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  • v.287(1935); 2020 Sep 30

Navigating cross-cultural research: methodological and ethical considerations

Tanya broesch.

1 Department of Psychology, Simon Fraser University, BC, Canada

Alyssa N. Crittenden

2 Department of Anthropology, University of Nevada, Las Vegas, NV, USA

Bret A. Beheim

3 Department of Human Behavior, Ecology and Culture, Max-Planck-Institute for Evolutionary Anthropology, Leipzig, Germany

Aaron D. Blackwell

4 Department of Anthropology, Washington State University, Pullman, WA, USA

John A. Bunce

Heidi colleran.

5 BirthRites Independent Max Planck Research Group, Max-Planck-Institute for Evolutionary Anthropology, Leipzig, Germany

Kristin Hagel

Michelle kline.

6 Centre for Culture and Evolution, Brunel University, London, UK

Richard McElreath

Robin g. nelson.

7 Department of Anthropology, Santa Clara University, CA, USA

Anne C. Pisor

8 Department of Anthropology, University of Missouri, MO, USA

Ilaria Pretelli

Benjamin purzycki.

9 Department of the Study of Religion, Aarhus University, Aarhus, Denmark

Elizabeth A. Quinn

10 Department of Anthropology, Washington University, Saint Louis, MO, USA

Brooke Scelza

11 Department of Anthropology, UCLA, Los Angeles, CA, USA

Kathrine Starkweather

12 Department of Anthropology, University of Illinois, Chicago, USA

Jonathan Stieglitz

13 Institute for Advanced Study, Toulouse, France

Monique Borgerhoff Mulder

14 Department of Anthropology, University of California, Davis, CA, USA

Associated Data

This article has no additional data.

The intensifying pace of research based on cross-cultural studies in the social sciences necessitates a discussion of the unique challenges of multi-sited research. Given an increasing demand for social scientists to expand their data collection beyond WEIRD (Western, educated, industrialized, rich and democratic) populations, there is an urgent need for transdisciplinary conversations on the logistical, scientific and ethical considerations inherent to this type of scholarship. As a group of social scientists engaged in cross-cultural research in psychology and anthropology, we hope to guide prospective cross-cultural researchers through some of the complex scientific and ethical challenges involved in such work: (a) study site selection, (b) community involvement and (c) culturally appropriate research methods. We aim to shed light on some of the difficult ethical quandaries of this type of research. Our recommendation emphasizes a community-centred approach, in which the desires of the community regarding research approach and methodology, community involvement, results communication and distribution, and data sharing are held in the highest regard by the researchers. We argue that such considerations are central to scientific rigour and the foundation of the study of human behaviour.

1. Introduction

The acknowledgement that most research in psychology and other adjacent fields is overwhelmingly based on so-called WEIRD (Western, educated, industrialized, rich and democratic) populations [ 1 ] has given way to intensified research funding, publication and visibility of collaborative cross-cultural studies across the social sciences that expand the geographical range of study populations (e.g. [ 2 – 10 ]). The rapid expansion of cross-cultural team science has been precipitated by the ever-increasing availability of online global data sources and the expansion of the cross-cultural enterprise into fields such as economics [ 11 ], political science [ 12 ] and other disciplines with little previous field research expectations or ethnographic focus. This expansion necessarily generates concerns regarding responsible methods and practice. For example, many of the so-called non-WEIRD communities who participate in research are Indigenous, from low- and middle-income countries in the global South, live in post-colonial contexts, and/or are marginalized within their political systems, creating power differentials between researchers and researched [ 13 , 14 ]. This creates a need for transdisciplinary discussion on the importance of community participation and the explanation and sharing of research outputs with participants.

Given increasing pressure for social scientists to expand the range of societies from which they recruit participants to test hypotheses about human behaviour, we convened a working group to discuss some of the unique scientific and ethical challenges of cross-cultural research. As a group of investigators engaged in such research in psychology and anthropology, our research objectives include testing theoretically derived hypotheses to examine general patterning and explain cultural variation in human behaviour. As such, we face challenges in how to collect systematic data, either as the primary fieldworker or in collaboration with shorter-term visitors who wish to collect their own data. The growing appetite for including diverse populations in work on demography, health, wealth, cooperation, cognition, infant and child development, and belief systems raises unique scientific and ethical issues, independent of discipline or research topic.

This paper adds to the growing dialogue on best practices when working with populations or cultural groups in low- to middle-income regions (see [ 13 – 18 ]) and touches on topics that many social scientists, particularly cultural anthropologists, have been writing about for decades [ 19 , 20 ]. Much cross-cultural research has historically been rooted in racist, capitalist ideas and motivations [ 19 ]. Scholars have long debated whether research aiming to standardize cross-cultural measurements and analysis is tacitly engaged and/or continues to be rooted in colonial and imperialist practices [ 21 , 22 ]. Given this history, it is critical that participating scientists reflect upon these issues and be accountable to their participants and colleagues for their research practices. We argue that cross-cultural research be grounded in the recognition of the historical, political, sociological and cultural forces acting on the communities and individuals of focus. These perspectives are often contrasted with ‘science’; here we argue that they are necessary as a foundation for the study of human behaviour.

Here, we present considerations that we have found to be useful in our own work. More specifically, we propose that careful scrutiny of (a) study site selection, (b) community involvement and (c) culturally appropriate research methods will begin to address some of the complex scientific and ethical challenges of cross-cultural research. Particularly for those initiating collaborative cross-cultural projects, we focus here on pragmatic and implementable steps. We stress that our goal is not to review the literature on colonial or neo-colonial research practices, to provide a comprehensive primer on decolonizing approaches to field research, nor to identify or admonish past misdemeanours in these respects—misdemeanours to which many of the authors of this piece would readily admit. Furthermore, we acknowledge that we ourselves are writing from a place of privilege as researchers educated and trained in disciplines with colonial pasts. Our goal is simply to help researchers in the future better plan and execute their projects with appropriate consideration and inclusion of study communities and culturally appropriate methodologies.

(a) Study site selection

Study site selection in cross-cultural research involves three major conceptual issues. First, the increased interest in data collected from so-called non-Western societies means that study communities outside of WEIRD contexts are prized as sites for testing theories about human behaviour. This has sometimes led to an inclusion of ‘non-WEIRD’ populations in cross-cultural research without further regard for why specific populations should be included [ 23 ]. The binning of non-Western populations as a comparative sample to the cultural West (i.e. the ‘West versus rest’ approach) is often unwittingly reinforced by researchers who heeded the call to expand study site selection beyond WEIRD societies [ 1 ]. Here, we propose that researchers identify a clear theoretical justification for inclusion of any study population—WEIRD or not—based on knowledge of the relevant cultural and/or environmental context (see [ 24 ] for a good example). Regardless of whether a research group is investigating human universals or cultural variation, including any population in a study sample without justification of their inclusion is tantamount to binning and is, therefore, theoretically problematic [ 21 ].

Second, contemporary ‘small-scale’ communities continue to be discussed in the literature as proxies of our ancestral past—to varying degrees, often based on their food economy and the degree to which it is considered to be ‘traditional’ (e.g. foraging, small-scale horticulture). While some of these groups may occupy areas that are ecologically similar to the environments in which early modern humans lived and have social systems that may inform our understanding of those lifeways, these communities differ from early human communities in key ways. Many communities engage in mixed-subsistence practices [ 25 ] and currently reside in marginal environments that may not reflect their ancestral homelands [ 26 ]. Far from the romantic notion that such populations are uncontacted and living in harmony with the natural environment, in reality, they are impacted by ecological, social and political changes from outside/globalizing forces [ 27 ]. Studying contemporary communities as referential models of ancestral lifeways not only acts to further marginalize these societies, but can also lead to erroneous scientific conclusions—for example, about ancestral patterns of diet or cooperation (see [ 28 – 31 ]).

Third, when researchers design their cross-cultural studies, it is important to be cognizant that they are (to some extent) constrained by the relatively limited number of active field sites that can generate appropriate data. As such, cross-cultural investigators are working with a potentially biased sample of global populations from which broad inferences about humanity must be cautiously drawn (see [ 23 ]). This concern parallels our call for theoretical justification of the selection of samples; it is both the diversity of samples and the match between theory and cultural context that make for improved research design (see [ 23 ] for full discussion and examples).

To address these three conceptual issues, we suggest that researchers and reviewers problematize the exoticizing of particular peoples and cultures [ 32 ]. Taking such an approach also works to minimize the inclusion of particular populations based on how popular or iconic they may be to researchers. One way to do this is to take a theoretically motivated approach to sampling communities. For example, one might select communities that vary along the specific axis of theoretical interest, such as age structure, female-biased kinship or extent of market integration (see [ 23 ]).

Intra-population sampling decisions are also important as they involve unique ethical and social challenges. For example, foreign researchers (as sources of power, information and resources) represent both opportunities for and threats to community members. These relationships are often complicated by power differentials due to unequal access to wealth, education and historical legacies of colonization [ 15 – 20 ]. As such, it is important that investigators are alert to the possible bias among individuals who initially interact with researchers, to the potential negative consequences for those excluded, and to the (often unspoken) power dynamics between the researcher and their study participants (as well as among and between study participants) [ 32 – 35 ].

We suggest that a necessary first step is to carefully consult existing resources outlining best practices for ethical principles of research. Many of these resources have been developed over years of dialogue in various academic and professional societies (e.g. American Anthropological Association, International Association for Cross Cultural Psychology, International Union of Psychological Science). Furthermore, communities themselves are developing and launching research-based codes of ethics [ 36 , 37 ] and providing carefully curated open-access materials (e.g. https://www.itk.ca ), often written in consultation with ethicists in low- to middle-income countries (see [ 38 ]).

(b) Community involvement

Too often researchers engage in ‘extractive’ research, whereby a researcher selects a study community and collects the necessary data to exclusively further their own scientific and/or professional goals without benefiting the community. This reflects a long history of colonialism in social science [ 15 – 20 , 33 – 35 ]. Extractive methods may not only lead to methodological challenges but also act to alienate participants from the scientific process and are often unethical. Many researchers are associated with institutions tainted with colonial, racist and sexist histories, sentiments and in some instances perptuating into the present. Much cross-cultural research is carried out in former or contemporary colonies, and in the colonial language. Explicit and implicit power differentials create ethical challenges that can be acknowledged by researchers and in the design of their study (see [ 39 ] for an example in which the power and politics of various roles played by researchers is discussed). To provide examples of how to do this, we draw on frameworks from cultural anthropology and development studies, including participatory research, community collaboration and grounded theory [ 40 – 43 ]. What these frameworks hold in common, and what we reiterate here, is that it is critical that communities be included in study design, implementation and presentation of research/return of results. There is no one-size-fits-all approach, yet a productive baseline may be for researchers to consider community inclusion as part of their project design from the start. Ideally, the community is not only central to the planned research, but is leading it. We realize that not all research approaches can include a research team that spans the research institution, the investigators and the community; however, we would like to note that in many instances, community-based participatory research is shifting towards this type of relationship between researchers and study communities [ 44 , 45 ].

Even if a research project does not include co-investigators from the study community, or establishing a long-term community collaboration is not an aim, the inclusion of research participants at the outset is possible. For example, in a population genetic study on the early population history of Vanuatu [ 46 ], one of the authors (H.C.) explored different approaches to explain the initial purpose of the research project before data collection. At a broad level, an analogy with linguistic family trees was most salient for discussion of population history and emerged naturally from conversations with communities about whether to carry out the research in the first place. Learning to describe the DNA itself in Indigenous idioms was far more challenging and was only possible by including the community in all stages of the project. Another co-author (A.N.C.), provided feedback on temporal changes in food and water insecurity in a foraging population in Tanzania using a different strategy: she enlisted community members as data collectors, whose feedback on interview questions was incorporated prior to data collection in order to ensure that the concepts being queried were understood by participants [ 47 ].

Context-specific knowledge is important when planning how to obtain and document informed consent in an ethical and culturally appropriate way. Most informed consent procedures were developed within the medical research community, with strict criteria for inclusion and high standards of linguistic comprehension expected. For people whose only experience of signing a formal agreement is from legal, political or medical contexts, standard consent forms can have unintended significance. Accordingly, researchers may consider an active community-level discussion as part of the consent process prior to the seeking of individual-level consent (see [ 48 ] for a full discussion). Consent is also often thought to be a one-time transaction, usually at the beginning of a study, experiment or interview. However, this is not an appropriate fit for communities where formal legal obligations carry less currency than do reciprocal social relationships. Consent should, therefore, be seen as a process and a dialogue, also referred to as ‘dynamic consent’, not merely the collection of names and signatures [ 49 – 52 ].

A new suite of challenges emerges once data collection has ended. There are ethical issues regarding the return of research results and associated data to the community. It is important that researchers discuss this with participants as part of the consent process and respect the desires of the community in this regard. It is often considered best practice for researchers to provide ample time for participants to query and discuss results, either or both in collaborative discussions with the community or private discussions with interested respondents [ 36 – 38 , 48 ]. Ideally, such community discussions provide the researcher with novel insights into data interpretation while providing participants with a satisfactory understanding of the knowledge generated by the research and an opportunity to engage with the researchers' study motivations.

We also suggest that researchers consider how communities might benefit from access to the data they provide, and how local capacity to use such data can identified as part of the research [ 44 , 45 ]. Ultimately, we suggest a participant-led rather than top-down approach in making these decisions. By having conversations with participating communities about how they would like data returned, researchers and participants may find solutions for data sharing that are meaningful to communities—often through the production of archival works. For example, co-author A.C.P. collected video footage that was returned to the community; in a project on the production of handicrafts, the resultant video footage was uploaded to the internet, where community members indicated that they (and future generations) would have better access to the footage. Researchers and communities may consider uploading digital media to community-run websites or even to YouTube. When considering data sharing, however, it is important to note that some types of data-storage facilities (e.g. computers, libraries, YouTube) may not be accessible or appropriate to their participants. One strategy used independently by three of the authors (H.C., J.A.B. and A.N.C.) is to provide SD cards to participants with project-related video, photo and audio data which can be read by mobile phones. This allows information to be either kept secret by phone owners or to be shared. Another option used by co-author M.B.M. was to draw on her research to facilitate workshops for the writing and publication of a collectively sourced cultural history; she made copies of the book freely available to local schools [ 53 ]. A two-way dialogue between researchers and participants is needed to arrive at a reasonable solution based on participants’ preferences.

Data sharing may also include shifting ownership of research outputs to participants in a more explicit manner. For example, there is a set of recommended practices for research conducted within Indigenous communities in Canada which stipulate that data remains the property of the participating communities [ 54 ]. It is important to meet the ethical standards of communities as well as those of government and research institutions (e.g. universities). For some types of data (e.g. open access data sharing), this may include carefully anonymizing results before transferring ownership in order to protect individual or community identities. However, we recognize that researchers will need to consider the ethics of publishing information from study communities alongside the requirements of funding agencies and institutional review boards, as well as the priorities of open science. We suggest that the research be designed (and budgeted) to allow time to return to the study communities to present and discuss the results and these issues, if possible, prior to publication. For example, the Wenner-Gren foundation has a grant designed to enable grantees to return to their research location (e.g. http://www.wennergren.org/programs/engaged-anthropology-grant ).

Far too often, little attention is paid to the politics of representation when disseminating research results more widely, especially in online forums (including social media). It is important that all stakeholders, including all collaborating researchers, assume responsibility for the language used to describe results, whether by press offices or journalists or by the researchers themselves, as well as for the use of photographs, videos, audio recordings, material culture and artefacts in research and public outreach efforts. The recording and use of these materials should be addressed in the process of informed consent (see above). Sensationalizing or exoticizing images or language not only demeans study communities but can also undo years of careful community-based work. These practices are unethical because they may misrepresent participants; they can also affect relationships between study communities and field researchers. All researchers can bear these issues in mind and exert more control over public dissemination of their work. One suggestion to address these potential issues is for investigators themselves to write the press releases or, minimally, to review and approve press releases and associated images prepared by third parties.

(c) Research design and methods

Data collection methods largely stemming from WEIRD intellectual traditions are being exported to a range of cultural contexts. This is often done with insufficient consideration of the translatability (e.g. equivalence or applicability) or implementation of such concepts and methods in different contexts, as already well documented [ 15 – 20 ]. It is critical that researchers translate the language, technological references and stimuli as well as examine the underlying cultural context of the original method for assumptions that rely upon WEIRD epistemologies [ 55 , 56 ]. This extends to non-complex visual aids, attempting to ensure that even scales measure what the researcher is intending (see [ 57 ] for discussion on the use of a popular economic experiment in small-scale societies).

For example, in a developmental psychology study conducted by Broesch and colleagues [ 58 ], the research team exported a task to examine the development and variability of self-recognition in children across cultures. Typically, this milestone is measured by surreptitiously placing a mark on a child's forehead and allowing them to discover their reflective image and the mark in a mirror. While self-recognition in WEIRD contexts typically manifests in children by 18 months of age, the authors tested found that only 2 out of 82 children (aged 1–6 years) ‘passed’ the test by removing the mark using the reflected image. Note that they began testing younger children and moved up the developmental trajectory, eventually testing older children who also did not ‘pass the test’ by Western standards. Their results are unexplained by existing developmental theories. The authors' interpretation of these results is that performance reflects false negatives and instead measures implicit compliance to the local authority figure who placed the mark on the child. This raises the possibility that the mirror test may lack construct validity in cross-cultural contexts—in other words, that it may not measure what it was designed to measure.

An understanding of cultural norms may ensure that experimental protocols and interview questions are culturally and linguistically salient. This can be achieved by implementing several complementary strategies. A first step may be to collaborate with members of the study community to check the relevance of the instruments being used. Incorporating perspectives from the study community from the outset can reduce the likelihood of making scientific errors in measurement and inference [ 54 ].

An additional approach is to use mixed methods in data collection, such that each method ‘checks’ the data collected using the other methods. A recent paper (see [ 59 ]) provides suggestions for a rigorous methodological approach to conducting cross-cultural comparative psychology, underscoring the importance of using multiple methods with an eye towards a convergence of evidence. A mixed-method approach can incorporate a variety of methods such as participant observation, semi-structured interviews and experiments. For example, in their study on mate choice among Himba pastoralists of Namibia, Scelza and Prall [ 60 ] first employed semi-structured discussion groups and informal conversations with study participants. After better understanding the ways in which Himba themselves express desired characteristics of formal and informal partners, the researchers incorporated these characteristics into a ranking task [ 61 ]. Similarly, in a study of contraceptive use in rural Poland [ 62 ], qualitative interviews prior to formal data collection allowed the researchers to understand that the distinction between ‘modern’ and ‘traditional’ methods elicited very different (and apparently underreported) use than when the distinction was made between ‘natural’ and ‘artificial’.

More generally, asking participants to talk aloud [ 63 ] as they complete a task or asking follow-up (debriefing) questions at the end of the experiment may allow researchers to better understand the decision-making processes at play (see [ 64 , 65 ] for recommendations and examples). Some guidelines for incorporating participant observation and qualitative interviews are available from Bernard [ 63 ] and Matsumoto & Van de Vijver [ 66 ]. For definitions, examples, and a full discussion of different kinds of bias in social science measures, see Van de Vijver & Tanzer [ 67 ]. There are also a number of Indigenous research methodologies that have been well-developed and extensively applied. For example, the Pagtatanong-tanong interview method developed and documented in the Philippines maximizes respect and equality by allowing equal time for participants and interviewers to engage in questioning (see [ 68 ]). We recommend using these resources as a guide prior to developing study methods and prioritizing the collection of baseline data, field testing instruments, and soliciting and incorporating community feedback before data collection commences.

2. Conclusion

Our aim here is to add to the growing dialogue on best practices in social science research, particularly as they relate to cross-cultural studies involving research participants from widely variable communities around the world. As research funding and publication of cross-cultural studies continues to expand across the social sciences, it is necessary to acknowledge the unique methodological and ethical challenges of this research. With scholars from a wide range of disciplines increasingly engaging in such research, often with little or no formal field training or experience working outside of post-industrialized contexts from the global North, special consideration of (a) study site selection, (b) community involvement and (c) locally appropriate implementation of research design and methods is essential. Our intention is not to discourage researchers from embarking on cross-cultural studies, but rather to alert them to the multi-dimensional considerations at play, ranging from study design to participant inclusion, and to encourage constructive exchange and collaboration with participant communities. We suggest one solution may be for researchers new to cross-cultural studies to collaborate with field researchers who have established, long-term relationships with communities. We are not proposing that long-term researchers should be considered gatekeepers to the communities where they work—that role should only be played by the communities themselves. Rather, we are suggesting that individuals with established ties to a community may be useful guides for locally relevant materials, locally appropriate ethical and practical guidelines, and local contacts.

Transdisciplinary dialogue on principles and practices are useful not only for researchers (at all career stages) but also for funding agencies and reviewers evaluating twenty-first-century cross-cultural research across multiple domains of science. In short, deeper consideration of how to select sites for comparative investigations, how to engage target communities, and how to design research protocols in culturally sensitive ways will allow researchers to address some of the ethical and logistical challenges highlighted here—issues that all of the co-authors of this piece continue to grapple with in our own research and the communities with whom we work.

Supplementary Material

Acknowledgements.

We thank the host communities with whom we have worked for their patience, collaboration and the knowledge that they have shared. We also thank Claudia Jacobi and the staff at MPI-EVA in Leipzig for their work in hosting the workshop, and Shani Msafiri Mangola, Elspeth Ready, Tim Caro and Daniel Benyshek for helpful feedback on earlier drafts of this manuscript. T.B. also thanks the Coady International Institute, particularly Allison Mathie and Gord Cunningham for hosting, teaching and supporting her transition to participant-engaged research.

Data accessibility

Authors' contributions.

All authors contributed to the idea, outline and structure of the manuscript at the MPI workshop. T.B. and A.N.C. wrote the first draft of the manuscript with edits by M.B.M. The following authors provided comments and edits on manuscript drafts: J.A.B., H.C., K.H., M.K., R.G.N., A.C.P., C.R. and B.S. The following authors contributed to discussions at the workshop: B.A.B., A.D.B., R.M., S.P., I.P., B.P., E.A.Q., K.S., J.S. All authors edited and approved the final manuscript.

The workshop that generated the basis for this manuscript was funded by the Department of Human Behaviour, Ecology and Culture at the Max Planck Institute for Evolutionary Anthropology in Leipzig, Germany (proposal written by authors M.K. and R.G.N. and coordinated by M.K., R.G.N., K.S.). J.S. acknowledges funding from the French National Research Agency under the Investments for the Future (Investissements d'Avenir) programme (ANR-17-EURE-0010).

Competing interests

We declare we have no competing interests.

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Monk Prayogshala Research Institution

Cross-Cultural Psychology

Art across cultures: a tapestry of diverse expressions, exploring the impact of culture on artistic perception and creation..

Posted June 4, 2024 | Reviewed by Monica Vilhauer

  • The diversity of artistic expression worldwide emphasizes culture's role in art creation and perception.
  • Emotional reactions to art and aesthetic judgments are deeply influenced by cultural factors as well.
  • Understanding cross-cultural perspectives on art fosters empathy and inclusivity in the global art community.

This post is written by Hreem Mahadeshwar and Valedeen D'Souza, Monk Prayogshala, Mumbai.

Art is like a deep, shared language that shows us the beauty and complexity of our cultures. Going beyond words, it helps us capture the elements that make each civilization unique and also succeeds in giving us a glimpse into the hearts of those who create it. More often than not, artists use the rich traditions and symbols of their backgrounds to inspire their creations, weaving their cultural stories into their work. The diversity of artistic expression worldwide—from the intricate calligraphy found in Islamic art, which is not just an aesthetic endeavor but also a profound manifestation of cultural and religious significance, to the vibrant patterns and colors in African art, rooted deeply in the continent's rich traditions—highlights the significant role culture plays in art creation. With various kinds of cultures present it isn't hard to posit that individuals from different cultures could perceive art through unique cognitive frameworks developed within their cultural contexts.

This cultural shaping extends into the cognitive processes that underlie artistic expression and appreciation. Culture molds our cognitive frameworks, influencing how we perceive, create, and interpret art. A study found that cultural differences between the East and West profoundly affect perception and thought processes, which in turn can be reflected in artistic expressions. For example, the emphasis on perspective and individual elements in Western art contrasts with the focus on harmony and the relationship between elements in Eastern art. These distinctions not only celebrate the diversity of artistic expression but also underscore how cultural contexts shape our appreciation and understanding of art.

Moreover, the varied use of symbols in art across different cultures adds layers of meaning and complexity to the global art landscape. The meanings attributed to colors, shapes, and motifs, and the storytelling and narrative techniques, vary significantly across cultures, enriching the art world with diverse perspectives. The color red , for instance, may symbolize luck and prosperity in Chinese culture, whereas it might represent negative connotations like blood or danger in some Western contexts. Additionally, storytelling and narrative techniques exhibit remarkable variation across cultural traditions, enriching the world of art with diverse perspectives.

Japanese manga also offers a unique way of telling stories that's different from Western comics. Its special distinctive panel layouts along with its unique storytelling ways provide a rather contrasting narrative experience compared to that of Western comic books. More specifically, manga’s narrative style is deeply influenced by Japanese aesthetics and values, emphasizing the flow of time and the internal states of characters, often through the use of visually quiet, contemplative panels that contrast sharply with the action. As emphasized by Scott McCloud in “ Understanding Comics ”, Western comics tend to be rooted in American and European traditions. Thus they emphasize the external action and dynamics between characters, with a stronger focus on linear storytelling and direct conflict. The art style in Western comics often highlights realism and proportion, with a vibrant color palette used to capture the attention and convey the mood or tone of the scene. The narrative structure is generally more straightforward, with each panel pushing the story forward through action or dialogue. These cultural differences in symbolism and narrative techniques not only underscore the diversity of artistic expression but also draw attention to the role of cultural context in the interpretation of art.

Zalfa Imani/Unsplash

Cultural backgrounds significantly shape how individuals perceive and engage with artworks, particularly through the lens of attentional processes. Cultural values, aesthetic norms, and familiarity influence what aspects of art capture attention. Cultural priming further accentuates attentional biases towards culturally congruent stimuli. For instance, while Western cultures tend to put more emphasis on the object itself, East Asian cultures pay more attention to the context surrounding the object. By recognizing and embracing the differences between cultures, we can make enjoying art a more inclusive and rewarding experience for everyone.

Also, in many cultures, people feel and show their emotions together, collectively , creating a sense of harmony, togetherness, and shared happiness . This contrasts with cultures that value individuality, where personal reactions to art can include deep self-reflection, intense feelings, and thoughts about life's big questions. This shows that different cultures have their own ways of understanding and showing emotions, which could play a role in the way individuals from various cultures look at a particular artwork. When we learn about these differences, we start to appreciate the wide range of human experiences and creativity even more. Recognizing how our backgrounds influence our views and feelings towards art helps us become more open-minded and respectful of others. This approach to art opens our hearts to the beauty of diversity, bringing us closer to art lovers around the world.

In the rich tapestry of human culture, art serves as a vibrant reflection of our diverse experiences. Rooted in cultural heritage, artistic expression resonates with varied emotions and perspectives across societies. Understanding these cross-cultural dynamics enriches our appreciation of art's universal appeal and cultural specificity. By acknowledging the influence of cultural factors on artistic interpretation and emotional reactions, we cultivate empathy and understanding across diverse cultural contexts. Ultimately, embracing cultural diversity enhances the inclusivity and richness of our artistic experiences, fostering a deeper connection to the global art community.

Monk Prayogshala Research Institution

Monk Prayogshala Research Institution is a not-for-profit academic research institution in Mumbai, India.

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research articles on cultural studies

  • 07 May 2024
  • Cold Call Podcast

Lessons in Business Innovation from Legendary Restaurant elBulli

Ferran Adrià, chef at legendary Barcelona-based restaurant elBulli, was facing two related decisions. First, he and his team must continue to develop new and different dishes for elBulli to guarantee a continuous stream of innovation, the cornerstone of the restaurant's success. But they also need to focus on growing the restaurant’s business. Can the team balance both objectives? Professor Michael I. Norton discusses the connections between creativity, emotions, rituals, and innovation – and how they can be applied to other domains – in the case, “elBulli: The Taste of Innovation,” and his new book, The Ritual Effect.

research articles on cultural studies

  • 29 Feb 2024

Beyond Goals: David Beckham's Playbook for Mobilizing Star Talent

Reach soccer's pinnacle. Become a global brand. Buy a team. Sign Lionel Messi. David Beckham makes success look as easy as his epic free kicks. But leveraging world-class talent takes discipline and deft decision-making, as case studies by Anita Elberse reveal. What could other businesses learn from his ascent?

research articles on cultural studies

  • 17 Jan 2024

Psychological Pricing Tactics to Fight the Inflation Blues

Inflation has slowed from the epic rates of 2021 and 2022, but many consumers still feel pinched. What will it take to encourage them to spend? Thoughtful pricing strategies that empower customers as they make purchasing decisions, says research by Elie Ofek.

research articles on cultural studies

  • 05 Dec 2023

What Founders Get Wrong about Sales and Marketing

Which sales candidate is a startup’s ideal first hire? What marketing channels are best to invest in? How aggressively should an executive team align sales with customer success? Senior Lecturer Mark Roberge discusses how early-stage founders, sales leaders, and marketing executives can address these challenges as they grow their ventures in the case, “Entrepreneurial Sales and Marketing Vignettes.”

research articles on cultural studies

Tommy Hilfiger’s Adaptive Clothing Line: Making Fashion Inclusive

In 2017, Tommy Hilfiger launched its adaptive fashion line to provide fashion apparel that aims to make dressing easier. By 2020, it was still a relatively unknown line in the U.S. and the Tommy Hilfiger team was continuing to learn more about how to serve these new customers. Should the team make adaptive clothing available beyond the U.S., or is a global expansion premature? Assistant Professor Elizabeth Keenan discusses the opportunities and challenges that accompanied the introduction of a new product line that effectively serves an entirely new customer while simultaneously starting a movement to provide fashion for all in the case, “Tommy Hilfiger Adaptive: Fashion for All.”

research articles on cultural studies

  • Research & Ideas

Are Virtual Tours Still Worth It in Real Estate? Evidence from 75,000 Home Sales

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research articles on cultural studies

  • 17 Oct 2023

With Subscription Fatigue Setting In, Companies Need to Think Hard About Fees

Subscriptions are available for everything from dental floss to dog toys, but are consumers tiring of monthly fees? Elie Ofek says that subscription revenue can provide stability, but companies need to tread carefully or risk alienating customers.

research articles on cultural studies

  • 29 Aug 2023

As Social Networks Get More Competitive, Which Ones Will Survive?

In early 2023, TikTok reached close to 1 billion users globally, placing it fourth behind the leading social networks: Facebook, YouTube, and Instagram. Meanwhile, competition in the market for videos had intensified. Can all four networks continue to attract audiences and creators? Felix Oberholzer-Gee discusses competition and imitation among social networks in his case “Hey, Insta & YouTube, Are You Watching TikTok?”

research articles on cultural studies

  • 26 Jun 2023

Want to Leave a Lasting Impression on Customers? Don't Forget the (Proverbial) Fireworks

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research articles on cultural studies

  • 31 May 2023

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research articles on cultural studies

  • 30 May 2023

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research articles on cultural studies

  • 24 Apr 2023

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research articles on cultural studies

  • 07 Apr 2023

When Celebrity ‘Crypto-Influencers’ Rake in Cash, Investors Lose Big

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research articles on cultural studies

  • 10 Feb 2023

COVID-19 Lessons: Social Media Can Nudge More People to Get Vaccinated

Social networks have been criticized for spreading COVID-19 misinformation, but the platforms have also helped public health agencies spread the word on vaccines, says research by Michael Luca and colleagues. What does this mean for the next pandemic?

research articles on cultural studies

  • 02 Feb 2023

Why We Still Need Twitter: How Social Media Holds Companies Accountable

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research articles on cultural studies

  • 06 Dec 2022

Latest Isn’t Always Greatest: Why Product Updates Capture Consumers

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research articles on cultural studies

  • 29 Nov 2022

How Much More Would Holiday Shoppers Pay to Wear Something Rare?

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research articles on cultural studies

  • 26 Oct 2022

How Paid Promos Take the Shine Off YouTube Stars (and Tips for Better Influencer Marketing)

Influencers aspire to turn "likes" into dollars through brand sponsorships, but these deals can erode their reputations, says research by Shunyuan Zhang. Marketers should seek out authentic voices on YouTube, not necessarily those with the most followers.

research articles on cultural studies

  • 25 Oct 2022

Is Baseball Ready to Compete for the Next Generation of Fans?

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research articles on cultural studies

  • 18 Oct 2022

When Bias Creeps into AI, Managers Can Stop It by Asking the Right Questions

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research articles on cultural studies

10 Amazing Benefits of Cultural Diversity in the Workplace

cultural diversity in the workplace

In this era of technology and globalisation, many companies are making an effort to succeed in cultural diversity in the workplace. There are some very positive benefits of having a more diverse workforce.

Let’s discuss ten amazing benefits to individuals and employing companies;

  • Increased productivity
  • Improved creativity
  • Increased profits
  • Improved employee engagement
  • Reduced employee turnover
  • Improved company reputation
  • Wider range of skills
  • Improves cultural insights
  • Improved customer service
  • Improved compassion

Before we dive into the main benefits though, what exactly do we mean when we say culture and diversity?

Culture encompasses the beliefs, values, norms and behaviours of people. Cultural elements may include; languages, what and how people eat, festivals, rituals and pastimes.

One may attain culture as a result of how they were brought up or from the societies in which they spend most of their time. An example of culture is the Chinese culture of gift giving.

Within culture comes a lot of considerations. In the gift giving culture of China for instance, care is taken to ensure that the gift achieves its intended purpose, which is to build and maintain relationships.

What is cultural diversity in the workplace?

Cultural diversity in the workplace is when companies are open to hiring employees from different backgrounds; regardless of race, religion or culture.

When companies recruit and retain a diverse pool of people, it brings about different benefits to the company as well as its employees.

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In a culturally diverse workplace you will find a multilingual team and have a diverse range of ages working together.

Other types of diversity in the workplace

Before diving into the benefits of cultural diversity, let’s discuss other types of diversity in the workplace. Being aware of these differences lends itself to a deeper understanding of cultural diversity.

Gender diversity

This pertains to the representation of both sexes in the workplace and availing growth opportunities for all.

Ethnic diversity

An ethnically diverse workplace has people from different ethnic groups at different levels in the workplace.

Age diversity

Both young and old employees are given opportunities commensurate with their skills. Both are also availed training opportunities.

Social diversity

With social diversity, employees are from different social groups. For instance, you will find that they are from different universities and neighbourhoods.

Workers who are differently abled

In such a workplace, people are hired for their skills and not what their bodies look like. In such a workplace you will likely find wheelchair ramps, bathrooms for wheelchair users and more improvements to cater to all employees.

“When employees respect each other and get along in the workplace, it’s amazing how productivity increases, morale increases and employees are more courteous to customers.” – Maureen Wild

Here are 10 benefits of cultural diversity:

Cultural diversity can improve productivity levels

Do you know that a diverse company can lead to greater productivity ? Diversity brings in different talents together, all of them working towards a common goal using different sets of skills.

In their research, The economic value of cultural diversity: evidence from US cities, the Authors conclude that “these findings are consistent with a dominant positive effect of diversity on productivity: a more multicultural urban environment makes US-born citizens more productive.”

Companies will also gain from each employee by learning from each other’s experiences and applying this new-found knowledge to their work. Employees from all sorts of different backgrounds get to learn from their colleagues’ experiences from a different perspective. Thus, they are able to bring fresh ideas to the project by thinking out of their comfort zone.

Remember that a diverse workplace combines employees from different backgrounds, ethnicity and experiences, and together breed a more productive environment.

Cultural diversity increases creativity

Another benefit of cultural diversity in the workplace is the increase in creativity among teams, and the ability to have a more diverse set of solutions to specific problems.

In this Forbes article, the writer points out that “Research on creativity and innovation has been consistent in showing the value of exposing individuals to experiences with multiple perspectives and worldviews. It is the combination of these various perspectives in novel ways that result in new ideas “popping up.”

With so many different and diverse minds coming and working together, many more solutions will arise as every individual brings in their personal way of thinking, operating and solving problems and making decisions.

More to the point, cultural diversity in the workplace makes room for new hybrid ideas. Picture a blend of ideas from employees with different perspectives and experiences. This can give you a completely new idea that can serve everyone better.

This episode of the Hidden Brain podcast discusses how diversity and creativity are linked in the workplace .  The podcast guest, social scientist Adam Galinsky found that in a study on creativity and diversity, students who interacted with people from other cultures were more creative than their counterparts.

The results from a diverse workforce can even be a source of competitive advantage for the company.

Cultural diversity can increase profits

Many recent studies have shown that increased cultural diversity in the workplace can lead to greater profits for the organisation.

A 2013 survey undertaken by think tank, Center for Talent Innovation , found that 48 per cent of companies in the US with more diversity at senior management level improved their market share the previous year, while only 33 per cent companies with less diverse management reported similar growth.

This may be in part to global business trends, and the benefits of language diversity in creating an entrepreneurial mindset .

For example, with the rise of companies dealing their businesses in China, a company that hires employees fluent in Mandarin to increase the company’s reputation in Chinese communities could see results like an increase in sales , which could in turn result in improved profits.

cultural diversity

Cultural diversity can improve employee engagement

What better way to learn about other cultures than from colleagues that come from a different background than your own? Forget about researching them online.

Ask and learn them from employees during lunch break or after work drinks. What is the point of having a pool of diverse employees when they do not learn more about each other’s lifestyle and culture?

When your employees are sharing their personal experiences about high school or what every festive season meant to them, they are building a trusting relationship with their colleagues. This is great because it increases employee engagement .

Feeling connected as a group, as well as feeling valued for our personal differences improves wellbeing.  It leads to improved self-worth. In addition to seeing an improvement in engagement, organisations can see improved job satisfaction and improved motivation. These are all good for the company’s performance.

Cultural diversity helps to attract and retain talent

There is an increased demand for qualified talent and businesses are doing their best to get the best people to work for them. One way they can beat the competition is by having a diverse workforce.

According to Glassdoor, 2 out of 3 job candidates consider diversity when deciding where to work. A company that embraces cultural diversity in the workplace immediately entices a wider pool of candidates for its job vacancies. Higher-educated candidates who experienced diversity while at university may feel that a diverse company is more progressive and therefore will want to work there.

Being known for diversity can lead to more candidates applying for a job with a company, widening the pool of applicants and increasing the company’s choices.

Workplace diversity can easily be achieved in today’s remote working age. Businesses have already identified tools such as Android Mobile Device Management Solutions that help them manage their remote operations, keep their employees from different parts of the world seamlessly connected and provide secure remote access to corporate resources.

See also How We Encourage Diversity and Equality in Our Content Marketing

When companies recruit from a diverse set of potential employees, they are more likely to hire the best of the best for the industry.

In a constantly increasingly competitive economy where skills and talents are crucial to improving the company, putting together the most diverse set of candidates is increasingly necessary to succeed in the market.

Studies also show that job seekers are often drawn to companies with diverse workforces because it is publicly obvious that these companies do not practice employment discrimination.

Cultural diversity reflects positively on reputation

Another benefit of cultural diversity in the workplace is the positive reputation that the company receives. Companies who recruit and encourage individuals from a wide range of backgrounds generally gain a reputation for being a good employer.

Potential clients can see themselves reflected in the staffing of the company. This can lead to them feeling more valued, which can drive business to the company.

A diverse collection of skills and experiences allows a company to provide services to customers on a global basis because the company is able to relate and understand their clients better, and some even on a personal level.

Cultural diversity encourages wider range of skills

When companies hire a more diverse workforce from all backgrounds, these employees inevitably bring their own specific skills that can often be just as diverse.

Having a wider range of skills and knowledge available to them, these companies often enjoy a more diverse and adaptable range of products and services that they can offer to their respective markets.

In addition, working with people from varied cultures provides employees with more confidence in dealing with situations outside of their comfort zones. If you are looking to offer your teams new experiences, to build character and confidence, pair them with people different from them.

Diversity in cultures means diversity in skills and therefore products and service offerings. At the same time, due to shared learning, it means growth in employee skills.

Cultural diversity can lead to improved customer service

The positive effects of a culturally diverse workforce trickle down to the employees. Employees who appreciate and value diversity are respectful, they are empathetic, keen to understand and thus can better serve diverse clients.

The awareness of diversity can be seen through active listening; allowing customers to share their concerns, listening without interrupting and above all, patience.

Even when they don’t know how to navigate a situation with a customer, employees in a diverse environment are curious and remain open to learning.

Cultural diversity improves insights and reduces racism

By enjoying a more culturally diverse workforce, it is often found that employees then spend more time in their daily lives with people from cultural backgrounds that they are often never exposed to.

The end result of this is that employees learn new cultural insights and this in turn, reduces negative emotions such as racism, homophobia, sexism and the like.

Cultural diversity leads to improved compassion

Compassion in the workplace is seen in how people interact with each other, with customers and with other stakeholders. Employees who are compassionate are able to see things from someone else’s perspective. Instead of being judgemental or dismissive, they are understanding.

This quality arises from working alongside people from different cultures. For instance, your employees will not be surprised if a client requests to have a meeting done on another day because of a cultural engagement. Compassion reduces conflicts and helps in the building of better team dynamics.

How to support cultural diversity in the workplace

Employers need to nurture cultural diversity in the workplace. Employees too have a role to play in being the kinds of employees who encourage and thrive in diversity.

What employers can do:

Carry out diversity training

In order to enjoy the benefits of diversity, employees need to know how to navigate intercultural encounters.  A diversity training program will arm your employees with the skills necessary.

This type of training will teach people to appreciate differences among colleagues, build their awareness of diverse groups, improve interpersonal skills and ultimately create a positive work environment.

The benefits of diversity training will not stop with employees, they will spill over to their interactions with customers and other stakeholders.

Have a culture day

To show employees that cultural diversity is supported, organisations can have culture days. On these days, people from different cultures have a chance to share their traditions with their colleagues. Invite employees to bring food, talk about their traditions, exhibit their dressing and more.

This encourages people to be proud of their culture and shows everyone in the workplace that the organisation values diversity.

Have clear policies around diversity

Workplaces have different policies guiding how things are done. These help to build culture and guide people on the right processes and systems to use. In order to encourage diversity in the workplace, organisations should institute policies around it.

These can be anti-discriminatory policies, hiring and promotion policies and different policies embedded in their HR code committing to creating a cultural diverse workplace.

Global HR  plays a crucial role in overseeing the implementation and enforcement of these policies on a worldwide scale, ensuring that the company’s commitment to cultural diversity and inclusivity is effectively integrated into all aspects of its operations across various countries and regions.

What employees can do:

Employees too have a role to play to create a culture where diversity thrives. This goes beyond asking workmates to explain their cultures. They too can take proactive steps to learn, welcome and accommodate diversity in the workplace.

Educate yourself

Read up on resources about different cultures. These can be books, articles and more. Remain curious and open to learning about other people and how they live.

Remain curious

It is not uncommon that terms we use and things we have done for so long can turn out to be hurtful to certain cultures. As an employee, remain open to learning when a colleague corrects you or shows you the right way.

Remember that culture evolves so remain open to learning.

When next planning to hire new employees, consider making an effort to hire a diverse range of people, across gender, age and cultural backgrounds. This should apply whether you have a remote workforce or you have one office. Companies that encourage diversity in the workplace inspire all of their employees to perform to their highest ability.

By having a diverse workforce, your organisation can soon enjoy a wide range of benefits, such as the ones we have mentioned in this article;

  • Improved cultural insights

I wish you all the best in increasing the cultural diversity in your team and workforce!

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The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada

  • Samina Idrees 1 ,
  • Gillian Young 1 ,
  • Brian Dunne 2 ,
  • Donnie Antony 2 ,
  • Leslie Meredith 1 &
  • Maria Mathews 1  

BMC Health Services Research volume  24 , Article number:  680 ( 2024 ) Cite this article

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Person-centred planning refers to a model of care in which programs and services are developed in collaboration with persons receiving care (i.e., persons-supported) and tailored to their unique needs and goals. In recent decades, governments around the world have enacted policies requiring community-care agencies to adopt an individualized or person-centred approach to service delivery. Although regional mandates provide a framework for directing care, it is unclear how this guidance is implemented in practice given the diversity and range of organizations within the sector. This study aims to address a gap in the literature by describing how person-centred care plans are implemented in community-care organizations.

We conducted semi-structured interviews with administrators from community-care organizations in Ontario, Canada. We asked participants about their organization’s approach to developing and updating person-centred care plans, including relevant supports and barriers. We analyzed the data thematically using a pragmatic, qualitative, descriptive approach.

We interviewed administrators from 12 community-care organizations. We identified three overarching categories or processes related to organizational characteristics and person-centred planning: (1) organizational context, (2) organizational culture, and (3) the design and delivery of person-centred care plans. The context of care and the types of services offered by the organization were directly informed by the needs and characteristics of the population served. The culture of the organization (e.g., their values, attitudes and beliefs surrounding persons-supported) was a key influence in the development and implementation of person-centred care plans. Participants described the person-centred planning process as being iterative and collaborative, involving initial and continued consultations with persons-supported and their close family and friends, while also citing implementation challenges in cases where persons had difficulty communicating, and in cases where they preferred not to have a formal plan in place.

Conclusions

The person-centred planning process is largely informed by organizational context and culture. There are ongoing challenges in the implementation of person-centred care plans, highlighting a gap between policy and practice and suggesting a need for comprehensive guidance and enhanced adaptability in current regulations. Policymakers, administrators, and service providers can leverage these insights to refine policies, advocating for inclusive, flexible approaches that better align with diverse community needs.

Peer Review reports

The community-care sector facilitates the coordination and administration of in-home and community-based health and social services. Community-care services include supports for independent living, residential services, complex medical care, and community-participation services to support personal and professional goals (e.g., education, employment, and recreation-based supports) [ 1 ]. There is substantial heterogeneity in the clinical and demographic characteristics of the community-care population, including individuals with physical and developmental disabilities, and complex medical needs [ 2 ]. We refer to the individuals served by these organizations as ‘persons-supported’ in line with person-first language conventions [ 3 , 4 ].

In recent decades, governments across the world have enacted policies requiring community-care agencies to adopt an individualized or person-centred approach to service delivery [ 5 , 6 , 7 , 8 ]. Person-centred care encompasses a broad framework designed to direct care delivery, as opposed to a singular standardized process. In the context of community-care, person-centred planning refers to a model of care provision in which programs and services are developed in collaboration with persons-supported and tailored to their unique needs and desired outcomes [ 9 , 10 ].

In Ontario, Canada, community-care services are funded by the Ministry of Health (MOH) and the Ministry of Children, Community and Social Services (MCCSS). Service agreements between these ministries and individual agencies can be complex and contingent on different factors including compliance with a number of regulatory items and policies [ 7 , 11 ]. MOH provides funding for health-based services including in-home physiotherapy, respiratory therapy, and personal support services, among several others. MOH funds Home and Community Care Support Services (HCCSS), a network of organizations responsible for coordinating the delivery of in-home and community-based care in the province. MCCSS funds social service agencies including those providing community participation and residential support for people with intellectual and developmental disabilities (IDDs).

Several tools and resources have been developed to aid organizations in providing person-centred care and organizations may differ in their use of these tools and their specific approach. Although regional mandates provide a framework for directing care delivery, it is unclear how this guidance is implemented in practice given the diversity and range of organizations within the sector. In addition, as noted by a recent scoping review, there is limited literature on the implementation process and impact of person-centred planning on individual outcomes [ 12 ]. Using a pragmatic, qualitative, descriptive approach [ 13 ], we outline how community-care organizations enact a person-centred approach to care and the factors that shape their enactment. By describing existing practices in the context of the community-care sector, we aim to provide insight on how to optimize care delivery to improve outcomes and inform current policy. This study is part of a larger, multi-methods project examining the implementation of person-centred care plans in the community-care sector. This project encompasses qualitative interviews with representatives from different community-care organizations, as well as staff and persons-supported at a partner community-care organization. This paper focuses on analyzing data from interviews with representatives from different community-care organizations.

We conducted semi-structured interviews with administrators from community-care organizations in Southwestern Ontario (roughly the Ontario Health West Region) between October 2022 and January 2023. We included community-care organizations funded by MOH or MCCSS. We excluded organizations that did not provide services in Southwestern Ontario. We identified eligible organizations and participants by searching online databases, including community resource lists, as well as through consultation with members of the research team.

We used maximum variation sampling [ 14 ], to recruit participants from organizations with a wide range of characteristics including location (i.e., urban, rural), organization type (i.e., for-profit, not-for-profit), and types of services provided (e.g., residential, recreation, transportation, etc.) We contacted eligible organizations via email, providing them with study information and inviting them to participate. We recruited until the data reached saturation, defined as the point at which there was sufficient data to enable rigorous analysis [ 14 , 15 ].

In each interview, we asked participants about their organization’s approach to developing and updating individual service agreements or person-centred care plans, and the supports and barriers (e.g., organizational, funding, staffing, etc.) that facilitate or hinder the implementation of these plans (Supplementary Material 1 : Interview Guide). We also collected information on relevant participant and organizational characteristics, including participant gender, position, years of experience, organization location, type (i.e., for-profit, not-for-profit), services offered, years in operation, and client load. The interviews were approximately one hour in length and conducted virtually via Zoom (Zoom Video Communications Inc.) or by telephone. The interviews were audio-recorded and transcribed verbatim. Interviewer field notes were also used in data analysis.

We analyzed the data thematically [ 16 ]. The coding process followed a collaborative and multi-step approach. Initially, three members of the research team independently reviewed and coded a selection of transcripts to identify key ideas and patterns in the data, and form a preliminary coding template. We then met to consolidate individual coding efforts. We compared coding of each transcript, resolving conflicts through discussion and consensus. In coding subsequent transcripts and through a series of meetings, we worked together to finalize the codebook to reflect more analytic codes. We used the finalized template to code all interview transcripts in NVivo (QSR International), a software designed to facilitate qualitative data analysis. We refined the codebook on an as-needed basis by incorporating novel insights gleaned from the coding of additional transcripts, reflecting the iterative nature of the analysis.

We increased the robustness of our methodology by pre-testing interview questions, documenting interview and transcription protocols, using experienced interviewers, and confirming meaning with participants in interviews [ 14 , 15 , 16 ]. We kept detailed records of interviews, field notes, and drafts of the coding template. We made efforts to identify negative cases and provided rich descriptions and illustrative quotes [ 17 ]. We included individuals directly involved in the administration of community-care services on our research team. These individuals provided important context and feedback at each stage of the research process.

This study was approved by the research ethics board at Western University. We obtained informed consent from participants prior to the onset of interviews. We maintained confidentiality through secure storage of interview data (e.g., audio recordings), password-protection of sensitive documents, and the de-identification of transcripts.

Positionality

The authors represent a multidisciplinary team of researchers, clinicians, and community-care leaders. The community-care leaders and clinicians on our team provided key practical expertise to inform the development of interview questions and the analysis of study findings.

We interviewed administrators across 12 community-care organizations in Southwestern Ontario. The sample included representatives from seven organizations that received funding from MCCSS, three organizations that received funding from MOH, and two organizations that received funding from both MCCSS and MOH (Table  1 ). Eleven organizations were not-for-profit, one was a for-profit agency. The organizations provided care in rural ( n =  3), urban ( n =  4), or both rural and urban populations ( n =  5). Seven of the 12 participants were women, nine had been working with their organization for more than 11 years, and all had been working in the community-care sector for more than 12 years (Table  2 ).

We identified three key categories or processes relating to organizational characteristics and their impact on the design and delivery of person-centred care plans: (1) organizational context, (2) organizational culture, and (3) the development and implementation of person-centred care plans.

Organizational context

Organizational context refers to the characteristics of persons-supported, and the nature of services provided. Organizational context accounts for the considerable heterogeneity across organizations in the community-care sector and their approach to person-centred care plans.

Populations served

The majority of organizations included in the study supported individuals with IDDs: “all of the people have been identified as having a developmental disability. That’s part of the eligibility criteria for any funded developmental service in Ontario.” [P10]. Participants described how eligibility was ascertained through the referral process: “ the DSO [Developmental Services Ontario] figures all of that out and then refers them to us .” [P08]. These descriptions highlighted a common access point for publicly-funded adult developmental services in the province. Accordingly, these organizations were primarily funded by MCCSS. Other organizations focused on medically complex individuals including those with acquired brain injuries or those unable to access out-patient services due to physical disabilities: “the typical reason for referral is going to be around a physical impairment… But, with this medically complex population, you’re often seeing comorbidities where there may be some cognitive impairment, early dementia.” [P04]. In these organizations, eligibility and referral were usually coordinated by HCCSS. These insights highlighted the diverse characteristics of community-care populations, emphasizing the need to consider both physical and cognitive health challenges in care provision approaches.

Services offered

The characteristics of persons-supported informed the context of care and the type of services offered by the organization. The different dimensions of services offered within this sector include social and medical care, short and long-term care provision, in-home and community-care, and full and part-time care.

Nature of care: social vs. medical

Many organizations serving individuals with IDDs employed a holistic, psychosocial model of care, designed to support all areas of an individual’s life including supports for independent-living, and community-based education, employment, and recreation services to support personal and professional goals: “we support people in their homes, so residential supports. We also support people in the community, to be a part of the community, participate in the community and also to work in the community.” [P06]. These descriptions reflect a comprehensive approach to care, aiming to address needs within and beyond residential settings to promote active participation within the broader community. In contrast, some organizations followed a biomedical model of care, designed to support specific health needs: “We provide all five therapies… physiotherapy, occupational therapy, speech, social work, and nutrition. In some locations we provide visiting nursing, at some locations shift nursing. We have some clinic-nursing… and we provide personal support and home-making services in a number of locations as well.” [P04]. These organizations adopted a more clinically-focused approach to care. In either instance, the care model and the nature of services offered were largely determined by an organization’s mandate including which gaps they aimed to fill within the community. Many organizations described providing a mixture of social and medical care for individuals with complex needs. However, the implementation of care plans could be impacted by the lack of integration between social and medical care sectors, as some participants spoke to the importance of “[integrating] all of the different healthcare sector services… [including] acute care and public health and home and community care and primary care, and mental health and addictions.” [P04].

Duration of care: short-term vs. long-term

The duration of care also varied based on the needs of persons-supported. Organizations serving individuals with IDDs usually offered support across the lifespan: “We support adults with developmental disabilities and we support them from 18 [years] up until the end of their life.” [P06]. Some organizations provided temporary supports aimed at addressing specific health needs: “For therapies – these are all short-term interventions and typically they’re very specific and focused on certain goals. And so, you may get a referral for physiotherapy that is authorized for three visits or five visits” [P04], or crisis situations (e.g., homelessness): “Our services are then brought in to help provide some level of support, guidance, stabilization resource, and once essentially sustainability and positive outcomes are achieved—then our services are immediately withdrawn.” [P12]. One organization employed a model of care with two service streams, an initial rehabilitation stream that was intended to be short-term and an ongoing service stream for individuals requiring continuing support.

In-home vs. community-based care

Many organizations provided in-home care and community-based supports, where residential supports were designed to help individuals lead independent lives, and community-based supports encouraged participation in community activities to further inclusion and address personal and professional goals. One participant spoke about the range of services offered in the home and community:

“There’s probably two big categories of [services we offer]: community support services—so that includes things like adult day programs, assisted living, meals on wheels, transportation, friendly visiting … and things like blood pressure clinics, exercise programs… and then on the other side we do home care services. In the home care basket, we provide personal support, and we also provide social work support.” [P05].

Likewise, another participant spoke in further detail on the types of services that allow individuals to live independently within their homes, or in community-based residential settings (e.g., long-term care facilities):

“We provide accommodation supports to about 100 people living in our community—which means that we will provide support to them in their own homes. So, anywhere from an hour a week to 24 hours a day. And that service can include things from personal care to home management to money management, cooking, cleaning, and being out and about in communities—so community participation. We also provide supports for about 50 people living in long-term care facilities and that is all community participation support. So, minus the last 2 and a half years because of the pandemic, what that means is that a person living in a long-term care facility with a developmental disability can have our support to get out and about for 2 or 3 hours a week, on average.” [P10].

Full-time vs. part-time support

The person-supported’s needs also determined whether they would receive care within their homes and if they would be supported on a full-time (i.e., 24 h a day, 7 days a week) or part-time basis:

“ It really does range from that intensive 24- hour/7 day a week support, which we actually do provide that level of intense support in the family home, if that’s needed. And then, all the way through to just occasional advocacy support and phone check-in.” [P01].

Organizational Culture

Organizational culture was described as a key influence in the development and implementation of person-centred care plans. The culture of the organization includes their perceptions, attitudes and beliefs surrounding persons-supported; their model of care provision; as well as their willingness to evolve and adapt service provision to optimize care delivery.

Perceptions, attitudes, and beliefs regarding persons-supported

Participants described their organization’s view of persons-supported, with many organizations adopting an inclusionary framework where persons-supported were afforded the same rights and dignities as others in the community. This organizational philosophy was described as being deeply intertwined with an organization’s approach to personalizing programs and services:

“…an organization needs to be able to listen to the people who are receiving the service… and support them, to learn more, figure out, articulate, whatever it is, the service or the supports that they need in order to get and move forward with their life.” [P10].

The focus on the person-supported, their needs, likes, and dislikes, was echoed across organizations, with an emphasis on the impact of “culture and trying to embed for each person who delivers service the importance of understanding the individual.” [P05]. Participants also described their organization’s approach to allowing persons-supported to take risks, make mistakes, and live life on their own terms:

“You have to go and venture out and take some [risks]… We try to exercise that philosophy - people with disabilities should have the same rights and responsibilities as other people in the community. Whether that’s birthing or education, getting a job, having a house they can be proud of, accessing community supports, whether that be [a] library or community centre, or service club, whatever that is.” [P03].

Model of care provision

The model of care provision was heavily influenced by the organization’s values and philosophy. Several organizations employed a flexible model of care where supports were developed around the needs, preferences, and desired outcomes of the person-supported:

“…if we don’t offer [the program they want], we certainly build it. Honestly, most of our programs were either created or built by someone coming to us [and] saying ‘I want to do this with my life,’ or …‘my son would like to do art.’” [P02].

Although there were similarities in models across the different organizations, one participant noted that flexibility can be limited in the congregate care setting as staff must tend to the needs of a group as opposed to an individual:

“Our typical plan of operation outside of the congregate setting is we design services around the needs of the person. We don’t ask them to fit into what we need, we build services for what they need. Within the congregate care setting, we have a specific set of rules and regulations for safety and well-being of the other people that are here.” [P11].

Evolving service orientation

In organizations serving individuals with IDDs, many described shifting from program-based services to more individualized and community-based supports: “The goal was always to get people involved in their community and build in some of those natural supports … [we] are looking to support people in their own communities based on their individual plans.” [P07]. One participant described this model as a person-directed approach as opposed to person-centred, citing the limitations of program-based services in meeting individual needs:

“[Persons-supported] couldn’t [do] what they wanted because they were part of a bigger group. We would listen to the bigger group, but if one person didn’t want to go bowling … we couldn’t support them because everybody had to go bowling.” [P06].

The focus on individualized support could potentially lead to increased inclusion for persons-supported in their communities:

“… people go to Tim Horton’s, and if they go every day at 9 they probably, eventually will meet other people that go at 9 o’clock and maybe strike up a conversation and get to know somebody and join a table … and meet people in the community.” [P02].

By creating routines centred on individual preferences, the person-supported becomes a part of a community with shared interests and values.

Person-centred care plans

Community-care organizations enacted a person-centred approach by creating person-centred care plans for each person-supported. Although all participants said their organization provided person-centred services, there was considerable variation in the specific processes for developing, implementing, and updating care plans.

Developing a person-centred care plan

The development of a care plan includes assessment, consultation, and prioritization. The initial development of the care plan usually involved an assessment of an individual’s needs and goals. Participants described agency-specific assessment processes that often incorporated information from service referrals: “ In addition to the material we get from the DSO [Disability Services Ontario] we facilitate the delivery of an intake package specifically for our services. And that intake package helps to further understand the nature and needs of an individual.” [P12]. Agency-specific assessment processes differed by the nature of services provided and the characteristics of the population. However, most organizations included assessments of “not only physical functioning capabilities, but also cognitive.” [P01]. Assessment also included an appraisal of the suitability of the organization’s services. In instances where persons-supported were seeking residential placements or independent-living support, organizations assessed their ability to carry out the activities of daily living:

“[Our internal assessment] is an overview of all areas of their life. From, ‘do they need assistance with baking, cooking, groceries, cleaning, laundry? Is there going to be day program opportunities included in that residential request for placement? What the medical needs are?’” [P02].

In contrast, the person-supported’s community-based activities were primarily informed by their interests and desired outcomes: “We talk about what kinds of goals they want to work on. What kind of outcomes we’re looking for…” [P06].

The development of the care plan also included a consultation phase, involving conversations with the person-supported, their family members, and potentially external care providers: “We would use the application information, we’d use the supports intensity scale, but we’d also spend time with the person and their connections, their family and friends, in their home to figure out what are the kinds of things that this person needs assistance with.” [P10]. Participants described the person-supported’s view as taking precedence in these meetings: “We definitely include the family or [alternate] decision-maker in that plan, but the person-supported ultimately has the final stamp of approval.” [P08]. Many participants also acknowledged the difficulty of identifying and incorporating the person-supported’s view in cases where opinions clash and the person-supported has difficulty communicating and/or is non-verbal: “Some of the people we support are very good at expressing what they want. Some people are not. Some of our staff are really strong in expressing what they support. …And some of the family members are very strong. So you have to be very careful that the [person-supported] is not being lost in the middle of it.” [P06].

Participants also noted that some persons-supported preferred not to have a care plan:

“Some of the people say ‘I hate [the plans] I don’t want to do them’…. we look at it in a different way then. We’ll use graphic art, we’ll use video, we’ll think outside the box to get them to somehow—because at the end of the day when we’re audited by MCCSS every [person-supported] either has to have [a plan]… or there has to be [an approval of] why it wasn’t completed.” [P02].

Plan development may also include a prioritization process, particularly in cases where resources are limited. A person-supported’s goals could be prioritized using different schemas. One participant noted that “the support coordinator takes the cue from the person-supported - … what they’ve identified as ‘have to have’ and ‘nice to have’. … because the ‘have to haves’ are prioritized.” [P09]. Likewise, the person-supported’s preference could also be identified through “[an] exercise, called ‘what’s important for and what’s important to .’” [P06]. This model, based on a Helen Sanderson approach [ 18 ], was described as being helpful in highlighting what is important to the person-supported, as opposed to what others (i.e., friends, family, staff, etc.) feel is important for them.

Several organizations updated care plans throughout the year, to document progress towards goals, adapt to changing needs and plan for future goals: “We revisit the plan periodically through the year. And if they say the goal is done, we may set another goal.” [P06]. Organizations may also change plans to adapt to the person-supported’s changing health status or personal capacity.

Implementing a person-centred care plan

The implementation of care plans differed based on the nature of services provided by the organization. The delivery of health-based or personal support services often involved matching the length and intensity of care with the individual’s needs and capacity:

“Sometimes that is a long time, sometimes it’s a short time, sometimes it’s an intervention that’s needed for a bit, and then the person is able to function.” [P05].

In contrast, the delivery of community-based services involved matching activities and staff by interests: “[if] a person-supported wants to go out and be involved in the music community, then we pull the staff pool in and match them up according to interest.” [P06].

Broad personal goals were broken down into smaller, specific activities. For example, one participant described their organization’s plan in helping a person-supported achieve his professional goal of securing employment:

“[The person-supported] said ‘Okay, I want a job.’ So for three weeks he was matched up with a facilitator. They came up with an action plan in terms of how to get a job, what kind of job he’s looking for, where he wants to go, where he wants to apply, how to conduct an interview. And after three weeks he got a job.” [P09].

Organizations that provided residential services focused on developing independent-living skills. One participant described their organization’s plan to empowering persons-supported by allowing them to make their own financial decisions:

“If one month they’re looking after their own finances, and they’ve overspent. Well, maybe we help them out with a grocery card or something and say ‘okay, next month how are you going to do this?’ [The person-supported may say], ‘well, maybe I’ll put so much money aside each week rather than doing a big grocery shop the first week and not having enough money left at the end of the month.’” [P03].

The participant noted that “a tremendous amount of learning [happens] when a person is allowed to [take] risks and make their own decisions.” [P03].

Likewise, participants representing organizations that provided residential services described tailoring care to the persons-supported’s sleeping schedule and daily routine:

“We develop a plan and tweak it as we go. With [the person-supported] coming to the home, what worked well was, we found that he wanted to sleep in, so we adjusted the [staff] time. We took a look at his [medication] times in the morning… and [changed] his [medication] times. We found that he wanted to sleep [until] later in the day, so he would get up at 10 o’clock, so then instead of having breakfast, lunch, and supper he would just have a bigger brunch. Just really tailoring the plan around the person-supported, and it’s worked out well.” [P08].

These examples highlight how organizational context and culture influence how organizations operationalize person-centred care plans; the same individual may experience different approaches to care and engage in different activities depending on the organization they receive services from.

In this paper, we described key elements of the person-centred planning process across different community-care organizations in Southwestern Ontario. We also identified that the context and culture of an organization play a central role in informing the process by which services are personalized to an individual’s needs. These findings shed light on the diversity of factors that influence the implementation of person-centred care plans and the degree to which organizations are able to address medical and social needs in an integrated fashion. They also inform future evaluations of person and system-related outcomes of person-centred planning.

There are regulations around individualizing services delivered by community-care organizations, whereby care providers must allow persons-supported to participate in the development and evaluation of their care plans. HCCSS or MOH-funded services are largely focused on in-home rehabilitation or medical care. In contrast, MCCSS-funded organizations often focus on developing independent living skills or promoting community participation, thus highlighting the role of the funding agency in determining organizational context as well as the nature of services and personalization of care plans.

We also identified organizational culture as a key influence in the person-centred planning process. In previous reports, organizational culture, and specifically the way in which staff perceive and view persons-supported and their decision-making capabilities can impact the effective delivery of person-centred care [ 19 ]. Staff support, including their commitment to persons-supported and the person-centred process, has been regarded as one of the most powerful predictors of positive outcomes and goal attainment in the developmental services sector [ 20 , 21 ]. Moreover, in order to be successful, commitment to this process should extend across all levels of the organization, be fully integrated into organizational service delivery, and be reflected in organizational philosophy, values and views of persons-supported [ 22 , 23 , 24 ].

MCCSS mandates that agencies serving individuals with IDDs develop an individual service plan (ISP) for each person-supported, one “that address[es] the person’s goals, preferences and needs.” [ 7 ]. We reference ISPs as person-centred care plans, as is in line with the view of participants in interviews. There are a series of checklists designed to measure compliance with these policies, and the process is iterative, with mandated annual reviews of care plans and active participation by the person-supported [ 25 ]. In our study, the agencies funded by MCCSS adhered to the general framework outlined by these regulations and informed service delivery accordingly. However, participants also described areas for improvement with respect to the implementation of these policies in practice. These policies, while well-intentioned, may imply a one-size-fits-all approach and appear more as an administrative exercise as opposed to a meaningful endeavor designed to optimize care. Participants spoke about individuals who preferred not to have an ISP, and how that in and of itself is a person-centred approach, respecting the person’s wishes. Additionally, we heard about how the goal-setting process may not be realistic as it can be perceived as unnatural to have goals at each point in one’s life. Moreover, participants noted challenges in implementing person-centred care in shared residential settings (e.g., group homes) or in cases where persons-supported had difficulty communicating.

Prior research indicates that individuals living in semi-independent settings fare better across several quality-of-life measures relative to individuals living in group homes, including decreased social dissatisfaction, increased community participation, increased participation in activities of daily living, and increased empowerment [ 26 ]. Furthermore, a recent study by İsvan et al. (2023) found that individuals living in the community (e.g., own home, family home, or foster home) exhibit greater autonomy in making everyday and life decisions, and greater satisfaction with their inclusion in the community [ 27 ]. These findings may be indicative of a reduced focus on person-centred care plan development and implementation in congregate care settings, where limited staff capacity can make it difficult to tend to the needs of everyone in the home. However, poor outcomes may also be explained by potentially more complex health challenges or more severe disability in persons-supported living in congregate care settings. The challenges described in our study are consistent with calls to improve the quality of care provided in residential group home settings [ 28 , 29 ].

In line with our findings, previous literature also describes challenges in implementing person-centred planning for individuals who have difficulty communicating or are non-verbal [ 19 , 30 , 31 , 32 ]. Communication has also been identified as a barrier to patient-centred care for adults with IDDs in healthcare settings [ 33 , 34 ]. Other reports have identified a need for increased training and awareness of diverse communication styles (including careful observation of non-verbal cues) to aid staff in including persons-supported in the development of care plans [ 35 , 36 , 37 ]. Importantly, these methods take substantial time which is often limited, and compounded by staffing shortages that are widespread across the sector [ 38 ]. Similar barriers were identified in interviews with staff and persons-supported at a partner community-care agency within our larger project [ 39 ]; other papers from the project examine strategies used by the organization to overcome these barriers.

Limitations

The findings from this study should be interpreted in the context of the following limitations. There is a risk for social desirability bias, whereby participants may feel pressure to present their care plan process in a more positive light due to societal norms and expectations [ 40 ]. Additionally, the experiences and views of community-care organizations may vary by region and organization type (i.e., for-profit vs. not-for-profit). In this study, we limited participation to agencies providing services in Southwestern Ontario and we were only able to interview one for-profit agency, despite concerted recruitment efforts. Consequently, we may not have fully captured how financial pressures, or different contextual and cultural components of an organization impact their implementation of care plans.

The person-centred planning process in community-care organizations is largely informed by the characteristics of the population served and the nature of services offered (i.e., organizational context). This process usually involves initial and continued consultations with persons-supported to tailor plans to their specific needs and desired outcomes. There are ongoing challenges in the implementation of person-centred planning, including a need for increased adaptability and clarity in current regulations. In some areas, there may be benefit to incorporating nuance in the application of policies (e.g., in cases where a person-supported does not want to have a formal plan in place). In other areas, it may be helpful to have increased guidance on how to optimize care delivery to improve outcomes (e.g., in cases where a person-supported has difficulty communicating, or is residing in a group home). Policymakers, administrators, and service providers can leverage these insights to refine policies, advocating for inclusive, flexible approaches that better align with diverse community needs.

Data availability

The datasets generated and analyzed in the current study are not publicly available to maintain participant confidentiality, however access may be granted by the corresponding author upon reasonable request.

Abbreviations

Acquired Brain Injury

Disability Services Ontario

Home and Community Care Support Services

Intellectual and Developmental Disabilities

Individual Service Plan

Ministry of Children, Community and Social Services

Ministry of Health

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Acknowledgements

The authors thank Ruth Armstrong, from PHSS - Medical & Complex Care in Community, for her valuable feedback and support throughout the research process.

This research was funded by the Canadian Institutes of Health Research. The funding agency had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

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Contributions

S.I. conducted the interviews, developed the coding template, coded the data, thematically analyzed the data, and prepared the manuscript. G.Y. helped develop the coding template, and reviewed and approved the final manuscript. B.D. and D.A. helped conceptualize the study, aided in the interpretation and analysis of study findings, and reviewed and approved the final manuscript. L.M. coordinated research activities, aided in the interpretation and analysis of study findings, and reviewed and approved the final manuscript. M.M. conceptualized the study, supervised its implementation, and was a major contributor in reviewing and editing the manuscript. All authors have read and approved the final manuscript.

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Correspondence to Maria Mathews .

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This study was approved by the research ethics board at Western University. We obtained informed consent from participants prior to the onset of interviews.

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Idrees, S., Young, G., Dunne, B. et al. The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada. BMC Health Serv Res 24 , 680 (2024). https://doi.org/10.1186/s12913-024-11089-7

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DOI : https://doi.org/10.1186/s12913-024-11089-7

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Depression and Older Adults

Feeling down every once in a while is a normal part of life, but if these feelings last a few weeks or months, you may have depression. Read this article to find common signs and symptoms of depression, treatment options, and if you or your loved one may be at risk for depression.

On this page:

What is depression?

What are risk factors of depression, what are signs and symptoms of depression, supporting friends and family with depression.

  • Talking with friends and family about suicide

How is depression treated?

  • Depression in people with dementia

Can depression be prevented?

Depression is a serious mood disorder. It can affect the way you feel, act, and think. Depression is a common problem among older adults, but clinical depression is not a normal part of aging. In fact, studies show that most older adults feel satisfied with their lives, despite having more illnesses or physical problems than younger people. However, if you’ve experienced depression as a younger person, you may be more likely to have depression as an older adult.

4 Things To Know About Depression and Older Adults infographic. Click link below to open full infographic webpage

Depression is serious, and treatments are available to help. For most people, depression gets better with treatment. Counseling, medicine, or other forms of treatment can help. You do not need to suffer — help and treatment options are available. Talk with your doctor if you think you might have depression.

There are several types of depression that older adults may experience:

  • Major Depressive Disorder – includes symptoms lasting at least two weeks that interfere with a person’s ability to perform daily tasks
  • Persistent Depressive Disorder (Dysthymia) – a depressed mood that lasts more than two years, but the person may still be able to perform daily tasks, unlike someone with Major Depressive Disorder
  • Substance/Medication-Induced Depressive Disorder – depression related to the use of substances, like alcohol or pain medication
  • Depressive Disorder Due to A Medical Condition – depression related to a separate illness, like heart disease or multiple sclerosis.

Other forms of depression include psychotic depression, postmenopausal depression, and seasonal affective disorder. Find detailed descriptions of different types of depression from the National Institute of Mental Health .

There are many things that may be risk factors of depression. For some people, changes in the brain can affect mood and result in depression. Others may experience depression after a major life event, like a medical diagnosis or a loved one’s death. Sometimes, those under a lot of stress — especially people who care for loved ones with a serious illness or disability — can feel depressed. Others may become depressed for no clear reason.

Research has shown that these factors are related to the risk of depression, but do not necessarily cause depression:

  • Medical conditions, such as stroke or cancer
  • Genes – people who have a family history of depression may be at higher risk
  • Stress, including caregiver stress
  • Sleep problems
  • Social isolation and loneliness
  • Lack of exercise or physical activity
  • Functional limitations that make engaging in activities of daily living difficult
  • Addiction and/or alcoholism —included in Substance-Induced Depressive Disorder

Older woman with depression looking out a window

The following is a list of common symptoms. Still, because people experience depression differently, there may be symptoms that are not on this list.

  • Persistent sad, anxious, or "empty" mood
  • Feelings of hopelessness, guilt, worthlessness, or helplessness
  • Irritability, restlessness, or having trouble sitting still
  • Loss of interest in once pleasurable activities, including sex
  • Decreased energy or fatigue
  • Moving or talking more slowly
  • Difficulty concentrating, remembering, or making decisions
  • Difficulty sleeping , waking up too early in the morning, or oversleeping
  • Eating more or less than usual, usually with unplanned weight gain or loss
  • Thoughts of death or suicide, or suicide attempts

If you have several of these signs and symptoms and they last for more than two weeks, talk with your doctor. These could be signs of depression or another health condition. Don’t ignore the warning signs. If left untreated, serious depression may lead to death by suicide.

If you are a health care provider of an older person, ask how they are feeling during their visits. Research has shown that intervening during primary care visits is highly effective in reducing suicide later in life. If you are a family member or friend, watch for clues. Listen carefully if someone of any age says they feel depressed, sad, or empty for long periods of time. That person may really be asking for help. Knowing the warning signs for suicide and how to get help. It can help save lives .

Depression is a medical condition that requires treatment from a doctor. While family and friends can help by offering support in finding treatment, they cannot treat a person’s depression.

As a friend or family member of a person with depression, here are a few things you can do:

  • Encourage the person to seek medical treatment and stick with the treatment plan the doctor prescribes.
  • Help set up medical appointments or accompany the person to the doctor’s office or a support group.
  • Participate in activities the person likes to do.
  • Ask if the person wants to go for a walk or a bike ride. Physical activity can be great for boosting mood .

Older man talking to a therapist.

Certain medications or medical conditions can sometimes cause the same symptoms as depression. A doctor can rule out these possibilities through a physical exam, learning about your health and personal history, and lab tests. If a doctor finds there is no medical condition that is causing the depression, he or she may suggest a psychological evaluation and refer you to a mental health professional such as a psychologist to perform this test. This evaluation will help determine a diagnosis and a treatment plan.

Common forms of treatment for depression include:

  • Psychotherapy , counseling, or “talk therapy” that can help a person identify and change troubling emotions, thoughts, and behavior. It may be done with a psychologist, licensed clinical social worker (LCSW), psychiatrist, or other licensed mental health care professional. Examples of approaches specific to the treatment of depression include cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT).
  • Medications for depression that may balance hormones that affect mood, such as serotonin. There are many different types of commonly used antidepressant medications. Selective serotonin reuptake inhibitors (SSRIs) are antidepressants commonly prescribed to older adults. A psychiatrist, mental health nurse practitioner, or primary care physician can prescribe and help monitor medications and potential side effects.
  • Electroconvulsive Therapy (ECT) , during which electrodes are placed on a person’s head to enable a safe, mild electric current to pass through the brain. This type of therapy is usually considered only if a person’s illness has not improved with other treatments.
  • Repetitive transcranial magnetic stimulation (rTMS) , which uses magnets to activate the brain. rTMS does not require anesthesia and targets only specific regions of the brain to help reduce side effects such as fatigue, nausea, or memory loss that could happen with ECT.

Treatment, particularly a combination of psychotherapy and medications, has been shown to be effective for older adults . However, not all medications or therapies will be right for everyone. Treatment choices differ for each person, and sometimes multiple treatments must be tried in order to find one that works. It is important to tell your doctor if your current treatment plan isn’t working and to keep trying to find something that does.

Some people may try complementary health approaches, like yoga, to improve well-being and cope with stress. However, there is little evidence to suggest that these approaches, on their own, can successfully treat depression. While they can be used in combination with other treatments prescribed by a person’s doctor, they should not replace medical treatment. Talk with your doctor about what treatment(s) might be good to try.

Don’t avoid getting help because you don’t know how much treatment will cost. Treatment for depression is usually covered by private insurance and Medicare . Also, some community mental health centers may offer treatment based on a person’s ability to pay.

Many people wonder if depression can be prevented and how they may be able to lower their risk of depression. Although most cases of depression cannot be prevented, healthy lifestyle changes can have long-term benefits to your mental health.

Here are a few steps you can take:

  • Be physically active and eat a healthy, balanced diet . This may help avoid illnesses that can bring on disability or depression. Some diets — including the low-sodium DASH diet — have been shown to reduce risk of depression.
  • Get 7-9 hours of sleep each night.
  • Stay in touch with friends and family.
  • Participate in activities you enjoy .
  • Let friends, family, and your physician know when you’re experiencing symptoms of depression.

You may also be interested in

  • Finding  ways to stay socially connected
  • Exploring fun ideas to stay physically active
  • Reading tips for talking with your doctor about sensitive topics

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For more information about depression.

Administration for Community Living (ACL) 202-401-4634 https://www.acl.gov

American Psychological Association 800-374-2721  202-336-6123 (TDD/TTY) www.apa.org

Centers for Disease Control and Prevention (CDC) 800-232-4636 888-232-6348 (TTY) [email protected] www.cdc.gov

Depression and Bipolar Support Alliance  800-826-3632 www.dbsalliance.org

MedlinePlus National Library of Medicine       www.medlineplus.gov

Mental Health America 800-969-6642 www.mentalhealthamerica.net

National Alliance on Mental Illness 800-950-6264 www.nami.org

National Center for Complementary and Integrative Health 888-644-6226 866-464-3615 (TTY) [email protected] www.nccih.nih.gov

National Coalition on Mental Health and Aging (NCMHA) 309-531-2816 [email protected] www.ncmha.org/

National Heart, Lung, and Blood Institute 301-592-8573 [email protected] www.nhlbi.nih.gov

National Institute of Mental Health 866-615-6464 866-415-8051 (TTY) [email protected] www.nimh.nih.gov

988 Suicide & Crisis Lifeline 988 or 800-273-8255 (24 hours a day) 711 then 988 or 800-799-4889 (TTY) https://988lifeline.org

Substance Abuse and Mental Health Services Administration 877-726-4727 800-487-4889 (TTY) [email protected] www.samhsa.gov

This content is provided by the NIH National Institute on Aging (NIA). NIA scientists and other experts review this content to ensure it is accurate and up to date.

Content reviewed: July 7, 2021

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  • Chronic stress puts your health at risk

Chronic stress can wreak havoc on your mind and body. Take steps to control your stress.

Your body is made to react to stress in ways meant to protect you against threats from predators and other aggressors. Such threats are rare today. But that doesn't mean that life is free of stress.

Instead, you likely face many demands each day. For example, you may take on a huge workload, pay bills or take care of your family. Your body treats these everyday tasks as threats. Because of this, you may feel as if you're always under attack. But you can fight back. You don't have to let stress control your life.

Understanding the natural stress response

When you face a perceived threat, a tiny region at the brain's base, called the hypothalamus, sets off an alarm system in the body. An example of a perceived threat is a large dog barking at you during your morning walk. Through nerve and hormonal signals, this system prompts the adrenal glands, found atop the kidneys, to release a surge of hormones, such as adrenaline and cortisol.

Adrenaline makes the heart beat faster, causes blood pressure to go up and gives you more energy. Cortisol, the primary stress hormone, increases sugar, also called glucose, in the bloodstream, enhances the brain's use of glucose and increases the availability of substances in the body that repair tissues.

Cortisol also slows functions that would be nonessential or harmful in a fight-or-flight situation. It changes immune system responses and suppresses the digestive system, the reproductive system and growth processes. This complex natural alarm system also communicates with the brain regions that control mood, motivation and fear.

When the natural stress response goes wild

The body's stress response system is usually self-limiting. Once a perceived threat has passed, hormones return to typical levels. As adrenaline and cortisol levels drop, your heart rate and blood pressure return to typical levels. Other systems go back to their regular activities.

But when stressors are always present and you always feel under attack, that fight-or-flight reaction stays turned on.

The long-term activation of the stress response system and too much exposure to cortisol and other stress hormones can disrupt almost all the body's processes. This puts you at higher risk of many health problems, including:

  • Depression.
  • Digestive problems.
  • Muscle tension and pain.
  • Heart disease, heart attack, high blood pressure and stroke.
  • Sleep problems.
  • Weight gain.
  • Problems with memory and focus.

That's why it's so important to learn healthy ways to cope with your life stressors.

Why you react to life stressors the way you do

Your reaction to a potentially stressful event is different from everyone else's. How you react to your life stressors is affected by such factors as:

  • Genetics. The genes that control the stress response keep most people at a fairly steady emotional level, only sometimes priming the body for fight or flight. More active or less active stress responses may stem from slight differences in these genes.
  • Life experiences. Strong stress reactions sometimes can be traced to traumatic events. People who were neglected or abused as children tend to be especially at risk of experiencing high stress. The same is true of airplane crash survivors, people in the military, police officers and firefighters, and people who have experienced violent crime.

You may have some friends who seem relaxed about almost everything. And you may have other friends who react strongly to the slightest stress. Most people react to life stressors somewhere between those extremes.

Learning to react to stress in a healthy way

Stressful events are facts of life. And you may not be able to change your current situation. But you can take steps to manage the impact these events have on you.

You can learn to identify what causes you stress. And you can learn how to take care of yourself physically and emotionally in the face of stressful situations.

Try these stress management tips:

  • Eat a healthy diet and get regular exercise. Get plenty of sleep too.
  • Do relaxation exercises such as yoga, deep breathing, massage or meditation.
  • Keep a journal. Write about your thoughts or what you're grateful for in your life.
  • Take time for hobbies, such as reading or listening to music. Or watch your favorite show or movie.
  • Foster healthy friendships and talk with friends and family.
  • Have a sense of humor. Find ways to include humor and laughter in your life, such as watching funny movies or looking at joke websites.
  • Volunteer in your community.
  • Organize and focus on what you need to get done at home and work and remove tasks that aren't needed.
  • Seek professional counseling. A counselor can help you learn specific coping skills to manage stress.

Stay away from unhealthy ways of managing your stress, such as using alcohol, tobacco, drugs or excess food. If you're worried that your use of these products has gone up or changed due to stress, talk to your health care provider.

There are many rewards for learning to manage stress. For example, you can have peace of mind, fewer stressors and less anxiety, a better quality of life, improvement in conditions such as high blood pressure, better self-control and focus, and better relationships. And it might even lead to a longer, healthier life.

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  • How stress affects your health. American Psychological Association. https://www.apa.org/topics/stress/health. Accessed March 19, 2021.
  • Stress effects on the body. American Psychological Association. https://www.apa.org/topics/stress/body. Accessed March 19, 2021.
  • Lower stress: How does stress affect the body? American Heart Association. https://www.heart.org/en/healthy-living/healthy-lifestyle/stress-management/lower-stress-how-does-stress-affect-the-body. Accessed March 18, 2021.
  • Stress and your health. U.S. Department of Health & Human Services. https://www.womenshealth.gov/mental-health/good-mental-health/stress-and-your-health. Accessed March 18, 2021.
  • AskMayoExpert. Stress management and resiliency (adult). Mayo Clinic. 2019.
  • Seaward BL. Essentials of Managing Stress. 5th ed. Jones & Bartlett Learning; 2021.
  • Seaward BL. Managing Stress: Skills for Self-Care, Personal Resiliency and Work-Life Balance in a Rapidly Changing World. 10th ed. Jones & Bartlett Learning; 2022.
  • Olpin M, et al. Stress Management for Life. 5th ed. Cengage Learning; 2020.
  • Hall-Flavin DK (expert opinion). Mayo Clinic. March 23, 2021.

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  • Cultural Issues and the 2024 Election

2. Immigration attitudes and the 2024 election

Table of contents.

  • Voters’ views about race and society, the impact of the legacy of slavery
  • Most voters, but not all, view the nation’s diversity as a strength
  • How should the country handle undocumented immigrants currently in the U.S.?
  • Attitudes toward hearing other languages in public places
  • Biden and Trump supporters’ views about discussing America’s historical successes, failures
  • How does the U.S. compare with other countries?
  • Views of women’s progress
  • How much of a priority should marriage and children be?
  • Abortion, IVF access and birth control
  • Views of gender identity
  • Voters’ attitudes toward use of gender-neutral pronouns
  • Societal impact of more social acceptance of lesbian, gay, bisexual people
  • Religion and government policy
  • How much influence should the Bible have on the nation’s laws, if any?
  • Views on the federal government’s role in promoting Christian values
  • Most voters say it is not necessary to believe in God to be moral
  • Is the justice system too tough on criminals, or not tough enough?
  • Policing and law enforcement
  • How Trump, Biden supporters view gun rights and ownership
  • Views on the increasing number of guns in the U.S.
  • Acknowledgments
  • The American Trends Panel survey methodology

Voters who are backing Joe Biden this fall and those who back Donald Trump express sharply contrasting views about immigration.

Chart shows Wide gaps between Biden and Trump supporters on immigration, language and national identity

In part, this reflects long-standing gaps between Republicans and Democrats over how much of a problem illegal immigration is for the country, and recent differences in views about the situation at the U.S.-Mexico border.

Trump and Biden supporters also diverge over the overarching question of whether the U.S. being open to people from all over the world is a core part of the nation’s identity, and the degree to which they are comfortable or uncomfortable when languages other than English are spoken in public.

About six-in-ten registered voters (59%) say that undocumented immigrants currently living in the U.S. should be allowed to stay in the country legally: 36% say they should be able to apply for citizenship, while 22% say they should be able to apply only for permanent residency.

Roughly four-in-ten voters (41%) say, instead, that undocumented immigrants should not be allowed to stay in the country legally. Most of this group (37% of the overall public) says that there should be a national effort to deport those who are undocumented.

Chart shows About 6 in 10 Trump supporters favor a national effort to deport undocumented immigrants currently living in the U.S.

Voters who support Trump and Biden are largely on different sides of this issue:

  • Roughly six-in-ten Trump supporters (63%) say there should be a national effort to deport undocumented immigrants currently living in the U.S. Just 11% of Biden supporters hold this view.
  • By contrast, Biden supporters overwhelmingly (85%) say undocumented immigrants should be eligible to stay legally if certain requirements are met – including 56% who say this should include a path to applying for citizenship. About a third of Trump supporters (32%) say undocumented immigrants should be eligible for legal status, including just 15% saying there should be a way for them to apply for citizenship.

Changing views on how the country should handle undocumented immigrants

Chart shows Growing share of voters say undocumented immigrants should not be allowed to stay in the country legally

Over the past several years, Americans have become more likely to say that undocumented immigrants currently living in the U.S. should not be allowed to stay in the country legally.

While a 59% majority of voters say that undocumented immigrants should be allowed to stay in the U.S. legally, this is a substantial drop compared with recent years. In June of 2020, 74% of voters said that undocumented immigrants should be allowed to stay legally.

Republican vs. Democratic voters

  • Today, about two-thirds of Republican and Republican-leaning voters (66%) say undocumented immigrants should not be allowed to stay in the country legally. This is up from 54% in April 2021 and 42% four years ago.
  • Democratic voters have also become somewhat more likely to say that undocumented immigrants should not be allowed to stay legally. While just 16% of Democratic and Democratic-leaning voters now say this, that is up from 9% in 2020.

Increasing shares favor a national deportation effort

Since 2021, the share of voters who favor a national effort by law enforcement to deport undocumented immigrants currently living in the U.S. has increased by 11 percentage points, from 26% to 37%.

Chart shows Growing support for national deportation efforts since 2021, particularly among GOP voters

A majority of Republican voters (63%) now favor a national deportation effort, up from about half (49%) three years ago. About one-in-ten Democratic voters (11%) favor this, up 5 points over the same period.

Demographic differences in immigration views within Biden and Trump coalitions

There are substantial demographic differences in views of immigration among Trump supporters.

Hispanic voters who support Donald Trump are about twice as likely as White Trump supporters to say that there should be a way for undocumented immigrants to stay in the country legally if they meet certain requirements.

Chart shows Wide gaps between the views of White and Hispanic Trump supporters on values related to immigration

And nearly half of Hispanic Trump supporters (46%) say that America’s openness to people from all over the world is essential to who we are as a nation, compared with 32% of White Trump supporters.

Roughly half of Trump supporters ages 18 to 34 (51%) say there should be a way for undocumented immigrants to stay legally. In other age groups – particularly those 50 and older – smaller shares say this.

About half of Trump supporters under 35 (49%) say America’s openness to people from all over the world is essential to the national identity, compared with far smaller shares of Trump supporters in older age groups.

Across racial and ethnic groups as well as age groups, at least three-quarters of Biden supporters express attitudes supportive of immigration on both questions. However, these views are somewhat less widespread among Black Biden supporters than among Biden supporters in other racial and ethnic groups.

Trump supporters

Chart shows How Biden and Trump supporters feel about people speaking a language other than English in their communities

  • 74% of Hispanic Trump supporters say they are comfortable with people in their communities speaking a language other than English. A far smaller share of White Trump supporters say this (48%).
  • 69% of Trump supporters under 50 say they’re comfortable hearing a language other than English in their community. That compares with 43% of Trump supporters 50 and older.

Biden supporters

  • Large majorities of Biden supporters across racial and ethnic groups say they are comfortable hearing languages other than English, though Hispanic Biden supporters are most likely, and Black Biden supporters least likely, to say they are comfortable with this.
  • 92% of Biden supporters under 50 and 76% of those 50 and older express comfort with hearing languages other than English in public places.

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More than half of Americans are following election news closely, and many are already worn out

Americans have mixed views about how the news media cover biden’s, trump’s ages, an early look at black voters’ views on biden, trump and election 2024, voters’ views of trump and biden differ sharply by religion, in tight presidential race, voters are broadly critical of both biden and trump, most popular, report materials.

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  • Published: 03 June 2024

Factors leading to lapses in professional behaviour of Gynae residents in Pakistan: a study reflecting through the lenses of patients and family, consultants and residents

  • Humera Noreen 1 ,
  • Rahila Yasmeen 2 &
  • Shabana Ali Mohammad 2  

BMC Medical Education volume  24 , Article number:  611 ( 2024 ) Cite this article

115 Accesses

Metrics details

Introduction

Professional behaviour is the first manifestation of professionalism. In teaching hospitals, the residents can be considered vulnerable to lapses in professional behaviour when they fail to meet the set standards of professionalism. Residents of some specialties are more at risk of lapses in professional behaviour due to the demanding nature of work. Research focusing on the behaviour of residents in the field of Gynae and the underlying factors contributing to such behaviour is notably lacking in the literature. Additionally, there is a gap in understanding the perspectives of patients from Pakistan on this matter, as it remains unexplored thus far, which constitutes the central focus of this study.

An increase in complaints lodged against Gynae resident’s professional behaviour in Pakistan Citizen Portal (PCP) was observed. Therefore, an exploratory qualitative study was conducted to investigate the factors and rationales contributing to the lapses in resident’s professional behaviour.

The study collected the viewpoints of three stakeholder groups: patients and their families, consultants and residents. The study was conducted in three phases. First, the document analysis of written complaints was conducted, followed by face-to-face interviews (11 per group) conducted by trained researchers from an independent 3rd party. Finally, the interview data was transcribed, coded and analysed.

In total 15 themes were identified from the interviews with 3 stakeholders, which were then categorized and resulted in 6 overlapping themes. The most prevalent lapse reported by all 3 stakeholders was poor verbal behaviour of residents.

The highly ranked factors contributing to triggering the situation were associated with workplace challenges, well-being of residents, limited resources, patients and family characteristics, patients’ expectations, lack of administrative and paramedic support, cultural factors and challenges specific to Gynae specialty .

Another intriguing and emerging theme was related to the characteristics of patients and attendants which helped in understanding the causes and implications of conflicting environments. The value of competency also emphasized that can be accomplished by training and mentoring systems. The thorough examination of these factors by key stakeholders aided in accurately analysing the issue, its causes, and possible solutions. The study's findings will assist higher authorities in implementing corrective actions and offering evidence-based guidance to policymakers to improve healthcare system.

Peer Review reports

Understanding human behaviour is very important to comprehend how people see, interpret and adapt to various environments and to have an insight about the reasons people change their behaviour [ 1 ]. The same principle applies to professional behaviour (PB) in workplace environments including healthcare. The professional behaviour in a healthcare system could be defined as placing the best interests of patients at the center of everything you do [ 2 ].

Lapses in professional behaviour lack a unified definition, one could say that any behaviour that impairs the ability of the medical team to achieve desired outcomes is considered as lapse in PB or when someone is not following the standards expected from a person in their profession and behaving against them. Lapses could also be taken as a behaviour characterized by actions that a reasonable person would view as humiliating, rude, disrespectful, abusive language, demeaning, and bullying [ 3 ]. Lapses in professional conduct not only impact patient-doctor relationships, patient safety, and the quality of care but also the doctor's career [ 4 ].

According to Accreditation Council for Graduate Medical Education (ACGME) guidelines, residents must acquire professional behaviour as a core competency. The expected domains of professional behaviour projected by the residents include empathy, honesty, and respect for others [ 5 ] . Residents are susceptible to engaging in a variety of lapses in professional behaviour throughout their residency, which is a crucial time for doctors to build their ethical norms. It is essential to have a complete awareness of the relevant causes or events in order to prevent resident misbehaviour [ 6 ].

There is a scarcity of literature specifically examining the assessment of trainees' reasons and varieties of professional conduct lapses [ 7 ]. In the existing body of literature, the behavioural deficiencies observed among residents encompass various misconduct aspects, including disruptive practices involving patient care neglect, absence of empathy, and disrespect toward patients, as well as verbal or nonverbal misuse of authority and unwelcoming demeanor [ 8 , 9 , 10 ].

However, it's been acknowledged that addressing lapses in professional behaviour poses one of the most difficult challenges for medical educators. Understanding the underlying reasons behind such lapses is intricate, with the context in which the behaviour manifests playing a pivotal role [ 7 ].

Research indicates a connection between unprofessional conduct during undergraduate and postgraduate training and similar behaviour in later practice [ 11 ]. A conceptual framework has been proposed for evaluating and addressing lapses in PB [ 3 ]. To identify the root causes of PB lapses, it is crucial to determine whether residents understand professional expectations and are willing to adhere to them, or if there are barriers or distractions hindering their ability to exhibit professional behaviour [ 12 ]. The problem of lapses in PB is not specific to any specialty and appears to be occurring in various demographic groups/countries [ 13 , 14 , 15 ].

In teaching hospitals tasked with training new physicians, the diverse background of patients and their attendants often leads to an overwhelming environment. This diversity breeds a behavioural gap, primarily driven by the varying interests of individuals involved. Patients and their attendants bring different levels of understanding, influenced by educational exposure, personal values, and background, which can disrupt interactions and impact patient-doctor relationships [ 16 ].

Furthermore, residents face additional pressures that contribute to their susceptibility to unprofessional behaviour. The urgency to quickly acquire clinical knowledge during their residency often supersedes their focus on professional conduct, leading to a lack of understanding in this regard [ 17 , 18 ]. Additionally, residents may feel compelled to remain silent about professional challenges they encounter during their training to uphold the hospital's public image [ 14 ]. Therefore, it becomes a difficult task for medical tutors to unfold the truth and deal with it in the best interest of doctors and patients.

Several studies reported by developed countries have explored various facets of professionalism in alignment with their respective healthcare systems and policies [ 13 , 15 , 18 ]. However, it is crucial to recognise that the findings of these studies may not be directly applicable to developing countries without appropriate contextual adaptation.

As a developing country, Pakistan presents a unique set of factors that differ from those observed in developed nations, including government policies, patient awareness, medical practices, doctor workload, and cultural influences. Furthermore, there is a scarcity of data regarding patient perceptions of PB lapses, the underlying reasons for inappropriate resident behaviour, and the specific contextual factors within the local environment that influence resident conduct.

Research indicates that certain medical specialties, such as OB-GYN and Surgery, face increased risks of specific unprofessional behaviours due to their distinct stressors [ 14 ]. Therefore, it is suggested to conduct context-specific assessments to identify and mitigate these stressors effectively [ 19 ]. A narrative study conducted in King Edward, Lahore Pakistan aimed to explore conflicts in Obs and Gynae, revealing organizational, interpersonal, and individual conflicts [ 20 ]. Further investigation is required to understand the underlying factors and triggers of these conflicts. While various factors influencing professionalism in junior medical professionals have been identified, there is a notable gap in research focusing specifically on Gynae residents. A recent study has reported high rates of unprofessional behaviour among dismissed General Practice residents (90%), with a significant proportion displaying disrespect towards patients or staff (27%) [ 21 ]. Unprofessional behaviour among doctors is regulated by disciplinary bodies of respective country which have extensive effects on doctors health and career. A higher incidence of disciplinary actions noted in Obstetrics and Gynaecology [ 22 ]. Majeed et al. reported in the narrative review that issues related to poor ethical behaviour by trainees are usually presented as patient’s complaints. Disrespectful behaviour (worrisome communication, reluctant to talk, behavioural change affecting patients and family) was one of the most reported unprofessional behaviour in the narrative review [ 23 ].

The study's context revolves around a non-profit public sector medical university situated in Rawalpindi (population range of 1,000,000–5,000,000 inhabitants), Punjab, recognized by the Higher Education Commission of Pakistan [ 24 ]. The medical university operates as a small-sized coeducational university (uniRank enrollment range: 3,000–3,999 students) with significant Obstetrics and Gynae patient workload across three allied hospitals [ 25 ]. Due to the overwhelming patient load and resource constraints, unresolved complaints and conflicts have arisen. To address this, Prime Minister's Performance Delivery Unit (PMDU) [ 26 ] initiated a national complaints and grievance redressal mechanism called Pakistan Citizen Portal (PCP) [ 27 ]. ( https://citizenportal.gov.pk/ ), aiming to provide citizens with a streamlined platform for resolving complaints efficiently. A substantial number of complaints were filed against Obs and Gynae residents, prompting the need to investigate the underlying reasons for such grievances. Existing literature highlights the importance of professional behaviour in residents, yet studies specifically targeting Gynae residents' conduct and the reasons behind lapses are lacking. Moreover, the perceptions of Pakistani patients, the primary stakeholders affected, remain unexplored, along with the comparative analysis of opinions among the three main stakeholders (patients, residents and consultants) to unveil the true circumstances surrounding the issue.

Study aims and research questions/objectives

⊳ Research questions

What are the lapses in professional behaviour of Gynae residents?

What are the factors and reasons leading to the lapses in professional behaviour of Gynae residents from the perspectives of patients and family, Gynae consultants and residents in Pakistani context?

⊳ Objectives

To determine the frequency of identified lapses in professional behaviour among the Gynae residents by analysing PCP complaints

To explore the factors and reasons leading to the lapses in professional behaviour of Gynae residents from the perspectives of patients & families, Gynae consultants and residents.

A comprehensive analysis was done which aided in accurately diagnosing the problem, identifying its root causes, and devising effective remedies. The findings of this study are considered key enablers for the higher authorities to implement corrective measures and offer evidence-based guidance to policymakers, thereby enhancing the overall healthcare system.

Study design

The conceptual framework of this study is illustrated in (Fig.  1 ) and represents an exploratory qualitative approach, commonly employed in education and social sciences research [ 28 ]. This qualitative study spanned a duration of 6 months, commencing from Dec 2021 till June 2022, and was conducted within two Obs and Gynae departments within the public healthcare sector in Rawalpindi, Pakistan.

figure 1

The Conceptual framework of our study. Note: OB1 (Objective 1), OB2 (Objective 2)

Two research methodologies were utilized: document analysis of PCP complaints to identify and confirm the frequency of lapses in professional behaviour among Gynae residents,

(Phase 1) , and in-depth interviews designed on the basis of findings of the document analysis (Phase 2) . The in-depth interviews, conducted with the written consent of the participants, aimed to delve deeper into the perspectives of various stakeholders regarding lapses in professional behaviour and their underlying causes, providing contextual meaning [ 29 ]. Document analysis inform the design of the interview schedule. The study was approved by the institutional review committee of Islamic International Medical College (Ref No Riphah/IIMC/IRC/22/2003; approval date: 27/01/2022).

Participants

The study population consisted of three groups.

  • Patients and family
  • Consultants

The recruitment of study participants employed purposive sampling, aiming to select individuals or groups highly knowledgeable or experienced in the phenomenon under investigation. Criteria included availability, willingness to participate, and the ability to articulate experiences and opinions effectively [ 30 ]. Participants were chosen from two public sector hospitals in Rawalpindi, Pakistan, comprising stable patients and family members with a minimum one-week hospital stay, residents with over six months of training in the Obs & Gynae department, and consultants engaged in residential calls alongside residents. To ensure the comfort and security of female patients during interviews, both the patient and her husband were included in the first group. Exclusions included patients with less than one-week hospital stay, those deemed unstable or unwilling to engage, newly inducted residents with less than six months of training, and senior medical officers not involved in residential calls. A total of 33 semi-structured interviews were conducted, 11 per group, to explore factors contributing to lapses in professional behaviour. Saturation was achieved by the 10th interview, with one additional interview conducted for confirmation.

Data collection

The data collection was done in a structured manner in two phases.

Phase 1: (The complaints data and document analysis)

In phase 1, complaints uploaded to the PCP portal were examined to address the first objective of this study. Access was granted to a nominated Deputy Medical Superintendent (DMS), who regularly logged in to the Citizen Portal website to review complaints. Specific complaints against residents involve prompt notification of the focal persons in the concerned department, who immediately addressed the issue by investigating the resident and their consultant. Following fact-gathering, complainants were invited for scheduled meetings to evaluate allegations and attempt resolution; unresolved complaints were escalated to higher authorities.

This study's initial step involved confirming the number of complaints against Gynae residents regarding their behaviour. Formal permission was obtained to access all complaints, facilitating the review to determine complaint frequency and comprehend complainants' messages for administrative authorities. Complaint phrases were consolidated into themes, supplemented by additional themes identified in the literature, laying the groundwork for designing a semi-structured interview questionnaire. Complaints lodged by patients and families were documented in Table 1 , highlighting lapses in professional behaviour as a primary concern.

Phase 2: (Interview data)

Interview structure.

In the second phase of data collection, in-depth interviews were conducted for two primary objectives. Firstly, to reconfirm the nature of complaints against Gynae residents, and secondly, to delve deeper into the underlying issues from three distinct perspectives.

Semi-structured one-to-one interviews were chosen as the research instrument due to the sensitive nature of the topic. Three separate interview guides were developed for patients and their families, as well as residents and consultants, following the structure of the AMEE guide 87 [ 31 ].

Special attention was paid to ensuring that the language used in the interview guides was clear and understandable. The guide for patients was prepared in Urdu, while those for consultants and residents were in English. All interviews were conducted in Urdu to accommodate the participants' comfort in expressing their views and were later translated as needed.

Expert validation and pilot testing

The questionnaire used in the interview guide underwent expert validation by four Medical Educationists, who possessed a minimum of 5 years of experience. This validation aimed to assess the clarity and relevance of the questionnaire items in relation to the construct being measured. Feedback provided by the experts led to modifications in some items and adjustments in their sequence.

Following this, pilot testing was conducted, involving one participant from each stakeholder group. The results of the pilot interviews prompted further refinements in the interview guides and probes.

The interview guide consisted of two parts : the first part focused on gathering demographic information, while the second part addressed the study objectives. The demographic section collected details such as age, education, profession, duration of marriage, and family structure. Patients and their families were asked seven questions, while residents and consultants were presented with ten questions, aiming to capture information relevant to the research objectives.

Through this investigation, not only were the specific instances of lapses in professional behaviour among residents examined, but also the broader spectrum of issues that patients raised in their complaints.

Bias control

Considering the sensitivity of the study topic and the senior position of the researcher within the organizational hierarchy, third-party researchers were engaged to conduct the interviews. Each of the three stakeholder groups was interviewed separately. These face-to-face interviews were conducted following rigorous protocols to ensure accuracy and reliability. To mitigate social desirability bias [ 32 ], which could skew responses, the interviews were conducted by a separate team of psychologists who were not affiliated with the organization being studied. This team comprised three members, with each member assigned to interview one of the stakeholder groups, allowing them to develop a better rapport with respondents over time.

Logistics for the interviews were managed by a liaison person from the hospital, ensuring smooth coordination. Participants were provided with information sheets detailing the study aims, interview process, and assurances of data confidentiality and anonymity. The interviews were conducted in a designated space within the hospital premises and began after obtaining written informed consent from each participant. Audio recordings of the interviews were made, with an average duration of 45 min per session.

Challenges encountered during the interviews were addressed through daily online meetings, allowing the interviewers to discuss and overcome any issues faced. Patients and their families initially exhibited reluctance to participate, but counseling and assurances of confidentiality helped alleviate their concerns. For residents, anonymity was assured by assigning specific IDs and group codes to the transcribed interviews.

Each interview was transcribed verbatim and provided to the main researcher for analysis. Similar sets of questions were posed to all three stakeholder groups, aiming to elicit their perspectives on the factors influencing lapses in professional behaviour.

Phase 3: (Data analysis—theme extractions)

In phase 3, the framework method of thematic analysis was employed, known for its structured approach facilitating systematic comparison of data across cases [ 33 ]. This method involves several steps, as depicted in Fig.  2 .

figure 2

Steps of framework method of thematic analysis

Firstly, the interview data was transcribed (Step 1), followed by familiarization with the transcriptions (Step 2). Initial codes were then generated to capture key concepts and ideas (Step 3), which were subsequently organized into themes, which aligned with the themes identified in the literature (Step 4). Additionally, new themes emerged during this process, enriching the analysis.

A working analytical framework was developed based on these themes (Step 5), and the final step involved interpreting the data within this framework to derive meaningful insights.

Quality and transparency

The study's expenses, which involved hiring third-party researchers, were solely supported by personal finances, without any contribution from public funds. Each researcher dedicated six days to conduct interviews with a total of 33 participants.

To ensure the quality of this study, several triangulation strategies were employed [ 34 ]. Credibility was enhanced through data triangulation by gathering information from three different stakeholder groups. Investigator triangulation involved the participation of multiple researchers, while method triangulation utilized both document analysis and semi-structured interviews.

To establish trustworthiness , transcripts were reviewed by additional researchers, and consultations were held with peers, study supervisors, and co-supervisors throughout the data processing stages. Thick descriptions were provided to elucidate behaviours, experiences, and contextual factors, increasing the study's transferability while acknowledging potential contextual differences.

The study's methodology was transparent, with each research step meticulously described from inception to reporting, ensuring dependability . Detailed records were maintained throughout the study, contributing to the transparency and reliability of the findings.

Team reflexivity

Semi-structured interview guide prepared by HN, main researcher and Gynaecologist by profession. Reviewed by RY, who is Dean of medical education department. Interviews were conducted and transcribed by US, AT and BM who are psychologists. Thematic analysis done by HN (Gynaecologist) and AG (who is also psychologist). Results were reviewed by LE (medical educationist) and FS (PhD and trained in qualitative research). The reflexivity was ensured by critical self-reflection about oneself as researcher and making the position of the researcher and the participants clear. The methodology explained in detail.

The results are described in 2 parts . The 1st part is the complaint data from document analysis of complaints on Pakistan Citizen Portal (PCP). The 2nd part explains the findings from the interview data sets.

Part 1-Complaint data

Participant characteristics for document analysis.

All the complaints are anonymised and can't be tracked back—no demographic data available which lead us to re-verification of these complaints.

The literature shows that complaints provide an opportunity to understand the problems and the ways these can be resolved [ 27 ]. In PCP document, the range of complaints were diverse, 26% ( n  = 10/38) were against resident’s professional behaviour which is the core investigation of this study. The rest were related to lack of facilities, infrastructure, and lack of facilities for attendants and huge workload. (Table  1 ).

Part 2- Interview data

Participants characteristics for the interviews.

The following Table  2 shows the demographic of all 3 stakeholders.

Reinforcing evaluation of the identified themes in PCP Document

The first question of interview was asked to re confirm the identified themes in PCP document. This part of the investigation provides a wider perspective of all three stakeholders related to the frequently observed/faced complaints (Table  3 ). Interestingly, the poor verbal communication and behaviour has been listed at the top with the highest value which reinforces the importance of this study. Other issues highlighted were lack of attention and insufficient communication by doctor and the complaints related to labour room. Few of the complaints were against paramedical and lower staff (Table  4 ).

Complaints other than lapses of professional behaviour includes prolonged waiting time, poor infrastructure and limited resources. (Table  4 ).

The interviews provided the researcher with rich insights into the factors and associated reasons for lapses in professional behaviour. Detailed findings are presented in the form of extracted themes and sub-themes for each stakeholder along with associated reasons.

Grouped classification of themes

The analysis was initiated by employing thematic analysis framework, as described in section of data analysis to examine data from three distinct stakeholder groups. Just to clarify, in this context, the term "themes" refers to the factors that each stakeholder perceived as potential contributors to professional lapses. Total; 15 themes extracted on analysis of data from 3 stakeholders (Fig.  3 ).

figure 3

Total themes, subthemes and codes extracted on analysis of data from 3 stakeholders

The identified themes and sub-themes from the perspectives of the three stakeholders revealed some commonalities. There are a total of six overlapping themes (these are the themes with common consensus and similar perspective). These are discussed in detail later in this section and presented in (Fig.  4 ), indicating the stakeholders with whom these themes overlap. These overlapping themes help in shedding the light on the issue from 3 different angels. A graphical representation of the overlapping themes is depicted as a mesh in Fig.  5 .

figure 4

Six overlapping themes from 3 stakeholders

figure 5

Mesh of overlapping themes (grouped classification of common themes)

In this section, we delve into the six overlapping themes, exploring the analysis results by comparing the perspectives of the three stakeholders. This comprehensive approach provides insights into each theme from various angles, shedding light on the factors influencing lapses in professional behaviour among residents. Additionally, notable quotes are incorporated to offer a vivid and relatable depiction of these findings, enhancing understanding and authenticity.

Theme 1: Personal

The first overlapping theme, depicted in Fig.  6 , illustrates the sub-themes and perspectives of stakeholders regarding this common theme. It showcases stakeholders' viewpoints on potential issues contributing to lapses, closely linked with their ‘personal needs and concerns’. These encompass family concerns, caring responsibilities, individual personality traits, basic human needs, quality of life considerations, competency levels, and overall well-being.

figure 6

Presenting the reasons associated with the common theme ‘Personal’

For majority residents, balancing caring responsibilities for young children without sufficient family support poses a significant challenge, adding to the stress of professional obligations. Additionally, residents experience frustration and disappointment when they are unable to meet their child's or their own health-related needs adequately.

[Resident] "Family support is very big factor. For example, there is a female doctor and she has children, so if there is a problem at home, it obviously affects the doctor."ID_03

The residents interviewed expressed concerns about their heavy workload, which has adverse effects on their emotional and physical well-being. This indicates the importance for hospital management and administration to devise strategies to address the specific needs of residents and provide them with adequate support for their unavoidable personal responsibilities.

[Resident] “We have mother residents who have to breastfeed their babies and sometime they did not even get time to pump milk for their babies” ID_01
[Resident] “As a Gynae resident we cannot spend proper time with our family. We have 30 to 32 hours so whatever time we have in our house we have to sleep at that time. ID_09

Personal factors such as childcare and household responsibilities have also been emphasised by both patients and consultants as potential triggers for behavioural issues.

[Patient & Attendant] “doc is also human she has to perform all her professional duties along with home responsibilities of taking care of kids and home.” ID_10
[Consultant] "Some of our doctors are very good, counsel the patient properly, talk comfortably and some doctors are in a bad mood in the morning, they may have their own problems that affect them, so they get tired."ID_1.

Many females in Gynae face challenges in securing support from their in-laws and family to manage their households. When in-laws fail to understand the demands of the profession or are not present in the same city, and hiring domestic help is difficult and costly, these stressors can significantly affect their performance and attitude towards their professional responsibilities.

[C] “Doctors mostly have their own tension going on. They may already be suffering from some tension that is affecting them”ID_3

Well-being serves as a vital metric in fostering a positive workplace environment. In the context of this study, we focus on the well-being of residents tasked with serving in the healthcare sector, particularly in the demanding field of Gynae. Recognized as a central aspect across various themes within this study, well-being emerges as a shared concern among all stakeholders, potentially contributing to lapses in professional behaviour.

[C] “if the resident is not feeling well that will also influence her behaviour with patients “ID_5”

The interview findings have outlined several influential factors impacting residents' well-being, with the most prominent being the long working hours, stringent duty schedules, and sacrifices made regarding basic human needs.

[R] There should be any stress relieving activities or vacations for us to spend time with our family. ID_07
[P] Residents are human and they are working a lot so they can get tired by working so much.” ID_09
[R] You cannot take off because it is a big issue and because of that you cannot have mental break from this entire situation. ID_0

There is a pressing need for institutional-level interventions to address various associated factors and support the well-being of residents. This will create a more conducive working environment that positively influences professional behaviour.

[R] “"it’s on the institutional level, patient load and tough routine. We are here for almost thirty six hour; we do not get short breaks for lunch and sleep. We are not machines we are humans, even then we try to give our 100%" ID_04.

Competency is pivotal in managing workload and meeting patients' needs. Notably, patients have never complained about treatment, reflecting positively on professional competency of residents. However, deficiencies in counseling skills, multitasking, and handling conflicts are observed. Consultants discern differences in attitude between senior and junior residents, highlighting the need for tailored training to equip residents for diverse situations.

[Consultant] “Experienced resident will stay cool and calm, and she knows that how to deal with things or how to answer about issues”ID_5

The management should implement a mentoring scheme to train junior members, offering them opportunities to shadow their seniors. Analysis of interview data strongly suggests that the interpersonal theme is closely linked with competency, the demands of the Gynae specialty, and administrative/management factors.

Theme 2: Workplace challenges

This theme delves into workplace challenges as perceived by stakeholders, shedding light on potential factors contributing to lapses in professional behaviour, as shown in Fig.  7 . Sub-themes include interpersonal dynamics, environmental factors, managing multiple responsibilities, workload issues, the role of senior staff, challenges with untrained paramedical personnel, labor room dynamics, basic human needs, and insufficient support from colleagues and superiors.

figure 7

Presenting ‘Workplace challenges’ as a common theme across stakeholders

Interpersonal challenges are frequently highlighted by both residents and consultants. Novice residents struggle with managing conflicts with patients, leading to a tense and stressful environment for all parties involved. This situation is compounded when there is inadequate support from fellow doctors and paramedical staff members.

[Consultant] “Residents and nursing staff did not have good interpersonal relationships and if residents not have nice behaviour with nursing staff they will not get that support from them “ID_6.

Furthermore, the absence of respectful collaboration from other related departments exacerbates the stress and disappointment experienced by residents, ultimately leading to personal frustration that can influence behavioural lapses.

[Resident] In Gynae department our personalities get suppress that even other departments do not respect us. ID_09

Consultants have stressed the importance of training for paramedical staff to offer timely and supportive assistance. They have highlighted the need for paramedical staff to be attentive and responsive, especially during critical emergency situations. Consultants noted that doctors often have to repeatedly request assistance from paramedical staff and may need to raise their voices to convey the urgency of following instructions during critical situations.

[C] “If your paramedical staff is not cooperative then obviously you will get stressed (the doctor not only has to deliver the baby but also send the attendants outside and shout for aya to help her) ID_4.

The physical environment and its related factors significantly impact the satisfaction levels of staff members. Analysis of the data has identified the "environmental factor" as a common theme from both resident and patient/family interviews, as depicted in Fig.  7 . The findings indicate that patients and their attendants recognize the workload of doctors and acknowledge that excessive burden is a primary cause of stress for residents, ultimately affecting their behaviour and well-being.

[P] Duty hours should be reduced and they should get some time for rest and food. There is lot of pressure on them. They start their round at 9am and finish at 2pm because there are 3, 3 patients on each bed. ID_5.
[P] If there are 2 patients on one bed than this will increase anxiety of doc as well. Too many patients are talking simultaneously so this will make her angry. ID_07
[P] On operation day doc is more stressed because she has to manage all the patients and she is alone and feels pressured.” ID_02

The patients have also expressed concern that working hours should be reduced, or the management should consider increasing human resources to cope with the workload. This highlights the interconnection of this theme with other relevant themes.

[P] We should increase the number of doc. The doctor only gets angry when she gets tired and loses her patience level.” ID_07
[P] Patients are coming to doc after 2pm and then they expect their doc to make file but they don’t understand that doc have many other responsibilities.” ID_02

Similarly, from the residents' perspective, it is evident that they are struggling with their workload, and inappropriate physical surroundings further exacerbate their frustrations. Additionally, residents have expressed concerns about issues related to management and counseling of attendants, which adds to their responsibilities. This aligns with the theme discussing various characteristics of attendants, considered significant in creating a conflicting environment.

[R] Unsatisfactory work conditions and patient doctor ratio are among few highlighted by the residents. This can greatly influence the working conditions in support of appropriate environmental factors. A large number of attendants can cause additional management and communication burden for residents to deal with. ID_6.
[R] “Every patient is accompanied by 2 to 3 attendants and you are dealing with patient so every attendant individually comes to us and ask you about the information”. ID_09

Workload emerged as a prevalent theme in both residents' and consultants' data as shown in Fig.  7 . It is consistently highlighted as a significant issue by both groups in their interviews. Patients and their attendants also expressed concerns about the high workload on doctors. Excessive workload is considered one of the most influential factors contributing to observed lapses in professional behaviour.

[R] “doctors get exhaust because of long 36 h duty, at times we did not eat anything or we could not have proper sleep” ID_01
[R] We are not allowed to refuse any referral even if we do they come back again with the reference of DMS. ID_02 "The biggest problem in this is that we are working in the government sector and there is a human capacity of a doctor, if a doctor has a capacity to check of 5 to 6 patients, but in the government sector, a doctor has to check 20 patients. So the doctor feels overburdened." ID_03.
[R] We have one doctor who is deal 130 to 140 patients from 8 to 2 AM. ID_09 “in other countries they have better working conditions and increase number of doctors because of that they have less work load” ID_09.

The findings discussed above highlight a strong association between the environmental factor and well-being, as well as unmet human needs.

There are labor room-related issues highlighted by residents, which can escalate misunderstandings for patients' attendants. Cultural norms often dictate that only female family members accompany the patient during the delivery process. Men are typically not permitted to enter the labor room, especially when female attendants are present or when maintaining the privacy of other patients is a concern. However, this practice can be perceived negatively by patients' male attendants, although it may not reflect the true intent in all cases.

[R] Patients want to have their husbands with them in labour room and in our culture it is not possible. ID_05
[R] “Not allowing male attendants in labor make them think that their patient is in danger”. ID_07

The two overlapping themes identified from residents and consultant data are 'Lack of support from seniors' and 'Role of seniors' , respectively as shown in Fig.  7 . Junior residents have raised concerns regarding the lack of support from senior members. Similarly, consultants have echoed these sentiments, suggesting that seniors are not fulfilling their roles in providing adequate support to junior residents.

[R] " Seniors also pressurize us; they say that you are not examining patients properly or too slowly, because of their responsibility of finishing OPD in given time”. ID_06

Both residents and consultants have emphasized that residents are burdened with multiple tasks , some of which consume significant additional time as shown in Fig.  7 . For instance, residents often find themselves tasked with arranging blood for seriously ill patients by making excessive calls to relevant blood banks and maintaining patient records. Consequently, they struggle to allocate sufficient time to meet every patient's expectations.

[R] “Residents are always concerned about the patients and they tried to arrange things as soon as they can”. ID_09
[C] “doctor has to be a multitasker, for example if we are short on medicine or blood we send our PGT(post graduate trainee) to blood bank in the middle of the night”ID_1

The findings indicate a lack of support from management in sharing additional responsibilities, while simultaneously expecting doctors to multitask . This theme is closely linked to the 'workload' and 'Demand of Gynae specialty' , contributing to a stressful and demanding environment for residents. Another recurring theme identified from resident and consultant data is the 'Unfulfilled basic human needs' . Patients and their attendants have also noted the exhausting routines of residents, who often lack time for relaxation or sleep.

[P] “They are human and they are working a lot so they can get tired by working so much” ID_9
[P] “These doctors are so busy with patients that they don’t have time for self” ID_4

Residents have highlighted long duty hours as a significant factor, leaving them with insufficient time and energy to spend quality time with their families. These extended shifts often involve an excessive workload of patients, leading residents to compromise even on their meal times.

[R] “Because of long duty hours and huge number of patients we do not have time to get proper sleep” ID_01
[R] As a Gynae resident we cannot spend proper time with our family we have 30 to 32 h so whatever time we have in our house we have to sleep at that time. ID_09

Theme 3: Stressful specialty

This theme, prominently observed in the data collected from both residents and consultants as depicted in Fig.  8 , encompasses the sub-themes of 'demand of Gynae specialty', 'nature of profession', and 'unpredictable outcomes related to this profession'. Notably, patients' data only minimally reflects this theme, with only one in 11 patients commenting on the stressful nature of the profession.

figure 8

Presenting ‘Stressful specialty’ as a common theme from two stakeholders

Both consultants and residents commonly perceive Gynae as the most stressful domain within the healthcare system, largely due to the simultaneous involvement in the lives of more than one individual. Consequently, this stress may manifest in various ways, potentially leading to lapses in professional behaviour or misinterpretations thereof. The data highlights several specific reasons inherent to the Gynae field, contributing to an overwhelming environment for residents, which can at times be challenging to navigate smoothly.

The unpredictable outcomes associated with Gynae further compound its demanding and challenging nature for those serving within this discipline.

[C] “We have to take care of two lives which is an additional stress for us “ID_6
[R] Residents have high level of tension when patients are non-cooperative, because we have to bear stress of both mother and fetus. ID_07

The interviewed residents have expressed the considerable stress they experience while working in a Gynae department with limited facilities. They highlighted the extra efforts required to arrange supporting resources, such as blood for seriously ill patients. Additionally, residents face the added stress of justifying their efforts and treatments in the unfortunate event of a patient casualty.

[R] “We are aware of our facilities and we have this pressure that even if we examine these excessive number of patients it would be difficult for us to manage them with compromised services, and later we have to justify if the patient expires”. ID_02.
[R] “In our department, our senior PGT herself rushes for the blood of serious patients”. ID_09

The field of Gynae presents unique challenges that are distinct from other areas of the healthcare system. The labor room environment, in particular, poses significant challenges for residents, especially when decisions and treatments are critical to more than one life. Dealing with patients with diverse needs requires patience and experience, as their behaviour can vary greatly during labor, depending on factors such as physical capability, pain tolerance, and cooperation.

Unfavorable workplace conditions can exacerbate the already demanding nature of the work, increasing the likelihood of professional lapses. However, organizational and management interventions can help mitigate these challenges. Improving workplace conditions, adjusting working hours, prioritizing resident well-being, and providing appropriate training are measures that can assist residents in handling such situations more effectively.

Multitasking, another significant challenge, should be minimized by involving support staff and experts at the right time. Residents should not bear sole responsibility for negative outcomes; trained staff should be available to assist them through challenging situations.

Overall, the discussion highlights the interconnectedness of various themes and sub-themes, highlighting the importance of organizational and management decisions in addressing workplace challenges and promoting resident well-being to reduce the occurrence of professional lapses.

Theme 4: Cultural

This theme is consistently identified across all three stakeholders, although residents and patients & families place greater emphasis on associated concerns, as depicted in Fig.  9 . Notably, the top concerns contributing to lapses in professional behaviour and poor understanding of cultural concerns and communication are highlighted.

figure 9

Presenting sub-themes for ‘Cultural differences’ as a common theme across stakeholders’ data

Cultural differences can create a discriminatory environment across various aspects, while a lack of understanding of diverse needs can lead to significant misunderstandings between patients and residents. Language barriers, in particular, emerge as a critical cultural factor identified by all stakeholders. Communicating with individuals with different language needs, especially when they adhere to distinctive cultural norms, poses considerable challenges. Consultants also raised this issue during their interviews, although it is merged with 'Patients' characteristics' as a matter of importance.

[C] “Language barrier is a big problem. We also have Pathan (Pakhtoon) population who do not understand”ID-1
[R] “Most of the time Pakhtoon community is very difficult to deal. They do not take your opinion even if they are high risk patients, they force for normal delivery”ID_02
[P] “Doctor in labour room are harsh. they move Pathan attendant out of the labour room and say that we will call you when needed but they don’t call anyone anytime” ID_08

In developed countries, the healthcare system is well-equipped with chaperones who assist healthcare professionals in communicating important information to patients and their attendants. However, in Pakistan, such a system is not in place, making it difficult to expect residents to understand a variety of regional languages. This lack of linguistic diversity among residents can exacerbate feelings of being 'left out' among many patients and their attendants, sometimes leading to arguments with residents.

[R] “We have language barrier with Pakhtoon patients and they are mostly aggressive and thought that we do not understand their issues”. 1D_01
[P] “Nobody allow us in ward if we have to discuss something with doc. Our patient is not educated; she can’t explain her concern in Urdu so how will the treatment proceed.” ID_4
[R] “Most of the Pakhtoon community thought that we are biased and most of the time when they are going back they often say that “we are Pathan that’s why you are not paying attention to us” ID_07.

Furthermore, the language barrier or poor understanding of cultural and regional norms can create a biased environment or negatively influence the thoughts of minorities. This theme is reasonably associated with residents' characteristics and management factors. We believe that the administration should carefully address these important issues and consider providing chaperones to assist residents and patients.

Another challenge for residents arises when dealing with patients whose rigid cultural beliefs influence their mindset. Sometimes, residents must follow recommended treatments to save patients' lives, but attendants may challenge these treatments, leading to conflicting arguments.

Residents also encounter situations where they must take actions to ensure privacy for other patients, especially when multiple patients share a room. However, these actions can be misinterpreted and biased against certain communities. While this issue is partly related to patients' and families' understanding of privacy concerns, it is also the responsibility of the administration and supporting staff to educate them about these sensitive aspects. This burden should not solely fall on residents.

Theme 5: Patients’ characteristics

This theme stands out as one of the most discussed, offering rich information about the specific characteristics of patients and their attendants seeking Gynae treatment, as depicted in Fig.  10 . It delves into associated factors attributed to the educational, economic, and cultural backgrounds of patients and their attendants, which significantly influence their  behaviour and expectations. Additionally, it addresses contextual causes that may lead to lapses in professional behaviour.

figure 10

Presenting sub-themes for ‘Patient characteristics’ as a common theme across stakeholders’ data

Pakistan, a developing country, with a literacy rate of 50% and a current birth rate of 3.6 per patient according to PDH 2018 survey, it is a common cultural practice to send senior female members to assist pregnant mothers. This practice is rooted in the belief that experienced females can provide valuable support to new mothers, which is often true. However, it's important not to overlook the fact that patients' attendants are typically the ones who maintain constant contact with residents and serve as the primary point of contact for treatment and critical decisions.

In order to ensure smooth provision of care, it is essential for attendants to cooperate with residents and be capable of interpreting important decisions and communicating needs from both ends. Patients and attendants with lower educational backgrounds often find it challenging to interpret complex information or navigate to the correct physical location when seeking assistance.

[R] “In government sectors literacy rate of patients are low which creates issue” ID_05

Lack of understanding about the sensitivity of the issue and unrealistic expectations from residents are frequent reasons that initiate arguments from patients and their attendants. For instance, they may argue if a resident is giving attention to a patient they don't consider to be serious. This behaviour is often perceived as neglectful by patients and attendants, though it may not accurately reflect the resident's intentions.

[R] “suppose we have emergency and I am checking that patient first so all other patients will start shouting, they will not understand the emergency, being a doctor we know that we have to see the emergency patients first but every patient thinks that their problem is the biggest one” ID_01.

In some cases, the unprofessional behaviour exhibited by residents may be a response to disrespectful acts from patients or attendants . Residents have reported instances of disrespect from patients and attendants who fail to grasp the sensitivity of certain treatments and the necessary preliminary measures before administering them. Additionally, the time taken for preoperative preparations may be misinterpreted as a 'delay' in treatment by patients and their attendants.

[R] "The patient complains that the doctor told us that we will have an operation, why don't you operate, if something happens to our child, you will be responsible, patient says" main tumain dekh lounga"( I will see you). They threaten us and misbehave with us".ID_06.

Residents frequently encounter unrealistic expectations from patients and their families regarding infrastructure and facilities, despite these not being within the residents' purview. Patients and their families may expect residents to provide beds and medication, leading to disappointment when residents are unable to fulfill these needs. Arguments where residents are unjustly blamed are unlikely to be accepted by residents and can escalate into conflicts. However, residents and supporting staff should undergo training to effectively communicate any limitations to patients in a more acceptable and understandable manner.

[R] “"When a patient enters the hospital. She doesn't get a bed and medicine. So it is no longer the doctor's responsibility, but because the doctor is in front of them, they feel that the doctor is responsible for these things" ID_06.

It is crucial for residents to recognize the various needs and support required by patients and their families, irrespective of their educational or economic backgrounds. This necessitates appropriate assistance provided to residents from various aspects such as staff, administration, and management support.

Trust is a fundamental element of the patient-doctor relationship, yet it is another concern highlighted by interviewed residents. Patients and their attendants may not fully trust the treatment provided by doctors, possibly due to limited exposure to the healthcare system in rural areas, where self-trained people (called Dai) are preferred over experienced doctors.

[R]”Even if doctor is thinking positive about the patient, patients have this trust issue that might be this doctor will not do my operation properly, or she will make my delivery difficult.” ID_07.
[R] “Patients with low literacy rate go to Dai. ID_09 Daiyon ka jo counselling level ha wo itna acha hota ha k patient kharab kr k bhi bhai jdain to attendant kuch bhi nahi kahe gain unki nazar ma Dai is very good”(counseling skills of Dai are so convincing that even if the patient encountered the complication they thought that Dai is competent). ID_09.

Patients seeking care at public hospitals are often economically deprived individuals, burdened with family responsibilities. Many rely on daily earnings, and prolonged absence from work can lead to financial strain. Additionally, they may have caregiving responsibilities that necessitate a swift return home, prompting them to insist on expedited treatment. While these unavoidable circumstances add stress to the situation, appropriate counseling can help patients understand the importance of receiving necessary treatment and alleviate the impact of missing appointments or procedures.

[R] “Patients in Gynae wards are in hurry because they have their family responsibilities and they have small kids at home” ID_07

Both residents and consultants have shared their experiences of navigating conflicting environments , which can sometimes lead residents to adopt a harsh tone when communicating with patients and attendants. For instance, in urgent situations requiring aggressive treatment critical to a patient's life, sudden behavioural changes may occur to emphasize the importance of the treatment. This behaviour has a strong link to the attendants' level of understanding and literacy regarding the healthcare system, particularly in the context of Gynae treatment where 2 or more lives may be at risk simultaneously.

[R] “Residents become harsh when attendants or patients do not understand the situation, for example they do not arrange the blood so we have to tell them harshly about it” ID_02

Some senior consultants have provided visionary statements, noting a cultural shift in how the public interacts with medical practitioners. Consequently, there has been a recent increase in aggressive behaviour observed from patients and attendants.

[C] “In past patients and attendants were not so violent but now a days they are violent “ID_6

Privacy is a fundamental concern for individuals worldwide, and developed countries have stringent policies and regulations in place to safeguard individual rights. Any breach of these rights can understandably trigger anxiety and concern. Therefore, it is crucial to communicate with patients and attendants about actions that may lead to security breaches involving residents, in order to prevent unpleasant situations.

[C] “Now a days people used to make our videos “ID_6 “people were aware in past as well but now they have got easy access to the portal for complaints”ID_6

This theme is closely linked with the understanding of patients and attendants regarding the healthcare environment, rules, regulations, and treatment specifics that can potentially trigger professional behavioural issues. Management or administration can play a crucial role in providing upfront information to patients and attendants regarding important regulations related to the Gynae specialty.

Theme 6: Organisational & administrative

Organizational and administrative authorities are integral in developing effective policies to ensure the smooth operation of healthcare systems. In the context of this study, we believe that the hospital administration can significantly contribute to mitigating the issues discussed thus far. They can take the lead in informing policymakers to design policies relevant to the sensitivity of this field.

This theme presents the perspectives of both residents and consultants on organizational and administrative issues that can lead to conflicts and lapses in professional behaviour, as depicted in Fig.  11 . Sub-themes include the lack of support from administration and management issues.

figure 11

Presenting sub-themes for ‘Organisational& administrative’ as a common theme across stakeholders’data

An important point to note is the understanding and expectations of patients regarding the provision of facilities and resources necessary for their treatment. During interviews, all patients and families expressed a lack of clarity regarding the roles of hospital administration and doctors.

Both consultants and residents have highlighted challenges including lack of support from administration, limited resources, and excessive workload . A high influx of patients can significantly impact working conditions and hinder the ability to provide maximum satisfaction to all patients.

[C] “We do not have anybody who controls the influx of patients outside the rooms or OPD “ID_6
[C] “Also there is the factor that the workload is very high, already you have many patients and doctors are less, sometimes the government does not give you enough resources to facilitate the patients.”ID_3.
[R] “We have two operation theaters and over there we have one anesthesiologist” ID_02

Administrative support is crucial in ensuring a secure and pleasant working environment for residents. One concern raised by consultants is the management of patient flow within the hospital. A system should be implemented to queue patients and prioritize them based on their order of arrival for check-ups.

[C] “doctor should be given security, they should be given support, one by one the patient should be sent to the doctor so that the resident also gets time to see the patient”ID_3

The doctor-to-patient ratio varies as per the workload and patient intake. A heavy workload can significantly impact the quality of patient care provided. Most importantly, it can adversely affect the well-being of residents, who are already vulnerable due to the high number of patients they must manage.

[R] “we have huge number of patients and ratio of doctors are much less” ID_01
[R] “we only have one guard for security and we have huge number of patients and every patient have 2 attendants along with her so there is almost 150 people in one room so obviously I will get aggressive”. ID_01.

All of the issues discussed above are likely to influence the professional behaviour of residents making them susceptible to react aggressively which is not a pleasant experience for patients and their family.

The findings from interviews involving three main stakeholders, shed light on potential triggers for unprofessional behaviour discussed in previous sections. The synthesis in the discussion session highlights the key insights gleaned from the interviews, emphasizing the importance of understanding and addressing the challenges faced by residents in their professional journey.

“Being a resident is not a crime” (ID_C7).
“Residency is just like War in battlefield” (ID_C7).

The quotes from the interviewed consultant underscore the struggles and efforts inherent in the professional life of residents, emphasizing the pivotal role of residency as a preparation for frontline healthcare responsibilities. As residents navigate hierarchical structures within hospitals, they confront diverse challenges and ethical dilemmas, often without adequate training or support. These circumstances can negatively impact their professional behaviour, contributing to a conflicting healthcare environment. It is imperative to comprehensively explore the realities faced by residents to understand and address inappropriate behaviour effectively.

Demographic inference

The demographic observations from the interviewed stakeholders provide valuable insights into personal issues and patient characteristics that may influence lapses in professional behaviour. For instance, all interviewed patients are housewives with a Matriculation education level, and 45% of them reside in a nuclear family system despite low socioeconomic backgrounds, contrary to societal norms. Consultants, despite higher education and financial independence, are bound to stay in joint families, likely due to the need for familial support in caring for their children amidst demanding work hours. Similarly, a majority of residents reside in a nuclear family system, possibly driven by being unmarried or already established in such living arrangements. These findings highlight a preference for joint family living among Gynae residents and consultants, largely driven by the need for support in childcare due to demanding and long work schedules. However, such living arrangements may also introduce additional stressors related to cultural expectations from family members, as discussed under the 'Personal factors' theme, where stakeholders reflected on their experiences and challenges regarding professional responsibilities and expectations from in-laws.

Role of competency and communication skills

The interview findings regarding personal factors also examined communication skills and patient expectations. Our study revealed that a lack of communication skills when dealing with challenging situations often led to conflicts. Therefore, we recommend enhancing competency in this area to avoid such situations. This finding aligns with the research by Alipour et al., which also underscores the importance of good communication skills in managing challenging patients [ 35 ].

Furthermore, our study found that patients expect physicians to prioritize their needs, respond respectfully to their inquiries and concerns, and uphold their dignity, particularly during sensitive procedures such as those in the delivery room. Patients also value empathy towards their health condition. Similar sentiments were echoed in patient complaints (PCPs), where lack of care or attention from doctors was highlighted. These findings are consistent with prior research emphasizing the importance of communication in maintaining good professional behaviour, with patients specifically emphasizing the significance of being listened to attentively and having medical information explained in understandable terms [ 17 ].

Indeed, previous studies have highlighted the impact of inappropriate practices on patients' satisfaction. For instance, practices like insufficient preparation before patient encounters and failure to provide accurate and relevant information have been associated with decreased patient satisfaction [ 36 , 37 ] Additionally, a common complaint in PCP is the lack of an appropriate number of doctors, which is closely linked to these issues. Addressing these concerns is essential for improving patient care and overall satisfaction levels within healthcare settings.

Contextual understanding and its influence

The study reveals context-specific challenges faced by residents, particularly concerning the involvement of in-laws during residency, a phenomenon unique to the cultural context of Pakistani society. Another pertinent issue is the scarcity of affordable housemaids or child-minders. Unlike many developed countries where joint family structures are less prevalent and childcare support is provided by organizations and governments, there are limited initiatives in Pakistan to offer such support. Developed countries have recognized the value of professional child-minders and after-school clubs, providing safe and reliable childcare services to working parents. Unfortunately, Pakistan lacks such reliable facilities, leaving working parents, including residents, with limited options for childcare. While there is a common perception that grandparents can provide adequate care, those without such support often experience stress and uncertainty regarding the safety and care of their children. These stressors are unavoidable for residents and can significantly impact their performance and attitude towards professional responsibilities.

Addressing these context-specific challenges is crucial for supporting residents and ensuring their well-being amidst the demands of their professional roles.

The interview data highlights residents' multitude of responsibilities , contributing to complaints about long working hours and patient burden, particularly unique to our healthcare system. Unrealistic demands placed on Gynae residents, extending beyond medical care, negatively affect their behaviour due to added burdens. Labour room issues arise from societal norms, with family members often leading to miscommunication between doctors and husbands outside the room. Public distrust in doctors and teaching hospitals, fueled by negative media portrayal, prompts family intervention and threatening behaviour in the labour room, forcing Gynae residents into defensive positions and hindering treatment decisions.

Workplace challenges and their impact

The second major complaint in the PCP document, lack of facilities, aligns well with interview data, which highlights various workplace challenges as possible causes of lapses in professional behaviour. These challenges encompass interpersonal, environmental, and workload-related factors, as well as issues with labor room conditions and support from seniors and paramedical staff.

Junior residents' difficulties in handling conflicts with patients are highlighted in our study, reflecting findings from another study in a Gyane department in Pakistan, emphasizing the need for training in interpersonal skills [ 20 ]. Additionally, our study emphasizes the negative impact of poor working conditions on residents, a finding consistent with previous research linking organizational and environmental factors to professional behaviour [ 38 ].

Excessive workload emerges as a significant factor contributing to observed lapses in professional behaviour, supported by complaints of a huge patient burden in the document analysis. Our results resonate with research from Iran, indicating that high workload and time constraints lead to declining empathy and unprofessional behaviour [ 39 ]. Moreover, a narrative review on physician behaviour underscores the role of increased workload in affecting doctor-patient communication and fostering aggressive behaviour [ 23 ]. Excessive working hours can also lead to unfulfilled basic human needs and burnout among physicians, as highlighted by stakeholders in our interviews.

Our study identifies workplace issues such as lack of staff support, leading to frustration among residents when instructions are not followed, resulting in perceived lapses in professional behaviour. Patient outbursts often stem from staff not meeting requirements, compounded by language barriers and patient illiteracy hindering communication about triage and treatment priorities. Junior residents' concerns about insufficient support from seniors underscore the importance of role modeling in professionalism, as emphasized by previous research highlighting the impact of role modeling on empathy and professional behaviour [ 38 ].

Distinctive stresses associated with this specialty

The study acknowledges existing literature linking high-pressure specialties like surgery and Obs and Gynae with violent behaviours due to unique stresses [ 14 ]. Gynae residents, consultants, and even patients and their families described the profession as inherently stressful and unpredictable. This study highlights how professional behaviour is influenced by the stress of managing the lives of both mother and baby. Additionally, factors such as a high influx of non-booked patients, complicated referrals, unrealistic patient expectations, limited resources, non-cooperative attendants, and unmet human needs contribute to the already stressful environment in our healthcare setup.

Cultural differences and their importance

In developed countries, the healthcare system provides chaperones to assist healthcare experts in communicating vital information to patients and attendants. However, in Pakistan, such a system is absent, making it difficult to expect residents to understand various regional languages like Pashtoo and Gilgiti. This language barrier can exacerbate feelings of exclusion among patients and attendants, leading to conflicts with residents. This finding underscores the complexity of professionalism as a social construct, emphasizing the need to consider context, geographic location, and culture when addressing lapses in professional behaviour [ 40 ].

Why it is important to consider patients characteristics

This study delves into the specific characteristics of patients and attendants, extracted from interviews and unique to this contextual study. Their educational, economic, and cultural backgrounds vary significantly, posing challenges for residents in their interactions. Patients typically have limited education and come from low socioeconomic backgrounds, with predetermined expectations and a sense of entitlement to care due to taxes paid. Accompanied by numerous attendants, they often hold fixed views about doctors' duties. This perception, evident in PCP complaints, contributes to conflicts with doctors, exacerbated by varying tolerance levels. Notably, literature lacks data on patients' perspectives regarding residents' professional behaviour. Remarkably, patients and families do not attribute lapses in professional behaviour to organizational/administrative issues but instead fault residents for perceived deficiencies in hospital facilities and medication availability, likely due to a lack of awareness about administrative roles—a finding specific to impoverished patients in public sector hospitals.

The patient holds a central role in the healthcare system and is a significant stakeholder whose perception of lapses in professional behaviour is explored in this study. This encompasses actions such as imposing additional financial burdens (e.g., recommending costly tests, requiring the purchase of operation accessories) and unnecessarily prolonging hospital stays. Particularly poignant is a patient's observation regarding class-based social discrimination among patients, where "the rich were preferred over the poor," highlighting disparities in access to facilities and guidance for attendants.

Role of organisational & administrative support

Organizational and administrative authorities are pivotal in providing effective hospital facilities, a theme emphasized by residents and consultants in this study. Issues such as limited infrastructure, uncooperative senior behaviour, absence of casual leaves, and inadequate salary packages relative to workload are identified as factors negatively influencing professional behaviour. This underscores the insufficient support provided by the administration, training systems, and external factors, which are perceived as more influential than personal factors. These findings align with other studies that highlight deficiencies in training hospital systems as contributing to lapses in professional conduct among residents [ 41 ]. Additionally, organizational deficits, such as inadequate facilities and poor security, along with a gap between administration and clinical departments, are identified as sources of conflicts [ 20 ]. Overall, these results support the notion that professionalism is situation-sensitive, and the training environment may contribute to the deprofessionalization of residents, as observed in literature [ 42 , 43 , 44 ].

Uniqueness and importance of this study

To the best of our knowledge, this study represents a pioneering effort in thoroughly evaluating the perspectives of patients, consultants, and residents regarding lapses in professional behaviour among Gynae residents in teaching hospitals in Pakistan. Existing literature underscores the significance of complaints in uncovering underlying issues and guiding solutions. Studies by Rogers et al. and Hoffmann et al. have highlighted the prevalence of complaints related to medical professional behaviour in various contexts [ 45 ]. Our research complements these studies by providing deeper insights from multiple perspectives. While professionalism is influenced by environmental and personal factors, literature lacks sufficient data on patients' expectations of doctors. Our study fills this gap by exploring Pakistani patients' perspectives on the factors contributing to lapses in professional behaviour among residents, thereby enriching understanding in this area. Additionally, our study integrates document analysis with interview data to provide a comprehensive analysis.

Contribution of the study

The paradigm shift in understanding professionalism lapses highlights the increasing importance of incorporating patients' perspectives. Our research offers valuable insights from key stakeholders, which can serve as a benchmark for addressing identified issues in healthcare. It emphasizes the need for training residents in professionalism, with educators leveraging the findings of patient complaints to inform their approach.

Traditionally, resident misbehaviour has been attributed to character flaws [ 46 , 47 ] but our study reframes this interpretation within the context of training systems and environments. This nuanced approach enables a deeper understanding of the phenomenon and opens avenues for incident prevention through educational and organizational interventions. While some findings may not be universally applicable, our approach to addressing trainee professional lapses holds implications for diverse educational settings.

The findings of our study disclose several perceptions as a possible influential cause of unprofessional behaviour of residents. Excessive workload, workplace challenges is the residents' most frequently mentioned contributing factors. Another interesting finding of this research is an emerging theme related to the characteristics of patients and attendants which has been attributed by both consultant and resident. These characteristics can be considered useful in understand the causes and implications of conflicting environment. Opinion from administration or higher authorities regarding issues faced by residents and patients offer insight for future work.

Implication for educational practice

This section highlights key lessons learned from the comprehensive interview datasets involving three stakeholders, accompanied by recommendations derived from the research.

Balancing professional commitments with family responsibilities is crucial, as it varies among individuals and can significantly impact professional behaviour.

Management's attention to residents' well-being is paramount, as an unsupportive working environment can negatively affect professional conduct.

Implementing a mentoring scheme for junior members, allowing them to shadow seniors, can enhance their ability to handle complex situations effectively.

Providing trained paramedical staff to assist residents can alleviate their workload, allowing them to focus on critical tasks and improve patient care.

Ensuring supportive working conditions, including physical environment and workload management, can enhance resident well-being and positively influence professional behaviour.

Recognizing the unique challenges of the Gynae specialty is essential for developing policies that support stakeholders in this field.

The specific characteristics of patients and families identified in this study underscore the need for further exploration of their beliefs, understanding, and expectations to address diverse cultural and social needs.

Addressing the specific needs of all stakeholders, including privacy, language comprehension, socio-economic factors, and personal well-being, can foster a harmonious environment and mitigate conflicts.

Strengths and methodological challenges

Major limitation rather challenge of my study was the difficulty in understanding the construct by patients and family. Although all are matriculation by education but they unable to comprehend that there are always some factors behind the some behaviour. It might be a reason of less rich data as compared to consultants and residents. Another limitation might be some element of social desirability bias in patients because we collected data from admitted patients. Although researchers were unbiased but there might be some fear that telling the truth might affect their treatment procedures or behaviour of resident in charge of their ward. Only 2 public sector hospitals were targeted which restrict the scope of the study. Moreover, almost all the participants were female except for 1 male resident (subject to availability) pose g ender-related limitation.

Implications for further research

The research on professionalism in healthcare departments in Pakistan has been limited, leaving several aspects unexplored regarding the reasons behind poor behaviour exhibited by both doctors and patients. A multicenter study involving Gynae departments across various public and private sectors in different cities of Pakistan would provide a more comprehensive understanding of the prevalence, risk factors, significance, and consequences of lapses in professional behaviour.

Future research should also consider including perspectives from paramedical staff, hospital administration, and senior consultants within the Gynae unit to gain a holistic view of the issue.

Given the limited presence of male residents in Gynae obstetrics training, reaching out to them for their perspectives and comparing them with female residents could provide valuable insights.

Additionally, further research focused on remedying the issues identified in this study would be beneficial for the medical education community in addressing professional behaviour concerns effectively.

Availability of data and materials

All datasets used and/or analysed during current study available from corresponding author on reasonable request.

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Acknowledgements

The authors would like to thank the participants for their involvement and time spent in the study. Special thanks to Dr Faiza Samreen for providing continuous support and guidance throughout the study. Authors would like to acknowledge the Professor Dr Luna Ejaz Kahloon (Dean of Department of Obs/Gynae Rawalpindi Medical University), and Dr Usman Hamdani (Global Institute of Human Development ) Zille e Huma, Ayella Gillani , Aabsha Tasawar, Bushra Mahjabeen, Ambreen Sadaf , MahNoor Urosa Safdar for their feedback and guidance.

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I Dr Humera Noreen as main author design the work, wrote the main Manuscript and prepared figures. Prof Dr Rahila Yasmeen and Dr Shabana Ali helped in interpretation and analysis of data. we all reviewed the manuscript.

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Noreen, H., Yasmeen, R. & Mohammad, S.A. Factors leading to lapses in professional behaviour of Gynae residents in Pakistan: a study reflecting through the lenses of patients and family, consultants and residents. BMC Med Educ 24 , 611 (2024). https://doi.org/10.1186/s12909-024-05509-9

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The OVAREX study: Establishment of ex vivo ovarian cancer models to validate innovative therapies and to identify predictive biomarkers

  • Lucie Thorel 1 , 2 ,
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Ovarian cancer is the first cause of death from gynecological malignancies mainly due to development of chemoresistance. Despite the emergence of PARP inhibitors, which have revolutionized the therapeutic management of some of these ovarian cancers, the 5-year overall survival rate remains around 45%. Therefore, it is crucial to develop new therapeutic strategies, to identify predictive biomarkers and to predict the response to treatments. In this context, functional assays based on patient-derived tumor models could constitute helpful and relevant tools for identifying efficient therapies or to guide clinical decision making.

The OVAREX study is a single-center non-interventional study which aims at investigating the feasibility of establishing in vivo and ex vivo models and testing ex vivo models to predict clinical response of ovarian cancer patients. Patient-Derived Xenografts (PDX) will be established from tumor fragments engrafted subcutaneously into immunocompromised mice. Explants will be generated by slicing tumor tissues and Ascites-Derived Spheroids (ADS) will be isolated following filtration of ascites. Patient-derived tumor organoids (PDTO) will be established after dissociation of tumor tissues or ADS, cell embedding into extracellular matrix and culture in specific medium. Molecular and histological characterizations will be performed to compare tumor of origin and paired models. Response of ex vivo tumor-derived models to conventional chemotherapy and PARP inhibitors will be assessed and compared to results of companion diagnostic test and/or to the patient’s response to evaluate their predictive value.

This clinical study aims at generating PDX and ex vivo models (PDTO, ADS, and explants) from tumors or ascites of ovarian cancer patients who will undergo surgical procedure or paracentesis. We aim at demonstrating the predictive value of ex vivo models for their potential use in routine clinical practice as part of precision medicine, as well as establishing a collection of relevant ovarian cancer models that will be useful for the evaluation of future innovative therapies.

Trial registration

The clinical trial has been validated by local research ethic committee on January 25th 2019 and registered at ClinicalTrials.gov with the identifier NCT03831230 on January 28th 2019, last amendment v4 accepted on July 18, 2023.

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Ovarian cancer: epidemiology and therapeutic management

Ovarian cancers are responsible for over 207.000 deaths worldwide in 2022, and in 80% of epithelial ovarian carcinoma cases the diagnosis is made at an advanced stage (FIGO III/IV), making it the first cause of death from gynecological malignancies [ 1 , 2 ]. Optimal surgery and platinum-based chemotherapy are the basis of the treatment of epithelial ovarian cancers. The treatment timeline will be based on the stage, resectability of the carcinomatosis, histological type and comorbidities of the patients. Even if first-line carboplatine/paclitaxel combination achieves response rates close to 80%, among patients whose tumors were initially sensitive to treatment, 75% relapse within 18 months, eventually developing chemoresistance [ 3 ]. The introduction of new treatments and the evolution of protocols over the last thirty years have only marginally improved overall survival, which remains around 45% at 5 years [ 4 ]. In ovarian cancers, innovative treatments are struggling to become established, and the only recognized and used prognostic factors (i.e. impacting management modalities) are stage of dissemination, residual tumor mass after excision, histology and the homologous recombination (RH) status. The development of new therapeutic strategies likely to overcome chemoresistance therefore remains a major challenge.

Over the years, targeted therapies such as antiangiogenic treatments and PARP inhibitors (PARPi) have been developed first as a treatment for recurrences before being recommended in first line, thanks to their effectiveness. Anti-angiogenic therapies (bevacizumab) have found their place in the management of these cancers with a real benefit in terms of quality of life, but very modest in terms of overall survival [ 5 , 6 ]. However, it still showed greater effectiveness in at-risk groups (inoperable stage III, unable to be debulked to < 1 cm maximum disease, and stage IV disease) [ 5 , 7 ]. In the other hand, PARPi have revolutionized the therapeutic management of epithelial ovarian cancers (EOC) [ 8 ]. All the different trials showed a significant improvement of progression-free survival in patients with EOC, in first-line and second-line or later maintenance therapy. However, PARPi provided the greatest clinical benefit in patient tumor carrying BRCA1/BRCA2 mutation or exhibiting homologous recombination deficiency (HRD). Indeed, PARP enzymes play a role in DNA repair and their inhibition leads to an accumulation of single and then double-strand breaks that will cause synthetic lethality in an HRD context. Although there is no companion test for carboplatin or bevacizumab, some have been developed for PARPi such as Myriad test or GIScar based on the HRD signature [ 9 , 10 ]. The development of a companion test is a key step in the development of new therapies to enable personalized medicine: having a suitable treatment for presumed sensitive tumors and avoiding unnecessary and potentially toxic treatment for patients. Functional tests could therefore be used to improve HR status profiling and accurately identify HRD tumors, as well as enabling the implementation of companion tests for other treatments [ 11 ].

Predictive functional assays

Functional precision medicine is a strategy whereby live tumor cells from patients are directly exposed to drugs to provide translatable, personalized information to guide therapy [ 12 ]. This approach generates dynamic, functional data that may highlight key vulnerabilities not necessarily driven by genomic alterations. Predictive functional assays rely on the ex vivo (or in vivo) modelling of a patient tumor from pathologically-qualified samples obtained during a medical procedure such as diagnosis biopsy, primary tumor or metastasis resection, blood containing circulating tumor, ascites, etc… Tumor samples are generally processed to primary cultures retaining the original features of the tumor cells of the patient and exposed to treatments of interest. This allows to determine their functional profile (sensitivity/resistance to treatment, ability to repair DNA, mitochondrial apoptotic priming, etc…) using different methods (viability/cytotoxicity assays, real-time imaging, histology/immunohistochemistry, BH3 profiling…). This profile can be used afterwards for predictive purposes and thus guide clinical decision making [ 12 ]. Such predictive functional assay can be performed on various biological materials and tumor models as detailed thereafter.

Tumor models

Developing functional precision medicine requires advanced experimental models to properly predict the behavior of a complex system such as cancer. In the past decades, much progress has been made in developing representative cancer models using in vitro, ex vivo and in vivo approaches that mirror cancer pathogenesis, tumor heterogeneity and angiogenesis [ 13 ]. Among others, they include ex vivo models such as patient-derived tumor organoids (PDTO) [ 14 ], spheroids from ascites [ 15 ] and tissue slices [ 16 , 17 , 18 ] or in vivo models such as patient-derived xenograft (PDX) models [ 19 ].

PDX models are established by transplanting human tumors into immune-deficient mice and then maintained by passaging from mouse to mouse. These models retain accurately the genetic, histological, and molecular characteristics of the original tumor and their response to treatments is correlated with clinical response [ 20 ]. However, they have some limitations, such as a low success rate of establishment for some tumor types, the long time required for the establishment, the time-consuming and costly process of their use, as well as the ethical issues associated to animal experimentation [ 21 ]. They offer therefore a suitable tumor model for testing innovative therapies but the above-mentioned limitations could restrict the use of these models for predictive purposes. However, their predictive value is currently tested in some clinical trials, as well as ex vivo models [ 12 ].

Among the ex vivo approaches, the technique of explants (or tumor slices) derives from the originally described technique of floating brain sections [ 22 ]. This model is obtained by cutting fresh tumor samples into slices 250 to 350 μm thick using a vibratome, and cultured ex vivo at 37 °C. The use of tumor slices maintains tumor-stroma interactions while preserving a tissue architecture that mimics the reality of the tumor in the short term. Despite a lack of reproducibility due to tumor heterogeneity, a study demonstrated the value of this model for predicting patient’s response to different anticancer agents [ 17 ] or for identifying predictive signature [ 16 ].

Ascites-derived spheroids (ADS) could offer as well a promising cancer model to guide clinical decision making. Ascites is most frequently associated with ovarian, pancreatic, colorectal, liver cancers, and provides a unique opportunity to easily sample tumor cells from these cancer patients. In the ascites, tumor cells shed from the primary tumor or visceral and parietal peritoneal carcinosis, forming free-floating spheroids [ 23 ]. These spheroids are poorly described and their predictive value has not been investigated so far. These samples can be used to perform ex vivo assays to assess their sensitivity to treatments [ 24 ] and therefore represent a particularly interesting alternative to explants, since the cells are abundant and can be collected at various time during the therapeutic management.

Finally, patient-derived tumor organoids (PDTO) have emerged more recently, as preclinical models that have the potential to predict an individual patient’s response to treatment. They are developed from patient tumor cells following embedding in basement membrane matrix and cultured in a medium supplemented with a cocktail of growth factors and inhibitors of signaling pathways to recapitulate in vivo niche conditions and allow long term growth [ 14 ]. These models are able to closely reproduce the genetic and morphological heterogeneous composition of the cancer cells in the original tumor. They can be rapidly grown from small amount of tumor cells, such as needle biopsy, with a high success rate compared to other models [ 14 ]. More importantly, despite the lack of stromal cells, there are more and more evidence that PDTO can recapitulate clinical response of patients [ 25 , 26 ], including ovarian cancer patients, although most of the studies were based on small sample size.

Therefore, it is crucial to develop relevant patient-derived tumor models (PDX, PDTO, explants and ADS) to evaluate new therapeutic strategies, identify predictive molecular signatures and to determine predictive value of ex vivo models in clinical studies based on larger patient cohorts. In this regard, our study will evaluate the feasibility of establishing these models and performing functional assay for drug testing and to compare their response to treatments to the clinical response of ovarian cancer patients.

Method/Design

The OVAREX study is a single-center non-interventional study conducted at Comprehensive Cancer Centre François Baclesse (Caen, France) to investigate the feasibility of establishing and testing ex-vivo tumor models from ovarian cancer to predict clinical response of the patient (Fig.  1 ).

figure 1

OVAREX study design (created with Biorender.com)

Study objectives and endpoints

The main objective of the study is to assess the feasibility of developing ex-vivo tumor models that can be used for functional predictive assays.

The secondary objectives are to: (i) evaluate the effectiveness of ex vivo functional assays to predict the response to treatment; (ii) identify predictive biomarkers in tumor and serum samples; (iii) compare the ex vivo response of tumor models to clinical response; (iv) establish PDX models from ovarian cancer samples; (v) develop co-cultures of PDTO with autologous immune cells allowing the evaluation of anticancer effects of immunotherapy.

Study population

Eligibility criteria are described in Table  1 . The OVAREX study focuses on patients with proven cancer of the ovary, fallopian tube, and peritoneum, all FIGO stages (I-IV) who undergo laparoscopic or laparotomy surgery at our institution.

Study assessment

The study was approved by the “East III” ethical committee (IDRCB: 2018-A02152-53). Clinicians will inform all patients enrolled in the study that their biological samples could be used for this study (specific information letter will be given to patients) and they will express their non-opposition. Moreover, we will obtain written informed consent from patients for the use of their biological samples for research purposes.

Medical data collection

In order to correlate the biological data obtained on the initial tumor with the response to ex vivo treatments and the response observed in the clinic, the patients’ clinical data will be routinely collected from medical records by the Calvados Cancer Registry, which also checks for data completeness and consistency, and will be transmitted for enrolled patients. The collected data are summarized in Table  2 .

This collection will be carried out from an already existing database which has been the subject of a prior declaration to the establishment’s French data protection authority (CNIL) representative. Indeed, a collection of samples annotated in terms of clinico-pathological parameters has been set up at the Centre François Baclesse in order to allow a correlation between the profile sensitivity to chemotherapy (conventional or innovative) and the parameters studied. The OVAREX project will therefore use pseudonymized data collected by our biological resource center for studies correlation between results obtained ex vivo and clinical data. The samples and associated data will be retrospectively collected at the Centre François Baclesse and stored in the Biological Resource Center (BRC) OvaRessources (NF-S 96,900 quality management, AFNOR No. 2016: 72860.5). All biological collections are declared to the MESR (Ministry of Education, Health and Research, France, No. DC-2010-1243).

Collection of tumor and blood samples

A laparoscopic surgery will be performed as part of the patient’s care and tumor sample will be collected for anatomopathological diagnosis. Tumor sample which is excess to diagnostic purposes will be sent directly to the laboratory in sterile vials filled with cold culture medium supplemented with a Rho-kinase inhibitor (Y-27632).

As ascites can also be punctured during the surgery or outpatient hospitalization, excess fluid unneeded for anatomopathological evaluation will be collected in sterile jars and transferred to the laboratory.

Blood sampling will be realized before surgical intervention as part of the blood test included in the patient’s care. No blood draw will be done specifically for this study. Two dry tubes of 5 mL and 7 EDTA tubes of 5 mL will be collected and processed at the laboratory for serum analysis and peripheral blood mononuclear cells (PBMC) isolation.

Biological sample processing

Tumor sample processing.

Different procedures will be carried out on tumor samples: for future characterization, two pieces will be snap frozen and stored at -80 °C for molecular analyses and one piece will be fixed in paraformaldehyde for paraffin embedding and subsequent histopathological analysis and immunohistochemistry. The rest of the tumor will be processed to establish different models as described hereafter. All tumor samples will be stored in the BRC ‘OvaRessources’. Histology of all samples will be confirmed by a certified pathologist.

Isolation of PBMC

PBMC will be isolated from blood by density gradient centrifugation using Ficoll-Paque in Leucosep tubes. Cells will be resuspended in cold culture media, and counted. PBMC will be then resuspended in freezing solution (10% DMSO, 90% FBS), aliquoted (about 5 cryovials, 4.10 6 cells/cryovial), and frozen with gradually decreasing temperatures (1 °C/min) to -80 °C before long-term storage at liquid nitrogen temperatures and stored in the BRC TCBN.

Establishment and culture of PDTO, PDX, explants and ADS

Pdto establishment.

Tumor samples and ascites will be processed as previously described [ 27 ]. Briefly, samples are mechanically and/or enzymatically dissociated to obtain single cells or small cell clusters. Cells will then be embedded in extracellular matrix BME2 and cultured in an enriched medium [Advanced DMEM (Gibco) supplemented with 100 UI/mL of penicillin and streptomycin (Gibco), 1% GlutaMAX (Gibco), 1X B27 (Gibco), 10 mM Nicotinamide (Sigma-Aldrich), 1.25 mM N-Acetyl-L-Cysteine (Sigma-Aldrich), 50 µg/mL Primocin (InvivoGen), 5 µM Y27632 (Interchim), 20 ng/mL FGF-10 (PeproTech), 500 nM A-83–01 (PeproTech), 50 ng/mL EGF (PeproTech), 1 ng/ml FGF-basic (PeproTech), 1 µM SB202190 (PeproTech), 1 µM PGE2 (Sigma-Aldrich), 10% RSPO1- conditioned media (Cultrex HA-R-Spondin1-Fc 293 T, Amsbio) and 50% L-WRN- conditioned media (Cultrex L-WRN, Amsbio)]. Culture medium will be changed every 3–4 days and PDTO passaged every 2–4 week in order to expand them. PDTO lines will be considered as established when they will be cultured for more than 3 passages. For each established PDTO line, samples will be kept frozen for DNA/RNA/protein analysis, others will be embedded in paraffin for histopathological analysis and dissociated cells will be biobanked at -150 °C.

PDX establishment

Immediately following patient’s surgery, tumor fragments will be subcutaneously engrafted into the scapular area of anaesthetized nude mice as previously described [ 26 ]. Tumor growth will be measured twice a week and serial fragment grafts of each tumor will be conducted on 3 to 5 athymic nude mice. When the tumors reach a volume of 800 to 1000 mm 3 , tumors will be harvested, one fragment will be fixed for paraffin embedding and histopathological/immunochemistry analyses, two pieces will be snap frozen and stored at -150 °C for DNA/RNA extractions and three pieces will be used for passage, residual fragments will be frozen in 10% (v/v) dimethylsulfoxid (DMSO) and 90% (v/v) fetal bovine serum (FBS).

As described by Lheureux et al. [ 16 ], vibratome-sliced nodes (300–400 μm) will be fixed with 3% paraformaldehyde, frozen at -80 °C for immunoblotting or transferred into sterile prewarmed complete culture medium (RPMI 1640 supplemented with 2 mM GlutamaxTM, 25 mM HEPES, 10% fetal calf serum, 33 mM sodium bicarbonate (Fisher Scientific Bioblock, Illkirch, France) and 1% antibiotic).

ADS culture

Following patient paracentesis, ascites will be centrifugated at 1300 g for 7 min, the supernatant will then be filtered using a 300 μm and a 50 μm sieves to retrieve the spheroids contained in ascites. Spheroids will be fixed in 3% PFA, frozen at -80 °C, biobanked at -150 °C or cultured in agarose-coated plate with the ascites supernatant obtained after filtration.

Coculture of PDTO with immune cells

PDTO specific autologous T cells will be induced according to modified version of the protocol described in Dijkstra et al. [ 28 ]. Briefly, PBMC will be activated with the corresponding PDTO lysate and specific T cells clones will be isolated based on their expression of CD154 and CD137 markers using flow cytometry sorting. Once isolated and their purity controlled, specific T cells will be amplified by the use of a stimulation matrix and then cryopreserved. A quality control will be performed before cryopreservation by flow cytometry to check for reactivity against PDTO using CD107a expression and cytokines production after antigen re-stimulation. Once produced and checked for antigen specificity, PDTO-specific T cells will be cocultured with PDTO to produce iPDTO for the evaluation of response to immunotherapy.

Evaluation of the response of tumor-derived models to treatment

Pdto treatment.

When PDTO reached the size of 75–150 μm in diameter, they will be collected and resuspended in PDTO treatment medium (PDTO culture medium lacking primocin, Y-27,632 and N-acetylcysteine) with 2% BME2. 200 PDTO per well will be seeded in 100 µL volume in a previously coated (1:1 PDTO treatment medium/BME2) white clear bottom 96-well plates (Greiner). Drug solutions will then be prepared in a 2% BME2/PDTO treatment medium, added to each well and plates will be transferred to a humidified 37 °C/5% CO2 incubator. During the treatment, PDTO will be monitored using IncuCyte S3 ZOOM (Sartorius). One week later, ATP levels will be measured by CellTiter-Glo 3D assay (Promega) and luminescence will be quantified using GloMax Discover Microplate Reader (Promega). The half-maximal inhibitory concentration (IC50) and the area under the dose-response curve (AUC) will be computed for each PDTO model.

PDX treatment

PDX fragments will be subcutaneously implanted into nude mice as described above. On the first day of treatment, the animals bearing 100 to 200 mm 3 tumors will be randomly distributed to the various treatment and control groups (8–10 mice per group). Drugs will be administered intraperitoneally. Mice will be weighed and tumor volumes will be determined once or twice weekly from two-dimensional caliper measurements using the equation: Tumor volume (mm 3 ) = [length (mm) x width (mm) 2 ]/2. After 28 days of treatment, the mice will be euthanized and the tumors will be harvested for analysis. These experiments will be performed under guidelines from the European Community Council (2010/63/EU) and are approved by the protocol APAFIS #9577 validated by the French ethics committee “Comité d’éthique de Normandie en matière d’expérimentation animale” (CENOMEXA).

Explants treatment

After the transfer into sterile prewarmed complete culture medium, slices will be treated in complete medium for 6 to 48 h in a 5% CO2 humidified atmosphere at 37 °C. Slices will then be fixed in PFA 3% and paraffin-embedded for further analyses including the immunohistochemical detection of cleaved caspase-3 in order to quantify apoptosis.

ADS treatment

Directly after filtration and spheroids seeding in agarose-coated plates, the spheroid will be exposed to treatments for 6 to 96 h. As for PDTO, ADS will be monitored using IncuCyte S3 ZOOM (Sartorius) and viability will be assessed using CellTiter-Glo 3D assay (Promega).

Evaluation of PDTO model relevance and identification of potential predictive biomarkers

Transcriptomic analysis.

RNA analysis will be performed according to the protocol described in Perréard et al. [ 29 ]. Briefly, total RNA will be extracted using the Nucleospin RNA kit (Macherey Nagel, Hoerdt) and libraries will be made with the QuantSeq 3’RNA Library Kit. Once produced, the final library will be purified and deposed on High sensitivity DNA chip to be controlled on Agilent bioanalyzer 2100 and sequenced on NovaSeq 6000 (Illumina). Elimination of poor-quality regions and poly(A) of reads will be done through the use of the fastp program. Read alignments will be performed using the program STAR with the human genome reference (GRCh38) and the Ensembl reference gene annotations. Reads counts will be obtained using FeatureCount and statistical analysis will be realized with the R/bioconductor package DESeq2.

Copy number variation (CNV) analysis by low-pass whole genome sequencing (WGS)

WGS will be performed using Illumina DNA PCR Free prep kit, starting with 500ng of DNA. Data will be analyzed with HMMcopy and ichorCNA.

Transcriptome and CNV analysis

Analysis of intra reproducibility and differences between original tumors or ascites and PDTO will be assessed by principal component analysis and unsupervised hierarchical clustering as described in Perréard et al. [ 29 ].

Panel BRCAness

In order to assess tumors’ homologous recombination (HR) status, tumors will be sequenced with a 127-genes panel including 15 h genes ( BRCA1, BRCA2, ATM, BARD1, BRIP1, CDK12, CHEK1, CHEK2, FANCL, PALB2, PPP2R2A, RAD51B, RAD51C, RAD51D, RAD54L ). The sequencing data will be also used to determine a genomic instability score (GIS) as described by Leman et al. [ 10 ].

Statistical consideration

Sample size determination.

To estimate the PDTO establishment rate, assumed around 90%, with a 95% confidence interval of 10% width, 141 tumor samples will be required. Anticipating non-assessable samples, it is planned to include 250 patients.

Statistical analyses

Qualitative variables will be described using the sample numbers and percentages. Quantitative variables will be described using the mean (+/- standard deviation) or the median and the range if normality hypothesis is not verified. The significative threshold is set to 5% for all statistical analysis and confidence interval.

To address the primary objective, the rate of successful PDTO establishment, i.e., the rate of tumor samples usable for predictive functional assays based on PDTO, will be estimated with its 95% confidence interval. Then, association between PDTO response to treatment and clinical response will be measured by the Chi2 test. Associations between biological parameters and clinical response will be assessed by one-way analysis of variance (or the non-parametric Kruskal-Wallis test, if necessary). Receiver Operating Characteristic (ROC) curves and a logistic regression model will also be used to identify predictive factors of clinical response. Survival curves will be estimated by using the Kaplan-Meier method; median survival and survival rates at different times will be provided with their confidence intervals.

Current approaches to precision oncology are mainly based on the detection of genomic alterations. Unfortunately, many patients still do not benefit from these approaches despite the presence of an actionable alteration [ 12 ]. The use of personalized tumor models, such as PDX, PDTO, spheroids or explants, is rapidly emerging as a strategy to complement the use of genomics. These models could be used for drug testing as part of a predictive functional assay to guide clinical decision making, as well as to test innovative therapeutic strategies and identify predictive biomarkers. Interestingly, responses of some ex vivo models to treatments have been positively correlated to patient responses [ 17 , 25 ], including ovarian cancer patients [ 30 ]. However, these studies were based on small sample size and it is therefore crucial to determine if the response of these different personalized models to treatments recapitulate clinical response on large patient cohorts.

In this clinical study, we propose to establish PDX and ex vivo models (PDTO, ascites-derived spheroids, and explants) from tumors or ascites of ovarian cancer patients who will undergo surgical procedure or paracentesis. We aim at demonstrating the predictive value of the ex vivo models for their potential use in routine clinical practice as part of precision medicine. In the meantime, we want to establish tumor model collection of PDTO and PDX for new therapeutic compounds/strategies testing as well as for the identification of predictive biomarkers. Special attention will be given to immunotherapy testing using co-culture of PDTO with immune cells. This study will allow the establishment of a collection of relevant ovarian cancer models of various histology including rare ovarian cancer types and could demonstrate the interest of ex vivo models to predict the response to treatments or to identify innovative therapeutic strategies. In the event that one (or several) model(s) could faithfully predict patient response in a clinical-adapted manner (high success rate of establishment, results available within clinically relevant time frames, etc.), a prospective randomized clinical trial could be designed. The implementation of such predictive functional assay could thus allow individualizing cancer care and enabling physicians to select the most effective treatment for their patients.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Ascites-Derived Spheroids

Area Under the Curve

Basement Membrane Extract

Biological Resource Center

Breast Cancer

Copy Number Variations

Dulbecco’s Modifed Eagle Medium

DeoxyriboNucleic Acid

EthyleneDiamineTetraacetic Acid

Epidermal Growth Factor

Epithelial Ovarian Cancer

Fetal Bovine Serum

Fibroblast Growth Factor

Federation of Gynecology and Obstetrics

Homologous Recombination Deficiency

Half maximal inhibitory concentration

ImmunoHisto Chemistry

Next-Generation Sequencing

Poly (ADP-Ribose) Polymerase Inhibitor

Peripheral Blood Mononuclear Cells

Patient-Derived Tumor Organoid

Patient-Derived Xenograft

ParaFormAldehyde

RiboNucleic Acid

Receiver Operating Characteristic

Whole Genome Sequencing

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Acknowledgements

The ORGAPRED core facility ‘Tumor organoids for research and predicting response to treatment’ is supported by the Normandy County Council, the European Union within the framework of the Operational Programme ERDF/ESF 2014–2020 and the French state which was conducted as part of the planning contract 2015–2020 between the State and the Lower Normandie Region (ORGAPRED, POLARIS and EquipInnovCaen2022-PLATONUS ONE projects). We thank the donors, the Lions clubs of Normandy, Vaincrabe and the other foundations for their support of the projects carried out by our teams on PDTO. We are grateful to Inserm, University of Caen Normandy and the Comprehensive Cancer Center François Baclesse for their support in the implementation of these activities.

This work is supported by Cancéropôle Nord-Ouest (“ORGRAFT” project), Ligue contre le Cancer (Calvados’s commitee), Fondation de l’Avenir (#AP-RM-19-020), the “Fondation ARC pour la recherche sur le cancer” (#PJA20191209649). “ORGATHEREX” project is co-funded by the Normandy County Council, the European Union within the framework of the Operational Programme ERDF/ESF 2014–2020 which was conducted as part of the planning contract 2015–2020 between the French State and the Normandy Region. The funders had no participation in study design, data management, or publication management.

Author information

Laurent Poulain and Enora Dolivet contributed equally to this work.

Authors and Affiliations

INSERM U1086 ANTICIPE (Interdisciplinary Research Unit for Cancers Prevention and Treatment), BioTICLA Laboratory (Precision Medicine for Ovarian Cancers), Université de Caen Normandie, Caen, France

Lucie Thorel, Jordane Divoux, Guillaume Babin, Pierre-Marie Morice, Romane Florent, Chloé Marde Alagama, Mélanie Briand, Christophe Denoyelle, Nicolas Vigneron, Cécile Blanc-Fournier, Matthieu Meryet-Figuiere, Louis-Bastien Weiswald, Laurent Poulain & Enora Dolivet

Comprehensive Cancer Center François Baclesse, UNICANCER, Caen, France

Lucie Thorel, Jordane Divoux, Pierre-Marie Morice, Romane Florent, Guillaume Desmartin, Lucie Lecouflet, Christophe Denoyelle, Nicolas Vigneron, Matthieu Meryet-Figuiere & Louis-Bastien Weiswald

ORGAPRED Core Facility, US PLATON, Université de Caen Normandie, Caen, France

Jordane Divoux, Romane Florent, Guillaume Desmartin, Lucie Lecouflet, Louis-Bastien Weiswald & Laurent Poulain

Clinical Research Department, Comprehensive Cancer Center François Baclesse, UNICANCER, Caen, France

Justine Lequesne, Alexandra Leconte, Bénédicte Clarisse & Florence Joly

Department of Surgery, Comprehensive Cancer Center François Baclesse, UNICANCER, Caen, France

Guillaume Babin, Roman Rouzier, Léopold Gaichies, Sandrine Martin-Françoise, Jean-François Le Brun & Enora Dolivet

Biological Resource Center ‘OvaRessources’, US PLATON, Université de Caen Normandie, Caen, France

Mélanie Briand, Cécile Blanc-Fournier & Laurent Poulain

Calvados General Tumor Registry, Comprehensive Cancer Center François Baclesse, UNICANCER, Caen, France

Nicolas Vigneron

Department of Pathology, Comprehensive Cancer Center François Baclesse, UNICANCER, Caen, France

Corinne Jeanne & Cécile Blanc-Fournier

Department of Cancer Biology and Genetics, U1245 “Cancer and Brain Genomics”, Comprehensive Cancer Center François Baclesse, UNICANCER, Caen, France

Raphaël Leman & Dominique Vaur

US 41 - UAR 2014 - PLBS, University of Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France

Martin Figeac

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Contributions

L.T., J.D., LB.W., L.P. and E.D. wrote the manuscript. J.D., J.L., G.B., PM.M., A.L., B.C., M.B., C.D., N.V., C.BF., D.V., F.J., LB.W., L.P. and E.D. devised the study concept and design. J.L. was responsible for overseeing the statistical section. L.T., J.D., J.L., G.B., PM.M., R.F., G.D., L.L., C.MA., A.L., B.C., M.B., R.R., L.G., S.MF., JF.LB., C.D., N.V., C.J., C.BF., R.L., D.V., M.F., M.MF., F.J., LB.W., L.P. and E.D. contributed to the study protocol, read and approved the final manuscript. Each author has been sufficiently involved in the work to take public responsibility for appropriate portions of the content. Figures and illustrations were designed and created by L.T., J.D. and LB.W. Funding was obtained by LB.W. and L.P.

Corresponding authors

Correspondence to Louis-Bastien Weiswald , Laurent Poulain or Enora Dolivet .

Ethics declarations

Ethics approval and consent to participate.

This study has received ethical approval from the Comité de Protection des Personnes Est IV (N°EudraCT: 2018-A02152-53) in January 2019 with last amendment (V4) accepted in March 2023. This committee is independent and not related with any affiliation of the authors. Any subsequent will of modification of the protocol would be submitted to agreement of the committee. The clinical trial has been registered at ClinicalTrials.gov with the identifier NCT03831230 on January 28th, 2019. The study will be explained to the patients by the surgeons or the oncologists, who will give them an information file. All patients will consent to be part of the study by giving their informed non-opposition.

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Thorel, L., Divoux, J., Lequesne, J. et al. The OVAREX study: Establishment of ex vivo ovarian cancer models to validate innovative therapies and to identify predictive biomarkers. BMC Cancer 24 , 701 (2024). https://doi.org/10.1186/s12885-024-12429-w

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Published : 07 June 2024

DOI : https://doi.org/10.1186/s12885-024-12429-w

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  • Ovarian cancer
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