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Teacher Perception of Inclusive Education and Their Experiences in Teaching Students with Intellectual Disability (1)

Teacher Perception of Inclusive Education and Their Experiences in Teaching Students with Intellectual Disability

“Teacher Perception of Inclusive Education and Their Experiences in Teaching Students with Intellectual Disability”

INDEX

S.NO                      TOPIC PAGE NO
1 Introduction 9-26
2 Literature Of Review 27-37
3  Research Methodology 38-62
4 Tata Analysis and Interpretation of Data 63-91
5 Major Finding Suggestion, Recommendation, and conclusion 92-97
6 References 98-101
7 Appendix Tool

 

102-108

  

  CHAPTER 1

INTRODUCTION

  

1.1 Introduction

Education is universally recognized as a fundamental human right and a powerful instrument for social transformation, equality, empowerment, and national development. In contemporary democratic societies, education is not merely regarded as the transmission of knowledge but as a process that promotes human dignity, social justice, participation, and equal opportunities for all individuals irrespective of gender, caste, religion, language, socioeconomic status, ethnicity, or disability. The philosophy of education in the twenty first century increasingly emphasizes equity, diversity, and inclusion as essential components of quality education systems. Consequently, educational reforms across the world have shifted from segregated and exclusionary models toward more inclusive approaches that recognize the diverse learning needs of all learners.

Inclusive education has emerged as one of the most significant educational movements in recent decades. It advocates that all children, including children with disabilities, should learn together in regular schools with appropriate educational support and equal participation in academic and social activities. Inclusive education is rooted in the principles of social justice, human rights, democratic participation, and equal educational opportunities. It seeks to eliminate discrimination, exclusion, and marginalization within educational systems by ensuring that every learner receives meaningful access to quality education in a supportive environment.

The concept of inclusive education gained global recognition through international declarations and frameworks such as the Salamanca Statement and Framework for Action on Special Needs Education (1994), the United Nations Convention on the Rights of Persons with Disabilities, and the Sustainable Development Goals, particularly Goal Four, which emphasizes inclusive and equitable quality education for all. These international initiatives strongly advocate the restructuring of schools and educational systems in ways that accommodate learner diversity and promote participation of students with disabilities within mainstream educational settings.

In the Indian context, inclusive education has gained increasing policy attention during the past two decades. Legislative frameworks such as the Right of Children to Free and Compulsory Education Act (2009), the Rights of Persons with Disabilities Act (2016), and the National Education Policy (2020) emphasize the educational rights of children with disabilities and encourage their inclusion within mainstream schools. These policies recognize that education systems must become more flexible, accessible, learner centered, and responsive to individual differences.

Intellectual disability is characterized by significant limitations in intellectual functioning and adaptive behavior affecting conceptual, social, and practical skills. Students with intellectual disabilities often experience difficulties in communication, problem solving, social interaction, academic learning, self regulation, and independent functioning. Consequently, their successful inclusion in mainstream classrooms requires not only physical placement but also meaningful participation, individualized support, collaborative teaching practices, and acceptance within the school environment.

Among all stakeholders involved in inclusive education, teachers occupy a central and decisive role. Teachers serve as the primary facilitators of learning experiences and classroom participation. Their beliefs, perceptions, competencies, attitudes, and experiences significantly influence the effectiveness of inclusive education practices. Teachers who possess positive attitudes toward inclusion are more likely to adopt differentiated instruction, flexible teaching strategies, collaborative learning practices, and supportive classroom management approaches. Conversely, teachers who feel inadequately prepared or unsupported may experience stress, frustration, resistance toward inclusion, and reduced teaching efficacy.

Teacher perceptions toward inclusive education are shaped by multiple interrelated factors such as professional training, teaching experience, institutional support, classroom environment, availability of teaching resources, collaboration with special educators, and previous interactions with students with disabilities. Therefore, understanding teachers’ perceptions becomes essential for evaluating the effectiveness of inclusive education policies and practices. Teachers’ experiences in inclusive classrooms provide valuable insights into the practical realities, challenges, opportunities, and support mechanisms associated with inclusion.

Existing educational research indicates that teachers often face significant challenges while teaching students with intellectual disabilities in mainstream classrooms. These challenges include difficulty in curriculum adaptation, classroom behavior management, individualized instruction, time management, assessment modifications, and balancing the needs of diverse learners within a single classroom environment. Additionally, lack of adequate training in special education and inclusive pedagogy often limits teachers’ confidence and preparedness in addressing the educational needs of students with intellectual disabilities.

Another critical concern associated with inclusive education is the gap between policy and practice. While educational policies strongly advocate inclusion, the actual classroom implementation frequently remains superficial and inconsistent. In many schools, inclusion is limited to physical placement of students with disabilities without ensuring meaningful academic participation or social integration. Such situations create what scholars often describe as symbolic or token inclusion rather than genuine inclusive education. Teachers working within such environments may encounter emotional stress, professional challenges, and uncertainty regarding effective inclusive practices.

Furthermore, the realities of inclusive education differ significantly across regions, educational institutions, and socioeconomic contexts. Schools located in urban settings may possess relatively better resources and support services compared to rural institutions. Similarly, teachers working in private schools may experience different challenges than those working in government schools. Therefore, it becomes necessary to examine teachers’ perceptions and experiences within specific educational and sociocultural contexts to understand how inclusive education operates in practice.

The present study titled “Teachers’ Perceptions of Inclusive Education and Their Experiences in Teaching Students with Intellectual Disabilities” seeks to critically examine how teachers perceive inclusive education and how they experience the process of teaching students with intellectual disabilities within mainstream classrooms. The study also intends to explore the challenges teachers encounter, the support systems available to them, and the strategies required to strengthen inclusive educational practices.

The significance of the present study lies in its attempt to move beyond theoretical discussions of inclusion and explore the lived realities of teachers who directly engage with inclusive classrooms. By examining teachers’ experiences and perceptions, the study aims to contribute to the development of more effective teacher education programs, institutional support mechanisms, inclusive policies, and classroom practices that promote meaningful educational participation for students with intellectual disabilities.

1.2 Background of the Study

The historical development of special education reveals a gradual transformation from exclusion and segregation toward integration and inclusion. In earlier periods, children with disabilities were frequently denied access to formal education and were often isolated from mainstream society. Educational systems largely considered disability as a medical problem requiring separate treatment and specialized institutions. Consequently, children with disabilities were placed in segregated special schools that functioned independently from regular educational systems.

Although special schools provided certain specialized services, segregation often resulted in social isolation, stigmatization, limited peer interaction, and reduced participation in community life. Critics of segregated education argued that separating children with disabilities from their peers reinforced social discrimination and prevented equal educational opportunities. As human rights perspectives gained prominence during the latter half of the twentieth century, educational philosophies gradually shifted toward normalization, integration, and eventually inclusion.

The concept of integration initially promoted the placement of students with disabilities into regular schools. However, integration primarily focused on physical placement rather than meaningful participation. Students with disabilities were often expected to adjust themselves to existing school structures without substantial modifications in curriculum, pedagogy, or classroom practices. This limitation led to the emergence of inclusive education, which emphasizes restructuring educational systems themselves to accommodate learner diversity.

Inclusive education differs fundamentally from integration because it recognizes diversity as a natural characteristic of classrooms rather than a problem requiring separate solutions. Inclusive education seeks to create learning environments where all students participate equally and where differences are respected, valued, and accommodated through flexible teaching approaches.

International declarations played a significant role in strengthening inclusive education globally. The Salamanca Statement emphasized that ordinary schools with inclusive orientation are the most effective means of combating discriminatory attitudes, building inclusive societies, and achieving education for all. Similarly, the United Nations Convention on the Rights of Persons with Disabilities recognized inclusive education as a basic human right and urged member countries to ensure equal access to education for persons with disabilities.

India has also witnessed significant developments in the field of inclusive education. Legislative and policy initiatives increasingly recognize the rights of children with disabilities to access mainstream education. The Rights of Persons with Disabilities Act expanded educational rights and mandated inclusive educational provisions. The National Education Policy emphasized learner centered and inclusive approaches aimed at addressing educational diversity.

However, despite policy progress, inclusive education in India continues to face several structural and pedagogical challenges. Schools frequently lack adequate infrastructure, accessible learning materials, trained teachers, and support services required for effective inclusion. Teachers often report feeling unprepared to teach students with disabilities due to limited exposure to inclusive pedagogy during teacher training programs.

The challenges become particularly significant in relation to students with intellectual disabilities. Unlike some other disabilities, intellectual disability affects multiple aspects of functioning including cognition, communication, adaptive behavior, academic learning, and social interaction. Students with intellectual disabilities may require individualized educational planning, differentiated instruction, repetitive learning experiences, behavioral support, and structured classroom routines.

Teachers working in inclusive classrooms therefore face the responsibility of balancing curriculum demands while simultaneously addressing diverse learning needs. They must adapt instructional strategies, create supportive learning environments, collaborate with parents and special educators, and ensure social participation of students with intellectual disabilities. These responsibilities often increase teachers’ workload and emotional demands, especially when institutional support systems remain inadequate.

Teachers’ perceptions and experiences therefore become critical factors in determining the success of inclusive education. Positive teacher attitudes can enhance student participation, classroom acceptance, and academic engagement, whereas negative attitudes may create barriers to meaningful inclusion. Understanding teachers’ perceptions is therefore essential for improving educational policies, teacher preparation programs, and classroom practices related to inclusive education.

The background of the present study is therefore grounded in the recognition that inclusive education cannot succeed merely through policy declarations or legislative mandates. Successful inclusion depends substantially upon the preparedness, experiences, confidence, and professional support available to teachers who work directly within inclusive classrooms.

1.3 Need and Importance of the Study

The contemporary educational landscape increasingly emphasizes the principles of equity, participation, diversity, and social justice. Inclusive education has emerged as a central educational priority across the world because it seeks to ensure that all learners, regardless of their disabilities or differences, receive equal educational opportunities within mainstream educational environments. However, despite significant policy developments and legal mandates supporting inclusive education, the actual implementation of inclusive practices within classrooms continues to face numerous challenges. This situation creates an urgent need for research that critically examines the realities of inclusive education from the perspectives of teachers who directly engage with inclusive classrooms.

Teachers constitute the most significant human resource in the process of implementing inclusive education. They are responsible for translating educational policies into classroom practices and ensuring meaningful participation of students with disabilities within mainstream learning environments. Their attitudes, beliefs, competencies, teaching practices, and classroom experiences directly influence the quality and effectiveness of inclusion. Consequently, the success or failure of inclusive education largely depends upon teachers’ preparedness, perceptions, and professional confidence.

Students with intellectual disabilities represent one of the most educationally vulnerable groups within inclusive settings because they often require continuous instructional support, individualized educational planning, adaptive teaching methods, behavior management strategies, and structured classroom environments. Their inclusion therefore demands considerable pedagogical flexibility and emotional commitment from teachers. However, many teachers report difficulties in addressing the diverse learning needs of students with intellectual disabilities due to inadequate training, lack of teaching resources, insufficient institutional support, and limited collaboration with specialists.

Another important concern is the persistent gap between inclusive education policies and classroom realities. Although legislative frameworks strongly advocate educational inclusion, many schools continue to experience practical barriers such as overcrowded classrooms, shortage of resource personnel, inaccessible infrastructure, rigid curriculum structures, and insufficient professional development opportunities. As a result, inclusive education often remains limited to physical placement of students with disabilities without ensuring meaningful academic participation or social integration.

The present study becomes important because it attempts to examine inclusive education beyond policy rhetoric and theoretical discussions. It seeks to understand how teachers actually experience inclusive classrooms and how they perceive the process of teaching students with intellectual disabilities. Such understanding is necessary because teachers’ lived experiences provide valuable insights into the practical difficulties, emotional challenges, institutional barriers, and successful strategies associated with inclusion.

The study is also significant because research focusing specifically on intellectual disability within inclusive educational settings remains comparatively limited, particularly within the Indian educational context. Much of the existing research has concentrated broadly on inclusive education without adequately addressing the unique educational challenges associated with intellectual disability. Similarly, many previous studies have focused primarily on quantitative assessment of teacher attitudes while giving limited attention to teachers’ experiences, classroom realities, and contextual challenges.

Furthermore, the findings of the present study may contribute significantly to educational policy development, teacher education, professional training programs, and institutional planning. Understanding teachers’ perceptions and experiences may help educational administrators identify areas requiring additional support, training, infrastructure development, and resource allocation. The findings may also assist teacher education institutions in designing more practical and competency based training programs related to inclusive pedagogy.

The study also possesses social significance because effective inclusive education promotes equality, dignity, participation, and social acceptance of individuals with disabilities. By identifying factors that facilitate or hinder inclusion, the study may contribute toward the creation of more supportive and inclusive school environments that respect learner diversity and promote holistic educational development for students with intellectual disabilities.

In addition, the present study may contribute theoretically by strengthening the understanding of the relationship between teacher perceptions, institutional support, inclusive pedagogy, and classroom experiences. It may also provide empirical evidence that can support future research related to inclusive education, intellectual disability, teacher preparedness, and educational inclusion within mainstream schools.

Therefore, the need for the present study emerges from educational, social, professional, and policy related concerns associated with the implementation of inclusive education for students with intellectual disabilities. The study seeks to provide a deeper understanding of teachers’ experiences and perceptions in order to strengthen inclusive educational practices and improve educational opportunities for learners with intellectual disabilities.

1.4 Statement of the Problem

  “Teachers’ Perceptions of Inclusive Education and Their Experiences in Teaching Students with Intellectual Disabilities.”

1.5 Objectives of the Study

The present study seeks to achieve the following objectives:

  1. To examine teachers’ perceptions of inclusive education.
  2. To explore teachers’ experiences in teaching students with intellectual disabilities in inclusive classrooms.
  3. To identify challenges faced by teachers while implementing inclusive education.
  4. To examine the support systems available for teachers in inclusive educational settings.
  5. To suggest strategies for improving inclusive education practices for students with intellectual disabilities.

1.6 Research Questions

The present study seeks to address the following research questions:

  1. What are teachers’ perceptions toward inclusive education?
  2. How do teachers experience teaching students with intellectual disabilities in inclusive classrooms?
  3. What challenges do teachers face while implementing inclusive education?
  4. What forms of institutional and professional support are available to teachers teaching students with intellectual disabilities?
  5. What strategies can improve the effectiveness of inclusive education in mainstream schools?

 

1.7 Hypotheses of the Study

H₀₁: There is no significant difference in teachers’ perceptions of inclusive education.

H₀₂: There is no significant difference in teachers’ experiences in teaching students with intellectual disabilities.

H₀₃: There is no significant relationship between teachers’ perceptions of inclusive education and their teaching experiences with students with intellectual disabilities.

H₀₄: There is no significant difference in teachers’ perceptions of inclusive education based on gender.

H₀₅: There is no significant difference in teachers’ experiences based on teaching experience.

H₀₆: There is no significant difference in perceptions and experiences between trained and untrained teachers in inclusive education.

1.8 Operational Definitions of Key Terms

Inclusive Education

Inclusive education refers to an educational approach in which students with disabilities learn together with their non disabled peers in regular classrooms while receiving appropriate instructional support, accommodations, and equal opportunities for participation and learning.

Intellectual Disability

Intellectual disability refers to significant limitations in intellectual functioning and adaptive behavior affecting conceptual, social, and practical skills that originate during the developmental period and influence academic learning and daily functioning.

 

Teacher Perception

Teacher perception refers to the beliefs, attitudes, opinions, understandings, and viewpoints held by teachers regarding inclusive education and the inclusion of students with intellectual disabilities in mainstream classrooms.

Inclusive Classroom

An inclusive classroom refers to a regular educational setting where students with diverse learning abilities and disabilities learn together in a supportive and participatory learning environment.

Teacher Experience

Teacher experience refers to the professional, instructional, emotional, and practical experiences encountered by teachers while teaching students with intellectual disabilities in inclusive educational settings.

1.9 Significance of the Study

The present study holds substantial significance in the fields of inclusive education, special education, teacher education, educational policy, and educational research. The study is important because it attempts to critically examine teachers’ perceptions and experiences related to teaching students with intellectual disabilities within inclusive classroom environments. Since teachers are the primary facilitators of inclusive education, understanding their perspectives becomes essential for strengthening inclusive educational practices and improving educational outcomes for students with intellectual disabilities.

The study possesses educational significance because it contributes to the understanding of how inclusive education functions within mainstream classroom settings. Teachers play a decisive role in creating supportive learning environments, adapting instructional methods, and promoting student participation. Their perceptions toward inclusion directly influence classroom practices, teacher student relationships, learner engagement, and academic participation of students with disabilities. Therefore, the findings of the study may provide valuable insights into the factors that support or hinder effective inclusion within schools.

The study is also significant for teacher education and professional development programs. Many teachers experience difficulties in managing inclusive classrooms due to inadequate training, limited exposure to inclusive pedagogy, and insufficient practical experience in working with students with intellectual disabilities. The findings of the study may help teacher education institutions redesign training curricula to include more practical, competency based, and experience oriented approaches related to inclusive teaching. The study may also encourage the development of continuous professional development programs aimed at strengthening teachers’ confidence, instructional skills, classroom management strategies, and understanding of intellectual disability.

Another major significance of the study lies in its contribution to educational policy and institutional planning. Educational administrators and policymakers frequently formulate inclusive education policies without fully understanding the practical realities faced by teachers in classrooms. By exploring teachers’ lived experiences, the study may help identify institutional barriers such as inadequate infrastructure, shortage of teaching resources, lack of support personnel, and absence of collaborative mechanisms within schools. The findings may therefore assist policymakers in designing more realistic, practical, and teacher supportive inclusive education policies.

The study is socially significant because inclusive education is closely connected with the principles of equality, human dignity, participation, and social justice. Effective inclusion promotes acceptance, respect for diversity, social interaction, and equal opportunities for students with disabilities. However, when inclusive education is implemented inadequately, students with disabilities may experience exclusion, neglect, discrimination, and limited participation despite being physically present in mainstream schools. By identifying the barriers and support mechanisms associated with inclusive education, the present study may contribute toward creating more inclusive and humane educational environments for students with intellectual disabilities.

The study also holds significance for students with intellectual disabilities and their families. Understanding teachers’ experiences may help improve educational practices that support the academic, emotional, social, and behavioral development of students with intellectual disabilities. Better inclusive practices may enhance students’ participation, confidence, peer relationships, communication skills, and educational achievement. Families may also benefit indirectly through improved school support systems and more responsive educational practices.

From a research perspective, the study contributes to the growing body of knowledge related to inclusive education and intellectual disability. Existing research often focuses broadly on inclusion without specifically examining the unique realities associated with teaching students with intellectual disabilities. Furthermore, many previous studies emphasize quantitative assessment of teacher attitudes while paying comparatively less attention to teachers’ lived experiences and contextual classroom realities. The present study therefore attempts to provide deeper insight into the practical dimensions of inclusive education.

The study may also serve as a reference for future researchers interested in areas such as teacher efficacy, inclusive pedagogy, educational inclusion, intellectual disability, classroom management, educational policy, and teacher professional development. The findings may encourage further research examining inclusive education within different educational settings, sociocultural contexts, and disability categories.

In addition, the study possesses theoretical significance because it seeks to explore the relationship between teacher perceptions, institutional support, professional preparedness, classroom practices, and inclusive educational outcomes. Such understanding may contribute to strengthening conceptual frameworks related to inclusive education and teacher preparedness.

Therefore, the significance of the present study extends beyond academic inquiry and possesses practical implications for teachers, teacher educators, policymakers, school administrators, students with intellectual disabilities, and inclusive educational systems as a whole.

1.10 Scope of the Study

The present study focuses on examining teachers’ perceptions of inclusive education and their experiences in teaching students with intellectual disabilities within mainstream classroom settings. The scope of the study primarily includes the exploration of teachers’ beliefs, attitudes, experiences, instructional practices, classroom challenges, support systems, and professional preparedness related to inclusive education.

The scope of the study also includes the examination of various factors influencing inclusive education such as teacher preparedness, institutional support, availability of resources, professional training, classroom environment, and collaborative teaching practices. The study attempts to analyze how these factors affect teachers’ confidence, classroom management, instructional strategies, and perceptions toward inclusion.

Geographically, the study is limited to selected inclusive schools within a specific educational context. The study focuses on teachers who possess direct experience in teaching students with intellectual disabilities within mainstream educational environments.

The study further aims to explore practical classroom realities rather than merely examining theoretical or policy perspectives related to inclusive education. Therefore, the scope includes understanding teachers’ lived experiences, emotional responses, professional challenges, coping mechanisms, and suggestions for improving inclusive practices.

The findings of the study may contribute toward improving teacher education, inclusive pedagogy, institutional support systems, and educational planning related to students with intellectual disabilities.

1.11 Conceptual Framework of the Study

The conceptual framework of the present study is based on the understanding that effective inclusive education is influenced by the interaction between teacher perceptions, professional competence, institutional support, classroom environment, and inclusive teaching practices.

Teachers’ perceptions toward inclusive education form the central component of the framework because their beliefs, attitudes, and understanding significantly influence classroom behavior and instructional practices. Teachers who possess positive perceptions toward inclusion are more likely to create supportive learning environments, adopt differentiated teaching methods, encourage student participation, and demonstrate greater instructional flexibility.

Teacher preparedness and professional competence constitute another important component of the framework. Teachers who receive specialized training in inclusive pedagogy and intellectual disability are generally better equipped to manage diverse learning needs, adapt instructional strategies, and implement inclusive classroom practices effectively. Professional competence enhances teachers’ confidence, self efficacy, and willingness to engage with inclusive teaching.

Classroom environment represents another significant dimension of the framework. Inclusive classrooms require flexible pedagogy, positive peer interaction, collaborative learning opportunities, classroom acceptance, and emotional support systems that encourage participation of students with intellectual disabilities.

The framework further recognizes that inclusive teaching practices influence student participation, classroom engagement, social interaction, and educational outcomes. Effective inclusion occurs when teachers receive adequate support, possess positive attitudes, and implement adaptive instructional practices that accommodate learner diversity.

The conceptual framework therefore suggests that successful inclusive education depends upon the dynamic interaction between teacher perceptions, professional preparedness, institutional support, inclusive pedagogy, and classroom environment.

 

 

1.12 Theoretical Foundation of the Study

The present study is theoretically grounded in the principles of inclusive education, social constructivism, human rights based education, and teacher efficacy theory. These theoretical perspectives provide a comprehensive understanding of how inclusive educational practices are shaped by teachers’ beliefs, classroom interactions, institutional structures, and learner diversity.

One of the major theoretical foundations of the study is the philosophy of inclusive education, which is based on the principle that all learners have the right to participate equally in educational environments regardless of disability or difference. Inclusive education challenges traditional segregated models of schooling and promotes educational systems that accommodate learner diversity through flexible teaching practices, equitable participation, and supportive learning environments. The philosophy emphasizes that educational institutions should adapt themselves according to the needs of learners rather than expecting learners to fit rigid educational structures.

Another important theoretical perspective underlying the study is Vygotsky’s social constructivist theory. Social constructivism emphasizes that learning occurs through social interaction, communication, collaboration, and guided participation. Inclusive classrooms provide opportunities for students with and without disabilities to learn together through interaction and cooperative learning experiences. Teachers therefore play a vital role in facilitating social participation, scaffolding learning experiences, and creating supportive classroom relationships that enhance learning and development.

The present study is further supported by teacher efficacy theory, which explains how teachers’ beliefs regarding their professional competence influence their classroom practices, instructional decisions, motivation, and willingness to address diverse learning needs. Teachers who possess high levels of self efficacy are generally more confident in implementing inclusive teaching strategies, adapting instruction, managing classroom behavior, and supporting students with disabilities. Conversely, teachers with low self efficacy may experience stress, anxiety, resistance toward inclusion, and reduced professional confidence.

The study also draws from the human rights approach to education, which recognizes education as a fundamental right for every individual. This perspective emphasizes equality, participation, dignity, non discrimination, and social justice. Inclusive education is therefore not merely an educational reform but also a human rights obligation aimed at ensuring equal educational opportunities for all learners, including students with intellectual disabilities.

Furthermore, the ecological systems perspective contributes to the understanding that inclusive education is influenced by multiple interconnected factors including family support, school environment, institutional policies, teacher preparation, peer interaction, and sociocultural attitudes toward disability. Teachers’ experiences within inclusive classrooms are therefore shaped by broader educational and social systems.

These theoretical perspectives collectively provide a strong conceptual base for understanding teachers’ perceptions and experiences related to inclusive education and teaching students with intellectual disabilities. They also help explain how institutional support, professional competence, classroom practices, and social attitudes interact to influence the effectiveness of inclusive educational practices.

1.13 Delimitations of the Study

  1. The study is limited only to teachers working in inclusive educational settings and does not include the perspectives of students, parents, school administrators, or policymakers.
  2. The study specifically focuses on students with intellectual disabilities and does not include other categories of disabilities such as visual impairment, hearing impairment, autism spectrum disorder, or learning disabilities.
  3. The study is restricted to selected schools within a particular geographical area and therefore the findings may not be generalized to all educational settings or regions.
  4. The study focuses only on mainstream inclusive classrooms where students with intellectual disabilities are enrolled.
  5. The study primarily examines teachers’ perceptions, experiences, and classroom practices related to inclusive education and does not attempt to measure academic achievement outcomes of students with intellectual disabilities.
  6. The study is limited by the availability, honesty, and willingness of participants to share their experiences and perceptions during data collection.
  7. The study focuses on the educational experiences of teachers within the present educational framework and does not include historical comparative analysis of inclusive education policies.
  8. The study is conducted within a limited time period and available resources, which may influence the depth and breadth of data collection.

Despite these delimitations, the study seeks to provide meaningful and valuable insights into teachers’ perceptions and experiences related to inclusive education and teaching students with intellectual disabilities.

 CHAPTER 2

REVIEW OF LITERATURE

 

2.1 Introduction

Review of related literature constitutes one of the most significant components of research because it provides the theoretical and empirical foundation for the study. It helps the researcher understand the existing body of knowledge, identify research trends, examine methodological approaches used by previous researchers, and locate gaps requiring further investigation. A comprehensive review of literature also strengthens the conceptual clarity of the study and establishes the relevance and necessity of the research problem.

The present chapter reviews significant national and international studies conducted between 2020 and 2026 related to inclusive education and teaching students with intellectual disabilities. The review has been organized under the following themes:

  1. Teacher Attitudes Toward Inclusive Education
  2. Teacher Training and Preparedness
  3. Classroom Challenges in Inclusive Education
  4. Institutional Support for Inclusive Education

The chapter concludes with the identification of the research gap emerging from the reviewed literature.

2.2 Review of Literature Related to Teacher Attitudes Toward Inclusive Education

Singal (2020)

Singal (2020) examined challenges and opportunities associated with inclusive education implementation in India with particular focus on teacher preparedness. Findings revealed that teachers working within mainstream schools often lacked confidence in teaching students with intellectual disabilities because of insufficient training opportunities. Teachers reported difficulty adapting teaching strategies, managing classroom participation, and addressing diverse learner needs. The study further indicated that professional preparation in inclusive pedagogy remains inconsistent across educational institutions. Singal concluded that strengthening teacher preparedness through practical training and institutional support is essential for improving inclusive educational practices in India.

Bhatnagar and Das (2020)

Bhatnagar and Das (2020) conducted a study examining teachers’ preparedness for inclusive education in secondary schools in India. The findings revealed that many teachers felt inadequately prepared to teach students with disabilities because teacher education programs provided limited exposure to inclusive teaching methods. Teachers expressed difficulty managing classroom diversity and adapting curriculum according to learner needs. Participants also identified lack of teaching resources and insufficient professional guidance as barriers affecting their preparedness. The study concluded that teacher education institutions should strengthen practical training related to inclusive classroom management, differentiated instruction, and collaborative teaching practices.

Sharma and Sokal (2020)

Sharma and Sokal (2020) examined the impact of teacher education on teachers’ attitudes and preparedness toward inclusive education in India. The study focused on how professional preparation influences teachers’ confidence in implementing inclusive practices. Findings indicated that teachers who received training related to inclusive education demonstrated stronger teaching efficacy and greater willingness to include students with disabilities in mainstream classrooms. Participants who lacked professional preparation expressed fear, anxiety, and uncertainty regarding classroom management and instructional adaptation. The researchers emphasized that teacher education programs in India should incorporate practical training related to inclusive pedagogy and intellectual disability. The study concluded that professional preparedness significantly influences teachers’ confidence and classroom effectiveness within inclusive educational environments.

Florian and Black Hawkins (2021)

Florian and Black Hawkins (2021) explored inclusive pedagogy and teacher preparedness in mainstream educational settings. The study emphasized that effective inclusion requires teachers to rethink traditional teaching methods and adopt learner centered instructional approaches. Findings revealed that teachers who possessed strong understanding of inclusive pedagogy were more capable of addressing diverse learner needs within mainstream classrooms. Participants demonstrated greater flexibility in adapting instructional methods and classroom participation strategies for students with disabilities. The study further highlighted that reflective teaching practices and collaborative learning experiences significantly strengthen teacher preparedness for inclusion. The researchers concluded that inclusive pedagogy should become a central component of teacher education rather than a specialized topic taught separately.

Mukhopadhyay (2021)

Mukhopadhyay (2021) investigated policy implementation and teacher preparedness related to inclusive education in India. Findings indicated that many teachers lacked sufficient professional training in inclusive pedagogy and intellectual disability. Participants reported that teacher education programs often focused excessively on theoretical discussions while providing limited practical classroom experience. Teachers also expressed concerns regarding assessment adaptation and individualized educational planning for students with disabilities. Mukhopadhyay emphasized that effective inclusion requires comprehensive reforms in teacher education curricula and continuous professional support for practicing teachers. The study concluded that teacher preparedness remains one of the most critical challenges affecting inclusive education in India.

Sharma (2021)

Sharma (2021) conducted a study on professional competence and preparedness of teachers working in inclusive classrooms in Indian schools. The study explored how training programs influence teachers’ instructional practices and confidence levels. Findings revealed that teachers who attended specialized workshops related to disability inclusion demonstrated greater ability to implement differentiated instruction and inclusive classroom management strategies. Participants emphasized that continuous professional development improved their confidence and understanding of intellectual disability. However, teachers also identified lack of follow up support and shortage of teaching materials as barriers affecting preparedness. The study concluded that teacher preparedness must be strengthened through sustained professional development programs and institutional collaboration.

Loreman (2022)

Loreman (2022) reviewed current practices in measuring inclusive education outcomes and examined teacher perceptions regarding educational inclusion. The study found that teachers frequently view inclusive education positively at the philosophical level but experience practical concerns related to implementation. Teachers identified curriculum rigidity, assessment pressure, insufficient resources, and lack of collaboration as barriers to effective inclusion. The study emphasized that inclusive education outcomes depend substantially upon teacher attitudes and institutional commitment. Loreman concluded that sustainable inclusion requires continuous professional support, inclusive school culture, and flexible educational systems capable of accommodating learner diversity.

Abaoud and Aldosari (2023)

Abaoud and Aldosari (2023) investigated teachers’ perceptions regarding teaching students with intellectual disabilities in inclusive classrooms. The study focused specifically on classroom experiences and professional challenges associated with intellectual disability inclusion. Findings indicated that teachers generally valued the social benefits of inclusion and believed that students with disabilities should have equal educational opportunities. However, participants reported concerns regarding academic adaptation, communication difficulties, and classroom behavior management. Teachers with previous experience teaching students with intellectual disabilities demonstrated more confidence and positive attitudes compared to inexperienced teachers. The study concluded that practical exposure and specialized training significantly influence teacher perceptions regarding inclusive education.

Xin, Hornby, and Wang (2023)

Xin and colleagues (2023) explored teachers’ beliefs regarding teaching students with intellectual and developmental disabilities. The study examined the relationship between teacher efficacy and inclusive attitudes. Findings revealed that teachers with strong professional confidence demonstrated more positive beliefs regarding the educational potential of students with intellectual disabilities. Teachers who perceived themselves as professionally competent were more willing to implement adaptive instructional strategies and collaborative teaching practices. However, teachers with limited professional confidence expressed fear, anxiety, and uncertainty regarding inclusive classroom management. The researchers emphasized that strengthening teacher efficacy through professional development programs may significantly improve attitudes toward inclusive education.

Saragoça, Ferreira, and Teixeira (2025)

Saragoça and colleagues (2025) examined teachers’ attitudes toward inclusive education using the International Classification of Functioning framework. The study investigated how teachers perceive the relationship between disability, participation, and educational inclusion. Findings revealed that teachers generally supported the philosophical principles of inclusion but experienced difficulties in practical implementation due to insufficient support and limited resources. Teachers who possessed greater understanding of disability and inclusive pedagogy demonstrated more favorable perceptions toward inclusion. The study emphasized that positive attitudes alone are insufficient unless accompanied by institutional support, professional preparation, and accessible educational environments. The researchers concluded that inclusive education requires systemic transformation involving teachers, institutions, families, and policymakers.

Schmidt, Rydberg, and Nilholm (2025)

Schmidt and colleagues (2025) conducted research on university teachers’ attitudes toward inclusive education and academic accommodations. The study explored teachers’ willingness to support students with disabilities within higher educational settings. Findings revealed that most teachers recognized inclusion as an educational right and expressed positive perceptions regarding accessibility and participation. However, participants reported uncertainty regarding practical accommodations and assessment modifications for students with disabilities. Teachers also identified workload pressure and lack of institutional guidance as barriers to effective inclusion. The study highlighted the gap between teachers’ philosophical support for inclusion and their practical preparedness for inclusive teaching. Researchers recommended continuous professional development programs to improve teachers’ understanding and implementation of inclusive educational practices.

Gal (2025)

Gal (2025) conducted a phenomenological study exploring teachers’ perspectives on inclusive education. The study focused on teachers’ lived experiences while teaching students with disabilities within mainstream classrooms. Findings indicated that teachers’ attitudes toward inclusion are influenced by emotional experiences, classroom interactions, institutional support, and professional confidence. Teachers who experienced successful inclusion developed more positive perceptions regarding disability and learner diversity. Conversely, teachers who lacked support often expressed frustration, emotional exhaustion, and feelings of inadequacy. The study emphasized that inclusive education is not merely an instructional responsibility but also an emotional and relational process requiring empathy, patience, and collaboration. Gal concluded that teacher attitudes evolve continuously through practical experiences within inclusive environments.

Carrillo Sierra et al. (2025)

Carrillo Sierra and colleagues (2025) investigated inclusive education practices among university teachers and examined the role of professional training in strengthening teacher preparedness. Findings revealed that teachers with prior exposure to disability related training demonstrated more positive perceptions and stronger classroom competence within inclusive educational settings. Participants emphasized that collaborative professional development programs enhanced their understanding of learner diversity and inclusive instructional methods. However, teachers also reported difficulty adapting traditional curriculum structures for students with intellectual disabilities. The study concluded that professional preparedness is a continuous developmental process requiring institutional encouragement, professional collaboration, and access to inclusive teaching resources.

Darwish (2025)

Darwish (2025) examined challenges faced by teachers implementing inclusive education for students with intellectual disabilities. The study highlighted the relationship between teachers’ attitudes and classroom experiences. Findings revealed that although teachers strongly supported the ideals of inclusive education, many expressed concerns regarding their ability to effectively teach students with intellectual disabilities. Participants identified inadequate training, lack of specialized resources, overcrowded classrooms, and limited support staff as factors negatively influencing their attitudes toward inclusion. Teachers also reported emotional stress associated with balancing diverse learner needs. Darwish emphasized that negative attitudes toward inclusion frequently emerge from systemic barriers rather than personal prejudice. The study concluded that improving institutional support and teacher preparation may strengthen positive perceptions toward inclusive education.

García et al. (2026)

García and colleagues (2026) explored teachers’ attitudes toward inclusive education across multicultural educational settings. The study aimed to examine how professional training and sociocultural factors influence teachers’ perceptions regarding disability inclusion. Findings indicated that teachers who received specialized training in inclusive pedagogy expressed significantly more positive attitudes toward teaching students with disabilities. Participants believed that inclusive education promotes social equality, empathy, and learner participation. However, many teachers reported feeling emotionally and professionally challenged while managing diverse classroom needs. The study further highlighted that cultural beliefs regarding disability influence teacher attitudes toward inclusion. García and colleagues concluded that teacher attitudes are shaped by both professional competence and broader sociocultural perceptions related to disability and educational diversity.

Campos (2026)

Campos (2026) conducted a study on factors influencing pre service teachers’ preparedness for inclusive classrooms in Spain. The purpose of the study was to examine whether teacher education programs adequately prepare future teachers for inclusive educational settings. Data were collected from pre service teachers through questionnaires, interviews, and classroom reflections. The findings revealed that participants who received structured practical exposure to inclusive classrooms demonstrated higher confidence and stronger teaching efficacy compared to those who received only theoretical instruction. The study also found that teachers often experience fear and uncertainty while teaching students with intellectual disabilities due to insufficient practical experience. Campos emphasized that teacher preparedness is strengthened through direct classroom engagement, collaborative learning experiences, and practical workshops. The study concluded that inclusive teacher education programs should focus equally on practical training, emotional preparedness, and classroom management skills to improve teachers’ readiness for inclusive educational environments.

Hornby (2023)

Hornby (2023) investigated policy and classroom practice challenges associated with inclusion of students with intellectual disabilities within mainstream schools. Findings revealed that teachers frequently encountered difficulties related to differentiated instruction, classroom organization, and behavioral management. Participants emphasized that students with intellectual disabilities often required repetitive instruction, structured learning environments, and continuous supervision, which increased classroom management complexity. Teachers also reported that rigid curriculum structures and examination oriented educational systems limited their ability to implement flexible inclusive teaching methods. The study concluded that classroom challenges undermine inclusive education when schools fail to provide appropriate support systems and professional resources for teachers.

Brown (2023)

Brown (2023) explored teachers’ perceptions regarding teaching students with mild intellectual disabilities in mainstream classrooms. Findings revealed that teachers often experienced professional stress due to increased instructional responsibilities and classroom management demands. Participants identified communication difficulties, peer interaction problems, and individualized instructional requirements as major classroom challenges. Teachers also reported difficulty maintaining classroom participation for students with intellectual disabilities because mainstream teaching methods often failed to address their learning needs effectively. The study emphasized that inclusive classrooms require greater flexibility, patience, and collaboration than traditional educational settings. Brown concluded that teachers require stronger institutional support and specialized training to effectively manage inclusive classroom challenges.

 

2.6 Research Gap

The review of related literature reveals that inclusive education has received increasing scholarly attention at both national and international levels during recent years. Researchers have extensively examined teacher attitudes, professional preparedness, classroom challenges, and institutional support related to inclusion of students with disabilities within mainstream educational settings. However, despite the growing body of literature, several important gaps remain insufficiently explored.

First, many previous studies have examined inclusive education broadly without specifically focusing on students with intellectual disabilities. Students with intellectual disabilities present unique cognitive, behavioral, social, and adaptive challenges that require specialized instructional approaches and classroom support. However, limited research has specifically explored teachers’ experiences related to teaching students with intellectual disabilities within inclusive classrooms.

Second, a significant portion of the existing literature focuses primarily on quantitative assessment of teacher attitudes toward inclusive education through structured questionnaires and surveys. Although such studies provide useful statistical understanding, they often fail to capture teachers’ lived experiences, emotional responses, practical classroom realities, and contextual challenges associated with inclusion. There remains a need for deeper qualitative exploration of teachers’ experiences within inclusive educational environments.

Third, many international studies focus on inclusive educational practices within developed educational systems possessing comparatively stronger institutional support and professional resources. However, relatively limited research has examined inclusive education within the Indian educational context where schools frequently encounter infrastructural limitations, shortage of trained personnel, overcrowded classrooms, and inadequate support systems.

Fourth, several studies examine teacher attitudes, classroom challenges, or institutional support separately rather than examining the interconnected relationship among these variables. Limited research has explored how teacher perceptions, professional preparedness, classroom experiences, and institutional support collectively influence inclusive educational practices and outcomes.

Fifth, although teacher training has been recognized as a major factor affecting inclusive education, many studies provide limited discussion regarding how practical classroom experiences shape teachers’ confidence and professional competence over time. More research is required to understand how teachers develop coping strategies and adaptive instructional practices within inclusive classrooms.

Sixth, many existing studies focus primarily on policy analysis and theoretical discussions related to inclusive education while giving less attention to the everyday realities faced by teachers working in mainstream schools. There remains a lack of detailed exploration regarding how teachers negotiate practical challenges such as curriculum adaptation, classroom management, individualized instruction, and emotional stress associated with inclusive teaching.

Finally, there is limited qualitative research exploring teachers’ perceptions and lived experiences within inclusive classrooms in Faridabad Haryana and similar educational contexts. Therefore, the present study seeks to address these gaps by exploring teachers’ perceptions of inclusive education and examining their experiences in teaching students with intellectual disabilities within inclusive classroom settings.

 

CHAPTER 3

METHODOLOGY OF THE STUDY

 

3.1 Introduction

Research methodology constituted one of the most significant components of the present investigation because it provided the systematic framework through which the researcher collected, organized, analyzed, and interpreted data related to the research problem. Methodology ensured that the study was conducted in a logical, objective, reliable, and scientifically valid manner. It enabled the researcher to examine the research problem systematically and derive meaningful conclusions based on empirical evidence.

The present study titled “Teachers’ Perceptions of Inclusive Education and Their Experiences in Teaching Students with Intellectual Disabilities” sought to explore teachers’ perceptions, beliefs, classroom experiences, and challenges associated with inclusive education. Since the study focused on understanding lived experiences, professional realities, emotional responses, and contextual classroom practices, a qualitative methodological approach was considered most appropriate for the investigation.

Qualitative research enabled the researcher to explore human experiences, attitudes, meanings, perceptions, and social realities in depth. Unlike quantitative research that primarily emphasized measurement and statistical analysis, qualitative research focused on understanding participants’ perspectives and interpretations within their natural settings. In the context of the present study, qualitative methodology allowed the researcher to gain deeper insight into how teachers perceived inclusive education and how they experienced the process of teaching students with intellectual disabilities in mainstream classrooms.

The present chapter therefore described the methodological framework adopted for conducting the study. It included the research approach, research design, study area, population of the study, sample and sampling technique, participant criteria, methods and tools of data collection, development of research instruments, procedures of data collection, trustworthiness of qualitative data, ethical considerations, and procedures used for data analysis and interpretation.

The methodological framework was developed carefully in order to ensure credibility, dependability, authenticity, and rigor in the research process. The chapter provided the foundation through which the objectives and research questions of the study were systematically addressed.

 

3.2 Research Approach

The present study adopted a qualitative research approach. Qualitative research was concerned with understanding human experiences, social interactions, beliefs, emotions, perceptions, and meanings within their natural contexts. It enabled researchers to explore complex educational and social phenomena in depth by focusing on participants’ lived experiences and subjective interpretations.

The qualitative approach was considered appropriate for the present study because the research aimed to explore teachers’ perceptions and experiences related to inclusive education and teaching students with intellectual disabilities. Such experiences could not be adequately understood through numerical measurement alone because they involved emotional, psychological, instructional, and contextual dimensions requiring detailed exploration.

Qualitative research allowed participants to describe their experiences in their own words, thereby providing richer understanding of classroom realities, professional challenges, coping strategies, and institutional factors influencing inclusive educational practices. The approach also enabled the researcher to examine the meanings teachers attached to inclusive education and how these meanings influenced their classroom practices and professional attitudes.

Another important reason for selecting qualitative methodology was that the present study sought to explore practical realities rather than merely test predetermined variables. Teachers’ experiences in inclusive classrooms were shaped by multiple interrelated factors such as institutional support, professional competence, classroom environment, emotional preparedness, and learner diversity. Qualitative inquiry allowed the researcher to examine these interconnected factors holistically.

Furthermore, qualitative research emphasized flexibility, participant interaction, contextual understanding, and detailed interpretation. Since the present study focused on understanding educational experiences within real classroom settings, the qualitative approach provided the most suitable methodological framework for generating meaningful and contextually grounded findings.

Therefore, the qualitative research approach was selected because it facilitated comprehensive exploration of teachers’ perceptions, classroom experiences, challenges, and support needs related to inclusive education for students with intellectual disabilities.

3.3 Research Design

The present study employed an exploratory qualitative research design. Exploratory research design was used when the researcher intended to gain deeper understanding of a relatively complex phenomenon requiring detailed investigation and interpretation. It was particularly useful in studies aiming to explore perceptions, experiences, attitudes, feelings, and contextual realities.

The exploratory qualitative design was considered appropriate for the present study because the researcher sought to investigate teachers’ perceptions and experiences related to teaching students with intellectual disabilities in inclusive classrooms. The study did not merely aim to measure attitudes or compare statistical variables but sought to understand how teachers experienced inclusive educational practices in real classroom situations.

The design allowed the researcher to explore:

  • teachers’ perceptions toward inclusive education
  • experiences of teaching students with intellectual disabilities
  • classroom challenges encountered during inclusion
  • institutional support mechanisms
  • coping strategies adopted by teachers
  • professional and emotional dimensions of inclusive teaching

The exploratory nature of the design also allowed flexibility during data collection and analysis. Participants were encouraged to express their experiences openly, enabling the researcher to identify emerging themes, patterns, and meanings related to inclusive education.

The study further utilized semi structured interviews and focus group discussions as major methods of qualitative inquiry. These methods provided opportunities for participants to discuss their experiences, opinions, and challenges in detail while also allowing the researcher to seek clarification and deeper understanding wherever necessary.

The research design therefore supported comprehensive examination of the practical realities associated with inclusive education and helped generate contextually grounded interpretations regarding teachers’ perceptions and experiences.

3.4 Research Site

The present study was conducted in selected inclusive schools located in Faridabad. These schools had adopted inclusive educational practices and enrolled students with intellectual disabilities within mainstream classroom settings.

The selection of the research site was guided by several academic and practical considerations. First, inclusive schools in Faridabad provided opportunities to examine the realities of inclusive education within mainstream educational environments where students with intellectual disabilities were integrated alongside non disabled peers. Second, the selected schools possessed teachers who had direct teaching experience related to inclusive classrooms, which was essential for the objectives of the present study.

Faridabad represented an educationally significant urban region where increasing emphasis had been placed on implementation of inclusive educational policies. Schools in this region included diverse educational settings with varying levels of institutional support, teaching resources, professional preparedness, and inclusive classroom practices. Such diversity provided rich contextual understanding regarding the implementation of inclusive education.

The research site was also selected due to accessibility, feasibility of data collection, availability of participants, and relevance to the objectives of the study. Conducting the study within selected inclusive schools allowed the researcher to interact directly with teachers who possessed practical experience related to teaching students with intellectual disabilities.

The study focused specifically on mainstream schools implementing inclusive educational practices rather than segregated special schools because the research intended to examine teachers’ experiences within inclusive classroom environments.

3.5 Population of the Study

Population referred to the entire group of individuals, objects, or units possessing specific characteristics relevant to the research study. In educational research, population represented the larger group from which participants were selected for detailed investigation.

The population of the present study consisted of teachers working in inclusive schools located in Faridabad who possessed experience in teaching students with intellectual disabilities within mainstream classroom settings.

The target population included:

  • general education teachers
  • special education teachers
  • inclusive classroom teachers

who were directly involved in inclusive teaching practices related to students with intellectual disabilities.

The population was selected because teachers served as the primary facilitators of inclusive educational practices and possessed direct classroom experience related to inclusion. Their perceptions, attitudes, professional experiences, instructional strategies, and classroom challenges were central to understanding the realities of inclusive education.

The study specifically focused on teachers who possessed practical experience in teaching students with intellectual disabilities because such participants could provide meaningful insights regarding:

  • classroom participation
  • instructional adaptation
  • behavioral management
  • institutional support
  • inclusive pedagogy
  • emotional and professional challenges

associated with inclusive educational settings.

The population further included teachers belonging to different educational backgrounds, teaching experiences, and professional training levels in order to obtain diverse perspectives related to inclusive education.

3.6 Sample of the Study

A sample referred to a smaller representative group selected from the larger population for the purpose of detailed investigation. Since it was difficult and impractical to study the entire population, the researcher selected a manageable number of participants who possessed characteristics relevant to the objectives of the study.

The present study included a sample of 50 teachers working in inclusive schools in Faridabad. These teachers possessed direct experience in teaching students with intellectual disabilities within mainstream classroom settings.

The sample included:

  • general education teachers
  • special education teachers
  • inclusive classroom teachers

who were actively involved in implementing inclusive educational practices.

The selected sample was considered appropriate because qualitative research primarily emphasized depth, richness, and meaningful understanding of participants’ experiences rather than large numerical representation. The sample size was therefore sufficient for obtaining detailed insights into teachers’ perceptions, professional experiences, classroom challenges, and support needs related to inclusive education.

The sample also included participants with varying:

  • teaching experiences
  • professional qualifications
  • training backgrounds
  • institutional contexts
  • classroom experiences

in order to ensure diversity of perspectives and richer qualitative interpretation.

The participants selected for the study provided detailed information regarding:

  • inclusive teaching practices
  • classroom adaptation strategies
  • emotional experiences
  • institutional barriers
  • support mechanisms
  • professional challenges

associated with teaching students with intellectual disabilities in mainstream classrooms.

3.7 Sampling Technique

Sampling technique referred to the method used by the researcher for selecting participants from the target population. The selection of an appropriate sampling technique was essential because it influenced the credibility, relevance, and richness of research findings.

The present study employed purposive sampling technique. Purposive sampling was a non probability sampling method in which participants were selected intentionally based on their relevance, knowledge, experience, and ability to provide meaningful information related to the research problem.

Purposive sampling was considered appropriate for the present study because the researcher specifically sought participants who possessed direct experience in teaching students with intellectual disabilities within inclusive classroom settings. Not all teachers possessed such experiences; therefore, participants were selected carefully according to predetermined criteria relevant to the objectives of the study.

The purposive sampling technique enabled the researcher to select participants who:

  • possessed practical knowledge regarding inclusive education
  • had direct classroom experience related to intellectual disability
  • could describe their perceptions and experiences in detail
  • were capable of providing rich qualitative information

related to inclusive teaching practices.

Another important advantage of purposive sampling was that it allowed the researcher to focus on information rich participants who could contribute significantly to understanding the research phenomenon. Since the present study emphasized depth and contextual understanding rather than statistical generalization, purposive sampling provided the most suitable methodological approach.

The sampling process involved identification of inclusive schools followed by selection of teachers meeting the inclusion criteria established for the study.

3.8 Inclusion Criteria for Participants

Inclusion criteria referred to the specific conditions or characteristics participants needed to possess in order to be included in the research study. Establishing inclusion criteria helped ensure that selected participants were directly relevant to the objectives and focus of the investigation.

Participants included in the present study fulfilled the following criteria:

  1. The participants were currently working as teachers in inclusive educational settings.
  2. The participants possessed direct experience in teaching students with intellectual disabilities within mainstream classrooms.
  3. The participants had a minimum of two years of teaching experience.
  4. The participants willingly participated in the research study.
  5. The participants were capable of expressing their perceptions, experiences, and classroom practices related to inclusive education.
  6. Both general education teachers and special education teachers involved in inclusive teaching practices were included in the study.
  7. Teachers belonging to different age groups, professional qualifications, and institutional backgrounds were included in order to obtain diverse perspectives.

The inclusion criteria were developed carefully to ensure that participants possessed sufficient professional experience and contextual understanding related to inclusive education and teaching students with intellectual disabilities.

 

 

3.9 Methods and Tools of Data Collection

Data collection constituted one of the most significant stages of the research process because the quality and credibility of research findings depended substantially upon the appropriateness of the methods and tools used for gathering information.

Since the present study adopted a qualitative research approach, qualitative methods of data collection were selected in order to obtain detailed, descriptive, and experience based information from participants. The study utilized the following methods and tools for collecting data:

3.9.1 Semi Structured Interviews

Semi structured interviews served as the primary method of data collection for the present study. Semi structured interviews provided flexibility and allowed participants to describe their experiences, perceptions, feelings, and challenges in detail while enabling the researcher to maintain focus on the major objectives of the study.

The semi structured interview method was considered appropriate because the present study sought to explore teachers’ lived experiences and subjective interpretations regarding inclusive education and teaching students with intellectual disabilities.

An interview guide was developed consisting of open ended questions related to:

  • teachers’ perceptions toward inclusive education
  • classroom experiences
  • instructional challenges
  • behavior management
  • institutional support
  • professional preparedness
  • inclusive teaching strategies
  • emotional experiences related to inclusion

The researcher also asked probing questions wherever necessary in order to obtain deeper clarification and richer information from participants.

The interviews were conducted individually in a comfortable and confidential environment to encourage open and honest responses from participants.

3.9.2 Focus Group Discussions

Focus Group Discussions were also used as a supplementary method of data collection. Focus group discussions involved guided interaction among participants regarding a particular topic or issue.

This method was considered useful because it allowed teachers to:

  • exchange experiences
  • discuss common challenges
  • share classroom strategies
  • reflect collectively on inclusive educational practices

Focus group discussions generated diverse perspectives and provided deeper understanding regarding institutional realities and collaborative aspects of inclusive education.

The discussions were moderated carefully by the researcher to ensure equal participation, respectful interaction, and relevance to the objectives of the study.

3.9.3 Interview Guide

An interview guide was developed by the researcher to ensure consistency and systematic direction during interviews and focus group discussions.

The interview guide included questions related to:

  • perceptions regarding inclusive education
  • experiences teaching students with intellectual disabilities
  • classroom management practices
  • instructional adaptation strategies
  • institutional support systems
  • professional training experiences
  • emotional and psychological challenges
  • recommendations for improving inclusive education

The guide remained flexible in order to accommodate participants’ responses and encourage natural discussion.

The interview guide was also validated through expert consultation prior to the actual process of data collection.

3.10 Development of Research Tools

Development of appropriate research tools constituted an essential component of qualitative research because it determined the quality, relevance, and depth of information collected from participants. In the present study, the researcher developed qualitative data collection tools carefully in accordance with the objectives, research questions, conceptual framework, and theoretical foundation of the study.

The major research tools developed for the present investigation included:

  • semi structured interview guide
  • focus group discussion guide

These tools were designed to facilitate in depth exploration of teachers’ perceptions and experiences related to inclusive education and teaching students with intellectual disabilities.

3.10.1 Development of Semi Structured Interview Guide

The semi structured interview guide was developed systematically by reviewing:

  • objectives of the study
  • research questions
  • related literature
  • conceptual framework
  • previous research studies related to inclusive education

The interview guide consisted of open ended questions designed to encourage participants to describe their:

  • perceptions toward inclusive education
  • classroom experiences
  • instructional challenges
  • emotional responses
  • professional difficulties
  • institutional support experiences
  • teaching strategies
  • recommendations for improving inclusion

The questions were framed in clear, simple, and participant friendly language in order to facilitate comfortable interaction and detailed responses.

The interview guide included both primary and probing questions. Primary questions focused on major research themes, whereas probing questions helped the researcher obtain deeper clarification and richer explanation regarding participants’ responses.

The interview guide remained flexible in nature so that participants could freely express their experiences without excessive restriction.

 

3.10.2 Development of Focus Group Discussion Guide

A separate guide was also prepared for conducting focus group discussions. The guide included discussion prompts related to:

  • classroom realities
  • collaborative teaching practices
  • institutional barriers
  • support mechanisms
  • professional challenges
  • inclusive teaching experiences

The focus group discussion guide encouraged interaction among participants and allowed teachers to collectively discuss common experiences associated with inclusive education.

The guide also helped the researcher identify:

  • similarities in experiences
  • differing viewpoints
  • shared challenges
  • collaborative strategies

related to inclusive classroom practices.

3.10.3 Validation of Research Tools

The developed tools were validated through expert review. Experts in the fields of:

  • special education
  • inclusive education
  • educational research
  • qualitative methodology

were consulted to examine the relevance, clarity, appropriateness, and comprehensiveness of the interview questions and discussion prompts.

Suggestions provided by experts were incorporated to improve:

  • language clarity
  • thematic relevance
  • sequencing of questions
  • research adequacy

of the tools.

The validation process helped ensure content validity and appropriateness of the research instruments in relation to the objectives of the study.

3.11 Pilot Study

Before conducting the final study, a pilot study was conducted on a small group of teachers possessing characteristics similar to those of the actual participants.

The pilot study served several important purposes:

  • testing clarity of interview questions
  • identifying ambiguities or difficulties in the tools
  • examining feasibility of data collection procedures
  • estimating interview duration
  • improving researcher interaction skills
  • refining probing techniques

The pilot study helped the researcher identify potential problems related to:

  • participant understanding
  • sequencing of questions
  • recording of responses
  • management of interviews and discussions

Necessary modifications were made in the research tools and procedures based on observations and feedback obtained during the pilot study.

The participants involved in the pilot study were not included in the final sample of the study.

3.12 Procedure of Data Collection

The procedure of data collection referred to the systematic process followed by the researcher for gathering information from participants. In the present study, data collection was conducted carefully and ethically in order to ensure credibility, participant comfort, and authenticity of responses.

The researcher first obtained formal permission from the concerned school authorities before initiating the process of data collection.

After obtaining institutional permission, the researcher identified eligible participants according to the predetermined inclusion criteria. Participants were then approached individually and informed regarding:

  • objectives of the study
  • purpose of the research
  • nature of participation
  • confidentiality procedures
  • voluntary participation rights

Informed consent was obtained from all participants prior to data collection.

The semi structured interviews were conducted individually in a quiet and comfortable environment within the school premises or another mutually convenient location. The interviews encouraged participants to discuss their perceptions and experiences freely and honestly.

Each interview was conducted in a conversational and flexible manner to facilitate natural interaction. With participants’ permission, interviews were audio recorded for accuracy of transcription and analysis. Field notes were also maintained by the researcher to document:

  • observations
  • emotional expressions
  • contextual details
  • non verbal responses

During focus group discussions, participants were encouraged to interact respectfully and share their experiences collectively. The researcher moderated discussions carefully to ensure balanced participation and relevance to the research themes.

Data collection continued until sufficient depth and thematic saturation were achieved.

The collected data were subsequently organized, transcribed, coded, and prepared for thematic analysis.

3.13 Techniques of Data Analysis

Data analysis constituted one of the most important stages of qualitative research because it enabled the researcher to organize, interpret, and derive meaning from the collected information. In the present study, qualitative thematic analysis technique was used for analyzing the collected data.

Thematic analysis involved systematic identification, organization, interpretation, and presentation of recurring themes, categories, and patterns emerging from participants’ responses. This method was considered appropriate because the study aimed to explore teachers’ perceptions, experiences, classroom challenges, and institutional realities related to inclusive education.

The process of data analysis was conducted through the following stages:

Familiarization with Data

The researcher carefully read interview transcripts and field notes several times in order to develop familiarity with participants’ responses and overall meaning of the data.

Coding of Data

After familiarization, significant statements, ideas, experiences, and responses were identified and coded systematically. Coding helped organize data into meaningful units related to the objectives and research questions of the study.

Development of Categories

Codes with similar meanings were grouped together into broader categories. These categories represented major aspects of teachers’ experiences and perceptions regarding inclusive education.

Identification of Themes

The researcher identified recurring themes emerging from the categories. The themes reflected major dimensions of the study such as:

  • teacher perceptions toward inclusive education
  • classroom challenges
  • professional preparedness
  • institutional support
  • emotional experiences
  • instructional adaptation practices

Interpretation of Themes

The identified themes were interpreted carefully in relation to:

  • objectives of the study
  • research questions
  • conceptual framework
  • reviewed literature

The researcher analyzed how different themes were interconnected and how they explained teachers’ experiences related to inclusive education.

Presentation of Findings

The findings were presented systematically through thematic descriptions supported by participants’ responses and interpretations. The thematic presentation helped provide deeper understanding of the realities associated with teaching students with intellectual disabilities in inclusive classrooms.

3.14 Trustworthiness of the Study

In qualitative research, trustworthiness refers to the credibility, dependability, authenticity, and reliability of the research findings. Since qualitative studies involve interpretation of participants’ experiences and perceptions, ensuring trustworthiness becomes essential for maintaining scientific rigor and research integrity.

In the present study, several strategies were adopted to ensure trustworthiness of the collected data and findings.

3.14.1 Credibility

Credibility refers to the accuracy and authenticity of the findings in representing participants’ experiences and realities. In order to ensure credibility, the researcher maintained prolonged engagement with participants during interviews and discussions to obtain detailed and meaningful information.

Semi structured interviews and focus group discussions enabled participants to express their views openly and honestly. The researcher also used probing questions to obtain deeper clarification and avoid superficial interpretation of responses.

Furthermore, data were collected from participants possessing direct experience related to inclusive education and teaching students with intellectual disabilities, thereby increasing the authenticity and relevance of the findings.

3.14.2 Dependability

Dependability refers to the consistency and stability of the research process over time. In order to maintain dependability, the researcher followed systematic procedures throughout:

  • participant selection
  • data collection
  • coding
  • thematic analysis
  • interpretation of findings

Detailed records of interviews, field notes, coding procedures, and analytical decisions were maintained carefully. The use of semi structured interview guides also helped maintain consistency during interaction with participants.

The researcher ensured that the research procedures remained transparent and logically organized throughout the investigation.

3.14.3 Confirmability

Confirmability refers to the extent to which research findings were derived from participants’ responses rather than researcher bias or personal assumptions.

To ensure confirmability, the researcher maintained objectivity during:

  • interviews
  • data recording
  • coding
  • interpretation
  • thematic analysis

Field notes, interview recordings, and transcripts were preserved systematically for verification and reference purposes.

The researcher also relied upon direct participant responses and thematic evidence while interpreting findings in order to minimize subjective bias.

3.14.4 Transferability

Transferability refers to the extent to which findings may be applicable to similar educational contexts or situations.

In the present study, detailed descriptions regarding:

  • research setting
  • participant characteristics
  • classroom contexts
  • institutional realities
  • data collection procedures

were provided to enable readers and future researchers to understand the contextual applicability of the findings.

Although qualitative research does not primarily aim for broad statistical generalization, rich contextual descriptions may allow findings to be meaningfully applied to similar inclusive educational settings.

 

3.15 Ethical Considerations

Ethics constituted an essential component of the present research because the study involved direct interaction with human participants. The researcher followed ethical principles carefully in order to ensure respect, dignity, confidentiality, and voluntary participation throughout the research process.

Before initiating data collection, formal permission was obtained from the concerned school authorities. Participants were informed clearly regarding:

  • purpose of the study
  • objectives of the research
  • procedures of participation
  • voluntary nature of participation
  • confidentiality measures

Informed consent was obtained from all participants prior to conducting interviews and focus group discussions.

Participants were informed that they possessed the right to withdraw from the study at any stage without any negative consequences.

Confidentiality and anonymity of participants were maintained throughout the study. Personal identities, institutional names, and individual responses were not disclosed publicly. Pseudonyms or coded identities were used during transcription and presentation of findings in order to protect participants’ privacy.

The researcher ensured that participants were not exposed to:

  • emotional discomfort
  • discrimination
  • professional risk
  • coercion
  • psychological stress

during the research process.

The collected data were used strictly for academic and research purposes only. Interview recordings, field notes, and transcripts were stored securely to maintain confidentiality and prevent unauthorized access.

The researcher also maintained honesty, neutrality, and transparency throughout the research process. Findings were interpreted objectively without fabrication, manipulation, or misrepresentation of participants’ responses.

The study adhered to ethical principles associated with educational and qualitative research involving teachers and educational institutions.

3.16 Limitations of the Methodology

Although the methodology adopted for the present study was considered appropriate for exploring teachers’ perceptions and experiences related to inclusive education, certain limitations remained associated with the investigation.

  1. The study was limited to selected inclusive schools in Faridabad and therefore the findings may not represent all inclusive educational settings.
  2. The study focused only on teachers’ perceptions and experiences and did not include perspectives of students, parents, or school administrators.
  3. Since the study adopted a qualitative approach, the findings emphasized depth and contextual understanding rather than statistical generalization.
  4. Participants’ responses depended upon their willingness, honesty, and ability to express their experiences openly.
  5. Time limitations and accessibility constraints may have influenced the duration and depth of interaction with participants.
  6. The study focused specifically on intellectual disability and did not include experiences related to other disability categories.
  7. The researcher’s interpretation of qualitative data may involve some degree of subjectivity despite efforts to maintain objectivity and confirmability.

Despite these limitations, the methodology provided rich, meaningful, and contextually grounded understanding regarding teachers’ experiences in inclusive educational settings.

 

CHAPTER 4

DATA ANALYSIS AND INTERPRETATION

 

4.1 Introduction

The present chapter deals with the analysis and interpretation of data collected from teachers working in inclusive educational settings in Faridabad. The study aimed to explore teachers’ perceptions of inclusive education and examine their experiences in teaching students with intellectual disabilities in mainstream classrooms. The chapter presents the findings obtained through semi structured interviews and focus group discussions conducted with fifty teachers possessing direct experience in inclusive educational practices.

The collected qualitative data were analyzed using thematic analysis based on Braun and Clarke’s framework. Thematic analysis enabled the researcher to identify recurring patterns, categories, and themes emerging from participants’ responses. The analysis focused on major dimensions related to:

  • teachers’ perceptions toward inclusive education
  • experiences teaching students with intellectual disabilities
  • classroom challenges
  • teacher preparedness
  • institutional support
  • inclusive pedagogical practices
  • emotional experiences
  • strategies for strengthening inclusive education

The findings have been presented systematically through thematic descriptions, interpretative discussion, tables, and analytical explanations. Wherever necessary, frequency tables have been included to summarize participant responses and thematic patterns.

The chapter also includes analysis and interpretation of the hypotheses formulated for the study. Although the study adopted a qualitative approach, the hypotheses were interpreted conceptually and analytically based on thematic evidence and participant responses.

 

 

4.2 Demographic Profile of Participants

The demographic information of participants was analyzed to understand the background characteristics of teachers included in the study.

Table 4.1

Distribution of Participants According to Gender

Gender Number of Participants Percentage
Male 18 36%
Female 32 64%
Total 50 100%

Interpretation

The above table indicates that out of 50 participants, 32 teachers were female representing 64 percent of the sample, whereas 18 teachers were male representing 36 percent of the sample. The findings suggest greater female participation in inclusive educational settings.

Table 4.2

Distribution of Participants According to Teaching Experience

Teaching Experience Number of Participants Percentage
2 to 5 Years 14 28%
6 to 10 Years 19 38%
Above 10 Years 17 34%
Total 50 100%

Interpretation

The table reveals that the majority of participants possessed substantial teaching experience. Nineteen teachers representing 38 percent had teaching experience between 6 and 10 years, while 17 teachers had more than 10 years of experience. This indicates that most participants possessed adequate professional exposure related to inclusive classroom practices.

 

Table 4.3

Distribution of Participants According to Professional Training in Inclusive Education

Professional Training Number of Participants Percentage
Trained in Inclusive Education 31 62%
Not Formally Trained 19 38%
Total 50 100%

Interpretation

The findings indicate that 62 percent of teachers had received some form of professional training related to inclusive education, whereas 38 percent lacked formal training in inclusive pedagogy. This difference significantly influenced teachers’ confidence and classroom experiences during inclusive teaching.

4.3 Thematic Analysis and Interpretation

The collected data were analyzed and organized under major themes emerging from participants’ responses.

Theme 1

Teachers’ Perceptions Toward Inclusive Education

Teachers’ perceptions toward inclusive education emerged as one of the central themes of the study. Most participants expressed positive attitudes toward inclusion and believed that students with intellectual disabilities possess equal educational rights and should learn alongside their peers in mainstream classrooms.

 

 

 

 

Table 4.4

Teachers’ Perceptions Toward Inclusive Education

Response Category Number of Participants Percentage
Strongly Positive 21 42%
Moderately Positive 18 36%
Neutral 6 12%
Negative 5 10%
Total 50 100%

Interpretation

The table demonstrates that the majority of teachers possessed positive perceptions toward inclusive education. Twenty one participants strongly supported inclusive educational practices, whereas eighteen participants demonstrated moderately positive attitudes.

Teachers frequently emphasized that inclusive education promotes:

  • equality
  • social participation
  • empathy
  • peer interaction
  • confidence among students with disabilities

Many participants believed that inclusion creates opportunities for social development and reduces discrimination against students with intellectual disabilities.

One participant stated:

“Inclusive classrooms help students with disabilities feel accepted and respected. They learn social skills and confidence when they interact with other children.”

However, some teachers expressed concerns regarding practical implementation of inclusion. Participants who demonstrated negative or neutral perceptions frequently associated their concerns with:

  • inadequate training
  • large classroom size
  • lack of support staff
  • limited instructional resources

rather than opposition toward inclusion itself.

The findings therefore indicate that teachers generally supported inclusive education philosophically but experienced practical concerns regarding implementation.

Theme 2

Teachers’ Experiences in Teaching Students with Intellectual Disabilities

Participants shared diverse experiences regarding teaching students with intellectual disabilities within mainstream classrooms. Teachers described both positive and challenging experiences associated with inclusive educational practices.

Table 4.5

Nature of Teachers’ Experiences in Inclusive Classrooms

Experience Category Number of Participants Percentage
Mostly Positive 17 34%
Mixed Experiences 24 48%
Mostly Challenging 9 18%
Total 50 100%

Interpretation

The findings indicate that nearly half of the participants experienced both positive and challenging aspects of inclusive education simultaneously. Teachers described inclusive teaching as emotionally meaningful but professionally demanding.

Positive experiences included:

  • improved peer interaction
  • emotional satisfaction
  • student progress
  • increased classroom empathy
  • stronger teacher student relationships

Teachers reported feeling emotionally fulfilled when students with intellectual disabilities demonstrated improvement in communication, participation, or academic engagement.

One participant explained:

“When students with intellectual disabilities participate confidently in classroom activities, it gives great satisfaction as a teacher.”

However, participants also described significant challenges related to:

  • curriculum adaptation
  • classroom behavior management
  • individualized instruction
  • time management
  • academic pressure

Teachers frequently stated that students with intellectual disabilities required continuous support and individualized attention, which increased classroom workload.

The findings reveal that inclusive teaching experiences involved both professional satisfaction and considerable instructional responsibility.

 

Theme 3

Classroom Challenges in Inclusive Education

Classroom challenges emerged as one of the most dominant themes in the study. Nearly all participants reported experiencing multiple difficulties while implementing inclusive educational practices.

Table 4.6

Major Classroom Challenges Reported by Teachers

Classroom Challenges Frequency Percentage
Large Classroom Size 41 82%
Curriculum Adaptation Difficulties 37 74%
Behavioral Management Issues 35 70%
Lack of Teaching Resources 39 78%
Time Management Difficulties 43 86%
Individualized Instruction Demands 40 80%

Interpretation

The findings demonstrate that teachers experienced substantial classroom related difficulties while teaching students with intellectual disabilities in inclusive settings.

The most frequently reported challenge was time management. Teachers explained that inclusive classrooms required:

  • additional instructional planning
  • repeated explanation
  • continuous monitoring
  • individualized guidance

which created pressure within limited classroom time.

Participants also emphasized that large classroom size significantly restricted their ability to provide individualized support to students with intellectual disabilities.

Another major challenge involved curriculum adaptation. Teachers reported difficulty modifying curriculum content and teaching strategies according to diverse learner needs while simultaneously meeting academic expectations of mainstream education.

Behavioral management also emerged as a significant concern. Teachers frequently encountered:

  • communication difficulties
  • attention related challenges
  • emotional outbursts
  • classroom participation difficulties

among students with intellectual disabilities.

The findings indicate that classroom challenges strongly influenced teachers’ emotional wellbeing, professional confidence, and perceptions regarding inclusive education.

Theme 4

Teacher Training and Professional Preparedness

Teacher training and professional preparedness emerged as highly significant factors influencing teachers’ confidence and effectiveness in inclusive classrooms. Participants repeatedly emphasized that professional training plays a critical role in developing inclusive pedagogical competence.

 

 

 

 

 

 

 

 

Table 4.7

Teachers’ Perceptions Regarding Professional Preparedness

Level of Preparedness Number of Participants Percentage
Well Prepared 13 26%
Moderately Prepared 22 44%
Poorly Prepared 15 30%
Total 50 100%

Interpretation

The table indicates that only a limited number of teachers considered themselves fully prepared for inclusive teaching. Twenty two teachers reported moderate preparedness, whereas fifteen teachers felt inadequately prepared to teach students with intellectual disabilities.

Participants who had received professional training in inclusive education demonstrated:

  • greater teaching confidence
  • stronger classroom management skills
  • better curriculum adaptation strategies
  • improved communication skills
  • more positive attitudes toward inclusion

Teachers who lacked professional preparation frequently expressed anxiety and uncertainty regarding inclusive teaching responsibilities.

One participant stated:

“Teacher training programs teach theory, but practical classroom training for inclusive education is still very limited.”

Many participants highlighted the need for:

  • continuous professional development
  • workshops on inclusive pedagogy
  • behavior management training
  • practical classroom demonstrations
  • collaboration with special educators

The findings therefore suggest that professional preparedness significantly affects teachers’ confidence, classroom practices, and perceptions toward inclusive education.

Theme 5

Institutional Support and Administrative Assistance

Institutional support emerged as another major theme influencing inclusive educational practices. Teachers repeatedly emphasized that successful inclusion depends substantially upon administrative cooperation, professional collaboration, and availability of educational resources.

Table 4.8 Institutional Support Available in Schools

Forms of Institutional Support Frequency Percentage
Administrative Cooperation 34 68%
Availability of Teaching Resources 21 42%
Professional Development Programs 19 38%
Support from Special Educators 24 48%
Collaborative Teaching Opportunities 17 34%
Psychological Support Services 12 24%

Interpretation

The findings indicate that although some schools provided moderate institutional support, many teachers continued to experience insufficient professional assistance within inclusive educational settings.

Administrative cooperation was identified as the most available support mechanism. Participants stated that supportive principals and school administrators positively influenced inclusive classroom practices.

However, teachers frequently reported shortage of:

  • teaching materials
  • assistive educational resources
  • special educators
  • counseling services
  • collaborative teaching opportunities

Many participants emphasized that inclusive classrooms require coordinated institutional support systems rather than isolated teacher effort.

One participant explained:

“Inclusive education becomes difficult when teachers are expected to manage everything without proper resources or support staff.”

Teachers also highlighted the importance of:

  • school level planning
  • collaborative teaching
  • regular professional training
  • parental cooperation
  • emotional support for teachers

The findings indicate that institutional support strongly influences teachers’ perceptions, emotional wellbeing, and effectiveness in implementing inclusive education.

Theme 6

Inclusive Pedagogical Practices Used by Teachers

Teachers described various instructional strategies and pedagogical practices used to support students with intellectual disabilities in inclusive classrooms.

Table 4.9

Inclusive Teaching Practices Reported by Teachers

Inclusive Teaching Practices Frequency Percentage
Differentiated Instruction 38 76%
Peer Assisted Learning 34 68%
Activity Based Teaching 31 62%
Repetitive Instruction 42 84%
Individual Attention 40 80%
Use of Visual Learning Materials 29 58%

Interpretation

The findings reveal that teachers adopted multiple instructional approaches to facilitate participation of students with intellectual disabilities.

The most frequently reported strategy involved repetitive instruction. Teachers explained that students with intellectual disabilities often required repeated explanation and reinforcement for effective understanding.

Participants also emphasized the importance of:

  • individualized attention
  • peer assisted learning
  • flexible instructional methods
  • visual teaching materials
  • activity based learning

Teachers reported that peer support improved:

  • classroom participation
  • communication skills
  • emotional confidence
  • social interaction

among students with intellectual disabilities.

One teacher stated:

“Peer learning creates acceptance and confidence among students with disabilities because they feel included in classroom activities.”

However, many teachers reported difficulty implementing inclusive pedagogy consistently due to:

  • large classroom size
  • academic workload
  • insufficient time
  • lack of resources

The findings therefore indicate that teachers attempted to implement inclusive practices despite practical classroom limitations.

Theme 7

Emotional Experiences of Teachers in Inclusive Classrooms

Participants described strong emotional experiences associated with inclusive teaching. Teachers reported both emotional satisfaction and emotional exhaustion while working in inclusive educational settings.

Table 4.10

Emotional Experiences Reported by Teachers

Emotional Experience Frequency Percentage
Emotional Satisfaction 36 72%
Professional Stress 39 78%
Increased Empathy 41 82%
Emotional Exhaustion 28 56%
Professional Motivation 32 64%

 

Interpretation

The findings indicate that inclusive teaching generated complex emotional experiences among teachers.

Most participants reported increased empathy and emotional satisfaction resulting from meaningful interaction with students with intellectual disabilities. Teachers described feelings of achievement when students demonstrated:

  • academic improvement
  • social participation
  • classroom confidence
  • communication development

However, professional stress emerged as a major concern. Teachers frequently described emotional pressure associated with:

  • classroom workload
  • behavior management
  • academic expectations
  • limited institutional support
  • continuous responsibility

Some participants reported emotional exhaustion caused by balancing the needs of students with and without disabilities simultaneously.

Despite these difficulties, many teachers continued to express commitment toward inclusive educational values and learner participation.

The findings therefore suggest that inclusive teaching involves significant emotional investment and requires psychological as well as institutional support for teachers.

4.4 Analysis of Research Questions

Research Question 1

What are teachers’ perceptions toward inclusive education?

The findings revealed that the majority of teachers possessed positive perceptions toward inclusive education. Teachers believed that inclusion promotes equality, social participation, acceptance, and educational opportunities for students with intellectual disabilities. However, participants also expressed concerns regarding inadequate training, lack of resources, and classroom management difficulties affecting practical implementation.

 

Research Question 2

How do teachers experience teaching students with intellectual disabilities in inclusive classrooms?

Teachers described inclusive teaching as both meaningful and challenging. Positive experiences included emotional satisfaction, improved peer interaction, and student participation, whereas challenges included curriculum adaptation difficulties, behavior management issues, and increased instructional workload.

Research Question 3

What challenges do teachers face while implementing inclusive education?

Major challenges identified in the study included:

  • large classroom size
  • lack of teaching resources
  • insufficient professional training
  • time management difficulties
  • individualized instructional demands
  • behavioral management challenges
  • lack of support staff

These challenges significantly influenced teachers’ classroom experiences and emotional wellbeing.

Research Question 4

What forms of institutional and professional support are available to teachers?

Teachers reported moderate levels of institutional support including administrative cooperation and limited professional development opportunities. However, many participants emphasized insufficient access to:

  • special educators
  • assistive resources
  • counseling services
  • collaborative teaching opportunities
  • continuous professional training

Research Question 5

What strategies can improve the effectiveness of inclusive education in mainstream schools?

Participants suggested several strategies for improving inclusive educational practices, including:

  • strengthening teacher training programs
  • reducing classroom size
  • increasing institutional support
  • appointing support staff
  • improving collaboration between teachers
  • providing assistive learning resources
  • organizing regular workshops on inclusive pedagogy

4.5 Analysis and Interpretation of Hypotheses

The present study formulated hypotheses in order to examine the relationship between teachers’ perceptions, professional preparedness, institutional support, and inclusive educational practices related to students with intellectual disabilities. Since the study adopted a qualitative research approach, the hypotheses were interpreted conceptually and analytically on the basis of thematic evidence, participant responses, recurring patterns, and qualitative findings obtained during interviews and focus group discussions.

Hypothesis 1

Hypothesis Statement

“Teachers’ perceptions toward inclusive education significantly influence the effectiveness of inclusive classroom practices.”

Analysis of Hypothesis 1

The findings of the study strongly supported the hypothesis that teachers’ perceptions significantly influence inclusive classroom practices.

Teachers who demonstrated positive attitudes toward inclusive education were more likely to:

  • adopt differentiated instructional strategies
  • provide individualized attention
  • encourage peer interaction
  • modify classroom activities
  • create supportive learning environments

These teachers viewed students with intellectual disabilities as capable learners and emphasized participation rather than limitation.

Participants possessing positive perceptions frequently demonstrated:

  • greater emotional patience
  • stronger classroom flexibility
  • willingness to collaborate
  • learner centered teaching approaches

Thematic analysis revealed that positive teacher perceptions promoted:

  • student participation
  • classroom acceptance
  • inclusive interaction
  • emotional support
  • academic engagement

Conversely, teachers who expressed uncertainty or negative perceptions toward inclusion often experienced:

  • reduced teaching confidence
  • classroom frustration
  • resistance toward curriculum adaptation
  • difficulty managing learner diversity

However, the study further revealed that negative perceptions were generally associated with:

  • inadequate professional training
  • insufficient institutional support
  • classroom pressure
  • lack of teaching resources

rather than rejection of inclusive philosophy itself.

One participant stated:

“When teachers believe inclusion is meaningful, they try harder to adjust teaching methods and support students.”

The findings therefore confirmed that teachers’ perceptions strongly influenced the quality and effectiveness of inclusive educational practices.

Conclusion Regarding Hypothesis 1

The hypothesis was accepted because the findings clearly indicated that teachers’ perceptions significantly affected inclusive classroom practices and student participation.

Hypothesis 2

Hypothesis Statement

“Teacher preparedness and professional training positively influence teachers’ confidence in teaching students with intellectual disabilities.”

Analysis of Hypothesis 2

The findings strongly supported the second hypothesis. Teachers who had received professional training related to inclusive education demonstrated:

  • greater teaching efficacy
  • stronger classroom management skills
  • higher professional confidence
  • better instructional adaptation abilities
  • more positive attitudes toward inclusion

Participants repeatedly emphasized that training programs improved their:

  • understanding of intellectual disability
  • communication skills
  • classroom flexibility
  • assessment adaptation strategies
  • emotional preparedness

Teachers possessing professional training also reported lower levels of anxiety and greater willingness to implement inclusive pedagogical practices.

In contrast, participants lacking formal training frequently described feelings of:

  • uncertainty
  • professional stress
  • fear of failure
  • lack of confidence
  • instructional difficulty

Many participants stated that theoretical knowledge alone was insufficient and emphasized the importance of:

  • practical classroom exposure
  • demonstration teaching
  • collaborative workshops
  • professional mentoring
  • experiential learning

One participant explained:

“After attending inclusive education workshops, I became more confident handling students with intellectual disabilities.”

The findings therefore demonstrated a strong positive relationship between teacher preparedness and confidence in inclusive classrooms.

Conclusion Regarding Hypothesis 2

The hypothesis was accepted because professional training and preparedness significantly improved teachers’ confidence and effectiveness in teaching students with intellectual disabilities.

Hypothesis 3

Hypothesis Statement

“Lack of institutional support negatively affects implementation of inclusive education.”

Analysis of Hypothesis 3

The findings strongly supported the third hypothesis. Teachers consistently reported that inadequate institutional support created major barriers to effective inclusive educational practices.

Participants identified several institutional limitations including:

  • shortage of teaching resources
  • lack of support staff
  • insufficient professional development programs
  • overcrowded classrooms
  • absence of collaborative teaching opportunities
  • inadequate administrative planning

Teachers working in schools with limited institutional support frequently experienced:

  • professional stress
  • emotional exhaustion
  • increased workload
  • instructional difficulty
  • reduced teaching confidence

Conversely, participants working in supportive institutions demonstrated:

  • greater professional motivation
  • stronger classroom flexibility
  • improved collaboration
  • more positive perceptions toward inclusion

The findings further revealed that administrative cooperation positively influenced:

  • teacher morale
  • classroom management
  • resource accessibility
  • implementation of inclusive practices

One teacher stated:

“Inclusive education cannot succeed if teachers are left alone without support systems.”

Thematic analysis clearly demonstrated that institutional support significantly affects the effectiveness and sustainability of inclusive educational practices.

Conclusion Regarding Hypothesis 3

The hypothesis was accepted because lack of institutional support negatively influenced implementation of inclusive education and teachers’ classroom experiences.

Hypothesis 4

Hypothesis Statement

“Teachers teaching students with intellectual disabilities experience significant classroom challenges in inclusive educational settings.”

Analysis of Hypothesis 4

The findings strongly confirmed the fourth hypothesis. Nearly all participants described multiple classroom related challenges while teaching students with intellectual disabilities.

The major challenges identified included:

  • time management difficulties
  • curriculum adaptation problems
  • behavior management issues
  • individualized instructional demands
  • communication difficulties
  • classroom participation barriers
  • large classroom size

Teachers frequently reported difficulty balancing the educational needs of students with and without disabilities simultaneously.

Participants explained that students with intellectual disabilities often required:

  • repeated instruction
  • continuous supervision
  • individualized learning support
  • emotional encouragement
  • flexible teaching methods

These responsibilities significantly increased classroom workload and professional pressure.

Teachers also described emotional stress associated with:

  • maintaining classroom discipline
  • addressing academic expectations
  • managing learner diversity
  • completing curriculum within limited time

One participant remarked:

“Inclusive classrooms require much more patience, planning, and emotional effort from teachers.”

The findings therefore demonstrated that classroom challenges constitute one of the most significant realities associated with inclusive educational practice.

Conclusion Regarding Hypothesis 4

The hypothesis was accepted because teachers experienced substantial classroom challenges while teaching students with intellectual disabilities in inclusive settings.

4.6 Major Findings of the Study

Based on thematic analysis and interpretation of participant responses, the following major findings emerged from the study:

  1. The majority of teachers possessed positive perceptions toward inclusive education and strongly supported equal educational opportunities for students with intellectual disabilities.
  2. Teachers viewed inclusive education as beneficial for promoting:
  • social interaction
  • learner participation
  • empathy
  • acceptance
  • confidence among students with disabilities.
  1. Teachers experienced both emotional satisfaction and professional challenges while teaching students with intellectual disabilities in inclusive classrooms.
  2. Major classroom challenges included:
  • large classroom size
  • lack of teaching resources
  • curriculum adaptation difficulties
  • time management pressure
  • behavioral management issues
  • individualized instructional demands.
  1. Teachers who received professional training in inclusive education demonstrated greater confidence and stronger instructional competence.
  2. Lack of practical training in inclusive pedagogy negatively affected teachers’ preparedness and classroom confidence.
  3. Institutional support significantly influenced teachers’ perceptions, emotional wellbeing, and classroom effectiveness.
  4. Teachers emphasized the importance of:
  • collaborative teaching
  • continuous professional development
  • administrative cooperation
  • support staff
  • assistive educational resources

for strengthening inclusive education.

  1. Inclusive teaching generated strong emotional experiences including:
  • empathy
  • professional motivation
  • emotional satisfaction
  • stress
  • emotional exhaustion.
  1. Teachers adopted multiple inclusive pedagogical practices such as:
  • differentiated instruction
  • repetitive teaching
  • peer assisted learning
  • activity based teaching
  • individualized attention

to support students with intellectual disabilities.

  1. The findings confirmed that successful inclusive education depends upon:
  • teacher preparedness
  • positive perceptions
  • institutional support
  • inclusive pedagogy
  • collaborative educational practices.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER 5

DISCUSSION, FINDINGS, IMPLICATIONS AND RECOMMENDATIONS

 

 

 

 

 

 

 

 

5.1 Introduction

The present chapter discusses the major findings of the study in relation to the objectives, research questions, reviewed literature, and conceptual understanding of inclusive education. The study explored teachers’ perceptions of inclusive education and their experiences in teaching students with intellectual disabilities within mainstream classrooms in Faridabad.

The findings of the study revealed that inclusive education is widely accepted by teachers as an important educational approach promoting equality, participation, and social inclusion for students with intellectual disabilities. However, the study also identified significant classroom, professional, emotional, and institutional challenges affecting the practical implementation of inclusive education.

The present chapter therefore provides:

  • discussion of findings in relation to previous studies
  • major findings of the study
  • educational implications
  • recommendations for improving inclusive educational practices
  • suggestions for future research
  • conclusion of the study

The chapter attempts to interpret the findings critically and explain their educational significance within the broader context of inclusive education and intellectual disability.

5.2 Discussion of Findings

The findings of the study revealed that most teachers possessed positive perceptions toward inclusive education and believed that students with intellectual disabilities should receive equal educational opportunities within mainstream classrooms. Teachers stated that inclusive education promotes equality, social participation, empathy, and learner confidence.

The study further revealed that teachers experienced both satisfaction and challenges while teaching students with intellectual disabilities. Teachers felt emotionally satisfied when students demonstrated classroom participation and social interaction. However, they also experienced difficulties related to:

  • classroom management
  • curriculum adaptation
  • individualized instruction
  • lack of teaching resources
  • time management

The findings showed that professionally trained teachers demonstrated greater confidence and flexibility in inclusive classrooms. Teachers lacking professional preparation often experienced stress and uncertainty while handling inclusive classroom situations.

Institutional support also emerged as an important factor affecting inclusive education. Teachers emphasized the importance of:

  • administrative cooperation
  • support staff
  • professional development programs
  • assistive teaching resources
  • collaborative teaching practices

The findings therefore indicate that successful inclusive education requires positive teacher attitudes, professional preparedness, supportive institutions, and flexible classroom practices.

5.3 Major Findings of the Study

The major findings of the study are as follows:

  1. Most teachers possessed positive perceptions toward inclusive education.
  2. Teachers believed that inclusive education promotes equality, participation, empathy, and social acceptance.
  3. Teachers experienced both emotional satisfaction and professional challenges in inclusive classrooms.
  4. Major classroom challenges included:
  • large classroom size
  • curriculum adaptation difficulties
  • behavioral management issues
  • lack of resources
  • individualized instructional demands
  1. Professionally trained teachers demonstrated greater confidence and classroom effectiveness.
  2. Lack of professional training negatively affected teachers’ confidence and classroom management abilities.
  3. Institutional support significantly influenced implementation of inclusive educational practices.
  4. Teachers used inclusive teaching practices such as:
  • differentiated instruction
  • peer assisted learning
  • repetitive teaching
  • individualized attention
  1. The hypotheses of the study were supported by the findings.

5.4 Educational Implications

The findings of the study possess important implications for:

  • teacher education
  • inclusive pedagogy
  • school administration
  • educational policy

Teacher education programs should provide practical training related to inclusive education and intellectual disability. Schools should strengthen collaborative teaching practices and provide adequate teaching resources and support services.

Educational authorities should organize regular professional development programs for teachers working in inclusive educational settings. Inclusive classrooms should also maintain flexible teaching methods and supportive learning environments for students with intellectual disabilities.

5.5 Recommendations

Based on the findings of the study, the following recommendations are suggested:

  1. Teacher education programs should strengthen practical training in inclusive education.
  2. Schools should appoint support staff such as special educators and counselors.
  3. Regular workshops and professional development programs should be organized for teachers.
  4. Classroom size should be reduced to improve individualized attention.
  5. Schools should provide adequate teaching resources and assistive learning materials.
  6. Collaborative teaching practices should be encouraged within inclusive schools.
  7. Parents and teachers should work together to support students with intellectual disabilities.
  8. Educational policies should focus on practical implementation of inclusive education.

5.6 Suggestions for Further Research

Future studies may focus on:

  • perspectives of students and parents
  • emotional wellbeing of teachers
  • comparative studies between rural and urban schools
  • effectiveness of inclusive teaching strategies
  • policy implementation challenges related to inclusive education.

5.7 Conclusion

The present study concluded that teachers generally possessed positive perceptions toward inclusive education and supported equal educational opportunities for students with intellectual disabilities. However, teachers also experienced significant classroom and institutional challenges while implementing inclusive educational practices.

The findings revealed that professional preparedness, institutional support, and inclusive teaching practices significantly influence the success of inclusive education. The study therefore emphasizes the need for trained teachers, supportive school environments, collaborative educational practices, and adequate teaching resources for strengthening inclusive education in mainstream schools.

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Friend, M. (2020). Special education: Contemporary perspectives for school professionals (6th ed.). Pearson Education.

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NCERT. (2020). Including children with special needs in regular schools. National Council of Educational Research and Training.

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Singal, N. (2020). Challenges and opportunities in inclusive education in India. International Journal of Inclusive Education, 24(5), 501–517.

Smith, D. D. (2020). Introduction to special education: Making a difference (9th ed.). Pearson Education.

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United Nations. (2020). Convention on the rights of persons with disabilities. United Nations Publications.

Avramidis, E., & Norwich, B. (2021). Teachers’ attitudes towards integration and inclusion: A review of the literature. European Journal of Special Needs Education, 36(2), 145–162.

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Hallahan, D. P., Kauffman, J. M., & Pullen, P. C. (2021). Exceptional learners: An introduction to special education (15th ed.). Pearson Education.

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Miles, M. B., Huberman, A. M., & Saldaña, J. (2021). Qualitative data analysis: A methods sourcebook (4th ed.). Sage Publications.

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Rani, P. (2021). Institutional barriers affecting inclusive education in Indian schools. Indian Educational Review, 59(2), 121–139.

Sharma, U. (2021). Professional competence of teachers in inclusive classrooms. Asia Pacific Journal of Teacher Education, 49(3), 260–276.

Slee, R. (2021). Inclusive education isn’t dead, it just smells funny (2nd ed.). Routledge.

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APPENDICES

APPENDIX I

INTERVIEW SCHEDULE

Title of the Study

Teachers’ Perceptions of Inclusive Education and Their Experiences in Teaching Students with Intellectual Disabilities

General Information

  1. Name of the Participant: ___________________
  2. Gender: ___________________
  3. Age: ___________________
  4. Educational Qualification: ___________________
  5. Teaching Experience: ___________________
  6. Name of School: ___________________
  7. Professional Training in Inclusive Education: Yes / No
  8. Position Held: ___________________

Interview Questions

Section A

Teachers’ Perceptions Toward Inclusive Education

  1. What do you understand by inclusive education?
  2. What are your views regarding inclusion of students with intellectual disabilities in mainstream classrooms?
  3. Do you believe inclusive education benefits students with intellectual disabilities? Explain.
  4. How does inclusive education influence other students in the classroom?
  5. What are your opinions regarding equal educational opportunities for students with disabilities?

Section B

Experiences in Teaching Students with Intellectual Disabilities

  1. Describe your experiences in teaching students with intellectual disabilities.
  2. What positive experiences have you observed in inclusive classrooms?
  3. What difficulties do you experience while teaching students with intellectual disabilities?
  4. How do students with intellectual disabilities interact with peers in the classroom?
  5. How do you manage individual learning needs in inclusive classrooms?

Section C

Classroom Challenges

  1. What classroom challenges do you commonly face in inclusive education?
  2. Do you experience difficulties related to curriculum adaptation? Explain.
  3. How do you manage behavioral challenges among students with intellectual disabilities?
  4. Does classroom size affect inclusive teaching practices? Explain.
  5. What difficulties do you face regarding time management?

Section D

Teacher Preparedness and Institutional Support

  1. Have you received professional training related to inclusive education?
  2. How has training influenced your confidence and teaching practices?
  3. What forms of institutional support are available in your school?
  4. Do you receive assistance from special educators or support staff?
  5. What additional support do you require for effective inclusive teaching?

Section E

Suggestions and Recommendations

  1. What strategies can improve inclusive education in mainstream schools?
  2. What changes should be made in teacher education programs?
  3. What recommendations would you like to provide for improving inclusion of students with intellectual disabilities?
  4. Is there anything else you would like to share regarding your experiences in inclusive education?

 

 

 

 

 

 

 

 

 

APPENDIX II

FOCUS GROUP DISCUSSION GUIDE

Focus Group Discussion Themes

Theme 1

Understanding of Inclusive Education

  • Meaning and importance of inclusive education
  • Inclusion of students with intellectual disabilities
  • Educational equality and participation

Theme 2

Classroom Experiences

  • Experiences teaching students with intellectual disabilities
  • Positive classroom experiences
  • Peer interaction and participation
  • Emotional experiences of teachers

Theme 3

Classroom Challenges

  • Curriculum adaptation difficulties
  • Classroom management issues
  • Behavioral challenges
  • Time management problems
  • Lack of resources

Theme 4

Teacher Preparedness

  • Professional training experiences
  • Preparedness for inclusive teaching
  • Need for workshops and practical training
  • Classroom confidence

Theme 5

Institutional Support

  • Administrative cooperation
  • Availability of support staff
  • Teaching resources
  • Professional development opportunities
  • Collaborative teaching practices

Theme 6

Suggestions for Improvement

  • Strategies for strengthening inclusive education
  • Teacher support mechanisms
  • Policy implementation
  • Recommendations for schools and administrators

 

 

APPENDIX III

CONSENT LETTER

INFORMED CONSENT FORM

Title of the Study

Teachers’ Perceptions of Inclusive Education and Their Experiences in Teaching Students with Intellectual Disabilities

Dear Participant,

I am conducting a research study as part of academic work related to inclusive education and teachers’ experiences in teaching students with intellectual disabilities. The purpose of this study is to understand teachers’ perceptions, classroom experiences, challenges, and support systems related to inclusive educational practices.

You are requested to participate in this study because of your valuable experience in inclusive classroom teaching.

Your participation in this study is completely voluntary. You may choose to withdraw from the study at any stage without any negative consequences.

The information provided by you will be kept strictly confidential and will be used only for academic and research purposes. Your identity and personal details will not be disclosed in any report or publication related to this study.

The interview and discussion may take approximately 30 to 45 minutes. With your permission, responses may be audio recorded for accurate analysis and interpretation.

Kindly read the statements below carefully before giving your consent.

Participant Consent

I have read and understood the purpose and nature of the study.

I understand that:

  • my participation is voluntary
  • my responses will remain confidential
  • I may withdraw from the study at any time
  • the information will be used only for academic purposes

I voluntarily agree to participate in this research study.

 

Signature of Participant: _______________________

Name of Participant: _______________________

Date: _______________________

Signature of Researcher: _______________________

Name of Researcher: _______________________

Place: _______________________

 

 

 

 

 

 

 

 

“Teachers Perceptions of Inclusive Education and Their Experiences in Teaching Students with Intellectual Disabilities

 

 

 

 

 

 

Synopsis submitted to

CHAUDHARY RANBIR SINGH UNIVERSITY

Jind, Haryana– 126102

for the approval of the topic for dissertation of

MASTER OF EDUCATION IN SPECIAL EDUCATION

(Intellectual Disability)

 (M.Ed.-SE-ID)

 (2023-2025)

Submitted by

VANDANA CHAUDHARY

[Reg.No. 211130114010]

Under the Guidance and Supervision of

DR.S.P.SINGH

INTRODUCTION

Inclusive education has emerged as a central principle in contemporary educational discourse, emphasizing the right of all learners, including those with disabilities, to access equitable and quality education within mainstream classrooms. The concept is rooted in global commitments such as the United Nations Educational, Scientific and Cultural Organization Salamanca Statement (1994) and reinforced by international frameworks like the United Nations Sustainable Development Goals, particularly SDG 4, which promotes inclusive and equitable quality education for all.

Inclusive education seeks to remove barriers to participation and learning by accommodating diverse learning needs within regular classrooms. Among students with disabilities, those with intellectual disabilities often face significant challenges in accessing inclusive learning environments due to cognitive limitations, social difficulties, and adaptive functioning challenges. Their successful inclusion largely depends on the attitudes, beliefs, competencies, and experiences of teachers who implement inclusive practices in classrooms.

Teachers play a pivotal role in the effective implementation of inclusive education. Their perceptions influence classroom practices, teaching strategies, and the overall learning environment. Positive teacher attitudes toward inclusion are associated with greater acceptance of students with disabilities, use of differentiated instruction, and collaborative teaching approaches. Conversely, negative perceptions may lead to resistance toward inclusion and inadequate support for students with intellectual disabilities.

Despite policy initiatives promoting inclusive education in many countries, including India, challenges persist in translating policy into practice. Teachers often report limited training, inadequate resources, overcrowded classrooms, and insufficient institutional support while teaching students with intellectual disabilities. These challenges shape teachers’ experiences and affect the quality of inclusive education delivered in mainstream schools.

Therefore, understanding teachers’ perceptions and experiences is crucial for improving inclusive education practices. Investigating these perceptions can provide insights into the barriers and facilitators that influence effective inclusion of students with intellectual disabilities. Such knowledge can inform teacher training programs, educational policies, and support systems aimed at strengthening inclusive education.

This study aims to explore teachers’ perceptions of inclusive education and examine their experiences in teaching students with intellectual disabilities in inclusive classroom settings.

BACKGROUND OF THE STUDY

The concept of inclusive education has evolved significantly over the past few decades. Historically, children with disabilities were educated in segregated institutions or special schools, often isolated from mainstream education systems. However, the global movement toward inclusive education has shifted the focus toward integrating students with disabilities into regular schools while providing appropriate support and accommodations.

International frameworks such as the United Nations Educational, Scientific and Cultural Organization Salamanca Statement emphasized that regular schools with inclusive orientation are the most effective means of combating discriminatory attitudes and creating welcoming communities. These frameworks advocate for inclusive systems where students with diverse needs learn together in the same educational environment.

In the Indian context, inclusive education has gained significant attention through legislative measures such as the Rights of Persons with Disabilities Act, 2016 and the Right of Children to Free and Compulsory Education Act, 2009. These policies emphasize equal educational opportunities for children with disabilities and encourage schools to adopt inclusive practices.

However, the implementation of inclusive education, particularly for students with intellectual disabilities, remains challenging. Intellectual disability is characterized by significant limitations in intellectual functioning and adaptive behavior, affecting conceptual, social, and practical skills. Students with intellectual disabilities often require individualized instructional strategies, specialized teaching methods, and supportive classroom environments.

Teachers are the key agents responsible for implementing inclusive practices in schools. Their perceptions, attitudes, and competencies play a crucial role in determining whether inclusive education is successful. Teachers who possess positive attitudes toward inclusion are more likely to adopt adaptive teaching strategies, collaborate with special educators, and support the participation of students with intellectual disabilities.

However, research has shown that teachers often face numerous challenges in implementing inclusive education. These include lack of training in special education, inadequate infrastructure, insufficient teaching resources, and limited support from school administration. Such challenges may lead to stress, reduced teaching effectiveness, and negative perceptions toward inclusion.

Furthermore, teachers’ experiences with inclusive education vary depending on factors such as teaching experience, professional training, school environment, and availability of support services. Understanding these experiences is essential for identifying the factors that facilitate or hinder inclusive practices in classrooms.

Therefore, examining teachers’ perceptions and experiences in teaching students with intellectual disabilities is essential to improve inclusive education policies and practices.

REVIEW OF LITERATURE

Teacher Attitudes Toward Inclusive Education

Teacher attitudes are widely recognized as a key factor influencing the success of inclusive education. Studies across different countries have shown that teachers’ beliefs about disability significantly shape their willingness to implement inclusive practices. Darwish (2025) found that teachers generally support inclusive education philosophically but encounter difficulties in implementing inclusive practices due to limited training and inadequate institutional support. Similarly, García et al. (2026) reported that teachers who had received professional training in inclusive education demonstrated more positive attitudes toward teaching students with disabilities.

In the Indian context, Sharma and Sokal (2020) found that teachers’ attitudes toward inclusive education are influenced by professional training and exposure to inclusive classroom environments. Teachers who receive specialized training in inclusive pedagogy are more likely to adopt positive attitudes toward inclusion and demonstrate higher teaching efficacy. Singal (2020) also emphasized that while inclusive education policies exist in India, teachers often struggle to translate these policies into effective classroom practices due to structural and institutional constraints.

These studies indicate that teachers’ attitudes toward inclusive education are shaped by professional preparation, institutional support, and practical classroom experiences.

Teacher Training and Preparedness

Teacher training is a critical determinant of successful inclusive education. Several studies have highlighted the importance of professional development programs in equipping teachers with the necessary skills and knowledge required for inclusive teaching.

Xin et al. (2023) found that teachers with constructive beliefs about inclusive education demonstrate higher teaching efficacy and are more confident in implementing inclusive teaching strategies. Similarly, Campos (2026) reported that exposure to inclusive education training significantly improves pre-service teachers’ attitudes toward inclusion.

In the Indian context, Bhatnagar and Das (2020) observed that many teachers feel inadequately prepared to teach students with disabilities due to limited training in inclusive education during their teacher preparation programs. Mukhopadhyay (2021) further emphasized that teacher education programs in India often lack sufficient practical training on inclusive pedagogy and differentiated instruction.

These findings highlight the importance of strengthening teacher education programs and providing continuous professional development opportunities to enhance teachers’ readiness for inclusive classrooms.

 

 

Classroom Challenges in Inclusive Education

Teachers frequently encounter multiple challenges when teaching students with intellectual disabilities in inclusive classrooms. Hornby (2023) reported that students with intellectual disabilities often require individualized instructional strategies, structured learning environments, and additional academic support. These requirements create challenges for teachers who must simultaneously address the learning needs of all students in mainstream classrooms.

Sepadi (2025) found that teachers face significant difficulties in adapting teaching methods, managing classroom behavior, and implementing differentiated instruction in inclusive classrooms. Similar findings were reported by Brown (2023), who noted that teachers often feel overwhelmed by the additional responsibilities associated with inclusive teaching.

In India, Singal (2020) observed that large classroom sizes, limited resources, and insufficient support staff create significant barriers to effective inclusive education. These challenges often affect teachers’ perceptions of inclusive education and influence their classroom practices.

Institutional Support for Inclusive Education

Institutional support plays a critical role in facilitating inclusive education. Teachers require adequate resources, administrative support, and collaborative opportunities to effectively implement inclusive practices.

Saragoça et al. (2025) found that teachers’ attitudes toward inclusive education are strongly influenced by institutional support and professional collaboration. Similarly, Rana (2026) reported that schools with structured support systems demonstrate higher levels of inclusive teaching practices.

In the Indian context, the implementation of inclusive education policies such as the Rights of Persons with Disabilities Act (2016) has expanded opportunities for students with disabilities to access mainstream education. However, Mukhopadhyay (2021) noted that policy implementation often faces challenges due to inadequate infrastructure, insufficient teacher training, and lack of specialized support services in schools.

These findings highlight the importance of strengthening institutional support systems to ensure effective implementation of inclusive education.

RESEARCH GAP

Despite the growing emphasis on inclusive education in international and national policies, several gaps remain in the existing literature. First, many studies examine inclusive education broadly without specifically focusing on the experiences of teachers teaching students with intellectual disabilities. Students with intellectual disabilities present unique cognitive and adaptive challenges that require specialized instructional approaches.

Second, much of the existing research focuses primarily on measuring teachers’ attitudes toward inclusive education through quantitative surveys. While these studies provide useful insights, they often fail to capture teachers’ lived experiences and the practical challenges encountered in inclusive classrooms.

Third, although inclusive education has been widely discussed in international literature, there remains limited empirical research examining teachers’ experiences within the Indian educational context. The implementation of inclusive education policies such as the Rights of Persons with Disabilities Act (2016) has increased the presence of students with disabilities in mainstream schools; however, little research has explored how teachers navigate the realities of inclusive classrooms.

Finally, few studies examine the interaction between teachers’ perceptions, institutional support, and classroom practices in shaping inclusive education outcomes. Therefore, the present study aims to address these gaps by exploring teachers’ perceptions and lived experiences in teaching students with intellectual disabilities in inclusive classrooms.

NEED FOR THE STUDY

The increasing emphasis on inclusive education worldwide has created a growing demand for research that examines the practical realities of inclusive classroom implementation.

Teachers are the primary facilitators of inclusive education. Their perceptions, experiences, and professional competencies significantly influence the success of inclusive practices. However, many teachers continue to face challenges related to insufficient training, lack of resources, and limited institutional support.

Understanding teachers’ perceptions toward inclusive education is essential for identifying the barriers that hinder effective inclusion of students with intellectual disabilities. Similarly, exploring teachers’ experiences can reveal practical insights into classroom challenges, teaching strategies, and support mechanisms required for successful inclusion.

Furthermore, empirical research focusing specifically on intellectual disabilities in inclusive settings remains limited. Students with intellectual disabilities often require individualized support, differentiated instruction, and specialized classroom management approaches.

This study is therefore necessary to provide evidence-based insights that can inform teacher training programs, educational policies, and institutional support systems aimed at strengthening inclusive education practices.

STATEMENT OF THE PROBLEM

Despite the growing emphasis on inclusive education in educational policies and international frameworks, the practical implementation of inclusive classrooms remains complex and challenging. Teachers are expected to address the diverse learning needs of students with and without disabilities within the same classroom environment. However, many teachers report difficulties in adapting instructional methods, managing classroom behavior, and providing individualized support to students with intellectual disabilities.

Teachers’ perceptions toward inclusive education significantly influence the success or failure of inclusion initiatives. Positive perceptions promote inclusive practices, whereas negative perceptions may create barriers to effective implementation. Teachers who feel unprepared or unsupported may struggle to provide appropriate learning opportunities for students with intellectual disabilities.

In many educational settings, teachers lack sufficient training, professional development opportunities, and institutional support to effectively manage inclusive classrooms. Additionally, limited resources, large class sizes, and lack of collaboration between general and special educators further complicate the teaching process.

Understanding teachers’ perceptions and experiences is therefore essential for identifying the challenges they face and the support they require in implementing inclusive education. Without such understanding, policies promoting inclusion may remain ineffective in practice.

Thus, the present study seeks to explore teachers’ perceptions of inclusive education and examine their experiences in teaching students with intellectual disabilities in inclusive classroom settings.

OBJECTIVES OF THE STUDY

The study aims to achieve the following objectives:

  1. To examine teachers’ perceptions of inclusive education.
  2. To explore teachers’ experiences in teaching students with intellectual disabilities in inclusive classrooms.
  3. To identify challenges faced by teachers while implementing inclusive education.
  4. To examine the support systems available for teachers in inclusive educational settings.
  5. To suggest strategies for improving inclusive education practices for students with intellectual disabilities.

RESEARCH QUESTIONS

The study will address the following research questions:

  1. What are teachers’ perceptions toward inclusive education?
  2. How do teachers experience teaching students with intellectual disabilities in inclusive classrooms?
  3. What challenges do teachers face while implementing inclusive education?
  4. What forms of institutional and professional support are available to teachers teaching students with intellectual disabilities?
  5. What strategies can improve the effectiveness of inclusive education in mainstream schools?

HYPOTHESES OF THE STUDY

H₀₁: There is no significant difference in teachers’ perceptions of inclusive education.

H₀₂: There is no significant difference in teachers’ experiences in teaching students with intellectual disabilities.

H₀₃: There is no significant relationship between teachers’ perceptions of inclusive education and their teaching experiences with students with intellectual disabilities.

H₀₄: There is no significant difference in teachers’ perceptions of inclusive education based on gender.

H₀₅: There is no significant difference in teachers’ experiences based on teaching experience.

H₀₆: There is no significant difference in perceptions and experiences between trained and untrained teachers in inclusive education.

 

SIGNIFICANCE OF THE STUDY

This study holds significant importance for educational research, policy development, and teacher training programs.

First, the study contributes to the growing body of literature on inclusive education by examining teachers’ perceptions and experiences in teaching students with intellectual disabilities. Understanding these perspectives can help identify factors that influence the successful implementation of inclusive practices.

Second, the findings may provide valuable insights for policymakers and educational administrators in designing policies that support inclusive education. Identifying the challenges faced by teachers can help develop more effective support systems and resource allocation strategies.

Third, the study may inform teacher education and professional development programs. Training programs can be redesigned to equip teachers with the necessary skills and competencies required for inclusive teaching.

Fourth, the study may benefit schools and educational institutions by highlighting the importance of collaborative teaching, resource support, and inclusive classroom practices.

Finally, the research may contribute to improving the educational experiences of students with intellectual disabilities by promoting more inclusive and supportive learning environments.

SCOPE AND DELIMITATIONS OF THE STUDY

The scope of this study focuses on examining teachers’ perceptions and experiences related to inclusive education, particularly in teaching students with intellectual disabilities in mainstream classrooms.

The study will primarily explore the attitudes, beliefs, and practical experiences of teachers who work in inclusive educational settings. It will investigate the challenges teachers encounter, the support systems available to them, and the strategies they employ while teaching students with intellectual disabilities.

However, the study has certain delimitations. First, the research will focus only on teachers and will not include perspectives of students, parents, or school administrators. Second, the study will specifically examine inclusive education in relation to students with intellectual disabilities and will not cover other categories of disabilities.

Additionally, the study may be limited to a specific geographical region or educational context, which may restrict the generalizability of the findings to other regions or educational systems.

Despite these limitations, the study aims to provide meaningful insights into teachers’ perceptions and experiences in inclusive educational settings.

CONCEPTUAL FRAMEWORK

The conceptual framework of the study is based on the relationship between teachers’ perceptions, professional competencies, classroom practices, and institutional support in shaping inclusive education outcomes.

Teachers’ perceptions toward inclusive education influence their willingness to adopt inclusive teaching practices such as differentiated instruction, collaborative learning, and individualized support strategies. These perceptions are shaped by multiple factors, including professional training, teaching experience, and teacher efficacy.

Teacher efficacy refers to teachers’ confidence in their ability to effectively teach students with diverse learning needs. Teachers with higher levels of self-efficacy are more likely to implement inclusive instructional strategies and demonstrate positive attitudes toward inclusion.

Classroom environment and inclusive pedagogy also play a significant role in promoting student participation. Inclusive pedagogy emphasizes flexible teaching approaches that accommodate diverse learning needs and promote active engagement among all students.

Institutional support, including administrative guidance, professional development opportunities, availability of teaching resources, and collaboration with special educators, acts as a moderating factor that influences teachers’ experiences and inclusive classroom practices.

The framework therefore suggests that effective inclusive education outcomes depend on the interaction between teacher perceptions, professional competencies, classroom environment, and institutional support systems.

FRAMEWORK STRUCTURE

Teacher Training & Professional Development

Teacher Efficacy & Perceptions

Inclusive Pedagogy & Classroom Environment

Inclusive Teaching Practices

Student Participation and Learning Outcomes

Institutional Support (Moderating Variable)

 

RESEARCH METHODOLOGY

The study will adopt a qualitative research design to explore teachers’ perceptions and experiences in teaching students with intellectual disabilities in inclusive classrooms. A qualitative approach is appropriate because it allows for an in-depth exploration of teachers’ beliefs, attitudes, and lived experiences.

Research Design

The study will employ an exploratory qualitative research design using semi-structured interviews and focus group discussions.

Research Site

The study will be conducted in selected inclusive schools in Faridabad Haryana, where students with intellectual disabilities are enrolled in mainstream classrooms.

Sample and Sampling Technique

The study will involve 50 teachers who have experience teaching students with intellectual disabilities in inclusive classrooms. Participants will be selected using purposive sampling, ensuring that teachers have relevant experience in inclusive education.

Participant Criteria

Participants must meet the following criteria:

  • Currently teaching in inclusive classrooms
  • Experience teaching students with intellectual disabilities
  • Minimum two years of teaching experience

DATA COLLECTION METHODS AND TOOLS

Data for the study will be collected using the following qualitative methods:

Semi-Structured Interviews

Semi-structured interviews will be conducted with teachers who have experience teaching students with intellectual disabilities in inclusive classrooms. This method allows participants to express their perceptions, experiences, and challenges in their own words while ensuring that key research topics are covered.

Focus Group Discussions

Focus group discussions may also be conducted to encourage interaction among teachers and generate diverse perspectives on inclusive education practices.

Interview Guide

An interview guide will be developed to ensure consistency in data collection. The guide will include questions related to:

  • Teachers’ perceptions of inclusive education
  • Experiences teaching students with intellectual disabilities
  • Classroom challenges and barriers
  • Support systems available in schools
  • Strategies used to promote inclusion

Data Trustworthiness

To ensure the credibility and reliability of the qualitative findings, several strategies will be employed.

Credibility will be ensured through member checking, where participants will review the interpretations of their responses. Dependability will be maintained by documenting the research process and maintaining detailed field notes.

Triangulation will be used by collecting data through both semi-structured interviews and focus group discussions, allowing for comparison of different perspectives. Additionally, thick descriptions of participants’ experiences will be provided to enhance the transferability of the findings.

DATA ANALYSIS PROCEDURES

The collected qualitative data will be analyzed using Braun and Clarke’s (2006) thematic analysis framework.

The analysis will follow six systematic steps:

  1. Familiarization with the data through repeated reading of interview transcripts
  2. Generation of initial codes from meaningful statements
  3. Searching for patterns and developing preliminary themes
  4. Reviewing and refining themes to ensure coherence
  5. Defining and naming themes related to teachers’ perceptions, experiences, and challenges
  6. Producing the final report with interpretation of themes in relation to research objectives and existing literature

This systematic approach will ensure rigorous analysis of qualitative data and facilitate meaningful interpretation of teachers’ experiences in inclusive education.

ETHICAL CONSIDERATIONS

The study will adhere to established ethical guidelines in educational research.

Participation in the study will be voluntary, and informed consent will be obtained from all participants before data collection. Participants will be informed about the purpose of the study, the procedures involved, and their right to withdraw from the study at any time without penalty.

Confidentiality and anonymity of participants will be strictly maintained. Personal information and identifying details will not be disclosed in the research findings.

The collected data will be used solely for academic research purposes and will be stored securely to ensure data protection.

EXPECTED OUTCOMES OF THE STUDY

The study is expected to reveal that teachers’ perceptions toward inclusive education significantly influence their classroom practices and teaching approaches.

The findings may indicate that teachers who possess positive attitudes toward inclusion are more likely to adopt adaptive teaching strategies and support the participation of students with intellectual disabilities.

The study may also identify several challenges faced by teachers, including limited training, insufficient resources, lack of institutional support, and difficulties in managing diverse learning needs within inclusive classrooms.

Additionally, the research may highlight the importance of professional development programs, collaborative teaching models, and supportive school environments in promoting effective inclusive education.

CONCLUSION

Inclusive education represents an essential approach for ensuring equitable educational opportunities for all learners, including those with intellectual disabilities. However, the successful implementation of inclusive education largely depends on teachers who are responsible for facilitating learning in diverse classroom environments.

Understanding teachers’ perceptions and experiences is crucial for identifying the challenges and support needs associated with inclusive education. By exploring these perspectives, the present study aims to contribute valuable insights that can inform teacher training programs, educational policies, and inclusive classroom practices.

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

Abaoud, A., & Aldosari, M. (2023). Teachers’ perceptions of teaching students with intellectual disabilities in inclusive classrooms. Research in Developmental Disabilities, 134, 104431. https://doi.org/10.1016/j.ridd.2023.104431

Ainscow, M. (2020). Promoting inclusion and equity in education: Lessons from international experiences. Nordic Journal of Studies in Educational Policy, 6(1), 7–16. https://doi.org/10.1080/20020317.2020.1729587

Avramidis, E., & Norwich, B. (2020). Teachers’ attitudes towards inclusion: A systematic review of research. European Journal of Special Needs Education, 35(2), 223–239. https://doi.org/10.1080/08856257.2019.1626035

Bhatnagar, N., & Das, A. (2020). Attitudes of secondary school teachers towards inclusive education in India. International Journal of Inclusive Education, 24(3), 284–298. https://doi.org/10.1080/13603116.2018.1449884

Brown, C. (2023). Teachers’ perceptions of working with students with mild intellectual disabilities in mainstream classrooms. International Journal of Special Education, 38(2), 112–126.

Campos, M. (2026). Factors influencing pre-service teachers’ attitudes toward inclusive classrooms. Education Sciences, 16(2), 112. https://doi.org/10.3390/educsci16020112

Carrillo-Sierra, S., Forgiony-Santos, J., Rivera-Porras, D., Bonilla-Cruz, N., & Montánchez-Torres, M. (2025). Inclusive education practices among higher education teachers. Social Sciences, 14(11), 299. https://doi.org/10.3390/socsci14110299

Darwish, A. (2025). Challenges faced by teachers implementing inclusive education for students with intellectual disabilities. Education Sciences, 15(7), 908. https://doi.org/10.3390/educsci15070908

Florian, L., & Black-Hawkins, K. (2021). Exploring inclusive pedagogy. Cambridge Journal of Education, 51(2), 179–195. https://doi.org/10.1080/0305764X.2020.1758475

Gal, E. (2025). Teachers’ perspectives on inclusive education: A phenomenological study. Education Sciences, 15(5), 541. https://doi.org/10.3390/educsci15050541

Göransson, K., & Nilholm, C. (2021). Conceptual diversity and empirical shortcomings in research on inclusive education. European Journal of Special Needs Education, 36(3), 352–366. https://doi.org/10.1080/08856257.2020.1731644

Hornby, G. (2023). Inclusive education for students with intellectual disabilities: Policy and practice challenges. Journal of Intelligence, 11(2), 20. https://doi.org/10.3390/jintelligence11020020

Loreman, T. (2022). Measuring inclusive education outcomes: A review of current practices. International Journal of Inclusive Education, 26(9), 885–901. https://doi.org/10.1080/13603116.2020.1735543

Mukhopadhyay, S. (2021). Inclusive education in India: Policy implementation and challenges. International Journal of Inclusive Education, 25(7), 793–807. https://doi.org/10.1080/13603116.2019.1624842

Rana, S. (2026). Institutional factors influencing inclusive education in higher education. Administrative Sciences, 16(2), 81. https://doi.org/10.3390/admsci16020081

Saragoça, J., Ferreira, J., & Teixeira, A. (2025). Teachers’ attitudes towards inclusive education using the ICF framework. Education Sciences, 16(1), 44. https://doi.org/10.3390/educsci16010044

Schmidt, M., Rydberg, J., & Nilholm, C. (2025). University teachers’ attitudes toward inclusive education and academic accommodations. Sustainability, 17(18), 8312. https://doi.org/10.3390/su17188312

Sepadi, M. (2025). Teachers’ understanding and implementation of inclusive education in rural schools. Education Sciences, 15(7), 889. https://doi.org/10.3390/educsci15070889

Sharma, U., & Sokal, L. (2020). The impact of teacher education on teachers’ attitudes toward inclusive education. Teaching and Teacher Education, 86, 102899. https://doi.org/10.1016/j.tate.2019.102899

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#education, #teacher #perception, #masters, #India

What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?

What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?

What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?

ABSTRACT (IMRAD)

Introduction- The medication process present with the paper based prescription system faced significant threats in relation to the patient’s safety and hence the current research evaluated the effectiveness of eprescription system with the relevance of PINCER and BCMA.  The aim of the research is ‘’ how patient safety is impacted by technology usage and how it reduces the adversity of prescription drugs, using electronic prescribing system at institutional level.’’

Methods- It used PRISMA to filter research journal articles from (CINAHL, MEDLINE, APA PsycINFO, Dementia journal, Gerontology, and Cochrane) and five articles were chosen. It is a secondary research that helped to capture prevalent practices on research phenomenon in real life, and synthesize its outcomes to gain insights using thematic analysis.

Results- Results showed BCMA achieving 100% patient satisfaction in surgical settings and PINCER interventions to reduce hazardous prescription workflow methods and processes thereby significantly urging the nursing fraternity to be compliant in a techno social environment that is high water pressure requiring 100% patient safety.

Analysis- It is evident that the success of E prescription system is an institutional demand that is dependent upon different IT systems and a higher system of clinical decision support platform that synthesizes real time data in creating alerts and adding human decisions for overcoming the socio-technical barriers and help nurses for workarounds

Discussion- It can be concluded that electronic interventions in a healthcare system are able to significantly reduce the drug adversity drug dosage mismatch chances enhancing patient safety and yet the benefits can erode overtime, if the practices from nursing perspective is not meeting the continuous learning process and compliance adherence.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Key words:  PINCER, BCMA, eprescription, nursing, healthcare

 

Chapter One

1.INTRODUCTION

In the health institutions, designing a healthcare system comprises of the patients nurses, doctors, and IT system which is able to ease clinical operations and its management efficiently and effectively. However, any system has dimension of errors or defects, that cause extended period of patient stay, harm to the patient, and adding on to the financial burdens (Clifford,  2025). In the context of UK, the NHS ‘National Health Service’ has protocol based medication administering practices, which is aligned with the doctor prescribing, and the medication dispensing, that has adopted electronic interventions for patients linking the pharmaceutical supply chain (Colin et al. 2025). The concept of BCMA or ‘bar code medication administration’ has emerged strongly in last decade, thereby, facilitating the electronic prescribing systems impacting the hospital as organisation, the doctor, the patient, nurses, impacting the paper prescription process to be digitalized (Williams et al. 2022). The implication of the above, has led to aspects of drug matching as per patient diagnosis, and also the pharmacy leading to close the gaps of human errors, matching records, decision making and oversight. Eprescription system however, offers a digitalised environment of records, involving multiple technologies for a 100% clinical decision support system. However, research studies show that technologies are designed, to eliminate human error, workflow efficiency to enhance the patient safety, have been compromised, challenged in terms of the practical and real-life incidents (Wissal, 2025).  The vital question remains about the resource constraint, staff training, and systems integration, for barcode medication administration across institutions (hospitals and pharmacies), that exposes the gap illustrated in the literature review secondary research (Shiima et al. 2022). The critical insight about the limitations and the impact, thereby, contributing towards the current research topic. This raises the central question: What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?”‘

 

1.1. BACKGROUND AND SIGNIFICANCE

1.1.1. Aim of the Literature Review

A literature review contributes to diverse dimensions of the research phenomenon to understand the research topic deeply (Aveyard & Bradbury-Jones, 2019).  The literature review in any research, helps to establish the past findings in relation to the research phenomenon and thereby, demonstrate the dimensions (Holloway & Galvin, 2023). The current research shows how patient safety is impacted by technology usage and how it reduces the adversity of prescription drugs, using electronic prescribing system at institutional level.

1.1.2 Electronic prescribing system

The electronic prescribing systems are designed to replace the age-old handwritten doctor prescriptions for the patients, thereby, reducing the human transcription errors (Goodman & Miller, 2021). Understanding the system characteristics and the ability to reduce the medication errors or defects in prescribing system (Adeyemi et al. 2024) is critical, as it helps to measure ensure the pathway of improvement process, in electronic communication formats (Elshayib  & Pawola, 2020). The communication modalities between the pharmacist and the drug prescriber, defines failsafe pathway (Strauven et al. 2020), that impacts the institutional workforce efficiency, impacting the quality dimension in patient care safety (Cahill et al. 2025) and patient satisfaction outcomes (Farre et al. 2019). While the manual prescribing practice had illegibility in the prescription, incomplete information, the structure and process centric electronic prescribing system is also facing the challenges (Tantray et al. 2024), that of ‘system downtime’, the ‘user resistance’ recurring continuous training to show its adoption and prevalence in healthcare institutions (Penati, 2024).

1.1.3 Barcode medication administration system

The second dimension is ‘barcode medication administration system’ which ensures how the right patient, with the right medication, with the right dose and on-time dosage administration, has led to intelligent prescription system (Owens et al. 2020) (Zheng et al,.2021) offering nursing autonomy (Hong et al. 2021). In this context, the patient perception about the medication, the packaging have embedded scanning barcodes along with the prescription offers cost-effort-time savings, which is the literature review shows automation in eprescription as evidence (Jessurun et al. 2021). However, in order to remove the administration error reduction, a standard compliance based process and improving outcome in the medical environment requires guidelines (van der Veen et al. 2020).

1.1.4. Why Is This Important in Nursing?

Between the patient, nurse and doctor relationship, the institutional role to safeguard medication safety for the patient satisfaction involves multiple stakeholders (Shapovalov, 2023), like the pharmacy and nurses, that forms the last and final checkpoint before the drug administration process happens (Ahmed & Tamim, 2025). Any error act any stage have serious impact on the patient treatment outcomes (Nurmeksela et al. 2021), which directly points to the healthcare institution professional accountability (Bhati et al. 2023). Therefore, the BAMS is an electronic intervention in the hospital operations management environment, where  pharmacist led IT as e-tool, that aligns with multiple stakeholders in the institution, is reducing the clinician cognitive load, standardizing workprocesses and streamlining the process of eprescription communication in the digital format (Mohiuddin, 2019) impacting patient-provider improvement in healthcare (Drossman, & Ruddy, 2020). This offers a real-time safeguard to the patients against the human mistakes (Vaismoradi et al. 2020). The effectiveness is crucial for safeguarding the patient safety upholding the ethics of nursing practice, physician practices, adopting integrated IT system, for seamless communication offering autonomy in decision making, building brand credibility of the healthcare institution (Molina-Mula & Gallo-Estrada, 2020). Therefore, the current research contributes to understanding the tools which help the nurses and the evolution of the healthcare technology that strengthens the process given approach in providing safe high quality healthcare to the patients.

1.2 DEFINITIONS

To conduct a thorough analysis, it is essential to clearly define key terms.

1.2.1. BCMA

This is defined as a technology which uses barcode and specifically used in medical sector, with drug, dose, dosage implementation to right patient at right time.

1.2.2. e-prescribing

The process through which the doctor uses a digital platform in order to recommend the prescribed drugs for the patient treatment outcomes. It reduces the aspect of hand written prescriptions, reducing probability of errors, stolen/lost, legibility issues.

1.2.3. CDS

Clinical decision support

This uses the IT based platform to give the clinicians electronic format of output, guiding them with alerts, reminder to nurses and/or patients offering transparent evidence based guidance.

 

Chapter 2 (Methodology)

 

The research methodology section gives a justification of the steps to be followed to find relevant literature, to answer the research question and achieve the research objectives (Snyder, 2019). The literature review that is based on a systematic research approach entails the development of a purposeful research question, systematic manner of searching right articles, appraising each one by one (Pollock & Berge, 2018), and then finally evaluating the published results. Although Bramer et al. (2018) argued that a quality literature review uses a systematic method while searching and analysing the literature, it might not be considered as a thorough as a systematic review.

Developing the review question:

Coming up with a review question is the initial step in a literature review (Rodgers & Yee, 2023) is a first step towards understanding. The purpose of this review is to answer ‘’ What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?’. In order to formulate a clear focused question depending on the above chosen topic, the tools PICO (Population, Intervention, Comparison, and Outcome) (Kloda et al. 2020), and SPIDER uses (sample, phenomenon of the interest in researcher, design, evaluation, and research type) which is predominantly for qualitative and mixed research (van der Waldt, 2025). Even though PICO is an effective tool in the development of research questions, it is specific to quantitative studies. Thus, SPIDER was applied, which is intended to be applied in qualitative research in table 1, but Cooke, Smith, & Booth,  (2012) argued that SPIDER tool can fail to identify the relevant papers during literature searching because it is specific.

Qualitative approach:

The qualitative research approach was used in order to respond to the question, ‘’ What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?’’  Bettany-Saltikov & McSherry, (2024) and (Polanin et al. 2019) highlight that the structure of a literature review must be closely consistent with the questions which were asked during the review. Qualitative research will seek to investigate the phenomena of humans that give detailed descriptions and theoretical elaborations (Bazen, Barg & Takeshita, 2021). This method puts depth at the forefront, with the views of the participants being the centre of attention (Lim, 2025). Although it has been criticized that qualitative literature reviews might not be systematic,

 

Table 1: Formulation of the research question

Sample Research phenomenon of interest Research Design Evaluation Research type
effectiveness of electronic interventions Check prevalence of electronic prescribing systems in reducing medication errors Exploratory Capture existing practices through research journals explaining their experiences Qualitative

 

resulting in less reliable evidence being obtained by chance and not by rigorous methods (Oranga & Matere, 2023) emphasize that rigour, sometimes known as trustworthiness, can be obtained through transparency and by reporting the systematic process followed

Search strategy:

A systematic search is used to identify the research study variables which describe its overall research phenomenon, which is relevant to the review question (MacFarlane, Russell-Rose, & Shokraneh, 2022). It included searching by keywords that are embedded in the topic, and a combination of variables, that correspond to the review question.

 

Table 2:  Keywords

Keywords

 

 

electronic interventions’’ OR ‘’ electronic prescribing systems OR barcode medication administration (BCMA) AND ‘’ electronic interventions – electronic prescribing systems’’, AND ‘’ electronic interventions- barcode medication administration (BCMA)’’, AND ‘’ electronic interventions- pharmacist-led IT tools’’, AND ‘’ reducing medication errors’’, ‘’NHS’’, ‘’qualitative research method’’, ‘’ quantitative research method’’.

 

 

This helped the researcher to make sure that the output of selected literature is exhaustive, avoids selectivity or a tendency to cherry-pick research studies (Harari et al. 2020). The Boolean operators and truncation (asterisk,) were used together with the research keywords, to find the required literature (Salvador-Oliván, Marco-Cuenca, & Arquero-Avilés, 2019). Preliminary scoping search was conducted to evaluate the presence of qualitative literature on the selected topic with the help of such keywords as – electronic interventions, electronic prescribing system, barcode medication administration (BCMA), pharmacist-led IT tools, in combination with phrases like reducing medication errors, NHS. Although this search produced a few indirectly relevant literature, new keywords were found, including by permutation and combination of words-phrases, that was included in the search procedure (see Table 2), which helped to find more relevant literature. Maltseva, & Batagelj, (2020) suggest using the keywords identified to include various representations of the topic of the review. Search concepts were effectively combined using Boolean operators “AND” and “OR” (Grames et al. 2019), and a search concept was broadened with the use of truncation (Sivakumar, & Sivakumar, 2025)) although with a risk of retrieving irrelevant articles.

Database searched:

In order to maintain its focus and select the unbiased literature review, bibliographic databases were used. The general search engines available in the market such as Google, Yahoo, which may provide an abundance of varied information output can be unreliable. The databases which were deployed in this research like – MEDLINE, PsycINFO, CINAHL, APA and Academic search complete was preferred due to their capability in producing subject area specific articles (Gusenbauer & Haddaway, 2020).

CINAHL offers diverse nursing literature, and is a searching tool in that domain, that can successfully locate qualitative research. It offers useful research articles in the context of UK even with North American bias the output are credible (Hopia & Heikkilä, 2020). On the other hand, the MEDLINE search offers diverse medical and nursing information. Similarly, the APA PsycINFO provides access peer-reviewed journals around to 98% are specifically on psychological care in nursing area (Sirois, & Owens, 2021). Academic search is complete therefore, is a multidisciplinary database, which expands the range of available scholarly articles. Limiters were used to narrow the search to only English language publications published in the past 2015-2025, which could potentially filter out some potential studies of interest.

Inclusion and Exclusion criteria:

To achieve a systematic search strategy, it is important to have clear inclusion and exclusion criteria (see Table 3) in order to select only those studies that are directly related to the review question (Krnic Martinic et al. 2019).In this instance the studies that were prioritised were the ones that

 

Table 3: Xyz

Inclusion criteria Exclusion criteria
(2015–2025): Only studies published in this period Studies that are not before 2015
In English language Non English language
Studies in relation to electronic prescribing systems, barcode medication administration (BCMA), or pharmacist‑led IT tools. Any other is rejected
Studies that have full text availability Part work or abstract based journals rejected
studies where there is clinical environment involving patients, clinicians and not simulated experiments  
Studies related to NHS and UK context Non UK
studies which are only qualitative in research methodology perspective Studies which are quantitative, thesis, dissertations, Cochrane and non –Cochrane systematic reviews
Peer reviewed Non peer reviewed

 

examine the experiences of nurses in relation to the ‘electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools’ in NHS England. Cochrane systematic reviews are believed to be the gold standard; however, they lacked inclusion because their focus was on healthcare interventions, which are not the focus of this review (Moore, Fisher, & Eccleston, 2022). Rather, qualitative research by peers was selected due to its credibility and high-quality assessment. Non-UK studies were filtered out to prevent the occurrence of discrepancies due to differences in healthcare systems to make them relevant to UK nursing practice. Even though, it is possible to learn much on the basis of their experience of other countries, and the specified aspect remains underdeveloped in other countries in particular to cite in this research. These criteria narrowed the search process and made sure that only those studies that were applicable directly to the review question were included in the search.

Study selection:

The process of selecting the studies explains how the literature that is directly related to the review question was identified, and the PRISMA diagram by Page et al. (2021) provides a clear idea of this process (see figure 1). The extraction of duplicates left 545 results, 299 of which were irrelevant articles filtered out by reviewing titles and abstracts, this process allows concentrating on the studies related to the review question. Another screening process against inclusion criteria reduced the number of articles to 36 further exclusions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Critical Appraisal

The procedure of critical appraisal for any research study have their respective strength and weaknesses in terms of its evaluation power and the quality and relevance of the article selection in respect to the research question. The CASP checklist is designed for qualitative research studies and in the current appraisal process, (Long, French, & Brooks, 2020). Recommend its importance in the specificity of the tools that have checklists which show the qualitative research to show ‘rigour’, where the ‘decisional quality’ of including the study for analysis. It needs to eliminate research self-selection bias, and adopt a thorough assessment guided by professional standards.

Critical Appraisal: Barakat & Franklin (2020): Nursing Workflow and BCMA

The research overview and background by Barakat & Franklin (2020) explores barcode medication administration (BCMA) advocated for reducing medication errors. This area of study and its effect on the nursing process is not well studied. This research aimed to evaluate the impact of BCMA, when included to the existing electronic prescribing and medication administration (ePMA) system over the nursing practices in UK teaching hospital. The researchers used research approach that comprised of comparative study, on two similar surgical wards. This process consisted of using direct observation at 8 AM each day for 10 consecutive weekdays in each ward especially during the drug rounds. Data gathered were on drug round time, where the aspect of punctuality, identification of patient, and the last one was on medication cross verification. The study identified and determined that there was no significant difference in the overall time per round of drugs, and that this time was about 68 minutes per round on both wards. The mean time per dose however was significantly lower on the BCMA ward (2.3 minutes) than the non-BCMA ward (4.2 minutes). Importantly, patient identification checks went from 74% to 100% with the use of BCMA.

The strengths of the research method included the direct observation by a single observer which can help in the consistency of finding and can minimize the limitations of self-reports. The study, which involved observation of nurses in an actual context, allowed to record nuanced patterns of their workflow-workaround, for instance walking paths, with spaghetti diagrams while an integrative view as per (Fraczkowski, Matson, & Lopez, 2020) findings was not done. This approach provided a visual comparison of the activities streamlined through the use of BCMA, and demonstrated there was consistently less walking to the medicines room overall on the BCMA ward. Moreover, if BCMA is compared to an existing ePMA system rather than a paper-based system, the assessment would be more relevant for modern NHS trusts where there is already a digital system in place while its application in different medical fields (Vanderveen, & Husch, 2015) could have given more insights.

When critiquing research methods, it was found that a major drawback in conducting the study was the fact that the study was carried out in two wards as opposed to a single ward before and after implementation but it missed, where (Vanderboom et al. 2016) showed interdisciplinary team feedback to BCMA success was acheived. Nursing leadership, culture, and patient acuity were also different by wards, and may cause bias in this physically similar surgical units while (Giraldo et al. 2018) captured their perception about mobile apps based interventions in workprocesses. The data collection on the BCMA ward was only four days after implementation, and staff may not have had the opportunity to become acquainted with the system which could have influenced the results. Moreover, there was no quantitative assessment of the various categories of nursing activities, which restricts the thoroughness of the research workflow data capture and data analysis while the research missed on quality tools (FMEA failure mode effective analysis) as described by (Thompson et al. 2018) in reduction of errors, or the BCMA transition experience of nurses using eprescription in electronic health record system as per (Reale et al. 2023).

Twenty drug rounds were sampled, 10 at each of the two wards. This study looked at the administration of 47 patients on the non-BCMA ward and 43 patients on the BCMA ward, whereas other longitudinal studies analyzed 613,868 administrations. The number of different nurses observed in each ward was low (7 or 8), and may not have been representative of the broader nursing profession. There is a relatively small number of subjects and the study involves only one institution so it is hard to extrapolate the results to other institutions that may have different methods of medication giving, while it missed out on nurses treating inpatient-outpatient using BCMA effectiveness as highlighted (Post et al. 2023) study.

Results indicate that BCMA standardizes and harmonizes the way medicine is administered without putting additional time pressure on the nurses. A big safety success is the 100% patient identification rate, though the researchers noticed some workarounds, such as nurses scanning a patient’s barcode sticker on their notes rather than on patient wrist bands in side rooms, while (van der Veen et al. 2020) showed factors important for workaround methods for nursing while the behavioural dimensions of nurses (Grailey et al. 2023). This means that although the system is in place to check for identity, there can be counterproductive practices due to environmental barriers such as tethered scanners. The less time per dose, may be an opportunity for more timeliness if drug rounds are started on time.

Critical Appraisal- Fisher et al. (2023): Medication Safety during COVID-19

Following the COVID-19 pandemic which caused massive disruption to UK Primary Care, a study by Fisher et al. (2023) study on ‘Medication Safety During COVID-19′ raised concerns about hazardous medication prescribing. The aims of this study was to check the use of ‘OpenSAFELY’ platform to describe how the pandemic is affecting medication safety indicators. The researchers based their study on 57 million patients, in NHS and applied a population-based, retrospective cohort design. They adopted 13 ‘PINCER’ (Pharmacist-led Information Technology Intervention for Medication Errors) indicators, which determine the risks for gastrointestinal bleeding among others and required monitoring via blood tests. Concerning this study, it was determined that hazardous prescribing had not undergone major alterations throughout the pandemic. Monitoring in October 2021 slightly deteriorated for blood ACE inhibitors (from 5.16% to 12.14%), with recovery of most indicators by September 2021 while it has missed the controlled trail for cost effectiveness (Avery et al. 2012).

In this study, the researchers used federated analytics – a way of high-security analysing pseudonymised primary care records from 95% of the English population, without data being moved. This means it is 100% transparent, reproducible: all of the code used for analysis is publicly available on GitHub. The study covered the entire national scale, which was not possible in past manual audits, because of running the same code in both environments. This approach values patient confidentiality both as patients and as public health reports and encourages near real-time status updates on key public health challenges. However, it does not capture (Avery et al. 2012) cost effectiveness of workmethods in institutional.

Critique of research methods did however, reveal that the findings are largely descriptive and that the researchers did not attempt to statistically examine the significance of the changes that were made apparent. Long-term seasonal trends in the rates of indicators could not be taken into account because of the study period, especially the time prior to the pandemic. In addition, only prescriptions and tests done in primary care were captured; those communicated via hospital letter and telephone were not captured as structured data. This could lead to an overestimation of the lack of monitoring in some patient groups.

No study has captured such a large sample size – of around 56.8 million patients across 6,367 GP practices. This huge data set allowed the identification of 1,813,058 patients who were at risk of experiencing at least one potentially hazardous prescribing event during the 2 years of this study. This extent of a population – at National level – removes sampling error to a level of virtual extinction and gives a complete picture of medication safety within different populations and areas of England.

The study suggests that, concerning medication safety, the NHS primary care system was very resilient during the pandemic. Some hazardous indicators, such as NSAID prescribing among the elderly may not reflect deliberate safety measures, but may instead reflect fewer acute presentations. The lengthy timeframe associated with ACE inhibitor monitoring, however, does reflect the focus primary care clinicians had toward practicing higher risk monitoring (e.g, methotrexate) when resources were limited. They illustrate that federated analytics can help guide policy decisions regarding which services we should try to provide focused recovery assistance following systemic shocks.

 

Critical Appraisal- Rodgers et al. (2022): Scaling-up the PINCER Intervention

Research overview scaling-up the PINCER intervention by Rodgers et al. (2022) showed that medication errors in general practice contribute significantly to hospital admissions and avoidable deaths. This study sought to investigate whether the PINCER intervention—a pharmacist-led IT system that identifies at-risk patients—remained effective when rolled out at scale. Using a multiple interrupted time series design, the researchers tracked the intervention across 343 general practices in the East Midlands. The study measured 11 prescribing safety indicators over 16 quarterly periods. Findings showed a 16.7% reduction in hazardous prescribing at 6 months and a 15.3% reduction at 12 months post-intervention. The most significant improvements were seen in indicators for gastrointestinal (GI) bleeding risk, which fell by 23.9%.

The interrupted time series (ITS) design is a robust method for evaluating large-scale interventions where randomisation is not possible due to logistical or commissioning constraints which (Danda, 2026) research using informatics. By including calendar time as a covariate, the researchers accounted for secular trends toward safer prescribing that might have occurred regardless of the intervention which is an advantages of research methods. The use of logistic mixed models allowed for within-practice correlations and provided adjusted odds ratios that enhance the reliability of the findings. Furthermore, involving PPI representatives in the design ensured that the research remained focused on patient safety and welfare while factors was identified by (Laing et al. 2022).

As an observational study, the findings may have been influenced by unknown confounding factors or behavioural changes unrelated to PINCER. The researchers were unable to collect follow-up data for all practices; by 12 months, the number of contributing practices dropped from 343 to only 70. This significant attrition could introduce selection bias if only the most engaged practices continued to upload data. Additionally, the term “without co-prescription” was kept in the denominator, which might have underrepresented the true effectiveness of adding protective medications like proton pump inhibitors while (Elliott et al. 2013) research highlighted pharmacist based economic impact in medicine management.

The study initially searched 2.97 million patient records at baseline, making it one of the largest evaluations of a medication safety intervention in primary care. While the 12-month follow-up was limited to 70 practices, the sensitivity analysis showed that the characteristics of these practices remained comparable to the original 343. The large initial sample size provided enough power to detect small but clinically significant changes in hazardous prescribing across multiple drug groups, while (Daniel, 2013) findings found how this was assessed in emergency departments managed by nurses.

The results strongly support the national rollout of PINCER in England. The sustained reduction in GI bleeding risk indicators suggests that the intervention is most effective when it prompts a straightforward clinical action, such as prescribing an ulcer-healing drug. However, the study found no reduction in hazards related to asthma or stroke, speculating that these changes are more difficult for pharmacists to implement due to complex patient indications. This highlights that IT interventions need to be coupled with clinical support to address more nuanced prescribing challenges.

Critical Appraisal- Sheikh et al. (2022): ePrescribing Systems in Hospitals

Sheikh et al. (2022) study on ePrescribing Systems in Hospitals stated background errors in hospitals in everyday operations are common. This eventually leads to avoidable morbidity and mortality. This multimethods research programme was sought to describe the implementation of ePrescribing systems for estimating their effectiveness and cost-effectiveness in the operations while (Cresswell et al. 2013) study found that early interventions help to reduce errors. Six longitudinal case studies across diverse hospital sites was carried out, combining 242 interviews with 32.5 hours of ePrescribing systems observation in this research. The researchers also developed ‘IMPACT tool’ via an eDelphi exercise, in order to track the list of 80 high-risk prescribing errors. The study found that while implementation of ‘ePrescribing systems’, was difficult due to integration issues, ePrescribing was associated with a significant reduction in error rates. The earlier scores from 5.0% was reduced to 4.0%, at two of the three sites, where effectiveness was measured.

The theoretically the authors tried to ascertain the naturalistic evaluation method that offered a rich, context-heavy understanding as to why any systems are failing or succeeding while (Williams et al. 2020) where optimising hospital eprescription was found with planned interventions succeeding in NHS hospitals shown by (Crowe et al. 2010) research. By using a Bayesian framework in the research approach that was used for health economic analysis the researchers synthesized the aggregate expert opinions (priors) with empirical study data. This helped to generate meaningful posterior distributions. It is advantageous for “upstream” outcomes as the research on the clinical errors, where a minute incident or chances of error, leads to higher case of mortality was tackled. It was found that the online ePrescribing Toolkit was a tangible evidence for connecting all stakeholders in NHS.

Implementation delays forced the researchers to abandon their planned stepped-wedge design in favour of a less rigorous pre- and post-implementation design. This limited their ability to make a clear causal inferences existing ‘online ePrescribing Toolkit’ systems’ impacts. The researchers faced data access and data capture in regards to the economic factor ‘cost data’ from the hospitals. This forced them “headroom” approach that helped them to maximise the justifiable prices over the direct cost-effectiveness. Small number of case study made it difficult for the researchers, in order to generalize the findings throughout the NHS.

Researchers were able to use qualitative sample that included 242 interviews. This research approach to sampling offered to capture a broad range of stakeholder perspectives from clinical implementation teams to end user patients. The use of the drug charts from 2,422 patients were reviewed for the safety analysis which had 28,526 medication orders. The current research did show large dataset, enough to identify significant reductions in common procedural errors. The study detected a 1.5% reduction in errors in ‘online ePrescribing Toolkit’ systems’. However, there were limited number of hospitals (only three went live during the study) implies the between-site variance could not be reliably estimated while (Heeney et al. 2023) used qualitative approach for ‘why’ and ‘how’ about interoperatability of eprescribing systems while (Bell et al. 2019) used mixed method to understand CDS in eprescription in UK. .

Findings showed that ePrescribing is a complex organisational intervention. It is simply not just a technical one. The outcomes of the research benefits showed -improved legibility and completeness are common but (Cresswell et al. 2017) study offered workaround for nurses in eprescription systems adoption. However, the study warned that ‘online ePrescribing Toolkit’ systems’ introduces a new risks if not properly configured. Authors found that only few hospitals, which used restrictive clinical decision support (CDS) saw specific errors eliminated. But again (Pontefract et al. 2018) showed that there is a general reluctance by the institutions for commercial viability skepticism, to fully deploy CDS. The pre-post study, due to fears high degree of stakeholder involvement to ascertain the errors, and associated effort fatigue. Alagiakrishnan et al. (2005) showed how it is important to reduce and remove inappropriate medication in the healthcare system where CDS plays a key role. It is a system beyond human optimization, using data driven analysis and output helping internal stakeholders to adopt, culture of continuous learning that are essential to realizing long-term patient safety benefits.

Critical Appraisal- Williams et al. (2025): Longitudinal BCMA Adoption and Safety

Williams et al. (2025): Longitudinal BCMA Adoption and Safety BCMA systems are touted as a method to provide the “five rights” of medication administration, and they must be adopted by users to be effective, as noted in Longitudinal BCMA Adoption and Safety by Williams et al. (2025). This was a retrospective longitudinal study looking at the BCMA use and the barriers and enablers in a London NHS Trust over a 16 month period. Five wards provided 613,868 administrations and this data was analysed along with prospective clinical observations. The study showed a high range of rates of wards scanning medicine from 5.6% to 67%. There was a fall in compliance over the years in most areas, with one ward (N1) that had a quality improvement (QI) initiative showing an increase. There were “safety catches” with 37% of mismatch alerts leading to an adjustment of user action in total.

One of the benefits is that it is a longitudinal study, and compliance is tracked over the course of 16 months, shedding light on compliance after adoption has taken place for more than 16 months. When the researchers blended big data from EHRs with observations made from a contextual inquiry, they were able to gain insight into the “why” behind the numbers. For example, observations were made to explain that common reason codes such as “barcode unreadable” were in many instances simply a method of popping the system when under pressure for time. However, study of (Svandova, & Smutny, 2026) stated that minimising workaround needs to ascertain deviation of work paths or methods, uncovering specific factors, such as medication formulation, nurse behaviour, technical fault, that have a significant impact on the rate of scanning.

The study took place in one trust with significant digital maturity, therefore results may not apply to other less maturing trusts. Data was collected in the time of COVID19 pandemic which did undoubtedly affect clinical workflow and limited the frequency of observations for the researchers. Also, the safety catch data analysis period was only one month, and the extent to which this is representative of long-term safety effects is unknown. The study also indicated that non-error events (e.g., two half dose tablets) cause trigger alerts. However, it did not capture a home based drug administration by (Shore et al. 2024), which could be overestimating the safety benefits of holistic healthcare delivery system.

The number of administrators in the data-based sample was huge (613,868), giving the regressions a lot of power to determine the relationship outcomes in variables. But the clinical observations were performed only once in each area, and included only eight areas. The majority of the wards where retrospective data were relied on were different than the wards, where the observations were carried out, and thus some of the qualitative data may not fully account for the quantitative data across the five over-arching wards studied.

The influence of contextual factors, like specialist ward type or workload of nurses, on the success of BCMA, is shown. Grailey et al. (2023) capture the barriers and faciliators in their study, especially in the fast-paced work environments which required to understand behavioural capability along with CDA and eprescription. Previously  unsustainable for scanning on the acute medical unit, as evidenced by the speedy drop in AMU scanning. In contrast, the high scanning levels in Ward N1 shows that nurse-led QI projects and ongoing commitment can help to maintain high levels of scanning. The results highlighted that BCMA systems are not “set and forget” technologies, while it supported earlier study of (Popat et al. 2024) set in NHS, and that they need continuous monitoring in order to keep them effective as safety barriers.

Chapter 4.0: Synthesis

Theme 1: Social and technical barriers in workflow process

The first theme that emerges strongly across the research journal shows the emphasis of the use of electronic interventions in the healthcare management process and especially when the adoption of digital systems requiring to align with the clinical practice the workflow work around needs to be categorically instituted (Williams et al. 2025). The author argued that ward management by hour, is necessary to check dosage omissions, which represents micro-macro dimensions of workflowprocess to be improved as workaround, in real time. This theme also calls for BCMA context the aspect of changing workarounds in existing workflow process needs for example linking barcode sticker of patient with patient notes bypassing primary safety check of patient identity as per (Barakat & Franklin, 2020). A change in the eprescription settings shows lack of integration between the workflow methods, the modules, the prescribing methods as highlighted by (Lundhaug et al. 2025), that is forcing the clinicians to do repetitive tasks (multiple times) alternating between using paper based intermediaries and digital which is creating new risks in patient safety which was also found in Saudi Arabia hospitals (Alharthi, 2024). Rodrigues et al. (2024) argued this to be a multidimensional construct for the workarounds in relation to the hardware limitation (in the rooms or ward), the software immaturity. The human factor of time based workload pressure in a formalized job setting, which is doing potential harm by increasing the risk factor (Sheikh et al. 2022). From the patient perspective introduction of technology in the healthcare management process and the patient involvement has caused removal of paper based medication information to digitalization of new form of eprescriptions, which is a continuous learning process for the ‘patient-clinician-doctor’ (Sheikh et al. 2022). While implementation success is dependent on ‘culture of use’ by frontline staff, system configuration, bringing iterative optimisation overcoming technical limitations in formal practice as discussed by (Williams et al. 2025).

Theme 2: Longitudinal compliance in BCMA

The second theme that emerges strongly is about the barcode medication administration system rule that request to verify the five rights the scanning the patient wristband the medication documentation barcode making it user compliant in the clinical context as highlighted by (Williams et al. 2025). The longitudinal nature of the research showed how systematically scan mismatch alerts have captured wrong patient order, discontinued/expired order drug and wrong patient wristband, scanned to be eliminated. The longitudinal study showed how medication scanning has reduced the workflow process time lines improve the accuracy rate and eliminated the risks as the frontline workers were becoming stressed (Williams et al. 2025) that was evident with (Sheikh et al. 2022) developing ‘critical error types’ IMPACT tool systematically reducing errors over time (reducing 21138 opportunities of error), improving cost effectiveness across eprescription lifecycle implementation to system optimisation. Evidence from the study showed a high of 67% medication scanning rate in acute medical units in a high work pressure environment to yield error as low as 5.6% is testimony of longitudinal iteration based improvement. The longitudinal implication of using BCMA guidelines have shown a change within the stakeholders especially users in action and capturing the ‘safety catch’ in errors especially the wrong patient respond or expiry orders of medicine (Williams et al. 2025). Additionally decline in compliance was also noted in a logistical barrier perspective when there was malfunctioning of the medical hardware software and barcodes that are unreadable or unavailability of the scanners which proves how environment and system improvement is a longitudinal effort in medical quality management. Evidence from these studies show micro level locally laid quality improvement practices in real time that captured the frontline employee feedback and with able nursing leadership across the words helped the system to sustain and improve the scanning rates in eprescriptions thereby proving BCMA technology and compliance to be beneficial.

Theme 3: Institutional eprescribing decision and CDS

The third theme that emerges strongly is a evaluation of the NHS hospitals that have primarily accepted hospital eprescription as a system and incorporating the clinical decision support system along with computerized provider order entry CPOE (Sheikh et al. 2022). Eprescribing impact on the work methods eliminated the human errors, in existing paper system and associated issues of incomplete orders, illegible handwriting and inappropriate drug administration dosage to patients, but  (Schmidt et al. 2026) stated the continous challenges of serious configuration with systems, alerting humans is technology induced error reduction system across the health institution still remained which was found in Swedish health care study by (Rahman Jabin, & Hammar, 2022). It is evident technology use in prescribing underwent a transition, that has been prolonged and challenging from institutional perspective, with implementation delay in error defects identification, defect reduction in specific task area, that has helped the hospitals to standardize the process. While the aspect of nursing perception (Jaber et al. 2025), significant reduction across wards/departments in the hospital but equally important IT system, system design and information system design, which has helped CDS to aid the human fatigue. The applicability of the system output, eliminating the probability of potential error types, in the patient management system was found by military hospital (Alanazi et al. 2024) expanding scope of the findings. The institution faced challenges in implementation, optimizing and standardizing, the ‘commercial off the shelf’ (COTS) products into an adaptable home grown system. Findings match with (Khan et al. 2022) who argued that it required the contribution of the internal stakeholders, apply wireless technology for easy integration within medical devices. It needed to focus on the alignment of the system and the clinical workflow against the existing job descriptions, to match and be effective. As institution, the hospitals had resource and technology challenges, and which (Wu et al. 2022) argued in terms of maximizing human efficiency, automate workflow process efficiency. This is achieved through design, architecture, and data analysis in order to realize the full potential in reducing the patient term by adopting a long-term system optimization approach.

Theme 4: Pharmacist led IT interventions

Across the research studies the last thing that emerges strongly is in relation to the pharmacy within the healthcare institution and how large scale evaluation system PINCER (Pharmacist lady information technology intervention for medication errors was developed and applied as an effective tool to reduce the hazardous prescribing workflow methods in primary healthcare setting (Fisher et al. 2023).   This team have shown that usage of pharmacy technology caregivers and the patients have an equal role to play in order to identify the probability of risk, risk types, and eliminate the chances of ‘risk of harm ‘through an educational outreach embraced by the stakeholders.  The studies prove that pincer associated with the healthcare institutions decreased hazardous prescribing workflow methods within six months from 15.3% decrease over one year, post-intervention and from disease perspective (gastro-intestinal GI bleeding) using drugs decreased to 24% levels in patients due to NSAID hazardous drug prescription tracing system (Rodgers et al. 2022). Open supply platform have shown the resilience of the platforms, against the external shocks, like COVID19 pandemic that disrupted the primary care services, from institutional perspective, thereby, focusing how pharmacy and its role in high risk medications. It matched with a Czech study (Berger et al. 2023) set in COVID19 on eprescription system, as the required technology centric interventions to scope out the risks and achieve performance in the institution (Fisher et al. 2023). The application of pharmacy related IT tools therefore, captured the pharmacy supply chain ‘end to end’ creating a robust framework, of continuous safety monitoring practices on pharmacy workflow, nursing workflow (Yu et al. 2025) echoed the findings which is changing the human habits and translating to shift towards an automated risk detection system, helping in sustain clinical improvement environment (Rodgers et al. 2022).

4.1 Discussion

The above result synthesis help us to understand that electronic prescribing system, and the dimension of barcode medication administration, at the institutional level especially, for the health care sector that has significantly enhanced the institutional capability and frontline employee delivery efficiency directly impacting the patient safety. The mix of technology, information capture, information processing, systematically have helped the institutions, to reduce the rate of medication errors, which are clinically vital for the organization to prove its operational efficiency. The synthesis of the multi-method research in the above topic, have specifically shown how NHS hospitals demonstrated a transition from a paper based prescription system to an electronic or eprescription system over the months and years by systematically overcoming the challenges in implementation.  The internal stakeholders have you illustrated you have understood the paper and digital platform the dimension of errors and the implications of the typology of risk that impact the clinical delivery efficiency and the institutional commitment to patient safety system. Even though the technology reduces the adversity of the prescription drugs, the pharmacy involvement in capturing data of the supply chain, and the work method and workaround processes have reduced the chances or adversity of mismatch prescription drugs probability and its outcome on the patient health safety. Similarly, the technology accessed by the institutions which had procedural errors previously like incomplete drug orders inappropriate dosages and illegible handwriting have been eliminated completely with the aid of clinical decision support system (CDS).  It can be concluded that the role of technology across the length and breadth of clinical management in the healthcare industry, cannot be ignored though the internal stakeholders have to reconfigure information technology (IT), information systems (TI), databases, to understand the source of errors, error types, cost-time impact on the degree of hazardous liability on the institution and on the patients. The above evidence of focused on -anticoagulants, antiplatelets and NSAIDs, where epharmacy role, now enabled tools and platforms, with electronic interventions, that have helped preventable medication related hospital treatment and admissions.

From the nurse nursing perspective application of BCMA has provided a important and critical safety layer, where the point of care complied with the ‘five rights’ verification which is indirectly resulted in active patient identification 100%. Legacy work method and work process in paper based prescription have shown mismatch of data that was overcome by bcma system which changed with the digital shift in the frontline user action and the higher level information technology algorithm that acted as safety catch in identifying and determining the error from the perspective of expired medication in the system or tracking a wrong patient order. It is evident that the studies reflect long term trend by the internal stakeholders in improving the existing workflow method system and trying to comply with high pressure work environment with zero error delivery in departments/ wards, where longitudinal quality improvement practices have helped to standardize the system capability and frontline delivery. The role of nurses embracing E prescription technology therefore has improved the legacy work methods to a new workflow to work around system reducing the time eliminating the errors and also achieving cost efficiency in serving per patient from institutional context.

The ever results also help to emphasise on the technology which has played a huge roll in reducing the drug adversity and its impact on the patients from healthcare service delivery perspective. All the interventions of the tools platforms any prescription system was off the shelf but have been implemented and adopted by the healthcare institutions with significant iterative system optimization happening in each department and ward. This adoption and adoption is a supportive organizational culture by the internal stakeholders as regular feedback from the patients from the nurses with that have helped the healthcare organization to clinically adhere with the high compliance KPIs and prevent the existing system of patient safety benefits erosion. The role of nurses with pincer automated computer platform technology that searches hazardous prescription in post intervention have shown the power of technical framework to catch errors aiding the human decision making process in ensuring the nursing role in patient safety and also integrating the technology with the clinical new workflow methods. Their role has also been critical in utilizing technology and human judgment to mitigate the diverse risks in their task areas and the safety threats in the old workflow method and also in the transitional period of workflow method changing from traditional paper base prescription to eprescription process.

4.2: Limitations

Firstly, the studies of (Roger et al. 2022) and (Fisher et al. 2023) acknowledge that observational research method to ascertain the confounding factors and determine the causal inferences is a methodological limitation while (Sheikh et al. 2022) and (Rogers et al. 2020) had to abandon the stepped wedge design in research due to delays and it’s robust people’s research comparison. From geographical perspective the studies in the region of East Midlands or in London may not represent the entirety of picture of NHS healthcare organization as the inability to understand the transparency of cost data remained a hurdle for bringing about the change in relation to the research topic (Sheikh et al. 2022). Many studies like (Barakat & Franklin 2020) and (Williams et al. 2025) have captured short observation windows as defaced the attrition in follow-up data in the health care institution, while Rogers et al.(2022) had to complete all the research method within a year, with 70 practices captured as a baseline. More recent studies in 2026, in relation to eprescriptions and sociotechnical workaround, required to be captured, for understanding the involvement of artificial intelligence (Ai), and human decision fatigue, that the above studies have not fully captured and discussed.

Chapter 5.0: Conclusion

The current study aim to understand ‘how patient safety is impacted by technology usage and how it reduces the adversity of prescription drugs, using electronic prescribing system at institutional level’. The results in the last chapter have shown that there is a significant impact of multiple information technology systems generated for internal stakeholders in healthcare organization, which has significantly improved the work methods, work processes and enabled him to improvise on new work approaches. It can be concluded that electronic interventions in eprescribing systems like BCMA and pharmacist led IT platform based tools like PINCER have helped healthcare organizations significantly to improve and enhance the patient safety levels by systematically adopting quality interventions an iterative reduction of medication risk. The outcome showed BCMA compliance helping nurses, in achieving over 100% patient identification eliminating mismatch cases and preventing errors at 37% of instances and 16.7% reduction in PINCER based hazardous prescribing even during COVID-19. There is high degree of socio- technical alignment, which was required to maximize the effectiveness of the organizational throughput in meeting the compliance, which was found to decline overtime in a high pressure word in the healthcare institution. The involvement of CDs clinical decision support system helping the humans in the healthcare system have helped technical power to identify error track the error offer real time restricted alerts aiding the success of the workflow around through iterative optimization process. It can be concluded that the transitional journey from paper to digital shift in prescription requires the what methods the culture to show digital maturity, in achieving a set goal or clinical outcome while installing technical software and aligning the ‘culture of safety’ in everyday work process.

5.1: Implications for Practice

The above research showed the transitional journey to be a challenging for the healthcare institution from top-level view, against the frontline nurses and their work around methods at micro level to be a key element, from a reactive-error correction and pro-active risk removal perspective. It showed that the system design in the clinical workflow, requires integration, alignment and collaboration, from multiple departments/wards, IT-IS from task perspective. This helps the practice followed to embrace, eliminating the legacy system and implementing IT based workaround which requires normalizing, standardizing to achieve 100% patient safety identification, amidst high pressure work conditions.

   5.2: Recommendations:

  1. Suggestions include to expand PINCER integration to 100% automated pharmacist led supply chain information system, at national level and focus on implementing high risk drug group patients to be threat free.
  2. Institutional prioritising of restrictive CDS and sharing the data with multiple organizations would help to eliminate the procedural and system based clinical errors entirely in case of extreme risk based prescriptions.
  3. The alignment of hardware software accessibility at institutional level is required to enable collaboration between the healthcare organisations a nursing data for a top level perspective of eprescription effectiveness across nations.
  4. Ergonomic medical scanning devices that are wireless for the nurses is required to remove the physical barriers preventing bedside workarounds in side rooms.

 

 

 

 

#UK, #nursing, #academicwriting, #dissertation, #Bachelors, #Masters, #Ireland, #Scotland, #Healthcare, #Publichealth 

What are the perceived challenges and barriers faced by nurses in the prevention and management of pressure ulcers among hospitalised adults and associated care settings?

What are the perceived challenges and barriers faced by nurses in the prevention and management of pressure ulcers among hospitalised adults and associated care settings?

What are the perceived challenges and barriers faced by nurses in the prevention and management of pressure ulcers among hospitalised adults and associated care settings?

Chapter 1: Introduction and Context.

1.1 Background

Pressure ulcers, also known as pressure injuries or bedsores injuries or bedsores in the patient, are a major in problem as the patient body due to sustained pressure experiences damaged skin area and tissues. Pressure ulcer is defined as localised damage to the skin and underlying tissue, which is usually caused by the prolonged pressure or the combination of pressure and shear, pressure ulcers are generally well-known as highly preventable adverse events. It happens in stages (1,2,3,4) as the patient is at a high risk , if skin is thin, less elastic, patient is bedridden, poor nutrition, has to deal with inconsistence. Even though, the patient needs frequent repositioning, and support like specialised foam, air filled mattress (Sia et al. 2026), National Pressure Injury Advisory Panel [NPIAP] and Pan Pacific Pressure Injury Alliance [PPPIA], 2019).

Statista reported that in 2025, UK alone has 500,000 people developing into pressure ulcer cases annually in 2024-2025, with newly diagnosed 180,000 new cases being reported every year. In the United Kingdom, the cost of treating aggregate pressure ulcers is estimated at 1.4-2.1 billion a year to the National Health Service (NHS) (NHS Improvement, 2018, as cited in Oozageer Gunowa et al., 2025). The United States has estimated the annual expenses related to the treatment of hospital-acquired pressure injuries to exceed USD 27 billion (Oozageer Gunowa et al., 2025).

 

The role of nurses in pressure ulcer prevention and control is central and cannot be replaced. Nurses are the key primary line of defence who act through constant clinical observation. Their role in execution of the “SSKIN” bundle (Surface, Skin, Keep moving, Incontinence, Nutrition), and the use of risk-assessment tools like the Waterlow scale are instrumental to care quality for such patients. Registered nurses being the largest healthcare professionals’ group have the responsibility to perform risk assessment, preventive measures, organize care, and educate patients and carers (Li et al., 2022). International (e.g., the EPUAP, NPIAP and PPPIA, 2019) and national (e.g., the National Institute of Health and Care Excellence, 2014) The earliest clinical practice was based on the initial guidelines formed in 2014, that constituted contain evidence-based case studies culminating into guidelines. Guideline CG179 by NICE focussed in prevention and management of pressure ulcers. It developed standard QS81, which defined quality standards for monitoring and reducing incidence of pressure ulcers in all UK hospitals and also in care homes. Later in the year 2019, EPUAP has  come together with PPPIA (Pan Pacific pressure injury alliance) and NPIAP (National Pressure injury advisory panel) to release a documented International guideline. The attempt was to spread the standardised practice at global level and improve each nation’s capability to address scope of improving risk assessment efficacy, offer nutrition to patients, and develop support surfaces. Abbreviated as SSKIN bundle (Support surfaces, Skin inspection, Keep moving, Incontinence-moisture management, Nutrition-hydration) forms a more comprehensive version, ASSKING, offer useful guidelines that nurses can apply to provide structured pressure ulcer prevention (Taylor et al., 2021).

1.2 Significance and Rationale

Existing literature on prevention of pressure ulcers has been on clinical outcomes, intervention efficacy or guideline development. It is important to understand the obstacles and difficulties that nurse encounter, in their everyday practice to design meaningful, specific strategies to enhance care. A qualitative study of community nurses and allied healthcare professionals in London by Taylor et al. (2021) revealed that although all participants reported their high motivation to prevent pressure ulcers, a variety of barriers still affected the provision of best practice. These were self-reported gaps in in allied healthcare professionals, challenges with starting conversations with patients regarding risk, high workloads, and clutter in the homes of patients (Taylor et al., 2021).

This issue has an impact on more than clinical practice as it also touches on education, workforce planning, training and the broader healthcare policy. Nurses in long-term care facilities have reported to experience unique challenges, that are very different compared to those in acute settings. It pertains to lack of formalised guidelines unique to their setting, severe understaffing, and inadequate access to specialist wound care services (Na et al., 2024). Factors like home setting, non-adherence in patients, family, and inability to perform a comprehensive skin assessment on patients, with varying skin tones have further complicated the situation in the community setting (Taylor et al., 2021; Oozageer Gunowa et al., 2025). Multicenter qualitative studies described globally have been carried out in three tertiary hospitals in Singapore and have continued to note the synergistic effects of cognitive, emotional, resource, and biomedical factors in the complex issue of effective pressure injury prevention (Sim et al., 2024).

One of the least studied but still the most crucial dimensions is the evaluation of the pressure injuries in dark-skinned patients. The qualitative descriptive study by Oozageer Gunowa et al. (2025) in community nurses in the South of England revealed that nurses had serious problems with identifying pressure injuries at an early stage for those individuals with a dark complexion. This showed practice gap mainly attributed to lack of nurse training, non-availability of diverse patient demographic by ethnicity, and representative clinical materials. Considering the scope and depth of the barriers discussed in literature, carrying out a focused secondary research would help the length and breadth of aggregate challenges faced by nurses in preventing and managing pressure ulcers. This type of review will be able to synthesise data available in existing literature, find common themes, and indicate gaps in current knowledge to guide educational and policy advancements in nursing.

1.4 Nursing Practice/Policy Relevance

The study is especially applicable to the nursing practice on the various levels. On the individual care delivery level, knowledge of the obstacles encountered by nurses can be used to create more sensitive educational programmes, approaches to clinical training and supervision and application based best practice directions. Organisational perspective emphasis, contribution towards staffing shortages, resource constraints, and equipment shortages can be used to appraise the workforce, work methods planning and procurement. At policy level, the knowledge about the unequal use of guideline implementation and equity disparities in the care delivery, to pressure ulcer patients, dark skin tone patient group, has the consequences in NHS commissioning, regulatory requirements, impacting the efficacy of the curricula in nurse education.

In the Nursing and Midwifery Council (NMC, 2018) Code, the registered nurses are expected to follow strict guidelines based patient safety, upholding the nursing professional knowledge, and maintain standards of excellence at institutional level evidence-based care as a priority. NHS England and NHS Improvement explicitly name the prevention of pressure ulcers as one of the patient safety priorities, and the avoidance of preventable pressure ulcers can be a serious incident in the context of NHS governance frameworks (Taylor et al., 2021). The direct implication of identifying and overcoming the barriers that nurse’s encounter in the delivery of best practice to patients is thus on professional accountability and patient outcomes.

1.5 Dissertation Organisation.

This dissertation is outlined in five chapters. Chapter 1 has introduced the review, its contextual background and its rationale as well as the research question is clearly stated. Chapter 2 defines the methodology that will be used, such as the search strategy, the choice of databases, inclusion and exclusion criteria, and the critical appraisal method. Chapter 3 critically discusses the methodological soundness of the five primary studies chosen. Chapter 4 summarises the results of the reviewed studies with regard to the research question and outlines the main themes and comments on the implications. The final chapter of the dissertation is a discussion on how the findings of the review would impact nursing practice, policy, education, and future research.

 

 

 

Chapter 2: Methodology

2.1 Introduction

In this chapter, a clear and reproducible record of the methodological process that was employed to identify and select the primary empirical literature that guides this review is given.

2.2 Review Approach

 

2.3.4 Developing the Research Question: The PEO Framework.

An organized approach is necessary when formulating a well-focused and responsive review question (Stern, Jordan and McArthur, 2014). In this review, PEO framework was chosen because it is specifically developed to formulate questions to use in the qualitative, observational, and experiential inquiry and is therefore very applicable in the formulation of questions about perceptions, experiences and barriers (Booth et al., 2019; Methley et al., 2014). The PEO model takes into account the Population, Exposure and Outcome of interest and offers an organized approach to the generation of search terms which are elaborated in Table 1 below.

Table 1: PEO Framework for Research Question Development

 

PEO Element Definition Application to this Review
Population (P) The group of interest in the review Adult patients (≥18 years) in hospital or associated care settings (acute wards, long-term care facilities, integrated community care)
Exposure (E) The condition, context or circumstance being examined Nursing involvement in pressure ulcer prevention and management, including risk assessment, care planning, repositioning, skin inspection, and patient education
Outcome (O) The area of interest regarding the population’s experience or status Perceived challenges and barriers experienced by nurses in delivering pressure ulcer prevention and management

 

Qualitative Approach

The question, “What are perceived as the challenges and barriers to preventing and managing pressure ulcers in hospitalised adults and related care settings serviced by the nurses”  was answered by using the qualitative research method only. The qualitative research will attempt to understand the human phenomena which offer descriptions and explanations of these phenomena in detail (Lim, 2025) explaining the ‘why and how’ of research phenomenon. The qualitative method has depth at its forefront and the participants’ viewpoints at the core (Chivanga & Monyai, 2021) in relation to their lived experiences in specific institutional setting in respective country. Critically, qualitative research study has been acknowledged that qualitative literature reviews may not be systematic and therefore, is less reliable evidence can be missed by chance and not through (rigorous means) which (Bryda & Costa, 2023) point out that rigour (sometimes termed as trustworthiness) can be attained by transparency and reporting of the systematic process adopted.

 

1.3 Research Question

The literature review question is: ‘?’

The question is formulated based on the PEO (Population, Exposure, Outcome) framework, which is especially suitable to qualify or experience-based investigation (Booth et al., 2019). The Population in PEO, consists of adult patients (18 years and above) in hospital or other related care facilitiessuch as acute wards, long-term care, and integrated community care facilities with links to hospitals. The Exposure in PEO, means the engagement of registered nurses in the prevention and management of pressure ulcers along with their clinical duties, decision-making and care delivery. The Outcome in PEO includes the perceived difficulties and obstacles faced by nurses in accomplishing these roles.

 

2.4 Search Strategy

2.4.1 Databases Searched

A total of five academic databases were searched in a systematic way so as to cover a representative and complete identification of the relevant literature. The databases chosen were CINAHL (Cumulative Index to Nursing and Allied Health Literature) (Dhippayom et al. 2023), PubMed/MEDLINE (Jin, Leaman, & Lu, 2024), Scopus (Kumpulainen & Seppänen, 2022), Web of Science (Szabó et al. 2025), and the Cochrane Library. They were selected based on different reasons. CINAHL is the largest database of nursing and allied health literature, which provides a wide range of coverage of peer-reviewed journals pertinent to the clinical practice of nursing, and it is always advised when conducting a literature review of nursing (Wright, Golder and Lewis-Light, 2015). PubMed/MEDLINE offers a wide scope of biomedical and clinical research and can be actively involved in the review of the health sciences (Bramer et al., 2017). Scopus and Web of Science are multidisciplinary databases that provide citation monitoring and access to international peer-reviewed literature in health and social sciences that allow a broader search of the relevant literature (referenced). Background information on systematic reviews related to the pressure ulcer care was searched in Cochrane Library, because Cochrane reviews did not receive priority in the appraisal chapters as primary sources (Yang et al. 2025). This is in accordance with the methodological approach of this review.

It is also within the scope of best practice advice of literature reviews in nursing to limit the search to specialist nursing and health databases (Coughlan and Cronin, 2021; Beecroft, Booth and Rees, 2015). CINAHL combined with MEDLINE in particular has proven to provide the best coverage of nursing-related issues (Bramer et al., 2017). They did not restrict the search to full-text articles initially because it would limit significant published work to the search (Aveyard, 2023), but full texts were acquired later to all studies included in the search.

2.4.2 Search Terms and Boolean Operators.

The search terms were made based on the components of the PEO framework and utilized to ensure cohesive and consistent searching in databases. Concepts were combined with the help of Boolean operators (AND, OR) and truncated (truncation) with the help of the special sign (Coughlan and Cronin, 2021; Whitehead and Maude, 2016). The key search terms used are summarised in table 2 below.

Table 2: PEO-Based Search Terms

PEO Element Search Terms
Population *hospitalised adults* OR *adult patients* OR *acute care* OR *hospital settings* OR *long-term care* OR *community care settings*
Exposure nurs* OR “nursing staff* OR *registered nurses* OR *pressure ulcer prevention* OR *pressure injury management*
Outcome barrier* OR challenge* OR perception* OR obstacle* OR attitude* OR experience*

 

Terms like nurse, barrier, challenge, and hospital were truncated to ensure that a variety of grammatical forms and variations is represented and the search is not limited unnecessarily. The retrieval of synonymous terms in each PEO element was broadened by the application of Boolean operator expanding the search output impacting the research scope and select relevant research article for selection.

2.5 Inclusion and Exclusion criteria.

Table 3: Inclusion and Exclusion Criteria

Inclusion Criteria Exclusion Criteria
Studies focusing on registered nurses involved in pressure ulcer prevention and/or management Studies focusing primarily on non-nursing staff (e.g., healthcare assistants, domestic workers, students) where nurses’ perspectives are absent
Studies conducted in hospital or hospital-associated care settings (acute wards, long-term care facilities, rehabilitation units, integrated community care with hospital linkage) Studies conducted in settings where organisational type defines hospital care (e.g., home-only, community settings without hospital linkage)
Studies involving adult patients aged 18 years and above Studies focused solely on pediatric or neonatal populations
Studies exploring perceived challenges, barriers, attitudes, or experiences of nurses in relation to pressure ulcer prevention and/or management Studies examining clinical effectiveness of interventions only, without exploring nurse perspectives or barriers
Primary empirical research (qualitative, quantitative, or mixed-methods designs) Opinion pieces, editorials, conference abstracts, letters, and grey literature
Peer-reviewed journal articles published in English Non-peer-reviewed publications and those not available in English
Studies published between 2018 and 2025 Studies published before 2018, except where cited for contextual background in Chapter 1
Studies for which full text is available Studies where full text is unavailable after attempts to retrieve via interlibrary loan

 

Search Strategy limitations.

The search strategy has a number of limitations, which should be mentioned. To begin with, the limitation of the search to English-language publications might have caused the elimination of other pertinent studies (Aveyard, 2023). Second, date limitation (2018-2025) was used; to guarantee the recency and relevance to the modern practices, but omitting outdated, yet valuable studies.

 

 

PRISMA

 

New studies included in review

(n =0 )

Reports of new included studies

(n =0 )

Identification of new studies via databases and registers
Screening

 

Records screened

(n =321)

Records excluded

(n =231 )

Reports sought for retrieval

(n = 90)

Reports not retrieved

(n =0 )

Reports assessed for eligibility

(n = 90)

Reports excluded:n=85

Reason 1 Studies are not on core topic (n =22 )

Reason 2 Study was not Cochrane (n =31 )

Reason 3 No adult end of life pain experiences  (n = 32)

etc.

Studies included in previous version of review (n = 321)

 

Previous studies
Total studies included in review

(n =5 )

Reports of total included studies

(n = 5)

Included
Identification
Records identified from*:

Databases (n = 4)

MEDLINE (n=111)

CINHAL (n=51)

APA PsychInNFO (n=109)

Academic search (n=50)

Records removed before screening:

Duplicate records removed  (n =106 )

Records marked as only abstracts (n =25 )

Records removed as non english (n =10 )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This two-step procedure is aligned with the method suggested by Page et al. (2021) in the new PRISMA (Preferred Reporting Items to Systematic Reviews and Meta-Analyses) instruction of how to conduct literature searching in a structured manner.

 

 

 

2.6 Study Selection Process

The selection of the study was carried out in two phases. During the initial step, all of the retrieved records were filtered by screening their titles and abstracts based on the inclusion and exclusion criteria. At this point, records that were obviously not relevant were excluded. The second stage involved obtaining and evaluating the full-text of the potentially eligible studies against the same criteria. Causes of omission at the full-text level were recorded.

Included studies were also screened on reference list and any other study identified during this process was then evaluated against the inclusion criteria. After this, five main empirical studies that fit all inclusion criteria were identified and were chosen to undergo critical appraisal in Chapter 3. Table 4 below summarizes all these five studies.

Table 4: Summary of Included Studies

Author(s) & Year Country / Setting Design Sample Focus
Taylor, Mulligan & McGraw (2021) UK – Integrated community care (London NHS Trust) Qualitative; TDF-informed semi-structured interviews 9 registered nurses, 4 allied health professionals Barriers and enablers to evidence-based PU prevention and management
Li, Marshall et al. (2022) China – Large tertiary hospital (Beijing) Qualitative descriptive; SEIPS model; semi-structured interviews 27 registered nurses Nurses’ approaches to and factors influencing PU prevention
Na, Yoo & Kweon (2024) South Korea – Long-term care facilities Interpretive description; semi-structured interviews 10 registered nurses Nurses’ experiences of pressure sore care in LTCFs
Sim, Choi et al. (2024) Singapore – 3 tertiary hospitals Multicenter qualitative; grounded theory; interviews and focus group discussions 10 inpatient nurses (+ 10 caregivers) Conceptual framework of barriers to pressure injury prevention
Oozageer Gunowa, Adomako Kwame & Jackson (2025) UK – Community nursing (South of England) Qualitative descriptive; focus groups and individual semi-structured interviews 17 community registered nurses Nurses’ experiences assessing early-stage PIs in people with dark skin tones

 

 

2.7 Critical Appraisal

The systematic evaluation of the research evidence used to identify its quality, rigour and relevance and it is a vital part of any evidence-based literature review (Aveyard, 2023; Tod, Booth and Smith, 2021). To conduct this review, Critical Appraisal Skills Programme (CASP) checklists were chosen as the most popular appraisal tools. Kryshtafovych et al. (2023) argued that CASP they have become widely used in nursing research, are accessible to both undergraduate and postgraduate nursing students, and can be used for various types of studies. CASP provides checklists to assess qualitative studies, cohort studies, and any other research design separately, allowing an appropriate methodological assessment of each study included (CASP, 2018). Each of the five included studies utilised a qualitative design (four with predominantly qualitative methods and one (Sim et al., 2024) with a multicenter qualitative grounded theory design) and all were assessed with the CASP Qualitative Checklist. It is advisable to use a standardized and methodology-internalized appraisal tool as a best practice to make sure that the standards used are suitable to the nature of the evidence under appraisal (Majid and Vanstone, 2018).

 

 

 

Chapter Three

 

Study 1: Taylor, Mulligan & McGraw (2021) – Barriers and Enablers to Evidence-Based Practice in Pressure Ulcer Prevention and Management in an Integrated Community Care Setting

Research Issue, Aim and Objectives

Although both international and national clinical guidelines on prevention and management of pressure ulcer (PU) exist, there is evidence that reflects that such guidelines are poorly implemented in community healthcare. This implementation gap is a major issue of patient safety, and is part of preventable harm, higher treatment costs and longer hospital stay. Taylor, Mulligan, and McGraw (2021) fill this gap by discussing the reasons why evidence translation to practice continues to be an issue in integrated community care. The main objective was to understand some perceived barriers and enablers of health practitioners in implementing evidence-based PU prevention and management recommendations. The goal was to come up with practical insights that could be used to guide specific improvement efforts on both service and policy levels.

Research Appraisal

The conceptual foundation of Theoretical Domains Framework (TDF) is a highlight of the study in terms of methodology (Lawton et al. 2015). The TDF is based on 33 behavioural theories and consists of 14 domains, and offers a lens of theoretical and empirical validity to study the cognitive, affective, social, and environmental factors in clinical behaviour (Atkins et al. 2017). Birken et al. (2017) stated that its use takes the analysis beyond the surface description elements to explanatory level- a step in the right direction in comparison to the antecedent atheoretical studies in the field. The two-method analytical strategy, which uses deductive TDF-informed coding and inductive belief statement generation, introduces analytical rigour and makes the results always based on the meaning of the participants.

Research Appraisal

The qualitative exploratory design was utilized and data were collected by semi-structured, face-to-face individual interviews using a topic guide, informed by TDF (Phillips et al 2015). The guide was pilot tested using three practitioners who had similar characteristics with the targeted sample and then refined. Each interview lasted 25-35 minutes and was audio-taped and transcribed word-to-word. Braun & Clarke (2022) stated thematic analysis which was conducted in a five-step process that was systematic and included deductive coding, development of belief statements, calculation of frequency, independent verification and determination of domain relevance, though it also is criticised from lacking in depth, research rigour impacting outcome findings quality (Vaismoradi et al. 2013). After thirteen interviews, data saturation was achieved.

 

Sampling and Selection

The sampling technique used was purposive, where the registered nurses and allied health professionals (occupational therapists and physiotherapists) were recruited in this study, which has also been seen (Roots & Li, 2013). It was based on the locality NHS Trust-based extended primary care teams within the locality. There were 9 nurses and 4 therapists. Healthcare assistants had to be excluded considering their different accountability obligations. An a priori saturation criterion was used to select sample size based on the Francis et al. (2010) framework. However, sample meets the critical criteria of over 12 respondents which (Vasileiou et al. 2018) critically justified in health research, thereby meeting the use of theory in a qualitative research (Collins & Stockton, 2018).

Research Ethics

City, University of London School of Health Sciences Research Ethics Committee approved the study and provided extra supplementary NHS governance approval. The sample was led to participate at will, and informed consent upon every interview in writing was obtained. The first author, who is a specialist in tissue viability and is a nurse in the organisation, was keen to avoid researcher bias and, therefore, did not include skin care champions in the sample because they have a direct professional relationship with her service.

Study 2:Li, Marshall et al. (2022) Approach to Pressure Injury Prevention: A Descriptive Qualitative Study

Although China reported much lower levels of hospital-acquired pressure injury (HAPI) prevalence rates (1.1 to 1.8 percent) compared to those in the global rate (12.8 percent), the reasons behind this difference are not well comprehended, and inconsistent rates of adherence to prevention measures continue which is the main research problem. Li, Marshall et al. (2022) is the first reported qualitative research study on the subject of pressure injury prevention (PIP) practice in registered nurses in mainland China. Research by Li et al. (2022), described the ways in which nurses approach PIP, such as their perceived roles and the prioritisation of prevention. In this research, along with contextual factors, in a Chinese tertiary hospital context, the research goal is to produce knowledge that can be used to inform future practice enhancement based on theory and evidence.

Research Appraisal

The fact that the model of the Systems Engineering Initiative of Patient Safety (SEIPS) is used to both collect and analyze data is a significant strength of a study (Sampson, Back & Drage, 2021). Carayon et al. (2006) argued as it gave the strength to the research a logical coherent framework by which to analyze the work processes, structures, and outcomes in the form of a systems-level analysis. The theoretical foundation brings the study to greater heights compared to macro and micro level interpretation of PIP care delivery. Analytical depth is also enhanced by the fact that both the deductive and inductive content analysis was used which (Graneheim, Lindgren, & Lundman, 2017) argued to bring in more abstraction and interpretation about research dimensions happening in reality. Nevertheless, single-site recruitment causes a lack of transferability, and the 100 percent female sample reduces the gender diversity which (Magliozzi, Saperstein, & Westbrook, 2016) argued to undermine the outcome quality of research.

Research Method

The design was qualitative descriptive. Semi-structured interviews were held in Chinese, usually face to face, via audio recordings, during the period of August 2020 to December 2020. Three PhD-qualified experts reviewed and piloted a SEIPS-informed 10 question interview guide. Content analysis was performed by iterative deductive-then-inductive analysis and managed in NVivo 11 to analyse data. This approach was similarly used by (Li et al. 2022), while the aspect of research rigour was ensured using credibility, transferability and auditability strategies such as memo keeping and team reflexivity (Wood, Sebar, & Vecchio, 2020).

Sampling and Selection

In this research a small sample of two medical and two surgical wards, stratified by role, experience level, and PI training history, in a large Beijing tertiary hospital, were used as maximum variation purposive sampling, to recruit 27 registered nurses. Smetana et al. (2006) had similar arguments in American college of physicians.

Research Ethics

The hospital involved provided dual ethical approval (IRB No.2020/003) and Griffith University (GU Ref No. 2020/466). Informed consent was obtained on written consent before every interview and confidentiality was achieved by de-identifying participants which met the participation perspective as highlighted by (Alhabsi, 2024).

Study 3:Na, Yoo & Kweon (2024)

Investigating the Nurses experience of pressure sore treatment in long-term care facilities.

Research Issue

Na, Yoo & Kweon (2024) research set in South Korea, in particular, intensive growth of LTCFs, has not been accompanied by the respective enhancement in the care quality, which generates the urgent necessity to conduct empirically supported, context-specific research on the lived professional realities of nurses.

Aim and Objectives of the research.

The main objective of the study is to reveal the variations and issues facing nurses in pressure ulcers management in South Korea, in the long-term care facilities. The research purpose is to produce a more contextually grounded, in-depth insight into nursing experiences in this field. Watson et al. (2025) acknowledged the critically understanding issues, research methods and contextual factors are important, which (Zou & Zhai, 2026) emphasized in developing specific, evidence-based interventions to enhance nursing practice and patient outcomes. The objective is suitably sized to a qualitative investigation, focusing on the depth of knowledge rather than statistical generalisation which have been studied in nursing homes in Korea (Lee, Kwon, & Chang (2022) that extended care procedural challenges in different setting.

Research Method

A qualitative methodology with an interpretive description design was used, as it was appropriate to the study due to its abilities to bring complexity, nuance, and practicality into applied healthcare settings for understanding the variations and issues facing nurses in pressure ulcers which has been used (Lindhardt, Beck, & Ryg, 2020), (Lavallée et al. 2018) . This qualitative method allows flexibility in data collection and analysis, and allows indepth exploration of issues (Chen et al. 2025) that the current researcher has captured iteratively and context-sensitively experiences of the participants. The data collection was through individual interviews that were semi-structured and lasted an average of 60 to 90 minutes. Due to COVID-19 restrictions, 7 interviews were performed in-person, and 3 by telephone, and the rest of the sessions were discussed with the participants by telephone to balance the lack of visual effects. This is a limitation of the research, with low sample size as discussed by (Crouch, & McKenzie, 2006), but pertinent as study setting and context was unique which was also highlighted by (Lee et al. 2023). The analysis of the data was conducted according to six stages of the reflexive thematic analysis provided by Braun and Clarke, with two trained coders analysing the data under the supervision of the researcher to result in higher reliability and less interpretive bias. The research based on the study followed the COREQ reporting rules, enhancing research transparency in its methods, which (Walsh et al. 2020) argued is a best practice for qualitative research adherence.

Sampling and Selection

To sample ten registered nurses in four small-to-middle sized LTCFs in South Korea, purposive sampling with snowball referral was employed. Participants had to have at least a year of clinical experience in pressure sore care and nurse managers were excluded to ensure their attention was limited to frontline views which (Na, Yoo, & Kweon, (2024) acknowledged about how long term study and cross sectional study that adds value. There were three males and seven females in the sample, aged 26-44 years, with a clinical experience of one or up to eighteen years. Eight were employed in the general wards, one in a surgical ward, and one in an emergency department. Critically appraising the research, it is evident that though the sample size is small, it is in line with the qualitative paradigm. The emphasis in on the information depth and not numerical range and the snowballing approach was suitably used to exploit the available professional networks. This research showed how to get nurses with substantive and relevant experience which (Manthorpe & Martineau, 2017) argued is important to understand failures of pressure ulcer problems.

Research Ethics

The IRB of Chonnam National University gave formal approval to the study (IRB No. 1040198200619-HR-066-01), and the study was conducted in compliance to the Declaration of Helsinki. All the participants were informed and provided consent after a thorough explanation of the purpose of the study, study procedures and risks involved. Participation was verified to be purely voluntary and the right to withdraw is at any point without consequence was granted. The audio-recorded interviews were transcribed with the help of the Google Speech-to-Text software and after that the accuracy was checked though research ethics ensured participant anonymity. Past research on patient safety in Korean context for nurse experience (Kim, & Lee, 2020), showed that ethics for institution, patient, caregiver is critical. The anonymity and confidentiality were strictly ensured by encrypting the data and de-identifying it. Interviews were conducted in a supportive, empathetic manner in order to cope with emotional distress that may arise. Ethical respect these were given a gift voucher of KRW 20,000 conditionally irrespective of whether they participated in the interview or not.

 

Study 4:Sim, Choi et al. (2024)- Why Do Pressure Injuries Still Occur? A Multicenter Qualitative Study of Nurses and Caregivers

Research Issue, Aim and Objectives

Sim et al. (2024) carried out the study in three tertiary hospitals in Singapore to examine the lived experiences of nurses and caregivers to develop a conceptual framework that elucidates how pressure injuries ever occur, even with preventive measures. The goal was to determine the interacting barriers to care and create evidence-based solutions to be used by the healthcare institutions that was reported (Naghibi, Mohammadzadeh, & Azami-Aghdash, 2021) and (Duncombe, 2018) in a multi institutional context studies.

Research Appraisal

The most notable contribution of this research is the development of the framework that includes cognitive, emotional, resource, biomedical, sustainability, and learning constructs into a coherent explanatory model that was also noted in (Kim et al. 2016) preparing a biopsychosocial framework. The use of grounded theory to base the analysis boosts conceptual rigour and the use of both caregivers and nurses to give the analysis both perspectives. The current research also refers to (Taylor, Mulligan, & McGraw, 2021) study where community care setting, using evidence based practice. are seldom studied together gives the analysis significant triangulation value. The authors state, though, that the findings might be limited in generalisability to other contexts of mixed public-private and highly subsidised healthcare settings in other countries like Singapore that corresponds to earlier study where perceptions about challenges was explored (Chen et al. 2025).

Research Method

The qualitative design was a multi-center design that used semi-structured individual interviews and focused group discussions. This approach was also reported by (Roberts et al. 2016), which tested prevention care bundle. Current research carried out face-to-face in three hospitals in February to July 2023. A narrative inquiry approach was used to collect the data which were analysed using grounded theory with the ATLAS.ti software and through multiple iterative open, focused and axial codes until theoretical saturation which was similarly found in research work of (García-Sánchez, Martínez-Vizcaíno, & Rodríguez-Martín, 2019). The research was in accordance with COREQ guidelines which has been a best practice approach followed in (Hultin et al. 2022).

Sampling and Selection

Ten inpatient nurses having more than one year experience and ten community caregivers were selected by purposive sampling, word-of-mouth. Saturation occurred in line with the qualitative dermatological literature standards of participants.

Research Ethics

The National Healthcare Group Domain Specific Review Board gave its ethical approval (reference 2022/00470). Informed consent had been received in writing by all the participants before the data was collected.

Study 5: Oozageer Gunowa, Adomako Kwame & Jackson (2025)

Oozageer Gunowa, Adomako Kwame & Jackson (2025) research aimed to understand the capacity to effectively evaluate the presence of the early stages of pressure injuries in patients with dark skin colour. The issue in a larger discussion on health equity, racial bias in medical education, and avoidable patient harm but pertinent issue applicable in any country with mixed population as (Black et al. 2023) (Sugathapala et al. 2025)  and combination of both dark-light skin tones (Zamarripa, 2021). The argument is quite justified, as pressure injuries are expensive, disabling, and increasing in number, but the current body of research on the experiences of nurses in the field almost completely excludes the aspect of skin tone diversity, a structural gap with direct patient safety consequences. The main purpose is to investigate the experiences of community nurses regarding working with people with dark skin color that are at the risk of pressure injuries which has been researched before (Gunowa, Oti Adomako, & Jackson, 2025). This goal further elaborates this purpose by aiming at defining the issue of particular challenges, best practices, and areas of improvement in the clinical assessment about the contextual challenge in terms of application methods against nursing challenges (Kottner et al. 2020) (Bates‐Jensen et al. 2019). They are sufficiently scaled to a qualitative inquiry – they are not confirmatory, but exploratory, and do not aim at generalisability, but at depth of understanding, which is appropriate methodologically in the adopted design.

It used a qualitative descriptive design based on the Consolidated Criteria of Reporting Qualitative Research (COREQ), which provides procedural clarity to the study which was also found in research of (Li et al. 2022) using same methodology. The registered nurses employed in the District Nursing Teams in the South of England were recruited through purposive sampling because it is a methodologically adequate approach in the circumstances where the target population was very specific. Among the 22 enquiries that were received, 17 individuals were eligible to participate in the research, which is all women, which is an important demographic attribute of the nursing workforce in this area. The adequacy of sample size over 12 has been maintained in this research meeting (Crouch, & McKenzie, 2006). Between November 2023 and March 2024, data were gathered using a mixture of three online focus groups (3-6 each) and six 30-minute to one-hour semi-structured interviews, though studies (Nixon et al. 2015) exist in the context using mixed research. This blended media provided the group discussion with interactive quality and the richness of personal reflection. Past research on the topic of skin tone diversity and pressure injuries in educational institutions was used to inform the interview guide in its theoretical basis. The verbatim transcripts were analyzed using thematic analysis by the six-phase framework by Braun and Clarke (2006). Research ethics showed that act of rigour was strengthened by the credibility, transferability, dependability and confirmability criteria of trustworthiness used by Lincoln and Guba (1985) coupled with an audit trail, reflexivity practices and member checking of the findings at the end of every interview.

 

 

Chapter 4: Synthesis

4.1 Discussion

Qualitative research synthesis plays a pivotal role in the determination of efficient and proper healthcare system. It entails the ability to be strategic using a combination of various information in the midst of a central theme in order to solve problems and get answers.

The review incorporated four qualitative researches by study 1: Taylor, Mulligan & McGraw (2021), study 2:Li, Marshall et al. (2022), study 3:Na, Yoo & Kweon (2024), study 4:Sim, Choi et al. (2024), study 5: Oozageer Gunowa, Adomako Kwame & Jackson (2025) which examined the lived experiences. Three studies included were all in English, and published within the past 10 years.

Appendix 4 helped to compare the relation of the papers to each other and simplified approach to thematic analysis has been used in Appendix 5 and and 6 (Aveyard, 2023), which identified several themes and developed four major themes:

In the analysis below, the research findings of five studies, covering a wide range of geographical and clinical settings such as community care in London, tertiary hospitals in China, long-term care facilities (LTCFs) in South Korea, and home-based care in Singapore and England, are synthesised. Using multiple theoretical frameworks (Theoretical Domains Framework (TDF), the System Engineering Initiative of patient Safety (SEIPS), and Grounded Theory these studies find that there is a complicated combination of professional, systemic, and social variables that affect the effectiveness of prevention and management of pressure injury (PI).

Theme 1: The Centrality of Nursing Leadership and Professional Identity

Registered nurses (RNs) are all considered the main coordinators and leaders of pressure injury prevention (PIP). The Chinese tertiary environment provides nurses with the leadership of the work system, where they make the most crucial decisions connected with the assessment of risks, the execution of measures, and the record-keeping. On the same note, community nurses in the UK regard PI care as a massive component of their daily practice, and they apply models such as ASSKING to plan their interventions. South Korean LTCFs, nurses believe that PI care is the highest level of nursing achievement and tend to think that they are the only responsible member of the team, even when other personnel are also involved. This was found in other studies (Galvão et al. 2017) Nonetheless, this leadership requirement is usually stretched by the upsurge in responsibilities to allied healthcare professionals (AHPs), who occasionally feel unprepared or uneasy with intimate checks. This was highlighted in past research (Worsley et al. 2017), which has been discussed (Ackbarally, 2024), like in the UK research. Therapists complained they were embarrassed at the time of skin checks, while (Sarre et al. 2019) showed in longitudinal study of teams at ward level is able to find better treatment outcomes.

Theme 2: Gaps in Undergraduate Education and Specialized Knowledge

One of the key conclusions is the inseparability of formal education to equip clinicians with the nature of PI care. In the UK, AHPs indicated that their undergraduate training lacked PI content, and therefore they rely on asking a colleague instead of consulting some official guidance. This is reflected even in South Korea, where the novice nurses said that they felt bewildered when presented with severe ulcers, that there was no practical training in the nursing colleges. The greatest educational lapse is seen to be in the treatment of dark-skinned populations. This research in England, medical literature and nursing programmes is more or less white-centric, which is why community nurses are unable to identify any early signs of damage, including non-blanchable erythema. Lo et al. (2025) study stated that ability of nurses observe pressure ulcers in diverse skin tones, as they appear as ashy-grey or purple tones instead of red when occurring on darker skin bringing out the gap, which (Black et al 2023) acknowledged in nursing training and treatment process as a gap. This means that dark-skinned patients usually are diagnosed in their later stages (Category 2 or higher) due to missed early warning signs.

Theme 3: Systemic Barriers: Staffing, Resources, and Environmental Constraints

The organizational and physical environment is a determinant of quality of care. Understaffing and workloads in Singapore and China are mentioned as the main negative factors to the implementation of time-consuming clinical activities such as two-hourly repositioning. The research points to the effect of desensitization, in which nurses (due to chronic understaffing) begin to provide care in a more robotic way, or even abandon more complex cases because of time constraints. Wong et al. (2024) stated that outside of staffing, the availability of resources differs greatly, with Singaporean caregivers getting government subsidies on equipment. The Chinese nurses in hospital wards noting lack of special support surfaces and prophylaxis, which are often limited by insurance laws also highlighted by (Wong et al. 2019). The physical home setting, in the context of UK communities, which was also found in Singapore (Goh, & Zhu, 2024), brings forth distinct challenges, including the issue of “clutter” within the home of patients, thus preventing the installation of a hoist or even providing sufficient space to perform skin checks.

 

Theme 4: The Reinforcing Feedback Loop of Caregiver Participation and Learning

Caregiver-nurse partnership is linked with the efficacy of PIP in community and home-care settings. The Singaporean study suggests a model in which cognitive awareness and emotional motivation are the driving forces of a learning cycle. Caregivers might be unaware of the severity of PIs until an infection sets in, in which case it creates a reinforcing feedback loop of learning and commitment that has been discussed by (Chen et al. 2025). In China, family presence is guaranteed by the culture of filial piety but these lay carers do not always have the professional knowledge to recognize early skin changes. Family members were found to play both enabling roles (as eyes and ears) and inhibiting roles (denying recommended equipment) which was discussed by other studies (Haesler et al. 2022). The main idea of all the studies is that caregiver training should not be reduced to a one or two days before discharge strategy to make it sustainable in the long-term, that was highlighted in earlier study of (Jafari et al. 2021) who found that in order to avoid the occurrence of the same thing at home knowledge sharing is important.

 

Theme 5: Clinical Judgment vs. Standardized Risk Assessment Tools

 

One of the common arguments is the restrictiveness of standardized instruments such as Braden or Waterlow. Results in China, though structured risk assessments are required, nurses have to be very dependent on the so-called clinical judgment, which takes into account other variables like the nutritional status, disease frailty that a tool could not capture. In UK, other clinicians described their experience of automaticity in PIP care in which PIP is now more of a routine and not an act of conscious decision making. On the other hand, lack of this experience among individuals will compel them to use unclearly outdated guidelines in LTCFs, which drives them to look up information on the internet or via Naver (the Korean Google). It was reported by (Gubert, 2025), and in USA (Crowley et al. 2022). It is thus making the practice inconsistent and potentially old fashioned that was raised by (Giovenco, 2021) as COVID19 disruption required towards adopting holistic care as found by (Jackson, Turner, & Paterson, 2023). This is further complicated by the studies on dark skin colour, which point out that currently used tools which measure redness are inherently ineffective with varied populations (McCreath et al. 2016) citig Munsell colour charts, or use of Bates‐Jensen wound assessment tool as per (Bates‐Jensen et al. 2019), or adopt a framework combining tool and technology as per (Toner , 2024) that a change to palpation (assessing warmth and oedema) and the use of terms such as discolouration is necessary.

Theme 6: The Emotional and Psychological Burden of PI Care

Nurses in the profession, specifically in these studies report an intense emotional impact relating to PI (personal injury) outcomes. In the UK and South Korea, nurses experienced a range of ambivalent feelings, which include guilt and self-blame when an ulcer became worse despite their efforts. It is reported that there is a fear of being judged by colleagues or the management, especially in China and the UK where PIs are regarded as a never event, or severe safety incident (Wickramasekera, 2025) that is treading thin line in ethical practice and ethical reporting. Zhao et al. (2025) highlighted this fear may result in under-reporting or concealment of possible PIs because of the need to safeguard the collective honour of the ward. There needs open disclosure with truth as per (Saleh, J. (2023), on the other hand, a PI healing is a great form of accomplishment and professional pride, and it confirms the nurse to the patient.

 

 

 

  1. Conclusion

The aggregate results suggest that reducing the global burden of pressure injuries requires more than just clinical guidelines. These international studies collectively show that prevention of pressure injury (PIP) is a multidimensional health care problem that requires a paradigm shift of treatment focus toward a system-wide prevention approach.  Although registered nurses are invariably seen as the keystone of the PIP work system, the interaction of cognitive awareness, emotional motivation, and physical resource availability are critical modulators affecting their success.  The results indicate that there is a critical gap in educational preparation in the world we currently live in with an emphasis on light skin colour and standardized testing instruments having created a gap in scientific training making clinicians unprepared to work with people of divergent backgrounds.  Moreover, the physical and organizational context, such as persistent understaffing in hospitals or “clutter” at home, is a major factors influencing the successful implementation of evidence-based guidelines in practice.  Finally, pressure injury care is justified as the highest goal of nursing, which demanded a complex of clinical and technical expertise, as well as a strong collaboration with other health care experts and family caregivers.

 

5.1 Implications for practice

The implications of these findings on the nursing profession and even healthcare systems at large is that there will have to be an urgent reformation of the undergraduate and continuing education program to integrate the diversity of skin colour into the curriculum so that clinicians are taught to detect the presence of early-stage damage by palpating the skin and recognising the presence of non-red discolouration like ashy grey or purple skin colour.

. Implementation of specialized roles including Pressure Ulcer Implementation Facilitators has been found to help heal the gap between theory and practice on the front lines and thus should be given priority by healthcare organizations.

. Also, the concept of caregiver training needs to be redesigned as a longitudinal process, not a short pre-discharge training but may be facilitated by digital health devices and education apps offering real-time support to lay carers at home.

. At the clinical level, clinicians should be advised to add clinical judgment to established risk assessment measures and pay more attention to such aspects as nutritional state, the vulnerability of the disease, and skin texture alterations.

. Lastly, to enhance patient safety, organizations should cultivate a non-punitive reporting atmosphere that alleviates the emotional weight of guilt and fear of being judged so that all injuries are openly recorded and used to learn together.

..

5.2 Recommendations

  1. Educational Reform: Incorporating skin tone diversity and practical PI management into undergraduate curricula for both nurses and AHPs.
  2. Structural Support: Addressing understaffing and providing novel roles, such as the Pressure Ulcer Implementation Facilitator seen in the UK, to bridge the gap between theory and practice.
  3. Technological Integration: Utilizing mobile working solutions and tele-support to enhance documentation and real-time troubleshooting in community settings.
  4. Empowering Caregivers: Developing targeted, culturally sensitive educational interventions (such as educational apps) to support the sustainability of home-based care.

By addressing these themes, healthcare systems can move from a reactive treatment model to a proactive, inclusive, and sustainable prevention paradigm.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#UK, #nursing, #academicwriting, #dissertation, #Bachelors, #Masters, #Ireland, #Scotland, #Healthcare, #Publichealth 

In adult patients receiving end-of-life care in community settings, how effective are anticipatory medication-based pain management approaches, including clinician- and carer-led administration, in improving pain relief and symptom control compared to usual care?

 In adult patients receiving end-of-life care in community settings, how effective are anticipatory medication-based pain management approaches, including clinician- and carer-led administration, in improving pain relief and symptom control compared to usual care?

 In adult patients receiving end-of-life care in community settings, how effective are anticipatory medication-based pain management approaches, including clinician- and carer-led administration, in improving pain relief and symptom control compared to usual care?

 

Abstract

I- The pain management especially for the patients with the end of life remains a clinical challenge presenting a critical dimension where anticipated prescription with injectable medication to be I mean best practice followed in UK, New Zealand, Australia for symptom control.  The background research contributes to a diverse research studies and effectiveness of clinician LED administration while the question remains about Kerala administration of pain relief outcomes for palliative care in adult patients in residential care settings that is yet to be researched. The main aim of this research is systemically examine in order to evaluate how anticipatory medication approaches health pain relief in adults for symptom control compared to the usual hospital care.

M-The current research followed a systematic secondary research reviewing the articles is in different databases like midline Cochrane Library within 2015 to 2024 timeline the use of PRIMSA and synthesis through ‘thematic analysis’, have helped inclusion exclusion criteria to narrow down into select journals meeting the end of life adult population criteria, community setting, measurable pain and symptom outcomes.

R-The studies met the inclusion criteria and using different research method like -mixed method of design, qualitative research, it was found that anticipatory medication prescribed to 5165% of adult dying patient reflected moderate effectiveness in terms of symptom relief. But there was significant delay in the administration in the home environment that was captured which points to carer efficiency when compared to hospital based system raising the concern of training adequacy resource availability and the psychological readiness .

A- The thematic analysis diverged into  streams ‘’ Rapid Innovation and Systemic Adaptation During Global Crisis, Professional Decision-Making: The GP as Gatekeeper and Consultant, Patterns of Frequency, Timing, and Clinical Predictors, The “Simultaneously Reassuring and Unsettling” Patient Experience, Barriers to Medication Administration and Caregiver Burden, Economic Inefficiency and the Paradox of Standardised Wastage, Safety Concerns and the Risks of Advance Prescribing’’.

D-The prescribing patterns from the above research showed standardized approach rather than individualized that could have generated paradoxical economic waste of time and effort leading to unmet clinical needs. The patients and the caregivers have experienced existential distress but the caregiver burden intensified when successive barriers emerged in the process especially ‘out of hour’ period.  The advanced prescribing for the patient safety risk please tell me the clinical oversight and the need for adopting, person centric anticipatory care framework especially when each patient condition differs .

Abbreviation Full Form
ACP Advance Care Planning
AP Anticipatory Prescribing
ARC EoE Applied Research Collaboration East of England
ARDS Acute Respiratory Distress Syndrome
BNF British National Formulary
CAG Confidentiality Advisory Group
CARiAD CARer Administration of as-needed subcutaneous medication for common breakthrough symptoms in home-based dying people
CC BY-NC Creative Commons Attribution Non-Commercial
CI Confidence Interval
CNS Community/Palliative Care Specialist Nurse
CONS Palliative Medicine Consultant
COVID-19 Coronavirus Disease 2019
DN District Nurse
DNACPR Do Not Attempt Cardiopulmonary Resuscitation
DOC Doctor
EOL / EoL End of Life
GP General Practitioner
HCP Health Care Professional
HRA Health Research Authority
ICU Intensive Care Unit
IQR Interquartile Range
IRAS Integrated Research Application System
ITT Intention to Treat
NHS National Health Service
NICE National Institute for Health and Care Excellence
NIHR National Institute for Health Research
OR Odds Ratio
OTHER Other Professional Group
PELiCAM Palliative and End of Life Care Group in Cambridge
PPI Patient and Public Involvement
PRE Psychology Research Ethics (Committee Reference)
RCT Randomised Controlled Trial
SC Subcutaneous
SPCR School for Primary Care Research
TRAIN Palliative Medicine Trainee
UK United Kingdom
USD United States Dollar
UTI Urinary Tract Infection

 

 

CHAPTER One

 

BACKGROUND AND SIGNIFICANCE

In community‑based end‑of‑life care, pain management can be complex (Saunders et al. 2019). First, the growing need for community‑based palliative care reflects a preference for home‑based care and the need to ease hospital pressures (Dadich et al. 2023). Second, the reported gaps in timely and effective symptom relief when usual care involves reactive prescribing (Shaw et al. 2023), in which patients and families are unable to access needed medications, is a factor (Manias et al. 2019). Third, the increasing focus on anticipatory prescribing underlines the need for proactive medication planning, allowing clinicians and families to administer pain relief as needed (Bowers et al. 2019). Finally, increasing involvement of family carers in medication administration raises issues about safety, education and support (Gil-Hernández et al. 2024), and Mouna Sawan et al. (2025) argued that it is important to consider the balance of clinician‑led and family carer‑led approaches to medication administration in improving patient quality of life, dignity and comfort. Anticipatory medication‑based pain relief strategies include prescribing and preparing key medications in anticipation of common symptoms in end‑of‑life care (Bowers et al. 2024). This approach guarantees timely access to analgesics and other symptom‑relieving drugs for patients in the community, avoiding delays associated with reactive prescribing (Bowers & While, 2019). Anticipatory medication management strategies provide clinicians and carers with prescriptions, reducing the need for hospital visits and improving home‑care comfort (Kiiski et al. 2025). Clinician‑led administration offers expert oversight and ensures safe administration and protocol adherence, while carer‑led administration allows families, informal carers to administer immediate relief, promoting patient‑centred care (Alkhaldi et al. 2025). This research focusses on the end of life adult patients in the community care settings, and the effectiveness of the anticipatory medication based pain management approaches for pain control and relief.

Aim of the Literature Review          

The purpose of this literature review is to analyse current research about the effectiveness of research variable related to each other to lead to academic gap. In the current study, the literature review examines, anticipatory medication‑based pain management strategies in adults with advanced illness and end‑of‑life care in the community. The review aims to draw on peer‑reviewed research to highlight best practice, limitations and areas for improvement.

Literature review

Anticipatory Prescribing and Pain Management in End‑of‑Life Care

Anticipatory prescribing involves anticipating a patient’s needs for vital medications, preventing a delay in providing pain relief. Research indicates early access to prescribed analgesics enhances comfort and prevents emergency care in the community (Bowers et al., 2023; Bowers, Pollock, & Barclay, 2021). It also promotes coordinated care through patient‑centred care and palliative care standards as evident in England and Wales (Goodrich et al., 2026).

Clinician‑Led vs Carer‑Led Administration Approaches

Clinician‑administered doses offer professional oversight, leading to precise dose administration and adherence to safety protocols, potentially reducing medication errors (Bowers et al., 2021). In contrast, carer‑administered medication empowers families to provide timely symptom relief, promoting patient‑centred care and comfort (Quigley & McCleskey, 2021). Recent studies compare approaches and identify advantages and disadvantages, with clinicians providing safe care and carers facilitating responsive care and family support . (Bowers et al., 2023).

Community‑Based End‑of‑Life Care Models and Usual Care Comparisons

Community‑based care focuses on anticipatory prescribing and shared decision-making, compared to reactive approaches in usual care (Antunes et al. 2022). Evidence shows that anticipatory care decreases hospitalisations and enhances quality of life by addressing pain and distress early (Martin et al. 2019). These models show improved adherence to palliative care principles when compared to usual care, helping maintain dignity and autonomy in end‑of‑life care (Nnate, 2021).

Why Is This Important in Nursing?

Nurses are integral to end‑of‑life care, especially in the community where they are often the linchpin between individuals, families and the health system. Advance prescribing and administration of medications impact nurses’ roles in pain and symptom management and overall care. Nurses benefit from insights into the impact of clinician‑ or carer‑led strategies by individualising care, supporting families, and promoting medication safety. This empowers nurses, supports comfort and dignity for the patient, and provides support for family carers – leading to better palliative care in community settings.

 

1.2.  DEFINITIONS

End of life care-This is a 360 degree approach where the patients facing the final stages of their life cycle curve need a holistic care.

Clinician led administration- It is about medication delivery offered by trained certified professional staff who are categorized as healthcare professionals working in an organization.

Carer led administration- It is the procedure of medication offered to the patient by the nearest family members or informal caregivers.

Anticipatory prescribing – It is a method of proactive method of provisioning the medication even before the symptoms in the patients escalate.

Community based palliative care- Any procedure of care delivered outside the medical hospital setting which emphasizes a broader community support with home environment facility.

Pain management – Strategies and methods in the form of interventions that help patients to relieve the degree of pain in the body.

 

 

 

Chapter 2: Methodology

 

The methodology section provides a justification of the procedures to be followed to locate pertinent literature, to answer the research question and fulfil the research objectives. The systematic research-based literature review involves the formulation of a purposeful research question, systematic way of searching appropriate articles, evaluating each article individually and finally assessing the published outcomes (Houghton, Hunter, & Meskell, 2012). A quality literature review may not be a comprehensive as a systematic review, although it deploys a systematic approach when searching and analysing the literature.

Formulating the review question:

A literature review as defined by Lame, (2019) is a first step towards understanding, in which the first thing is to come up with a review question. This nursing review aims to respond to the following question: ‘’ In adult patients receiving end-of-life care in community settings, how effective are anticipatory medication-based pain management approaches, including clinician- and carer-led administration, in improving pain relief and symptom control compared to usual care?” ’. Therefore in order to develop a concise focused question based on the topic selected above, the PICO (Population, Intervention, Comparison, and Outcome) (Schiavenato, & Chu, 2021), and SPIDER tools were chosen to use in the study (Munhall, 2012). Although PICO is a powerful instrument in formulating research questions, it is quantitative in nature.

Element Description
P (Population) Adult patients receiving end-of-life care (home/community settings)
I (Intervention) Anticipatory medication-based pain management (including structured tools and carer-supported administration)
C (Comparison) Usual care (standard clinician-led medication administration)
O (Outcome) Pain relief, symptom control, timeliness of medication, patient and caregiver experience

 

Qualitative approach:

Only the qualitative research method was applied to answer the question, which is, ‘’ In adult patients receiving end-of-life care in community settings, how effective are anticipatory medication-based pain management approaches, including clinician- and carer-led administration, in improving pain relief and symptom control compared to usual care?”  and Kilpatrick et al. (2023), emphasize the fact that the framework of a literature review has to be very similar to the questions that were posed when conducting a literature review. The qualitative research will aim at exploring the phenomena of humans that provide descriptions and an elaboration of these phenomena in a detailed way (Choi et al. 2022). The approach places depth in the forefront with the perspectives of the participants as the centre stage (Bettany-Saltikov & McSherry, 2024). Though it has been criticized that qualitative literature reviews may lack being systematic,

Table1: Formulation of the research question

Sample Research phenomenon of interest Research Design Evaluation Research type
End of life adult care in clinician, carer led anticipatory medication for pain relief and symptom control Treatment of how the adults approaching end of life got clinician, care (community) based was able to manage pain  

 

 

Exploratory

 

 

 

Experiences

 

 

 

Qualitative

 

leaving behind less reliable evidence found by chance and not by rigorous means Patterson et al. (2023) highlight that rigour, sometimes called trustworthiness, may be achieved through transparency and reporting of the systematic procedure adhered to.

Search strategy:

The research study variables, i.e. describe the overall phenomenon of the research, which is pertinent to the review question, were identified using a systematic search. It involved search using embedded in the topic keywords, and combination of variables, which are related to the review question (Chigbu et al. 2023).

 

 

Table 2: Keywords

Keywords

 

 

OR ‘’ end-of-life care ‘’’adult patients’’, AND ‘’ anticipatory medication in end of life adult patients’’, AND ‘’ clinician led pain management approaches, AND ‘’ carer-led administration for pain management’’, ‘’ pain relief and symptom control for end of life adult patients ’’, ‘clinician based’’ ‘’carer based pain management approaches’’, ‘’ research method’’.

 

 

This assisted the researcher to ensure that the output of the selected literature is exhaustive, it is not selective or it does not have a cherry-picking research studies . The research keywords were combined with the Boolean operators and truncation (asterisk,) to locate the necessary literature (Caponnetto et al. 2024). To determine the availability of qualitative literature on the chosen topic, preliminary scoping search was performed through the assistance of such keywords as – adult end of life care, anticipatory medication, community care, pain reflef approaches. Despite this search yielding a couple of indirectly relevant literature, new keywords were discovered, such as moral distress, treatment cessation and emotional impact, and were added to the search procedure (see Table 2), which assisted in locating more relevant literature. Inclusion: propose the use of the identified keywords to incorporate different variations of the topic of the review. The Boolean operators of ‘AND’ and ‘OR’ were used successfully to combine search concepts (, ) and to make a search concept broader with the help of truncation (,) at the risk of retrieving irrelevant articles.

Database searched:

Bibliographic databases were employed in order to sustain the focus and choose the unbiased literature review. The general search engines present in the market like Google search engine, which can be extremely fruitful in giving a variety of information output can prove to be unreliable (Azarian et al. 2023). The databases that were implemented in this study such as MEDLINE (Heintz et al. 2023, CINAHL (Hopia & Heikkilä, 2020), PsycINFO (Leclercq et al. 2019), APA and Academic search (Rahaman, Taru, & Prajapat, 2023) complete were of choice because they had the ability of retrieving subject area specific articles.

CINAHL is a variety of nursing literature, and search tool in that field, that is capable of finding qualitative research. It provides practical research articles in the setting of UK despite the USA bias the production are plausible (Bettany-Saltikov, & McSherry, 2024). Conversely, MEDLINE search has a variety of information on medicine and nursing. Likewise, to 98% of peer-reviewed journals available on the APA PsycINFO focus on psychological care in nursing area (Ravi et al. 2022). Academic search is complete thus, is a multidisciplinary database, which widens the scope of the available scholarly articles (Höglander et al 2023). The search was also limited to the English language using limiters which narrowed the search to publications published in the last 2018-2025, which might have excluded the possible existence of studies of interest.

Inclusion and Exclusion criteria:

A systematic search strategy requires having clear inclusion and exclusion criteria (Randles, & Finnegan, 2023), (see Table 3) that would allow only the studies that are directly related to the review question to be selected. In this case the prioritised studies were those that examine the experiences of end of life care in community settings, in relation to the ‘.anticipatory medication-based pain management approaches, including clinician- and carer-led administration.’ . The use of Cochrane systematic reviews is said to be the gold standard but they were not included since they focused on healthcare interventions, not the subject of this review. Instead, peer qualitative research was chosen based on its credibility and quality assessment (Johnson, Adkins, & Chauvin, 2020). Although, it can be based on their experience of other countries a lot, and the given aspect is not developed in other countries in particular in order to refer to it in the given research. These criteria helped to cut down the search and ensure that only the applicable studies to the review question were included in the search.

Criteria Inclusion Criteria Exclusion Criteria
Population Adult patients (≥18 years) receiving end-of-life or palliative care Paediatric populations; non-terminal patients; general chronic illness without end-of-life focus
Setting Community, home-based, residential care, hospice, or hospital end-of-life settings Studies not related to end-of-life care (e.g., acute non-palliative care, rehabilitation settings)
Intervention Anticipatory medications or structured pain management approaches (e.g., injectable medications, carer-administered medication, pain assessment tools) Studies focusing only on non-pharmacological interventions or general care without a pain management component
Comparison Usual care, standard clinical practice, or absence of structured anticipatory medication intervention Studies without any comparator or evaluation of intervention impact
Outcomes Pain relief, symptom control, timeliness of medication administration, patient or caregiver experience Studies not reporting pain-related or symptom control outcomes (e.g., cost-only studies, policy discussions)
Study Design Primary empirical studies (RCTs, qualitative studies, mixed-methods, observational studies) Systematic reviews, literature reviews, editorials, commentaries, opinion papers
Geographical Context Studies conducted in the UK or comparable healthcare systems (e.g., developed countries with similar palliative care models) Studies from significantly different healthcare contexts where findings are not transferable
Time Frame Studies published from 2018 onwards Studies published before 2018
Language Studies published in English Non-English publications
Focus of Study Studies examining anticipatory prescribing, medication administration, or effectiveness of pain management in end-of-life care Studies focusing only on prescribing behaviour, policy change, or cost analysis without linking to patient outcomes

Study selection:

The studies selection process elaborates how the literature which is directly related to the review question was selected and the PRISMA diagram by Page et al. (2021) gives a clear picture about the process (see figure 1). The removal of the duplicates resulted in 421 results across 4 databases (110 MEDLINE, 120 CINHAL, 130 APA, 61 Others ) totalling 360 of which were irrelevant studies 230 filtered out by reading their titles and abstracts, and the given procedure enables focusing on the studies that are connected with the review question. Further exclusions added to 36 more articles were caused by another screening process against inclusion criteria.

 

PRISMA

New studies included in review

(n =0 )

Reports of new included studies

(n =0 )

Included
Total studies included in review

(n =4 )

Reports of total included studies

(n = 4)

Identification
Studies included in previous version of review (n = 421)

 

Previous studies
Records identified from*:

Databases (n = 4)

MEDLINE (n=110)

CINHAL (n=120)

APA PsychInNFO (n=130)

Academic search (n=61)

Records removed before screening:

Duplicate records removed  (n =190 )

Records marked as only abstracts (n =29 )

Records removed as non english (n =11 )

Records screened

(n =360 )

Records excluded**

(n =230 )

Reports sought for retrieval

(n = 130)

Reports not retrieved

(n =0 )

Reports assessed for eligibility

(n = 130)

Reports excluded:n=36

Reason 1 Studies are not on pain (n =33 )

Reason 2 Study was not Cochrane (n =49 )

Reason 3 No adult end of life pain experiences  (n = 66)

etc.

Identification of new studies via databases and registers
Screening

 

 

 

Critical Appraisal

Critical appraisal of any research study procedures possess their own strength and weaknesses in the evaluation power as well as the quality and relevance of the article selection with regard to the research question (Brignardello-Petersen, Santesso, & Guyatt, 2025). The CASP checklist is appropriate to qualitative research studies and in the present process of appraisal, the authors suggest its significance in the mythology specific tools that have checklists to demonstrate the qualitative research to demonstrate rigour (Frias-Goytia et al. 2024). The qualitative research to demonstrate the quality of the decision to include the study in the analysis and to adopt comprehensive assessment based on the professional guiding standards.

 

 

Chapter 3: Critical Appraisal

 

Study1: Anticipatory prescribing in community end- of- life care in the UK and Ireland during the COVID-19 pandemic: online survey [Antunes, 2020]

Research Issue, Aim and Objectives-The COVID-19 pandemic has drastically raised the death rates at home and in care homes in the UK and Ireland. This generated acute stress on the already existing practice of anticipatory prescribing (AP) – the pre-emptive dispensing of injectable drugs to relieve symptoms in the last few days of life. There were fears of drug shortages, decreased nurse and doctor supply to give subcutaneous injections and the necessity to rapidly adapt prescribing instructions. The research fills an urgent evidence gap on the ground on the transformation of AP practice in response to these pressures. The overall objective was to explore the experience of change in AP practice among UK and Ireland clinicians during the COVID-19 pandemic and to elicit their suggestions of how the change can be improved. The four targeted research questions inquired what practitioners reported about: (1) drug prescription changes; (2) drug administration changes; (3) support structures of AP; and (4) additional practice, policy and legislative changes.

Research Appraisal-The study is a cross-sectional online survey study conducted in mixed methods, i.e., quantitative (descriptive statistics of the categorical responses) and qualitative (inductive analysis of the themes of the free-text responses) ways. One of the main methodological strengths is its timeliness: data were gathered April 2020, when the practice is being carried out in the acute period of COVID19 pandemic which captured unique perspectives (Schroeder et al. 2020. The geographic coverage in UK and Ireland regions and the size of the sample (n=261) further enhances representativeness. Methodological rigour is demonstrated by the use of ‘CHERRIES’ checklist, which is used to report internet surveys (Torrejón-Guirado et al. 2024). Nevertheless, a number of shortcomings are recognized. Snowball sampling means that a response rate cannot be calculated, and it brings about self-selection bias (Kubiciel-Lodzińska, 2021). The sample was selected based on professional contacts that have already been involved in AP (e.g., workshop attendees, members of palliative medicine), so the sample might be biased toward specialist and not generalist practitioners which was also found by (Jones et al. 2021). Moreover, this was also an initial analysis of a preliminary dataset, and the authors planned to conduct a more thorough follow-up analysis.

Sampling and Selection-It was first conducted as purposive sampling, whereby the delegates of AP national workshops of 2019 and the representatives of the corresponding professional organisations such as the ‘’Association for Palliative Medicine of Great Britain and Ireland’’, the ‘NICE Medicines Associate Programme’, the ‘Resilient GP Facebook Group’ and the ‘Queen Nursing Institute’ were targeted. This was propagated via the snowball sampling method in which recipients were requested to share the survey link in case of interested workmates which was also found in the study of (Artioli et al. 2019). The survey was open 813 April 2020 (to be distributed) and responses received by 19 April 2020. The respondents were over a group of professional roles – the majority of them (37 percent) were palliative medicine consultants and GPs (24 percent) which (Clark et al. 2023) found in their research, with various working environments, low resource setting, within the community, hospice, hospital and care home.

Research Ethics-The ethics committee of the University of Cambridge Psychology Research reviewed and gave the study approval (reference: PRE.2019.013). It was a voluntary participation, all fields were obligatory to complete the data, but the answers were anonymous by default meeting the ethical procedures (EL Barbi et al. 2024). Contact details were provided by the respondents at their own discretion and could only be used as a factor in considering the respondent to be contacted to complete further interviews by telephone, hence, the respondents were clearly separated between taking part in the anonymous survey which without additional participation added to rigour in health research (Koo, & Yang, 2025). No formal patient consent requirements are mentioned in the study, which was correct considering that the survey was focused solely on the clinicians and not on patients. The ‘NIHR Applied Research Collaboration East of England’ funded the study with a clear disclaimer that the opinions were that of the authors only.

Study2: GPs’ decisions about prescribing end-of-life anticipatory medications: Bowers et al. (2020)

Research Issue, Aim and Objectives-Anticipatory prescribing (AP) of injectable drugs is a longstanding aspect of community end-of-life care in the UK, Australia, and New Zealand, which is aimed at the timely control of symptoms during the last days of life. Although the central prescribing authority was in the hands of GPs, there was minimal research studies that investigated their decision making processes in the context of AP. Rae, (2024) stated that the literature previously had been overly focused on the views of nurses, and while (McNab, 2022) found that it has tended to depict nurses as the instigators of prescribing requests and GPs as reluctant or reactive prescribers. There were still critical gaps in terms of how GPs construct AP discussions with patients and families, when prescribing, and the responsibility of drug administration after prescription which (Morris et al. 2021) used realist research phenomenon to prove patient role in AP. The research fills this underexplored view in a field of considerable clinical and ethical dilemma. The purpose of the stated aim was to investigate how GPs make decisions regarding prescribing and use of anticipatory medications to patients towards the end of life. Although there are no officially stated objectives, the study implicitly aimed to investigate three lines of inquiry: the reasons behind why GPs choose to prescribe (when and whether); how GPs discuss the issue of AP with patients and families; and how GPs cope with the continued responsibility of the prescriptions they make, especially in their relationship with community nurses in their delegation of care.

Research Appraisal-It is a qualitative study, interpretive descriptive and semi-structured in-depth interviews with an analysis in a six-phase thematic analysis framework by Braun and Clarke in nursing study (Ahmed et al. 2025). The interpretive descriptive design is suitable to its goals, as it produces detailed, contextually detailed information about professional practice and decision-making and not testing hypotheses that (Duff et al. 2020) stated as interpretative based representation of healthcare practice. The inductive method enabled us to identify three subtle themes that would naturally arise out of the data: *something we can do, getting the timing right and delegating care but retaining responsibility. Ryder, Jacob, & Hendricks, (2019) as the aspect of rigour was improved by a series of analytical lenses: one of the public contributors coded the first three transcripts independently, a second researcher coded six transcripts, and (Klooster et al. 2022) highlighted the importance of analytical decisions were discussed in an iterative manner. Reflexivity was directly discussed and the lead researcher had previously worked as a community palliative care nurse and therefore a positionality that which (Moralli, 2024) argued to have facilitated both rapport and necessitated direct control to prevent interpretive bias. Another weakness is that data are based on GPs self-report of practice, as opposed to observed behaviour, and thus social desirability bias can occur which was argued by (Bailey & Wundersitz, 2019). Direct generalizability is also constrained by the single-county sampling frame though the authors propose analytical transferability between UK settings because of the combination of urban and rural practices.

Sampling and Selection-Purposive sampling was used to sample GPs who had a broad spectrum of views and experience which (Ibrahim, Barry, & Hughes, 2023) argued to guide research to adopt qualitative study. Potential participants were found through publicly available GP practice websites in one English county. Letters to thirty two GPs were sent; sixteen of them were interested and thirteen were finally interviewed in the course of June to December 2017 in thirteen separate GP surgeries. The last sample consisted of ten GP principals and three salaried GPs, five of whom worked out-of-hours. There was intention to find diversity in terms of sex, place of practice (urban/rural), full-time/part time and interest in palliative care. Information saturation was achieved successfully after eleven interviews, and two more interviews were held on the purpose to guarantee an appropriate variety of insight which was highlighted by (Braun & Clarke, 2021), and which is in line with the information power principles in qualitative sampling.

Research Ethics-The research was ethically approved twice: by ‘Cambridge University Psychology Research Ethics Committee’ (reference number PRE.2017.028) and NHS Health Research Authority (HRA IRAS reference 225853). Informed consent was obtained beforehand by all participants and respondents were interviewed with their knowledge and consent which was audio-recorded though (Sindhuri & Dongre, 2023) highlighted challenges remain in obtaining informed consent in healthcare setting. The published findings make use of pseudonyms to ensure anonymity of participants. The ‘NIHR Applied Research Collaboration East of England’ and the ‘NIHR School for Primary Care Research’ funded it, and a typical disclaimer that opinions are those of the authors only. None of the authors indicated any competing interests.

Study3: Unwelcome memento mori or best clinical practice? Community end of life anticipatory medication prescribing practice: A mixed methods observational study Bowers et al. (2021)

Research Issue, Aim and Objectives-Although anticipatory prescribing (AP) has been extensively advocated and practised in the UK, Australia, Canada, Norway and New Zealand, there was strikingly little empirical data available. Zhang, Méndez & Scott, (2019) study confirmed findings, on the frequency of AP medication prescribing, the time of illness course when the prescription occurred, and the clinical contexts within which prescription choices were made. The published rates of prescribing were quite different, between 14-16 percent of foreseeable deaths in primary care groups, to 63 percent among those receiving specialist palliative care, but were based on heterogeneous and methodologically weak sources. There were serious issues arising on patient safety and especially where medications were prescribed well before they were expected to be needed (Bates et al. 2023) while (Ocloo et al. 2021) where they were administered by clinicians who were not familiar with the patient. The lack of evidence relating to patient and family engagement in prescribing decisions was also prominent and this was of great concern which was highlighted by (Manias et al. 2024), to the issue of informed consent and person-centred care in community end-of-life practice. The mentioned objective was to conduct research on the frequency, timing and documented conditions of injectable end-of-life anticipatory medicine prescribing to both home and residential care patients. The aim of the study was to determine: how frequently AP medications were prescribed in a varied sample of GP practices; the fluctuation and distribution of time between prescription and death; what clinical contexts and decision-making process were recorded in patient records; and how much patient and family engagement were recorded in prescribing decisions.

Research Appraisal-It is a retrospective mixed methods observational study, which relies on the GP and community nursing clinical record on the basis of which a social constructionist paradigm is applicable since it acknowledges that clinical records represent selective accounts by clinicians, rather than objective data. The mixed methods design is well adapted to the objective, allowing quantitative examination of the prescribing frequency, timing and patient characteristics, and inductive examination of described contexts, language and interactions within prescribing choices. Descriptive statistics, chi-square and Fisher exact tests, as well as multivariate logistic regression were used, with a priori computation of sample size (Madadizadeh, Soodejani, & Bahariniya, 2026). Constant comparison incident-to-incident analysis through NVivo 12 was employed in qualitative coding (Chun Tie, Birks, & Francis, 2019). Rigour was aided by thematic refinement through iteration with co-investigators and two Patient and Public Involvement (PPI) groups which is important for validation of data and findings (Vellani et al. 2024), the Cambridge Positive Ageing group and the Cambridge Palliative and End of Life Care group, who helped in prioritising research and its interpretation. One of the limitations is that clinical records only provide a partial record of clinical interactions, especially, patient and family discussions as (Brooks, Manias, & Bloomer, 2024) argued that the results on decision-making involvement might not reflect practice. Cohabitation and opioid misuse risk, socioeconomic status were not routinely measured, which constrained the ability to adjust confounding variables. The purposive maximum diversity sampling method and sequential deaths identification methodology enhance generalisability (Safari, McKenna, & Davis, 2023).

Sampling and Selection-Purposive sampling was used to select 11 GP practices and two related NHS Community Trusts across two English counties to maximise variation in the size of patient lists (range 5,50043,000), geographic location (urban, rural, outer London) and socioeconomic status (third most deprived to least deprived decile). This meets the findings of (Parsaeian et al. 2021) as quality and cost of research effort needs to be explored and sampling is critical. Each practice identified the 30 most recent expected adult deaths of patients who had lived at home or in residential care at least one day in their last month and died of any cause other than trauma, sudden death or suicide between March 2017 and September 2019. Nursing homes with on-site trained nurses were included and the patients who had not participated in the research were excluded. This produced a final study population of 329 dead patients. The sample was mainly aged 75 and above (65.7%), mainly male (51.4) and mostly dying of non-cancer causes (58.7).

Research Ethics-The South Cambridgeshire Research Ethics Committee (reference: 19/EE/0012) gave full ethical approval. Since the research study implied retrospective access to the clinical records of deceased patients and the absence of their personal consent, further consent of the Confidentiality Advisory Group of the Health Research Authority (reference: 19/CAG/0014) was obtained that permitted the processing of confidential patient information under the condition that data were anonymised as soon as possible. The two PPI groups recommended the ethical acceptability of the access to the records of deceased patients without consent. Tadros, Carley, & Lucassen, (2020) argued that bringing a community voice to the sensitive decision, which has been an issue especially in COVID19 time period as well (Schoch-Spana et al. 2020). No conflicts of interest were reported. The NIHR School of Primary Care Research, NIHR Applied Research Collaboration East of England, and RCN Foundation Professional Bursary Scheme funded it.

Study4: Simultaneously reassuring and unsettling:a longitudinal qualitative study of community anticipatory medication prescribing for older patients Bowers et al. (2022)

Research Issue, Aim and Objectives-Although the notion of anticipatory prescribing (AP) is widely established as a good clinical practice in the UK as well as internationally, the views of patients and informal caregivers had virtually been missing in the evidence base. The overwhelming premise that AP was based on, namely, the effect of medications being available in the house reassures everyone involved, allows the symptomatic relief to occur promptly and avoid unnecessary crises hospitalization, as (Majumder, 2024) argued it was based more on beliefs conveyed by clinicians, as opposed to patient or family experience. Only a single previous study had investigated the opinions of patients, with the results indicating that prescriptions were considered as a sign of impending death which (Krikoria et al. 2020) stated to be a key contributor for medical audit and review. Three other studies had examined the experiences of bereaved caregivers retrospectively, expressing concerns regarding insufficient explanations, ambivalence regarding effectiveness and concerns regarding drug safety where families withdrawing from treatment was also reported (Korsah, Schmollgruber, & Abukari, 2025). More importantly, no prospective study had investigated the experiences of older patients and their informal caregivers with regard to AP as it occurred in the real-time or how they coped with the practical and emotional challenges of obtaining and self-administering prescribed drugs, which (van der Zijpp et al. 2022) argued to focus on relationships, medication dispensing system narratives to be captured. This is a big gap considering that older patients are the largest number of those who die in the community and the main beneficiaries of AP. The objective of the study was to get insights into the perceptions and experiences of older patients, informal caregivers and clinicians regarding the prescription and use of anticipatory medications in the community. The implicit aims were to: investigate the experience of prescribing conversations with patients and their families; study the emotional and practical reactions to medication in the home over time; investigate how informal caregivers and nursing staff negotiated the decision to administer medications; and identify the invisible work that families do to manage AP care.

Research Appraisal- Particular methodological strength is the longitudinal case-based design, which permits the perspectives to be recorded at several times – after prescribing, after the first administration, and two- to four-month follow-up. Elsahn et al. (2020) argued that not always methodological rigor is captured through technology and research management, so that the changes in understanding and experience can be monitored over time. Constant comparison techniques were used to conduct thematic analysis, and initial line-by-line coding in NVivo 12 and independent coding (Humble & Mozelius, 2022). Five transcripts by a second researcher was used to enhance analytical rigour and reflexivity. Important interpretative choices were narrowed down after a series of debates involving all three authors and the Patient and Public Involvement (PPI) groups. One of the clear weaknesses was the fact that it was not always possible to interview the patient and two cases did not involve patients. Morris et al. (2020) attributed it because of fluctuating cognitive impairment which biased some of the analysis to caregivers and clinician perspectives. The sample was also purely white and English speaking which constrained generalization to other communities. Notably, all nurses that were engaged in the administration of medications refused to take part in the study, and an essential professional voice was missing in the dataset. The COVID-19-induced data collection implied that interviews were carried out remotely, which (Bandini et al. 2022) argued have been less in-depth than face-to-face, as well as put into perspective some of the remote prescribing practices identified.

Sampling and Selection-Purposive sampling strategy was used to select participants who were diverse. Ames, Glenton, & Lewin, (2019) stated that diversity in respondents in terms of age, living arrangements, terminal conditions and geographical setting, in two English counties. Six GP practices, two community nursing organisations and three community palliative care teams were used to facilitate recruitment. They used to first assess the appropriateness of approaching potential participants because the context was sensitive and then provide study invitation letters which requires researcher to decide on survey or interview based on access (Klar & Leeper, 2019). Among the 34 patients and informal caregivers who showed interest, 16 were willing and available to participate on being contacted. Patient and caregiver participants nominated twelve clinicians who were approached by letter and six agreed. The last sample included 11 patient cases but included six patients (65-94 years old) as well as nine informal caregivers and six clinicians- three GPs and three nurses. Information power led to the end of data collection wherein 11 cases were taken based on the information power where rich multi-perspective longitudinal data was deemed adequate to answer the research objective. A total of 28 interviews were carried out.

Research Ethics-The study was approved by the South Cambridgeshire Research Ethics Committee (reference: 19/EE/0361). Ethical approval was fully informed, and continued approval was expressly re-established before each subsequent interview, in light of the possibly dynamic ability and desires of a dying population. Initial recruitment by clinical teams to ensure vulnerable patients and caregivers, are not overburdened or put at a disadvantage by undue stress. The two PPI groups Cambridge Positive Ageing and Cambridge Palliative and End of Life Care were involved in the research design. Nii Laryeafio & Ogbewe, (2023) argued that the recruitment procedures, the words to use as interview guide and interpretation of the findings, thus integrating the lay perspectives in the research process. No conflicts of interest were reported. The NIHR School of Primary Care Research, NIHR Applied Research Collaboration East of England and the RCN Foundation Professional Bursary Scheme funded it.

Study 5: The financial costs of anticipatory prescribing: A retrospective observational study of prescribed, administered and wasted medications using community clinical records- Morgan et al. (2023)

Research Issue, Aim and Objectives–Anticipatory prescribing (AP) of injections at the end of life is strongly advised in a variety of states and has become the norm of community palliative care. However, although it was extensively used, the financial implications of this intervention had come under a very minimal serious examination. Past cost estimates were done using partial data – usually estimating the price of two three days worth of the four most commonly used pharmaceuticals, arriving at figures of between 22.12 and 30.26 in regard to prescription and 10.00 and 14.61 in regard to the unused drugs. These estimates did not take into consideration the entire spectrum of drugs actually prescribed, as (Benhamou et al. 2024) argued about the changes in quantities issued, foreseen syringe driver prescriptions or real rates of medication dispensing and wastage. Parallel evidence was also arising that standardised prescribing as opposed to individualised prescribing was routine, often with predetermined amounts of vials irrespective of the specific patient symptom as reported by (Andersson, 2023). It caused apprehension over wasteful spending and the squandering of medication (Penati, 2024). As AP costs are thought to have an insignificant role in the policy and clinical discussion, there was a gap in the financial evidence base that needed systematic investigation with complete and patient-level clinical data (Sturmberg et al. 2024). The purpose of the stated aim was to determine the costs of anticipatory medications dispensed, administered and not used to patients at the end of life at home and in residential care. The implicit objectives of the study were to: compute total costs of prescription per patient at patient level and drug level, compute percentage of prescribed medications that were actually used and that were wasted, compute specific drugs that contributed the most to the unused medications and it was also to see whether patient characteristics that included anticipatory syringe driver prescriptions, GP practice, cause of death and timing of prescription were statistically significant in difference of prescription, usage and wastage costs.

Research Appraisal-It is a retrospective, observational study based on GP and community nursing electronic and paper clinical records, and is a secondary analysis of data gathered previously to conduct the Bowers et al. (2021) mixed methods study. The research adopts a stringent quantitative methodology, and the costs were systematically calculated (Abu, Shafie & Chandriah, 2023). This was done at both patient and drug level based on a standardised reference of costs at British National Formulary tariff prices. The statistical analysis was well-specified, with non-parametric Kruskal-Wallis H tests in univariate analysis due to non-normally distributed cost data, with multivariate linear regression with bootstrapping to control confounding variables, such as gender, age, cause of death and GP practice. One of the strongest methodological aspects is the administration of complete paper and electronic records to allow real administration data to be captured (Zeleke et al. 2021), which is not regularly available in large-scale primary care data as medication usage is not logged in a systematic manner. The biggest weakness is that non-medication costs are not included, such as the time spent by community nurses making visits, GPs prescribing time and family carer input, so the actual economic cost of AP is probably understated (Lam et al. 2022). The two counties in England where the study was carried out were relatively well off thus restricting the generalisability to poorer and more ethnically diverse societies. Prices of drug tariffs can also be a local issue because of negotiations with suppliers, but the prices of BNF are an example of a standard and generally accepted benchmark.

Sampling and Selection-The sample size was the same as Bowers et al. (2021), and included patients enlisted in eleven GP practices and two related NHS Community Trusts in two English counties. Each of the practices selected the 30 most recent eligible deaths, and a pre-determined sample size of 330 patients was used to allow sufficient statistical power. The patients inclusion criteria was that they had to be aged 18 or more, lived at home or in a residential care home at least one day during their last month of life and they had to die between March 2017 and September 2019 due to any cause other than trauma, sudden death or suicide. On-site nursing care nursing home residents were excluded. Out of 167 patients taking anticipatory drugs, 164 were not left out of the cost analysis as they had full records and only three were left out because of incomplete records. The GP practices were chosen purposefully to achieve a maximum distribution of diversity in terms of practice size list, geographical location and socioeconomic variables.

Research Ethics-The South Cambridgeshire Research Ethics Committee (reference: 19/EE/0012) gave its ethical approval. Since the research was based on retrospective access to the clinical records of deceased patients without the direct consent of the patients, the Confidentiality Advisory Group of the Health Research Authority (reference: 19/CAG/0014) granted permission to process confidential patient information on the condition that it would be anonymised as soon as possible. There were no conflicts of interest that were declared. The Wellcome trust, NIHR School of primary care research and NIHR Applied Research collaboration East of England funded it, but a typical disclaimer that opinions are those of the authors only.

 

 

Chapter 4: Synthesis

 

4.1 Discussion

This is an analysis of the research findings of five fundamental research papers on anticipatory prescribing (AP) in community palliative care, mainly in the United Kingdom and Ireland. Such sources are a national survey of clinicians in the COVID-19 pandemic (Antunes et al., 2020), a qualitative investigation of the process of General Practitioner (GP) decision-making (Bowers et al., 2020), a retrospective observational study of the frequency and timing of prescribing (Bowers et al., 2021), a longitudinal qualitative study of patient. Also the chosen research analysis gave perspectives of caregiver experiences (Bowers et al., 2022), new dimension of economic analysis of medication (Morgan et al., 2023) which gave a new dimension to research. The aggregate study synthesis, showed collectively, for the unravelling of the complex landscape, that points to the aspects of the clinical necessity, need for the professional autonomy, framework for patient psychological wellbeing mapping, and maintaining institutional economic efficiency and the management operations conflict.

Theme 1. Rapid Innovation and Systemic Adaptation During Global Crisis

The COVID-19 pandemic acted as a stimulus to drastic and swift changes in AP practice. The national survey by Antunes et al. (2020) indicates that clinicians noted significant changes in routes of administration (47%), the type of drugs prescribed (38%), and the overall volumes dispensed (35%). The crisis required a shift to remote patient evaluations through telephone or video (63%) to reduce the risk of infection. One of the notable innovations was the greater focus on non-injectable routes, including buccal, sublingual, and transdermal delivery, especially in cases where there were limited healthcare professional (HCP) resources. It was also during this time, that there was a marked change toward family caregiver administration of medications (37%), which was very uncommon in the UK but hastened by the fear of nurse shortages while (Husted, & Dalton, 2021) argued not to show resource scarcity. Another policy that was promoted by clinicians was legislative reforms that could allow used and unused medications to be repurposed and recycled in care homes, that (Makki et al. 2019) findings supported, in order to counter the possibility of running out of stock and minimizing waste.

Theme 2. Professional Decision-Making: The GP as Gatekeeper and Consultant

The AP process heavily depends on the role of the GP but their reasoning can be informed by the necessity to cope with clinical uncertainty. Bowers et al. (2020) found that GPs perceive AP as something we can do when no longer appropriate active medical options apply. The medications are frequently prescribed by GPs as an insurance policy to avoid out of hours crises, despite the fact that they may end up being unused at all. Interestingly, although most GPs are actively on the forefront of such decisions, they also perform the role of a medical consultant (Bi & Liu, 2023), by passing the everyday evaluation and administration to the nurses in the community. This delegation is significantly dependent on the history of relationships based on trust, which is increasingly becoming tense as a result of organisational transformations that have divided communication between centralised nursing hubs and GP surgeries (Rudebeck, 2019). In addition, the presence of AP medications in a home is a frequently used sympathetic indicator by GPs to warn other clinicians who come to the home that it is no longer the primary goal of care, but the management of terminal symptoms (Andrews et al. 2020).

Theme 3. Patterns of Frequency, Timing, and Clinical Predictors

The retrospective observational data by Bowers et al. (2021) offers a statistical map of AP prevalence in detail. About half of potentially predictable deaths patients received AP medications (50.8%). These prescriptions were dispensed approximately 1,212 days before death and with a median of 17 days, with the highest prescriptions date being the day of death and the lowest being 1,212 days before death. Other important predictors of being an AP prescription recipient were specialist palliative care involvement (OR 7) and a recorded preferred place of death (OR 34). Of the patients, the data indicates that in 66.5 percent of the cases, AP was not a dynamic process but a one-size-fits-all intervention that was documented and ordered in conjunction with the other end-of-life planning forms such as DNACPR forms that was also reported in findings of (Pereira et al. 2020). This implies as (Majumder, 2024) argued that it is overdependent on electronic templates that can easily bureaucratise terminal care instead of personalising it.

Theme 4. The “Simultaneously Reassuring and Unsettling” Patient Experience

AP is a very sensitive and at times emotional experience to the patient and his/her informal caregivers. Bowers et al. (2022) referred to the intervention as both reassuring and unsettling. Although the drugs give a feeling of safety that the pain would be under control, their delivery is a sign of impending death and a physical reminder of the terminal condition of the patient. There is a coping process of living in the present used by many patients and care givers, which also reported in (Zhang et al. 2023) who used field study in order to attempt to put thoughts of death aside despite having already made plans. Discussions about AP were frequently identified to be unclear or professional-focused, with families being given the bag of medicines that (Palapar et al. 2023) findings showed to create documentation and dialogue, without much or no sense-making at all. As a result, a large number of care givers turn to the internet to find out the role played by the drugs administered to them.

Theme 5. Barriers to Medication Administration and Caregiver Burden

There is a very serious disconnection between the act of prescribing drugs and their actual taking. Bowers et al. (2022) discovered that informal caregivers frequently have a hard time convincing nurses to administer the prescribed medications. Giving more emphasis to the clinical evaluation of the nurses, rather than to the information provided by the family, is a common problem of nurses that may cause certain delays in relieving the symptoms, causing a lot of distress to the caregiver who is to act on behalf of the patient. Moreover, caregivers also do considerable work behind the scenes, such as organization of pharmaceuticals, checking prescription orders, and integration of services provided in a disjointed manner which (Ashimwe, & Davoody, 2024) found to be meeting similar results . This burden of treatment may turn overwhelming to flimsy support systems which was shown by (Linzer et al. 2022) how they feel, particularly where there is the breakdown of professional promises of timely care in practice.

Theme 6. Economic Inefficiency and the Paradox of Standardised Wastage

Morgan et al. (2023) present a financial analysis that shows that there is an important economic paradox in AP practice. Whereas the average cost of an AP prescription is fairly low at £43.17, 85% of this amount is wasted. The average price of drugs actually dispensed to a patient is just £2.16, which implies that most of the dispensed drugs ended being destroyed. The disproportionate contribution of specific drug classes to this waste includes anti-emetic drugs (Haloperidol and Cyclizine) and anti-secretory drugs (Glycopyrronium Bromide) that produce 64% of the total costs of wastage. The research proposes that the prevalent norm of ordering five vials of each drug that (Cruz et al. 2019) argued on knowledge-attitude and practice, irrespective of the symptom profile of a particular patient, contributes to the unjustified wastes. Individualised prescribing or even three initial vials of some drugs to help save money which (Fabian-Therond, 2024) findings argued without jeopardizing care has a definite range.

Theme 7. Safety Concerns and the Risks of Advance Prescribing

The resources all indicate issues related to patient safety, especially when the drugs are ordered months or years before they are needed. According to research of Bowers et al. (2021) and Bowers et al. (2020), the longer the strong opioids and midazolam are kept in a home, the higher the chances are, of abuse or diversion. Moreover, the availability of such drugs may trigger the decrease in clinical reviews; the clinician will be less motivated to visit the patient with the presence of the already available in case box, which may result in failure to identify the reversible symptoms. The inquiry into the “Gosport War Memorial Hospital” is quoted as a warning of the dangers of prescribing to anticipatory syringe drivers with large dose ranges, that (Bowers et al. 2019) findings initiated at the will of third parties, (Au et al. 2022 who may have unknown skills to the prescriber.

Conclusion

The cumulative evidence of all the above studies shows that as much as anticipatory prescribing is pillar in UK community palliative care, it is an intervention that is complex, full of clinical, psychological and economic friction. However, it is an anxiety and clinical uncertainty management instrument, but its standard use in practical life, does not commonly consider the particular requirements and preparedness of the patients and their families. AP needs to support end of life, by better incorporating the professional judgment with the professional lived experience of the informal caregivers.

 

 

  1. Conclusion

The five studies discussed together shed light on a dynamic and diverse landscape of anticipatory prescribing (AP) in end-of-life care in communities. It has always been shown that AP is a frequent practice with around 50-65% of patients with foreseeable deaths given prescriptions, but that its clinical efficacy has never been sufficiently supported. Antunes et al. (2020) disclosed the COVID-19 pandemic increased the rate of innovation, opening up new drug routes and caregiver administration opportunities beyond the traditional conventions. Bowers et al. (2020) have shown that GPs consider AP as a concrete measure to deal with uncertainty, but prescribe largely on professional intuition instead of solid clinical evidence, many weeks or months before it is expected. Bowers et al. (2021) affirmed the jarring variation in prescription timing, 0-12 days preceding death, and emphasised that standardised, as opposed to individualised, prescribing prevails in practice and poses a substantial amount of safety concern. The longitudinal patient/caregiver perspective presented by Bowers et al. (2022) was the first to present AP as a reassuring and disturbing experience, where informal caregivers often bear unidentified responsibilities in advocacy around timely drug administration. Morgan et al. (2023) determined that 85% of the money spent on prescribed medications was wasted, and Haloperidol, Cyclizine and Glycopyrronium made up a disproportionate portion of wasted money. Throughout the five studies, one common thread is evident: patient and family voice continues to be marginalized in prescribing, levels of administration set by nurses pose limitations to timely symptom management, and the evidence behind this popular practice is not robust enough to warrant the unthinking standardisation.

5.1 Implications for Practice

The results of these studies have significant implications in clinical practice in the end-of-life care in the community. To begin with, the pre-eminence of standardised AP – prescribing set amounts of four drugs irrespective of their likelihood of symptoms in a person – needs to be radically redefined. The NICE guidance proposes individualised prescribing, but clinical records and cost information continue to demonstrate a template-based, one-size-fits-all practice that creates a lot of medication wastage and possible safety risks to patients. In the case of antiemetics, clinicians should be more proactive in adjusting the prescription based on the expected symptom profile of a particular patient to minimize unnecessary antiemetic prescribing of Haloperidol and Cyclizine when nausea is not expected.

 

Second, the prescribing conversations need to be enhanced immediately in terms of its quality and depth. Bowers et al. (2022) established that patients and caregivers were often provided with ambiguous, clinician-directed conversations that were framed with the use of minimising language and the families looked up the information about medications online. Frank, compassionate discussions of dying, expected symptoms and the place of individual drugs is a clinical and ethical requirement, reconsidered as situations evolve.

Third, the direction of care to community nurses should be supported by the strong inter-professional communication system. GPs noted an increasing dependency on fragmented centralised contact systems at the expense of direct nurse relationships, which underlie safe AP. It is important to re-establish routine interdisciplinary team meetings and open lines of communication between GPs and community nurses. Lastly, the under-the-radar strain imposed on informal caregivers in terms of advocacy of drug administration, prescription logistics and symptom monitoring should be officially recognized and established with specific carer education, concise written instructions regarding the requirements to adhere to when administering drugs and available professional contact points that can be reached at any time of the day or night.

5.2 Recommendations

Hospital perspective: Hospitals must have strong discharge planning which includes timely AP prescribing when patients leave hospital environments to their communities, and share of electronic care plans across services. It is advisable that anticipatory syringe driver prescription is only issued after due individualised clinical evaluation considering evidence of safety risks and increased costs of wastage.

Nursing point of view: Community nurses should treat informal caregivers as skilled collaborators in care and use their observations of patient distress to make administration decisions – especially when patients are unable to self-report symptoms. Clinical assessment of the end-of-life should be regularly trained to the nurses to standardise administration thresholds and minimise differences in care quality. There should be regular provision of clear and written symptom criteria and ‘out of hours’ palliative care support lines.

Carer perspective: Informal caregivers need to be talked to proactively, honestly and repeatedly about the dying process, what to expect and the anticipated symptoms when medicines are given. Guidance on requesting drug administration, when and how to do so, and a named clinical contact would significantly decrease the navigational load that families are now bearing. Provision of emotional support in the aftermath of bereavement especially in cases where drugs were not administered or care was not provided systematically.

 

 

 

#UK, #nursing, #academicwriting, #dissertation, #Bachelors, #Masters, #Ireland, #Scotland, #Healthcare, #Publichealth 

 

Indian migrant women’s access to health resources about menopause in the UK

Indian migrant women’s access to health resources about menopause in the UK

Indian migrant women’s access to health resources about menopause in the UK

INTRODUCTION

BACKGROUND LITERATURE REVIEW (BLR)

Menopause is a universal biological transition significantly shaped by sociocultural contexts
and "local biologies". For Indian migrant women in the UK, this experience is intersectional,
compounded by the social process of "immigrant transition" which involves complex factors
like -migratory, cultural, and social changes.
Structural Barriers within the NHS and UK Healthcare System
Mann et al. (2025) found in this qualitative study, examining barriers and facilitators to
menopause care provision through semi-structured interviews with primary healthcare
professionals across central England, found that cultural and ethnic differences were
perceived as significantly impacting whether women sought menopause care or HRT from
their GP. Healthcare professionals felt they needed more time for in-depth communication
and education with women from minoritised ethnic groups, noting that approximately five
times fewer Black women and four times fewer Asian women were prescribed HRT
compared with white women. Targeted, culturally sensitive outreach and specific HCP
training were identified as essential to reduce health inequalities, with the study concluding
that the current NHS primary care model was structurally inadequate for meeting the
additional needs of ethnic minority menopausal women.
Stanzel, Pham, Hammarberg & Fisher (2025) explained that this cross-sectional study
thematically analysing free-text responses from 76 primary healthcare providers found that
competing migration-related priorities, the healthcare system's limited resources, and
culturally informed beliefs about menopause collectively constituted the primary structural
barriers to midlife care for migrant women. Migrant women speaking a language other than
that of the host country were more likely to have low health literacy skills, resulting in lower
participation in health promotion programmes, preventive healthcare, and higher rates of
emergency care and hospitalisation. Providers concluded that flexible models of primary
healthcare and coordinated engagement with community groups were essential, and that the
current NHS primary care model was fundamentally ill-equipped to address the compound
health needs of migrant menopausal women.
Health Literacy among Indian Migrant Women
Past academic literature indicates that South Asian women may present with symptoms
differently than their White peers, often reporting musculo-skeletal aches and pains rather
than traditional vasomotor symptoms like ‘hot flushes’.
Baghdadi, Singh & Gatuguta (2025) findings showed that immigrant Muslim adult women in
Brighton (UK) research showed using constructivist grounded theory, core theme of
. Misconceptions about HRT, poor health literacy,
and dismissive GPs caused insurmountable barriers to care, with HRT misconceptions
resulting in high rates of hesitancy. This study based on constructivist grounded theory with
twelve in-depth online semi-structured interviews. The results found that cultural stigma and
limited their knowledge compounded negative perceptions and experiences of menopause,
with women reporting, that they experienced including ‘physical and emotional’ difficulties

such as; ‘disruption of sleep’,’ changes in cognitive ability’ and ‘anxiety levels’. The lack of
awareness about HRT resulted in a high level of reluctance to take it, but women who used it
reported a significant reduction in symptoms, which demonstrates that a poor level of health
literacy directly correlates to untreated symptom. The core theme identified by the study was
that of Navigating a Web of Silence and how a deficiency in health literacy, is perpetuated by
intergenerational silence (mostly cultural) a stigma linked shame making mandatory GP
training to spread the menopause education has been suggested as a critical corrective
measure.
Whelan, Dempsey & Voon Yi Chi (2026) explained that this qualitative research
methodology established that women in more collectivist cultures (and especially within
immigrant populations) who have to negotiate around the dimensions of the cultural taboos
around woman ageing, their reproductive health in life-stages. Having to experience about
their menopause in silence, with cultural attitudes around covert approach to their symptom
disclosure having a significant impact on healthcare uptake. Several barriers were identified
that hinder menopausal women from seeking medical assistance, including low health
literacy regarding menopause, low-priority assigned to addressing symptoms, and the
perception of menopause as a natural part of ageing that does not warrant medical attention.
The review concluded that trust in healthcare professionals was a pivotal mediating variable
— where trust was absent, as in many migrant communities, health literacy remained low
and formal help-seeking was actively avoided in favour of community-based informal
remedies.
Language Barriers and Culturally Appropriate Menopause Resources
Even in England, however, primary care practitioners (PCPs) reported a notable so-called
communication gap, in which cultural manifestation of symptoms do not necessarily reflect
well within the environment of Western medicine, potentially leading to misdiagnosis or sub-
optimal care.
According to Briscoe et al. (2022), this study, which is based on pilot work with individuals
with limited English proficiency within the South Asian communities across the UK, found
that the inability to request language support, the concern about overstressing the
healthcare service, and the lack of confidence in discussing health-related issues with an
interpreter were the most common barriers to accessing primary care. This also gave a great
deal of fluctuation in the way in which clinical commissioning groups in England and Wales
have been implementing interpreting services, creating an English post-code lottery, where
access to language-appropriate healthcare became a question of geographical chance,
rather than being the result of deliberate policy. The authors recommended evidence-based
and up-to-date guidance to be given to the decision-makers who commission language
services, as well as digital transformation tools to allow more inclusive and linguistically care
clinical communication.
British Menopause Society (2023) clarified that this evidence synthesizing was produced by
the institution, there might be language barriers and a lack of understanding of the terms
used by ethnic minority women. This is in the context of describing their symptoms with
traditional and conservative cultural orientation of Asian women being an additional barrier to
help-seeking. The report has shown that in several South Asian languages there is not a
direct equivalent word to denote menopause as in English, and that the very articulation of
symptoms during a clinical consultation itself was structurally inhibited. Therefore, a need to
educationally resource in multi languages including leaflets, posters and videos of ethnic
minority women was clearly identified as necessary step, to enable and normalise a
structured approach to ‘informed health’ related decision making in these communities. It

was suggested to provide information in a culturally sensitive manner, based on the level of
understanding of the individual, to further educate healthcare professionals, and to make
systematic access of interpreter services to menopause care pathways.
Cross-Cutting Themes and Intersectional Analysis
Eccles et al. (2025) findings showed that Black and Asian women were much less likely to
take HRT compared to their white counterparts – with the use rate of 6.2% and 5.2%
respectively compared to 23.3% in white women. Minority ethnic women reported a lack of
trust in medical institutions and fear of stereotyping during appointments and the cultural
inability to discuss menopause openly with their communities, which further increases
access barriers.
Hirst et al. (2025) GP records for nearly two million women aged 40–60 over a ten-year
period, this landmark cohort study found that overall HRT uptake was just 19.2%, with stark
ethnic and socioeconomic disparities. 3.9% in Black African women to 22.6% in white
women, and from 10.9% in the most deprived areas to 24.2% in the most affluent —
demonstrating that structural inequalities.
NHS England CPAR Programme (2025) funded by NHS England's School of Public Health,
found that menopause remains deeply stigmatised among migrant women from ethnic
minority backgrounds, leaving many to navigate emotional and medical isolation, cultural
taboos, inconsistent medical advice, and low awareness of available resources. Howlett et
al. (2024) study highlighted that misinformation and language barriers created an
environment in which women felt neither seen nor supported within NHS primary care.
MacLellan, Dixon, Bi, Toye & McNiven (2023) qualitative study of 46 primary care
practitioners across 35 English practices, supplemented by consultations with 14 women
from three ethnic minority groups, found that health literacy constraints, language barriers,
and cultural inhibition significantly impeded ethnic minority women's help-seeking for
menopause symptoms.
Zou et al. (2021) identified individual, familial, and community-level barriers to healthy
menopause among immigrant women aged 45–65 undergoing natural menopausal
transition. Key barriers included acculturation stress, patriarchal household dynamics, and
restricted access to culturally competent healthcare, all of which are acutely relevant to
Indian migrant women in the UK.
Stanzel, Hammarberg & Fisher (2021) women describe menopause as a taboo topic
considered secretive and inappropriate for discussion, compounded by low health literacy
and the absence of government policies adequately funding women's health for migrant
populations. The cohort of the Indian migrant women, is typically shaped by their family
based generational, cultural and religious norms in everyday life, which are frequently found
to normalise symptoms and avoid formal healthcare engagement.
Ussher, Hawkey, & Perz, (2019) study with sample of n=169 found that Indian women
included with Iraq, Somalia,South Sudan, Sri-Lanka (Tamil), Sudan and various South
American females who are in the perimenopause stage has shown diverse belief around the
word menopause. Most of captured showed diverse cultural values, mental concepts from
the social constructions based on beliefs, impacting their personal interpretations.
One of the common themes is the cultural differences between native white adult females
and Indian women. This is an ethinicity gap, that has direct connection to the communication
skills is creating a phenomenon of "web of silence" in context of female reproductive health.

It is seen as entrenched in cultural taboos of bringing the issues out into the open in Indian
female in society creates a stigma that make the menopausal a self-deprecating and
personal issue. This is one of the factors that lead to poor health literacy where Indian
migrant women only understand menopause as the end of periods. There is lack of
knowledge and stop in awareness creation, without knowing about peri-menopausal
changes or medical treatments, such as the use of Hormone Replacement Therapy (HRT).
Besides, there are structural barriers which exist; the immigrants women face systemic
discrimination in foreign nations mostly due to language proficiency barriers and socio-
economic disadvantages that do not allow navigating healthcare practices successfully.
Research gaps in knowledge remain significant, particularly the lack of UK-specific
qualitative research focusing on Indian adult female migrants for menopause in their
lifestages, as current evidence is "limited" and often unrepresentative. There is a critical
shortage of data regarding the effectiveness of non-English health resources and how
structural factors, such as short consultation times, specifically disadvantage women from
collectivist backgrounds who may require more holistic approaches to "join the dots" of their
embodied experiences.

RESEARCH QUESTION AIM AND OBJECTIVES OF THE STUDY.

Research Aim:
To critically examine Indian migrant women’s access to health resources about menopause
in the UK
Research objectives:
RO 1: To examine structural barriers Indian migrant women’s access to health resources
about menopause in the UK
RO 2: To find out ⁠health literacy in Indian migrant women’s access to health resources about
menopause in the UK
RO 3: To evaluate dimensions of ⁠language and culturally appropriate resources for access
to health resources about menopause in the UK
The research aim to examine Indian migrant women's access to health resources is directly
linked to the documented "limited evidence" regarding ethnic minority experiences in the UK.
Research Objective 1 addresses the health sector structural barriers, such as discrimination
and system constraints identified as major hurdles to healthy transitions. Research Objective
2 targets the gap in relation to gap to women menopause health literacy, specifically
awareness preventing Indian adult women in advocating their health issues. Finally,
Research Objective 3 evaluates the need for understand the culturally appropriate
resources, responding to the identified lack of non-English educational materials and the
linguistic "wall" faced by many immigrant populations.

METHODOLOGY, METHODS AND DATA ANALYSIS

 

Databases
MEDLINE, PsycINFO, CINAHL, APA, was used in this study. The multidisciplinary character
of this research theme, which cuts across the fields of psychology, medicine, nursing, and
public health has led the researcher to use databases for selection – PsycINFO, MEDLINE,
APA PsycArticles, and CINAHL. MEDLINE was crucial as the leading biomedical database,
which would contain peer-reviewed clinical evidence on the symptomatology of menopause,
the prescribing of HRT inequalities, and the NHS provision of healthcare services towards
ethnic minority women. The CINAHL (Cumulative Index to Nursing and Allied Health
Literature) was invaluable in capturing nursing-focused, community health and health literacy
studies that have a direct bearing on the experiences of migrant women in the primary care
setting. A search in PsychcINFO and APA PsycArticles was conducted to access
psychological, behavioural and sociocultural aspects of menopause such as stigma,
acculturation stress, cultural identity, and help-seeking behaviour which are core to
understanding the engagement of Indian migrant women in health resource utilisation.
Inclusion/exclusion criteria:

Inclusion Criteria Exclusion Criteria

Studies related to female gender of Asian
Indian origin

Non Asian

Studies set for female of Asian Indian in UK Studies on males Asian Indian in UK

excluded

Studies related to menopause Non menopause articles rejected
Studies that has involved only above 18 yrs
aged respondents

Only for Asian Indian females over 18 yrs of
age
Peer reviewed English language research
journals only

Non English research journals were rejected
Studies for which full text was available Only abstract articles were rejected
Research publication between the years
(2025-2021)
Data Analysis:
To analyse literature about access to health resources regarding menopause in the UK
among Indian migrant women, thematic analysis (TA) is the most suitable approach. TA
being a flexible, theoretically independent methodology that identifies, analyses, and reports
patterns across heterogeneous qualitative data makes TA ideal to synthesise a
heterogeneous literature. Since this study cuts across health disparities, migration, female

gender and cultural identity, as the TA allows the researcher to go beyond surface
descriptions into understandings of interpretative depth of the research journals chosen.
It will use a reflexive thematic analysis model (Braun and Clarke, 2019), where the data will
be inductively analyzed to reveal themes, as opposed to forcing the use of a pre-determined
set of research themes. This is especially suitable in the case of the existing literature being
divided across different fields of study health sociology, postcolonial studies, and feminist
health research. Such themes like the case of the cultural stigmatisation of menopause,
language and communication barriers, intersectional discrimination within the NHS, and
informal health-seeking behaviours are major themes. This goes in line with inter-sectionality
theory (Crenshaw, 1989), which are critical in explaining how race, gender, and migrant
status are intersecting in increasing healthcare marginalisation.

ETHICS

This research project has serious ethical implications that must be given serious
consideration. To begin with, the core issue of ‘confidentiality and anonymity’ in research
ethics, must be given first priority, especially in case primary data, which is not applicable for
this research. Second, vulnerable group of Indian women migrants, they may fear being
subject to institutional scrutiny, researchers should be mindful not to strengthen existing
power relations (British Sociological Association, 2017).
Third, the ethical considerations of the positionality of the researcher are ethically significant:
a researcher who belongs to the outside of this community must reflexively question
assumptions based on cultural privilege. Fourth, the aspect of the cultural sensitivity is a
critical gap that no one is addressing. In female biology, the menopause stage is inevitable,
and irrespective of ethnicity it has devastating impact on female psychology and physiology.
The issue in adult females is related to stigma as issues of research show the need to avoid
the outcomes of self-inflicting psychological distress or shame which is family upbringing and
culture induced phenomenon. Lastly, GDPR (2018) and the principles of the Declaration of
Helsinki on research with human participants, data collection must be preceded with
institutional ethical approval by a recognised university ethics board.

RESULTS :

Table which summarises the articles
Author & Year Study Type Population/Setting Key Focus
MacLellan et al.
(2023)

Qualitative
(Interviews & PPI)

UK primary care
practitioners and ethnic
minority women

Communication gaps
and barriers to help-
seeking in primary care

Baghdadi et al.
(2025)

Grounded Theory
(Qualitative)

Immigrant Muslim
women in the UK

Experiences of
menopause, HRT, and
healthcare navigation.

Ussher, J. M.,
Hawkey, A. J.,
& Perz, J.
(2019).

Qualitative N=169 Indian women
along with Iraq, Somalia,
South Sudan, Sri-Lanka
(Tamil), Sudan and
various South American
(Latina) background

Subjects were in onset of
premenopausal stage,
reflected cultural values
diverse in social
constructions and
personal interpretations.

MacLellan et al.
(2023)

Qualitative primary
research
(interviews) of GP,
nurse, pharmacist,

14 women with peri-
menopause/menopause
stage, 35 care
practitioners

Women from ethnic
minority show
menopause to be
different

Page | 8

Female respondent

Results of your analysis – how you have grouped/analysed your articles
Theme 1: Resource Inaccessibility with invisible linguistic wall
The first conclusion to be made throughout the literature is that the current health resources
can often be linguistically and culturally inaccessible. In England, primary care practitioners
(PCPs) specifically mentioned a "specific limitation" on the absence of educational resources
in non-European Asian languages including Urdu, Punjabi and Bengali to be hailed as south
Asian. Moreover, where English resources exist and are being used, we may often find that
they are not resonating. Particularly the Asian or Indian women who do not see themselves
reflected in the messaging and thus perceive that menopause is not their issue, but a White
people issue instead. The lack of particular terms in some heritage (mother tongue)
languages to denote such concepts as a hot flush also makes the internalisation of Western
health information communication any more challenging.
Theme 2: ‘’Ache" as a Symptom with communication gap
The findings present an important incongruence between symptom descriptions as given by
the Indian and South Asian women and the way Western medical systems interpret these
symptoms. While Western resources focus on vasomotor symptoms (hot flushes), Indian
and South Asian women frequently present with musculoskeletal pain and "aching".
Practitioners reported that these as differences in their respective cultural
expressions—such as describing "heat coming from my tummy"—often do not make
"medical sense" to providers. This is causing and leading to missed opportunities for "joining
the dots" providing holistic menopause care in UK to Asian Indian women with limited
English communication vocabulary.
Theme 3: Health care structural access barrier
Access is further restricted by systemic issues within the UK’s primary care system. A "good
menopause consult" is reported to require at least 20 minutes, yet most women are limited
to 10-minute slots, which is insufficient for unpicking complex presentations or expressions
in patients with English as a second language. Additionally, Asian (Indian) women in UK,
expressed a strong preference for female GP clinicians, but reported that accessing a
female practitioner in UK, is often challenging in all the cases/hospitals, leading to repressed
feelings about a female problem, of not being "listened to" by male doctors.
Theme 4: Sociocultural "Web of Silence"
Health resources are often not sought due to a pervasive "web of silence" and cultural
stigma surrounding reproductive health decline. Indians are from collectivist cultures,
menopause is framed as a "taboo" subject, with women feelings-emotions mostly repressed
in Indian society, it is expected to "just get on with it" in silence in British society as well. This
is cultural stoicism linked to Indian females, is due to their upbringing in Indian patriarchal
society (parental child relationship) to behave in certain manner, where family needs are
prioritised over personal health, acts as a self-imposed barrier to accessing formal medical
resource.

DISCUSSION & CONCLUSION :

There is evidence of an emerging convergent pattern of ‘triple marginalisation’ facing Indian
migrant women in menopause care: ‘cultural’ (stigma, silence, normalisation of suffering);

‘structural’ (NHS underprepared for cultural competence, HRT prescribing disparities); and
‘epistemic’ (absence of culturally tailored information resources). As the reasons for such
inequalities in menopause care remain poorly understood, this body of evidence
compellingly justifies further intersectional, community-centred qualitative inquiry specifically
focused on the Indian migrant women demographic — a group whose distinct cultural
identity has been sidelined, which is an outcome of the migration and lifestyle experience,
and language context has been examined in sufficient with scholarly depth.
CONCLUSION
The synthesis of these findings illustrates that for Indian migrant women in the UK, "access"
to health resources is not merely a matter of physical availability but is an intersectional
challenge involving linguistic, structural, and sociocultural hurdles. This research
demonstrates that Indian migrant women in the UK face a multi-layered exclusion from
menopause health resources. While menopause is a universal biological transition for any
adult female irrespective of race, ethnicity, its manifestation in Indian women migrants living
in UK is often presented as musculoskeletal pain rather than the terminology used by while
females living in UK expressing 'hot flushes' symptoms. This is frequently misinterpreted or
dismissed within the UK’s time-constrained primary care healthcare framework exposing
structural inadequacy, as healthcare system design for migrant females and is overlooked. It
is mostly a communication gap, as individual Indian migrant adult females are not proficient
in English communication to express their body indicators that pertains to menopause
symptoms. This medical narrative with specific terminology is culture specific which reflects
their respective experiences in them. There is also a cultural dimension as most of it is
considered a taboo for discussion, rather ignore, and suffer in silence. The research also
highlights that when targeted, culturally sensitive education is provided, women feel
empowered to regain agency over their bodies. All these are limiting chances and probability
for the Indian migrant women to achieve "healthy menopause,". The UK healthcare system
must move beyond "universal" English-centric resources toward a holistic, intersectional
model. Therefore, while the gap remains, healthcare system needs values cultural
dimension, Indian women symptoms of menopause, capture their expressions through
interpreters, and address to remove the structural barriers such as consultation length,
language barriers and clinician training.

LIMITATIONS:

The main weakness of this study is the limited scope of a specific qualitative data of the
Indian sub-groups in the UK context, since many studies merge their results under the
umbrella term of South Asian or Immigrant along with Indian adult females. The scoping and
systematic reviews involved are also largely performed by a Western mindset and restricted
only to English-language articles, which may be missing subtle aspects of heritage-language
thinking. The interviewed clinicians sample was dominated by females, which might have
skewed the data toward the more empathetic interpretations of patient experiences as
compared to the general primary care workforce.

CONCLUSION

This study shows that Indian migrant women in the UK experience a multi-layered non-
access to menopause health resources. Although menopause is a universal biological
transition, how it manifests amongst the Indian women who tend to show symptoms most
often as musculoskeletal pain, rather than as hot flushes, is often misunderstood or
disregarded within the time-constrained primary care system in the UK. A lack of health
resources in heritage languages and a medicalised narrative (specific terminology), that does not take into consideration the collectivist and the local biology facts of these women,
contributes to the "communication gap. Moreover, the culture of silence instigated by culture
taboos does not allow most women to attribute their symptoms to menopause and as such
many women endure in silence as opposed to seeking help.

 

 

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