Expertise among critical care nurses: A grounded theory study

OBJECTIVES

Explore critical care nurses' personal perceptions of expertise, expert performance and transition from novice to expert performer in clinical practice.

DESIGN

Following constructivist approach to grounded theory this investigation used qualitative open-ended interviews focused on the social construction of expertise in critical care nursing and the experiences of clinical practice that define that process.

SETTING

A multi-site urban area in the southeastern United States.

PARTICIPANTS

10 certified critical care nurses, three males and seven females, with 10-30+ years of critical care experience.

FINDINGS

Experience and knowledge are the foundation of expertise and expert performance. The higher the acuity the more frequent the experience the greater the nurses' aptitude and opportunity for learning and professional growth. It was also noted that self-actualisation was a major determinant in the development of expertise in critical care.

CONCLUSION

Key findings suggested that clinical experience and personal motivation combined with self-actualisation, the drive to maximise personal potential, determine critical care nurse's trajectory towards professional excellence. Expert performance evolves over time. Knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Social expectations and experiences have a direct impact on professional aptitude and development if expertise.

Mothers' food choices and consumption of ultra-processed foods in the Brazilian Amazon: A grounded theory study

In recent decades, an increase in consumption of ultra-processed foods (UPF), a type of product frequently associated with diet-related obesity, chronic diseases, decrease of eating traditions and loss of culinary diversity, has been observed in middle-income countries. However, there is lack of information on factors related to choosing UPF. In this study, we aimed to understand the factors promoting UPF choices and consumption among mothers living in an urban context in the Brazilian Amazon, and to present a conceptual model grounded on their experiences that illustrates the dynamics between the observed factors. For this qualitative study, we used a constructive grounded theory approach, with a theoretical sampling of 40 women, to choose mothers with high and low consumption of ultra-processed foods. Data production and the first steps of analysis were performed concomitantly, followed by four steps of coding focused on creating conceptual categories and explaining the interactions between them. Our findings highlighted the importance of context in promoting UPF choice and consumption, particularly the "food environment", physical and virtual, and the "sociocultural environment". These contextual aspects interacted with the two main personal aspects influencing participants' UPF consumption, one concerning practices, "cooking behaviors", and the other concerning preferences, "food tastes". Factors such as economic and time constraints were also important and competed to shape eating practices through interactions with participants' health valorization. Findings are discussed in relation to food choice theories, social roles and the food environment. Implications for public health initiatives include the importance of considering environmental changes, sociocultural and economic influences, the reliance on UPF, and the role of women in the home, when promoting healthy diets.

A new grounded theory model of sexual adjustment to HIV: facilitators of sexual adjustment and recommendations for clinical practice

BACKGROUND

Life expectancy of people living with HIV (PLWH) is increasing. Effective biomedical prevention methods (treatment as prevention and preexposure prophylaxis) are being widely implemented in high-income nations. Therefore, research into quality of life, including sexual adjustment, is of increasing importance to HIV care. Yet, sexual adjustment of PLWH has been neglected in past research. We propose a new model of sexual adjustment to HIV which explores the dynamic process, facilitators and barriers characterising sexual life of PLWH overtime.

METHOD

Thirty PLWH (19 male, 11 female) recruited from two HIV treatment centres as well as community groups, completed semi-structured interviews which were audio-recorded and transcribed verbatim for analysis using grounded theory.

RESULTS

The model of sexual adjustment to HIV is the first to establish how undue fears of transmission of HIV during sex and/or fear of rejection by sexual partners determine initial sexual behaviour after diagnosis and also sexual adjustment over time. Within the model, sexual adjustment to HIV is facilitated by factors which assist PLWH to overcome such fears, including: partner acceptance, peer, community and health professional support, and accurate knowledge of risk of transmission including of undetectable viral load and pre-exposure prophylaxis. Adjustment is inhibited when undue fears of transmission and of rejection persist long term, resulting in maladaptive behaviours to cope with such fears including avoidance of sex and problematic drug and alcohol use.

CONCLUSION

This model offers clear directions for promoting sexual adjustment to HIV. Health professionals should: (a) assess and intervene for sexual quality of life (not just risk) among PLWH; (b) be aware that serosorting facilitates adjustment in the short to medium term, but may interfere with adjustment long-term, (c) promote opportunities for positive connection between PLWH, and (d) intervene directly with PLWH and HIV negative sexual partners to promote accurate risk of transmission knowledge, including how this applies to their own sexual practices, and whether they are experiencing undue fear of transmission over time.

Perceptions of artificial intelligence in healthcare: findings from a qualitative survey study among actors in France

BACKGROUND

Artificial intelligence (AI), with its seemingly limitless power, holds the promise to truly revolutionize patient healthcare. However, the discourse carried out in public does not always correlate with the actual impact. Thus, we aimed to obtain both an overview of how French health professionals perceive the arrival of AI in daily practice and the perception of the other actors involved in AI to have an overall understanding of this issue.

METHODS

Forty French stakeholders with diverse backgrounds were interviewed in Paris between October 2017 and June 2018 and their contributions analyzed using the grounded theory method (GTM).

RESULTS

The interviews showed that the various actors involved all see AI as a myth to be debunked. However, their views differed. French healthcare professionals, who are strategically placed in the adoption of AI tools, were focused on providing the best and safest care for their patients. Contrary to popular belief, they are not always seeing the use of these tools in their practice. For healthcare industrial partners, AI is a true breakthrough but legal difficulties to access individual health data could hamper its development. Institutional players are aware that they will have to play a significant role concerning the regulation of the use of these tools. From an external point of view, individuals without a conflict of interest have significant concerns about the sustainability of the balance between health, social justice, and freedom. Health researchers specialized in AI have a more pragmatic point of view and hope for a better transition from research to practice.

CONCLUSION

Although some hyperbole has taken over the discourse on AI in healthcare, diverse opinions and points of view have emerged among French stakeholders. The development of AI tools in healthcare will be satisfactory for everyone only by initiating a collaborative effort between all those involved. It is thus time to also consider the opinion of patients and, together, address the remaining questions, such as that of responsibility.

The transmission of violence and trauma across development and environmental contexts: Intimate partner violence from the perspective of men with histories of perpetration

BACKGROUND

Research has established a relation between ecological contexts and intimate partner violence (IPV), but little is known about how environmental factors affect childhood development over time and culminate in IPV perpetration from the perspective of men who perpetrated IPV.

METHODS

Using grounded theory, this study employed focus groups with 32 predominately low-income, African American men in batterer intervention programs to explore factors and processes through which families, neighborhoods, and policy influence men's development, contributing to their use of IPV. Using an inductive approach, the researchers cycled between data collection and analysis resulting in a parsimonious conceptual model validated by participants.

RESULTS

Three core categories emerged from focused and axial coding: adverse childhood experiences (ACEs) and trauma, structural forces, and systemic forces. Theoretical coding illuminated how these core categories relate to each other, producing a collective narrative illustrating how environmental contexts contributed to men's development. Study participants described childhood exposure to adversity and trauma within the home that diminished essential foundations of trust and safety. Positive (e.g., Old Heads, matriarchs) and negative (e.g., gangs, community violence) structural neighborhood forces influenced the social learning of violence and exposed participants to re-traumatization outside the home during their adolescence. Finally, key macro forces such as mass incarceration exacerbated violence and trauma exposure through the proliferation of high-risk neighborhoods, predisposing men toward IPV as young adults.

CONCLUSIONS

Findings reinforce the notion that environmental stress not buffered by protective adults profoundly affects development and behavior. From the perspective of male perpetrators, our results help identify those stressors and how they might contribute to male-to-female IPV.

A patient-centered approach to understanding long-term psychosocial adjustment and meaning-making, 15 to 20 years after epilepsy surgery

OBJECTIVE

Different psychosocial trajectories have been identified following treatment with epilepsy surgery, as patients adjust to possible changes in seizure frequency and the subsequent impact on their psychosocial functioning. Qualitative research has been key to understanding this adjustment process, particularly in the short-term (2-5 years). Currently, however, there is a lack of qualitative research examining longer-term (>15 years) outcomes, precluding the same rich, detailed understanding of longer-term psychosocial outcomes. Using a grounded theory approach, we explored how patients reflected on and made sense of their adjustment trajectories, 15 to 20 years after surgery. This included the impact of surgery on their sense of self and broader psychosocial functioning.

METHODS

We recruited 40 adult patients who had undergone anterior temporal lobectomy (ATL) 15 to 20 years ago (24 females; 26 left-sided). Median age at habitual seizure onset was 9.7 years (Interquartile range; IQR = 13.8), and at surgery was 31 years (IQR = 12). Median length of follow-up was 18.4 years (IQR = 4.3). Comprehensive one-on-one interviews (median time = 86 min, IQR = 28) were used to elicit patient experiences of their surgery and subsequent psychosocial outcomes. Data were analyzed using a grounded theory inductive-deductive process.

RESULTS

Patient narratives revealed a common process of psychosocial change and meaning-making triggered by surgery, which was often perceived as a major turning point in life. Patients reflected on moving through an early postsurgical period (<5 years) of upheaval and psychological disequilibrium. While this period was often remembered as stressful, difficulties were softened and/or reframed in hindsight. Through this process of reframing and meaning-making, patients were able to reestablish equilibrium and a sense of normality. Differences were evident in how patients navigated the process of meaning-making, and the extent to which they felt surgery had changed their self-identity.

DISCUSSION

We propose a model of postsurgical meaning-making, evident in the narratives of patients who have undergone ATL, providing a new perspective on long-term psychosocial outcomes. This model contributes to our understanding of patient well-being and quality of life, by acknowledging the active role that patients play in seeking to create their own sense of normality after epilepsy surgery.

Factors associated with refusal or acceptance of older patients (≥ 65 years) to provide consent to participate in clinical research in cardiology: a qualitative study

BACKGROUND

Clinical research is an essential step in the successful translation of knowledge from basic research into concrete clinical applications, yet many people are reluctant to provide consent when actually approached to actively participate in clinical trials.

AIMS

We investigated the factors that influence older patient's (≥ 65 years) decisions to accept or refuse to participate in a prospective randomized clinical trial in secondary prevention after acute coronary syndrome.

METHODS

Qualitative approach based on individual semi-structured interviews with patients who were approached for consent to participate in a currently ongoing clinical trial was adopted. Patients were interviewed after the consent process (8 accepted; 8 refused the trial). Interviews were analysed using grounded theory methodology.

RESULTS

Sixteen patients aged ≥ 65 years participated. The main concept to emerge from these interviews is that the actual trial itself does not appear to be the primary determinant in the decision to participate in clinical research. Rather, patients' decisions to participate (or not) in clinical research appear to be primarily determined by their capacity to deal with the current health event that has disrupted their life, and by their available mental and physical resources.

DISCUSSION AND CONCLUSION

Older patients display varying levels of engagement in their own health, ranging from low engagement with high trust in the medical profession, to high engagement mirrored by distrust of the medical profession. Structural conditions, such as personal benefit from trial participation, or logistic barriers to participation, seem to affect both accepters and refusers in the same manner.

Explanatory Model of Voluntary Childlessness among Iranian Couples in Tehran: A Grounded Theory Approach

Background:

Global and Iranian statistics indicate a rise in the newly emerging phenomenon of voluntary childlessness as a permanent status among couples. Childlessness is one of the main challenges of modern society. In Iran, studies on the process of voluntary permanent childlessness are scarce. The present study aimed to investigate the causes and underlying factors of voluntary childlessness and to provide an explanatory model of this phenomenon among Iranian couples.

Methods:

The present qualitative study was conducted using the grounded theory approach proposed by Strauss and Corbin. Married couples from Tehran (Iran) with no infertility problems who chose to be permanently childless were invited to take part in this research. Theoretical saturation was reached after 33 semi-structured in-depth interviews.

Results:

Based on the results, the causal conditions of childlessness included the high-risk society and adverse experiences. Contextual and intervening conditions included social problems, social support, transitional society, natural resources, social presence of women, and marriage age. The strategies and interactions observed in childless couples included the suppression of feelings, conflicts, rationality, and malingering. The core phenomenon was individualism.

Conclusion:

Increased social problems and reduced social support endanger a society in transition toward modernity. Individualists resort to permanent childlessness by suppressing parental feelings, overcoming doubts about childbearing, and becoming nonchalant by running away from child-rearing responsibilities. Such people may resort to child adoption or to have pets in order to cope with loneliness.

Selection process for botulinum toxin injections in patients with chronic-stage hemiplegic stroke: a qualitative study

Background

Botulinum toxin (BT) injection is a new treatment for spasticity with hemiplegia after stroke. How a patient decides to receive BT injections after becoming aware of the treatment remains unclear. In this exploratory qualitative study, we aimed to investigate patients’ decision-making about treatment strategies in collaboration with family and health professionals and to identify conflicts in patients’ feelings about BT treatment.

Methods

The study included six patients with stroke sequelae. Data were collected using comprehensive interviews and were analyzed using the grounded theory approach and trajectory equifinality modeling.

Results

After patients learned about BT treatment, they clearly exhibited the following two concurrent perceptions: “the restriction of one’s life due to disabilities” and “the ability to do certain things despite one’s disabilities.” Some patients reported a “fear of not being able to maintain the status quo owing to the side effects of BT.” To alleviate this fear, timely support from family members was offered, and patients overcame anxiety through creative thinking. However, there were also expressions that revealed patients’ difficulties dealing with negative events. These factors influenced the patients’ development of “expectations of BT” or “hesitations about BT.”

Conclusions

To establish treatment strategies in collaboration with patients, healthcare professionals should show supportive attitudes and have discussions with patients and their family members to help patients resolve their conflicts and should establish treatment strategies that maintain the positive aspects of patients’ lives.

A model to explain self-medication by Iranian people: a qualitative grounded theory study

Background

Self-medication (SM) is a common and global health problem. The process of attempting SM is still unclear. Exploration of SM and its contributing factors would help policymakers design and develop preventive programs. This qualitative study aimed to explore the process of attempting SM among Iranian people.

Methods

This grounded theory (GT) study was conducted among people with the experience of attempting SM (n = 17) and medical staff (n = 9) in Iran selected via semi-structured interviews. The recorded and transcribed interviews were analyzed using open, axial, and selective coding based on Strauss and Corbin’s (1998) approach.

Results

The study results revealed that people sought to deal as simply and quickly as possible with their illnesses/symptoms according to their attitudes towards and perceptions of illnesses/symptoms as well as their economic and social problems. This simple and quick approach was the participants’ main concern, resulting in taking decision-making strategies as SM facilitators. SM, in turn, provided short-term improvement and temporary satisfaction as a predominant outcome. Overall, “to avoid being trapped in the vortex of illness” was the central category, which covered and connected all the other categories developed in this study.

Conclusions

The elements of this model could be used as a guide for healthcare policymakers to design preventive programs and to plan for increasing people’s knowledge about the complications and consequences of SM. In addition, identification of barriers to referral to physicians and treatment of illnesses through the right way as well as reducing the health system’s problems would help reduce SM.

Parents' experiences of an e-health intervention implemented in pediatric healthcare: a qualitative study

BACKGROUND

The growing field of participation in healthcare has the potential to provide a number of benefits for children, patients, healthcare professionals and also the healthcare systems. According to the Convention on the Rights of the Child (UNCRC), children have the right to participate in their own healthcare and make their voice heard. Children's opportunities for understanding their conditions, sharing their views and participating in decisions regarding their care depend on healthcare professionals but also on parents' ability to communicate and include children. E-health solutions can remove barriers to children's communication with healthcare professionals. The aim of this study was to explore parents' perspectives on the outcomes of an e-health solution, Sisom, used by children during healthcare appointments.

METHODS

The empirical data is based on interviews with 16 parents. In the present study constructivist, grounded theory was chosen as the method.

RESULTS

The theory of enhancing participation, by orientating communication about healthcare towards the voice of the child instead of the parents, summarizes the process of how the outcome of Sisom for children lead to enhanced participation, by making the child the main actor and an agent in his/her own healthcare. The facilitators for achieving participation in Sisom were four interrelated outcomes; engaging, voice-guarding, raising awareness and integrity preserving. In addition to generating increased participation, it emerged that the use of Sisom also initiated a process, which was evident in all four subcategories that facilitated the child in coping with the experience of having an illness.

CONCLUSIONS

We conclude, that Sisom orientated communication about healthcare towards the voice of the child instead of the parents as well as including the child in the dialogue with the healthcare professional and thus increasing the child's participation and human rights.

Evaluating unintended program outcomes through Ripple Effects Mapping (REM): Application of REM using grounded theory

Several evaluation models exist for investigating unintended outcomes, including goal-free and systems evaluation. Yet methods for collecting and analyzing data on unintended outcomes remain under-utilized. Ripple Effects Mapping (REM) is a promising qualitative evaluation method with a wide range of program planning and evaluation applications. In situations where program results are likely to occur over time within complex settings, this method is useful for uncovering both intended and unintended outcomes. REM applies an Appreciative Inquiry facilitation technique to engage stakeholders in visually mapping sequences of program outcomes. Although it has been used to evaluate community development and health promotion initiatives, further methodological guidance for applying REM is still needed. The purpose of this paper is to contribute to the methodological development of evaluating unintended outcomes and extend the foundations of REM by describing steps for integrating it with grounded theory.

Learning to interact and interacting to learn: a substantive theory of clinical workplace learning for diverse cohorts

Social interactions are integral to clinical workplace functioning and are recognised to play an important role in clinical workplace learning. How, why and to what end students, in the context of today's culturally and linguistically diverse cohorts, interact with members of clinical workplace communities during clinical workplace learning is not well understood. The aim of this research was to generate a theoretical understanding of students' interactive processes in clinical workplace learning that accounted for high levels of cultural/linguistic diversity. In accordance with constructivist grounded theory methods, data collection and analysis were premised on theoretical sampling and constant comparative analysis, and undertaken from an informed and reflexive stance. This involved iterations of survey, interview and diary data from two diverse cohorts of final year veterinary students who had undergone 11 months of clinical workplace learning. Clinical preceptors were also interviewed. As an aid to theory building, testing and refinement, and in order to test the theory's relevance, usefulness and transferability beyond veterinary clinical education, critical feedback was sought from medical and allied health educators. Our substantive level theory demonstrates that upon entering the clinical workplace community, students learn how to 'harness dialogue' in order to effectively coordinate three, inter-related interactive processes: (i) functioning in the workplace, (ii) impression management and (iii) learning-in-the-moment. We found both positive and negative consequences ensued, depending on how students harnessed dialogue. The theory responds to a perceived need in international student education to move away from a deficit discourse by developing educational theory which focuses on the nature of participation, rather than the nature of the student.

Disrupting a cycle of mistrust: A constructivist grounded theory study on patient-provider trust in TB care

Despite the importance of patient-provider trust identified in earlier research on tuberculosis (TB) care, there has been no in-depth exploration of its determinants and how it affects TB patient experiences. We conducted a constructivist grounded theory study to explore the process of patient-provider trust in the context of TB care. This study took place in Cape Town, South Africa, an urban setting with a high prevalence of TB, and where treatment for TB is provided free-of-charge. We used theoretical sampling to select participants (TB patients and providers) from four public primary care clinics and one public TB hospital between Dec. 2015 to May 2017. We conducted in-depth, semi-structured interviews with 33 adult TB patients and 26 TB providers (including doctors, nurses, counsellors and community health workers). Interviews were transcribed and analyzed using a constant comparative approach. Our resultant theory, entitled "Disrupting a cycle of mistrust", describes a cycle of mistrust between TB patients and their providers that is grounded in health system norms and guidelines, and in subsequent provider and patient actions. This cycle is disrupted when providers develop and demonstrate trust towards their patients, which in turn builds patient trust in them and promotes positive treatment experiences. This theoretical model demonstrates the connection between structure (health system, local norms) and agency (individual practices and behaviours), and shows how the rigidity of current global TB treatment practices undermines opportunities to establish patient-provider trust. The model should guide future research on measuring and building patient-provider trust in TB care, and motivate for a new TB treatment paradigm that focuses more on patient-provider trust, and less on patient supervision and mistrust.

Experiences of Care in the Emergency Department Among a Sample of Homeless Male Veterans: A Qualitative Study

INTRODUCTION

Homeless populations are historically high users of the emergency department for low-acuity issues that could be treated in more appropriate settings such as primary care. Veterans make up 11% of the homeless adult population and are often seen in community and Veterans Affairs Medical Center (VAMC) emergency departments. The purpose of this study was to describe the experiences of a sample of homeless male veterans as they attempt to access health care in the emergency department.

METHODS

Grounded theory methodology provided the overarching framework for this research project. Structured interviews were conducted with 34 male homeless veterans, with 25 discussing their ED care. Veterans were recruited and interviewed from one VAMC emergency department, an all-male emergency shelter, and 1 soup kitchen. Text units about ED use were extracted and compared from 25 recorded transcripts to identify categories.

RESULTS

Three categories defined ED experiences: "no other option," "lack of voice," and "feeling valued."

DISCUSSION

The sample of homeless veterans in this study provided first-person knowledge about their experiences receiving care in emergency departments. These results are consistent with previous research indicating that homeless populations are high users of ED care; however, they often feel undervalued and lack of empathy from health providers. Emergency nurses are an integral part of the ED health care delivery system for the homeless, providing advocacy and much needed education about health problems and alternatives to ED care. The insight obtained about the lives and experiences of veterans in the ED is valuable to the practice of emergency nurses.

Qualities and Methods of Highly Effective Surgical Educators: A Grounded Theory Model

OBJECTIVE

To identify personal qualities and teaching methods of highly effective surgical educators using a novel research design.

DESIGN

In this qualitative study, surgical residents were sent an electronic survey soliciting nominations for faculty perceived as highly effective surgical educators. In-depth, semistructured interviews were conducted with surgeons receiving the most nominations. Grounded theory methodology identified themes for analysis.

SETTING

General, vascular, and plastic surgery residents and faculty at the University of Pennsylvania Health System.

PARTICIPANTS

A total of 77 surgical residents were surveyed. Data saturation occurred after 12 semistructured interviews with attending surgeons, corresponding to the top 15% of faculty.

RESULTS

Interviewees described both personal characteristics and specific teaching approaches that facilitated successful learning. These included providing exceptional surgical education as a mission, a strong influence from past mentors and role models, a love for the profession, and a low rate of self-professed burnout. Desirable teaching methods included promoting a culture of psychological safety (the perceived ability to take interpersonal risks within one's environment), progressive autonomy, accountability of trainees, and individualized teaching for the learner. Interviewees saw education as inseparable from clinical duties, and all surgeons believed providing exceptional patient care was the foundation of effective surgical teaching. The derived themes suggested that educators prefer "cognitive-based" approaches, focusing on learning processes rather than specific outcomes.

CONCLUSIONS

This study identified characteristics and educational styles of highly effective educators in a cohort of academic surgeons. This framework may inform the development of educational programs for residents and faculty in effective teaching methods.

The journey of thesis supervisors from novice to expert: a grounded theory study

BACKGROUND

Supervision is a well-defined interpersonal relationship between the thesis supervisors and their students. The purpose of this study was to identify the patterns which can explain the process of expertise attainment by thesis supervisors. We aimed at developing a conceptual framework/model to explain this development based on the experience of both students and supervisors.

METHODS

We have conducted a qualitative grounded theory study in 20 universities of medical sciences in Iran since 2017 by using purposive, snowball sampling, and theoretical sampling and enrolled 84 participants. The data were gathered through semi-structured interviews. Based on the encoding approach of Strauss and Corbin (1998), the data underwent open, axial, and selective coding by constant comparative analysis. Then, the core variables were selected, and a model was developed.

RESULTS

We could obtain three themes and seven related subthemes, the central variable, which explains the process of expertise as the phenomenon of concentration and makes an association among the subthemes, was interactive accountability. The key dimensions during expertise process which generated the supervisors' competence development in research supervision consisted maturation; also, seven subthemes as curious observation, evaluation of the reality, poorly structured rules, lack of time, reflection in action, reflection on action, and interactive accountability emerged which explain the process of expertise attainment by thesis supervisors.

CONCLUSIONS

As the core variable in the expertise process, accountability must be considered in expertise development program planning and decision- making. In other words, efforts must be made to improve responsibility and responsiveness.

A grounded theory of interprofessional learning and paramedic care

Interprofessional learning (IPL) is a dynamic process. It incorporates adult learning principles and requires active participation. Contemporary paramedic care typically involves collaboration with other health-care professionals. However, little is known about how paramedics work and construct meaning within this interprofessional milieu. Rural areas, where professional collaboration is well illustrated, provide an opportune setting from which to conduct the examination of IPL and paramedic care. Twenty-six participants took part in this investigation. Participants were paramedics and other professionals involved in collaboration in rural locations across the state of Tasmania, Australia. Rural Tasmania provided a diverse range of paramedic practice for investigation, including traditional (pre-hospital) care, extended care, volunteer services, and hospital-based practices. A grounded theory approach was adopted, and semi-structured interviews used to collect critical incidents in which participants described effective and less effective episodes of collaboration. Memos were kept during the research process. Analysis of data followed a process of initial and then focused coding from which the main concepts could be determined. From 75 episodes of collaboration, three main concepts emerged to create a theory of IPL and paramedic care. Relationships included reciprocity and respect, as well as professional acknowledgment. Cooperation recognized professionals as interdependent practitioners adopting open communication. Operational barriers identified contextual features under which professionals work, with constituent categories of protecting turf, and workplace culture. The findings provide new insight into IPL and paramedic care. Hierarchy, professional dominance, and gender disparity emerged as barriers to IPL. Knowledge and skills were shared between professions and this influenced how individuals interacted within interprofessional teams. A successful collaboration produced a clinical environment where patient care was informed by contributions from all team members.

Psychedelic microdosing benefits and challenges: an empirical codebook

BACKGROUND

Microdosing psychedelics is the practice of consuming very low, sub-hallucinogenic doses of a psychedelic substance, such as lysergic acid diethylamide (LSD) or psilocybin-containing mushrooms. According to media reports, microdosing has grown in popularity, yet the scientific literature contains minimal research on this practice. There has been limited reporting on adverse events associated with microdosing, and the experiences of microdosers in community samples have not been categorized.

METHODS

In the present study, we develop a codebook of microdosing benefits and challenges (MDBC) based on the qualitative reports of a real-world sample of 278 microdosers.

RESULTS

We describe novel findings, both in terms of beneficial outcomes, such as improved mood (26.6%) and focus (14.8%), and in terms of challenging outcomes, such as physiological discomfort (18.0%) and increased anxiety (6.7%). We also show parallels between benefits and drawbacks and discuss the implications of these results. We probe for substance-dependent differences, finding that psilocybin-only users report the benefits of microdosing were more important than other users report.

CONCLUSIONS

These mixed-methods results help summarize and frame the experiences reported by an active microdosing community as high-potential avenues for future scientific research. The MDBC taxonomy reported here informs future research, leveraging participant reports to distil the highest-potential intervention targets so research funding can be efficiently allocated. Microdosing research complements the full-dose literature as clinical treatments are developed and neuropharmacological mechanisms are sought. This framework aims to inform researchers and clinicians as experimental microdosing research begins in earnest in the years to come.

A theory to guide nursing students caring for patients with suicidal tendencies on psychiatric clinical practicum

Research concerning this issue demonstrates that nursing students initially feared interacting with and caring for patients with suicidal tendencies. However, there is a lack of research, which examines the care that is provided to patients that are suicidal, by nursing students. The aim of this study was to develop a theory to guide nursing students when caring for patients with suicidal tendencies on their psychiatric clinical practicum. A qualitative approach using Grounded Theory was used. A total of 22 nursing students who had provided care for suicidal patients were interviewed. The core category that emerged from the data was the 'changing of mindsets towards caring for suicidal patients and promotion of suicidal care competencies'. Other key categories linked to and enfolded within this core category were: suicidal risk assessment; protecting patients' safety; and, developing therapeutic communication competencies to advance suicidal care. This study could help fill a theory-practice gap for both psychiatric nursing teachers and students. Nurse teachers could use this theory as a map to help guide students caring for patients with suicidal tendencies and develop nursing students' suicidal care competencies.

'You can give them wings to fly': a qualitative study on values-based leadership in health care

BACKGROUND

Within contemporary health care, many of the decisions affecting the health and well-being of patients are not being made by the clinicians or health professionals, but by those involved in health care management. Existing literature on organizational ethics provides insight into the various structures, processes and strategies - such as mission statement, ethics committees, ethical rounds … - that exist to create an organizational climate, which fosters ethical practices and decision-making It does not, however, show how health care managers experience their job as being intrinsically ethical in itself. In the present article, we investigate the way in which ethical values are present in the lived experiences and daily practice of health care management. What does it imply to take up a managing position within a health care institution and to try to do this in an ethically inspired way?

METHOD

We carried out a qualitative study (Grounded Theory Approach) to explore the essence of values-based leadership in health care. We interviewed 15 people with extensive experience in health care management in the fields of elderly care, hospital care and mental health care in the various regions of Flanders, Belgium.

RESULTS

Six predominant themes, presented as metaphors, illustrate the essence of values-based leadership in health care management. These are: (1) values-based health care management as managing a large garden, (2) as learning and using a foreign language, (3) going on a trekking with an ethical compass, (4) embodying integrity and authenticity in a credible encounter with everyone, (5) being a present and trustworthy leader during sun and storm, and (6) contributing to human flourishing by giving people wings to fly.

CONCLUSIONS

Notwithstanding the importance of organizing a good ethics infrastructure, values-based leadership in health care entails much more than that. It is about the co-creation of an integrated and comprehensive ethical climate of which community-model thinking and authentic leadership are essential components. As a never-ending process, the six metaphors can help leaders to take substantive proactive steps to shape a fruitful ethical climate within their organization.

Life and expectations post-kidney transplant: a qualitative analysis of patient responses

BACKGROUND

The effect of a kidney transplant on a recipient extends beyond the restoration of kidney function. However, there is limited qualitative analysis of recipient perspectives on life following transplantation, particularly in the United States. To understand the full patient experience, it is necessary to understand recipient views on life adjustments after kidney transplantation, medical management, and quality of life. This could lead to improvements in recipient care and sense of well-being.

METHODS

We conducted a paper-based survey from March 23 to October 1, 2015 of 476 kidney transplant recipients at the University of Michigan Health System in Ann Arbor, Michigan. We analyzed their open-ended responses using qualitative research methods. This is a companion analysis to a previous quantitative report on the closed-ended responses to that survey.

RESULTS

Common themes relating to changes following transplantation included: improvements in quality of life, a return to normalcy, better health and more energy. Concerns included: duration of graft survival, fears about one day returning to dialysis or needing to undergo another kidney transplant, comorbidities, future quality of life, and the cost and quality of their healthcare. Many recipients were grateful for their transplant, but some were anxious about the burdens transplantation placed on their loved ones.

CONCLUSIONS

While most recipients reported meaningful improvements in health and lifestyle after kidney transplantation, a minority of participants experienced declines in energy or health status. Worries about how long the transplant will function, future health, and cost and quality of healthcare are prevalent. Future research could study the effects of providing additional information, programs, and interventions following transplantation that target these concerns. This may better prepare and support kidney recipients and lead to improvements in the patient experience.

How general practitioners decide on maxims of action in response to demands from conflicting sets of norms: a grounded theory study

BACKGROUND

The work of general practitioners (GPs) is infused by norms from several movements, of which evidence based medicine, patient-centredness, and virtue ethics are some of the most influential. Their precepts are not clearly reconcilable, and structural factors may limit their application. In this paper, we develop a conceptual framework that explains how GPs respond, across different fields of interaction in their daily work, to the pressure exerted by divergent norms.

METHODS

Data was generated from unstructured interviews with and observations of sixteen Swedish GPs (who have by definition more than five years of experience after license to practice) and family medicine residents (with less than five years of experience) between 2015 and 2017. Straussian Grounded Theory was used for analysis.

RESULTS

We found that GPs' maxims of action can be characterised in terms of dichotomous responses to demands from four distinct sets of norms, or "voices": the situation, the self, the system, and the profession. From the interactions between these voices emerge sixteen clusters of maxims of action. Based on the common features of the maxims in each cluster, we have developed a conceptual framework that appears to be rich enough to capture the meaning of the ethical decisions that GPs make in their daily work, yet has a high enough level of abstraction to be helpful when discussing the factors that influence those decisions.

CONCLUSIONS

Our four-dimensional model of GPs' responses to norms is a first step toward a middle-range theory of quality from GPs' perspective. It brings out the complexity of their practice, reveals tensions that easily remain invisible in more concrete accounts of their actions, and aids the transferability of substantive theories on GPs' ethical decision making. By explaining the nature of the ethical conflicts that they experience, we provide some clues as to why efforts to improve quality by imposing additional norms on GPs may meet with varying degrees of success.

Multiple sclerosis self-management model: Personal and contextual requirements for successful self-management

OBJECTIVE

To explore self-management strategies used by people with multiple sclerosis (MS) with aim of developing a MS self-management model.

METHODS

A grounded theory approach guided development of a MS self-management model. Eighteen individuals living with MS for three or more years and self-identifying as successfully managing their MS were interviewed twice using semi-structured face-to-face or telephone interviews six months apart. Demographic and disease characteristics were descriptively analyzed. Field notes and interview data were qualitatively analyzed to identify concepts and categories.

RESULTS

The emerging model revealed six person-related categories describing self-management strategies: adjusting outlook, managing stress, managing symptoms, healthy lifestyle, effective communication, and setting priorities and planning. Three context-related categories that required successful navigation for self-management were also identified: physical environment, personal social network, and community services and resources.

CONCLUSIONS

The emerging self-management model that is grounded in the perspective of people with MS includes person and context-related strategies that can be used concurrently to guide self-management in the variety of challenges experienced by people with MS.

PRACTICAL IMPLICATIONS

A self-management model of MS is useful to service providers, health professionals, advocacy organizations and people with MS to draw upon an organized and comprehensive approach to self-management.

Towards the contributing factors for stress confronting Chinese PhD students

Purpose: A review of literature reveals that stress is prevalent among PhD students who are experiencing higher levels of stress than age-matched general population normative data, and has drawn attention worldwide. However, few studies have examined the factors influencing the psychological well-being of Chinese PhD students and the type of supports most needed.

Method: This study was conducted by a qualitative method employing the Grounded Theory. Through purposive sampling, 10 Chinese PhD students were selected on the basis of theoretical sampling, and data were collected through semi-structured, in-depth interviews with the participants.

Results: Chinese PhD students experienced stress of nuanced nature at their varied years of PhD study. The obtained codes were categorized under four themes, including graduation, job prospects, relationship and other factors.

Conclusion: Chinese PhD students experienced stress from a variety of sources, corroborating with and reinforcing previous research findings. By exposing the explanations of the factors for stress confronting Chinese PhD students, this study compels us rethink the relationship between the widely existing stress and relevant policy or regulations, and proposes suggestions for counselling and policy reform.