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Revitalizing global cultural studies

International Journal of Cultural Studies is a leading venue for scholarship committed to rethinking cultural practices, processes, texts and infrastructures beyond traditional national frameworks and regional biases. Established to revitalize cultural studies against the dangers of parochialism and intellectual ossification, the journal interrogates what culture means, and what culture does, across global and local scales of power and action, diverse technologies and forms of mediation, and multiple dimensions of performance, experience and identity. International Journal of Cultural Studies provides a critical space for theoretical and methodological innovation in global cultural research. __ "From first people's internet to Hong Kong's creative industries, no finer explorers of sweaty nightclubs and cultural policy guide us through the jungles of contemporary culture than the contributors to IJCS " – Sean Cubitt, Goldsmiths, University of London, UK __

" IJCS is the place to be when you want to participate in important academic debates on media and culture; it's the international arena of intellectual exchange you cannot afford to miss" – José van Dijck, University of Amsterdam, The Netherlands __

"Drawing on the very finest work by scholars around the globe, IJCS lives up to its billing as the most international journal in the field of cultural studies" – Michael Curtin, University of California, Santa Barbara, USA __

“ IJCS captures the forefront of advanced critical cultural research, marked by a commitment to transnational inquiry. It is characterized by robust intellectual curiosity, not the usual, dry, and predictable theoretical maneuvers” – John Nguyet Erni, Hong Kong Baptist University, Hong Kong, China __

"The IJCS has remained a valuable, interesting, and engaging journal over its career - never boring, never patronising, always keen to open its pages to the new idea and the new researcher" – Graeme Turner, University of Queensland, Australia

All issues of International Journal of Cultural Studies are available to browse online .

International Journal of Cultural Studies is committed to rethinking cultural practices, processes, texts and infrastructures beyond traditional national frameworks and regional biases. The journal publishes theoretical, empirical and historical analyses that interrogate what culture means, and what culture does, across global and local scales of power and action, diverse technologies and forms of mediation, and multiple dimensions of performance, experience and identity. Dedicated to theoretical and methodological innovation in cultural research, the journal is multidisciplinary in outlook, publishing relevant contributions that integrate approaches from the social sciences, humanities, information sciences and more.

International Journal of Cultural Studies publishes original research articles. The journal gives preference to papers that extend existing theory or generate new theory through interpretive engagement with empirical cases. Papers based on single country case-studies should clearly indicate and develop the broader relevance of their analyses for an international readership. The journal does not publish close readings of single texts; but it does consider critical, contextualised readings that similarly indicate and develop the broader relevance of their analyses to the field.

International Journal of Cultural Studies regularly publishes special issues on urgent questions in the field as well as on specific regions, industries and practices.

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Open Cultural Studies

• Type: Journal
• Language: English
• Publisher: De Gruyter Open Access
• First published: May 18, 2017
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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.

Transforming traditions into academic resources: a study of Chinese scholars in the humanities and social sciences

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• Yanzhen Zhu   ORCID: orcid.org/0000-0003-3530-6942 1 ,
• Yuting Shen   ORCID: orcid.org/0000-0002-2065-3653 2 &
• Rui Yang   ORCID: orcid.org/0000-0002-3211-2870 1  

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The asymmetrical global higher education and knowledge systems ordered by Euro–American hegemony have been increasingly interrogated, especially by scholars in the humanities and social sciences (HSS). With gathering awareness, growing HSS scholars from non-Western backgrounds have called for global intellectual pluriversality. Responding to such a trend, this article sheds new light on the status quo of East Asian and other non-Euro–American intellectual traditions by taking Chinese intellectual traditions as a case. Since the nineteenth century, generations of Chinese intellectuals have strived to transform their intellectual traditions into modern resources. This historical mission has been carried on by contemporary scholars and become even more complex in the current global era. By unpacking the real perceptions and recent experiences of Chinese HSS scholars, this study demonstrates that Chinese intellectual traditions deeply influence today’s knowledge production and have been transformed into three kinds of academic resources: approaches, methodologies/paradigms, and theories. However, the transformation process has never been smooth. Domestically, the great endeavours of Chinese HSS scholars are often impeded by the dominant intellectual extraversion and coercive audit culture; internationally, they feel constrained by epistemic injustice. This article proposes an empirical approach to examining and presenting intellectual traditions in the individual experiences of scholars. It reveals the high complexities of navigating through asymmetrical globalisation to achieve intellectual pluriversality.

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Introduction

The establishment of modern global higher education worldwide has been based on global knowledge asymmetries ordered by Euro–American centrism and hegemony. As learners of Euro–American models and experiences, non-Euro–American agents have been rendered peripheral, facing such challenges as linguistic imperialism (Phillipson, 1992 ), academic dependency (Alatas, 2003 ), epistemic injustice (Fricker, 2007 ), intellectual extraversion (Hountondji, 2006 ), to name but a few. Despite increasing attempts to challenge the determinist centre–periphery pattern (Marginson & Xu, 2023 ), asymmetrical globalisation continues, especially in the humanities and social sciences (HSS) that are deeply entangled with social and cultural contexts (Yang, 2014 ).

Recent reflections on Euro–American domination have burgeoned. With growing awareness of the significance of their traditional resources, more and more non-Western HSS scholars call for intellectual pluriversality (Reiter, 2018 ) to break the Euro–American epistemic dictatorship, better meet their local needs, and provide alternative cultural perspectives on global issues to enrich human wisdom. It is thus important and highly timely to bring more non-Western intellectual traditions into global theorisation. Some HSS scholars from non-Western civilisations have introduced their intellectual traditions into English, such as Africa (Hilliard, 1998 ), Latin America (Kamugisha, 2019 ), and Asia (Squarcini, 2011 ), showing their intellectual traditions surviving colonisation and/or modernisation with deep impact on education and knowledge production. Such studies, however, are overwhelmingly philosophical, historical, or biographical, lacking empirical data on how present-day intellectuals deal with their intellectual traditions.

As China’s role grows, Chinese Footnote 1 intellectual traditions are increasingly highlighted as global epistemic resources, to which HSS scholars have made great efforts and contribution. HSS disciplines in China are established under the umbrella of ‘wenke’, separated from the natural sciences and engineering (NSE) (Liu, 2018 ). Although differences in academic patterns exist within HSS disciplines, HSS research in general is more rooted in Chinese contexts than NSE research and thus faces more challenges in the process of internationalisation. An urgent task for Chinese HSS researchers is ‘to explore how, and under what conditions, China’s indigenous traditions of thought can serve to inspire and structure more generally applicable social and political theory’ (Yang, 2023 , p. 13). This qualitative study explores how Mainland Chinese HSS scholars have transformed intellectual traditions in today’s contexts within China and globally. We argue that while Chinese intellectual traditions can be transformed into crucial academic resources, China’s HSS scholars face domestic and international complexities in knowledge production.

Based on the case of China, we argue empirically for approaches to contextualise different intellectual traditions in the actions, perceptions, and even struggles of East Asian scholars. Although sharing similar cultural heritage and modern history, each East Asian society has its unique intellectual pattern (see more in the next section). Taking Confucian tradition as an instance, it has been interacting with Buddhism and Shinto traditions in Japan, mixed with Taoism in Taiwan, and developed another Neo-Confucian branch in Korea (Shin, 2013 ). These traditions have been transformed throughout modernisation, constitute the ‘twisted roots’ (Altbach, 1989 ) of higher education, and influence today’s HSS researchers in each East Asian society (Takayama, 2022 ). By illustrating the current state of Chinese intellectual traditions in HSS research, this study paves the way for comparisons across East Asian traditions to identify similarities and differences. Doing so could contribute to the individual perspective of scholars to fostering an inter-referencing East Asian academic community (Chen, 2010 ) and global intellectual pluriversality.

Theoretical and historical background

Although lacking a wide consensus, there have been continuing debates around the issue of knowledge production in non-Western societies from various perspectives. However, little attention has been paid to the role of intellectual traditions in tackling this issue, which is essential for understanding the past and the present of non-Western scholarships.

For most non-Western societies, globalisation is a programme of colonialisation and/or Westernisation that has been inextricably intertwined with modernisation (Mignolo, 2011 ). Many researchers have analysed the disadvantaged academic/epistemic position of non-Western societies in the world through various geospatial routes. Southern theory (Connell, 2007 ) and centre-periphery model (Altbach, 2009 ) picture the global space according to the asymmetrical knowledge distribution, laying theoretical foundations for empirical explorations (Marginson & Xu, 2023 ). Epistemic injustice, which basically refers to an act of discriminating against someone in their capacity as a knower (Fricker, 2007 ), and Foucault’s theory of knowledge/power are adopted as powerful tools to reveal the Western dominance in knowledge globalisation (Geerlings & Lundberg, 2018 ).

Some postcolonial inquiries are valuable for rethinking the present condition of knowledge production in non-Western places. Argentine semiotician Mignolo’s ( 2018 ) intellectual ‘pluriversality’ calls for constructing a global intellectual landscape where diverse forms of knowledge and pluriversal epistemologies coexist. African philosopher Hountondji ( 2006 ) proposes ‘intellectual extraversion’ to describe the tendency of scientific research in post-colonial countries to turn to the outside world and respond to the demands of the ‘intellectual centre’. Taiwanese sociologist Chen’s ( 2010 ) ‘Asia as method’ points out the epistemic anxieties shared by postcolonial societies, highlighting the importance of inter-Asian mutual understanding.

Although fruitful, the above debates seldom delve into the tension brought by globalisation between modernisation and intellectual traditions in non-Western societies. Shils ( 1972 ) defined an intellectual tradition as ‘a set or pattern of beliefs, conceptions of form, sets of verbal (and other symbolic) usages, [and] rules of procedure’ (p. 23), transmitted by intellectuals and especially rooted in indigenous cultures for intellectuals in Africa, Asian, and Latin America. In these societies, intellectuals have been torn between Western-derived modernity and pre-modern cultural heritage, struggling with defining, repositioning, and transforming their traditions. Extensive evidence can be found in the literature about African, Asian, and Latin American educational and intellectual histories. To provide the most relevant historical information, we will give a snapshot of HSS intellectual pathways in East Asia and particularly in China.

East Asian higher education systems are commonly characterised by a mixture of Western institutional patterns and the Confucian tradition (Marginson, 2011 ). Sharing similar experience of learning from the West, East Asian societies have established modern universities and disciplines patterning after Western models since the nineteenth century. In this process, they experienced different encounters with the West, developed various understandings of ‘tradition’, and thus stepped on divergent historical trajectories (Hayhoe, 1995). Nonetheless, the common core issue of how to integrate imposed Western and indigenous traditional values in higher education has never been settled, which is particularly true for HSS scholars. Modern Japanese scholarship developed in absorbing both traditional Chinese and Western (first European and then American) scholarships (Kaneko, 2004 ; Nakayama, 1984 ). Since the Meiji period (1868–1912), the Japanese government and intellectuals have been struggling to explore their own cultural roots and indigenous patterns of HSS research (Hayhoe, 1998 ; Phan, 2013 ). For Korean intellectuals, the process of intellectual synthesis of traditional and borrowed ideas began in 1876. Since then, the nationalism tendency has continued to influence South Korean HSS research (Shin & Han, 2010 ). While pursuing internationalisation, today’s Korean higher education and academic culture are still significantly shaped by the Confucian tradition (Kim, 2005 ; Shin, 2012 ).

China’s modern intellectual history unfolded as globalisation brought Western-patterned universities, disciplines, and knowledge at the turn of the twentieth century. In this process, Chinese intellectuals gradually discarded traditional Chinese scholarship and turned to French, American, British, and Germany patterns for modernity (Hayhoe, 1996 ). During the 1920s–1930s, many scholars in the humanities advocated a ‘systematic reorganisation of the national heritage’ ( zhengli guogu ) based on the ‘advanced’ and ‘scientific’ ideas from the West (Yu, 2016 , p. 209). Social scientists strived to localise social science subjects by applying Western theories and methodologies to China’s social circumstances (Gransow, 2008 ).

The establishment of the People’s Republic of China in 1949 reoriented modernisation to the Soviet model. During the 1950s–1960s, Chinese HSS scholars gave up both the Western and their traditional academic patterns and devoted themselves to building a socialist nation. This was interrupted by the Cultural Revolution (1966–1976), a political turmoil that tried to uproot both traditional Confucian and foreign (including Western and Soviet) values (Hayhoe, 1996 ). Until 1978, China’s opening up ushered in an era of internationalisation. Since the 1980s, Chinese HSS scholars have enthusiastically reembraced international academic patterns following Euro-American methodologies, discourses, theories, and paradigms (Deng, 2010 ). Simultaneously, debates on how to transform traditions persist among Chinese HSS scholars in and beyond Mainland China, including Lin ( 1988 ) proposal for ‘creative transformation’, Li ( 1998 ) ‘transformative creation’, and Wang ( 2003 ) distinctive political culture based on combining Chinese tradition and Western modernity.

For Chinese and other East Asian HSS scholars, transforming intellectual traditions is not a new task but an arduous journey across generations. It becomes even more complex in today’s global era. As Yang et al. ( 2019 ) argue, it is a continuing cultural mission to figure out how to wed Western higher education standards with Chinese traditional values. Only when this is achieved can Chinese HSS scholars find their spiritual homeland and feel settled. This study contextualises this mission in present-day Chinese HSS scholars’ pursuits and attendant pains and gains. Doing so can uncover the current conditions of Chinese intellectual traditions with implications for other East Asian and non-Western societies. Specifically, we focus on the following two questions:

How do contemporary Chinese HSS scholars transform their intellectual traditions into modern and global academic resources?

In doing so, what difficulties and challenges do Chinese HSS scholars confront both domestically and internationally?

Method and data

Aiming to capture the participants’ perceptions and experiences, which lie at the centre of qualitative research (Patton, 2015 ), this study employs a qualitative methodology to interpret what Chinese intellectual traditions mean to the participants and builds a holistic and informative picture of how the participants have transformed these traditions in knowledge production.

Our data collection was divided into three steps from October 2021 to August 2022. It started with extensively reading published works, to identify potential participants for purposive sampling. Fifty Chinese HSS scholars were selected as target participants, all of whom were working in research-intensive universities in Mainland China and had shown great concern about Chinese traditions in their published works. Diversity of gender, age, location of their affiliated institutions, and research fields was also considered. Two groups of Chinese scholars were not included as our participants. One group was Mainland Chinese scholars born before the 1950s. Because most of them had retired, their contact information was seldom publicly posted. It was difficult to find their email address and phone numbers to contact them. The other group was (ethnic) Chinese scholars outside of Mainland China who were widely divergent in location, higher education system, academic culture, cultural background, etc. Considering such a huge complexity and our limited time, we decided to focus on Mainland Chinese HSS scholars who constitute the majority of Chinese HSS scholars.

We designed semi-structured interview outlines consisting of basic questions about Chinese intellectual traditions. We then tailored questions based on the life experiences and academic viewpoints of each targeted participant and contacted them through email. Twenty of them accepted our interview invitation. Before each interview, we sent them the consent form, clearly explaining research topics and questions, procedures, and potential risks and ensuring their participation was totally voluntary. All interviews were conducted online due to the COVID-19 pandemic, ranging from 1 to 3 h in length. After each interview, we collated the interview transcript through member-checking so that interviewees could correct factual errors and decide what information to put on record.

Our basic content analysis went simultaneously with data collection. We reread the published works of the interviewees in depth, including their articles, books, (auto)biographies, and other public interviews. We also included eight additional targeted participants who did not participate in the interviews as complementary participants, as their experiences and perceptions reflected in published works could significantly enrich our findings. All the participants were numbered for the convenience of data analysis and article writing. We numbered the twenty interviewees with the prefix ‘P’ and the eight complementary participants with the prefix ‘Pc’. Detailed information on all 28 participants is listed in Table  1 . P3, P4, P8, P9, P13, and P18 expressed explicitly that they did not mind being identified. Therefore, we kept their identifying ideas when presenting findings. For the other interviewees who preferred to be anonymous and complementary participants, we removed their identifying particulars and details as much as possible. Considering most of them preferred to be anonymous, we dealt with the participants’ interviews and published works as textual data rather than citations.

After organising the data, we conducted a six-step thematic analysis (Braun & Clarke, 2022 ) of (1) the 20 interview transcripts and (2) the published works of all 28 participants. The two parts of data corroborated each other, ensuring the comprehensive and valid identification of themes. After familiarising ourselves with the data, we first captured the relevant meanings about Chinese tradition through systematic coding. We then generated initial themes inductively by identifying the shared patterns among the segment codes across different participants and contexts. The themes were further developed, refined, and named around three key points of our main research questions: the forms of intellectual traditions in their knowledge production, the difficulties they experienced in domestic academia, and the challenges they faced in international academic communities.

Research findings

Three main forms of academic resources.

Our data show that the participants are transforming Chinese intellectual traditions into three main forms of academic resources: approaches, methodologies/paradigms, and theories. By exploiting Chinese intellectual traditions, some participants have produced academic innovations and gained reputation.

Form 1: approaches

There were three major dimensions of Confucian learning in ancient China: evidential investigation ( kaozheng or kaoju ), the study of moral principles ( yili ), and literary art ( cizhang or wenzhang ) (Ropp, 1981 ; Yu, 2016 ). Footnote 2 Our findings demonstrate that today’s Chinese HSS scholars draw upon the three dimensions as their scholarly approaches to examining historical or literary texts, interpreting social phenomena and philosophical ideas, and developing new writing styles.

Aiming at ‘sifting out the true from the false and determining the true message of ancient sages’ (Ropp, 1981 , p. 43), evidential investigation in ancient China referred to carefully examining various versions of Chinese classics, based on textual evidence and minute analysis of the language. As experts in different HSS fields, nine participants (P3, P13, P14, P17, P18, P20, Pc23, Pc24, Pc25) have used this approach to examine texts far beyond Confucian classics, including all kinds of ancient Chinese classics (Pc25) and historical documents for aesthetic (P13) and literary (P20) research. Some researchers tend to associate it with textual criticism (Hein, 2019 ). For example, Pc23 has focused on the similarities between textual criticism and evidential investigation and tried to combine them in modern Chinese literary research. By so doing, he has systematically established ‘modern evidential investigation’, involving knowledge of historiography, geography, and political sciences. He claimed: ‘[Traditional evidential investigation] mainly examined a text with other texts, while modern evidential investigation covers other materials (like underground antiquities) and absorbs ideas of other disciplines as a new approach.’

In ancient China, the study of moral principles sought guidance from the classics to handle social relationships. Within the process, Confucian moral principles were established chiefly through metaphysical speculations and interpretations (Yu, 2016 , p. 8). The participants use this interpretative approach today to analyse various texts (P3, P8, P10, P16, P17) and even to understand the society (P18). In philosophy, it is usually associated with hermeneutics. Indeed, three participants see it as a Chinese hermeneutic tradition and an important approach to studying Chinese philosophy (P8, P10, P16). P10 stated that ‘there are many schools in hermeneutics [in the world], and the study of moral principles can be seen as one.’ The approach enables researchers to reinterpret ancient classics based on present times and then form new philosophical ideas for addressing social issues (P16). P18 viewed the study of moral principles as a bridge between the text and the society. It could help researchers contextualise legal history in social realities of different periods and gain new insights into today’s Chinese society.

Ancient Chinese literary art was rendered as the skilful and aesthetic pursuit of literary expression, genres, and stylistic excellence (Jin, 2020 ). Four participants mentioned literary art as traditional writing genres (P5, P10, P16, P20). According to P10, traditional dialogical (exemplified by The Analects of Confucius ) and epistolary genres are more suitable than academic papers for philosophical writing. P20 has taken full advantage of the traditional biographical genre ( jizhuan ti ) Footnote 3 in his doctoral thesis writing. He analysed the development of modern Chinese literature by vividly portraying the lives of some literary giants and their relationships. By borrowing this traditional genre, he found a ‘character-centred’ approach to presenting literary history other than the regular linear narrative style. In the interview, P20 explained: ‘Chinese historians had notably accentuated the character since Sima Qian . … But in modern times, the event has become the unit of historical writing’. He thought adopting the traditional biographical genre enabled a more effective articulation of Chinese literature’s nuanced historical changes.

Form 2: methodologies/paradigms

As before mentioned, Chinese HSS scholars have customarily relied on Euro–American methodologies and paradigms in their research since the 1980s. Seven participants attempted to break away such reliance by developing their own methodologies ( fangfa lun ) (P4, Pc24) and paradigms ( fanshi ) (P3, P6, P9, P12, P14), as they claimed, by selecting, modulating, and synthesising Chinese traditions.

P4 and Pc24 rethought and improved existing research tools in their fields by borrowing some traditional Chinese ideas. Pc24 published on how to generate new methodologies of Chinese–English translation by harnessing traditional ideas. For example, yin – yang , a traditional Chinese cosmology rooted in dynamic correlative thinking (Graham, 1986 ), ‘as an interpretative methodology has not drawn enough attention’ (Pc24). After critically examining some existing English translations of The Analects of Confucius , he criticised many of them for detaching the text from its context as well as the lives of Confucius and his students. In Pc24’s eyes, the text is not static but is always in the interaction with information beyond it. A good translation emerges from the dynamic meaning synthesis between the context and the author’s life, between Chinese and English, just like the unceasing interaction between yin and yang .

Similarly, P4 constructed an eight-dimension methodology for sociological fieldwork based on Chinese traditions and his research experience. Two dimensions came from The Classic of Changes ( I Ching or Yi Jing ): He interpreted ‘[g]rasping the infinitesimally small and what is manifestly obvious’ as that anthropologists should start with noticing details, accumulate knowledge of subtle aspects of people’s lives, and then construct a holistic scenario of society and culture; and ‘understanding the soft as well as the hard’ as combining ‘hard’ rational data collection with ‘soft’ feelings and empathy. Footnote 4

More participants proposed ‘new paradigms’ based on traditional Chinese scholarship to better contextualise HSS knowledge in China. Two political scientists, P6 and P14, shared a similar view: the ‘classics-history tradition’ ( jing shi chuantong ) should be exploited as a primary paradigm of Chinese political research. While the discipline of political science did not exist in ancient China, political thoughts can be found in ancient classics ( jing ) and history ( shi ). P12 attached great importance to traditional epigraphy ( jinshi xue ) Footnote 5 as an archaeological paradigm. Traditional epigraphy combined the collection and connoisseurship of antiquities and studied steles for their historical, epigraphic, and calligraphic value. By borrowing it in archaeological studies, researchers can simultaneously obtain the historical information an antiquity carries, enjoy the sense of beauty it possesses, and enter the spirit of the age when the antiquity was made. P12 believed that traditional epigraphy could make new contributions to Chinese and world archaeology.

Form 3: theories

According to our data, quite a few participants tried to avoid being trapped by the two well-beaten paths of most Chinese HSS scholars: applying Western ‘universal’ theories directly to the China case or using the case of China to contribute to Western theories (Zhang, 2017 ). They adopted two strategies to put forward new theories based on Chinese traditions: (1) extracting theories directly from traditional resources and (2) theorising traditions as counterparts of existing (mainly ‘Western’) theories.

Six participants distilled theories from traditional Chinese notions or ideas (P1, P7, P10, P14, P18, Pc22). For example, three education researchers, P1, P18, and Pc22, called for unearthing Mohist and Confucian educational thoughts after critically examining current educational theories and pedagogies. Mohism was a school of thought in ancient China, containing the germs of science and logic (Graham, 1978 ). Pc22 introduced it into scientific education, holding that ‘reviving Mohist logical and experimental thoughts [as a theory of scientific education] can help [Chinese educators] resolve the conflicts between traditional Chinese humanistic and modern scientific ideas.’ P18 extracted five Confucian constant virtues ( wuchang ) Footnote 6 as a coherent theory for moral education. He claimed that ‘[t]he system of five virtues is not fixed; rather, it is dynamic through history’, and ‘[w]hether it is still valuable depends on how we grasp and reinterpret it. Only on this basis can we fully integrate it into the current Zeitgeist and educational activities.’

More participants indicated a preference for the second strategy (P6, P8, P11, P13, P15, P19, Pc22, Pc24, Pc26). They presumed that their theories are alternative vantage points from Chinese culture and can complement existing theories that are limited by a monocultural perspective. P13’s theoretical innovations are telling. The most famous is Chinese ‘living aesthetics’ ( shenghuo meixue ), which he has published in both Chinese and English. His thinking followed four steps: (1) critically reviewing the growing trend of the ‘aesthetics of everyday life’ in Euro–American scholarship, (2) introducing the differences between Chinese and Western ideas about life and aesthetics, (3) analysing the fundamental elements of traditional Chinese aesthetics and then synthesising them into theories of living aesthetics with ‘neo-Chineseness’, and (4) arguing for the global value of Chinese living aesthetics and a new aesthetic agenda shared by Asia and Euro–America.

Similar steps could be observed in the works of P8, who tried to promote the dialogue between cosmopolitanism and Confucianism. He believed that although cosmopolitanism originated from the West, cosmopolitan ideas do exist elsewhere. Borrowing the African American philosopher Appiah ( 1997 ) ‘rooted cosmopolitanism’, P8 excavated a kind of Confucian rooted cosmopolitanism by systematically examining and comparing Appiah’s ideas with those of Confucius. He further argued that Confucianism, as a form of rooted cosmopolitanism or cosmopolitan patriotism, can serve as theoretical and practical resources for reconciling the tension between cosmopolitanism and patriotism/nationalism.

Difficulties and challenges

Most of the participants have made notable contributions to their fields. Yet, the process of transforming Chinese intellectual traditions has been fraught with hindrances. Three types of difficulties and challenges emerged from their experiences: domestically, the dominant intellectual extraversion and coercive audit culture have impeded their efforts; and internationally, they have felt constrained by epistemic injustice.

Intellectual extraversion

Our findings demonstrate that the intellectual extraverted tendency has prevailed in Chinese academic circles, manifesting in two extremes: a Western-oriented mindset and particularism. Both have hindered the transformation of Chinese intellectual traditions.

Twenty-one participants reflected that a Western-oriented mindset has been deeply ingrained in the minds of many Chinese HSS scholars. They pointed out various manifestations of the Western-oriented mindset: some scholars blindly worship ‘the advanced Western scholarship’ and its ‘logical and scientific qualities’ (P7, Pc24); some are habituated to turning to Euro–American coordinates and patterns (P10, P13), including issues, discourses, paradigms, and theories (P5, P17, P18, Pc24, Pc28); and some define Chinese thoughts (P15) or study Chinese societies (P4) exclusively with Western frameworks. The pervasive Western-oriented mindset has led many Chinese HSS scholars to abandon traditional Chinese scholarship while failing to truly understand Western scholarship (P12, P20, Pc22, Pc25, Pc26, Pc27), which further makes them lack the basic knowledge, awareness, and capacity of developing new methodologies, paradigms, and theories.

This Western-oriented mindset causes Chinese traditions to be largely unknown, underestimated, and misunderstood, which in turn reinforces the Western orientation. The participants lamented that knowing what Chinese traditions are is a prerequisite for transforming or reviving them (P11, P14, P15, P20), but people, especially younger generations (P6, P17), rarely have enough knowledge of traditions (P2, P5, Pc24, Pc26). Some participants frankly admitted that this applies to themselves, and that they have to make up missed lessons through self-study in order to know Chinese traditions better (P4, P5, P7, P11). Researching Chinese traditions is time-consuming as learning those traditions requires a significant investment of time and energy. Even worse, Chinese traditions are sometimes underestimated or misunderstood by many other scholars. They consider Chinese traditions ‘useless’ unless being systematised and structuralised into ‘Western frameworks’ (P6, P8, P14, P16, P18, Pc27) or ‘unadvanced’ and ‘unscientific’ when measured against ‘Western yardsticks’ including rigour, validity, and generality (P3, P12, P16, Pc25). Since the approaches, methodologies/paradigms, and theories, adopted by the participants, are built upon Chinese traditions, they are easily challenged or rejected by others (P14, P19, P20) and are unlikely to become as popular as Western ones.

Another manifestation of intellectual extraversion is that researchers at the periphery often confine themselves to the particular and are unable and unwilling to raise their speculations to the universal (Hountondji, 1990 ). As criticised by sixteen participants, many Chinese HSS scholars exhibit such particularism, exclude themselves from international academic communities, and undermine the global value of Chinese traditions. These participants believe that while uncritically imitating the West is infeasible, it is also untenable to return to ancient China (P7, P9, P12) or revive the so-called ‘authentic traditional scholarship’ (P8) because today’s Chinese scholarship is a mix of ancient, modern, indigenous, and foreign elements (P13, P18). The dangerous delusion that Chinese scholarship should be isolated from all ‘Western discourses’ (P10) can only lead to perverse nationalism, traditionalism, and nativism (P8, P13, Pc21). To avoid these problematic tendencies, the participants try to connect Chinese traditions with other globally recognised resources in their approaches as well as methodological and theoretical construction. Good examples include evidential investigation and textual criticism, the study of moral principles and hermeneutics, the construction of Chinese living aesthetics, and Confucian-rooted cosmopolitanism as discussed previously.

Particularism has two consequences. Firstly, Chinese traditions have been romanticised or simplified. As the participants noted, some Chinese HSS scholars have become obsessed with traditions and indulged in a sort of ‘romantic nostalgia’ (P3, P10), while some are busy chanting empty and mawkish slogans without any real action (P5, Pc27). Additionally, Chinese traditions are often narrowed to Confucianism, with other schools of thought marginalised (P13, P15). Sometimes, Chinese traditions are overprotected as if ‘in a vacuum without modern bacteria’ (P3), just like ‘antiques in the museum’ (P8). P3 and Pc27 believed that scholars who hold on to the particularism are ‘destroying traditions with the intention of re-establishing or reviving traditions.’ Secondly, the East–West dichotomy remains quite popular among Chinese HSS scholars. Some have focused too much on the separation and differences between ‘Chinese/Eastern scholarship’ and ‘Western scholarship’ (P8, Pc21, Pc28), ignoring the interplay between them and other ‘neither-Chinese-nor-Western’ scholarships (P9, Pc24). All of these means that transforming Chinese traditions into modern and global resources is not widely supported and practised.

Coercive audit culture

Audit culture in higher education is often represented by the officially imposed uniform categories, reckonings, evaluations, and assessments on a varied set of institutions (such as global university ranking schemes) and scholars (such as academic promotion systems) (Shore & Wright, 2015 ). It is also coercive in China’s academic community and strongly shackles the participants’ explorations of Chinese traditions, which usually require flexible writing formats (i.e. traditional dialogical and epistolary genres), sufficient time for creative thinking to develop new paradigms and theories, and supportive academic environments for their innovations. These requirements are hardly fulfilled due to the efficiency-seeking climate, the rigid rules set by journals, and the hierarchical systems.

The pressure to publish bears heavily on the participants in their everyday knowledge production practices, as researching Chinese traditions is time-consuming. Overstretched by innumerable quantified tasks and indicators, the participants struggle to make time for innovative thinking and writing (P5, P13, Pc26, Pc27). Their attention has been drawn by external mechanisms, including the reputation and promotion that are obtainable only through ceaseless publishing (P9, P17, Pc25). For, Pc25, today’s scholars have to publish as much as possible during a short-term project, which is detrimental to evidential investigation as it requires researchers to be patient ‘bench warmers.’ To P5 and P17, some scholars have even been promoting such a climate, rendering themselves auditable by setting high publishing efficiency as an overarching goal, and spending little time conducting solid studies and caring about others’ works (P5, P17).

The publish-or-perish imperative also influences China’s academic journals. To maintain high citation scores and ranks, journals focus on ‘hot topics’ (P17), set rigid writing formats and unified academic standards (P6, P10, P16, P20), and require submissions to follow popular paradigms and theories (P18). This only produces fragmented scholarship and leaves little space for traditional genres and innovative thoughts (P2, P3, P13, Pc27). For example, the dialogical and epistolary genres, which are mentioned above as two traditional Chinese resources of literary art, are more flexible for philosophical writing but have been replaced by standard academic articles (P10). P3 is also unhappy with the prevailing academic writing formats, describing them as a ‘skeleton without flesh.’ However, these formats have been exclusively authorised, and to assert one’s own writing style would mean being ‘out of tune with the mainstream standards’ (P3).

In addition, the audit culture relies upon hierarchical systems and relationships, leaving the studies on Chinese traditions even more unpopular, esoteric, and marginalised in today’s higher education environment. The biggest problem is the asymmetrical official support, including financial (Pc25, Pc27) and human resources (P1, P12) as well as institutional establishments (P18). According to Pc25, the studies of ancient Chinese classics and evidential investigation are not sufficiently valued by universities and governments. It is also hard to win grant funding. P12 expressed concern about the lack of talents and experts in traditional epigraphy ( jinshi xue ), as formal archaeological education rarely takes it into consideration. These asymmetries are intertwined with the publish-or-perish climate, creating inadequate incentives for research on Chinese traditions (P19).

Epistemic injustice

When bringing Chinese intellectual traditions into international knowledge production, half of the participants have encountered epistemic injustice (P3, P4, P5, P7, P8, P9, P10, P12, P13, P15, P18, P19, P20, Pc24). They argue that ‘the precondition of academic dialogue is an equal footing (P20)’, but in fact, not many international researchers are willing to ‘listen to Chinese stories’ (P4) or embrace ‘Chinese literature’ (P5).

The most explicit difficulty caused by epistemic injustice is English as the academic lingua franca (Catala, 2022 ), hindering the participants’ international knowledge production on Chinese traditions. Some participants find it almost insurmountable to translate some traditional Chinese notions and concepts into English (P3, P4, P7, P8, P10, P12, Pc24). As P7 and P8 stated, ‘English has its own thousand-year cultural traditions’ (P7) and that it is extremely difficult for Chinese scholars to ‘write English as sophisticatedly as Anglophone scholars’ (P8). Therefore, many Chinese scholars with deep knowledge of Chinese traditions have been shut out of the international academic circles (P8). P3 even admits that he gave up writing in English because he failed to find a way out of the untranslatability of Chinese traditions.

For those participants who can write skilfully and have published works in English, bilingual writing is a burden since it demands double efforts. It is also unfair for them to compete with Anglophone scholars for international publications (P13, P15, P19). ‘I’m proficient in English writing, which proves to be an advantage’, P15 said, ‘but on the flip side, it means that not everyone can do this.’ Despite his proficiency, P15 acknowledges that writing a paper in English expounding upon Chinese traditions is no easy task; instead, it requires sophisticated abilities and enormous energy.

Compared with linguistic problems, some intellectual biases are implicit but not unusual, making the participants’ theoretical innovations based on Chinese traditions undervalued by international colleagues. P9 and P13 had similar unpleasant experiences of publishing in English. P9 conducted an anthropological study using the Daoist thinker Laozi’s thoughts as a theoretical lens. When he tried to publish it in English, he found that the international reviewers, who were great experts in anthropological theories, knew little about Laozi’s thoughts. ‘They told me that Laozi’s idea is about an imaginary society and questioned me why his idea can be used to observe a real society,’ he contended, ‘but, for instance, isn’t Plato’s idea also about an imaginary society? Why is it so important and widely used to study China and other societies?’ P13’s Chinese living aesthetic theory was also challenged by an editor of a prestigious international journal. ‘[The editor] kept asking me: Does it have global significance? Can it be globalised or be examined under a universalist principle? Is it just local knowledge?’ (P13).

Three philosophy researchers mentioned the marginal position of Chinese philosophy in the world (P7, P8, P10). P7’s story about teaching Chinese philosophy at a German university is very telling. During his teaching, he faced many challenges from students, mainly about whether ancient Chinese thoughts could be accounted as ‘philosophy’. One student said, ‘I know what Confucius said makes sense, but I don’t think it’s philosophy.’ P7 understood why some students thought this way, because in Western contexts, ‘philosophy’ is an old discipline that always refers to Western philosophy characterised by logic and reasoning. Chinese philosophy has been categorised into Sinology, along with Chinese literature and history. It is quite simply a Western matter.

Discussion and conclusion

This study provides lively evidence of how intellectual traditions function in the knowledge production of China’s HSS scholars. For the participants, Chinese intellectual traditions have various meanings and contents. Overall, they are perceived as certain notions, ideas, and ways of knowing and writing that originated from ancient China. They can be applied in today’s knowledge production after certain modifications. They can be research approaches as well as critical components of new methodologies/paradigms and theories. Some of them have already been introduced to the world through international publications. Continuing to guide contemporary Chinese HSS scholars in academic work, they can be transformed into modern and global resources. This study also presents the most recent difficulties and challenges for Chinese HSS scholars to break the centre-periphery mould. While utilising traditional Chinese resources as approaches, methodologies/paradigms, and theories, Chinese HSS scholars lack sufficient support from domestic and international academic communities due to intellectual extraversion, the audit culture, and epistemic injustice. Their experiences prove fostering intellectual pluriversality to be a long-term intractable task.

The experiences of Chinese HSS scholars can help us rethink the intellectual traditions and the tendency of Sinocentrism in East Asia. Reflecting a Chinese perspective on nationalism, Sinocentrism features the universality of Confucian ethics and the idea that Chinese culture is the best. Such a mentality turns into strong isolationism and humiliation when faced with stronger rivals, underlies China’s modern development policy, and influences Chinese higher education at all levels (Yang, 2002 ). At the individual level, Chinese scholars have hardly dealt with Chinese and Western scholarships on equal footing during global knowledge exchange, as shown in our findings. Due to China’s great impact on the region, the Sino-centric mindset and the problems it causes are possibly prevalent in East Asia (Pakhomov, 2021 ). This study calls for more studies exploring how contemporary East Asian HSS scholars in/from different societies transform their intellectual traditions, cope with Sinocentric issues, and face internationalisation. Comparing their experiences could promote regional inter-referencing and global intellectual construction.

Furthermore, there are rich intellectual traditions in other civilisation zones to be detected. In Africa and Latin America, for example, higher education and HSS knowledge systems have historically relied on foreign languages. Indigenous traditions are scattered in local communities and circulated in oral forms (Carvalho & Flórez-Flórez, 2014 ). Transforming traditions into resources and knowledge decolonialisation has been highly challenging for their HSS scholars. In international knowledge production, they encounter similar epistemic injustice as Chinese HSS scholars (Chimakonam, 2017 ). As the diversity and intricacy of traditions in broad non-Western societies still largely remain unknown, this study points to possible directions for discovering less-known intellectual traditions and for presenting the concerted efforts made by scholars to navigate asymmetrical globalisation.

This study has its limitations. First, its participants are all high-achieving scholars in their fields working at research-intensive universities. The broader community of scholars, especially those with less reputation, is difficult to identify through extensive reading. Nonetheless, high-achieving scholars are more likely to have a good knowledge of traditions and participate in international academic activities, making their experiences sufficiently enlightening for others. Due to the limitation of accessibility and time, the study did not involve Mainland Chinese scholars born before the 1950s, (ethnic) Chinese scholars outside of Mainland China, and non-Chinese East Asian scholars within and outside of Mainland China. The generations born during the 1930s–1940s, whose academic careers overlapped with the Soviet model and the Cultural Revolution, may have been more influenced by socialism and Maoism. (Ethnic) Chinese outside of Mainland China and non-Chinese East Asian scholars may also understand Chinese intellectual traditions differently because of their complex cultural backgrounds and living experiences. This study can thus be a stepping stone to future studies of scholars with diverse generations and identities.

Second, we use the terms ‘Chinese/Western’, ‘Western/non-Western’, and ‘Euro–American/non-Euro–American’ with no intention to accentuate dichotomies. Instead, we adopt them as a tool to reveal some tensions in asymmetrical globalisation. In reality, ‘Western’ and ‘non-Western’ elements have been already inseparable with a huge diversity within ‘Chinese’ and ‘Western’ as well as in ‘Euro–American’ and ‘non-Euro–American’ spheres.

The present study is a piece of the large jigsaw puzzle of global intellectual pluriversality. To make the ‘jigsaw puzzle’ more complete, higher education stakeholders worldwide need to work jointly and take actions step by step. Researchers need to integrate traditional knowledge resources into theoretical construction, develop methodologies to capture living traditions through empirical research, and pay more attention to real individual experiences of practising traditions in various ways. In addition, in-depth comparisons across traditions are needed through cross-cultural collaborations. With an equal footing and an open mind, it is feasible for teachers to involve multiple traditions in the curriculum to equip students with multicultural awareness and pluriversal epistemologies. International journals should also contribute to epistemic diversity in knowledge production by engaging editors and reviewers with different cultural perspectives. Only by taking small steps constantly and consistently can we embrace intellectual pluriversality more fully.

Data availability

The data used during the study are available from the corresponding author, Yanzhen Zhu, by reasonable request.

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Acknowledgements

We sincerely thank the chair Prof. Simon Marginson, the discussant Dr. Lili Yang, and the audience for their enlightening comments. We also appreciate the reviewers’ valuable suggestions as well as the interviewees’ generous sharing of their experiences and insights.

This study was supported by the University Postgraduate Fellowships provided by the University of Hong Kong.

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Objectifs et portée

La revue Journal of African Cultural Studies (JACS) publie des travaux de recherche de premier plan sur la culture africaine, tant en Afrique qu’en dehors de l’Afrique, avec un engagement particulier envers les auteurs basés en Afrique et envers les langues africaines. Notre politique éditoriale encourage une approche interdisciplinaire impliquant les sciences humanes et sociales qualitatives, y compris les sciences environnementales. La revue porte sur les dimensions de la culture africaine, des arts de la scène, des arts visuels, du cinéma, du rôle des médias, de la relation entre la culture et le pouvoir, ainsi que sur leurs sous-domaines tels que la culture populaire en Afrique, les sujets sociolinguistiques d’intérêt culturel, et la culture et le genre. Nous accueillons en particulier les articles qui attestent d’une compréhension de la vie sur le terrain, et qui démontrent des connaissances locales et des compétences linguistiques. Nous ne publions pas d’articles qui offrent essentiellement des analyses textuelles de productions culturelles tels que romans et films, ni d’articles essentiellement historiques ou principalement basés sur des sources secondaires (numériques ou de bibliothèque, par exemple).

Cette revue est née de la revue African Languages and Cultures , fondée en 1988 au sein de la Faculté des langues et cultures de l’École des études orientales et africaines (SOAS) de Londres. Depuis 2019, elle est publiée en association avec l’Institut africain international de Londres.

La revue Journal of African Cultural Studies publie des articles de recherche originaux. Elle publie également de manière occasionnelle une rubrique intitulée Contemporary Conversations, dans laquelle des auteurs réagissent à des questions d’actualité. Dans cette rubrique peuvent figurer des compte-rendus, des entretiens et des communications sollicitées ou des exposés de position. Nous vous invitons à proposer de futurs thèmes pour la rubrique Contemporary Conversations.

Éditorial sur le passé et l’avenir de la revue JACS

Cet éditorial annonce une nouvelle phase dans la vie de la revue Journal of African Cultural Studies, et présente la structure révisée de la rédaction et de la direction, ainsi que l’affiliation de la revue à l’Institut africain international. Retrouvez l’intégralité de l’éditorial ici. Retrouvez l’intégralité de l’éditorial ici.

APPEL À CONTRIBUTION: La politique de langue dans le hip hop africain. Rédactrice invitée: Msia Kibona Clark

La question de la langue en littérature africaine a fait l’objet de débats dans les années 1960 et 1970. Au cœur de ces débats figuraient les questions suivantes : qu’est-ce qui qualifie quelqu’un d’auteur africain ? et qu’est-ce qui qualifie quelque chose de littérature africaine ? Des auteurs africains comme Ngũgĩ wa Thiong’o et Chinua Achebe se sont prononcés de différents côtés du débat. On assiste actuellement à un débat similaire au sein de diverses communautés hip hop en Afrique. Des questions similaires ont émergé : Qu’est-ce qui qualifie quelqu’un de MC africain ? Et qu’est-ce qui qualifie quelque chose de hip hop africain ? Lisez l’intégralité de l’appel à contribution

Numéro spécial de la revue JACS: Campus Forms

Pour ce numéro spécial, nous recherchons des contributions d’articles de recherche et autres œuvres académiques (tels qu’entretiens ou essais photo) qui examinent les approches littéraires et culturelles africaines contemporaines de l’université en tant qu’idée, institution et espace physique. Lisez l’intégralité de l’appel à contribution

Instructions aux contributeurs

Vous trouverez de plus amples informations sur la page Instructions aux auteurs

Comité de rédaction

Rédactrice

Carli Coetzee, IAI, UK

Comité de rédaction Moradewun Adejunmobi, UC Davis, USA Abimbola A. Adelakun, University of Texas at Austin, USA Bukola Aluko-Kpotie, SOAS, University of London, UK Karin Barber, London School of Economics and Political Science, UK Gus Casely-Hayford, V&A East, London, UK Msia Kibona Clark, Howard University, USA Ying Cheng, PKU, Beijing, China Naminata Diabate, Cornell University, USA Dominic Dipio, Makerere University, Uganda Louisa Egbunike, Durham University, UK Rotimi Fasan, Osun State University, Nigeria Chege Githiora, Kenyatta University, Nairobi, Kenya Alessandro Jedlowski, FNRS, Belgium Rebecca Jones, UK David Kerr, University of Johannesburg, South Africa Stephanie Kitchen, Managing Editor, IAI Sandra Manuel, Eduardo Mondlane University, Mozambique Carmen McCain, SOAS, University of London, UK Grace A. Musila, Wits University, South Africa Stephanie Newell, Yale, USA Joseph Oduro-Frimpong, Ashesi University, Ghana Katrien Pype, KU Leuven University, Belgium Connor Ryan, University of Bristol Lynn Taylor, UK Solomon Waliaula, Maasai Mara University, Kenya James Yeku, University of Kansas, USA, Helen Yitah, University of Ghana, Ghana

Revista de Estudos Culturais Africanos

Objectivos e alcance.

O Journal of African Cultural Studies publica os principais trabalhos de investigação focados nos estudos sobre a cultura africana de pesquisadores de dentro e fora da África, com um compromisso especial com os autores residentes em Africa e com as línguas africanas. A nossa política editorial encoraja uma abordagem interdisciplinar, envolvendo humanidades, e ciências sociais qualitativas, incluindo ciências ambientais. A revista centra-se em dimensões da cultura africana, artes performativas, artes visuais, música, cinema, o papel dos media, a relação entre cultura e poder, bem como questões dentro de campos como a cultura popular em África, tópicos sociolinguísticos de interesse cultural, e cultura e género. São bem-vindos em particular, artigos que mostrem evidências de compreensão da vida no terreno, e que demonstrem conhecimentos locais e competência linguística. Não publicamos artigos que ofereçam principalmente análises textuais de produtos culturais como romances e filmes, nem artigos que sejam na sua maioria históricos ou baseados principalmente em fontes secundárias (como o digital e a biblioteca).

A revista evoluiu da revista African Languages and Cultures, fundada em 1988 no Departamento de Línguas e Culturas de África da School of Oriental and African Studies (SOAS), Londres. A partir de 2019, passa a ser publicada em associação com o Instituto Internacional Africano, Londres.

O Journal of African Cultural Studies publica artigos originais de investigação. A revista publica também uma secção ocasional de Conversas Contemporâneas, na qual os autores respondem a edições actuais. A secção tem incluído revisões, entrevistas e artigos de resposta ou de posição. São bem-vindas propostas para futuros temas de Conversas Contemporâneas.

Editorial sobre o passado e o futuro da JACS

Este editorial anuncia uma nova fase na vida do Journal of African Cultural Studies, e introduz a versão revista da estrutura editorial e de gestão, bem como a afiliação da revista ao Instituto Internacional Africano. Leia o editorial completo.

CHAMADA DE ARTIGOS: A Política da Língua no Hip Hop Africano. Editor convidado: Msia Kibona Clark

A questão da língua na literatura africana foi debatida nas décadas de 1960 e 1970. No centro do debate estavam questões como: quem se qualifica como escritor africano? E o que se qualifica como literatura africana? Autores africanos como Ngũgĩ wa Thiong'o e Chinua Achebe pesaram em diferentes lados do debate. Hoje em dia, está a ocorrer um debate semelhante em várias comunidades de hip hop em África. Questões semelhantes têm surgido: Quais são as qualificações para ser classificado como um MC africano? E o que se qualifica como hip hop africano ? Leia a chamada de trabalhos completa.

Edição Especial da JACS: Formulários do Campus

Para esta edição especial procuramos contribuições de artigos de investigação e outros trabalhos académicos (incluindo entrevistas ou ensaios fotográficos) que investiguem abordagens literárias e culturais africanas contemporâneas à universidade como uma ideia, uma instituição, e um espaço físico. Leia a chamada de artigos completa.

Instruções para os colaboradores

Por favor, veja mais detalhes na página Instruções aos autores

Conselho Editorial

Carli Coetzee, IAI, Reino Unido

Moradewun Adejunmobi, UC Davis, EUA Abimbola A. Adelakun, University of Texas at Austin, USA Bukola Aluko-Kpotie, SOAS, Universidade de Londres, Reino Unido Karin Barber, London School of Economics and Political Science, Reino Unido Gus Casely-Hayford, V&A East, Londres, Reino Unido Msia Kibona Clark, Universidade de Howard, EUA Ying Cheng, PKU, Pequim, China Naminata Diabate, Universidade de Cornell, EUA Dominic Dipio, Universidade de Makerere, Uganda Louisa Egbunike, Universidade de Durham, Reino Unido Rotimi Fasan, Universidade Estadual de Osun, Nigéria Chege Githiora, Universidade Kenyatta, Nairobi, Quénia Alessandro Jedlowski, FNRS, Bélgica Rebecca Jones, Reino Unido David Kerr, Universidade de Joanesburgo, África do Sul Stephanie Kitchen, Editora-chefe, IAI Sandra Manuel, Universidade Eduardo Mondlane, Moçambique Carmen McCain, SOAS, Universidade de Londres, Reino Unido Grace A. Musila, Universidade Wits, África do Sul Stephanie Newell, Yale, EUA Joseph Oduro-Frimpong, Universidade de Ashesi, Gana Katrien Pype, Universidade KU Leuven, Bélgica Connor Ryan, University of Bristol Lynn Taylor, Reino Unido Solomon Waliaula, Universidade Maasai Mara, Quénia James Yeku, Universidade de Kansas, EUA, Helen Yitah, Universidade do Gana, Gana

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• CAREER FEATURE
• 09 September 2024

The human costs of the research-assessment culture

• Rachel Brazil 0

Rachel Brazil is a freelance journalist in London, UK.

You can also search for this author in PubMed   Google Scholar

Illustration: Stephan Schmitz

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The term ‘REF-able’ is now in common usage in UK universities. “Everyone’s constantly thinking of research in terms of ‘REF-able’ outputs, in terms of ‘REF-able’ impact,” says Richard Watermeyer, a sociologist at the University of Bristol, UK. He is referring to the UK Research Excellence Framework (REF), which is meant to happen every seven years and is one of the most intensive systems of academic evaluation in any country. “Its influence is ubiquitous — you can’t escape it,” says Watermeyer. But he and other scholars around the world are concerned about the effects of an extreme audit culture in higher education, one in which researchers’ productivity is continually measured and, in the case of the REF, directly tied to research funding for institutions. Critics say that such systems are having a detrimental effect on staff and, in some cases, are damaging researchers’ mental health and departmental collegiality.

Unlike other research benchmarking systems, the REF results directly affect the distribution of around £2 billion (US$2.6 billion) annually, creating high stakes for institutions. UK universities receive a significant proportion of their government funding in this way (in addition to the research grants awarded to individual academics).

Research assessment toolkit

Since its inception, the REF methodology has been through several iterations. The rules about which individuals’ work must be highlighted have changed, but there has always been a focus on peer-review panels to assess outputs. Since 2014, a team in each university department has been tasked with selecting a dossier of research outputs and case studies that must demonstrate societal impact. These submissions can receive anything from a four-star rating (for the most important, world-leading research) to just one star (the least significant work, of only national interest). Most departments aim to include three- or four-star submissions, often described as ‘REF-able’.

But the process is time-consuming and does not come cheap. The most recent REF, in 2021, was estimated to have cost £471 million. Tanita Casci, director of the Research Strategy & Policy Unit at the University of Oxford, UK, acknowledges that it’s resource-intensive, but says that it’s still a very efficient way of distributing funds, compared with the cost of allocating money through individual grant proposals. “I don’t think the alternative is better,” she concludes. The next exercise has been pushed back a year, until 2029, with planned changes to include a larger emphasis on assessment of institutional research culture.

Tanita Casci says the UK REF assessment is an efficient way to distribute funding. Credit: University of Oxford

Many UK academics see the REF as adding to an already highly competitive and stressful environment. A 2021 survey of more than 3,000 researchers (see go.nature.com/47umnjd ) found that they generally felt that the burdens of the REF outweighed the benefits. They also thought that it had decreased academics’ ability to follow their own intellectual interests and disincentivized the pursuit of riskier, more-speculative work with unpredictable outcomes.

Some other countries have joined the assessment train — with the notable exception of the United States, where the federal government does not typically award universities general-purpose research funding. But no nation has chosen to copy the REF exactly. Some, such as the Netherlands, have instead developed a model that challenges departments to set their own strategic goals and provide evidence that they have achieved them.

Whatever the system, few assessments loom as large in the academic consciousness as the REF. “You will encounter some institutions where, if you mention the REF, there’s a sort of groan and people talk about how stressed it’s making them,” says Petra Boynton, a research consultant and former health-care researcher at University College London.

Strain on team spirit

Staff collating a department’s REF submission, selecting the research outputs and case studies to illustrate impact, can find themselves in an uncomfortable position, says Watermeyer. He was involved in his own department’s 2014 submission and has published a study of the REF’s emotional toll 1 . It’s a job that most academics take on “with trepidation”, he says. It can change how they interact with colleagues and how colleagues view and interact with them.

“You’re trying to make robust, dispassionate, critical determinations of the quality of research. Yet at the back of your mind, you are inescapably aware of the implications of the judgements that you’re making in terms of people’s research identities, their careers,” says Watermeyer. In his experience, people can get quite defensive. That scrutiny of close colleagues’ work “can be really disruptive and damaging to relationships”.

UK research assessment is being reformed — but the changes miss the mark

Watermeyer often found himself not only adjudicating on work but also acting as a counsellor. “You have to attend to the emotional labour that’s involved; you’re responsible for people’s welfare and well-being,” and no training is provided, he says. A colleague might think that their work has met expectations, only to find that assessors disagree. “I’ve been in situations where there are tears,” Watermeyer recalls. “People break down.”

For university support staff, the REF also looms large. Sometimes, more staff must be hired near the submission deadline to cope with the workload. “It is an unbelievable pressure cooker,” particularly at small institutions, says Julie Bayley, former director of research-impact development at the University of Lincoln, UK. Bayley was responsible for overseeing 50 case studies to demonstrate the impact of Lincoln’s research, and describes this as akin to preparing evidence for a legal case. “You are having to prove, to a good level of scrutiny, that this claim is true,” Bayley says. This usually involves collecting testimonial letters from organizations or individuals who can vouch for the research impact, something she sometimes did on behalf of researchers who feared straining the external relationships they had developed.

Boynton says there can be an upside. “There’s something really exciting about putting together [a case study] that shows you did something amazing,” she says. But she also acknowledges that those whose research is not put forward can feel as if their work doesn’t matter or is not respected, and that can be demoralizing.

The clamour about achieving four stars can skew attitudes about research achievements. Bayley recounts a senior academic tearfully showing her an e-mail from his supervisor that read, “It’s all well and good that you’ve changed national UK policy, but unless you change European policy, it doesn’t count.” She says her own previous research on teenage pregnancy met with similar responses because it involved meeting real needs at the grass-roots level, rather than focusing on national policy. “That’s the bit I find most heartbreaking. Four-star is glory for the university, but four-star is not impact for society,” says Bayley.

The picking and choosing between individual researchers has implications for departments. “That places some people on the ‘star player competition winner’ side and, particularly where resources are limited, that means those people get more support” from their departments, explains Bayley. She has witnessed others being asked to pick up the teaching workload of researchers who are selected to produce impact case studies for a REF submission. Boynton agrees: “It’s not a collegiate, collective thing — it’s divisive.”

Hidden contributions

Research assessment can also affect work that universities often consider ‘non-REF-able’. Simon Hettrick, a research software engineer at the University of Southampton, UK, was in this position in 2021. He collaborates with researchers to produce crucial software for their work. But, he says, universities find it hard to look beyond academic papers as the metric for success even though there are 21 categories of research output that can be considered, including software, patents, conference proceedings and digital and visual media.

In the 2021 REF, publications made up about 98.5% of submissions. Hettrick says that although other submissions are encouraged, universities tend not to select the alternatives, presumably out of habit or for fear they might not be judged as favourably.

Simon Hettrick says evaluations should include more contributions such as software. Credit: Simon Hettrick

The result is that those in roles similar to Hettrick’s feel demotivated. “You’re working really hard, without the recognition for that input you’re making,” he says. To counter this, Hettrick and others launched an initiative called The hidden REF that ran a 2021 competition to spotlight important work unrecognized by the REF, garnering 120 submissions from more than 60 universities. The competition is being run again this year .

In April, Hettrick and his colleagues wrote a manifesto asking universities to ensure that at least 5% of their submissions for the 2029 REF are ‘non-traditional outputs’. “That has been met with some consternation,” he says.

Regarding career advancement, REF submissions should not feed into someone’s prospects, according to Casci, who says that universities make strong efforts to separate REF assessments from decisions about individuals’ career progression. But “it’s a grey area” in Watermeyer’s experience; “it might not be reflected within formal promotional criteria, but I think it’s the accepted unspoken reality”. He thinks that academic researchers lacking ‘REF-able’ three- or four-star outputs are unlikely to be hired by any “serious research institution” — severely limiting their career prospects and mobility.

Watermeyer says the consequences for these individuals will vary. Some institutions try to boost the ratings of early-career academics by putting them on capacity-building programmes, including buddying schemes to foster collaborations with more ‘REF-able’ colleagues. But, for more senior staff, the downside could be a performance review. “People might be ‘encouraged’ to reconsider their research role, if they find themselves unable to satisfy the three-star criteria,” he says.

There’s a similar imperative for a researcher’s work to be used as an impact case study. “If your work is not selected for that competition, you lose the currency for your own progression,” says Bayley.

The REF also exacerbates inequalities that already exist in research, says Emily Yarrow, an organizational-behaviour researcher at Newcastle University Business School, UK. “There are still gendered impacts and gendered effects of the REF, and still a disproportionate negative impact on those who take time out of their careers, for example, for caring responsibilities, maternity leave.” A 2014 analysis she co-authored of REF impact case studies in the fields of business and management showed that women were under-represented: just 25% of studies with an identifiable lead author were led by women 2 . Boynton also points out that there are clear inequalities in the resources available to institutions to prepare for the REF, causing many researchers to feel that the system is unfair.

Emily Yarrow found that women were under-represented in research-evaluation case studies. Credit: Toby Long

Although not all the problems researchers face can be attributed to the REF, it certainly contributes to what some have called an epidemic of poor mental health among UK higher-education staff. A 2019 report (see go.nature.com/3xsb78x ) highlighted the REF as causing administrative overload for some and evoking a heightened, ever-present fear of ‘failure’ for others.

UK research councils have acknowledged the criticisms and have promised changes to the 2029 REF. Steven Hill, chair of the 2021 REF Steering Group at Research England in Bristol, UK, which manages the REF exercise, says these changes will “rebalance the exercise’s definition of research excellence, to focus more on the environment needed for all talented people to thrive”. Hill also says they will implement changes to break “the link between individuals and submissions” because there will no longer be a minimum or maximum number of submissions for each researcher. The steering group aims to provide more support in terms of how REF guidance is applied by institutions, to dispel misconceptions about requirements. “Some institutions frame their performance criteria in REF terms and place greater requirements on staff than are actually required by REF,” Hill says.

Other ways forward

Similar to the REF, the China Discipline Evaluation (CDE) occurs every four to five years. Yiran Zhou, a higher-education researcher at the University of Cambridge, UK, has studied attitudes to the CDE 3 and says there are pressures in China to produce the equivalent of ‘REF-able’ research and similar concerns about the impact on academics. China relies much more on conventional quantitative publication metrics, but researchers Zhou interviewed criticized the time wasted in producing CDE impact case studies. Those tasked with organizing this often had to bargain with colleagues to collect the evidence they needed. “Then, they owe personal favours to them, like teaching for one or two hours,” says Zhou.

Increased competition has become a concern among Chinese universities, and Zhou says the government has decided not to publicize the results of the most recent CDE, only informing the individual universities. And, Zhou says, some of those she spoke to favoured dropping the assessment altogether.

Mammoth UK research assessment concludes as leaders eye radical shake up

In 2022, Australia did just that. Ahead of the country’s 2023 Excellence in Research for Australia (ERA) assessment, the government announced that it would stop the time-consuming process and start a transition to examine other “modern data-driven approaches, informed by expert review”. In October 2023, the Australian Research Council revealed a blueprint for a new assessment system and was investigating methods for smarter harvesting of evaluation data. It also noted that any data used would be “curated”, possibly with the help of artificial intelligence.

Some European countries are moving away from the type of competitive process exemplified by the REF. “For the Netherlands, we hope to move from evaluation to development” of careers and departmental strategies, says Kim Huijpen, programme manager for Recognition and Reward for the Universities of the Netherlands, based in The Hague, and a former chair of the working group of the Strategy Evaluation Protocol (SEP), the research evaluation process for Dutch universities. In the SEP, institutions organize subject-based research-unit evaluations every six years, but the outcome is not linked to government funding.

The SEP is a benchmarking process. Each research group selects indicators and other types of evidence related to its strategy and these, along with a site visit, provide the basis for review by a committee of peers and stakeholders. The protocol for 2021–27 has removed the previous system of grading. “We wanted to get away from this kind of ranking exercise,” explains Huijpen. “There’s a lot of freedom to deepen the conversation on quality, the societal relevance and the impact of the work — and it’s not very strict in how you should do this.”

The Research Council of Norway also runs subject-based assessments every decade, including institutional-level metrics and case studies, to broadly survey a field. “From what I hear from colleagues, the Norwegian assessment is much milder than the REF. Although it’s similar in what is looked at, it doesn’t feel the same,” says Alexander Refsum Jensenius, a music researcher at the University of Oslo. That’s probably because there is no direct link between the assessment and funding.

Refsum Jensenius has been involved in the Norwegian Career Assessment Matrix , a toolbox developed in 2021 by Universities Norway, the cooperative body of 32 accredited universities. It isn’t used to assess departments, but it demonstrates a fresh, broader approach.

What differentiates it from many other assessments is that in addition to providing evidence, there is scope for a researcher to outline the motivations for their research directions and make their own value judgements on achievements. “You cannot only have endless lists of whatever you have been doing, but you also need to reflect on it and perhaps suggest that some of these things have more value to you,” says Refsum Jensenius. For example, researchers might add context to their publication list by highlighting that opportunities to publish their work are limited by its interdisciplinary nature. There is also an element of continuing professional development to identify a researcher’s skills that need strengthening. Refsum Jensenius says this approach has been welcomed in the Norwegian system. “The toolbox is starting to be adopted by many institutions, including the University of Oslo, for hiring and promoting people.”

For many UK researchers, this more nurturing, reflective method of assessment might feel a million miles away from the REF, but that’s not to say that the REF process does not address ways to improve an institution’s research environment. Currently, one of the three pillars of assessment involves ‘people, culture and environment’, which includes open science, research integrity, career development and equity, diversity and inclusion (EDI) concerns. Since 2022, there have been discussions on how to better measure and incentivize good practice in these areas for the next REF.

Bayley thinks the REF can already take some credit for an increased emphasis on EDI issues at UK universities. “I will not pretend for a second it’s sorted, but EDI is now so commonly a standing item on agendas that it’s far more present than it ever was.”

But she is less sure that the REF has improved research culture overall. For example, she says after the 2014 REF, when the rules changed to require that contributions from all permanent research staff be submitted, she saw indications that some universities were gaming the system in a way that disadvantaged early-career researchers. Junior staff members were left on precarious temporary contracts, and she has seen examples of institutions freezing staff numbers to avoid the need to submit more impact case studies. “I’ve seen that many times across many universities, which means the early-career entry points for research roles are reduced.”

“The REF is a double-edged sword,” concludes Bayley. The administrative burden and pressures it brings are much too high, but it does provide a way to allocate money that gives smaller institutions more of a chance, she says. After the 2021 REF, even though top universities still dominated, many received less of the pot than previously, whereas some newer, less prestigious universities performed strongly. The biggest increase was at Northumbria University in Newcastle, where ‘quality-related’ funding rose from £7 million to £18 million.

For Watermeyer, the whole process is counterproductive, wasting precious resources and creating a competitive, rather than a collaborative, culture that might not tolerate the most creative thinkers. He would like to see it abolished. Hettrick is in two minds, because “the realist in me says it is necessary to explain to the taxpayer what we’re doing with their money”. He says the task now is to do the assessment more cheaply and more effectively.

Other research communities might not agree. As Huijpen points out, “there’s quite a lot of assessments in academic life, there are a lot of moments within a career where you are assessed, when you apply for funding, when you apply for a job”. From her perspective, it’s time to opt for less ranking and more reflection.

Nature 633 , 481-484 (2024)

doi: https://doi.org/10.1038/d41586-024-02922-4

Watermeyer, R., Derrick, G. E. & Batalla, M. B. Res. Eval. 31 , 498–506 (2022).

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Davies, J., Yarrow, E. & Syed, J. Gend. Work Organ. 27 , 129–148 (2020).

Zhou, Y. High. Educ. 88 , 1019–1035 (2024).

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Research: How Anxiety Shapes Men’s and Women’s Leadership Differently

• Ivona Hideg,
• Tanja Hentschel,

A study of 137 leaders and their direct reports during the early stages of Covid-19 shows that men were more likely to resort to abusive behavior during stressful moments.

One of the oldest erroneous gender stereotypes is that women are too emotional to be effective leaders, especially in uncertain times. Contrary to this belief, research on 137 leader-report pairs in Europe during the early stages of the Covid-19 pandemic indicates that women may actually be less likely to let their emotions negatively influence their leadership behaviors compared to men. During this time, women leaders reported higher anxiety levels but did not translate these emotions into abusive behaviors, unlike their male counterparts who exhibited more hostile supervision when anxious. Women typically engaged in family-supportive behaviors regardless of their emotional state. The research emphasizes the importance of recognizing the unique strengths women bring to leadership roles, especially their capacity to lead compassionately and prioritize others, but also notes that caring leadership behaviors are evaluated differently based on the gender of the leader. The study calls for more inclusive research that addresses diverse gender identities and cultural contexts.

One of the oldest and most persistent gender stereotypes is that women are too emotional. This stereotype hurts women’s leadership prospects as they are seen as less fit for leader roles because they are perceived to be more likely to make irrational, emotion-driven decisions than men.

• IH Ivona Hideg is Professor of Organisation Studies at the Saïd Business School, University of Oxford, and the Ann Brown Chair of Organization Studies in the Schulich School of Business, York University. Previously, she was a research fellow with the  Women and Public Policy Program at Harvard Kennedy School , she served as an Associate Editor at  Academy of Management Journal and is currently serving as Past Chair of the Canadian Society for Industrial & Organizational Psychology .  Her main program of research includes workplace equity, diversity and inclusion with a focus on gender, but she also examines issues surrounding race, language, and socio-economic background diversity.
• TH Tanja Hentschel is an Associate Professor of Organizational Behavior at the Amsterdam Business School, University of Amsterdam . She received her PhD from the Technical University of Munich and was a research fellow at the Department of Psychology, New York University . Tanja is an editorial board member of Journal of Business and Psychology . Her research focuses primarily on (gender) stereotypes, biases, leadership, and career choices.
• WS Winny Shen is an Associate Professor of Organization Studies at the Schulich School of Business, York University. She is currently an Associate Editor at Journal of Occupational Health Psychology and Journal of Business and Psychology . Her program of research focuses on issues of leadership, diversity and inclusion, and worker health and well-being, and has appeared in leading psychology and management journals.

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• Open access
• Published: 18 September 2024

Toward a roadmap for sustainable lean adoption in hospitals: a Delphi study

• Maria M. Van Zyl-Cillié 1 , 2 ,
• Desirée H. van Dun 2 &
• Hanneke Meijer 1  

BMC Health Services Research volume  24 , Article number:  1088 ( 2024 ) Cite this article

Metrics details

The benefits of lean adoption in healthcare include improved process efficiency and quality of patient care. However, research indicates that lean implementation in healthcare, and specifically hospitals, is often not sustained. Furthermore, there is a need for maturity models that guide lean implementation, specifically in hospitals. This study develops a prescriptive maturity model named the Sustaining of Lean Adoption in Hospitals Roadmap (SOLAR) that acts as a practical guideline for the sustainable adoption of lean in hospitals.

The SOLAR has three theoretical foundations, namely lean implementation success factors in hospitals, implementation science, and change management theory. A systematic literature review was conducted to determine the lean implementation success factors in hospitals as the first building block. Secondly, practices from implementation science were used to create the action items in the SOLAR. Ten change steps were elicited from change management theory as the third theoretical building block of the roadmap. We refined the roadmap through three Delphi rounds that verified its useability in hospitals.

The final SOLAR consists of four maturity phases (prepare, plan, experiment and learn, and sustain) and includes action items for each phase related to the hospital’s strategy, resources, engaging of people, and culture. The action items and change management steps shown in the SOLAR are not intended as an exhaustive list but provide guidelines on aspects hospitals must consider when they aim to adopt lean sustainably.

Conclusions

The strong theoretical base of the SOLAR enables hospitals to safely experiment and learn which implementation methods are best suited to their unique environment. The SOLAR is, therefore, an actionable guideline that informs both academics and practitioners involved in lean adoption in hospitals. This roadmap can guide future retrospective longitudinal or action research.

Peer Review reports

Hospitals, also called inpatient care services, experience many operational challenges. Delivering healthcare services efficiently whilst improving the flow and reducing patients’ waiting time is one of these challenges [ 1 ]. Lean management, which originated in the manufacturing industry, has proven to drive improved efficiencies in the healthcare sector in general and in hospitals in particular [ 2 ] as well as improved quality of patient care and overall performance gains [ 3 ]. Many hospitals have implemented lean in recent years due to these benefits. Lean implementation requires a complete change in organisational culture and thinking, but adopting lean tools does not ensure that the implementation is sustainable or has been adopted as part of the organisation’s culture. This is confirmed by several researchers, like Van Rossum et al. [ 4 ] who argued that lean implementation in healthcare organisations is not always maintained. In the healthcare environment, lean adoption is only seen as successful if the implementation thereof permanently improves the quality of service and patient satisfaction [ 5 ]. Van Beers et al. [ 3 ] further argued that lean implementation in hospitals often does not achieve the desired results and is a lengthy process. Indeed, Akugizibwe and Clegg [ 6 ], observed that healthcare providers (such as hospitals) struggle to sustain the success achieved after initial lean implementation.

Implementing continuous improvement interventions such as lean, Total Quality Management and Six Sigma, is often challenging due to the organisational change management process it requires [ 7 ]. In addition, such implementations are complicated due to, amongst other things, the complexity of healthcare organisations [ 8 , 9 , 10 ]. These complexities include the typical organisational structures of hospitals where different units often function in isolation as their own profit and loss entities, with little motivation for functioning across silos. In addition, hospitals have strict hierarchical structures [ 11 ] and not all stakeholders involved in a patient’s journey (such as physicians) are employed by the hospital, making it difficult to ensure that they buy into the hospital’s lean journey.

Models and frameworks that guide the successful implementation of continuous improvement initiatives in organisations do exist. Despite the availability of such maturity or implementation models [ 12 ], continuous improvement implementation initiatives have a high failure rate [ 7 ]. In line with this, researchers contend that there is minimal evidence of lean healthcare implementations sustained over the long term [ 13 ]. Indeed, D’Andreamatteo et al. [ 14 ] found that although the factors that contribute toward successful lean implementation in healthcare are established in the literature, research on adopting lean sustainably and the implementation process of lean in healthcare is lacking. Henrique et al. [ 15 ] made a first attempt to aggregate key factors that might influence the sustainability of lean interventions in hospitals. Furthermore, Kunnen et al. [ 16 ] thematically analysed the barriers and facilitators that influence the sustainable adoption of lean in healthcare organisations, but not specifically in hospitals.

Lameijer et al. [ 7 ] found that while implementation readiness factors often form part of implementation guidelines or maturity models, factors related to the sustainability of results are lacking. Furthermore, the available guidelines do not address contextual factors such as the industry or environment. Indeed, Andersen et al. [ 17 ] emphasise the importance of tailoring lean specifically for hospitals. Similarly, Antony et al. [ 18 ], Zanon et al. [ 19 ], and our own literature review identified the lack of a fully developed framework and assessment methodology for lean implementation, specifically at the hospital level. In addition, although prescriptive maturity models can provide organisations with the general direction for deploying lean, they do not necessarily guide implementation using clear action items [ 12 ]. Lameijer et al. [ 7 ] argued that there is thus a need for industry- and implementation-specific guidelines or maturity models to boost the success and durability of lean initiatives.

In sum, although lean can address prominent challenges in hospitals there is a gap in the literature on how to sustain lean in hospitals [ 14 ]. With many hospitals facing pressure to improve their financial performance, efficiency and patient care quality, there is a critical need for guidelines on sustaining lean in such settings. This research aims to design a prescriptive maturity model, the S ustaining o f L ean A doption in Hospitals R oadmap (SOLAR), that will help guide practitioners and scholars alike towards sustainable lean implementation in a hospital environment. The first research phase entailed developing the SOLAR from solid theoretical principles: The known success factors for lean implementation, change management theory, and the relatively novel theory of implementation science. In the second research phase, the proposed model was tested utilising a three-round Delphi study, during which feedback from lean healthcare expert practitioners and academics was obtained.

The resulting roadmap is intended to guide the lean adoption process in hospitals through action items throughout the change management process. Furthermore, the SOLAR contributes to the literature by integrating known lean implementation success factors and change management theory with implementation science. The resulting multidisciplinary model takes various prominent features of the hospital setting into account, including the risk-aversity of hospital staff members and the hierarchical, siloed organisational structure, requiring many stakeholders’ involvement beyond only identifying customer/patient value.

The next section provides an overview of the theory on which the initial SOLAR is built. The methodology section explains how the SOLAR was developed in dialogue with experts across the globe. The results section then discusses the content of the SOLAR, after which the theoretical and practical implications are drawn in the final discussion section.

Initial SOLAR development: literature review

The first phase of developing the SOLAR was to establish the building blocks from the literature. A brief background to the purpose and use of maturity models is provided, after which lean implementation success factors, implementation science, and change management theory are reviewed.

• Maturity models

Becker et al. [ 20 ] summarised a maturity model as a guide to organisational transformation from an initial to a desired state, where the model offers the maturity levels to guide organisational transformation. Maturity models are generally applied for two reasons. Firstly, to determine the current maturity level of an organisation [ 21 ]. Maturity models in this context are called descriptive maturity models [ 22 ] and are used to assess an organisation’s progress to achieve a desired level of maturity. Secondly, to guide the organisation’s journey to the desired state, i.e. prescriptive maturity models [ 21 ] that typically include detailed actions developed from historical data to prescribe organisational transformation [ 22 ].

Maturity models can be used in lean deployment to guide organisations on what steps to take to achieve sustainable lean adoption or to assist organisations in assessing how far along the journey towards complete lean adoption they are. Yet, lean adoption is a long-term venture, and many argue that it has no clear ‘end’ because it aims for continuous improvement. Some authors refer to the level at which an organisation has adopted lean as ‘leanness’, i.e. the extent to which lean practices have been adopted and the resulting performance achievements [ 19 ]. Ways to assess the extent to which lean has been infused into an organisation, include benchmarking [ 23 ], storytelling [ 24 ] and assessment tools such as the ‘Lean Enterprise Self-Assessment’ [ 25 ]. Maturity models can also act as evaluation tools to determine an organisation’s current state and guide toward achieving a desired state [ 26 ].

A review by Zanon et al. [ 19 ] revealed 19 lean maturity models that are presented in the literature. All models assess the general adoption of lean in “phases” or “milestones”, both of which are synonymous with “maturity levels”, and the extent to which maturity has been achieved is measured against different criteria. These 19 maturity models are predominantly descriptive. In order to determine the maturity levels of the SOLAR, we investigated the terms used in the models presented by Zanon et al. [ 19 ] and two models [ 22 , 23 ] from our own review of lean maturity models. The six lean maturity models with their respective descriptions of maturity phases are summarised in Table  1 . It was found that all of the models described progressive phases with unique, diverse labels. The phases of maturity are described in intervals of between four and eight steps.

Because of this diversity, Zanon et al. [ 19 ] proposed that lean maturity levels be described as follows:

Level 1 is associated with some (small) lean initiatives being undertaken, which are not fully integrated into the organisation. This level description is similar to, amongst others, level 1 (initial stage, limited awareness) of Verrier et al. [ 31 ] as well as level 1 (adopt lean paradigm) presented by Tortorella et al. [ 29 ]. During this level, preparation for adopting lean in the organisation, typically occurs.

Level 2 is the phase during which customer value is identified and improvements and lean implementation are directed towards isolated areas in the organisation [ 19 ]. This level corresponds to levels 2 and 3 (basic lean implementation and strategic lean implementation) of Jørgensen et al. [ 28 ] as well as levels 3 and 4 of Tortorella et al. [ 29 ] (define value and identify flow of value). In essence, this phase focuses on planning the lean adoption of the organisation and how the lean adoption will realise value.

Level 3 is described by Zanon et al. [ 19 ] as the phase during which improvement initiatives are aligned, and stakeholders can observe how process improvements contribute towards performance metrics. This description is similar to level 4 (quantitatively managed stage) of Verrier et al. [ 31 ], level 3 of Marsilio et al. [ 23 ] (expanding to other units and getting traction) as well as level 4 (proactive lean culture) as presented in the work of Jørgensen et al. [ 28 ].

The final level of lean maturity is characterised by the continuous use of lean concepts throughout the organisation and focuses on sustaining lean adoption in the organisation [ 19 ]. Verrier et al. [ 31 ] describe this level as optimisation (continuous improvement through lean). Marsilio et al. [ 23 ] refer to this level of maturity as “mature transformational performance improvement” and Maier et al. [ 22 ] as “maintenance”.

Furthermore, maturity levels are typically associated with capabilities and activities that an organisation needs to perform or are measured against as they progress on a maturity path [ 32 ]. While investigating such progress of improvement, Netland and Ferdows [ 33 ] observed that an S-shaped operational performance improvement occurs in phases over time. During the initial phases of lean implementation, operational improvement occurs slowly, followed by a drastic and rapid improvement, whereafter the improvement gradually tapers off [ 33 ]. This non-linearity of business performance improvement during lean adoption was confirmed by Negrão et al. [ 34 ]. At the saturation point lean adoption is mature and can be sustained if the correct focus is maintained.

In sum, in keeping with the notion that lean maturity is achieved in phases whereby there must be room for continuous improvement to sustain lean adoption over time, we developed our SOLAR as a prescriptive maturity model comprising four phases deduced from our overview of lean maturity models, as shown in Fig.  1 : Prepare, Plan, Experiment and Learn, and Sustain.

Sustainable lean hospital adoption roadmap maturity phases

Lean implementation success factors

The second building block of the SOLAR is informed by literature-based factors that could influence the successful adoption of lean in a hospital environment. These factors, amongst others, are described as barriers , facilitators , challenges , readiness factors , success factors , inhibitors , and managerial attributes [ 35 , 36 , 37 , 38 , 39 , 40 ]. We refer to them as success factors for brevity. In terms of lean deployment, success factors are those that enable employees to adopt lean thinking in their everyday routines [ 41 ] and can be seen as part of a change-implementation strategy that influences the sustainability of the change [ 8 ]. It is, therefore, critical to incorporate success factors into a lean healthcare adoption maturity model.

This research follows a similar approach to that of Kunnen et al. [ 16 ] but is specific to a hospital environment. Hence, a systematic literature review (SLR) was conducted at the start of this study in 2019 to determine the success factors necessary for lean implementation and adoption in hospitals, and integrated into the SOLAR by addressing the following research question: What factors influence lean implementation success within a hospital environment?

In conducting the SLR following the PRISMA statement [ 42 ], nineteen articles on lean implementation success factors were selected following the systematic approach proposed by Siddaway et al. [ 43 ]. The search terms used in the search databases Scopus and EBSCOhost (which included databases such as Academic Search Premier and MEDLINE) were as follows:

(“lean” OR “continu* improvement”) AND (“implement” OR “deploy*” OR “adopt” OR “adapt” OR “appl*” OR “conscious*” OR “integrat*”) AND (“health care” OR “healthcare” OR “hospital” OR “clinic” OR “health cent*” OR “medical service” OR “medical care environment” OR “medical facility*” OR “medical cent*”) AND (“success factor*” OR “success” OR “critical factor*” OR “change factor*” OR “driver” OR “important factor” OR “facilitate*” OR “sustain” OR “long term” OR “long term” OR “read* factor*” OR “failure factor*” OR “challenge” OR “barrier” OR “lesson*” OR “issue”).

As inclusion criteria, only English papers with available full texts, published in accredited journals or established (peer-reviewed) conference proceedings, and focused on one or more factors influencing lean implementation in a hospital setting were selected by one author (HM), and then independently checked by the first author (MVZ-C). These inclusion criteria meant to account for the relevance and quality of the included papers. Book chapters and studies executed outside of a hospital environment, in non-service parts of the hospital, or those concerned with implementing lean in combination with another methodology, such as Six Sigma, were excluded. In particular, studies combined with Six Sigma were excluded due to their specific focus on quantitative statistical process control initiatives and not primarily on lean success factors. The final selection of papers was then determined by the entire author team (including also DVD); to avoid any omissions, the papers were discussed elaborately.

Before analysing the selected studies in more depth, the author team screened the journal impact factors as well as methods used and rigour to account for the quality of the corpus. SCImago Journal Ranking indicator, which assesses the impact and influence of journals independently, was consulted, and we found that 12 of the 19 articles in our sample were published in the top 25-50% (quartiles one and two) journals. Four articles were published in quartile three (top 75%) journals, two in peer-reviewed conference proceedings, and one in a quartile four journal. The journal ‘Quality Management in Health Care’ (quartile two journal) contributed the most articles (3 articles). The methods followed in our sample ranged from semi-structured interviews (7 articles), literature reviews (6 articles), field observations (2 articles), and quantitative methods such as structural equation modelling (4 articles). The diversity of the sample of selected papers, both in terms of methodology and countries of data collection ranging from Sweden to Iran, is proposed to curb any remaining biases in the selected studies, allowing for high-quality insights. The SLR approach, following the PRISMA statement, is summarized in Fig.  2 .

Systematic literature review approach to determine lean adoption success factors, following the PRISMA statement

In terms of content analysis, any mention of factors influencing the success of lean implementation within a healthcare environment was extracted from the selected studies. To minimize bias and ensure that all relevant factors were collected, we followed the 21-item ENTREQ guidelines [ 44 ]. Firstly, one author (HM) extracted factors influencing successful lean implementation from the selected studies. Then, a second author (MVZ-C) reviewed the selection of factors and compared them to the nineteen selected studies to ensure a balanced view. In line with Kunnen et al. [ 16 ], inductive reasoning was used to create labels for similar factors. The two authors further refined the factor labels with the third author (DVD) whereafter the factors were grouped under four themes: (1) strategy, (2) resources, (3) engaging people, and (4) organisational culture. Table  2 depicts each theme, corresponding lean adoption success factors, and the original sources which identified them.

The success factors listed in Table  2 were used in conjunction with a well-researched framework from implementation science, as discussed in the next section, to develop the proposed action items of the SOLAR under each maturity phase.

• Implementation science

Implementation science, an emerging field in healthcare evidence-based standard practices adoption, was used as the theory that informs the third element of the SOLAR. Implementation science is concerned with the study of methods that aim to diffuse research findings and evidence-based practices into an organisation’s routine [ 57 ]. May and Finch [ 58 ] further defined implementation as a deliberate effort to introduce something new to an environment to bring about change.

According to the theory of implementation science, this change is realised in organisations through a diffusion-dissemination-implementation continuum [ 55 ], which implies an ever-evolving change process. This diffusion-dissemination-implementation continuum is valuable to improving the spread of research findings that could improve a healthcare environment [ 59 ]. Diffusion is the inactive part of imparting knowledge about new practices [ 55 ], whereas dissemination requires more action and actively communicating new practices to the target group to ‘helping it happen’ [ 59 , 60 ]. Implementation is the deliberate action of ensuring that research findings are truly incorporated into the environment’s everyday practices [ 55 ]; in other words, ‘making it happen’ [ 60 ].

A key framework in the field of implementation science that guides the diffusion-dissemination-implementation process is the Quality Implementation Framework (QIF) [ 59 ]. This framework is suitable for informing the action items included in the SOLAR because the QIF may be generalised for any environment, it provides clear process steps for its application, and is widely cited and frequently used.

The QIF lists 14 critical steps in a four-phased approach that contributes towards a quality implementation where fidelity of the innovation is maintained throughout the implementation process [ 61 ]. Examples of these critical steps are determining the organisation’s current state regarding needs and resources, creating implementation teams, ensuring a supportive feedback system, and learning from the experience of implementing the change. Furthermore, the framework provides questions under each critical step the researcher needs to consider when implementing a change intervention. The proposed action items in the SOLAR were thus further developed by incorporating the QIF and its 14 critical steps.

Change management theory

In organisational behaviour literature, it is contended that planned organisational change is more likely to succeed if the change process considers all organisational stakeholders, whereby change needs to occur in a group where individuals’ behaviour and reaction to change is a function of the group environment [ 62 ]. The theory of change management uses frameworks and mechanisms to manage change in an organisation whilst causing minimal negative disruption to the workforce [ 63 ].

Although many useful change management methods and theories have been developed, the variability in each organisation and change environment may require adjustment according to their specific context [ 64 , 65 ]. Al-Haddad and Kotnour [ 62 ] explained the taxonomy of change in literature as consisting of change types, methods, enablers, and outcomes. The change type is classified in terms of the scale and duration of the change. Once the change type is defined, the most appropriate change method can be determined; these methods, in turn, are divided between systematic change methods and change management methods. Systematic change methods include processes and tools that assist organisational change agents (such as managers) to take change-related decisions [ 62 ]. These systematic change methods are cyclical and integrative, as opposed to some traditional change theories that mainly suggest management-driven change through incremental process adjustment. Examples of systematic change methods include Six Sigma, Total Quality Management and process re-engineering. On the other hand, change management methods are more conceptual and broader [ 62 ], as they assist management in aligning the change initiative with the overall organisational strategy and mission and embed the change into the organisational culture.

Al-Haddad and Kotnour [ 62 ] further argued that certain factors increase the probability of successful change and are known as organisational change enablers. Some examples of such enablers include setting a shared vision and direction for the change, clearly communicating the benefit and clarifying the roles of the employees involved in the change [ 63 ]. Notably, training employees and measuring the evolution of organisational change will also increase the probability of sustainable change [ 66 ]. Change outcomes, as depicted by Al-Haddad and Kotnour’s [ 62 ], relate to measuring the change’s performance from both a customer and organisational perspective. Errida and Lotfi [ 67 ] emphasise the importance of setting goals for such performance measures that are continuously tracked.

Furthermore, Stouten et al. [ 64 ] highlighted seven prescriptive change management models. These models (see Table  3 ) guide the management team through sequential steps in executing change interventions in their organisations. Some of the models corresponded with both the change management methods and systematic change methods [ 62 ]. Although lean implementation in a hospital environment will evolve organically and iteratively, it must be embedded in the hospital culture [ 63 ] which tends to be a large change stretched over an extended period. Therefore, change management methods [ 62 ] would be appropriate to guide lean implementation in hospitals, especially the prescriptive ones which provide specific guidance on steps to take. Hence, we focused on the prescriptive change management models classified by Stouten et al. [ 64 ]. In selecting the appropriate models to inform the SOLAR, those prescriptive change management models were filtered to ensure that they were also classified as change management methods by Al-Haddad and Kotnour [ 62 ]. Table  2 shows the result of the filtering process and the subsequent four change management models that are used to inform the SOLAR: (i) Lewin’s three-phase process method, (ii) Judson’s five steps, (iii) Kanter, Stein and Jick’s ten commandments, and (iv) Kotter’s eight-step model.

Stouten et al. [ 64 ] argued that many of the prescriptive models have similar practices and processes. The models also have a flow that acknowledges the start of the change intervention followed by the dissemination and, finally implementation or adoption of the change. As such, Stouten et al. [ 64 ] synthesised these prescriptive change management models into ten change steps, starting with assessing the opportunity to motivate the change and ending with institutionalising the change in the organisational culture and practices. Given the overlap with Al-Haddad and Kotnour [ 62 ], we contend these ten change steps are a comprehensive synthesis of prescriptive change management models and change management methods included in this SOLAR.

Research design

Given the exploratory aim of the research, a Delphi study was conducted where the initial literature-inspired design of the prescriptive maturity model was refined through feedback from lean healthcare experts. The Delphi method elicits the opinion of a panel of experts over multiple rounds on a specific research subject [ 68 , 69 ]. Expert feedback was collected from two rounds of online surveys and from narrative interviews in the third and final round, whereby the initial model was amended after each round. The surveys and the questions used in the narrative interviews were designed based on the approach followed by Tortorella et al. [ 70 ] and further refined after several dry-runs among the author team. They can be found in Additional File 1. The result of the Delphi study is the model we named ‘SOLAR’, presented herein.

Sampling approach and sample description

Delphi study respondents were selected to complete the first-round survey based on their knowledge and experience in implementing lean in hospital environments and their availability and willingness to participate [ 71 , 72 ]. A purposive expert sampling technique was followed, complemented by snowball sampling to avoid selection bias [ 73 ]. Thus, members from the Southern African Industrial Engineering (SAIIE) society were contacted via e-mail. Respondents with experience in academia, public healthcare, and private healthcare were thus identified to form a heterogeneous lean expert group. The respondents were requested to forward the survey to other potential respondents who met the inclusion criteria thereby completing the snowball sampling process. For the second Delphi round, the same method was followed and the recruitment list was expanded to include lean healthcare experts from the Netherlands. Since the third Delphi round was used to validate the SOLAR, respondents from South Africa and the Netherlands who participated in the second round were selected to participate in this final round.

During the first round, 14 participants responded to the online survey. Their experience was balanced between private and public healthcare and academia. The majority of respondents (10 out of 14) were male and six of the respondents had more than 10 years of experience. The second round also elicited responses from 14 individuals, five of whom also participated in the first round. Most respondents of this second Delphi round indicated their lean in healthcare experience as private healthcare, nine were male and five female. All four respondents (three males, one female) who participated in the third round also participated in the second round, and one of them also took part in the first round. The respondents’ experience in lean in healthcare was equally represented by public and private healthcare as well as academia. Table  4 summarises the respondent data for all three Delphi rounds.

Data collection

Delphi round 1 – approach and outcomes.

The initial prescriptive maturity model was presented to respondents in an explanatory video, followed by an online survey (Supplementary Table 1, Additional file 1) which consisted of multiple closed-ended questions. Specifically, respondents were asked to indicate to what degree they agreed with the statement: ‘ Although initial lean implementations in hospitals might be successful , it is often not sustained’ and: ‘The maturity model contributes towards the sustainability of lean implementation in a hospital’ . Respondents rated their level of agreement on a five-point scale ranging from ‘strongly disagree’, ‘disagree’, ‘undecided’, ‘agree’, or ‘strongly agree’. The survey also contained an open field for suggestions for improvement of the maturity model.

Ten out of 14 respondents agreed that hospitals often do not sustain lean implementation. Although 11 of the 14 respondents agreed that the initial maturity model contributed towards lean sustainability in hospitals, suggestions for improvement were also made. One respondent noted that the original naming of the four maturity phases (i.e., prepare, plan, implement and sustain) did indicate a clear implementation path but did not indicate how maturity evolved. Another respondent argued that the lean implementation strategy needs to be aligned with the hospital’s strategy. Another point of feedback was that the model’s action items should be more descriptive to be more actionable. Based on this feedback the model was altered incorporating change management theory, renaming the maturity phases, and refining the action items to be more descriptive and aligned with respondents’ feedback.

Delphi round 2 – approach and outcomes

The amended model was presented to respondents in a second Delphi round, using the same method as round one. The survey questions for the second round can be found in Supplementary Table 2, Additional file 1. Although some questions were similar to the first round, to evaluate the model’s usefulness, new questions were posed, such as ‘ Do you agree that the action items of the maturity model address all the relevant steps that need to be taken to successfully implement and sustain Lean in a hospital?’

The results from this round indicated that seven out of 14 respondents agreed that lean implementation in hospitals is often not sustained. Twelve respondents agreed that, once the four phases of the maturity model and the corresponding action items were completed, lean implementation in a hospital would be sustained over the long term. Furthermore, ten respondents indicated that the model could be applied to any hospital setting. Some suggested changes regarding how the change steps were integrated within each model phase whereas others noted that actions within lean implementation were ‘ongoing , iterative , and circular’ . Respondents also commented that it was a ‘very elaborate and well thought through model’ and ‘I can see that a well-structured , scientific method was followed’. The feedback from this second round helped alter the model to clarify how change steps were associated with maturity levels and to rename the third maturity level to “Experiment and Learn”. Action items were further refined.

Delphi round 3 – approach and outcomes

During the one-on-one online interviews of the third round, the final prescriptive maturity model was shared with the four respondents who took part in the second round and offered differing viewpoints. During these interviews, the researcher(s) presented the final SOLAR and the revisions based on the second round. (Supplementary Table 3, Additional File 1). The first question we asked was ‘ Do you agree with the naming of the model? ’. We also asked whether ‘the presentation of the phases of the maturity model was clearer’ . These questions stimulated an open conversation. The narrative that followed generally indicated that respondents were now clear that the aim of the prescriptive maturity model was to act as a guideline rather than a set of instructions. All respondents agreed that the final SOLAR was sound. Respondents also supported naming the third phase as ‘experiment and learn’, saying that ‘it’s very clear now that it’s cyclical’. Regarding the model’s usefulness, respondents said they ‘really thought this made sense from a theoretical and practical standpoint’ and ‘it is a useful model and the updates are practical’ . The final SOLAR, the result of a thorough theoretical investigation and three Delphi rounds, is presented in the next section.

The final SOLAR is a prescriptive maturity model consisting of four phases: Prepare, Plan, Experiment and Learn, and Sustain. The underlying action items are informed by lean implementation success factors, as discussed in Sect. 2.2, and by the 14 critical steps of the QIF discussed in Sect. 2.3. The action items of each phase are presented under four themes, namely strategy, resources, engaging people, and culture. The final element of the SOLAR is change management theory: The ten change steps, derived from Stouten et al. [ 64 ] are highlighted and incorporated during each phase and theme of the SOLAR. The action items and change management steps shown in the SOLAR are not intended as an exhaustive list but provide guidelines on aspects one must consider for a hospital that aims to adopt lean sustainably. Table  5 depicts the final SOLAR, which is discussed here in relation to the literature.

Phase 1: Prepare

As suggested by Zanon et al. [ 19 ], the first phase (Prepare) is associated with minor changes and setting the scene for lean implementation. In terms of the ‘strategy’ action items, following Grove et al. [ 37 ] and Lorden et al. [ 51 ] it is essential for a hospital to specify its (lean) strategic direction and improvement needs. It is key to contextualise how lean would fit into the hospital’s operating environment, the stakeholders of the lean adoption, and how they would benefit from lean adoption. Some stakeholders benefit more directly, such as patients, and others more indirectly such as suppliers. Furthermore, researching prior continuous improvement efforts and their successes and failures in a specific hospital is critical to setting the lean adoption strategy [ 14 , 56 ]. These actions contribute to fulfilling Stouten et al.’s change step 1 [ 64 ].

‘Resources’ such as technology and trained lean staff members are required for a successful lean implementation in a hospital [ 52 ]. This implies the need to identify staff with previous exposure to lean in the form of training or practical lean experience. In addition, assessing whether other stakeholders are currently adopting lean is recommended to ensure alignment with their efforts and possibly leveraging from them. One must also identify technology currently in place that may ease team communication and enable aspects such as visual (performance) management in wards.

An initial engagement with people on lean and the value that may be realised will set the scene for the change initiative. In terms of ‘engaging people’, further involving management, staff members, and other stakeholders is characterised by change step 2 [ 64 ]. It is important to obtain management commitment for lean adoption at an early stage [ 51 ]. The underlying action items of this theme resonate with the ‘strategy’-related action items in that management needs to align the strategy of the organisation and hospital with the strategy of lean adoption. Moreover, communicating a sense of urgency to staff and introducing the lean philosophy will mobilise energy for change during the preparation phase.

During this initial engagement with employees, their readiness for change can be assessed [ 45 ]. A clear indication of employees’ change readiness is their realisation that the hospital needs process improvement [ 67 ]. Simultaneously the extent to which the hospital’s culture aligns with the lean philosophy will highlight behaviour that is not conducive to a lean culture. This will guide the implementation team in determining where to place their change efforts as the lean implementation progresses. Altogether, these action items allow an organisation to move on to the next phase.

Phase 2: Plan

The planning phase is characterised by (initially) isolated lean improvements in the organisation [ 19 ]. The development of change-related knowledge and abilities is predominant in this phase [ 64 ]. With a clear company strategy in place from the preparation phase, the lean adoption strategy should be determined and set out in a clear adoption plan co-created by leaders at various hierarchical levels [ 3 ], for instance, by setting up monthly lean performance meetings at the top management level. Moreover, the specific value for various stakeholders anticipated by the lean adoption must be identified along with the criteria for measuring this value [ 74 ]. The value of lean in, for example, reducing waste such as waiting time that often occurs across all specialisations, can be articulated in this phase [ 1 ].

The planning phase provides the opportunity to list outstanding supporting resources and enlist external experts’ services to provide employees with the required lean knowledge and capability training specific to healthcare [ 17 , 48 ] aligned with, change step 7 [ 64 ]. The engagement of people across the organisation is a priority during this phase [ 45 ]. This includes appointing a lean adoption team, ideally consisting of lean champions and other front-line staff. Since hospitals often have clear hierarchies in place that may limit teamwork [ 52 ], staff members from all organisational levels must be included as lean practitioners to curb any communication barriers. These employees must be informal leaders and have an inherent mindset of critical thinking and questioning the status quo [ 45 ]. This lean adoption team’s supportive roles, processes, and responsibilities must also be specified during this phase. The variability of patient demand often leads to the last-minute acute engagement of front-line staff in patient care and during scheduled lean activities. Hence, during the planning phase, the roles, processes and responsibilities in such scenarios must be clarified. Furthermore, the lean adoption team must be empowered to lead the lean change by providing them with training on lean, leadership, and change management principles. Altogether these change steps are clearly aligned with change steps 2, 6 and 7 [ 64 ].

As part of ‘engaging people’, the shared vision for lean and common direction that was determined during the preparation phase must now be communicated clearly (i.e., Stouten et al.’s [ 64 ] change step 4). Because this should lead to initial acceptance of lean (and not resistance), in the context of a fast-paced hospital environment, it should emphasise how value will be added and waste eliminated [ 75 ], allowing healthcare workers to focus on the quality of patient care.

Also measuring the progress of lean adoption will contribute to engaging people. Indeed, Noori [ 49 ] contends that quick wins are essential to motivate hospital staff towards lean adoption. Developing an organisational performance feedback system enables the measurement of the relationship between lean adoption and performance improvement across all levels of the organisation. The performance should be discussed at time intervals that align with strategic, tactical, and operational performance meetings. Bhasin [ 76 ] noted that such a lean performance management and measurement system needs to fit each organisational level to promote positive organisational behaviour and change acceptance. Possible performance indicators include reduced patient waiting time, improved resource utilisation, and patient satisfaction [ 76 ].

The measurement of lean adoption might also identify certain behaviours that are not conducive to a lean culture, leading to interventions to build a more supportive continuous improvement lean culture [ 45 ]. Once the change readiness of most employees has been determined and that the lean philosophy aligns with the cultural preferences of the hospital, the planning phase can be used to start establishing a supportive culture of continuous improvement and to manage resistance to change [ 52 ] by giving positive attention to those employees who embrace change.

Phase 3: Experiment and learn

Each hospital has a unique operating environment and case mix [ 77 ]. A lean implementation maturity model must thus be contextualised as highlighted in the preparation phase. Therefore, the third phase has the longest duration, and this phase is associated with adapting lean according to the hospital’s specific requirements. This phase of lean maturity focuses on experimenting with lean adoption in various areas and proactively learning from this adoption by reviewing performance metrics.

From a strategic perspective, it is critical that top management support the lean adoption process and change its behaviour accordingly during this phase [ 50 ]. This may include revising some key performance indicators (KPIs) such as bed utilisation measures that management traditionally promotes [ 78 ]. Should such measurements prove to promote non-lean behaviour, top management needs to be proactive and change such KPIs. Installing lean performance meetings on a tactical and operational level will further assist in continuously learning from the lean adoption. These meetings provide a platform for discussing the measurement of lean’s value for stakeholders using the measurement criteria established in the planning phase [ 74 ]. Lastly, lean performance meetings will facilitate Stouten et al.’s [ 64 ] change step 4, 5, and 8. It is also beneficial to precisely plan and create short-term wins during this phase; those short-term successes can be used to reinforce the lean transformation (change step 8).

Change step 2 can be further executed by developing internal lean experts [ 52 ] through establishing a guiding coalition consisting of internal staff members. Although external experts enlisted during the previous phase may still be involved in the experiment and learn phase, their involvement will diminish over time as internal experts are developed [ 79 ] who could then start training other staff members during this phase. Using staff to train other employees on aspects of lean (such as the use of the unique lean vocabulary applicable to healthcare) can be a valuable tool in accelerating the adoption of lean while empowering staff to identify waste in their respective areas [ 35 ], which will mobilise the change and develop the required knowledge and abilities that promote the general acceptance of lean throughout the organisation (as described in Stouten et al.’s [ 64 ] change step 5 and 7). Inter-departmental cooperation is a hospital-specific aspect to establish for the realisation of this acceptance [ 36 ]. This tends to be a challenge, given the highly specialised disciplines in a hospital as well as the subsequent organisational silos that this creates [ 80 ].

Internal experts are referred to as lean champions, and the development of these resources is closely related to change step 6. Other supporting resources, such as software enabling knowledge management must also be provided [ 81 ]. Certain processes may need to be changed in such a way that they are aligned with the change vision set out in the preparation phase of the strategy theme. If, for example, the change vision of the hospital was set in the preparation phase to include collaboration between suppliers such as pathology and radiology services, process adaptations may include regular lean meetings between the front-line hospital staff and the supply staff.

The performance measurement system installed during the previous phase will act as a support tool through which the adoption team’s performance can regularly be evaluated. This action item also enables teams across units in the hospital to benchmark their performance in terms of achieving lean goals set out during the earlier phases, which will assist in eliminating organisational silos typical in hospitals whilst also embedding the lean adoption [ 70 ]. The feedback system must trigger remedial action so hospital staff can learn from mistakes [ 14 ] and make changes accordingly. Furthermore, feedback on lean adoption must be communicated throughout the hospital [ 51 ], providing all stakeholders with information on the implementation progress. From the above, it is clear that change steps 5, 6, 7 and 8 are addressed in the action items.

Most employees will experience changes in the hospital during the experiment and learn phase. It is important to reinforce the lean organisational culture of continuous improvement as the phase continues [ 53 ], whereby management needs to display exemplary lean behaviour [ 82 ]. Change steps 6 and 9 are clearly aligned with those actions. Finally, the experiment and learn phase is iterative in nature. As lean implementation and the associated action items of the SOLAR are progressing, it is important to modify actions to fit in with the specific hospital environment. For example, redefining the value that lean unlocks for some stakeholders may be necessary. This implies that some aspects of the planning phase should be amended.

Phase 4: Sustain

The final phase of the SOLAR is characterised by the continuous monitoring of process improvements [ 19 ]. Change steps 9 and 10 promote the monitoring and institutionalisation of the change and are associated with this final phase [ 64 ]. Change will be institutionalised by maintaining the initial strategy and common direction [ 36 ]. It also remains important during this phase to continue to set lean goals and measure the value that lean realises for all stakeholders.

Resources such as technology and specific software need to be kept up-to-date, and changes to processes institutionalised by continuously updating standard operating procedures and staff structures [ 56 ]. Allocating resources to amend the reporting structure of certain units may be necessary. Furthermore, some KPIs, such as waiting time and its definition [ 1 ], may change as the hospital environment evolves. It remains critical to continue with lean training during this final phase whilst normalising the supportive lean culture of continuous improvement [ 48 ].

The high failure rate of continuous improvement initiatives [ 7 ] and lean implementation in hospitals [ 13 ] indicate a latent need for more clarity on how to adopt lean in a hospital setting. So far, however, there was no lean maturity model specific to healthcare or a hospital environment [ 19 ]. This is problematic because the hierarchical nature of healthcare is often a barrier to bottom-up improvement and the adoption of lean throughout the hospital (system-wide) instead of applying tools and techniques in isolation [ 11 ]. The SOLAR developed herein, therefore, responds to the need for a hospital-wide lean maturity model that takes into account the complexities of healthcare. In developing the SOLAR, relevant aspects from the literature were synthesised. As such, this research expands on the prolific lean implementation in healthcare literature by combining the known success factors with implementation science and change management theory. This makes the SOLAR simultaneously unique, comprehensive, and more practical.

A prominent complexity covered by the SOLAR is the primary goal of healthcare workers in hospitals to ensure the quality of patient care. Due to the sensitive nature of hospital settings and the human lives that are often at stake, hospital staff are more risk averse. A hospital is not the ideal setting for ‘trial and error’, often part of regular lean adoptions [ 70 ]. Continuous improvement initiatives may, therefore – initially – seem counter-intuitive for healthcare workers. However, since a key building block of the SOLAR is evidence-based implementation science, hospital staff are more likely to have confidence in using the SOLAR to guide them along their lean adoption journey. Furthermore, the SOLAR provides guided experimentation and learning in the third phase of sustainable lean implementation. The action items in this phase of the SOLAR allow hospitals to tailor implementation methods that are best suited to their unique operating context through guided experimentation and learning.

A second hospital-specific complexity is covered by integrating change management theory [ 64 ] throughout the SOLAR. Specialisation silos and hierarchies are often a barrier to sustainable lean implementation in hospitals [ 83 ]. The change coalition that is established in the planning phase of the SOLAR consists of staff from all units across all levels of the hospital which enables the permeation of barriers that existed because of hierarchies and silos. Consequently, the SOLAR emphasises the importance of identifying the stakeholders throughout the hospital that will be impacted by lean adoption in the preparation phase, as well as the subsequent defining of stakeholder value, and measuring and evaluating how lean adds value throughout the hospital. The concept of ‘value’, which is often conceptualised solely from the customer’s (the patient’s) perspective, is also determined for the different stakeholders. Ensuring that the perspectives of multiple stakeholders are proactively taken into account also reduces the risk of focusing on internal lean goals such as efficiency and cost reduction, which is often seen in public service settings [ 84 ].

In sum, in conjunction with the solid theoretical base, the SOLAR utilises input from lean healthcare practitioners and academics. As confirmed by them, the SOLAR is based on relevant theory and yet remains practical.

Practical implications

The SOLAR was developed to be used by practitioners and academics as a practical guideline to test their approach on implementing lean in hospitals against. In particular, we envisage that top managers of hospitals, strategic advisors, and those in organisational development and continuous process improvement roles will find the SOLAR useful to tailor their hospital’s lean adoption approach. For example, using the SOLAR as an inspiration, data on the lean adoption progress can be captured by the lean adoption team and then discussed during periodical lean adoption strategy meetings. This data will be useful to (top) managers since it drives their learning process and informs decisions on support required to sustainably adopt lean.

The SOLAR also addresses the critical aspects pertaining to strategy, resources, the engagement of people, and organisational culture throughout lean adoption in hospitals. As mentioned, the SOLAR guides the implementation approach by emphasizing certain actions along the phases of the lean implementation journey in a hospital. This has proven to be a suitable characteristic of the SOLAR since respondents to the Delphi study agreed on its usefulness. Although the maturity phases of the SOLAR have been presented sequentially, there may be a need for hospitals implementing lean to revisit some of the phases as insights are gained during their lean implementation journey. Such tailoring to the unique hospital environment also enables hospital staff to accept lean adoption [ 83 , 85 ]. While balancing between ‘theorising’ and ‘generalising’ as called for by Åhlström et al. [ 86 ], the model is further adaptable to local hospital environments.

Limitations and future research

Creating an exhaustive list of items that need to be completed in a lean adoption journey is impossible, given that different contexts might require slightly different foci and organizational change is a dynamic process. And although we followed a systematic approach to reviewing the literature and Delphi study respondents have screened the SOLAR in various rounds, we may still have missed certain points. We propose that for purposive expert sampling, one could also consider approaching formal interest groups and associations with members who specialise in lean (i.e. the Lean Institute Africa, the Dutch Lean Healthcare community united in the ‘Lean in de Zorg’ (LIDZ) foundation, and the Lean Global Network).

Because some respondents in the Delphi study expressed the need for a more descriptive maturity model, this may be another valuable extension of our research. Reponen et al. [ 87 ] proposed a conceptual framework that can be used to benchmark lean performance in healthcare environments against best practices whilst taking the context of the environment into account. Since the inclusion of specific instructions on how to implement aspects such as training, communicating the strategy, and organising resources were not included in the aim of this research, the authors recommend that future research should include these aspects.

The next step is to validate the SOLAR in a hospital setting by further testing and possibly refining it. This can either be done retrospectively through a longitudinal study of hospitals that have implemented lean or as an intervention study following the action research approach [ 88 , 89 ]. In the case of action research, positioning the SOLAR as a guideline for the lean implementation will be the starting point. Post-implementation focus groups can subsequently be used as a further validation tool of the SOLAR. We further propose to assess to what extent the lean intervention is brought about by the further operationalizing the action items of the SOLAR. One way to assess this is by using the PARTI (Participatory Action Research, Translation, and Implementation) model underpinned by implementation science [ 90 ].

Hospitals are unique service environments that provide an essential and critical service to the community. Furthermore, hospitals tend to be high-pressure environments with variable demand and specialised services. These specialisations often result in silo structures which are hierarchical in nature and associated with waste and inefficiencies. Lean implementation in hospitals has, however, been proven to result in significant process improvements and enhanced quality of patient care. To address lean implementation efforts that are often not sustained in hospitals, we have developed the SOLAR: A unique maturity model that can act as a guideline for hospitals embarking on a lean implementation journey. After gathering expert feedback in three Delphi rounds, the SOLAR is suitable for use by academics and practitioners involved in lean deployment in hospitals, particularly because of its strong underpinning by implementation science and change management theory.

Availability of data and materials

The data used for the Systematic Literature Review was retrieved from publicly available internet databases as specified in the manuscript and is available from the authors upon reasonable request. The dataset for the Delphi study is not publicly available to protect the identity of respondents.

Abbreviations

Enhancing Transparency in Reporting the Synthesis of Qualitative Research

Lean in de Zorg

Participatory Action Research, Translation, and Implementation

Preferred Reporting Items for Systematic reviews and Meta-Analyses

Quality Implementation Framework

Systematic Literature Review

Sustaining of Lean Adoption in Hospitals Roadmap

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Maria M. Van Zyl-Cillié & Hanneke Meijer

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The authors’ contributions are as follows: MVZ-C: Conceptualization, Methodology and research design, Data analysis, Writing-Review and Editing; DVD: Conceptualisation, Methodology and research design, Writing-Review and Editing; HM: Conceptualization, Methodology and research design, Data analysis. All authors have read and approved the final manuscript.

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Van Zyl-Cillié, M.M., van Dun, D.H. & Meijer, H. Toward a roadmap for sustainable lean adoption in hospitals: a Delphi study. BMC Health Serv Res 24 , 1088 (2024). https://doi.org/10.1186/s12913-024-11529-4

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Perceived structural empowerment, resilience, and intent to stay among midwives and registered nurses in Saudi Arabia: a convergent parallel mixed methods study

• Areej Ghalib Al-Otaibi   ORCID: orcid.org/0000-0002-3698-1248 1 ,
• Ahmad E. Aboshaiqah 2 ,
• Fatimah Ali Aburshaid 3 ,
• Anwar Nader AlKhunaizi   ORCID: orcid.org/0000-0003-4082-3530 4 &
• Sarah Abdulaziz AlAbdalhai 5  

BMC Nursing volume  23 , Article number:  649 ( 2024 ) Cite this article

Metrics details

Retaining midwives and registered nurses in the Obstetrics and Gynecology department/unit (OB/GYN) is not just a matter of organizational effectiveness and financial wellness. It’s a crucial aspect of ensuring quality healthcare delivery. This study aimed to discuss the degree to which midwives and nurses in OB/GYN departments are structurally empowered, resilient, and committed to remaining at the organizations and to examine whether nurses’ and midwives’sense of structural empowerment and resilience is a good predictor of their decision to stay with the organization.

This study employed a unique convergent parallel mixed methods approach. The research was conducted in two distinct phases. The first phase involved a cross-sectional quantitative survey with a convenience sample of 200 midwives and nurses in OB/GYN departments. The second phase was a qualitative study utilizing semi-structured, open-ended interviews. Eighteen nurses and midwives, specifically chosen as the target population, were invited to participate in individual interviews. The data collection took place at three major hospitals in Saudi Arabia, starting in January 2023 and concluding in February 2023.

The study results revealed that structural empowerment and resilience were statistically significant predictors of the intent to stay in the organization (F = 35.216, p  < 0.001), with 26.3% variation, the structural empowerment is higher predictor (β = 0.486, p  < 0.000) to intent to stay if compared to resilience (β = 0.215, p  < 0.008). Five major themes emerged from the narratives of the nurses and midwives: the nurturing of the physical and physiological, the development of the psychological, the managing finances, the restructuring of the organization, and the enrichment of the professional and occupational.

The study’s findings have significant implications for healthcare organizations. They highlight the importance of cultivating a culture of empowerment and resilience, which can serve as a powerful tool to encourage registered nurses and midwives to remain in their organizations. This insight empowers healthcare administrators, human resource managers, and obstetrics and gynecology professionals to take proactive steps toward improving retention rates.

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Nurses and midwives are the backbones of the medical system and the most visible segment of the health sector. There are about 29 million nurses and midwives worldwide, according to the World Health Statistics Report [ 1 , 2 , 3 ]. The World Health Organization (WHO) predicts that by 2030, the world will need 9 million more nurses and midwives to meet increasing healthcare demands [ 4 , 5 ]. Nurses are in low supply in the Kingdom of Saudi Arabia (KSA) [ 6 ]. Under the KSA’s Saudi Vision 2030, midwifery is a healthcare service that will be vastly upgraded [ 7 ]. Providing high-quality midwifery, enhanced maternal health, and emotional and practical support to patients and their families are all within the purview of a midwife’s professional responsibilities [ 8 ]. The healthcare organization is constantly evolving at a fast pace. According to Johnson [ 9 ] and Altaweli et al. [ 7 ], the total number of births reported by the KSA’s Ministry of Health (MOH) hospitals in 2018 was 265,318. This represents an annual 2.43% increase in the Saudi Arabian population. Therefore, aspiring midwives require diverse characteristics and abilities to launch and sustain successful careers. This includes the traits of being able to bounce back from adversity, having confidence in one’s abilities, and having the ability to handle difficult situations at work.

However, nursing and midwifery professions requiring specialized care are susceptible to staffing gaps. According to Altaweli et al. [ 7 ], the MOH needs more than 7,000 additional midwives to care for mothers and newborns. The health transformation strategy expects more than 100,000 nursing positions to be required by 2030 to realize Saudi Vision 2030 [ 10 ]. However, whether nurses and midwives will continue working in healthcare facilities in the KSA is still being determined. In fact, the KSA has a relatively high nursing turnover rate, as with midwifery, which is higher than in other countries. For example, the KSA has a 20% higher nursing turnover rate than the United Kingdom [ 11 ]. The lack of healthcare professionals is causing problems, but it also needs to be clarified how hard and committed the present crop of nurses and midwives is. There hasn’t been a study done in KSA to investigate the factors of structure empowerment and resilience and determine whether they could help reduce nurses and midwives’ turnover in the future and encourage them to remain in their organization.

Much research has looked into the factors leading to high turnover rates in the midwifery field and nursing workforce [ 12 ]. In both healthcare professions, a lack of appreciation, stress, strenuous working responsibilities, lack of management support, poor compensation, and insufficient quality of life due to a lack of family and social life have all been recognized as contributing factors to this issue. Structural empowerment concerns social structures that facilitate the employee’s work. Structural empowerment, a term broadly used in the nursing literature, refers to successfully resolving these negative influences. It entails substantial factors that must exist in the workplace if midwives are to be effectively empowered. One such paradigm is Kanter’s structural empowerment, and its components include education, social networks, material resources, and professional development possibilities [ 13 ]. Sullivan et al. [ 14 ]. Corroborate this, finding many elements connected to a midwife’s capacity for resiliency, empowerment, and a long career. Support from superiors, easy access to information, and a sense of agency and control in carrying out one’s duties all affect longevity in one’s career.

In their studies, Hezaveh et al. [ 15 ] and Pallant et al. [ 16 ] asserted that Nurses’ and midwives’ improved professional effectiveness is related to their increased resilience after experiencing empowerment. They can better adjust to stress on the job and boost their professional health as they receive more managerial backing, professional recognition, and the appropriate skills and resources. In turn, creating a pleasant workplace and conducive settings for professional work helps to keep nurses around for the long haul. In their study, Al-Hamdan et al. [ 17 ] found that nurses are more likely to commit to an organization if they feel supported by the leadership, have access to the tools they need, and have positive relationships with their coworkers. Nurses are more likely to feel loyal to their employers and stay with the organization if they are given responsibility, respect, and encouragement to do their best work in service of the organization’s mission [ 18 ]. To the researchers’ knowledge, no previous studies have analyzed the connection between structural empowerment, resilience, and intention to stay in the context of the Saudi Arabian midwifery and nursing workforce. Consequently, the current literature about this crucial area of research lacks depth. The present study stands out from the rest of the literature because it attempts to investigate three variables that have not been thoroughly explored in previous research.

Based on the literature gap, this study aimed to discuss the degree to which midwives and nurses in OB/GYN departments are structurally empowered, resilient, and committed to remaining at the organizations and to examine whether nurses’ and midwives’ sense of structural empowerment and resilience is a good predictor of their decision to stay with the organization.

A convergent parallel mixed methods design including quantitative cross-sectional research design and qualitative research design was adopted, which means the collection of quantitative and qualitative data is independent, the analysis of both types of data is separate, and the two datasets are merged finally to see whether the findings converged, diverged or enhanced each other [ 19 ]. The justification for utilizing convergent mixed-methods design in this study is that the researchers would like to gain a more holistic and comprehensive understanding of the nurse’s and midwives’ perceptions towards structural empowerment, resilience, and intent to stay, which is to strengthen the findings of one component with the findings of the other component and to answer different types of questions [ 20 ]. Thus, the main aim of this study fits the five purposes of mixed-method designs: triangulation, complementarity, development, initiation, and expansion [ 21 ]. The researchers in this study used a mixed-methods approach because they believed that neither the quantitative nor the qualitative approaches taken separately would provide adequate information to accomplish their goals and answer the concerns.

Participants

Quantitative sample.

This study was conducted at the beginning of January 2023 and continued until the end of February 2023. The quantitative phase of the data collection involved gathering quantitative data from participants who met the inclusion criteria and were selected using a convenient non-probability sampling strategy. The sample size required for this study was derived based on a rigorous power analysis using G*Power 3.1™, a trusted scientific tool. A power of 95%, α = 0.05, a medium-effect size (f 2 = 0.15), and two predictors (structural empowerment and resilience) were used as the statistical basis for calculating a linear multiple regression analysis (fixed model, R2 deviation from zero). Based on the results, 107 participants from the total population ( n  = 297) were sufficient for this study.

Participants were included in the research study if they met the following selection criteria at the time of data collection–nurses and midwives who had three or more years of practical experience working in (delivery rooms, OB/GYN emergency rooms, and obstetrics departments), and were willing to participate in the research study. The participants were excluded from the research study if they were nurses and midwives newly recruited in the orientation period at the time of data collection. The careful selection of participants was a key aspect of the study’s design, ensuring the relevance and accuracy of the study’s findings and providing a solid foundation for the research.

To select the required sample, the researchers coded all eligible registered nurses employed at the three hospitals based on lists provided by the senior hospital administrators and the hospital director. The researchers then sent the research questionnaire link for all of them to participate in the research.

Qualitative sample

For qualitative study, the participants were eighteen registered nurses and midwives working in the OB/GYN departments of the three selected government hospitals located in the Eastern Province of Saudi Arabia (Al Khobar, Dammam, and Al Hasa), who had met the inclusion criteria by utilizing a purposive sampling: an OB/GYN nurse or midwife in the selected organizations, a minimum of three or more years of working experience to enhance credibility and trustworthiness of data, and willingness to cooperate with the researchers.

Each participating nurse and midwife were interviewed in a semi-structured individual interview. These interview sessions lasted 30 to 60 min and took place at the participants’ place of work. When the researchers determined that no new issues continued to emerge and the same topics would be repeated, data saturation was considered to have been attained, and data collection was terminated.

Setting of the study

The study was conducted in three maternity hospitals in the Eastern Province of Saudi Arabia. These hospitals were selected based on their capacity, which exceeds 500 beds in total, and their provision of 24/7 high-quality integrated health services in the field of Obstetrics and Gynecology. Additionally, their large staff of over 250 nurses and midwives in the Obstetrics departments, and their recognition as mother-friendly hospitals, where midwives provide high-standard and quality delivery care, were key factors in their selection.

Data collection

Structural empowerment.

The Conditions of Work Effectiveness Questionnaire (CWEQ-II) is a self-reported questionnaire developed by Spence Laschinger et al. [ 22 ]. The researchers adapted it to measure the midwives’ and nurses’ perceptions of structural empowerment.

The CWEQ-II is used in international nursing research; a questionnaire consists of 19 items based on Kanter’s structural theory of organization empowerment; these items were grouped under six dimensions: Access to opportunity, access to support, access to resources, having formal power and having informal power. Responses were measured on a five points Likert scale ranging from (1) to (5) where 1 represents ‘none’ and 5 represents ‘a lot’.

The components can vary from 6 to 30, with values between 6 and 13 meaning low level of structural empowerment, between 14 and 22 meaning moderate levels, and between 23 and 30 representing high value of structural empowerment. A high score indicated a high level of participants’ perception of structural empowerment. Cronbach’s previous studies reported alpha reliabilities for the instrument, which ranged from 0.81 to 0.87 [ 23 ].

The Connor–Davidson Resilience Scale 10-Item (CD-RISC-10) version questionnaire [ 24 ] was chosen to measure resilience in this study. This shortened version of the original 25-item questionnaire is a widely used, unidimensional self-report questionnaire. It contains ten statements, and the responses to each statement were measured on a five-point Likert scale, where 0 represents ‘not true at all’ and four means ‘true nearly all the time.’

Nurses’ and midwives’ responses to all ten statements in this section can provide insight into their organizations’ resilience perceptions. The final score on the questionnaire was the sum of the responses obtained on each item (range from 0 to 40), with values between 0 and 29 meaning the lowest level of resilience, between 30 and 32 meaning low levels, between 33 and 36 meaning moderate level, and between 37 and 40 representing the high value of resilience. The highest scores indicate the highest level of resilience. Cronbach’s alpha ranged from 0.6 to 0.7 and has a moderate reliability rating [ 24 ].

• Intent to stay

Nurses’ and midwives’ intent to stay in the organizations was measured by McCain’s Behavioral Commitment Scale (MBCS), which was developed by McCloskey and McCain [ 25 ]. The MBCS consists of 38 items; McCain extracted five items from this scale to measure nurses’ intent to stay [ 26 ]. The 5-item Subscale from McCain’s Behavioral Commitment Scale is used in the current study. This section contains five statements used to measure midwives’ and nurses’ perceptions of their intention to stay in their current organizations. The responses to each statement were measured on a five-point Likert scale, where one represents ‘strongly disagree,’ and five represents ‘strongly agree.’ The Cronbach’s alpha of McCain’s subscale of intent to stay was (0.90). The total score ranges from 5 to 25, and the scores are summed and divided by the number of statements to attain the participant’s perception mean. A higher score indicated a higher intent to stay.

Socio-demographic characteristics of the participants

The researchers developed the socio-demographic questionnaire, which was used to collect information about the participants’ socio-demographic characteristics. This information included the participants’ ages, marital status, work settings, years of experience, and educational levels. These items for the questionnaire were developed based on the reviewed literature about structural empowerment, resilience, and the intention to stay in the organization.

Qualitative phase

The research instruments were a series of semi-structured interviews, field notes, and audio recordings. These strategies were chosen to generate an in-depth exploration of the participants’ working experiences with research phenomena. A semi-structured interview guide was developed by the researchers to elicit participant data. Creswell & Creswell [ 19 ] indicated that the interview-guided questionnaire consisted of a series of open-ended questions that elicited the participants’ experiences. This type of data allowed the researchers to ask follow-up/probing questions from the participants so that they could clarify and expound their thoughts and have a deeper understanding of the facts presented [ 27 ].

The transcript files contained the raw data from the interviews, such as a detailed consecutive account of the participants, settings, and reflective notes on the research experience and methodological issues. The information likewise was obtaining the personal files, which enabled the reconstruction of conversations in context rather than simply relying on a contextual verbal recording. Information on the participants’ reflections and insights was also included. Audio recording was used during the interview to facilitate data gathering and verification of the information supplied during the interview.

Ethical considerations

Ethical approval.

Permission to carry out the study and record the interviews was obtained from the ethics bodies of King Saud University’s Institutional Review Board (Ref no: KSU-HE-22-785) and Governmental Hospitals (Ref No: EXT-MS-2022-001) -(Ref No: H-05-HS-065). To further protect participant anonymity, they were assigned color-coded numbers and pseudonyms. Before the interviews, participants signed a written consent form, demonstrating their voluntary participation and allowing the researchers to make audio recordings. We assured participants that their contributions, names, and recordings would be treated with the utmost respect and confidentiality.

Participants were also informed they could withdraw from the research or stop the recording at any time. The researchers showed the utmost care for the participants by adhering to the rigorous ethical concept of protecting the participants’ health and their right to privacy during the research, the participants’ informed consent was sought in the form of a written document that was signed during face-to-face contact. As a direct consequence of this, each participant was given a sheet of information. On the form that was sent to participants, information regarding the purpose of the study, its methods, dangers, potential benefits, and participant rights was detailed. Before providing their signed consent, the researchers made sure that the participants read and comprehended the information sheet that was provided to them.

Data analysis

Quantitative data analysis.

In preparing the data for analysis, the raw data were extracted from the Question Pro questionnaires and imported into the Statistical Package for Social Science (SPSS) Version 25. Question Pro program’s ability to accept imported information helped minimize data entry errors. Subsequently, each participant’s response was assigned a unique participant code number before coding the data. The researchers checked all the soft-copy questionnaires against the data entered in SPSS. Any data entry errors were edited to clean the data before analyzing it.

Descriptive and Inferential statistics of the quantitative data were performed. Descriptive statistics were carried out and represented by means and standard deviations using the frequency distribution tables to determine the level of each of the study variables. Frequencies and percentages of specific (socio-demographic) variables were used to clarify the characteristics of the sample population and their general information. The results were categorized and tabulated using Microsoft Office to produce tables and figures that visualized the data. Values of p  < 0.05 and 0.01 were considered statistically significant, and a p-value < 0.001 was considered highly statistically significant. Inferential statistical tests such as multiple regression analyses were used after all assumptions regarding linearity, multicollinearity, independence of error, homoscedasticity, and normality were achieved.

Qualitative data analysis

The Colaizzi method was used to analyze and interpret data [ 28 ]. After completing Colaizzi’s data analysis steps, the participants clarified their initial words and phrases, expanded on what they wanted to convey, changed misunderstood experiences, added more information, and rectified grammatical and typographical errors. The results were verified using the Consolidated Criteria for Reporting Qualitative Data [ 29 ].

Quantitative findings

A total of 200 out of 297 nurses and midwives participated in the study (67.3) percent response rate). Most participants (42.5%) worked in wards (Antenatal, Postnatal). The majority of the participants (63.0%) were aged (31–40 years). Regarding their years of experience, the majority of participants (33.0%) had (11–15 years) of experience, then (31.5%) of participants had (6–10 years), followed by (19.5%) with (< 6 years) of work experience, then (12.5%) with (16–20 years) of work experience and only (3.5%) with (> 20 years) of work experience. Most of the participants (51.0%) held a bachelor’s degree in nursing/midwifery, while (42.5%) had a diploma level, and only (6.5%) of the participants had Master’s or postgraduate qualifications. Of the 200 participants who indicated their marital status, the majority (77.0%) were married, and (23.0%) were single [ 30 ]. ( Table  1 )

Our findings revealed that the overall structural empowerment score level was 19.67, with a mean score and SD (3.28 ± 0.671). This means the overall perception of the participants about structural empowerment was moderate. About the - CWEQ-II subscales, the “Opportunity” dimension was the highly perceived dimension and ranked first with a mean score of (3.55 ± 0.956), followed by the “Information” dimension with a mean score (3.51 ± 0.903), then the “Support” dimension with a mean score (3.32 ± 0.844). The informal power dimension came fourth rank with a mean score (3.26 ± 0.784), followed by the “Resources” dimension with a mean score of (3.20 ± 0.847), while the minimally perceived dimension by the participants was “Formal Power” with a mean score of (2.83 ± 0.952) and ranked as the sixth and the last dimension among the structural empowerment dimensions. (Table  2 ).

Regarding resilience, our findings revealed that the overall resilience score level was 26.80, with a mean score and SD (2.68 ± 0.744). This means the overall perception of the participants about resilience was the lowest. Regarding the CD-RISC-10 subscales, the “Regulate Emotion” component was the most highly perceived. It ranked first with a mean score of (2.80 ± 1.058), followed by the “Self-Efficacy” component with a mean score of (2.78 ± 0.827), then the “Cognitive focus/maintaining attention under stress” component with a mean score of (2.68 ± 0.996). The “Optimism” component came fourth rank with a mean score of (2.67 ± 0.832), and lastly, the “Flexibility” component, with a mean score of (2.49 ± 0.878) came fifth rank among the resilience components. (Table  3 ).

Regarding the Intent to Stay, our findings revealed that the overall intent to stay mean score and SD was (3.29 ± 0.840). This means the overall perception of the study subjects about intent to stay was “Neutral” perception (between 2.61 and 3.40). The questions’ means ranged between (3.17–3.44) that’s ranged between (Neutral - Agree) perception; the highest mean belonged to statement five, which stated: “I plan to keep this job for at least two or three years,” with a mean score of (3.44 ± 1.255), followed by statement three “Even if this job does not meet all my expectations, I will not quit,” with a mean score of (3.34 ± 1.095), then statement one “I plan to work at my present job for as long as possible” with a mean score of (3.32 ± 1.194). Statement four came as fourth rank: “Under no circumstances would I leave my present job,” with a mean score of (3.18 ± 1.136). The second statement stated, “I will probably spend the rest of my career in this job or jobs that it leads to in this hospital,” with a mean score of (3.17 ± 1.112) coming fifth rank. (Table  4 ).

A multiple regression was used to identify the most significant predictor from the main factors that were found to influence participant’s intent to stay in the current working organization.

Table  5 presents “variables in the equation” that is, those factors that were found to be predictive of respondents’ Intent to Stay ( p  < 0.000). This multiple regression analysis showed that Structural Empowerment and Resilience were predictive of intent to stay, based on the Pearson correlation, significantly correlated level.

Likewise, Table  6 presents model one (structural empowerment, resilience) recorded a positive R  = 0.513 a correlation, R 2  = 0.263, which indicates that 26.3% of the variation in Intent to Stay (the dependent variable) can be explained by the independent variable (Structural empowerment, Resilience).

Moreover, the R 2 for the variables in the equation was used to determine the joint predictive contribution to the dependent variable (Intent to Stay) of the independent variables (Structural Empowerment and Resilience.

Thus, based on the multiple regression analysis, the best predictor of Intent to Stay from among the two variables analyzed is structural empowerment if compared to resilience.

Table  7 indicates that for the Model of the regression, the sum of squares = is 36.990 (p = < 0.000). Thus, the results of the ANOVA confirm differences of variance between the independent variables in terms of their predictive strengths, thereby supporting the finding that the independent variables structural empowerment and resilience are dominant predictors of intent to stay. (Table  7 )

Qualitative findings

Findings from the semi-structured interviews.

The qualitative findings were related to five major themes in the form of individual (nurses and midwives) dimensions from the narratives of 18 participants, including (1) physical and physiological, (2) psychological, (3) financial, (4) organizational, and (5) professional and occupational. The first major theme, nurturing physical and physiological, displays the activities of daily living (ADLs) and instrumental activities of daily living (IADLs) of an individual trying hard to adapt to situations. IADLs are activities that everyone does regularly, from personal hygiene tasks (shaving, brushing their teeth, and taking a bath) to professional and social obligations (going to work) to recreational pursuits (playing sports) to eating and drinking. The second major theme, the developing psychological, displays the affective-emotional or affective-motivational status of the individual. Psychological empowerment is a response to certain empowering conditions and an outcome of structural empowerment. It portrays the lived experiences of the nurse and midwives in pursuit of their cognitive (intellectual), affective (emotional), and psychomotor (skills) well-being. Thus, the third major theme, managing the financial, portrays the capacity to address practical requirements with financial resources and a sense of control and financial literacy. The fourth major theme, restructuring the organizational, covers the structure and general managerial mechanisms that serve as its backbone and fundamental building block. Lastly, the fifth major theme is called the enriching professional and occupational, exploring employee enrichment and satisfaction through work in their organization. Employment may fall under this category, but it might also refer to involvement in any activity, even if it is unpaid. This theme is actualized to the degree that derives satisfaction from engaging in these pursuits [ 31 ]. (Table  8 )

Synthesis and integration (mixing both result strands)

Separately and independently, each data type can be collected and evaluated using the methods that have been developed over time. This is a perfect opportunity for multidisciplinary teams to do research, with members having competence in both quantitative and qualitative methods. Furthermore, the design allows for a direct comparison between participant perspectives gleaned through open-ended questions (e.g., a semi-structured interview) and researchers’ perspectives gleaned via close-ended questioning (e.g., a survey chosen by the researchers). With this method, the researchers can reveal statistical trends while simultaneously giving participants a voice.

In our study’s quantitative findings, we observed that the perceptions of midwives/nurses working in OB/GYN departments were 19.67, which was at a moderate level of structural empowerment. During the interview, the theme clusters to the major theme of managing financial confirms that access to recourses is critical to enhancing midwives’ and nurses’ structural empowerment level in the organization. The participants discussed that they needed additional monetary compensation. As the participant stated:

“Our salary is not enough, according to what we are doing; we are dealing with mothers and babies.” (P1).

Moreover, theme clusters to the major theme of restructuring organizational confirm that access to support is essential for enhancing the midwives’ and nurses’ structural empowerment level. During the qualitative phase, participants described experiencing the need for organizational support for growth and development. As the participant stated:

“Okay, I guess the nursing office they must see as our staff developed educationally and regarding nursing practice, they need to see what’s their needs they need to ask us what you need to get developed in your career and what you need to increase our patient care quality. Yeah, this is my opinion. So, they started I told you this is my first year to take an education or something rather than work by my hand in every day”. (P4)

Furthermore, the theme clusters to the major theme of enriching professional and occupational confirm that access to opportunities to learn and grow is also an essential of enhancing midwives’ and nurses’ structural empowerment levels. The participants discussed their need to have technological skills to comply with modernization and advancements, continuous professional development to improve their skills in performing their duties and responsibilities, mentoring and coaching programs to teach and cultivate the best practices of the nurse leaders and managers in the unit, and participation in training and development.

On the other hand, some participants viewed the workplace as their bread and butter to support financial needs. Concerning restructuring organizational, midwives and nurses express their experience of having a strong support system, feeling motivated each time peers and patients recognize and appreciate their good performance, receiving constant feedback from different members in the organization, and they can freely exercise their power to speak up in their workplace. Thus, all of these dimensions discussed by the participants relate to the high structural empowerment level. Finally, participants mentioned that they have strong social support in their departments and freely exercise their power to speak up with their perspective on the unit as emerged in the major theme restructuring organizational dimension as being contradictory with the midwives and nurses are experiencing burnout as emergent in the major theme developing psychological dimension.

Regarding resilience, the quantitative result reveals that the perception level of midwives/nurses working in OB/GYN departments was 26.8, the lowest level of resilience. During the qualitative interview, participants discussed feeling stressed, having insufficient time to rest because of the long hours of duty, and developing different physiological changes due to their workplace issues. During the interview, the theme clusters to the major theme of nurturing physical and physiological confirm that employees lack energy, motivation, concentration, and interest when physically weary. Consequently, during the interview, the theme clusters to the major theme of developing psychological confirms that employee behavior and attitudes to work are heavily influenced by structural empowerment and resilience. Participants discussed that they are experiencing burnout. As the participant stated:

“Of course, I burned out already " (P15).

“I am dealing with the same kind of patient. I am dealing with the same problems with the same challenge. I need a new chapter in my professional life”. (P14)

However, with this theme finding, participants felt empowered knowing they could influence their patients, develop their self-confidence, and make their own decisions based on the organizational policies and regulations. Most participants recognized that not all midwives and nurses in their departments were pleased with resilience. Some staff needed to be more interested in challenges, responsibilities, and joint decision-making. Finally, according to the theme cluster adaptive competence, most participants discussed that they could seek ways and means to adapt, adjust, and cope with unfavorable situations; they imagine their selves as skillful and patient during tough times and are willing to share their competencies in the future generation.

Regarding intent to stay, the quantitative result reveals that the perception level of midwives/nurses working at OB/GYN departments was 3.29, which was a neutral intent to stay score in their organization. During the interview, the theme clusters to the major theme of managing financial confirms that access to resources is essential to why midwives and nurses stay in the organization. During the interview, the participants described how they experienced managing their finances accordingly. Moreover, the theme clusters to the major theme of restructuring organizational confirm that organizational benefits employees enhance the intention to stay. Participants discussed that they have strong support in their workplace, a strong support system, freely exercising their power, and a tenacious policy to follow. There were favorable perceptions and experiences about the hospital’s top management and policy; some participants felt empowerment as an obligation. The opportunities and support the organization provides may affect the midwives’ and nurses’ intention to stay in the organization. In addition, participants discussed that the availability of job resources is related to their decision to stay in the organization. As the participant stated:

“ I’m just work in Saudi Arabia to save money to support my family in India. But of course, I still want to settle down in my own country”. (P6)

Quantitatively, linear multiple regression analysis of structural empowerment, resilience, and intent to stay showed that structural empowerment and resilience are significant predictors of intent to stay in the organization. Structural empowerment gives midwives and nurses greater resilience, enhancing their decision to stay in the organization. The participants perceived that structural empowerment and resilience could influence their decisions to stay in the organization. During the interview, the theme clusters to the major theme of developing psychological and theme clusters to the major theme of restructuring organizational dimension; both confirm that midwives and nurses feel structurally empowered and know they can influence their patients. Thus, their ability to recognize, control, and express their emotions reflects their resilience in the organization. Consequently, access to opportunity, recourses, and positive challenges is a motivated dimension of why midwives and nurses stay in the organization. Two of the participants shared their experiences:

“Ok what motivates me, the everyday challenges here in the labor room, we don’t have a routine as I’ve said, every day and every situation is new for us. So, dealing with mother also the relationship with my colleagues, our teamwork, the respect here, the appreciation, if they say thank you, our mother trust, that motivates me.” (P1).

“I am empowered because of my colleagues are helping. Sometimes doctor is also more helpful for us. Sometimes the patient delivered at the same time delivery room may be not accepted for sometimes they are busy. They said they cannot accept it for this patient at that time, doctor said no, it’s already delivered this patient at that time our doctor stopped are helping for us.” (P7).

However, with this theme finding, participants discussed that they are experiencing burnout and still need organizational support for growth and development.

“I don’t have interest like before. Yes, yes, because every day we handle delivery, especially if it new, or we facing new challenge but it’s still the same, the same routine”. (P1)

We noticed that the level of structural empowerment of midwives and nurses in this study was moderate, which reflects partial access to components such as opportunities, resources, support, information, and formal and informal power in the organizations.

The triangulation and integration of quantitative and qualitative findings in this study provide a comprehensive and multifaceted analysis of the experience of nurses’ and midwives’ views on structural empowerment, resilience, and intent to stay. Therefore, this convergent parallel mixed method study assures a thorough understanding of the strength of participants’ perceptions of these factors.

The data analysis displayed key findings indicating that structural empowerment and resilience predicted intent to stay in the organization. Our study’s midwives and nurses reported moderate structural empowerment, lowest resilience, and neutral intent to stay in their organization. Previous studies have also demonstrated moderate structural empowerment among nurses [ 13 , 31 , 32 , 33 , 34 , 35 , 36 ].

According to structural empowerment, there are six organizational structures of access: opportunity, information, support, resources, formal power, and informal power. The findings of this study reveal that the participants perceived the greatest access to the opportunity component, followed by information and support. The informal power component was fourth, followed by resources and formal power. The higher perceived level of access to opportunity is significantly related to all participants having more than three years of work experience. This experience allows them more access to learning, growth, and expertise in their midwifery and OB/GYN specialties. This result aligns with a study by Gholami et al. [ 37 ], which revealed the highest score in the access to opportunity subscale and the lowest score in their perceptions of access to formal power. Similar studies have shown access to opportunity as the primary driver of structural empowerment [ 38 , 39 ]. In contrast, some structural empowerment studies have prioritized access to resources [ 18 , 40 ]. Oliver et al. [ 41 ]. showed lower-than-expected scores on the resource subscale and acceptable scores on the subscales of support, formal power, and informal power.

Our study results showed that midwives’ and nurses’ perceptions of structural empowerment were moderate. The participants discussed that they needed additional monetary compensation and a competitive housing allowance. Arslan Yürümezoğl and Kocaman [ 42 ] pointed out that structural empowerment through rewards and recognition for a well-done job could contribute to employee satisfaction. Our findings indicate that access to support is essential to enhancing midwives’ and nurses’ empowerment in the organization. This finding is in line with Hagerman et al. [ 43 ], who revealed that access to support must be through feedback, guidance, emotional support, helpful advice or hands-on assistance, and problem-solving advice, all of which can benefit nurses in their workplace.

Furthermore, our study results confirm that access to opportunities to learn and grow is also essential for enhancing midwives’ and nurses’ empowerment levels. The participants discussed their need to have technological skills to comply with modernization and advancements and continuous professional development to improve their skills in performing their duties and responsibilities. According to Kanter [ 44 ], when employees do not have access to resources, support, and opportunities, they experience powerlessness.

Our study also revealed that the participants perceived their resilience levels as the lowest in the organization. Several studies have addressed healthcare providers’ resilience, but few have examined midwives’ resilience. No study was found that measured levels of resilience about structural empowerment or intent to stay in the organization. Our study participants perceived their resilience as a process facilitated by various coping strategies, including accessing peer support and developing self-awareness and self-protection. Moreover, the participants identified the importance of the workplace environment in enhancing resilience.

In this study, it was evident that the participants suffered from feeling stressed and having insufficient time to rest. It confirmed that employees lack energy, motivation, concentration, and interest when physically weary. McGowan et al. [ 45 ] revealed that resilience is related to improved physical and mental health. According to this, midwives and nurses need resilience more than any other profession [ 46 ]. However, the participants felt empowered knowing they could influence their patients, develop their self-confidence, and make their own decisions based on organizational policies and regulations. Gover and Duxbury [ 47 ] point out that employee engagement in decision-making is essential to organizational resilience.

Most previous studies have focused on turnover intention rather than intention to stay. In the current study, the participants’ perceptions of their intent to stay were neutral. Various studies have found that nurses have moderate to low intentions to stay at their organizations [ 31 , 32 ]. The present study’s findings contrast with those of Al-Hamdan et al. [ 17 ]. and Alhadidi et al. [ 48 ], who found that the overall mean intention of nurses to stay in their organizations was high.

Furthermore, the results confirm that access to resources is essential to why midwives and nurses stay in the organization. Moreover, the participants confirm that organizational benefits employees enhance the intention to stay. Participants discussed that they have strong support in their workplace. There were favorable perceptions and experiences about the hospital’s top management and policy; some participants felt empowerment as an obligation. The opportunities and support the organization provides may affect the midwives’ and nurses’ intention to stay in the organization. Kleine et al. [ 49 ] Pointed out that leaders such as empowerment and supportive leadership relate to turnover. In addition, participants discussed that the availability of job resources is related to their decision to stay in the organization. Management and leadership are related to turnover [ 50 ].

In this research, the linear multiple regression analysis of structural empowerment, resilience, and intent to stay showed that structural empowerment and resilience are significant predictors of intent to stay in the organization. The participants perceived that structural empowerment and resilience could influence their decision to stay in the organization. The findings are similar to those of Liu et al. [ 51 ], who revealed that resilience had the strongest direct effect on the intention to stay in the organization. Likewise, Meng et al. [ 18 ] found that structural empowerment significantly positively affected nurses’ intent to stay. Cowden and Cummings [ 52 ] revealed that empowerment strongly influences a nurse’s intent to stay.

Resilience has high practical value and could significantly enhance nurses’ intent to stay [ 53 , 54 ]. Previous studies’ results support the current study’s findings [ 42 , 55 ]. In contrast, Hall [ 56 ] indicated that structural empowerment did not predict nurses’ intent to stay in their organizations. Kelly et al. [ 57 ] also found that structural empowerment was not significantly related to intent to leave.

Liu et al. [ 51 ]. Found that resilience had the strongest direct effect on the intention to stay in the organization. Interestingly, a component of structural empowerment, such as opportunity, resources, formal and informal power, and adaptive resilience competence, can be related to midwives’ and nurses’ intention to stay in the organization. Previous studies’ results support the current study’s findings [ 18 , 33 , 42 , 52 , 53 , 54 ]. However, participants discussed experiencing burnout and needing organizational support for growth and development. Along the same lines, a study conducted by Hall [ 56 ] showed that structural empowerment does not predict the intent to stay of nurses in the organization.

In particular, Hezaveh et al. [ 15 ] and Pallant et al. [ 16 ] reiterate the key points, assuring us that the relationship between resilience, structural empowerment, and professional effectiveness is well-supported in their studies. This reaffirms our confidence in the findings and their implications for midwifery and nursing. Although extant literature has reported that support from superiors, easy access to information, and a sense of agency and control in carrying out one’s duties all affect longevity and satisfaction in one’s career and are connected to a midwife’s capacity for resiliency, structural empowerment, and a long career [ 14 ].

Our mixed-method study contributes to the body of knowledge in various ways. Our results recommended that any healthcare organization enhance its staff’s intent to stay through empowering work conditions, promoting empowering behaviors, and increasing resilience. They should ensure the five empowering dimensions at the workplace to keep their staff resilient and to have a greater sense of loyalty to stay in their organization. Accordingly, it is essential to develop and implement a national staff empowerment standardizing policy to transform the healthcare and services system in Saudi Arabia. A policy of this type will save significant resources and provide insight into coping strategies to prevent adverse employee turnover outcomes and create retention strategies; as a result, policymakers can benefit from our results if they formulate a policy to increase midwives’ growth, power, resilience, and competence.

Our study limitations include the study’s cross-sectional design and reliance on self-reported survey questionnaire data, both of which prevent the researchers from drawing causal conclusions about study variables. Likewise, the sampled nurses and midwives were all located in the Eastern Province; therefore, the results cannot be generalized to the rest of the KSA. Finally, this error in the sampling process was attributable to using convenience sampling in quantitative research. It is challenging to detect variations in a population subgroup when using a convenience sample, which leads to underrepresentation of the sample; as a result, research study conclusions need to be more generalizable to the target population. Therefore, the sampling strategy used in the qualitative phase was deliberate, which raises the possibility of selection bias impacting the findings.

Conclusions

The study’s researchers are optimistic that drawing attention to the importance of cultivating a culture of empowerment and resilience would encourage nurses and midwives to remain in their current roles. It takes nurses and midwives succeeding in two fields simultaneously to have a global impact. The emergent themes underlined the physical, physiological, psychological, financial, organizational, professional, and vocational aspects of nurses and midwives, giving them agency, resilience, and determination to remain in the sector. All of these requirements must be met to avoid consequences for the rest. The outcome might be fatigue, burnout, workplace antagonism, and a general lack of enthusiasm among nurses and midwives.

Evidence from quantitative and qualitative studies suggests that healthcare organizations’ leaders and managers can do more to help nurses and midwives feel empowered and resilient at work and reduce turnover.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors thank the study participants for their contributions, and dedication for sharing their lived experiences, which can shed light for other registered nurses and midwives in the kingdom to continue striving harder to achieve the Saudi Vision 2030.

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Conceptualization, A.G.A-O and A.E.A methodology, A.G.A-O and A.E.A; software, A.G.A-O ; validation, A.G.A-O , A.E.A.; A.N.A and S.A.A formal analysis A.G.A-O , A.E.A.; A.N.A and S.A.A.; investigation, A.G.A-O., and F.A.A; writing—original draft preparation, , A.G.A-O and A.E.A.; writing—review and editing, A.G.A-O, A.N.A and S.A.A; visualization, A.N.A supervision, A.E.A. All authors guarantee the integrity of the content and the study. All authors have read and agreed to the published version of the manuscript.

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Al-Otaibi, A.G., Aboshaiqah, A.E., Aburshaid, F.A. et al. Perceived structural empowerment, resilience, and intent to stay among midwives and registered nurses in Saudi Arabia: a convergent parallel mixed methods study. BMC Nurs 23 , 649 (2024). https://doi.org/10.1186/s12912-024-02325-w

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