Nurses’ perspectives on district residency program and standard treatment workflow implementation in pediatric care: an observer-based Q study

To explore and reconstruct nurses’ shared viewpoints regarding perceived barriers and facilitators to District Residency Program (DRP) and Standard Treatment Workflows (STWs) implementation in pediatric and neonatal services at district hospitals in Uttarakhand. An exploratory sequential mixed methods study combining focus group discussions (FGDs) with observer-based Q-sort methodology was conducted. Five FGDs involving 23 participants from district hospitals in Uttarakhand, India, were conducted between September 2024 and July 2025. FGD transcripts were iteratively reviewed and thematically analysed to develop a Q-set comprising 38 statements. Four trained researchers independently performed an observer-based Q-sort using an unforced distribution ranging from − 4(strongly disagree) to + 4(strongly agree). Q-sort data were analysed using PQ Method software to identify the distinguishing and shared perspectives across three factors. Factor one (36% variance and an eigenvalue of 1.55) highlighted the significance of telemedicine and teamwork (Q-sort value (Q-SV) = 1; Z score value (Z-SCR) = 1.02) over regular review of manpower and equipment (Q-SV= -4; Z-SCR= -2.24). Factor two defined by a single observer-sort (26% of the variance and an eigenvalue of 1.12) laid emphasis on technology and teamwork (Q-SV = 0; Z-SCR = 0.63), denied inconsistent training of nurses as a limitation to professional competence (Q-SV = -4; Z-SCR= -3.45) and perceived good interaction between nurses and the residents during DRP. Factor three, also defined by a single observer-sort (26% variance and an eigenvalue of 0.83), had a strong loading on staff shortage (Q-SV = 4; Z-SCR = 1.46). Though FGDs did not a measure of implementation effectiveness and causal relationships were not established, but the Nurses’ perspectives on District Residency Program and Standard Treatment Workflows gave insights about organizational factors, including interprofessional collaboration, teamwork, existing workload, digitalization of documentation, and telemedicine. Addressing these contextual factors may strengthen implementation within district hospitals and improve the delivery of secondary-level healthcare. Not applicable.