative emotions identified in this study. Further supporting the transition to the first clinical placement could be fundamental to reducing the theory-practice gap and allaying anxiety. Such support is crucial during their first clinical placement to reduce attrition and boost the nursing workforce.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the conditions of our ethics approval but may be available from the corresponding author on reasonable request and subject to permission from the Human Research Ethics Committee.

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Acknowledgements

The authors wish to thank the first-year nursing students who participated in this study and generously shared their experiences of undertaking their first clinical placement.

No funding was received for this study.

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Jennifer M. Weller-Newton

Present address: School of Nursing and Midwifery, University of Canberra, Kirinari Drive, Bruce, Canberra, ACT, 2617, Australia

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Department of Nursing, The University of Melbourne, Grattan St, Parkville, VIC, 3010, Australia

Philippa H. M. Marriott

Department of Rural Health, The University of Melbourne, Grattan St, Shepparton, VIC, 3630, Australia

Present address: Department of Medical Education, Melbourne Medical School, The University of Melbourne, Grattan St, Parkville, VIC, 3010, Australia

Katharine J. Reid

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All authors made a substantial contribution to conducting the research and preparing the manuscript for publication. P.M., J.W-N. and K.R. conceptualised the research and designed the study. P.M. undertook the data collection, and all authors were involved in thematic analysis and interpretation. P.M. wrote the first draft of the manuscript, K.R. undertook a further revision and all authors contributed to subsequent versions. All authors approved the final version for submission. Each author is prepared to take public responsibility for the research.

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Marriott, P.H.M., Weller-Newton, J.M. & Reid, K.J. Preparedness for a first clinical placement in nursing: a descriptive qualitative study. BMC Nurs 23 , 345 (2024). https://doi.org/10.1186/s12912-024-01916-x

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Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium

• Monica Verhofstadt 1 ,
• Loïc Moureau 2 ,
• Koen Pardon 1 &
• Axel Liégeois 2 , 3  

BMC Medical Ethics volume  25 , Article number:  60 ( 2024 ) Cite this article

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Introduction

Previous research has explored euthanasia’s ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium.

Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts.

Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient’s inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent.

The study underscores ethical discourse’s central role in navigating euthanasia’s intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors’ needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia’s multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration.

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Medical assistance in dying is allowed in 27 jurisdictions in the world and if so, it is mainly restricted to the terminally ill (see BOX 1 in OSF) [ 1 ]. Medical assistance in dying entails that a patient’s death request can be granted via euthanasia , defined as the intentional termination of life by a physician at the patient’s explicit request, which is currently decriminalised in Australia, Belgium, Canada, Colombia, Luxembourg, the Netherlands, Spain, and New Zealand. In addition, it can be granted by means of assisted suicide , also defined as the intentional termination of life by a physician at the patient’s explicit request, but in these cases, the lethal drugs are provided by a physician and self-administered by the patient at a time of the latter’s own choosing (e.g., Australia, Austria, Switzerland, United States). In some countries, not only a physician, but also a nurse practitioner can be involved in the procedure (e.g., Canada, New Zealand).

Euthanasia has been legal in Belgium since 2002, positioning the country as a pioneer in this field with two decades of euthanasia practice [ 2 ]. According to Belgian legislation, individuals can be deemed eligible for euthanasia when they are, among other criteria, in a medically futile state characterized by constant and unbearable physical or psychological suffering resulting from a serious and incurable disorder caused by accident or illness [ 2 ]. Belgium is one of the few countries that does not exclude people from assisted dying who suffer predominantly from irremediable psychiatric conditions (see BOX 2 in OSF for all legal criteria in Belgium). As regards prevalence, euthanasia accounted for up to 3.1% of all registered deaths in 2023 in Belgium [ 3 ]. Whereas most registered euthanasia deaths concerned the terminally ill (approximately 84%), predominantly suffering from cancer, only 48 or 1.4% of euthanasia deaths concerned non-terminally ill adults predominantly suffering from psychiatric conditions. Since euthanasia was legalised, in total 457 such euthanasia cases have been reported, less than 1.5% of all registered euthanasia cases in Belgium [ 3 , 4 , 5 , 6 , 7 , 8 , 9 ].

However, this is only the tip of the iceberg, as there is reason to believe that the total number of requests for euthanasia in Belgium (regardless of outcome), is at least 10 times higher. For instance, recent annual reports from Vonkel, an end-of-life consultation centre in Belgium, revealed around 100 unique patients per year applying for euthanasia for psychiatric reasons. Less than 10% of those euthanasia requests were reported to be carried out [ 10 , 11 , 12 ]. Moreover, a recent survey among psychiatrists working in Flanders, Belgium, revealed that 8 out of 10 respondents had been confronted at least once throughout their career with patients requesting euthanasia for psychiatric reasons [ 13 ]. The survey also showed that, although three-quarters are supportive of not excluding the option of euthanasia for this specific patient group [ 14 ], the majority is hesitant to be actively engaged in a euthanasia procedure [ 13 , 14 ]. The literature ascribed the reluctance to the complexity of euthanasia assessment in this patient group, inherently high in professional and emotional demands [ 15 , 16 , 17 , 18 , 19 ]. The complexity was for a large part described in terms of the practical considerations surrounding euthanasia requests and assessment, e.g., whether and when these patients can meet the legal criteria.

There is thus reason to believe that healthcare workers’ overarching ethical considerations influence their attitudes on euthanasia in general and in the context of psychiatry specifically, and their practice. As empirical in-depth studies are lacking, this area is largely understudied. To date, only two recent qualitative studies among Dutch physicians emphasised the value-based reasons for euthanasia decision-making, but did not [ 20 ] or only summarily [ 21 ] scratch the specific context of psychiatry. Another recent qualitative study among Dutch physicians, including psychiatrists, emphasized the value-based reasons for supportive attitudes towards euthanasia, e.g. the value of self-determination, compassion, fairness, and suicide prevention, versus the value-based reasons for not supporting euthanasia, e.g. the mission of medicine of hope and healing [ 22 ]. Furthermore, a recent systematic review described the main ethical challenges surrounding the euthanasia practice in the context of psychiatry [ 23 ]. However, this ethical debate was mainly concentrated on the permissibility and implementation of euthanasia from a practical-clinical point of view, e.g. whether euthanasia in the context of psychiatry should be permitted, and why the legal requirements can (not) be adequately embedded in the field of psychiatric medicine. How practically and juridically relevant these considerations may be, they remain the outcome of ethical values being weighed up, which means that no single consideration can be considered ethically irrelevant, neutral, or value-free. Moreover, the review was based on articles that have been selected in a timeframe in which sound empirical data regarding euthanasia in the context of psychiatry were largely lacking.

Also, the overarching value-based views of other professionals involved in psychiatric euthanasia practice have not yet been studied. This is striking, as a recent Belgian survey study revealed that that half of the psychiatric nurses (53%) are frequently and directly confronted with such euthanasia requests [ 24 ], but in-depth insights into their value-based views are lacking. Furthermore, there are many more formal caregivers, other than psychiatric nurses, involved in euthanasia assessment procedures. End-of-life centres employ e.g., paramedical personnel such as psychologists, psychiatric nurses for intake and registration purposes, and well-trained volunteer personnel such as buddies, entrusted with the task to help these patients to cope with the euthanasia procedure. In addition, rehabilitation-oriented support groups (REAKIRO) were established to help these patients (and their relatives) in walking the tightrope of life and death [ 25 ]. All of these caregivers may also have an unacknowledged but influential role in these euthanasia assessment procedures, and therefore, an interesting perspective to reflect on euthanasia legislation and practice. Gaining insight into healthcare workers’ ethical considerations related to euthanasia in psychiatry will lay bare the ethical foundations underlying current practice and is important to inform and spark further debate around this extremely thorny issue, and to promote sound ethical analysis.

Hence, the purpose of this research is to explore healthcare workers’ ethical considerations regarding euthanasia in general and euthanasia concerning adults suffering predominantly from psychiatric conditions in particular.

Theoretical research framework

Our research was guided by the framework of ‘critical social constructionism’ [ 26 ], providing a nuanced perspective that diverges from the acknowledgment of an objective reality. This approach intricately examines the interplay of personal, social, and societal dimensions within the phenomena under study. It necessitates an acknowledgment of the layered complexities influencing our understanding of phenomena such as euthanasia, a notion supported by both our prior research [ 27 ] and additional studies [ 23 , 28 ].

Our interpretation of the data was informed by social constructionism, which recognizes the role of internalized societal norms in shaping individuals’ perceptions of reality over time. Furthermore, we embraced a contextualist epistemology [ 29 ], acknowledging the contextual influence on knowledge formation among both researchers and participants. This methodological approach aimed to capture diverse lived experiences (e.g., diversity in clinical and euthanasia trajectories) and perspectives, including varied attitudes toward euthanasia based on specific relationships (e.g., professional healthcare worker or volunteer). Consequently, we maintained a reflexive stance regarding the potential impact of our individual experiences and identities on our analyses and interpretations, as elaborated in the Ethical Considerations section.

Study design

The qualitative research design consisted of semi-structured face-to-face interviews with healthcare workers in Flanders and Brussels, Belgium.

Participants

All participants were Dutch-speaking and had at least one concrete experience with euthanasia requests and procedures concerning adults with psychiatric conditions in the period 2016–2020, either as professional or volunteer healthcare workers. We adopted a broad recruitment approach, with a particular focus on all healthcare providers directly involved in medical practice rather than in managerial or policy-making roles. No further exclusion criteria were employed.

Recruitment and interview procedure

Purposive sampling was used to ensure diversity and heterogeneity in terms of: participants’ affiliation with institutions holding different stances on ‘euthanasia and psychiatry’; being to a different extent confronted with these euthanasia procedures as regards the amount of experiences (sporadically versus regularly); the nature of the experiences (e.g. confronted with or engaged in euthanasia procedures that were still under review or that had been rejected, granted, performed or withdrawn); and their specific role as professional or volunteer healthcare worker.

Participants were recruited via assistance of our contact persons at: (1) the end-of-life consultation centre Vonkel; (2) the Brothers of Charity; (3) the rehabilitation-oriented centre REAKIRO in Louvain; and (4) the Review Belgian Euthanasia Law for psychological suffering (REBEL) group, a group of Belgian physicians (e.g. psychiatrists), therapists (e.g. psychologists) as well as academics who express their concern on euthanasia in the context of psychiatry via the media. Participants were also recruited via a notice on the sites, newsflashes and/or in the online newsletters of LEIF (Life End Information Forum), Recht op Waardig Sterven (the Flemish Right to Die with Dignity Society) and Vlaamse Vereniging voor Psychiatrie (Flemish Psychiatric Association).

Potential participants contacted MV or a study assistant by phone or mail. The patients were then given an information letter and informed consent form that consisted of 2 main parts. All interviews were conducted by MV or a study assistant, who both have experience in conducting interviews on end-of-life topics. Interviews were held at the participant’s location of choice, except for five interviews which were held online via video call by Whereby 14 due to the Covid-19 crisis lockdown regulations. Interviews lasted between 55 min and 2 h, and were audio recorded (the online video interviews were recorded by Whereby’s software and immediately transferred in an mp.3 format).

Measurements

The interview guide (see OSF) contained the following consecutive questions of importance to the present report: (1) What is your personal stance regarding euthanasia as a legalised medical end-of-life option? and (2) What is your personal stance regarding euthanasia in the context of psychiatry?

Data management and analysis

We used a model of sampling-based saturation, namely inductive thematic saturation, that relates to the emergence of new themes (defined as 7 consecutive interviews without new themes) [ 30 ]. We continued to recruit and conduct interviews so that the sample would be heterogenous in terms of socio-demographics, clinical profile, and clinical setting. In particular, our focus was on recruiting individuals with the following profiles: psychologists, male psychiatric nurses and moral consultants/spiritual caregivers employed in residential psychiatric settings ( n  = 5).

All interviews were then transcribed verbatim and de-identified by the interviewers.

We made use of hybrid inductive and deductive coding and theme development by means of a 2-staged process. Stage 1 consisted of an inductive data-driven thematic coding procedure.

We made use of these four phases; (1) identification and coding of all transcripts; (2) the placing of the codes in subthemes, i.e., arguments in favour versus critical concerns; (3) the placing of these subthemes in overarching main themes, i.e., different stakeholders (patient/medicine/society); (4) the comparison and discussion of the findings (with all co-authors). In addition to the inductive approach, we also used a deductive, theory-driven template approach during stage 2. We made use of these four phases; 1) the development of an ethical interpretation framework (see OSF). The framework consists of four key concepts, each involving a multitude of ethical concepts: (a) ethical theories and methodologies, (b) ethical values, (c) basic ethical virtues, and (d) dialogue/decision making ethics; 2) the identification of codes that fit the ethical framework and the theory-driven renaming of these codes; 3) the placing of some of the subthemes in an additional main theme; and 4) the comparison and discussion of the findings (with all co-authors).

Ethical considerations

The research team comprised two experienced clinical psychologists, one specializing in euthanasia within the cancer patient population and the other skilled in conducting interviews on this sensitive topic within the adult psychiatric context. Additionally, two ethicists with expertise in assisted dying, including euthanasia, were part of the team. Some authors also have backgrounds in psychiatric practice, including outpatient and residential settings, while others bring expertise through personal experiences. Furthermore, all contributing authors have personal and/or professional connections with individuals navigating death ideation, offering diverse perspectives on euthanasia. Additionally, some authors hold religious beliefs, while others maintain a more agnostic stance. These perspectives vary depending on the predominant viewpoints adopted—whether that of the patient, a close relation, a clinician, an ethicist, or policy stances. To mitigate potential undue influence on data interpretation, three team assemblies were convened. These sessions served to share firsthand encounters from interviews and their outcomes, fostering reflection and deliberation among team members. This proactive measure was implemented to prevent both personal and professional biases from affecting the interpretation of the data.

The main characteristics of the 30 participants are listed in Table  1 . The sample consisted of 16 physicians, 7 other care professionals (ranging from psychiatric nurses to mobile support teams), and 7 volunteers, all of whom were engaged in one or more euthanasia procedures predominantly based on psychiatric conditions.

The participating physicians held various roles regarding the handling of euthanasia requests:

1 physician refused to discuss the request with the patient on principle grounds.

7 physicians managed the clarification of euthanasia requests from their own patients or referred them to colleagues for further clarification.

10 physicians provided one of the two legally required formal advices or an additional advice on the euthanasia request.

5 physicians performed the act of euthanasia.

3 physicians held a more normative, dissuasive stance against euthanasia in the context of psychiatry but were willing to explore and discuss the euthanasia request with the patient.

The sample further included 14 non-physicians, among them members holding one or more roles:

2 members were part of mobile teams providing psychiatric care and support in the patient’s home setting.

3 were psychiatric nurses working either in a general hospital or in a psychiatric residential setting.

2 were Experts by Experience, individuals with a history of mental distress trained to provide support for individuals new to the euthanasia procedure and/or rehabilitation approaches.

3 were buddies, individuals entrusted with assisting and supporting the patient throughout the euthanasia procedure.

3 were moral consultants/spiritual caregiver, tasked with offering various forms of existential guidance and support to patients considering euthanasia, including religious, moral, and/or other perspectives.

5 were consultants at end-of-life information and/or consultation centers responsible for patient intake.

Participants’ ethical considerations regarding euthanasia, in the broadest context of medicine

As can be seen from the coding structure in Table  2 , we ordered coding categories on the level of 1) the individual patient, 2) the patient’s social inner circle, 3) the (para)medical field, and 4) the society. Note that words used verbatim by the interviewees (often interview fragments instead of quotes, as to better illuminate the complexities and nuances of interviewees’ first-hand lived experiences) from the transcribed interviews are incorporated that provide both additional insightful details and reveal the at times interwoven nature of the analysed codes.”

The level of the individual patient

On the level of the individual patient, the following five ethical considerations were distinguished: (1) autonomy, (2) dignity, (3) quality of life, (4) compassion, and (5) the meaning and transformative value of suffering.

First, Autonomy was a recurrent theme in all the interviews. Some participants expressly valued individual autonomy , and more specifically its following two underpinning characteristics: (1) self-determination in terms of the fundamental right for each individual to direct the course of one’s own life, which also includes ‘taking control over the timing and circumstances of one’s end-of-life’, and (2) freedom of choice , as they strongly believed that individuals are free to choose what meaning and purpose they assign to their lives. According to them, as each individual should be enabled ‘to live according to one’s own value system’, so should the ending of one’s life also be congruent with one’s own value system. Hence, in their opinion, euthanasia should remain ‘one of the many options to die’.

Other participants called this individualistic approach of autonomy ‘unrealistic’ or even ‘delusional’, as it shies away from: (1) the relational account of autonomy, in which a true autonomous decision was seen as the outcome of a decision-making process which is shaped by individual, social and contextual components, and (2) the internalised downside of autonomy, as the feeling underpinning many euthanasia requests, namely ‘not wanting to be a burden to others’ may lead to ‘self-sacrifice’ and ‘the duty to die’ under the false pretence of autonomy. In addition, some pointed to the power of susceptibility and subliminality, as human beings are subliminal creatures whose behaviour is continuously influenced on both a subconscious and even conscious level. Consequently, internalised pressure cannot be excluded when a patient requests euthanasia. One psychiatrist even stated that ‘ there exists no such thing as a free will, as human beings are always manipulated in many areas of human life and functioning’ .

“I believe that that there should still be places in society where you could die without considering euthanasia. While many people today are facing dementia, and you almost must…. Interviewer: Yes. “Yes, like how should I deal with it? Should I exit life before it becomes inevitable dementia or something similar? Because I think that in a neo-liberal society, many people internalize the idea that at some point, it becomes a moral duty to step aside. They feel obliged to eliminate themselves. Self-elimination. In a neo-liberal model, as long as you can keep up and contribute, everything is fine. But if you can’t keep up, well, if you cannot fully exercise autonomy, then… Essentially, you should hold your honour and step aside.” (spiritual caregiver)

Second, participants mentioned euthanasia as an option to die with dignity . For those in favour of the Law, euthanasia is considered (1) a ‘dignified way of dying’ when everything that leads up to death, including individual, medical, and social needs and expectations, is consistent with one’s own sense of integrity, belief-system and lifestyle, and (2) a ‘good death’, when referring to the literal meaning of the concept ‘euthanasia’, namely ‘a soft and gentle passing’. Other participants raised concerns on the reference to euthanasia and dignified dying in the same breath, as if “ other ways of dying are not or less dignified ”.

Third, the value of quality of life underpinned the arguments made in favour of the Law on Euthanasia, as (1) life itself should not be prolonged unnecessarily, (2) meaningless suffering should be prevented, and (3) a good life should pertain to all stages in life, from the very beginning until the very end, which is feasible if quality of dying circumstances can be guaranteed. As one buddy stated: “ Living a full and good life implies dying a good death ”. Other participants made use of this value underpinning their argument against euthanasia, based on (1) the “protect-worthiness” of life itself and (2) the suffering that must be considered an inherent feature of the human condition.

Fourth, and seamlessly fitting with the former value, divergent courses also emerged regarding the aspect of how to deal with suffering . Some participants were in favour of euthanasia out of compassion in terms of (1) bringing a kind of relief to the patient when providing her the prospect of an end to the suffering and (2) ending the suffering once it has become ‘useless and meaningless’ and ‘disclosing the limits of the carrying capacity of the self’. Some participants referred to the insufficient degree of quality of life in some patients and valued euthanasia as sort of ‘ compensation for a life gone wrong’.

Others considered the option of euthanasia as compromising patients’ ability to accept, bear and cope with suffering experiences by offering the opportunity ‘to quickly resign from it’.

Some participants referred to the dynamic features and hence, the potential enriching value of suffering. They believed that one can and must revolt against the perception of pointless suffering, as suffering may offer unique opportunities to achieve personal growth through the realisation of self-actualising tendencies amidst the suffering and though all kinds of hardship and adversity in life. Therefore, the real challenge is to support the sufferer to (re)gain the ability to transform the suffering by means of redefining, accepting, and making sense of it. One psychiatrist referred to the Myth of Sisyphus and stated:

A rock that must be pushed up the mountain, which is terrible, and then Sisyphus lets the rock fall back down, and he must start all over again. And what is the purpose of that suffering? Pushing the rock up? It’s absurd, really, but still. I find it so vital, human, uh, yes. That is something that inspires me enormously and often makes me, well, yes, vitality and suffering, suffering is inherent to being, of course, and one can suffer, of course, that is very serious suffering, terrible suffering. I know that. But well, accept suffering, right? I’m not glorifying suffering, no, I don’t belong to that category. Some Catholics do that; the suffering of Christ, we must… No, not at all. Suffering is inherent to life. Interviewer: It’s just more bearable for some than for others. Interviewee: Then it’s our task to make it more bearable. Yes. (…) Look, that sets a dynamic in motion. By dynamic, I also mean movement. A euthanasia request is often rigid. I am for movement. That’s what Eastern philosophy teaches us too, that everything moves, and we must keep that movement and that the question may change or that people may also discover things. Or indeed, a suffering that is even more exposed, but on which one can then work. There is still much to do, yes, before the ultimate and final act of euthanasia, by a doctor for all sakes, should be considered. (psychiatrist)

The level of the patient’s inner circle

On the level of the social inner circle, the following three ethical considerations were distinguished: (1) involvement, (2) connectedness, and (3) attentiveness.

Some participants stressed that euthanasia can only be a soft and thus ‘good’ way of dying, if the patient’s social inner circle can be involved in the euthanasia procedure and if sufficient support to them can be provided. All participants in favour of the legal framework on euthanasia echoed the importance of the social circle being involved in an early stage of the euthanasia procedure, as the prospect of the end of life may challenge a patient’s ability of staying and feeling connected . If the euthanasia request is to be carried out, it offers a unique opportunity for both the patient and her social inner circle of consciously being present and sharing goodbyes. Other participants considered this reasoning as potentially deceiving, as concern was raised regarding the trap of false assumptions, in terms of words being left unspoken and the bottling up of one’s own needs for the sake of the other.

As the third doctor, I was asked to provide advice about someone, and the [adult child] was present, a charming [adult child]. The [adult child] was also very friendly but didn’t say much. The man explained why he himself wanted euthanasia and so on. To be honest, at first, I thought, “Well, this won’t take long,” because there were many arguments and reports I had received, but as the conversation went on, I started to feel something different. It turned into a very long conversation, during which the [adult child] also had their say. In short, the father believed that he couldn’t burden his children. He was a kind man who knew what he wanted, and his children were inclined to follow his idea, to follow his vision. However, the children thought, “Yes, we are actually going to agree with our father, and we’ll allow it,” but deep down, they still wanted to take good care of him. The father didn’t want them to take care of him, and there were many other things, but after that long conversation with the [adult child] and the father, and everything else, like, “We’ll still celebrate Christmas together,” there was a complete turnaround. The other physicians involved accepted this very well, and they said, “Okay, for us, it wasn’t clear. (physician)

In addition, concern was raised regarding the inner circle’s respect of individual patient autonomy and freedom of choice outweighing their r esponsibility and accountabilit y to take care for one another and to act according to all these subjects’ best interest.

Consequently, divergent discourses on the virtue of attentiveness emerged. Whereas for some, the euthanasia procedure may offer a unique opportunity for both the patient and her relatives to be better prepared for death and for the bereaved to better cope with grief, others pointed to the inner circle’s continued grappling with unresolved feelings and perceived helplessness after such a fast-track to death.

Yes, and sometimes I also see people, family members after such euthanasia, yeah, I’ve experienced it several times. They say things like, “Yes, I supported it, but I didn’t know it would affect me like this,” you know? They try to convince themselves, saying, “It was good, it was good, and I stand behind it.” Yeah, you are hardly allowed to do otherwise, but you feel that inner struggle in them, you know? Like, “Was it really okay?” But you can’t question it because you think, “Poor them,” but you still feel it, like, “How sad, how sad. (psychiatrist)

The level of medicine

The following five ethical considerations were distinguished: (1) professional duties, (2) responsibility to alleviate suffering, (3) subsidiarity, (4) professional integrity, and (5) monologic versus dialogic approaches.

First and as regards professional duties, it was (only) reported by some physicians that the physician’s duty is “ to provide good care, which includes good end-of-life care ”. Hence, physicians are the ones who should have euthanasia “as a tool in their end-of-life toolbox”. Others held a different stance and referred to Hippocrates’ Oath when stating that the physician’s duty is to save life at all costs.

Second, all the participants agreed that clinicians have the responsibility to alleviate the patient’s suffering . Whereas some welcomed the option of euthanasia due to the experienced limits of palliative care, that in some cases is deemed an insufficient response to intractable suffering, others stated that euthanasia is not needed as physicians have proper palliative care in their toolbox to alleviate all kinds and degrees of suffering.

Third and as regards the subsidiarity principle , opinions differed on the use of a palliative filter, i.e., whether a consultation with specialist palliative care units should precede euthanasia.

Fourth and as regards professional integrity , some participants relativized the physicians’ executive autonomy. As one psychiatrist stated “because in the end, we do not decide whether someone might die or not. We only decide whether we want to be of help and assist in it.” All the ones in favour of the current legal framework echoed that as physicians are the ones that have better access to the lethal drugs and the technical expertise to end the patient’s life in more efficacious ways than non-physicians, they should remain entrusted with euthanasia assessment procedures. Others (only physicians) criticized the Belgian legislator for placing too much power in the physicians’ hands so that the latter “ can play for God instead of using their pharmacological and technical know-how to save lives ”.

Fifth, and as regards the decision-making process, most participants valued the ethical principle of shared decision-making between the patient and her physicians, and some even preferred a triadic dialogue in which the patient, her relevant health carers and her social inner circle is involved in euthanasia assessment procedures. For most of them, this type of extended or relational autonomy is considered as best clinical euthanasia practice, especially when death is not foreseeable. According to some non-physicians, a strict dyadic patient-physician approach is to be preferred when death is reasonably foreseeable in a patient with sufficient mental competence. In this event, no intermediary should be tolerated as the medical secret is considered ‘sacred’. One participant elaborated further on this strict dyadic approach and said:

“ But actually, in my opinion, the request for euthanasia is something between two people. So…. Interviewer: The singular dialogue? “So, a relationship between the patient and the doctor, yes. That’s what I think. And I do understand that the legislation exists, primarily to protect the doctor against misuse or accusations, because euthanasia used to happen before too, but in secret. But for me as a doctor, it would be enough if a patient whom I’ve known for years, followed for years, maybe 20 years, 30 years, 40 years, and who is terminally ill, asks me in private, ‘I want it.’ For me, it doesn’t need to be more than that for me to say, ‘yes.’ So, there’s no need for a whole set of legislation, except of course to protect myself, maybe from the heirs who might have a different idea about it, yes, but I find it beautiful. And they say, you know, our legislation is such that you can write your euthanasia request on the back of a beer coaster and that’s enough, you know? But how it used to be, euthanasia happened just as well, that’s what I heard from my older colleagues. But it was done in private. Actually, that is the most beautiful sign of trust between a doctor and a patient. ” (Physician and consultant)

Others, all physicians without a favourable stance on euthanasia, considered medical paternalism morally justified in the end-of-life context, as (1) physicians have more intimate knowledge of the patient and are thus best placed to act in the patient’s best interests, (2) only the independent evaluation from well-trained and experienced physicians may rule out external or internalized pressure from the patient’s social inner circle, and (3) some patients may show impaired decision-making capacity when confronted with the end of life.

The level of society

As regards the origins and impact of euthanasia legislation on the level of society, the following four ethical themes emerged: (1) protection, (2) dignified dying, (3) solidarity, and (4) distributive justice.

First and as regards protection , some participants valued the existence of a legal framework for an ‘underground’ practice before 2002. According to them, this framework was highly needed to protect the patient against malicious practices and the physician against being charged for murder when ensuring herself that all the legal requirements are met.

So, I believe that it should be well-regulated in a state. In a country, it should be well-regulated. You can either be in favour of it, have reservations, or question it, but when it happens and many people want it or think it’s okay, then it should be regulated. And those, like me, who may be against it, have doubts about it, or wonder, “Is this really necessary?” I would say, or “Does it align with our purpose?” the existential comments that you can make about it, we must accept it because it would be terrible if it, well, it would be even worse if it happened in the underground, like before those laws were established, that’s, yeah. So, I think the laws should exist. Whether I would have made those laws is a different question, or whether I would vote for the parties in parliament that, you know, that support it, that’s another question, but apparently, here in North-western Europe, the need for those practices exists, and it should be regulated properly. And yes, it shouldn’t be left to amateurs or something like that, that’s not the intention. Yes, well, it serves to protect, both in terms of health and to ensure that it doesn’t become a business, of course. I’d prefer it to be integrated into the healthcare system rather than turning it into a profit-driven and exploitative affair for some others. So, that’s…. (psychiatric nurse)

Critical concerns were raised on the lack of protection of the most vulnerable people, i.e., the mentally ill and the elderly. Some of them referred to the amended Law in 2014, that also allowed minors to die by means of euthanasia – be it under more strict circumstances, inter alia, when based on unbearable physical suffering resulting from a medically terminal condition – and feared that the Law will be amended again, so it would no longer exclude the people suffering from dementia or for groups without serious incurable illness, e.g., the elderly with a perceived ‘completed life’.

Second, a major societal shift in thoughts regarding what constitutes dignified dying was reported. For some, the Law on Euthanasia reflects a nascent movement of death revivalism, in terms of people reclaiming control over their dying process. In this respect, euthanasia is deemed a counterreaction to the former dominant paternalistic attitude in Western society to systematically marginalise conversations on death and dying, e.g., due to the mechanisms of denial, avoidance, and postponement, and with the line between life and death increasingly held in physician’s hands, which has left many people ill-equipped to deal with dying and death. The current broad public support for euthanasia is seen as the individual patient taking back the decision-making process of dying and death in her own hands. They further considered euthanasia as a logical consequence of living an artificially prolonged life due to e.g., advances in medicine, that have not necessarily enhanced the quality of life.

“ One thing I also consider is that a part of our lives is artificially prolonged, you know. We don’t live longer because we are healthier, but because we have good pills or better surgical procedures, so we can afford to buy our health. So that part of life is still valuable to me, it’s not less valuable, but it’s artificially extended. So, I think we should keep that in mind, that we can prolong something artificially and maybe even go beyond a point where it no longer works. Interviewer: Beyond the expiration date? That’s what I was looking for (laughs). So, in that sense, I believe we should keep in mind that we can artificially extend something and then maybe, even if it’s just that artificial part, stop or be allowed to stop when the person no longer wants to, I think that makes perfect sense. ” (psychiatrist)

Others provided arguments against the increased death revivalism, referring to euthanasia as a ‘fast-track to death’ resulting in ‘the trivialisation of death’ in the face of formerly known and experienced Art of Dying. For instance, the current societal tendency to avoid suffering and the fear of dying may lead to patients (too quickly) resigning from a slow track to death, in which there is time to e.g., hold a wake.

But I won’t just grab a syringe, fill it up, and administer a lethal injection, you know? I follow the symptoms. And if they become uncomfortable, then I’ll increase the dosage so they can rest peacefully and not have to suffer. That’s what I call a dignified death. And if the family can be present, sometimes it takes a while for them to arrive, and they’ll say, “Come on, even a dog is not allowed to suffer that long.” Meanwhile, the person is just lying peacefully. But that too. Everything should, even that, should progress, and there isn’t much time left for vigil and, yes, I don’t want to romanticize it, but sometimes you see so much happening between families. There’re all kinds of things happening in those rooms, with the family, reconciliations being made. Memories being shared. “Oh, I didn’t know that about our father.“, an aunt walking in and telling a story. Well, so much still happens. I don’t want to romanticize it, but to say that all that time is useless, that’s not true either. And at the farewell, there’s always, the time, you think there’s time for it, but people are still taken aback when an infusion is given, that it can happen within a minute, even if they’re behind it and have been informed beforehand. Just a minute… and it’s done. The banality of death, it’s almost like that. (psychiatrist)

These and other participants also criticised ‘the romanticised image of euthanasia’, that masks the economics of the death system, taking financial advantage of ‘patients not wanting to be a burden to society’.

Third and consequently, divergent discourses on the value of solidarity emerged. For some, decades of civic engagement pointed to the need of death revivalism and patient empowerment, that resulted in the current legal framework. Others strongly criticised the lack of solidarity underpinning the legal framework on the following three counts: 1) the emphasis on patient autonomy is deemed a ’societal negligence in disguise’, as citizens are no longer urged to take care of others, 2) equating autonomy and dignity in euthanasia debates leads to the trap of viewing the ill or the elderly as having ‘undignified’ lives, and 3) wealth over health has become the credo of the current neoliberal society, as the Law on Euthanasia discourages further investments in health care but settles on the ‘commodification’ of health care.

“ I believe that we should take care of each other and especially care for the most vulnerable in our society. We shouldn’t just leave them to fend for themselves. I don’t think the motto should be all about autonomy, autonomy, and then the flip side, saying, “figure it out on your own.” That’s not acceptable. We have a responsibility to take care of each other. We are meant to care for one another. In biblical terms, we are each other’s keeper, right? “Am I my brother’s keeper?” Yes, I am my brother’s keeper. I must take care of each other, take care of others. So, I think in the long term, speaking maybe 100 years from now, people might say, “Sorry, that was a real mistake in the way they approached things.” I don’t know, but that’s looking at it from a meta-level, as historians call it, “longue durée,” and combining it with a neoliberal model, right? Neoliberalism and euthanasia thinking, it would be interesting to do a doctoral thesis on how they fit together perfectly. How they fit together perfectly… They are no longer patients, they are no longer clients, and I also don’t like the word ‘clients.’ They have become ‘users’. Sorry, but that’s our Dutch translation of the English word ‘consumers’ right? It’s like buying Dash detergent or a car; you buy care, just like the Personal Budget for people with disabilities. You buy your care, sorry, this goes against the very essence of what care fundamentally is. Care is a relationship between people; it’s not something you buy. It’s not something you say, “It’s a contract, and I want that.” It doesn’t work like that. [raising voice] The burden is on society. [end of raising voice] And when the money runs out, you have nothing left. If you can’t buy it, then it doesn’t come. “Here’s your little package,” that’s how it’s translated, and it’s always a hidden cost-cutting operation, let’s be very honest about it, a nice story, but it’s always a hidden cost-saving measure. I see right through that story, but well, big stories are always told, and they are always about saving money. [raising voice] It doesn’t bring anything, right? [end of raising voice] People’s self-reliance, they must stay at home, etc. How many people would benefit from going to a care centre, not at the end of their lives, but just because they feel totally lonely at home, but they can’t get in because nobody wants them there, as they don’t bring any profit. ” (spiritual caregiver)

Fourth, critical concerns were expressed concerning the lack of (distributive) justice due to the many existing misperceptions and misconceptions regarding medical end-of-life options that need to be uncovered. For instance, many people would be unaware of euthanasia and palliative sedation can both be dignified ways of dying, with euthanasia functioning as a fast-track and palliative sedation functioning as slow track to death. Also, the evolution of death literacy was contested: there was a sense that patients did not become more death literate, as many of them have insufficient knowledge of the content of the many end-of-life documents in circulation.

Yeah, I mean, you see, and I hear many people saying, “My papers are in order.” I won’t say every day, but I hear it almost every day, “My papers are in order.” That’s also something. It’s an illusion of control, right? Because what papers are they talking about? “My papers are in order.” When you ask them about it, they themselves don’t really know what that means, some kind of ‘living will’, ‘an advance care plan’, but yeah, with all… A living will or advance care plan is not that simple either, and then they think, “Oh, if I get dementia and I don’t recognize anyone anymore, they will give me an injection.” Ah yes, but then we are in a different domain, and that’s a whole other… But yeah, people are not well-informed, I find. They have totally wrong ideas and sometimes fear the wrong things, don’t know what is possible and what is not, and they also let themselves believe all kinds of things. Well, there are many misconceptions out there. (psychiatrist)

Participants’ ethical considerations regarding the additional procedural criteria for people with a non-terminal illness

As can be seen from the coding structure in Table  3 , participants made use of the principle justice to motivate their stance on additional (procedural) criteria that people with a non-terminal illness must meet before euthanasia can be carried out, in comparison with people with terminal illness. Those in favour of the additional procedural criteria referred to the differences between the terminally ill and the non-terminally ill regarding the aspect of content (i.e., the difference between general life expectancy and healthy life expectancy) and the aspect of time (i.e., the probability verging on certainty concerning the terminally ill versus the rough estimation concerning the non-terminally ill). Some of them also referred to the legal proceedings and stated that the Law was meant only for people with terminal illnesses to die by means of euthanasia. Others were of the opinion that it concerns only an arbitrary difference due to 1) the vagueness of the concept ‘naturally foreseeable’, i.e., suffering from a terminal illness, and the subjectivity of the calculated course and prognosis of e.g., degenerative somatic illnesses and dementia. A few participants said that this is beside the question, as one’s individual carrying capacity trumps the course and prognosis of an illness.

Participants’ ethical considerations regarding adults with psychiatric conditions

As can be seen from the coding structure in Table  4 , when asked about participants’ stances on euthanasia in the context of psychiatry, we distinguished value-based themes at the level of (1) the patient, (2) the field of psychiatry, and (3) society in general.

The level of the patient

Justice was the main value-based principle that emerged at the level of the patient. Participants in favour of not legally amending additional procedural criteria in the context of psychiatry stated that every patient with a non-terminal illness should receive equal end-of-life care options. The main counterargument given concerned the differences in patient profile, as some questioned whether the mentally ill can meet the legal criteria or stated that extreme caution is needed and thus additional criteria are in place due to the factor of e.g., ambiguity, impulsivity, and manipulation in the mentally ill.

“I find, the way the procedure is conducted for psychiatric suffering, I find it only natural that they handle it more cautiously because it’s indeed less… It’s not so easy to determine everything, is there really no other option left? And then I understand somewhere that time must be taken to investigate all of that. Because some of these people can be very impulsive, and that impulsivity needs to be addressed somewhere, of course. You also have people who can use their setbacks in the sense of, ‘I’ve been through all that, so I deserve euthanasia.’ And those are the people you need to single out because that’s just… I think those are also people who, with the necessary guidance, can still get out of it. Do you understand? It’s a form of self-pity, in a way. I think there might be resilience there, but they haven’t tapped into it themselves yet; it’s a kind of deflection or something. People with a history of, who say ‘I’ve experienced this and that, so I don’t need it anymore, just give me euthanasia, I deserve that. I’ve been through all that.’ While maybe, if they see, that’s still worth something to me, who knows, maybe that can still happen. They’re people who give up a little too quickly.” (Moral consultant)

Regarding the field of medicine, the following four value-based considerations emerged: (1) justice, (2) responsiveness to suffering, (3) protection, and (4) proportionality.

First, and as regards the principle of justice , participants in favour of equal procedural criteria for all non-terminally ill pointed to the indissociable unity of soma and psyche. A few physicians went one step further and reported that some psychiatric conditions can be considered terminal, e.g., suicidality, or predominantly of somatic nature, e.g., anorexia. The main counterarguments in this respect were (1) the firm belief in the inexistence of irremediableness in psychiatry (only mentioned by some physicians) or (2) that more caution is needed due to the higher level of subjectivity in terms of diagnostics, prognosis, and outcome.

Second, arguments against the distinction between the somatically versus the mentally ill were based on the attitude of responsiveness to the extreme extent and duration of mental suffering that can also render the mentally ill in a medically futile situation and the field of psychiatry empty-handed.

And many of the psychiatric patients I see suffer more than the average ALS patient who has to endure it for three years. In my experience, we’re less advanced in psychiatry compared to most other medical fields. You can easily say “we don’t know” in other areas of medicine and people will understand, but when it comes to psychiatric conditions, it’s different. Doctors might admit “it’s not working” or “there’s no trust,” and they might refer patients elsewhere or even refuse further appointments. I’ve even told a judge during a forced admission, “There’s simply no treatment available.” Yes, sometimes it’s just over and society must accept that there’s no solution. I’m not saying euthanasia is the solution for everyone, but I think it can be an option for some people. (Psychiatrist)

Other participants were not blind to the deep suffering, but strongly believed in the ground principle and core strength of psychiatry, namely the beneficial effect of hope. In addition, they pointed to the differences in the nature and course of somatic versus psychiatric illnesses when stating that considerably more time is needed in psychiatry, with inclusion of the therapeutic effect of hope to become effective.

“And I also believe that collectively, within psychiatry, we can and must provide additional support to endure profound despair. So, even in the face of seemingly endless hopelessness, we must maintain hope, look towards the future with trust, and continuously offer encouragement to those who feel hopeless. Our unwavering optimism and support convey the message that together, we can overcome. Because individuals who suffer from severe mental illness are treatable, I consider myself to be a genuinely optimistic psychiatrist. I have witnessed individuals who have harbored feelings of hopelessness and despair for extended periods, sometimes even decades, undergo profound transformations and experience significant improvement, and in some cases, complete recovery.” (Psychiatrist)

Third, participants in favour of the current legal framework reported that allowing euthanasia for the mentally ill was needed in the light of protection , as it might protect the patient against brutal suicides and also against therapeutic tenacity that more often occurs in psychiatry. Other participants in favour of, as well as participants against the current framework held a different stance on the following two counts: (1) allowing euthanasia conflicts with the aim of psychiatry to prevent suicide at all costs, and (2) the mentally ill are insufficiently protected by the Law as there are insufficient built-in safeguards against therapeutic negligence.

But usually with a psychiatric condition, death isn’t imminent. That’s the tricky part, you know? How many suicides do we have here? But anyway, I have an issue with that, using euthanasia as a kind of antidote against, well, against suicide, that’s a completely different matter. But death and psychiatry, why do we have all those government programs against suicide then? Isn’t that dying as a result of a psychiatric condition? (Psychiatrist, supportive of maintaining euthanasia option in psychiatric settings)

Fourth and as regards proportionality , a few participants with a normative stance against euthanasia in the context of psychiatry argued that psychiatric patients may not be allowed to die by means of euthanasia for as long as the field of psychiatry is under-resourced. They pointed to e.g., the lack of sufficient crisis shelters with a 24/7 availability and the lack of palliative approaches in the field of psychiatry. Instead of allowing euthanasia, they argue ‘to jolt the Belgian government’s conscience on mental health policies’. As a revolution to defeat the built-up inequalities in the field of medicine and knowing that palliative and rehabilitation initiatives in psychiatry require time.

“I oppose euthanasia in psychiatry. Compared to somatic medicine, psychiatry lags behind by 50 years. While physical pain can be managed with medication, there’s insufficient research on treatments for psychological suffering. Promising options like psilocybin and ketamine show potential in easing existential mental struggles. Magnetic stimulation can also alleviate depression, yet access remains limited. Unfortunately, these treatments are underused and under-researched. Many patients aren’t informed about these alternatives to euthanasia. It’s frustrating to see reluctance in exploring these options, especially when they offer hope to long-suffering patients. Utilizing these methods in psychiatric settings carries no risk of addiction. However, current restrictions impede access to these treatments, depriving patients of viable alternatives.” (Shortened excerpt from an interview with a psychiatrist)

When taking a societal perspective, no new arguments emerged from the respondents strongly in favour of the current euthanasia legislation, other than the main value of justice described in the subsection above. According to some, the current Law on Euthanasia busts some myths on the malleability of life and medical omnipotence, and even on psychiatric illnesses as a ‘Western phenomenon’, with e.g., depression and suicidality as a consequence of material wealth instead of a neurologic issue in the brain (only reported by some non-physicians).

There are quite a few people who consider the whole issue of the unbearable nature of psychological suffering a luxury problem, you know? They say something like, “Yeah, where are the suicide rates, to put it in equivalent terms, the lowest in the world? In Africa, because they obviously don’t have the luxury to concern themselves with that. They are already happy if they have a potato on their plate every day.” This is a viewpoint held by many, right? They call it a luxury problem, a modern, typical Western luxury problem. And perhaps there is some truth to it, right? But there are other causes of mortality there, which are much higher, such as child mortality, for example. (non-physician)

Counterarguments were also given and pointed to the value of (distributive) Justice. First, euthanasia was considered as ‘a logical but perverse consequence of systemic societal inequities’ on the one hand and the ‘further evolution towards the commodification or commercialisation of health care in individualised Western societies’ on the other. This would then lead to another vicious circle, with a rapidly growing ‘perception of vulnerable patient groups as irremediable’ and hence less likely to receive potentially beneficial treatment or other interventions. Some took a more radical stance against euthanasia in psychiatry, as they were convinced that euthanasia is nothing but ‘a perverse means to cover societal failures’. In addition, some participants with permissive stances on euthanasia in the context of psychiatry pointed to gender disparities in euthanasia requestors. This was based on the evidence that in the context of psychiatry, many more females request and die by means of euthanasia than males, and proportionally more female patient suffering from psychiatric disorders request and die by means of euthanasia compared to their fellow peers suffering from life-limiting or predominantly somatic conditions.

Finally, some respondents said that they could understand and, in some cases, even support euthanasia in some individual cases, but felt uncomfortable with its impact on the societal level. They pointed to the vicious circle of stigma and self-stigma that may impede the mentally ill to fully participate in societal encounters. In the long run, this type of societal disability may lead to vulnerable patients no longer wanting to perceive themselves a burden to society or to remain ‘socially dead’.

While considering their ethical perspectives towards euthanasia, participants weigh up various values related to and intertwining with the following levels: (1) the patient, (2) the patient’s inner circle, (3) the field of medicine, and (4) society in general. Overall, the participants shared an amalgam of ethical values on each of these four levels, regardless of their stance on euthanasia. It was mainly the interpretation of some values, the emphasis they placed on the key components underpinning each value and the importance they attach to each of the four levels, that determined their stance towards euthanasia. It was uncommon for different ethical values to be explicitly mentioned, which could distinguish distinct stances for or against euthanasia.

As regards euthanasia in the context of psychiatry, the focus has primarily been on arguments for and against euthanasia [ 23 ]. However, our study takes a more comprehensive approach, exploring the issue from a wider range of perspectives. This approach allowed us to uncover more complex insights that may have been overlooked if we had only considered it as a black-and-white issue.

Both the systematic review of Nicolini et al. [ 23 ] and our study emphasized fundamental ethical domains such as autonomy, professional duties, and the broader implications of euthanasia on mental healthcare. While our findings aligned with those of the systematic review, our inquiry delved deeper into psychiatry-specific considerations, including the influence of sudden impulses and feelings of hopelessness. This underscores the importance of healthcare professionals carefully assessing the timing and contextual aspects of such decisions within psychiatric contexts, ensuring individuals receive timely and tailored support and interventions.

Furthermore, our study extended beyond the boundaries of medical discourse, addressing broader societal ramifications. Participants engaged in discussions about ‘social death,’ a phenomenon that describes the marginalization of individuals despite their physical existence. This discussion highlighted entrenched structural inequities and societal attitudes perpetuating social alienation, particularly affecting marginalized demographics, including individuals grappling with mental health issues. Advocating for societal inclusivity and supportive measures, our study strongly emphasized the need to foster a sense of unity and respect for everyone’s worth, regardless of their circumstances.

Interpretation of the main findings

We make explicit and discuss the values corresponding to the four classical principles of biomedical ethics, in particular beneficence, non-maleficence, respect for autonomy and justice [ 31 ]. We place these values in the context of different ethical approaches, such as religious, professional, emancipatory, social, societal, and virtue-oriented approaches (see the ethical interpretation framework in OSF).

In the discussion section, therefore, the following main values and virtues are addressed: (1) the values of beneficence and non-maleficence in a religious perspective, (2) those same values in the professional context, (3) the value of autonomy in the contemporary emancipation paradigm, (4) the virtue of compassion stemming from virtue ethics theory, (5) the value of quality care in a social approach, and (6) the value of justice in societal policy contexts.

Beneficence and non-maleficence: religious perspective

In the realm of euthanasia debates, the interplay of religious beliefs and the values of ‘beneficence’ (the act of doing good) and ‘non-maleficence’ (do no harm) has emerged as a pivotal point of contention, often giving rise to divergent perspectives on this complex ethical issue [ 32 , 33 ]. Some religious traditions staunchly oppose medical end-of-life decisions, including euthanasia and abortion, viewing them as morally wrong and as disruptive to the natural order of life and death. The principle of ‘sanctity of life’ forms the bedrock of their belief system, underscoring the significance they attach to preserving life at all costs, as an embodiment of beneficence [ 34 , 35 ]. Conversely, those who argue for the ethical consideration of euthanasia emphasize the concept of beneficence in alleviating suffering and granting autonomy to individuals in their final moments. However, intriguingly, our examination of the topic has revealed a nuanced relationship between religious beliefs and attitudes toward euthanasia. While some individuals in our sample expressed strong religious convictions ( n  = 5) and even considered themselves as practicing Catholics, they did not necessarily adopt a firm normative stance against euthanasia, signifying a complex balancing of beneficence and possible maleficence within their belief system. Conversely, certain participants who held steadfastly against euthanasia ( n  = 3) did not identify with any religious belief system, yet their position was firmly grounded in their perception of potential maleficence associated with medical intervention in life and death decisions. This observation aligns with recent studies highlighting the intricate and multifaceted nature of religiosity, where individuals within various religious frameworks may hold diverse beliefs and values surrounding beneficence and non-maleficence [ 36 , 37 ]. Moreover, it underscores the powerful influence of societal culture on shaping personal perspectives on euthanasia, and how these views are entwined with the values of beneficence and non-maleficence [ 36 , 37 ].

Beneficence and non-maleficence: professional values

Second, a profound division arises between proponents and opponents, particularly in the field of medicine, where interpretations of the Oath of Hippocrates play a central role. At its core, the Oath emphasizes the deontological values of beneficence and non-maleficence, as physicians are bound by a prohibition against administering a deadly drug to ‘anyone,’ even at their explicit request, highlighting the reverence for the sanctity of life inherent in medical practice. This interpretation has led some to perceive active euthanasia as contrary to these sacred principles of preserving life. The notion of beneficence, understood as promoting the well-being of patients, appears to be in tension with the act of intentionally ending a life. Critics argue that euthanasia undermines the fundamental duty of physicians to protect and preserve life. Additionally, the principle of ‘non-maleficence,’ which entails not harming the patient or their life, is seen by some as being in accordance with the ‘sanctity of life’. However, the Oath also recognizes the significance of alleviating relentless suffering, opening the door to a nuanced debate on how these timeless principles align with the modern concept of euthanasia. As the discourse unfolds, perspectives emerge, with some viewing euthanasia as a compassionate form of care, that respects the autonomy and dignity of patients facing terminal illness or unbearable suffering. Advocates argue that euthanasia can be an act of beneficence, providing relief from pain and allowing individuals to die with dignity and control over their own fate. On the other hand, opponents of euthanasia steadfastly uphold the sanctity of life principle, viewing it as an ethical imperative that must not be compromised. They argue that intentionally ending a life, even in the context of relieving suffering, undermines the fundamental values of medical ethics and the intrinsic worth of every human life. For these individuals, euthanasia represents a profound ethical dilemma that conflicts with the near sanctity of medical ethics and the value of preserving life [ 38 , 39 , 40 ].

Autonomy: contemporary emancipation paradigm

The principle of autonomy emerges as one of the most prominent and contentious values in our contemporary emancipation paradigm. Autonomy, grounded in the belief in individual self-governance, is often cited as a foundational ethical principle in euthanasia legislation, emphasizing the significance of an individual’s capacity to make choices aligned with their own personal values and desires [ 31 ]. However, the discussion on autonomy extends beyond pure individualism, with considerations for relational autonomy, recognizing that individuals are not isolated entities but are shaped by their relationships, communities, and broader societal structures [ 41 ]. Within the context of euthanasia, the complexities of autonomy become evident as participants in the debate strived to find a delicate balance. On one hand, they stress the importance of respecting a patient’s individual autonomy in end-of-life decisions, ensuring that their choices are honoured and upheld. Simultaneously, they acknowledge the necessity of accounting for the patient’s social context and broader community when considering euthanasia as a compassionate option. Nevertheless, concerns are raised by some about the potential risks posed by euthanasia legislation, particularly for the most vulnerable individuals, such as the elderly and the mentally ill. These concerns centre on the negative consequences that may arise when individual autonomy is exercised without consideration for others or for societal well-being, and the concept of “social death,” which refers to the marginalization and exclusion of individuals from social relationships and networks due to illness or disability [ 42 , 43 ].

Amidst these complexities, the ethical value of autonomy stands as a paramount consideration. However, its application necessitates thoughtful consideration and balance with other values, including justice, equality, and societal responsibility. Recent reflections on “relational autonomy” have prompted critical evaluations of the idea of pure autonomy, emphasizing the need to delve deeper into the micro, meso, and macro levels that underpin autonomy and address potential conflicts between individual and relational autonomy [ 44 ]. Further, it highlights the imperative to take the broader societal context into account when grappling with the ethical challenges associated with euthanasia [ 45 ].

Compassion: virtue ethics

Our study confirms that while the value of autonomy holds importance, it is not the sole determinant in the ethical considerations surrounding euthanasia [ 46 ]. In this complex discourse, numerous other ethical values and virtues come to the fore, including the significance of compassion towards suffering individuals and the imperative of alleviating their distress. Notably, compassion is not merely a singular principle, but rather a profound ground attitude or virtue that motivates individuals to empathize with the pain of others and take actions to provide relief.

As revealed in our research, participants who opposed euthanasia did not invoke religious frameworks; instead, they explored diverse philosophical approaches to comprehend suffering and compassion. Among these, non-Western philosophies emphasized embracing suffering as an intrinsic aspect of life, acknowledging the impermanence of all things, including suffering. Additionally, the existentialist perspective of Albert Camus underscored suffering’s innate connection to human existence, leading to deeper self-understanding and comprehension of the world.

These philosophical viewpoints find relevance in the realm of ethics as well. Virtue ethics, in particular, highlights the significance of cultivating virtues such as courage and resilience, while narrative ethics emphasizes storytelling as a means to gain profound insight and reflection on experiences of suffering [ 47 , 48 ]. Such narratives foster empathy and create a shared sense of experience and community.

Our results show that, for some, suffering may hold positive value in various ways. The nature and intensity of suffering, alongside an individual’s values and virtues, beliefs, and coping capacity, significantly influence the ethics of euthanasia decision-making. An intricate approach that recognizes the multifaceted impacts of suffering becomes essential, acknowledging that various factors could potentially influence the experience of suffering as well as the interpretation of the consequences of the suffering experience. It’s possible that this approach doesn’t solely depend on the quantity of suffering or even its nature. Instead, it could be related to the delicate balance between one’s ability to endure suffering, the burden it places on them, and the (ir)remediableness of this burden, which can vary greatly among individuals as well as it might change over time. Such an approach aims to alleviate relentless suffering and, in certain cases, relieve unnecessary and enduring distress without consistently imposing interpretations upon it. Thus, acknowledging that, experiences of suffering are inherent to life and might act as drivers for personal development, fostering resilience, empathy, and a deeper apprehension of life’s essence, while it also might represent something irremediable, underscores the significance of a broader meaning of the concept of compassion as guiding principle in euthanasia discussions. These discussions further extend to the recognition of the dynamic trajectory inherent to the burden of suffering, as well as its potential for temporal evolution within the individual experiences of the afflicted. Such recognition not only fosters a more intricate understanding of the complex interplay between suffering and resilience but also highlights the acknowledgment that there may be moments when suffering becomes unendurable, surpassing the individual’s capacity to cope. This dimension introduces a layer of intricacy to the ethical considerations inherent in these discussions, thus necessitating a nuanced approach that contemplates the potentialities as well as the constraints of human endurance and the associated ethical ramifications.

Quality care: social approach

Examining euthanasia debates from a sociological perspective sheds light on the influence of societal inequalities in healthcare access and quality on the practice of euthanasia, and how it can shape personal, relational, and societal values, leading to the normalization or culturalization of euthanasia [ 49 ]. A noteworthy finding in this context is the contrasting perspectives on the evolving process of dying, transitioning from being perceived as in God’s hands to a more medical realm, where proponents of euthanasia view medicine as a catalyst for granting individuals greater control over the timing, manner, and circumstances of their own deaths. They envision the opportunity to be surrounded by loved ones and maintain consciousness while embracing the option of euthanasia, which they believe improves the quality of life at the end.

Proponents also emphasize additional benefits, such as enhanced transparency and regulation, ensuring ethical conduct through regulatory measures. They express concerns about a cultural environment where certain physicians adopt paternalistic attitudes and resist accepting death, prioritizing the extension of life as a moral imperative. In contrast, critical voices argue that death and dying have become increasingly medicalized, leading to their institutionalization. Some critics further contend that this medicalization has devalued the dying process and commodified life itself, leading patients, and families to increasingly rely on medical interventions at life’s end.

Moreover, as shared by some of the interviewees, the growing acceptance of medical assistance in dying may raise concerns. It’s conceivable that this evolving attitude could contribute to a perception of death undergoing a shift in seriousness, resulting in decisions about one’s life conclusion being made with less comprehensive thought and insufficient reflection. Consequently, this scenario could potentially lead individuals who are more susceptible to experiencing feelings of life’s insignificance, weariness, or sense of being ‘through with life’, to lean towards considering euthanasia. However, this inclination might also be driven by a lack of sufficient access to the necessary, long-term quality mental health care that would otherwise facilitate the pursuit of a life imbued with adequate significance, comfort, and dignity, achievable through appropriate (mental) healthcare.

Earlier research indicates that Belgium’s psychiatric care system has been grappling with underfunding and fragmentation, leading to individuals falling through the gaps in the mental health safety net [ 50 ]. One critical aspect is, e.g., the inadequate investment in long-term, intensive care, which is precisely the kind of support that individuals grappling with such existential questions may require.

Hence, in the context of euthanasia debates, the value of quality care emerges, encompassing the principle of beneficence, which emphasizes the obligation to provide good care and enhance the overall well-being of individuals. Ethical considerations go beyond the individual’s right to autonomy, extending to societal factors that influence healthcare practices and attitudes towards euthanasia. Addressing the impact of healthcare disparities and the medicalization of dying becomes imperative to ensure ethical and compassionate decision-making that upholds the true value of quality care and respect for human dignity.

Justice: societal policy contexts

In the context of euthanasia in somatic versus psychiatric medicine, ethical considerations regarding euthanasia often revolve around the fundamental value of justice [ 23 , 51 , 52 ]. Some respondents in our study emphasized the need for parity between somatic and psychiatric illnesses, recognizing that there should be no distinction between patients suffering from either. They argued that upholding the principle of justice demands equal treatment and recognition of the suffering experienced by individuals with psychiatric illnesses.

However, for others, achieving justice requires acknowledging and addressing the unique challenges faced by patients predominantly suffering from psychiatric illnesses. A comprehensive and integrated healthcare approach is proposed, where mental health is regarded as an integral part of overall health. This approach involves allocating the same level of attention and resources to psychiatric medicine as given to somatic illnesses, aiming to combat stigma and discrimination towards individuals with psychiatric conditions. Equitable treatment during life and at the end of life becomes the focus.

Yet, the Belgian context of psychiatry presents significant challenges. The field is characterized by underfunding and fragmented care, particularly for individuals with longstanding and complex psychiatric problems [ 53 ]. Additionally, the end-of-life care for psychiatric patients is still underdeveloped, and palliative psychiatry is in its early stages, lacking a uniformly agreed-upon definition or clear implementation guidelines [ 54 ]. In response, Belgium is exploring the “Oyster Care” model, designed to provide flexible, personalized care for individuals with severe and persistent mental illness who may be at risk of neglect or overburdened by psychiatric services [ 55 ]. This model aims to create a safe “exoskeleton” or supportive environment for patients, recognizing that recovery, reintegration, and resocialization might not be attainable for everyone with certain psychiatric conditions [ 55 ].

However, the integration of Oyster Care in today’s psychiatric practice is still limited and requires further development. Emphasizing the value of justice calls for continued efforts to enhance and refine psychiatric care, ensuring that individuals with psychiatric illnesses receive equitable treatment throughout their lives, including end-of-life care decisions [ 55 , 56 ].

Implications for future research, policy, and practice

In terms of policy and practice, our findings indicate that the discourse surrounding euthanasia extends beyond legal or medical considerations and encompasses fundamental ethical values that underpin our society. These values may not always be aligned and can create ethical dilemmas that are challenging to address. A value-centred approach to the euthanasia debate necessitates a constructive ethical dialogue among various actors involved, including patients, healthcare practitioners, and the wider community. This conversation should strive to comprehend the diverse values involved and endeavour to achieve a balance between these values. Additionally, ethical dialogue might encourage individuals to reflect on their own assumptions and beliefs, leading to more informed and thoughtful decision-making on ethical and moral issues. Ultimately, ethical dialogue can promote a more just and equitable society that prioritizes empathy, understanding, and mutual respect.

It is also crucial to acknowledge that patients with somatic illnesses and those with psychiatric illnesses may have different needs and expectations regarding the end of life. Hence, end-of life healthcare must be sensitive to the unique needs of each group. This recognition of differences does not justify unequal treatment or discrimination based on the type of illness. Instead, it involves addressing the different needs and expectations of each patient group while ensuring equitable and high-quality care for all.

As regards research, most articles on euthanasia legislation to date placed the emphasis on what other countries and states can learn from the Belgian and Dutch euthanasia practice. In addition, what can be learned is mainly restricted to the evidence and reflections on factual issues from a global practical-clinical perspective. Consequently, one of the main ethical, clinical, and societal issues remains unrequited, namely the impact of legislation and its consequences on an intrapersonal, interpersonal, medical, social, and societal level. Although cultural diversity is recently put high on the research agenda concerning general health care and mental health care, it is largely understudied in the context of end-of-life decisions and largely ignored in the context of psychiatry. Fewer articles have focused on what the latter countries may learn from those not implementing or not considering euthanasia legislation. In an increasingly diverse society, rapidly evolving in terms of fluidity and multi-ethnicity, cross-cultural research can help us learn from one another. To address the many dimensions of euthanasia, there is a need for input from a variety of academic fields, including sociology, anthropology, communication studies, and history. Further interdisciplinary research in all these areas could help inform policy and practice related to euthanasia.

Strengths and limitations

This is the first empirical in-depth interview study that uncovered the underlying ethical considerations of a variety and relatively large sample of health care professionals and volunteers in Belgium, a country with one of the most permissive legislative frameworks regarding euthanasia, as – unlike in some other countries – it does not exclude adults with psychiatric conditions per definition. Belgium is also one of the pioneering countries with such a legislative framework and can boast on two decades of euthanasia legislation and implementation.

We succeeded in providing a unique and representative sample of participants, varying in gender, work setting and expertise, and stances regarding euthanasia. Finally, and unlike former scientific studies that focused on either the somatic or psychiatric context, we now gauged for participants’ ethical perspectives on euthanasia in both fields of medicine.

There are also several limitations to our study. We may have experienced selection bias, as our sample of non-physicians had varying ages, but the sample of physicians was mostly older than 60. In addition, some interviews had to be postponed or cancelled due to COVID-19 restrictions and, potentially, due to legal and emotional concerns surrounding a high-profile euthanasia case being brought to court. Additionally, our sample exhibited heterogeneity regarding worldview (religious or non-religious), but possibly not regarding other culture-sensitive aspects, like migration background. As our qualitative research focused on exploring themes, narratives, and shared experiences rather than on ensuring high participation rates for statistical generalizability, drawing definitive conclusions regarding the prevalence of each opinion (pro/ambivalent/critical/against), the level of experience, or perspective across the entire spectrum of euthanasia practice is beyond the scope of our study.

Finally, although there is a growing number of countries and states around the globe with a legislative framework on euthanasia, all the legal frameworks differ from one another, so the results of our study cannot be generalized to the specific euthanasia context in e.g., Switzerland or Canada.

Our study illuminates the foundational values guiding perceptions of euthanasia, including autonomy, compassion, quality care, and justice, which permeate through four interconnected tiers: the patient, their inner circle, the medical community, and society at large. Despite varied stances on euthanasia, participants demonstrated a convergence of ethical principles across these tiers, shaped by nuanced interpretations and considerations. While explicit discussions of distinct ethical values were infrequent, their profound impact on euthanasia perspectives underscores the importance of ethical discourse in navigating this complex issue. By fostering inclusive dialogue and reconciling diverse values, we can promote informed decision-making, justice, and empathy in end-of-life care, particularly in psychiatric settings. Interdisciplinary research is essential for a comprehensive understanding of euthanasia’s dimensions and to inform policy development. While our study is rooted in Belgium, its implications extend to the broader euthanasia discourse, suggesting avenues for further exploration and cross-cultural understanding.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due reasons of privacy and anonymity, but are available from the corresponding author on reasonable request, following procedures from all 3 Medical Ethics Committees involved. To access the supplementary materials, see the Open Science Framework repository at https://osf.io/26gez/?view_only=af42caddb2554acfb7d1d5aabd4dec7a . Upon publication of this paper, the repository will be made public, and a shorter link will be provided.

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Acknowledgements

The authors wish to thank prof. dr. Kenneth Chambaere and prof. dr. Kurt Audenaert for their preliminary advice regarding the ethics of the research methodology, dr. Steven Vanderstichelen for his help with the interviews (i.e., conducting and transcribing) and all the participants for sharing their professional and in some cases also personal experiences during the interview. We’d also like to thank prof. dr. Kenneth Chambaere for the supervision during the conducting of the interviews and his feedback on the ‘near to final’ draft.

MV is funded by the Research Foundation Flanders via research project (G017818N) and PhD fellowship (1162618 N).

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The article has been developed with the following authors’ contributions: MV was responsible for the study methodology and managed ethical approval; MV conducted most of the interviews and wrote the main manuscript texts. AL drafted the ethical interpretation framework. MV, LM, KP and AL were responsible for the coding structure and data interpretation and performed a critical review and revision of the final manuscript.

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Correspondence to Monica Verhofstadt .

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This research project was performed in accordance with the Declaration of Helsinki and the European rules of the General Data Protection Regulation. It received ethical approval from the Medical Ethics Committee of the Brussels University Hospital with reference BUN 143201939499, from the Medical Ethics Committee of Ghent University Hospital with reference 2019/0456, and from the Medical Ethics Committee of the Brothers of Charity with reference OG054-2019-20. The interviews were held after obtaining informed consent from all the participants.

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MV has received research grants from the Research Foundation Flanders; no other relationships or activities that could appear to have influenced the submitted work were declared. All other authors declare that they do not have any competing interest.

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MV is the guarantor of the manuscript and affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancy from the study have been noted and explained in the manuscript.

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Verhofstadt, M., Moureau, L., Pardon, K. et al. Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium. BMC Med Ethics 25 , 60 (2024). https://doi.org/10.1186/s12910-024-01063-7

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DOI : https://doi.org/10.1186/s12910-024-01063-7

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Home > HLAW > PROGRAM > 18

Shifting Gears: Language Practices, Attitudes, and Shift in Austin, TX Among Heritage Language Speakers of Spanish

Patrick Lawrence , SUNY University at Albany Follow

31-5-2024 9:00 AM

31-5-2024 9:30 AM

Area of the Proposal

Attitudes and identity in heritage languages

The current work presents a mixed-methods study examining the intersection between language usage, attitudes, and intergenerational language shift among heritage language speakers in Austin, TX, an understudied community for language shift research. Only one study, Laosa (1975), has examined this topic here, a city where 34% of the population identifies as Hispanic, and one that has experienced unprecedented growth in the last fifteen years (U.S. Census Bureau 2022). Participants consisted of four generations of 20 heritage language speakers, whom I define as those who: a) have a personal and ethnic connection to Spanish; b) grew up in a Spanish-speaking home; and c) experienced some degree of disruption in their Spanish-language acquisition by undertaking some or all their coursework in English (Belpoliti & Gironzetti 2019; Zyzik 2020). Data collection consisted of an online questionnaire examining participants’ proficiency and language usage patterns in Spanish and English and semi-structured sociolinguistic interviews. Applying Ethnolinguistic Vitality Theory (Giles, Bourhis, and Taylor 1977) and Fishman’s Language Reversal Theory (Fishman 1991, 2001), I examined interview transcriptions to glean participants’ perceived importance of Spanish and bilingualism, as well as their personal experiences with language shift to English. I applied this approach to humanize the data, and to center voices that have been conspicuously underrepresented in previous work on this topic.

Quantitative analysis revealed that generations farther removed from immigration showed statistically significant lower rates of Spanish usage and proficiency and higher rates of English usage and proficiency (pmachistanorms in household language decisions, and fear of deportation all contribute to language shift by discouraging speakers to use Spanish and teach it to their children, thereby negatively impacting both the subjective and objective ethnolinguistic vitality of Spanish in Austin (Giles et al. 1977; Gao, Schmidt, and Gudykunst 1994; Yagmur and Ehala 2011). In sum, then, while participants expressed positive attitudes towards Spanish, they speak it less frequently than English, due do a variety of sociocultural factors, of all which underscore the difficulties of intergenerational language transmission, an apparent paradox as the overall Spanish-speaking population continues to grow both in Austin and nationwide.

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