qualitative case study interview

Qualitative Interviewing

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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

Qualitative Inquiry

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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 101: Interviewing

5 Common Mistakes To Avoid When Undertaking Interviews

By: David Phair (PhD) and Kerryn Warren (PhD) | March 2022

Undertaking interviews is potentially the most important step in the qualitative research process. If you don’t collect useful, useable data in your interviews, you’ll struggle through the rest of your dissertation or thesis.  Having helped numerous students with their research over the years, we’ve noticed some common interviewing mistakes that first-time researchers make. In this post, we’ll discuss five costly interview-related mistakes and outline useful strategies to avoid making these.

Overview: 5 Interviewing Mistakes

• Not having a clear interview strategy /plan
• Not having good interview techniques /skills
• Not securing a suitable location and equipment
• Not having a basic risk management plan
• Not keeping your “ golden thread ” front of mind

1. Not having a clear interview strategy

The first common mistake that we’ll look at is that of starting the interviewing process without having first come up with a clear interview strategy or plan of action. While it’s natural to be keen to get started engaging with your interviewees, a lack of planning can result in a mess of data and inconsistency between interviews.

There are several design choices to decide on and plan for before you start interviewing anyone. Some of the most important questions you need to ask yourself before conducting interviews include:

• What are the guiding research aims and research questions of my study?
• Will I use a structured, semi-structured or unstructured interview approach?
• How will I record the interviews (audio or video)?
• Who will be interviewed and by whom ?
• What ethics and data law considerations do I need to adhere to?
• How will I analyze my data? 

Let’s take a quick look at some of these.

The core objective of the interviewing process is to generate useful data that will help you address your overall research aims. Therefore, your interviews need to be conducted in a way that directly links to your research aims, objectives and research questions (i.e. your “golden thread”). This means that you need to carefully consider the questions you’ll ask to ensure that they align with and feed into your golden thread. If any question doesn’t align with this, you may want to consider scrapping it.

Another important design choice is whether you’ll use an unstructured, semi-structured or structured interview approach . For semi-structured interviews, you will have a list of questions that you plan to ask and these questions will be open-ended in nature. You’ll also allow the discussion to digress from the core question set if something interesting comes up. This means that the type of information generated might differ a fair amount between interviews.

Contrasted to this, a structured approach to interviews is more rigid, where a specific set of closed questions is developed and asked for each interviewee in exactly the same order. Closed questions have a limited set of answers, that are often single-word answers. Therefore, you need to think about what you’re trying to achieve with your research project (i.e. your research aims) and decided on which approach would be best suited in your case.

It is also important to plan ahead with regards to who will be interviewed and how. You need to think about how you will approach the possible interviewees to get their cooperation, who will conduct the interviews, when to conduct the interviews and how to record the interviews. For each of these decisions, it’s also essential to make sure that all ethical considerations and data protection laws are taken into account.

Finally, you should think through how you plan to analyze the data (i.e., your qualitative analysis method) generated by the interviews. Different types of analysis rely on different types of data, so you need to ensure you’re asking the right types of questions and correctly guiding your respondents.

Simply put, you need to have a plan of action regarding the specifics of your interview approach before you start collecting data. If not, you’ll end up drifting in your approach from interview to interview, which will result in inconsistent, unusable data.

2. Not having good interview technique

While you’re generally not expected to become you to be an expert interviewer for a dissertation or thesis, it is important to practice good interview technique and develop basic interviewing skills .

Let’s go through some basics that will help the process along.

Firstly, before the interview , make sure you know your interview questions well and have a clear idea of what you want from the interview. Naturally, the specificity of your questions will depend on whether you’re taking a structured, semi-structured or unstructured approach, but you still need a consistent starting point . Ideally, you should develop an interview guide beforehand (more on this later) that details your core question and links these to the research aims, objectives and research questions.

Before you undertake any interviews, it’s a good idea to do a few mock interviews with friends or family members. This will help you get comfortable with the interviewer role, prepare for potentially unexpected answers and give you a good idea of how long the interview will take to conduct. In the interviewing process, you’re likely to encounter two kinds of challenging interviewees ; the two-word respondent and the respondent who meanders and babbles. Therefore, you should prepare yourself for both and come up with a plan to respond to each in a way that will allow the interview to continue productively.

To begin the formal interview , provide the person you are interviewing with an overview of your research. This will help to calm their nerves (and yours) and contextualize the interaction. Ultimately, you want the interviewee to feel comfortable and be willing to be open and honest with you, so it’s useful to start in a more casual, relaxed fashion and allow them to ask any questions they may have. From there, you can ease them into the rest of the questions.

As the interview progresses , avoid asking leading questions (i.e., questions that assume something about the interviewee or their response). Make sure that you speak clearly and slowly , using plain language and being ready to paraphrase questions if the person you are interviewing misunderstands. Be particularly careful with interviewing English second language speakers to ensure that you’re both on the same page.

Engage with the interviewee by listening to them carefully and acknowledging that you are listening to them by smiling or nodding. Show them that you’re interested in what they’re saying and thank them for their openness as appropriate. This will also encourage your interviewee to respond openly.

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3. Not securing a suitable location and quality equipment

Where you conduct your interviews and the equipment you use to record them both play an important role in how the process unfolds. Therefore, you need to think carefully about each of these variables before you start interviewing.

Poor location: A bad location can result in the quality of your interviews being compromised, interrupted, or cancelled. If you are conducting physical interviews, you’ll need a location that is quiet, safe, and welcoming . It’s very important that your location of choice is not prone to interruptions (the workplace office is generally problematic, for example) and has suitable facilities (such as water, a bathroom, and snacks).

If you are conducting online interviews , you need to consider a few other factors. Importantly, you need to make sure that both you and your respondent have access to a good, stable internet connection and electricity. Always check before the time that both of you know how to use the relevant software and it’s accessible (sometimes meeting platforms are blocked by workplace policies or firewalls). It’s also good to have alternatives in place (such as WhatsApp, Zoom, or Teams) to cater for these types of issues.

Poor equipment: Using poor-quality recording equipment or using equipment incorrectly means that you will have trouble transcribing, coding, and analyzing your interviews. This can be a major issue , as some of your interview data may go completely to waste if not recorded well. So, make sure that you use good-quality recording equipment and that you know how to use it correctly.

To avoid issues, you should always conduct test recordings before every interview to ensure that you can use the relevant equipment properly. It’s also a good idea to spot check each recording afterwards, just to make sure it was recorded as planned. If your equipment uses batteries, be sure to always carry a spare set.

4. Not having a basic risk management plan

Many possible issues can arise during the interview process. Not planning for these issues can mean that you are left with compromised data that might not be useful to you. Therefore, it’s important to map out some sort of risk management plan ahead of time, considering the potential risks, how you’ll minimize their probability and how you’ll manage them if they materialize.

Common potential issues related to the actual interview include cancellations (people pulling out), delays (such as getting stuck in traffic), language and accent differences (especially in the case of poor internet connections), issues with internet connections and power supply. Other issues can also occur in the interview itself. For example, the interviewee could drift off-topic, or you might encounter an interviewee who does not say much at all.

You can prepare for these potential issues by considering possible worst-case scenarios and preparing a response for each scenario. For instance, it is important to plan a backup date just in case your interviewee cannot make it to the first meeting you scheduled with them. It’s also a good idea to factor in a 30-minute gap between your interviews for the instances where someone might be late, or an interview runs overtime for other reasons. Make sure that you also plan backup questions that could be used to bring a respondent back on topic if they start rambling, or questions to encourage those who are saying too little.

In general, it’s best practice to plan to conduct more interviews than you think you need (this is called oversampling ). Doing so will allow you some room for error if there are interviews that don’t go as planned, or if some interviewees withdraw. If you need 10 interviews, it is a good idea to plan for 15. Likely, a few will cancel , delay, or not produce useful data.

5. Not keeping your golden thread front of mind

We touched on this a little earlier, but it is a key point that should be central to your entire research process. You don’t want to end up with pages and pages of data after conducting your interviews and realize that it is not useful to your research aims . Your research aims, objectives and research questions – i.e., your golden thread – should influence every design decision and should guide the interview process at all times. 

A useful way to avoid this mistake is by developing an interview guide before you begin interviewing your respondents. An interview guide is a document that contains all of your questions with notes on how each of the interview questions is linked to the research question(s) of your study. You can also include your research aims and objectives here for a more comprehensive linkage. 

You can easily create an interview guide by drawing up a table with one column containing your core interview questions . Then add another column with your research questions , another with expectations that you may have in light of the relevant literature and another with backup or follow-up questions . As mentioned, you can also bring in your research aims and objectives to help you connect them all together. If you’d like, you can download a copy of our free interview guide here .

Recap: Qualitative Interview Mistakes

In this post, we’ve discussed 5 common costly mistakes that are easy to make in the process of planning and conducting qualitative interviews.

To recap, these include:

If you have any questions about these interviewing mistakes, drop a comment below. Alternatively, if you’re interested in getting 1-on-1 help with your thesis or dissertation , check out our dissertation coaching service or book a free initial consultation with one of our friendly Grad Coaches.

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• Types of Interviews in Research | Guide & Examples

Types of Interviews in Research | Guide & Examples

Published on March 10, 2022 by Tegan George . Revised on June 22, 2023.

An interview is a qualitative research method that relies on asking questions in order to collect data . Interviews involve two or more people, one of whom is the interviewer asking the questions.

There are several types of interviews, often differentiated by their level of structure.

• Structured interviews have predetermined questions asked in a predetermined order.
• Unstructured interviews are more free-flowing.
• Semi-structured interviews fall in between.

Interviews are commonly used in market research, social science, and ethnographic research .

Table of contents

What is a structured interview, what is a semi-structured interview, what is an unstructured interview, what is a focus group, examples of interview questions, advantages and disadvantages of interviews, other interesting articles, frequently asked questions about types of interviews.

Structured interviews have predetermined questions in a set order. They are often closed-ended, featuring dichotomous (yes/no) or multiple-choice questions. While open-ended structured interviews exist, they are much less common. The types of questions asked make structured interviews a predominantly quantitative tool.

Asking set questions in a set order can help you see patterns among responses, and it allows you to easily compare responses between participants while keeping other factors constant. This can mitigate   research biases and lead to higher reliability and validity. However, structured interviews can be overly formal, as well as limited in scope and flexibility.

• You feel very comfortable with your topic. This will help you formulate your questions most effectively.
• You have limited time or resources. Structured interviews are a bit more straightforward to analyze because of their closed-ended nature, and can be a doable undertaking for an individual.
• Your research question depends on holding environmental conditions between participants constant.

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Semi-structured interviews are a blend of structured and unstructured interviews. While the interviewer has a general plan for what they want to ask, the questions do not have to follow a particular phrasing or order.

Semi-structured interviews are often open-ended, allowing for flexibility, but follow a predetermined thematic framework, giving a sense of order. For this reason, they are often considered “the best of both worlds.”

However, if the questions differ substantially between participants, it can be challenging to look for patterns, lessening the generalizability and validity of your results.

• You have prior interview experience. It’s easier than you think to accidentally ask a leading question when coming up with questions on the fly. Overall, spontaneous questions are much more difficult than they may seem.
• Your research question is exploratory in nature. The answers you receive can help guide your future research.

An unstructured interview is the most flexible type of interview. The questions and the order in which they are asked are not set. Instead, the interview can proceed more spontaneously, based on the participant’s previous answers.

Unstructured interviews are by definition open-ended. This flexibility can help you gather detailed information on your topic, while still allowing you to observe patterns between participants.

However, so much flexibility means that they can be very challenging to conduct properly. You must be very careful not to ask leading questions, as biased responses can lead to lower reliability or even invalidate your research.

• You have a solid background in your research topic and have conducted interviews before.
• Your research question is exploratory in nature, and you are seeking descriptive data that will deepen and contextualize your initial hypotheses.
• Your research necessitates forming a deeper connection with your participants, encouraging them to feel comfortable revealing their true opinions and emotions.

A focus group brings together a group of participants to answer questions on a topic of interest in a moderated setting. Focus groups are qualitative in nature and often study the group’s dynamic and body language in addition to their answers. Responses can guide future research on consumer products and services, human behavior, or controversial topics.

Focus groups can provide more nuanced and unfiltered feedback than individual interviews and are easier to organize than experiments or large surveys . However, their small size leads to low external validity and the temptation as a researcher to “cherry-pick” responses that fit your hypotheses.

• Your research focuses on the dynamics of group discussion or real-time responses to your topic.
• Your questions are complex and rooted in feelings, opinions, and perceptions that cannot be answered with a “yes” or “no.”
• Your topic is exploratory in nature, and you are seeking information that will help you uncover new questions or future research ideas.

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Depending on the type of interview you are conducting, your questions will differ in style, phrasing, and intention. Structured interview questions are set and precise, while the other types of interviews allow for more open-endedness and flexibility.

Here are some examples.

• Semi-structured
• Unstructured
• Focus group
• Do you like dogs? Yes/No
• Do you associate dogs with feeling: happy; somewhat happy; neutral; somewhat unhappy; unhappy
• If yes, name one attribute of dogs that you like.
• If no, name one attribute of dogs that you don’t like.
• What feelings do dogs bring out in you?
• When you think more deeply about this, what experiences would you say your feelings are rooted in?

Interviews are a great research tool. They allow you to gather rich information and draw more detailed conclusions than other research methods, taking into consideration nonverbal cues, off-the-cuff reactions, and emotional responses.

However, they can also be time-consuming and deceptively challenging to conduct properly. Smaller sample sizes can cause their validity and reliability to suffer, and there is an inherent risk of interviewer effect arising from accidentally leading questions.

Here are some advantages and disadvantages of each type of interview that can help you decide if you’d like to utilize this research method.

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

• Student’s  t -distribution
• Normal distribution
• Null and Alternative Hypotheses
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Data cleansing
• Reproducibility vs Replicability
• Peer review
• Prospective cohort study

Research bias

• Implicit bias
• Cognitive bias
• Placebo effect
• Hawthorne effect
• Hindsight bias
• Affect heuristic
• Social desirability bias

The four most common types of interviews are:

• Structured interviews : The questions are predetermined in both topic and order. 
• Semi-structured interviews : A few questions are predetermined, but other questions aren’t planned.
• Unstructured interviews : None of the questions are predetermined.
• Focus group interviews : The questions are presented to a group instead of one individual.

The interviewer effect is a type of bias that emerges when a characteristic of an interviewer (race, age, gender identity, etc.) influences the responses given by the interviewee.

There is a risk of an interviewer effect in all types of interviews , but it can be mitigated by writing really high-quality interview questions.

Social desirability bias is the tendency for interview participants to give responses that will be viewed favorably by the interviewer or other participants. It occurs in all types of interviews and surveys , but is most common in semi-structured interviews , unstructured interviews , and focus groups .

Social desirability bias can be mitigated by ensuring participants feel at ease and comfortable sharing their views. Make sure to pay attention to your own body language and any physical or verbal cues, such as nodding or widening your eyes.

This type of bias can also occur in observations if the participants know they’re being observed. They might alter their behavior accordingly.

A focus group is a research method that brings together a small group of people to answer questions in a moderated setting. The group is chosen due to predefined demographic traits, and the questions are designed to shed light on a topic of interest. It is one of 4 types of interviews .

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

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The case study as a type of qualitative research

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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

New directions in case study

Although “pragmatic” case studies (ie, utilizing practical and applicable methods) have existed within psychotherapy for some time, 47 , 48 only recently has the applicability of pragmatism as an underlying paradigmatic perspective been considered in HSR. 49 This is marked by uptake of pragmatism in Randomized Control Trials, recognizing that “gold standard” testing conditions do not reflect the reality of clinical settings 50 , 51 nor do a handful of epistemologically guided methodologies suit every research inquiry.

Pragmatism positions the research question as the basis for methodological choices, rather than a theory or epistemology, allowing researchers to pursue the most practical approach to understanding a problem or discovering an actionable solution. 52 Mixed methods are commonly used to create a deeper understanding of the case through converging qualitative and quantitative data. 52 Pragmatic case study is suited to HSR because its flexibility throughout the research process accommodates complexity, ever-changing systems, and disruptions to research plans. 49 , 50 Much like case study, pragmatism has been criticized for its flexibility and use when other approaches are seemingly ill-fit. 53 , 54 Similarly, authors argue that this results from a lack of investigation and proper application rather than a reflection of validity, legitimizing the need for more exploration and conversation among researchers and practitioners. 55

Although occasionally misunderstood as a less rigourous research methodology, 8 case study research is highly flexible and allows for contextual nuances. 5 , 6 Its use is valuable when the researcher desires a thorough understanding of a phenomenon or case bound by context. 11 If needed, multiple similar cases can be studied simultaneously, or one case within another. 16 , 17 There are currently three main approaches to case study, 5 , 17 , 24 each with their own definitions of a case, ontological and epistemological paradigms, methodologies, and data collection and analysis procedures. 37

Individuals’ experiences within health systems are influenced heavily by contextual factors, participant experience, and intricate relationships between different organizations and actors. 55 Case study research is well suited for HSR because it can track and examine these complex relationships and systems as they evolve over time. 6 , 7 It is important that researchers and health leaders using this methodology understand its key tenets and how to conduct a proper case study. Although there are many examples of case study in action, they are often under-reported and, when reported, not rigorously conducted. 9 Thus, decision-makers and health leaders should use these examples with caution. The proper reporting of case studies is necessary to bolster their credibility in HSR literature and provide readers sufficient information to critically assess the methodology. We also call on health leaders who frequently use case studies 56 – 58 to report them in the primary research literature.

The purpose of this article is to advocate for the continued and advanced use of case study in HSR and to provide literature-based guidance for decision-makers, policy-makers, and health leaders on how to engage in, read, and interpret findings from case study research. As health systems progress and evolve, the application of case study research will continue to increase as researchers and health leaders aim to capture the inherent complexities, nuances, and contextual factors. 7

• Open access
• Published: 04 September 2024

Experiences of patients with advanced chronic diseases and their associates with a structured palliative care nurse visit followed by an interprofessional case conference in primary care – a deductive-inductive content analysis based on qualitative interviews (KOPAL-Study)

• Nadine Janis Pohontsch   ORCID: orcid.org/0000-0002-0966-4087 1 ,
• Jan Weber   ORCID: orcid.org/0000-0001-5563-368X 2 ,
• Stephanie Stiel   ORCID: orcid.org/0000-0002-5963-2526 2 ,
• Franziska Schade   ORCID: orcid.org/0000-0003-3158-4259 2 , 3 ,
• Friedemann Nauck   ORCID: orcid.org/0000-0001-7592-1654 3 ,
• Janina Timm 1 ,
• Martin Scherer 1 &
• Gabriella Marx   ORCID: orcid.org/0000-0001-6807-9518 1  

BMC Primary Care volume  25 , Article number:  323 ( 2024 ) Cite this article

Metrics details

Chronic, non-malignant diseases (CNMD) like chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia in advanced stages are very burdensome for patients. Timely palliative care with strong collaboration between general practitioners (GPs) and specialist palliative home care (SPHC) teams can reduce symptom burden, hospitalization rates, hospitalization costs and overall healthcare costs. The KOPAL-study on strengthening interprofessional collaboration for patients with palliative care needs tested the effect of an intervention comprising of a SPHC nurse assessment and an interprofessional case conference. This qualitative evaluative study explores patients’, proxies’ and their associates’ motivation to participate in the KOPAL-study and views on the (benefits of the) intervention.

We interviewed 13 male and 10 female patients as well as 14 proxies of patients with dementia and six associates of study participants using a semi-structured interview guide. All interviews were digitally recorded, transcribed verbatim and analysed with deductive-inductive qualitative content analysis.

Motivation for participation was driven by curiosity, the aim to please the GP or to support research, respectively to help other patients. Few interviewees pointed out to have expected positive effects for themselves. The nurse visit was evaluated very positively. Positive changes concerning health care or quality of life were reported sparsely. Most study participants did not prepare for the SPHC nurse assessment. They had no expectations concerning potential benefits of such an assessment, the interdisciplinary case conference and an early integration of palliative care. The majority of interviewees reported that they did not talk about the nurse visit and the interprofessional case conference with their GPs.

Our results lead to the conclusion that SPHC nurses can serve as an advocate for the patient and thereby support the patients’ autonomy. GPs should actively discuss the results of the interdisciplinary case conference with patients and collaboratively decide on further actions. Patient participation in the interdisciplinary case conference could be another way to increase the effects of the intervention by empowering patients to not just passively receive the intervention.

Trial registration

DRKS00017795 German Clinical Trials Register, 17Nov2021, version 05.

Peer Review reports

Chronic, non-malignant diseases (CNMD) like chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia are very burdensome in advanced stages. CNMD are among the most frequent causes of death in Europe and worldwide [ 1 , 2 , 3 , 4 ]. Their numbers will increase in the near future. CNMD are often characterized by high medical complexity and prognostic uncertainty of their course. Timely palliative care can reduce symptom burden, hospitalization rates, hospitalization costs and overall healthcare costs [ 5 , 6 , 7 , 8 , 9 , 10 ]. Either way, it is provided predominantly to patients with oncological diseases (e.g., [ 11 ]), but not to patients with CNMD. Unsurprisingly, research indicates unmet palliative care needs in patients with CNMD [ 12 , 13 ].

In Germany, palliative home care is divided in general (GPHC) and specialist palliative home care (SPHC). GPHC is provided by general practitioners (GPs), medical specialists and nursing services. SPHC is provided by high qualified health care professionals’ in multiprofessional SPHC teams. Intensive collaboration between GPs and SPHC teams supports the appropriate provision of care for patients with CNMD [ 12 ]. Case conferences are one option to intensify collaboration. Mitchell et al. [ 14 ] showed in a pilot study in Australia that a case conference between GPs and a SPHC team, preceded by a patient-caregiver-nurse conversation on issues of importance, can reduce the number of emergency department visits, hospital admissions and length of stay in hospitals. A strong desire for more intensive collaboration between GPs and specialist palliative care providers exists [ 15 , 16 , 17 ]. Either way, different barriers, e.g. insufficient communication and fragmentation [ 18 ], lack of clarity of prognosis and the hegemony of the curative approach [ 19 ], prevent a timely collaboration. Collaboration between these groups of health care providers needs to be facilitated. Well-prepared case conferences could be part of the solution [ 14 , 20 ]. The (potentially positive) role of palliative care nurses or nurse practitioners in timely delivery of palliative care is widely discussed (e.g., [ 21 , 22 ]). There are some indications from the field of residential aged care and palliative care that health professionals, patients and family caregivers support the idea of interdisciplinary case conferences (e.g. [ 14 , 23 , 24 ]). For instance, Mitchell et al. [ 14 ] report health care professionals’ enthusiasm about an interdisciplinary case conference with a preceding patient-caregiver-nurse conversation.

The KOPAL-study on strengthening interprofessional collaboration for patients with palliative care needs is a multicentre, two-arm, cluster-randomized controlled trial (RCT, [ 25 ]). It tested the effect of an intervention comprising of a SPHC nurse assessment, a brief consultation between this SPHC nurse and a SPHC physician and an interprofessional case conference of SPHC nurse, SPHC physician and GP. It aimed at reducing hospitalizations, symptom burden, medication use, and increasing patients’ quality of life and medical providers’ collaboration within 48 weeks after intervention [ 25 ]. A multiperspectival quantitative and qualitative evaluation including all participating actors was part of the KOPAL-study [ 26 , 27 ]. In this paper the qualitative evaluation of the patients’ perspective will be addressed.

We aimed to answer the following research questions: What motivated patients and their proxies to take part in the study? How did the patients experience the individual components of the intervention? From the patients’ and proxies’ point of view, what has changed in patients’ health and healthcare as a result of study participation?

We conducted qualitative interviews with patients, proxies (for persons with dementia) and their associates, and analyzed them using a deductive-inductive approach of content analysis [ 28 ] to assess feasibility and acceptance of the KOPAL-intervention.

The KOPAL-study and intervention

The KOPAL-study [ 25 ] comprises a RCT and its quantitative and qualitative evaluation from different perspectives (GPs, SPHC nurse and physicians, and patients, their proxies and associates). Patients with COPD [ 29 ], CHF [ 30 ] and dementia [ 31 ] and dementia patients’ associates (as proxies) took part in the study. For further description of the patient population see [ 26 ]. The control arm provided patients with usual care (i.e. intervention was not offered at a later point in time) while the intervention comprises of a home-visit or (due to the COVID-19 pandemic) telephone call of a SPHC nurse, followed by a consultation between this nurse and a SPHC physician, and an interprofessional case conference (via telephone) of the GP, the SPHC nurse and the SPHC physician.

The SPHC nurses used the ´KOPAL conversation guide´ [ 32 ] to assess patients’ current life and health situation. Participants were neither instructed to prepare for the conversation with the nurse nor to discuss it with the GP afterwards. Correspondingly GPs were not instructed to explicitly discuss the case conference and its results with the patients. The SPHC nurse home visit (respectively phone call) lasted approx. 60 min. Case conferences lasted 5–60 min (on average 18 min) per patient and followed no prescribed structure. The qualitative evaluation interviews took place after the last follow-up-interview (48 weeks after baseline assessment/intervention) to avoid influencing the intervention.

Recruitment and participants

Following a purposive sampling approach [ 33 ] we aimed at recruiting participating patients or proxies respectively and close relatives or acquainted persons of the patients (hereafter called associates). At the end of the last standardized follow up-interview all 65 study participants remaining in the intervention group (patients or proxies) were invited to participate in a qualitative interview to share their experiences with and thoughts about the KOPAL-study/intervention. Patients willing to take part in the qualitative interview were invited to name an associate to be interviewed, too. Usually these associates did not participate in any component of the KOPAL-study, but nevertheless had (some) knowledge about the patients’ participation in the study. Proxies of people with dementia were not asked to name another potential interviewee as they already fill the associate role.

Potential interviewees received verbal and written study information, a response sheet and a prepaid envelope. Interview participation was voluntary, reasons for non-participation were not collected. Persons willing to participate gave their written informed consent before the interview conduction. Interviewees did not receive an allowance.

Of those invited, 37 participants (42%) [patients ( n  = 23), proxies ( n  = 14)] were willing to take part in an interview. All 23 patients willing to participate were asked to name an associate. Seven patients did so. Subsequently seven associates were invited of which 6 (86%) participated. We interviewed 13 male patients ( n  = 8 with COPD, n  = 5 with CHF) and 10 female patients with COPD ( n  = 2), CHF ( n  = 5) or both ( n  = 2). 14 proxies of patients with dementia ( n  = 7 wives, n  = 3 daughters and one sister, son, husband and partner respectively) and six associates ( n  = 4 wives, n  = 2 husbands; living together) of study participants were also interviewd. Patient interviews lasted 14–45 min (mean 26 min), interviews with proxies 18–54 min (mean 27 min) and interviews with associates 8–50 min (mean 25 min).

Interview conduction

JW and NP conducted all the interviews using a semi-structured topic guide [ 34 ] via telephone between 02/2021 and 03/2022. Telephone interviews were favored to face-to-face-interviews due to the ongoing COVID-19-pandemic. All interviews were digitally recorded and transcribed verbatim. NP and JW were known to some, but not all study participants from the recruiting and standardized interviewing procedures of the KOPAL-study. No further relationship/dependency existed between researchers and interviewees.

Interview guide

The interview guide was based on the research questions. The guide was available in three different versions (for patients, proxies of a person with dementia or associates). Topics were: the overall evaluation of the KOPAL-intervention, changes in health care and state triggered by the intervention, as well as the GP-patient-/-proxy/-associate-interaction following the case conference. See Table  1 for a translated version of the interview guide for patients who talked to the SPHC nurse on the phone (majority of interviewees). Corresponding guides for the interviews with the proxies and associates can be found in additional file 1 and 2.

Data analysis

We (NP, JT and JW) analyzed the data using structuring qualitative content analysis as described by Kuckartz [ 28 ]. This kind of qualitative analysis is used to systematically extract, structure, describe and condense interviewees’ answers to open questions following designated rules. We chose a deductive-inductive approach to category-building using the same coding system for all interviews. NP, JT and JW familiarized themselves with the interview transcripts before coding. As starting point for the analysis deductive categories were derived from the interview guide and research questions by NP (in discussion with JW). Additional inductive categories were created either when existing deductive categories did not capture the content of the transcripts (e.g. new topics emerged from the material) or deductive categories needed subcategories to refine the coding system. If a relevant fragment was first identified, a category name was derived from this fragment and a description of the category was drafted, supplemented by a supporting quote. Codes could be assigned to text fragments adopting different sizes (ranging from part of a sentence to one or more paragraphs) in relation to the segment length needed to understand the content and context of the relevant accounts.

NP started the coding process with two transcripts and discussed coding with JW. JW coded two more manuscripts using and refining the coding system created by NP. When necessary additional inductive categories were created throughout the further coding process by JT, JW and NP. All changes to the coding system were discussed between NP, JW, JT and GM. Coding and category development were constantly discussed throughout the research process until the data relevant to the research questions were completely coded. To ensure intersubjective comprehensibility and credibility [ 35 ] of the analysis the results were discussed with GM on regular basis and presented and discussed at the DEGAM congress 2022. Data were managed and analysis was carried out using MAXQDA 12. Illustrating quotes in the results section were translated from German by NP and double checked by JW. “/” indicates an abrupt ending of a word or sentence.

Researcher characteristics

Researchers’ characteristics, beliefs and assumptions can influence qualitative research and data interpretation [ 36 ]. NP: female, psychologist, experiences in qualitative research (QR) in the field of health services/care research; JT: female, student of Public Health (M.A.), experiences in QR; JW: male, public health researcher, experiences in QR, GM: female, sociologist, experiences in QR in the field of medical sociology and health services/care research.

The study was reviewed and approved by the local ethics committee of the Medical Association Hamburg, Germany (no. PV7090) as well as the ethics committees of the University Medical Centre Goettingen, Germany (no. 34/1/20Ü), the Hannover Medical School (no. 8815 BO K 2019), and the University of Oldenburg (no. 2019 − 145). The trial is registered in the German clinical trial register (registration number DRKS00017795; first registration 09/01/2020).

Interviewees talked positively about study participation and the nurse visit. They described themselves as being motivated to participate by curiosity, wanting to do the GP a favor and support research to help other patients. Positive effects concerning health care or quality of life were meagerly reported. Most interviewees reported no communication about the KOPAL study or intervention with their treating and participating GPs.

All in all, 43 interviews were analyzed and coded. The results section is structured according to the research questions: (a) motivation to take part in the study, (b) evaluation of the intervention components and (c) changes in health and healthcare. Table  2 shows an overview over the main and subcategories described in the following section.

A) Motivation to take part in the study

Interviewees stated different motivations to take part in the study, most of them not related to their potential personal benefit, but to overarching goals like satisfying their own curiosity and being helpful to GPs, researchers and other patients.

Participants stated that they were curious to take part in the study or flattered that the university was interested in them. Some saw a chance to learn something new or get insights into research studies by taking part in the study, like this patients’ with dementia wife (taking part as a proxy): “Y es , I said I’d do it , why not? I mean , you can only learn from it.” (R1). Nearly no interviewee seemed to be motivated by specific hopes or expectations in relation to their own health or care burden.

Pleasing the GP

Potential participants received the invitation to take part in the study from their treating GPs. Study participants stated that they took part in the study because their GP proposed or ‘recommended’ the study to them, implying that it would be good for them to take part.

Patient: Well participation , because and my GP Dr. [name] somehow recommended me , recommended me or I don’t know how that/ , that’s how it came about and I didn’t want to say no , because I like Dr. [name] very much and he actually is a , I would say , very open-minded doctor. (R2, COPD)

Other just participated in order to please or help their GPs (being study participants on cluster level). This impetus was mostly based on a stable positive relationship between the patients (or their proxies) and the GPs.

Proxy: […] So because she is , she is very engaged and puts out her feelers in many areas , I will say , is very curious and I have already benefited from that. I just thought , if Ms. [name] wants to take part in such a study , then it is also important to her , and that’s why I said , okay , she looks after my mother so well , so we really feel in good hands there , […] , but I thought so , if Ms. [name] takes part there , then I would also like to support her there. (R3, daughter)

In both cases it seemed as if interviewees did not want to refuse their family doctor’s request to participate.

Make a contribution to research and helping other patients

Interviewees described that in their opinion doing research has a value in itself and should therefore be supported.

Associate: […] well there is little stuff with regard to studies […] on COPD , […] from a scientific point of view that’s a relatively new disease. […] you have to be thankful and support everything there is , […] that there are people , who try to do something against it or search for or find help. Well/ And that’s why this was for us , well , if I may speak for us , this was self-evident , that we would take part. […] (R4, husband)

Participants described themselves as motivated by the prospect of helping others, future patients or patients that are worse off than themselves.

Patient: Well , I think it is very important to conduct studies , […] from which everybody can learn […] , however , that you are open to it for a start and help even more. That’s why I’m always willing to take part in studies. (R5, heart failure)

Asked globally, many of the interviewed patients did not remember or state to have expected immediate specific positive effects for themselves from taking part in this research study.

Specific care-related expectations

Many interviewees were unable to name specific expectations that motivated their study participation or stated that they had none except the abovementioned (e.g. doing the GP a favor or one’s stint for research). Some interviewees mentioned specific care-related expectations such as reduction or change of medication. For example one patient with heart failure and a long medication list stated: “ Well , I hoped that I would have to take less tablets. And also , that I would maybe a little bit less worn-out. […]” (R6). Others expected to get better treatment in general, get recommendations with regard to physicians to consult or improvement of their health (behavior).

Patient: Well , in fact , that what I said at the end , with a background of “Maybe they can help me.” , no? With my bronchia , for example , no? That you really say “Gosh , Mr. [name] , […] , maybe you could go there and there , to this or that physician. Or to this or that clinic. And then you let yourself get examined thoroughly.” […] . (R7, COPD)

Another care-related expectation was to receive support and recommendations for associates or informal caregivers.

Proxy: […] and I had expected that you would have one or the other hint , what to do better or how my mother’s care could get more extensive […] . (R3, daughter)

Some interviewees reported rather unspecific expectations like getting some (unspecified) kind of help or impulses for caring for their relatives (interviewed proxies) and having another contact person. Some had misguided expectations like taking part in a trial to test a new medication.

B) Evaluation of the KOPAL intervention

Even though recall was often limited due to the long period of time since the intervention, interviewees reported some assessments of the intervention components. The overall evaluation of the KOPAL-intervention was positive. Little communication between patients and professionals was reported.

Evaluation of the SPHC nurse home-visit

Positive evaluation.

The guided conversation left room for questions not only to be asked by the nurse, but also by the interviewees. Sometimes welcome advice was given by the SPHC nurse, although that was not intended. Interviewees reported that there was enough time to discuss all topics of importance.

Proxy: Well , I thought it to be very good and intimate , no? To some extend she counseled us on what you could do and it was very intimate somehow. In contrary to being pegged , queried and then we will see what we can do , no? […] She had also taken a lot of time to do it. Not working under time pressure. (R8, life partner)

Interviewees described the palliative care nurse as friendly, attentive and competent. All in all, interviewees evaluated the SPHC nurse home-visit positively. Some interviewees stated that they had not benefited from the nurse visit, but they did not evaluate that negatively.

Topics discussed

According to the interviewees the content of the conversations with the SPHC nurse covered a wide spectrum from more general discussions of the overall situation to counselling on targeted support measures.

Patient: Yes , it was a lot about my degree of care and […] how I can get other support besides my husband , who is my carer , can get other support. And I found that very good. (R5, heart failure)

Other topics were dying and palliative care, provision of medical aids, pain and nursing services.

Patient: Yes , […] that one then also possibly has such , an example , if one now has it [COPD/CHF] really extremely […] that one can then also go to such a ward , that one is cared for palliative , to die. […] Or that you might want to die at home , but what I have often explained in our conversations is that […] I don’t want that. That I would die here at home somehow. (R9, COPD)

General topics included for example health, household chores, self-care or mobility. More specific topics like getting support from volunteers, application for services of the public care insurance (‘care degree’) or preparation of mandates.

Communication between the GP and the patient

All in all the interviewees reported little communication between themselves and the GPs concerning the KOPAL study and intervention.

Communication on study participation

Most of the interviewees reported that there was no conversation about the KOPAL-study between them and their treating GPs. It seems, from the interviewees’ perspective, that GPs might have had too little time to discuss the subject in a consultation: “No , she didn’t have time for that (laughs). […] (R5 , heart failure). Some GPs inquired whether the patients decided to take part in the study but never mentioned the study again as far as the interviewees remembered.

Proxy: […] The doctor , Ms. [name] , had not commented on it at all. She had only asked at the beginning whether we had participated and whether we had received a visit from Cobra [mispronounced name of the KOPAL-study] , and I had said “Yes , that’s so and the first talks have already been held , also by telephone” and she agreed to that. That was enough for her. (R8, life partner)

Other interviewees mentioned that they seldom consulted the GP during the time of the study indicating that that might have been a reason for not having discussed aspects of the KOPAL study or intervention during consultations.

Communication on the palliative care nurse visit and case conference

The study design did not specify whether the GPs should communicate the results of the case conference. It has been shown, that apparently only few of them have sought a conversation with their patients (or patients’ proxies). Most interviewees reported that neither the visit of the SPHC nurse nor the case conference were addressed between them and the treating GPs.

Patient: Yes , I was surprised , but he didn’t talk to me about it , and I said I didn’t really have to talk to him about it. Because he has always found out everything I need in terms of my health and I have discussed it with him. But I didn’t talk it through with him. (R10, heart failure)

In most cases neither the patients or proxies nor the GPs seem to have taken initiative to talk about the component of the KOPAL-intervention with each other.

C) Changes in health and healthcare

Interviewees did not associate many positive effects, benefits or changes to the KOPAL-intervention. They did not mention any negative consequences due to their study participation either.

Subjective benefit from the intervention and specific changes

Some specific changes due to the KOPAL-intervention were mentioned. The interviewees sometimes also mentioned other positive aspects or benefits from the KOPAL-study. Some patients reported changes or reduction in medications.

Patient: […] I had announced all my tablets , there was a woman here with me once and she wrote down everything with my tablets , and the professor [incorrect reference to the SPHC physician] immediately called my doctor […]. And then he immediately said , “She should leave that tablet out and he’ll prescribe another one instead.“. And that really helped , it was very good. […] (R11, heart failure)

Other interviewees mentioned additional household help respectively nursing service, the grant of a new care degree and associated eligibility for services by the public care insurance, more home visits of the GP, and the expansion of care to a SPHC service.

Patient: […] since they were here and I get care allowance , if that’s what you mean. […] Yes , that’s it for the moment , at the moment the tablets for the whole week , they come on Monday from community (A) from the deaconry […] and bring them to us for the whole week , and we need household help […] I can’t manage that either , because I can’t bend down so well […] Anyway , now we have the money for the help we need. (R12, heart failure)

All in all, patients, proxies and associates reported only little or often no subjective benefits that they trace back to the KOPAL-intervention throughout the interviews. “ Well , nothing at all in terms of medical care. Everything has remained the same.” (R4, husband) therefore was a common statement. Most interviewees do not seem to have noticed any major changes.

Main results

The KOPAL-study [ 25 ] tests the effect of a novel compact intervention (SPHC nurse home-visit and an interprofessional case conference) on reduction of hospital admissions, symptom burden, health costs, and improvement of quality of life. We evaluated the patients’, proxies’, and associates’ perception of the intervention, specifically the SPHC nurse visit, by conducting and analyzing qualitative interviews. Motivation for participation was driven by curiosity, the aim to please the GP or to support research, respectively to help other patients. Only few interviewees pointed out to have expected positive effects for themselves. The nurse visit was evaluated very positively. Positive changes concerning health care or quality of life were reported sparsely. Most interviewees reported that they did not talk about the nurse visit and the interprofessional case conference with their GPs.

Discussion of results and comparison with existing literature

Our results show that the nurses’ home visit/phone call using the KOPAL conversation guide [ 32 ] to assess the patients’ current life and health situation and identify patients’ specific palliative care needs was very well accepted by patients, proxies and associates. Similar assessments of palliative care needs were shown to be well accepted in other studies, too, e.g. [ 37 ]. In some cases our interviewees reported to have received some advice during the structured assessment by the SPHC nurse and some patients reported changes due to having had this conversation. Therefore it can be assumed that the SPHC home visit might have a positive effect itself and can be considered a reasonable addition to conducting case conferences just as it was the case in Mitchell et al.’s pilot study [ 14 ].

We found that participants did not prepare for the conversations with the SPHC nurse. Maybe this was partly because they did not expect an individual benefit for themselves (or the associated patient) from the intervention, but were motivated by positive attitudes towards research and altruistic motives to help other as it was shown by Carandang et al. [ 38 ] for elderly patients. Interviewees reported a rather passive role in the intervention. This might also have been the case due to participants’ confusion over the role of the SPHC nurse visit and the role of the interdisciplinary case conference for their own or the associated patients’ future care. Not all interviewees seemed to have made the connection between the SPHC nurse visit and the interdisciplinary case conference. This confusion is already known from other studies (e.g., [ 23 ]). Other studies show that being asked to identify questions before such an exchange with professionals might be beneficial and that it is important explicitly explain the purpose of the intervention to increase acceptability and benefit for patients [ 39 ].

Interviewees reported lack of communication between patients and GPs about the results of the interdisciplinary case conferences. This could have hindered resolved changes in care to be implemented. Integrating a mandatory discussion of case conference results and refinement of the plan between the GP and the patient or proxy (as it was the case in Mitchell et al.’s study [ 14 ]) could have helped to realize potential changes/actions decided on in the case conference. This could increase the impact of the intervention.

Strengths and limitations

We interviewed patients in an advanced stage of their disease, proxies of patients with dementia, and patients’ associates. We were able to obtain a comprehensive view on and a subjective evaluation of the KOPAL-intervention. Due to the randomized controlled design of the KOPAL-study we decided to schedule qualitative interviews after the last quantitative follow-up interview to prevent contamination of intervention effects and to maintain the comparability with the control group. Therefore no qualitative interview data is available from participants deceased during the follow-up period. Furthermore, the rather long time period between study enrollment, intervention and evaluation interview might have induced a reduced memory of the SPHC nurse home-visit/phone call.

The results give some indication what to consider in a future implementation of the KOPAL-intervention in regular care. Most study participants did not prepare for the SPHC nurse assessment and had no expectations concerning the potential benefits of such an assessment, the interdisciplinary case conference and an early integration of palliative care. This points to the conclusion that the SPHC nurse can act as an advocate for the patient and thereby support the patients’ (and their proxies’/caregivers’) autonomy. Another way to increase the effects of the intervention could be letting the patients (and/or their proxies/caregivers) take part in the interdisciplinary case conference. This could empower patients (and/or their proxies/caregivers) to not just passively receive the intervention but to actively take part in deciding on further actions. Besides this measure to activate the patients (and/or their proxies/caregivers), GPs should actively discuss the results of the interdisciplinary case conference with the patients and collaboratively decide on further actions to be realized. Further research is needed to evaluate the effects of the proposed changes.

Data availability

No data are available. The data generated and analyzed during the current study are not publicly available due to the study’s assurances to participants that the full raw interview data would not be shared publicly, and that all attempts would be made to maintain confidentiality.

Abbreviations

Congestive heart failure

Chronic, non-malignant diseases

Chronic, obstructive pulmonary disease

General practitioner

Specialist palliative home care

Strengthening interprofessional collaboration for patients with palliative care needs – development and evaluation of a new concept

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Acknowledgements

We would like to thank all interviewees for their time and willingness to participate in the study and its evaluation and all scientific experts and representatives (physicians, nurses, researchers, and patient representatives) in the advisory board for their helpful input and support.

Open Access funding enabled and organized by Projekt DEAL. The KOPAL study was supported by the Federal Joint Committee (G-BA), grant number 01VSF18024. Funding period: 06/2019–11/2022. This funding source had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results. ( https://innovationsfonds.g-ba.de/ ). We acknowledge financial support from the Open Access Publication Fund of UKE - Universitätsklinikum Hamburg-Eppendorf.

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Contributions

GM, NP, SSt, FN and MS contributed substantially to the conception of the study. MS (principal investigator), GM (coprincipal investigator), FN and SSt are applicants of the trial. GM coordinates the trial. NP, JW, FS and GM scripted the interview guide. NP and JW conducted the interviews. NP, JW and JT analyzed the interviews. NP wrote the first draft of the manuscript and coordinated co-authors feedbacks and revisions. All authors revised the draft critically and gave approval of the final version of the manuscript.

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KOPAL has been approved by the local ethics committee of the Medical Association Hamburg, Germany (number PV7090) as well as the ethics committees of the University Medical Centre Goettingen, Germany (number 34/1/20Ü), the Hannover Medical School (number 8815 BO K 2019) and the University of Oldenburg (number 2019–145). The study has been performed in accordance with the Declaration of Helsinki. Participants gave written informed consent to be interviewed, for the interviews to be recorded and transcribed and the data being published anonymously.

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Pohontsch, N.J., Weber, J., Stiel, S. et al. Experiences of patients with advanced chronic diseases and their associates with a structured palliative care nurse visit followed by an interprofessional case conference in primary care – a deductive-inductive content analysis based on qualitative interviews (KOPAL-Study). BMC Prim. Care 25 , 323 (2024). https://doi.org/10.1186/s12875-024-02572-5

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• Published: 08 September 2024

Longitudinal analysis of teacher self-efficacy evolution during a STEAM professional development program: a qualitative case study

• Haozhe Jiang   ORCID: orcid.org/0000-0002-7870-0993 1 ,
• Ritesh Chugh   ORCID: orcid.org/0000-0003-0061-7206 2 ,
• Xuesong Zhai   ORCID: orcid.org/0000-0002-4179-7859 1 , 3   nAff7 ,
• Ke Wang 4 &
• Xiaoqin Wang 5 , 6  

Humanities and Social Sciences Communications volume  11 , Article number:  1162 ( 2024 ) Cite this article

Metrics details

Despite the widespread advocacy for the integration of arts and humanities (A&H) into science, technology, engineering, and mathematics (STEM) education on an international scale, teachers face numerous obstacles in practically integrating A&H into STEM teaching (IAT). To tackle the challenges, a comprehensive five-stage framework for teacher professional development programs focussed on IAT has been developed. Through the use of a qualitative case study approach, this study outlines the shifts in a participant teacher’s self-efficacy following their exposure to each stage of the framework. The data obtained from interviews and reflective analyses were analyzed using a seven-stage inductive method. The findings have substantiated the significant impact of a teacher professional development program based on the framework on teacher self-efficacy, evident in both individual performance and student outcomes observed over eighteen months. The evolution of teacher self-efficacy in IAT should be regarded as an open and multi-level system, characterized by interactions with teacher knowledge, skills and other entrenched beliefs. Building on our research findings, an enhanced model of teacher professional learning is proposed. The revised model illustrates that professional learning for STEAM teachers should be conceived as a continuous and sustainable process, characterized by the dynamic interaction among teaching performance, teacher knowledge, and teacher beliefs. The updated model further confirms the inseparable link between teacher learning and student learning within STEAM education. This study contributes to the existing body of literature on teacher self-efficacy, teacher professional learning models and the design of IAT teacher professional development programs.

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Introduction.

In the past decade, there has been a surge in the advancement and widespread adoption of Science, Technology, Engineering, and Mathematics (STEM) education on a global scale (Jiang et al. 2021 ; Jiang et al. 2022 ; Jiang et al. 2023 ; Jiang et al. 2024a , b ; Zhan et al. 2023 ; Zhan and Niu 2023 ; Zhong et al. 2022 ; Zhong et al. 2024 ). Concurrently, there has been a growing chorus of advocates urging the integration of Arts and Humanities (A&H) into STEM education (e.g., Alkhabra et al. 2023 ; Land 2020 ; Park and Cho 2022 ; Uştu et al. 2021 ; Vaziri and Bradburn 2021 ). STEM education is frequently characterized by its emphasis on logic and analysis; however, it may be perceived as deficient in emotional and intuitive elements (Ozkan and Umdu Topsakal 2021 ). Through the integration of Arts and Humanities (A&H), the resulting STEAM approach has the potential to become more holistic, incorporating both rationality and emotional intelligence (Ozkan and Umdu Topsakal 2021 ). Many studies have confirmed that A&H can help students increase interest and develop their understanding of the contents in STEM fields, and thus, A&H can attract potential underrepresented STEM learners such as female students and minorities (Land 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ). Despite the increasing interest in STEAM, the approaches to integrating A&H, which represent fundamentally different disciplines, into STEM are theoretically and practically ambiguous (Jacques et al. 2020 ; Uştu et al. 2021 ). Moreover, studies have indicated that the implementation of STEAM poses significant challenges, with STEM educators encountering difficulties in integrating A&H into their teaching practices (e.g., Boice et al. 2021 ; Duong et al. 2024 ; Herro et al. 2019 ; Jacques et al. 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ). Hence, there is a pressing need to provide STEAM teachers with effective professional training.

Motivated by this gap, this study proposes a novel five-stage framework tailored for teacher professional development programs specifically designed to facilitate the integration of A&H into STEM teaching (IAT). Following the establishment of this framework, a series of teacher professional development programs were implemented. To explain the framework, a qualitative case study is employed, focusing on examining a specific teacher professional development program’s impact on a pre-service teacher’s self-efficacy. The case narratives, with a particular focus on the pre-service teacher’s changes in teacher self-efficacy, are organized chronologically, delineating stages before and after each stage of the teacher professional development program. More specifically, meaningful vignettes of the pre-service teacher’s learning and teaching experiences during the teacher professional development program are offered to help understand the five-stage framework. This study contributes to understanding teacher self-efficacy, teacher professional learning model and the design of IAT teacher professional development programs.

Theoretical background

The conceptualization of steam education.

STEM education can be interpreted through various lenses (e.g., Jiang et al. 2021 ; English 2016 ). As Li et al. (2020) claimed, on the one hand, STEM education can be defined as individual STEM disciplinary-based education (i.e., science education, technology education, engineering education and mathematics education). On the other hand, STEM education can also be defined as interdisciplinary or cross-disciplinary education where individual STEM disciplines are integrated (Jiang et al. 2021 ; English 2016 ). In this study, we view it as individual disciplinary-based education separately in science, technology, engineering and mathematics (English 2016 ).

STEAM education emerged as a new pedagogy during the Americans for the Arts-National Policy Roundtable discussion in 2007 (Perignat and Katz-Buonincontro 2019 ). This pedagogy was born out of the necessity to enhance students’ engagement, foster creativity, stimulate innovation, improve problem-solving abilities, and cultivate employability skills such as teamwork, communication and adaptability (Perignat and Katz-Buonincontro 2019 ). In particular, within the framework of STEAM education, the ‘A’ should be viewed as a broad concept that represents arts and humanities (A&H) (Herro and Quigley 2016 ; de la Garza 2021 , Park and Cho 2022 ). This conceptualization emphasizes the need to include humanities subjects alongside arts (Herro and Quigley 2016 ; de la Garza 2021 ; Park and Cho 2022 ). Sanz-Camarero et al. ( 2023 ) listed some important fields of A&H, including physical arts, fine arts, manual arts, sociology, politics, philosophy, history, psychology and so on.

In general, STEM education does not necessarily entail the inclusion of all STEM disciplines collectively (Ozkan and Umdu Topsakal 2021 ), and this principle also applies to STEAM education (Gates 2017 ; Perignat and Katz-Buonincontro 2019 ; Quigley et al. 2017 ; Smith and Paré 2016 ). As an illustration, Smith and Paré ( 2016 ) described a STEAM activity in which pottery (representing A&H) and mathematics were integrated, while other STEAM elements such as science, technology and engineering were not included. In our study, STEAM education is conceptualized as an interdisciplinary approach that involves the integration of one or more components of A&H into one or more STEM school subjects within educational activities (Ozkan and Umdu Topsakal 2021 ; Vaziri and Bradburn 2021 ). Notably, interdisciplinary collaboration entails integrating one or more elements from arts and humanities (A&H) with one or more STEM school subjects, cohesively united by a shared theme while maintaining their distinct identities (Perignat and Katz-Buonincontro 2019 ).

In our teacher professional development programs, we help mathematics, technology, and science pre-service teachers integrate one component of A&H into their disciplinary-based teaching practices. For instance, we help mathematics teachers integrate history (a component of A&H) into mathematics teaching. In other words, in our study, integrating A&H into STEM teaching (IAT) can be defined as integrating one component of A&H into the teaching of one of the STEM school subjects. The components of A&H and the STEM school subject are brought together under a common theme, but each of them remains discrete. Engineering is not taught as an individual subject in the K-12 curriculum in mainland China. Therefore, A&H is not integrated into engineering teaching in our teacher professional development programs.

Self-efficacy and teacher self-efficacy

Self-efficacy was initially introduced by Bandura ( 1977 ) as a key concept within his social cognitive theory. Bandura ( 1997 ) defined self-efficacy as “people’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives” (p. 71). Based on Bandura’s ( 1977 ) theory, Tschannen-Moran et al. ( 1998 ) defined the concept of teacher self-efficacy Footnote 1 as “a teacher’s belief in her or his ability to organize and execute the courses of action required to successfully accomplish a specific teaching task in a particular context” (p. 233). Blonder et al. ( 2014 ) pointed out that this definition implicitly included teachers’ judgment of their ability to bring about desired outcomes in terms of students’ engagement and learning. Moreover, OECD ( 2018 ) defined teacher self-efficacy as “the beliefs that teachers have of their ability to enact certain teaching behavior that influences students’ educational outcomes, such as achievement, interest, and motivation” (p. 51). This definition explicitly included two dimensions: teachers’ judgment of the ability related to their teaching performance (i.e., enacting certain teaching behavior) and their influence on student outcomes.

It is argued that teacher self-efficacy should not be regarded as a general or overarching construct (Zee et al. 2017 ; Zee and Koomen 2016 ). Particularly, in the performance-driven context of China, teachers always connect their beliefs in their professional capabilities with the educational outcomes of their students (Liu et al. 2018 ). Therefore, we operationally conceptualize teacher self-efficacy as having two dimensions: self-efficacy in individual performance and student outcomes (see Table 1 ).

Most importantly, given its consistent association with actual teaching performance and student outcomes (Bray-Clark and Bates 2003 ; Kelley et al. 2020 ), teacher self-efficacy is widely regarded as a pivotal indicator of teacher success (Kelley et al. 2020 ). Moreover, the enhancement of teaching self-efficacy reflects the effectiveness of teacher professional development programs (Bray-Clark and Bates 2003 ; Kelley et al. 2020 ; Wong et al. 2022 ; Zhou et al. 2023 ). For instance, Zhou et al. ( 2023 ) claimed that in STEM teacher education, effective teacher professional development programs should bolster teachers’ self-efficacy “in teaching the content in the STEM discipline” (p. 2).

It has been documented that teachers frequently experience diminished confidence and comfort when teaching subject areas beyond their expertise (Kelley et al. 2020 ; Stohlmann et al. 2012 ). This diminished confidence extends to their self-efficacy in implementing interdisciplinary teaching approaches, such as integrated STEM teaching and IAT (Kelley et al. 2020 ). For instance, Geng et al. ( 2019 ) found that STEM teachers in Hong Kong exhibited low levels of self-efficacy, with only 5.53% of teachers rating their overall self-efficacy in implementing STEM education as higher than a score of 4 out of 5. Additionally, Hunter-Doniger and Sydow ( 2016 ) found that teachers may experience apprehension and lack confidence when incorporating A&H elements into the classroom context, particularly within the framework of IAT. Considering the critical importance of teacher self-efficacy in STEM and STEAM education (Kelley et al. 2020 ; Zakariya, 2020 ; Zhou et al. 2023 ), it is necessary to explore effective measures, frameworks and teacher professional development programs to help teachers improve their self-efficacy regarding interdisciplinary teaching (e.g., IAT).

Teacher professional learning models

The relationship between teachers’ professional learning and students’ outcomes (such as achievements, skills and attitudes) has been a subject of extensive discussion and research for many years (Clarke and Hollingsworth 2002 ). For instance, Clarke and Hollingsworth ( 2002 ) proposed and validated the Interconnected Model of Professional Growth, which illustrates that teacher professional development is influenced by the interaction among four interconnected domains: the personal domain (teacher knowledge, beliefs and attitudes), the domain of practice (professional experimentation), the domain of consequence (salient outcomes), and the external domain (sources of information, stimulus or support). Sancar et al. ( 2021 ) emphasized that teachers’ professional learning or development never occurs independently. In practice, this process is inherently intertwined with many variables, including student outcomes, in various ways (Sancar et al. 2021 ). However, many current teacher professional development programs exclude real in-class teaching and fail to establish a comprehensive link between teachers’ professional learning and student outcomes (Cai et al. 2020 ; Sancar et al. 2021 ). Sancar et al. ( 2021 ) claimed that exploring the complex relationships between teachers’ professional learning and student outcomes should be grounded in monitoring and evaluating real in-class teaching, rather than relying on teachers’ self-assessment. It is essential to understand these relationships from a holistic perspective within the context of real classroom teaching (Sancar et al. 2021 ). However, as Sancar et al. ( 2021 ) pointed out, such efforts in teacher education are often considered inadequate. Furthermore, in the field of STEAM education, such efforts are further exacerbated.

Cai et al. ( 2020 ) proposed a teacher professional learning model where student outcomes are emphasized. This model was developed based on Cai ( 2017 ), Philipp ( 2007 ) and Thompson ( 1992 ). It has also been used and justified in a series of teacher professional development programs (e.g., Calabrese et al. 2024 ; Hwang et al. 2024 ; Marco and Palatnik 2024 ; Örnek and Soylu 2021 ). The model posits that teachers typically increase their knowledge and modify their beliefs through professional teacher learning, subsequently improving their classroom instruction, enhancing teaching performance, and ultimately fostering improved student learning outcomes (Cai et al. 2020 ). Notably, this model can be updated in several aspects. Firstly, prior studies have exhibited the interplay between teacher knowledge and beliefs (e.g., Basckin et al. 2021 ; Taimalu and Luik 2019 ). This indicates that the increase in teacher knowledge and the change in teacher belief may not be parallel. The two processes can be intertwined. Secondly, the Interconnected Model of Professional Growth highlights that the personal domain and the domain of practice are interconnected (Clarke and Hollingsworth 2002 ). Liu et al. ( 2022 ) also confirmed that improvements in classroom instruction may, in turn, influence teacher beliefs. This necessitates a reconsideration of the relationships between classroom instruction, teacher knowledge and teacher beliefs in Cai et al.’s ( 2020 ) model. Thirdly, the Interconnected Model of Professional Growth also exhibits the connections between the domain of consequence and the personal domain (Clarke and Hollingsworth 2002 ). Hence, the improvement of learning outcomes may signify the end of teacher learning. For instance, students’ learning feedback may be a vital source of teacher self-efficacy (Bandura 1977 ). Therefore, the improvement of student outcomes may, in turn, affect teacher beliefs. The aforementioned arguments highlight the need for an updated model that integrates Cai et al.’s ( 2020 ) teacher professional learning model with Clarke and Hollingsworth’s ( 2002 ) Interconnected Model of Professional Growth. This integration may provide a holistic view of the teacher’s professional learning process, especially within the complex contexts of STEAM teacher education.

The framework for teacher professional development programs of integrating arts and humanities into STEM teaching

In this section, we present a framework for IAT teacher professional development programs, aiming to address the practical challenges associated with STEAM teaching implementation. Our framework incorporates the five features of effective teacher professional development programs outlined by Archibald et al. ( 2011 ), Cai et al. ( 2020 ), Darling-Hammond et al. ( 2017 ), Desimone and Garet ( 2015 ) and Roth et al. ( 2017 ). These features include: (a) alignment with shared goals (e.g., school, district, and national policies and practice), (b) emphasis on core content and modeling of teaching strategies for the content, (c) collaboration among teachers within a community, (d) adequate opportunities for active learning of new teaching strategies, and (e) embedded follow-up and continuous feedback. It is worth noting that two concepts, namely community of practice and lesson study, have been incorporated into our framework. Below, we delineate how these features are reflected in our framework.

(a) The Chinese government has issued a series of policies to facilitate STEAM education in K-12 schools (Jiang et al. 2021 ; Li and Chiang 2019 ; Lyu et al. 2024 ; Ro et al. 2022 ). The new curriculum standards released in 2022 mandate that all K-12 teachers implement interdisciplinary teaching, including STEAM education. Our framework for teacher professional development programs, which aims to help teachers integrate A&H into STEM teaching, closely aligns with these national policies and practices supporting STEAM education in K-12 schools.

(b) The core content of the framework is IAT. Specifically, as A&H is a broad concept, we divide it into several subcomponents, such as history, culture, and visual and performing arts (e.g., drama). We are implementing a series of teacher professional development programs to help mathematics, technology and science pre-service teachers integrate these subcomponents of A&H into their teaching Footnote 2 . Notably, pre-service teachers often lack teaching experience, making it challenging to master and implement new teaching strategies. Therefore, our framework provides five step-by-step stages designed to help them effectively model the teaching strategies of IAT.

(c) Our framework advocates for collaboration among teachers within a community of practice. Specifically, a community of practice is “a group of people who share an interest in a domain of human endeavor and engage in a process of collective learning that creates bonds between them” (Wenger et al. 2002 , p. 1). A teacher community of practice can be considered a group of teachers “sharing and critically observing their practices in growth-promoting ways” (Näykki et al. 2021 , p. 497). Long et al. ( 2021 ) claimed that in a teacher community of practice, members collaboratively share their teaching experiences and work together to address teaching problems. Our community of practice includes three types of members. (1) Mentors: These are professors and experts with rich experience in helping pre-service teachers practice IAT. (2) Pre-service teachers: Few have teaching experience before the teacher professional development programs. (3) In-service teachers: All in-service teachers are senior teachers with rich teaching experience. All the members work closely together to share and improve their IAT practice. Moreover, our community includes not only mentors and in-service teachers but also pre-service teachers. We encourage pre-service teachers to collaborate with experienced in-service teachers in various ways, such as developing IAT lesson plans, writing IAT case reports and so on. In-service teachers can provide cognitive and emotional support and share their practical knowledge and experience, which may significantly benefit the professional growth of pre-service teachers (Alwafi et al. 2020 ).

(d) Our framework offers pre-service teachers various opportunities to engage in lesson study, allowing them to actively design and implement IAT lessons. Based on the key points of effective lesson study outlined by Akiba et al. ( 2019 ), Ding et al. ( 2024 ), and Takahashi and McDougal ( 2016 ), our lesson study incorporates the following seven features. (1) Study of IAT materials: Pre-service teachers are required to study relevant IAT materials under the guidance of mentors. (2) Collaboration on lesson proposals: Pre-service teachers should collaborate with in-service teachers to develop comprehensive lesson proposals. (3) Observation and data collection: During the lesson, pre-service teachers are required to carefully observe and collect data on student learning and development. (4) Reflection and analysis: Pre-service teachers use the collected data to reflect on the lesson and their teaching effects. (5) Lesson revision and reteaching: If needed, pre-service teachers revise and reteach the lesson based on their reflections and data analysis. (6) Mentor and experienced in-service teacher involvement: Mentors and experienced in-service teachers, as knowledgeable others, are involved throughout the lesson study process. (7) Collaboration on reporting: Pre-service teachers collaborate with in-service teachers to draft reports and disseminate the results of the lesson study. Specifically, recognizing that pre-service teachers often lack teaching experience, we do not require them to complete all the steps of lesson study independently at once. Instead, we guide them through the lesson study process in a step-by-step manner, allowing them to gradually build their IAT skills and confidence. For instance, in Stage 1, pre-service teachers primarily focus on studying IAT materials. In Stage 2, they develop lesson proposals, observe and collect data, and draft reports. However, the implementation of IAT lessons is carried out by in-service teachers. This approach prevents pre-service teachers from experiencing failures due to their lack of teaching experience. In Stage 3, pre-service teachers implement, revise, and reteach IAT lessons, experiencing the lesson study process within a simulated environment. In Stage 4, pre-service teachers engage in lesson study in an actual classroom environment. However, their focus is limited to one micro-course during each lesson study session. It is not until the fifth stage that they experience a complete lesson study in an actual classroom environment.

(e) Our teacher professional development programs incorporate assessments specifically designed to evaluate pre-service teachers’ IAT practices. We use formative assessments to measure their understanding and application of IAT strategies. Pre-service teachers receive ongoing and timely feedback from peers, mentors, in-service teachers, and students, which helps them continuously refine their IAT practices throughout the program. Recognizing that pre-service teachers often have limited contact with real students and may not fully understand students’ learning needs, processes and outcomes, our framework requires them to actively collect and analyze student feedback. By doing so, they can make informed improvements to their instructional practice based on student feedback.

After undergoing three rounds of theoretical and practical testing and revision over the past five years, we have successfully finalized the optimization of the framework design (Zhou 2021 ). Throughout each cycle, we collected feedback from both participants and researchers on at least three occasions. Subsequently, we analyzed this feedback and iteratively refined the framework. For example, we enlisted the participation of in-service teachers to enhance the implementation of STEAM teaching, extended practice time through micro-teaching sessions, and introduced a stage of micro-course development within the framework to provide more opportunities for pre-service teachers to engage with real teaching situations. In this process, we continuously improved the coherence between each stage of the framework, ensuring that they mutually complement one another. The five-stage framework is described as follows.

Stage 1 Literature study

Pre-service teachers are provided with a series of reading materials from A&H. On a weekly basis, two pre-service teachers are assigned to present their readings and reflections to the entire group, followed by critical discussions thereafter. Mentors and all pre-service teachers discuss and explore strategies for translating the original A&H materials into viable instructional resources suitable for classroom use. Subsequently, pre-service teachers select topics of personal interest for further study under mentor guidance.

Stage 2 Case learning

Given that pre-service teachers have no teaching experience, collaborative efforts between in-service teachers and pre-service teachers are undertaken to design IAT lesson plans. Subsequently, the in-service teachers implement these plans. Throughout this process, pre-service teachers are afforded opportunities to engage in lesson plan implementation. Figure 1 illustrates the role of pre-service teachers in case learning. In the first step, pre-service teachers read about materials related to A&H, select suitable materials, and report their ideas on IAT lesson design to mentors, in-service teachers, and fellow pre-service teachers.

Note: A&H refers to arts and humanities.

In the second step, they liaise with the in-service teachers responsible for implementing the lesson plan, discussing the integration of A&H into teaching practices. Pre-service teachers then analyze student learning objectives aligned with curriculum standards, collaboratively designing the IAT lesson plan with in-service teachers. Subsequently, pre-service teachers present lesson plans for feedback from mentors and other in-service teachers.

In the third step, pre-service teachers observe the lesson plan’s implementation, gathering and analyzing feedback from students and in-service teachers using an inductive approach (Merriam 1998 ). Feedback includes opinions on the roles and values of A&H, perceptions of the teaching effect, and recommendations for lesson plan implementation and modification. The second and third steps may iterate multiple times to refine the IAT lesson plan. In the fourth step, pre-service teachers consolidate all data, including various versions of teaching instructions, classroom videos, feedback, and discussion notes, composing reflection notes. Finally, pre-service teachers collaborate with in-service teachers to compile the IAT case report and submit it for publication.

Stage 3 Micro-teaching

Figure 2 illustrates the role of pre-service teachers in micro-teaching. Before entering the micro-classrooms Footnote 3 , all the discussions and communications occur within the pre-service teacher group, excluding mentors and in-service teachers. After designing the IAT lesson plan, pre-service teachers take turns implementing 40-min lesson plans in a simulated micro-classroom setting. Within this simulated environment, one pre-service teacher acts as the teacher, while others, including mentors, in-service teachers, and other fellow pre-service teachers, assume the role of students Footnote 4 . Following the simulated teaching, the implementer reviews the video of their session and self-assesses their performance. Subsequently, the implementer receives feedback from other pre-service teachers, mentors, and in-service teachers. Based on this feedback, the implementer revisits steps 2 and 3, revising the lesson plan and conducting the simulated teaching again. This iterative process typically repeats at least three times until the mentors, in-service teachers, and other pre-service teachers are satisfied with the implementation of the revised lesson plan. Finally, pre-service teachers complete reflection notes and submit a summary of their reflections on the micro-teaching experience. Each pre-service teacher is required to choose at least three topics and undergo at least nine simulated teaching sessions.

Stage 4 Micro-course development

While pre-service teachers may not have the opportunity to execute the whole lesson plans in real classrooms, they can design and create five-minute micro-courses Footnote 5 before class, subsequently presenting these videos to actual students. The process of developing micro-courses closely mirrors that of developing IAT cases in the case learning stage (see Fig. 1 ). However, in Step 3, pre-service teachers assume dual roles, not only as observers of IAT lesson implementation but also as implementers of a five-minute IAT micro-course.

Stage 5 Classroom teaching

Pre-service teachers undertake the implementation of IAT lesson plans independently, a process resembling micro-teaching (see Fig. 2 ). However, pre-service teachers engage with real school students in partner schools Footnote 6 instead of simulated classrooms. Furthermore, they collect feedback not only from the mentors, in-service teachers, and fellow pre-service teachers but also from real students.

To provide our readers with a better understanding of the framework, we provide meaningful vignettes of a pre-service teacher’s learning and teaching experiences in one of the teacher professional development programs based on the framework. In addition, we choose teacher self-efficacy as an indicator to assess the framework’s effectiveness, detailing the pre-service teacher’s changes in teacher self-efficacy.

Research design

Research method.

Teacher self-efficacy can be measured both quantitatively and qualitatively (Bandura 1986 , 1997 ; Lee and Bobko 1994 ; Soprano and Yang 2013 ; Unfried et al. 2022 ). However, researchers and theorists in the area of teacher self-efficacy have called for more qualitative and longitudinal studies (Klassen et al. 2011 ). As some critiques stated, most studies were based on correlational and cross-sectional data obtained from self-report surveys, and qualitative studies of teacher efficacy were overwhelmingly neglected (Henson 2002 ; Klassen et al. 2011 ; Tschannen-Moran et al. 1998 ; Xenofontos and Andrews 2020 ). There is an urgent need for more longitudinal studies to shed light on the development of teacher efficacy (Klassen et al. 2011 ; Xenofontos and Andrews 2020 ).

This study utilized a longitudinal qualitative case study methodology to delve deeply into the context (Jiang et al. 2021 ; Corden and Millar 2007 ; Dicks et al. 2023 ; Henderson et al. 2012 ; Matusovich et al. 2010 ; Shirani and Henwood 2011 ), presenting details grounded in real-life situations and analyzing the inner relationships rather than generalize findings about the change of a large group of pre-service teachers’ self-efficacy.

Participant

This study forms a component of a broader multi-case research initiative examining teachers’ professional learning in the STEAM teacher professional development programs in China (Jiang et al. 2021 ; Wang et al. 2018 ; Wang et al. 2024 ). Within this context, one participant, Shuitao (pseudonym), is selected and reported in this current study. Shuitao was a first-year graduate student at a first-tier Normal university in Shanghai, China. Normal universities specialize in teacher education. Her graduate major was mathematics curriculum and instruction. Teaching practice courses are offered to students in this major exclusively during their third year of study. The selection of Shuitao was driven by three primary factors. Firstly, Shuitao attended the entire teacher professional development program and actively engaged in nearly all associated activities. Table 2 illustrates the timeline of the five stages in which Shuitao was involved. Secondly, her undergraduate major was applied mathematics, which was not related to mathematics teaching Footnote 7 . She possessed no prior teaching experience and had not undergone any systematic study of IAT before her involvement in the teacher professional development program. Thirdly, her other master’s courses during her first two years of study focused on mathematics education theory and did not include IAT Footnote 8 . Additionally, she scarcely participated in any other teaching practice outside of the teacher professional development program. As a pre-service teacher, Shuitao harbored a keen interest in IAT. Furthermore, she discovered that she possessed fewer teaching skills compared to her peers who had majored in education during their undergraduate studies. Hence, she had a strong desire to enhance her teaching skills. Consequently, Shuitao decided to participate in our teacher professional development program.

Shuitao was grouped with three other first-year graduate students during the teacher professional development program. She actively collaborated with them at every stage of the program. For instance, they advised each other on their IAT lesson designs, observed each other’s IAT practice and offered constructive suggestions for improvement.

Research question

Shuitao was a mathematics pre-service teacher who participated in one of our teacher professional development programs, focusing on integrating history into mathematics teaching (IHT) Footnote 9 . Notably, this teacher professional development program was designed based on our five-stage framework for teacher professional development programs of IAT. To examine the impact of this teacher professional development program on Shuitao’s self-efficacy related to IHT, this case study addresses the following research question:

What changes in Shuitao’s self-efficacy in individual performance regarding integrating history into mathematics teaching (SE-IHT-IP) may occur through participation in the teacher professional development program?

What changes in Shuitao’s self-efficacy in student outcomes regarding integrating history into mathematics teaching (SE-IHT-SO) may occur through participation in the teacher professional development program?

Data collection and analysis

Before Shuitao joined the teacher professional development program, a one-hour preliminary interview was conducted to guide her in self-narrating her psychological and cognitive state of IHT.

During the teacher professional development program, follow-up unstructured interviews were conducted once a month with Shuitao. All discussions in the development of IHT cases were recorded, Shuitao’s teaching and micro-teaching were videotaped, and the reflection notes, journals, and summary reports written by Shuitao were collected.

After completing the teacher professional development program, Shuitao participated in a semi-structured three-hour interview. The objectives of this interview were twofold: to reassess her self-efficacy and to explore the relationship between her self-efficacy changes and each stage of the teacher professional development program.

Interview data, discussions, reflection notes, journals, summary reports and videos, and analysis records were archived and transcribed before, during, and after the teacher professional development program.

In this study, we primarily utilized data from seven interviews: one conducted before the teacher professional development program, five conducted after each stage of the program, and one conducted upon completion of the program. Additionally, we reviewed Shuitao’s five reflective notes, which were written after each stage, as well as her final summary report that encompassed the entire teacher professional development program.

Merriam’s ( 1998 ) approach to coding data and inductive approach to retrieving possible concepts and themes were employed using a seven-stage method. Considering theoretical underpinnings in qualitative research is common when interpreting data (Strauss and Corbin 1990 ). First, a list based on our conceptual framework of teacher self-efficacy (see Table 1 ) was developed. The list included two codes (i.e., SE-IHT-IP and SE-IHT-SO). Second, all data were sorted chronologically, read and reread to be better understood. Third, texts were coded into multi-colored highlighting and comment balloons. Fourth, the data for groups of meanings, themes, and behaviors were examined. How these groups were connected within the conceptual framework of teacher self-efficacy was confirmed. Fifth, after comparing, confirming, and modifying, the selective codes were extracted and mapped onto the two categories according to the conceptual framework of teacher self-efficacy. Accordingly, changes in SE-IHT-IP and SE-IHT-SO at the five stages of the teacher professional development program were identified, respectively, and then the preliminary findings came (Strauss and Corbin 1990 ). In reality, in Shuitao’s narratives, SE-IHT-IP and SE-IHT-SO were frequently intertwined. Through our coding process, we differentiated between SE-IHT-IP and SE-IHT-SO, enabling us to obtain a more distinct understanding of how these two aspects of teacher self-efficacy evolved over time. This helped us address the two research questions effectively.

Reliability and validity

Two researchers independently analyzed the data to establish inter-rater reliability. The inter-rater reliability was established as kappa = 0.959. Stake ( 1995 ) suggested that the most critical assertions in a study require the greatest effort toward confirmation. In this study, three methods served this purpose and helped ensure the validity of the findings. The first way to substantiate the statement about the changes in self-efficacy was by revisiting each transcript to confirm whether the participant explicitly acknowledged the changes (Yin 2003 ). Such a check was repeated in the analysis of this study. The second way to confirm patterns in the data was by examining whether Shuitao’s statements were replicated in separate interviews (Morris and Usher 2011 ). The third approach involved presenting the preliminary conclusions to Shuitao and affording her the opportunity to provide feedback on the data and conclusions. This step aimed to ascertain whether we accurately grasped the true intentions of her statements and whether our subjective interpretations inadvertently influenced our analysis of her statements. Additionally, data from diverse sources underwent analysis by at least two researchers, with all researchers reaching consensus on each finding.

As each stage of our teacher professional development programs spanned a minimum of three months, numerous documented statements regarding the enhancement of Shuitao’s self-efficacy regarding IHT were recorded. Notably, what we present here offers only a concise overview of findings derived from our qualitative analysis. The changes in Shuitao’s SE-IHT-IP and SE-IHT-SO are organized chronologically, delineating the period before and during the teacher professional development program.

Before the teacher professional development program: “I have no confidence in IHT”

Before the teacher professional development program, Shuitao frequently expressed her lack of confidence in IHT. On the one hand, Shuitao expressed considerable apprehension about her individual performance in IHT. “How can I design and implement IHT lesson plans? I do not know anything [about it]…” With a sense of doubt, confusion and anxiety, Shuitao voiced her lack of confidence in her ability to design and implement an IHT case that would meet the requirements of the curriculum standards. Regarding the reasons for her lack of confidence, Shuitao attributed it to her insufficient theoretical knowledge and practical experience in IHT:

I do not know the basic approaches to IHT that I could follow… it is very difficult for me to find suitable historical materials… I am very confused about how to organize [historical] materials logically around the teaching goals and contents… [Furthermore,] I am [a] novice, [and] I have no IHT experience.

On the other hand, Shuitao articulated very low confidence in the efficacy of her IHT on student outcomes:

I think my IHT will have a limited impact on student outcomes… I do not know any specific effects [of history] other than making students interested in mathematics… In fact, I always think it is difficult for [my] students to understand the history… If students cannot understand [the history], will they feel bored?

This statement suggests that Shuitao did not fully grasp the significance of IHT. In fact, she knew little about the educational significance of history for students, and she harbored no belief that her IHT approach could positively impact students. In sum, her SE-IHT-SO was very low.

After stage 1: “I can do well in the first step of IHT”

After Stage 1, Shuitao indicated a slight improvement in her confidence in IHT. She attributed this improvement to her acquisition of theoretical knowledge in IHT, the approaches for selecting history-related materials, and an understanding of the educational value of history.

One of Shuitao’s primary concerns about implementing IHT before the teacher professional development program was the challenge of sourcing suitable history-related materials. However, after Stage 1, Shuitao explicitly affirmed her capability in this aspect. She shared her experience of organizing history-related materials related to logarithms as an example.

Recognizing the significance of suitable history-related materials in effective IHT implementation, Shuitao acknowledged that conducting literature studies significantly contributed to enhancing her confidence in undertaking this initial step. Furthermore, she expressed increased confidence in designing IHT lesson plans by utilizing history-related materials aligned with teaching objectives derived from the curriculum standards. In other words, her SE-IHT-IP was enhanced. She said:

After experiencing multiple discussions, I gradually know more about what kinds of materials are essential and should be emphasized, what kinds of materials should be adapted, and what kinds of materials should be omitted in the classroom instructions… I have a little confidence to implement IHT that could meet the requirements [of the curriculum standards] since now I can complete the critical first step [of IHT] well…

However, despite the improvement in her confidence in IHT following Stage 1, Shuitao also expressed some concerns. She articulated uncertainty regarding her performance in the subsequent stages of the teacher professional development program. Consequently, her confidence in IHT experienced only a modest increase.

After stage 2: “I participate in the development of IHT cases, and my confidence is increased a little bit more”

Following Stage 2, Shuitao reported further increased confidence in IHT. She attributed this growth to two main factors. Firstly, she successfully developed several instructional designs for IHT through collaboration with in-service teachers. These collaborative experiences enabled her to gain a deeper understanding of IHT approaches and enhance her pedagogical content knowledge in this area, consequently bolstering her confidence in her ability to perform effectively. Secondly, Shuitao observed the tangible impact of IHT cases on students in real classroom settings, which reinforced her belief in the efficacy of IHT. These experiences instilled in her a greater sense of confidence in her capacity to positively influence her students through her implementation of IHT. Shuitao remarked that she gradually understood how to integrate suitable history-related materials into her instructional designs (e.g., employ a genetic approach Footnote 10 ), considering it as the second important step of IHT. She shared her experience of developing IHT instructional design on the concept of logarithms. After creating several iterations of IHT instructional designs, Shuitao emphasized that her confidence in SE-IHT-IP has strengthened. She expressed belief in her ability to apply these approaches to IHT, as well as the pedagogical content knowledge of IHT, acquired through practical experience, in her future teaching endeavors. The following is an excerpt from the interview:

I learned some effective knowledge, skills, techniques and approaches [to IHT]… By employing these approaches, I thought I could [and] I had the confidence to integrate the history into instructional designs very well… For instance, [inspired] by the genetic approach, we designed a series of questions and tasks based on the history of logarithms. The introduction of the new concept of logarithms became very natural, and it perfectly met the requirements of our curriculum standards, [which] asked students to understand the necessity of learning the concept of logarithms…

Shuitao actively observed the classroom teaching conducted by her cooperating in-service teacher. She helped her cooperating in-service teacher in collecting and analyzing students’ feedback. Subsequently, discussions ensued on how to improve the instructional designs based on this feedback. The refined IHT instructional designs were subsequently re-implemented by the in-service teacher. After three rounds of developing IHT cases, Shuitao became increasingly convinced of the significance and efficacy of integrating history into teaching practices, as evidenced by the following excerpt:

The impacts of IHT on students are visible… For instance, more than 93% of the students mentioned in the open-ended questionnaires that they became more interested in mathematics because of the [historical] story of Napier… For another example, according to the results of our surveys, more than 75% of the students stated that they knew log a ( M  +  N ) = log a M  × log a N was wrong because of history… I have a little bit more confidence in the effects of my IHT on students.

This excerpt highlights that Shuitao’s SE-IHT-SO was enhanced. She attributed this enhancement to her realization of the compelling nature of history and her belief in her ability to effectively leverage its power to positively influence her students’ cognitive and emotional development. This also underscores the importance of reinforcing pre-service teachers’ awareness of the significance of history. Nonetheless, Shuiato elucidated that she still retained concerns regarding the effectiveness of her IHT implementation. Her following statement shed light on why her self-efficacy only experienced a marginal increase in this stage:

Knowing how to do it successfully and doing it successfully in practice are two totally different things… I can develop IHT instructional designs well, but I have no idea whether I can implement them well and whether I can introduce the history professionally in practice… My cooperation in-service teacher has a long history of teaching mathematics and gains rich experience in educational practices… If I cannot acquire some required teaching skills and capabilities, I still cannot influence my students powerfully.

After stage 3: “Practice makes perfect, and my SE-IHT-IP is steadily enhanced after a hit”

After successfully developing IHT instructional designs, the next critical step was the implementation of these designs. Drawing from her observations of her cooperating in-service teachers’ IHT implementations and discussions with other pre-service teachers, Shuitao developed her own IHT lesson plans. In Stage 3, she conducted simulated teaching sessions and evaluated her teaching performance ten times Footnote 11 . Shuitao claimed that her SE-IHT-IP steadily improved over the course of these sessions. According to Shuitao, two main processes in Stage 3 facilitated this steady enhancement of SE-IHT-IP.

On the one hand, through the repeated implementation of simulated teaching sessions, Shuitao’s teaching proficiency and fluency markedly improved. Shuitao first described the importance of teaching proficiency and fluency:

Since the detailed history is not included in our curriculum standards and textbooks, if I use my historical materials in class, I have to teach more contents than traditional teachers. Therefore, I have to teach proficiently so that teaching pace becomes a little faster than usual… I have to teach fluently so as to use each minute efficiently in my class. Otherwise, I cannot complete the teaching tasks required [by curriculum standards].

As Shuitao said, at the beginning of Stage 3, her self-efficacy even decreased because she lacked teaching proficiency and fluency and was unable to complete the required teaching tasks:

In the first few times of simulated teaching, I always needed to think for a second about what I should say next when I finish one sentence. I also felt very nervous when I stood in the front of the classrooms. This made my narration of the historical story between Briggs and Napier not fluent at all. I paused many times to look for some hints on my notes… All these made me unable to complete the required teaching tasks… My [teaching] confidence took a hit.

Shuitao quoted the proverb, “practice makes perfect”, and she emphasized that it was repeated practice that improved her teaching proficiency and fluency:

I thought I had no other choice but to practice IHT repeatedly… [At the end of Stage 3,] I could naturally remember most words that I should say when teaching the topics that I selected… My teaching proficiency and fluency was improved through my repeated review of my instructional designs and implementation of IHT in the micro-classrooms… With the improvement [of my teaching proficiency and fluency], I could complete the teaching tasks, and my confidence was increased as well.

In addition, Shuitao also mentioned that through this kind of self-exploration in simulated teaching practice, her teaching skills and capabilities (e.g., blackboard writing, abilities of language organization abilities, etc.) improved. This process was of great help to her enhancement of SE-IHT-IP.

On the other hand, Shuitao’s simulated teaching underwent assessment by herself, with mentors, in-service teachers and fellow pre-service teachers. This comprehensive evaluation process played a pivotal role in enhancing her individual performance and self-efficacy. Reflecting on this aspect, Shuitao articulated the following sentiments in one of her reflection reports:

By watching the videos, conducting self-assessment, and collecting feedback from others, I can understand what I should improve or emphasize in my teaching. [Then,] I think my IHT can better meet the requirements [of curriculum standards]… I think my teaching performance is getting better and better.

After stage 4: “My micro-courses influenced students positively, and my SE-IHT-SO is steadily enhanced”

In Stage 4, Shuitao commenced by creating 5-min micro-course videos. Subsequently, she played these videos in her cooperating in-service teachers’ authentic classroom settings and collected student feedback. This micro-course was played at the end of her cooperating in-service teachers’ lesson Footnote 12 . Shuitao wrote in her reflections that this micro-course of logarithms helped students better understand the nature of mathematics:

According to the results of our surveys, many students stated that they knew the development and evolution of the concept of logarithms is a long process and many mathematicians from different countries have contributed to the development of the concept of logarithms… This indicated that my micro-course helped students better understand the nature of mathematics… My micro-course about the history informed students that mathematics is an evolving and human subject and helped them understand the dynamic development of the [mathematics] concept…

Meanwhile, Shuitao’s micro-course positively influenced some students’ beliefs towards mathematics. As evident from the quote below, integrating historical context into mathematics teaching transformed students’ perception of the subject, boosting Shuitao’s confidence too.

Some students’ responses were very exciting… [O]ne [typical] response stated, he always regarded mathematics as abstract, boring, and dreadful subject; but after seeing the photos of mathematicians and great men and learning the development of the concept of logarithms through the micro-course, he found mathematics could be interesting. He wanted to learn more the interesting history… Students’ such changes made me confident.

Furthermore, during post-class interviews, several students expressed their recognition of the significance of the logarithms concept to Shuitao, attributing this realization to the insights provided by prominent figures in the micro-courses. They also conveyed their intention to exert greater effort in mastering the subject matter. This feedback made Shuitao believe that her IHT had the potential to positively influence students’ attitudes towards learning mathematics.

In summary, Stage 4 marked Shuitao’s first opportunity to directly impact students through her IHT in authentic classroom settings. Despite implementing only brief 5-min micro-courses integrating history during each session, the effectiveness of her short IHT implementation was validated by student feedback. Shuitao unequivocally expressed that students actively engaged with her micro-courses and that these sessions positively influenced them, including attitudes and motivation toward mathematics learning, understanding of mathematics concepts, and beliefs regarding mathematics. These collective factors contributed to a steady enhancement of her confidence in SE-IHT-SO.

After stage 5: “My overall self-efficacy is greatly enhanced”

Following Stage 5, Shuitao reported a significant increase in her overall confidence in IHT, attributing it to gaining mastery through successful implementations of IHT in real classroom settings. On the one hand, Shuitao successfully designed and executed her IHT lesson plans, consistently achieving the teaching objectives mandated by curriculum standards. This significantly enhanced her SE-IHT-IP. On the other hand, as Shuitao’s IHT implementation directly influenced her students, her confidence in SE-IHT-SO experienced considerable improvement.

According to Bandura ( 1997 ), mastery experience is the most powerful source of self-efficacy. Shuitao’s statements confirmed this. As she claimed, her enhanced SE-IHT-IP in Stage 5 mainly came from the experience of successful implementations of IHT in real classrooms:

[Before the teacher professional development program,] I had no idea about implementing IHT… Now, I successfully implemented IHT in senior high school [classrooms] many times… I can complete the teaching tasks and even better completed the teaching objectives required [by the curriculum standards]… The successful experience greatly enhances my confidence to perform well in my future implementation of IHT… Yeah, I think the successful teaching practice experience is the strongest booster of my confidence.

At the end of stage 5, Shuitao’s mentors and in-service teachers gave her a high evaluation. For instance, after Shuitao’s IHT implementation of the concept of logarithms, all mentors and in-service teachers consistently provided feedback that her IHT teaching illustrated the necessity of learning the concept of logarithms and met the requirements of the curriculum standards very well. This kind of verbal persuasion (Bandura 1997 ) enhanced her SE-IHT-IP.

Similarly, Shuitao’s successful experience of influencing students positively through IHT, as one kind of mastery experience, powerfully enhanced her SE-IHT-SO. She described her changes in SE-IHT-SO as follows:

I could not imagine my IHT could be so influential [before]… But now, my IHT implementation directly influenced students in so many aspects… When I witnessed students’ real changes in various cognitive and affective aspects, my confidence was greatly improved.

Shuitao described the influence of her IHT implementation of the concept of logarithms on her students. The depiction is grounded in the outcomes of surveys conducted by Shuitao following her implementation. Shuitao asserted that these results filled her with excitement and confidence regarding her future implementation of IHT.

In summary, following Stage 5 of the teacher professional development program, Shuitao experienced a notable enhancement in her overall self-efficacy, primarily attributed to her successful practical experience in authentic classroom settings during this stage.

A primary objective of our teacher professional development programs is to equip pre-service teachers with the skills and confidence needed to effectively implement IAT. Our findings show that one teacher professional development program, significantly augmented a participant’s TSE-IHT across two dimensions: individual performance and student outcomes. Considering the pressing need to provide STEAM teachers with effective professional training (e.g., Boice et al. 2021 ; Duong et al. 2024 ; Herro et al. 2019 ; Jacques et al. 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ), the proposed five-stage framework holds significant promise in both theoretical and practical realms. Furthermore, this study offers a viable solution to address the prevalent issue of low levels of teacher self-efficacy in interdisciplinary teaching, including IAT, which is critical in STEAM education (Zhou et al. 2023 ). This study holds the potential to make unique contributions to the existing body of literature on teacher self-efficacy, teacher professional learning models and the design of teacher professional development programs of IAT.

Firstly, this study enhances our understanding of the development of teacher self-efficacy. Our findings further confirm the complexity of the development of teacher self-efficacy. On the one hand, the observed enhancement of the participant’s teacher self-efficacy did not occur swiftly but unfolded gradually through a protracted, incremental process. Moreover, it is noteworthy that the participant’s self-efficacy exhibited fluctuations, underscoring that the augmentation of teacher self-efficacy is neither straightforward nor linear. On the other hand, the study elucidated that the augmentation of teacher self-efficacy constitutes an intricate, multi-level system that interacts with teacher knowledge, skills, and other beliefs. This finding resonates with prior research on teacher self-efficacy (Morris et al. 2017 ; Xenofontos and Andrews 2020 ). For example, our study revealed that Shuitao’s enhancement of SE-IHT-SO may always be interwoven with her continuous comprehension of the significance of the A&H in classroom settings. Similarly, the participant progressively acknowledged the educational value of A&H in classroom contexts in tandem with the stepwise enhancement of SE-IHT-SO. Factors such as the participant’s pedagogical content knowledge of IHT, instructional design, and teaching skills were also identified as pivotal components of SE-IHT-IP. This finding corroborates Morris and Usher ( 2011 ) assertion that sustained improvements in self-efficacy stem from developing teachers’ skills and knowledge. With the bolstering of SE-IHT-IP, the participant’s related teaching skills and content knowledge also exhibited improvement.

Methodologically, many researchers advocate for qualitative investigations into self-efficacy (e.g., Philippou and Pantziara 2015; Klassen et al. 2011 ; Wyatt 2015 ; Xenofontos and Andrews 2020 ). While acknowledging limitations in sample scope and the generalizability of the findings, this study offers a longitudinal perspective on the stage-by-stage development of teacher self-efficacy and its interactions with different factors (i.e., teacher knowledge, skills, and beliefs), often ignored by quantitative studies. Considering that studies of self-efficacy have been predominantly quantitative, typically drawing on survey techniques and pre-determined scales (Xenofontos and Andrews, 2020 ; Zhou et al. 2023 ), this study highlights the need for greater attention to qualitative studies so that more cultural, situational and contextual factors in the development of self-efficacy can be captured.

Our study provides valuable practical implications for enhancing pre-service teachers’ self-efficacy. We conceptualize teacher self-efficacy in two primary dimensions: individual performance and student outcomes. On the one hand, pre-service teachers can enhance their teaching qualities, boosting their self-efficacy in individual performance. The adage “practice makes perfect” underscores the necessity of ample teaching practice opportunities for pre-service teachers who lack prior teaching experience. Engaging in consistent and reflective practice helps them develop confidence in their teaching qualities. On the other hand, pre-service teachers should focus on positive feedback from their students, reinforcing their self-efficacy in individual performance. Positive student feedback serves as an affirmation of their teaching effectiveness and encourages continuous improvement. Furthermore, our findings highlight the significance of mentors’ and peers’ positive feedback as critical sources of teacher self-efficacy. Mentors and peers play a pivotal role in the professional growth of pre-service teachers by actively encouraging them and recognizing their teaching achievements. Constructive feedback from experienced mentors and supportive peers fosters a collaborative learning environment and bolsters the self-confidence of pre-service teachers. Additionally, our research indicates that pre-service teachers’ self-efficacy may fluctuate. Therefore, mentors should be prepared to help pre-service teachers manage teaching challenges and setbacks, and alleviate any teaching-related anxiety. Mentors can help pre-service teachers build resilience and maintain a positive outlook on their teaching journey through emotional support and guidance. Moreover, a strong correlation exists between teacher self-efficacy and teacher knowledge and skills. Enhancing pre-service teachers’ knowledge base and instructional skills is crucial for bolstering their overall self-efficacy.

Secondly, this study also responds to the appeal to understand teachers’ professional learning from a holistic perspective and interrelate teachers’ professional learning process with student outcome variables (Sancar et al. 2021 ), and thus contributes to the understanding of the complexity of STEAM teachers’ professional learning. On the one hand, we have confirmed Cai et al.’s ( 2020 ) teacher professional learning model in a new context, namely STEAM teacher education. Throughout the teacher professional development program, the pre-service teacher, Shuitao, demonstrated an augmentation in her knowledge, encompassing both content knowledge and pedagogical understanding concerning IHT. Moreover, her beliefs regarding IHT transformed as a result of her engagement in teacher learning across the five stages. This facilitated her in executing effective IHT teaching and improving her students’ outcomes. On the other hand, notably, in our studies (including this current study and some follow-up studies), student feedback is a pivotal tool to assist teachers in discerning the impact they are effectuating. This enables pre-service teachers to grasp the actual efficacy of their teaching efforts and subsequently contributes significantly to the augmentation of their self-efficacy. Such steps have seldom been conducted in prior studies (e.g., Cai et al. 2020 ), where student outcomes are often perceived solely as the results of teachers’ instruction rather than sources informing teacher beliefs. Additionally, this study has validated both the interaction between teaching performance and teacher beliefs and between teacher knowledge and teacher beliefs. These aspects were overlooked in Cai et al.’s ( 2020 ) model. More importantly, while Clarke and Hollingsworth’s ( 2002 ) Interconnected Model of Professional Growth illustrates the connections between the domain of consequence and the personal domain, as well as between the personal domain and the domain of practice, it does not adequately clarify the complex relationships among the factors within the personal domain (e.g., the interaction between teacher knowledge and teacher beliefs). Therefore, our study also supplements Clarke and Hollingsworth’s ( 2002 ) model by addressing these intricacies. Based on our findings, an updated model of teacher professional learning has been proposed, as shown in Fig. 3 . This expanded model indicates that teacher learning should be an ongoing and sustainable process, with the enhancement of student learning not marking the conclusion of teacher learning, but rather serving as the catalyst for a new phase of learning. In this sense, we advocate for further research to investigate the tangible impacts of teacher professional development programs on students and how those impacts stimulate subsequent cycles of teacher learning.

Note: Paths in blue were proposed by Cai et al. ( 2020 ), and paths in yellow are proposed and verified in this study.

Thirdly, in light of the updated model of teacher professional learning (see Fig. 3 ), this study provides insights into the design of teacher professional development programs of IAT. According to Huang et al. ( 2022 ), to date, very few studies have set goals to “develop a comprehensive understanding of effective designs” for STEM (or STEAM) teacher professional development programs (p. 15). To fill this gap, this study proposes a novel and effective five-stage framework for teacher professional development programs of IAT. This framework provides a possible and feasible solution to the challenges of STEAM teacher professional development programs’ design and planning, and teachers’ IAT practice (Boice et al. 2021 ; Herro et al. 2019 ; Jacques et al. 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ).

Specifically, our five-stage framework incorporates at least six important features. Firstly, teacher professional development programs should focus on specific STEAM content. Given the expansive nature of STEAM, teacher professional development programs cannot feasibly encompass all facets of its contents. Consistent with recommendations by Cai et al. ( 2020 ), Desimone et al. ( 2002 ) and Garet et al. ( 2001 ), an effective teacher professional development program should prioritize content focus. Our five-stage framework is centered on IAT. Throughout an 18-month duration, each pre-service teacher is limited to selecting one subcomponent of A&H, such as history, for integration into their subject teaching (i.e., mathematics teaching, technology teaching or science teaching) within one teacher professional development program. Secondly, in response to the appeals that teacher professional development programs should shift from emphasizing teaching and instruction to emphasizing student learning (Cai et al. 2020 ; Calabrese et al. 2024 ; Hwang et al. 2024 ; Marco and Palatnik 2024 ; Örnek and Soylu 2021 ), our framework requires pre-service teachers to pay close attention to the effects of IAT on student learning outcomes, and use students’ feedback as the basis of improving their instruction. Thirdly, prior studies found that teacher education with a preference for theory led to pre-service teachers’ dissatisfaction with the quality of teacher professional development program and hindered the development of pre-service teachers’ teaching skills and teaching beliefs, which also widened the gap between theory and practice (Hennissen et al. 2017 ; Ord and Nuttall 2016 ). In this regard, our five-stage framework connects theory and teaching practice closely. In particular, pre-service teachers can experience the values of IAT not only through theoretical learning but also through diverse teaching practices. Fourthly, we build a teacher community of practice tailored for pre-service teachers. Additionally, we aim to encourage greater participation of in-service teachers in such teacher professional development programs designed for pre-service educators in STEAM teacher education. By engaging in such programs, in-service teachers can offer valuable teaching opportunities for pre-service educators and contribute their insights and experiences from teaching practice. Importantly, pre-service teachers stand to gain from the in-service teachers’ familiarity with textbooks, subject matter expertise, and better understanding of student dynamics. Fifthly, our five-stage framework lasts for an extended period, spanning 18 months. This duration ensures that pre-service teachers engage in a sustained and comprehensive learning journey. Lastly, our framework facilitates a practical understanding of “integration” by offering detailed, sequential instructions for blending two disciplines in teaching. For example, our teacher professional development programs prioritize systematic learning of pedagogical theories and simulated teaching experiences before pre-service teachers embark on real STEAM teaching endeavors. This approach is designed to mitigate the risk of unsuccessful experiences during initial teaching efforts, thereby safeguarding pre-service teachers’ teacher self-efficacy. Considering the complexity of “integration” in interdisciplinary teaching practices, including IAT (Han et al. 2022 ; Ryu et al. 2019 ), we believe detailed stage-by-stage and step-by-step instructions are crucial components of relevant pre-service teacher professional development programs. Notably, this aspect, emphasizing structural instructional guidance, has not been explicitly addressed in prior research (e.g., Cai et al. 2020 ). Figure 4 illustrates the six important features outlined in this study, encompassing both established elements and the novel addition proposed herein, describing an effective teacher professional development program.

Note: STEAM refers to science, technology, engineering, arts and humanities, and mathematics.

The successful implementation of this framework is also related to the Chinese teacher education system and cultural background. For instance, the Chinese government has promoted many university-school collaboration initiatives, encouraging in-service teachers to provide guidance and practical opportunities for pre-service teachers (Lu et al. 2019 ). Influenced by Confucian values emphasizing altruism, many experienced in-service teachers in China are eager to assist pre-service teachers, helping them better realize their teaching career aspirations. It is reported that experienced in-service teachers in China show significantly higher motivation than their international peers when mentoring pre-service teachers (Lu et al. 2019 ). Therefore, for the successful implementation of this framework in other countries, it is crucial for universities to forge close collaborative relationships with K-12 schools and actively involve K-12 teachers in pre-service teacher education.

Notably, approximately 5% of our participants dropped out midway as they found that the IAT practice was too challenging or felt overwhelmed by the number of required tasks in the program. Consequently, we are exploring options to potentially simplify this framework in future iterations.

Without minimizing the limitations of this study, it is important to recognize that a qualitative longitudinal case study can be a useful means of shedding light on the development of a pre-service STEAM teacher’s self-efficacy. However, this methodology did not allow for a pre-post or a quasi-experimental design, and the effectiveness of our five-stage framework could not be confirmed quantitatively. In the future, conducting more experimental or design-based studies could further validate the effectiveness of our framework and broaden our findings. Furthermore, future studies should incorporate triangulation methods and utilize multiple data sources to enhance the reliability and validity of the findings. Meanwhile, owing to space limitations, we could only report the changes in Shuitao’s SE-IHT-IP and SE-IHT-SO here, and we could not describe the teacher self-efficacy of other participants regarding IAT. While nearly all of the pre-service teachers experienced an improvement in their teacher self-efficacy concerning IAT upon participating in our teacher professional development programs, the processes of their change were not entirely uniform. We will need to report the specific findings of these variations in the future. Further studies are also needed to explore the factors contributing to these variations. Moreover, following this study, we are implementing more teacher professional development programs of IAT. Future studies can explore the impact of this framework on additional aspects of pre-service STEAM teachers’ professional development. This will help gain a more comprehensive understanding of its effectiveness and potential areas for further improvement. Additionally, our five-stage framework was initially developed and implemented within the Chinese teacher education system. Future research should investigate how this framework can be adapted in other educational systems and cultural contexts.

The impetus behind this study stems from the burgeoning discourse advocating for the integration of A&H disciplines into STEM education on a global scale (e.g., Land 2020 ; Park and Cho 2022 ; Uştu et al. 2021 ; Vaziri and Bradburn 2021 ). Concurrently, there exists a pervasive concern regarding the challenges teachers face in implementing STEAM approaches, particularly in the context of IAT practices (e.g., Boice et al. 2021 ; Herro et al. 2019 ; Jacques et al. 2020 ; Park and Cho 2022 ; Perignat and Katz-Buonincontro 2019 ). To tackle this challenge, we first proposed a five-stage framework designed for teacher professional development programs of IAT. Then, utilizing this innovative framework, we implemented a series of teacher professional development programs. Drawing from the recommendations of Bray-Clark and Bates ( 2003 ), Kelley et al. ( 2020 ) and Zhou et al. ( 2023 ), we have selected teacher self-efficacy as a key metric to examine the effectiveness of the five-stage framework. Through a qualitative longitudinal case study, we scrutinized the influence of a specific teacher professional development program on the self-efficacy of a single pre-service teacher over an 18-month period. Our findings revealed a notable enhancement in teacher self-efficacy across both individual performance and student outcomes. The observed enhancement of the participant’s teacher self-efficacy did not occur swiftly but unfolded gradually through a prolonged, incremental process. Building on our findings, an updated model of teacher learning has been proposed. The updated model illustrates that teacher learning should be viewed as a continuous and sustainable process, wherein teaching performance, teacher beliefs, and teacher knowledge dynamically interact with one another. The updated model also confirms that teacher learning is inherently intertwined with student learning in STEAM education. Furthermore, this study also summarizes effective design features of STEAM teacher professional development programs.

Data availability

The datasets generated and/or analyzed during this study are not publicly available due to general data protection regulations, but are available from the corresponding author on reasonable request.

In their review article, Morris et al. ( 2017 ) equated “teaching self-efficacy” and “teacher self-efficacy” as synonymous concepts. This perspective is also adopted in this study.

An effective teacher professional development program should have specific, focused, and clear content instead of broad and scattered ones. Therefore, each pre-service teacher can only choose to integrate one subcomponent of A&H into their teaching in one teacher professional development program. For instance, Shuitao, a mathematics pre-service teacher, participated in one teacher professional development program focused on integrating history into mathematics teaching. However, she did not explore the integration of other subcomponents of A&H into her teaching during her graduate studies.

In the micro-classrooms, multi-angle, and multi-point high-definition video recorders are set up to record the teaching process.

In micro-teaching, mentors, in-service teachers, and other fellow pre-service teachers take on the roles of students.

In China, teachers can video record one section of a lesson and play them in formal classes. This is a practice known as a micro-course. For instance, in one teacher professional development program of integrating history into mathematics teaching, micro-courses encompass various mathematics concepts, methods, ideas, history-related material and related topics. Typically, teachers use these micro-courses to broaden students’ views, foster inquiry-based learning, and cultivate critical thinking skills. Such initiatives play an important role in improving teaching quality.

Many university-school collaboration initiatives in China focus on pre-service teachers’ practicum experiences (Lu et al. 2019 ). Our teacher professional development program is also supported by many K-12 schools in Shanghai. Personal information in videos is strictly protected.

In China, students are not required to pursue a graduate major that matches their undergraduate major. Most participants in our teacher professional development programs did not pursue undergraduate degrees in education-related fields.

Shuitao’s university reserves Wednesday afternoons for students to engage in various programs or clubs, as classes are not scheduled during this time. Similarly, our teacher professional development program activities are planned for Wednesday afternoons to avoid overlapping with participants’ other coursework commitments.

History is one of the most important components of A&H (Park and Cho 2022 ).

To learn more about genetic approach (i.e., genetic principle), see Jankvist ( 2009 ).

For the assessment process, see Fig. 2 .

Shuitao’s cooperating in-service teacher taught the concept of logarithms in Stage 2. In Stage 4, the teaching objective of her cooperating in-service teacher’s review lesson was to help students review the concept of logarithms to prepare students for the final exam.

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Acknowledgements

This research is funded by 2021 National Natural Science Foundation of China (Grant No.62177042), 2024 Zhejiang Provincial Natural Science Foundation of China (Grant No. Y24F020039), and 2024 Zhejiang Educational Science Planning Project (Grant No. 2024SCG247).

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Xuesong Zhai

Present address: School of Education, City University of Macau, Macau, China

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College of Education, Zhejiang University, Hangzhou, China

Haozhe Jiang & Xuesong Zhai

School of Engineering and Technology, CML‑NET & CREATE Research Centres, Central Queensland University, North Rockhampton, QLD, Australia

Ritesh Chugh

Hangzhou International Urbanology Research Center & Zhejiang Urban Governance Studies Center, Hangzhou, China

Department of Teacher Education, Nicholls State University, Thibodaux, LA, USA

School of Mathematical Sciences, East China Normal University, Shanghai, China

Xiaoqin Wang

College of Teacher Education, Faculty of Education, East China Normal University, Shanghai, China

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Conceptualization - Haozhe Jiang; methodology - Haozhe Jiang; software - Xuesong Zhai; formal analysis - Haozhe Jiang & Ke Wang; investigation - Haozhe Jiang; resources - Haozhe Jiang, Xuesong Zhai & Xiaoqin Wang; data curation - Haozhe Jiang & Ke Wang; writing—original draft preparation - Haozhe Jiang & Ritesh Chugh; writing—review and editing - Ritesh Chugh & Ke Wang; visualization - Haozhe Jiang, Ke Wang & Xiaoqin Wang; supervision - Xuesong Zhai & Xiaoqin Wang; project administration - Xuesong Zhai & Xiaoqin Wang; and funding acquisition - Xuesong Zhai & Xiaoqin Wang. All authors have read and agreed to the published version of the manuscript.

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Jiang, H., Chugh, R., Zhai, X. et al. Longitudinal analysis of teacher self-efficacy evolution during a STEAM professional development program: a qualitative case study. Humanit Soc Sci Commun 11 , 1162 (2024). https://doi.org/10.1057/s41599-024-03655-5

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DOI : https://doi.org/10.1057/s41599-024-03655-5

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Barriers and enablers for equitable healthy food access in baltimore carryout restaurants: a qualitative study in healthy food priority areas.

1. Introduction

2. materials and methods, 2.1. study context, 2.2. sampling and participant recruitment, 2.3. data collection, 2.4. data management and analysis, 3.1. interpersonal drivers, 3.1.1. perceptions of consumer preferences, 3.1.2. care for consumer well-being, 3.1.3. maximizing transactions, 3.2. sociocultural drivers, multicultural ownership shapes food offerings, 3.3. business drivers, cost of business impacts carryouts’ ability to offer healthy options, 3.4. policy drivers, 3.4.1. taxation, 3.4.2. government regulations and policy, 3.4.3. information challenges, 3.4.4. uneven investment across neighborhoods, 4. discussion, 4.1. implications for policy, 4.2. limitations and strengths, 5. conclusions, supplementary materials, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Share and Cite

Hua, S.; Vong, V.; Thomas, A.E.; Mui, Y.; Poirier, L. Barriers and Enablers for Equitable Healthy Food Access in Baltimore Carryout Restaurants: A Qualitative Study in Healthy Food Priority Areas. Nutrients 2024 , 16 , 3028. https://doi.org/10.3390/nu16173028

Hua S, Vong V, Thomas AE, Mui Y, Poirier L. Barriers and Enablers for Equitable Healthy Food Access in Baltimore Carryout Restaurants: A Qualitative Study in Healthy Food Priority Areas. Nutrients . 2024; 16(17):3028. https://doi.org/10.3390/nu16173028

Hua, Shuxian, Vicky Vong, Audrey E. Thomas, Yeeli Mui, and Lisa Poirier. 2024. "Barriers and Enablers for Equitable Healthy Food Access in Baltimore Carryout Restaurants: A Qualitative Study in Healthy Food Priority Areas" Nutrients 16, no. 17: 3028. https://doi.org/10.3390/nu16173028

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