Enduring to gain new perspective: a grounded theory study of the experience of perinatal bereavement in Black adolescents

Black adolescents in the US experience perinatal loss at a higher rate than other races and ethnicities. The experience of eight Black urban adolescents through the first 3 months after perinatal loss was studied using grounded theory. The process of "enduring to gain new perspective" began with "denying and hesitating" when surprised by unplanned pregnancy but led to "getting ready for this whole new life," followed by shock of "suffering through the loss," "all that pain for nothing," and "mixed emotions going everywhere." Over time, the adolescents began "reaching out for support" and eventually "preserving the memory and maintaining relationship," "searching for meaning and asking why," and "gaining new perspective on life." Parallels are noted to extant bereavement theory.

Trialing to pain control: a grounded theory

The aim of this study was to examine the basic social psychological process of managing inadequately relieved pain in adults. Transcribed data from 23 ambulatory medical visits of adults with pain and interviews with four practitioners and four patients with pain were analyzed using constant comparative analysis. The basic problem was perception of running out of treatment options. Trialing was the process used to resolve the problem and consisted of four phases: finding the right practitioner, initiating the trial, adjusting treatments, and continuing to monitor with the patient taking control over the pain. Failure to achieve control over pain occurred when providers were unclear or failed to listen or when patients disagreed about treatment. Improving patient-provider communication may enhance trialing.

Acceptance and decision making in amyotrophic lateral sclerosis from a life-course perspective

Researchers have explored perceptions of health care services among people with amyotrophic lateral sclerosis (ALS), but little is known about how and why people with ALS engage with services. We undertook a grounded theory study to identify key psychosocial processes that underpin how and why people with ALS engage with health care services. We conducted in-depth interviews with 34 participants sampled from the Irish ALS population-based register. We found that age and life stage shaped participants' decision making about care. Participants in later life were more accepting of ALS and of death than young and middle-aged participants. Family was the primary context to how participants engaged with services, and their decisions about care were shaped by parenthood at different life stages. Health care professionals need to be attuned to the impact of life-course trajectories and family relations on the decisions people with ALS make about their care.

The impact of chronic illness in suicidality: a qualitative exploration

Objectives: To explore the experiences of patients with chronic physical illness in relation to suicidal behaviours and ideas. Design: A qualitative study using semi-structured interviews. Methods: Fourteen patients with either multiple sclerosis or stage 5 chronic kidney disease were interviewed. Grounded theory was used to analyse the data. Results: Suicidal ideation was commonly reported by the study participants, and the relationship between the impact of a chronic physical illness, suicidality and risk factors was described. Several participants reported having planned suicide attempts as a consequence of finding living with their illness intolerable, and some had used non-adherence to treatment as a deliberate method to end their life. Conclusion: The findings suggest suicidality may be a relatively common experience in those with chronic illness facing a future of further losses, and that alongside passive thoughts of not being alive this may also include active thoughts about suicide. Health professionals should be alert to intentional non-adherence to treatment as an attempt to end one's life.

"It's good for me": physical activity in older adults with schizophrenia

Physical activity (PA) interventions to improve the physical function of older adults with schizophrenia are necessary but not available. Older adults with schizophrenia may have unique barriers and facilitators to PA. The purpose of this study was to describe the perceptions of older adults with schizophrenia about barriers and facilitators to engage in physical activities that promote physical function. We conducted qualitative interviews with 16 older adults with schizophrenia. Data were collected and analyzed with grounded theory methodology. Participants expressed interest in becoming more physically active for a variety of perceived benefits including psychiatric symptom management and maintenance of basic function. Key barriers and facilitators to PA emerged in five broad categories: Mental Health, No longer a spring chicken, Pride and Sense of Well-being, Comfort and Safety, and Belonging. Interventions in this population should address negative attitudes towards aging and promote routine physical activities that enhance well-being and companionship.

Being transgender: the experience of transgender identity development

This article is based on a grounded theory analysis of interviews with transgender-identified people from different regions of the United States. Participants held a variety of gender identities under the transgender rubric (e.g., crossdresser, transman, transwoman, butch lesbian). Interviews explored the participants' experiences in arriving at their gender identity. This article presents three clusters of findings related to the common processes of transgender identity development. This process was made possible by accessibility of transgender narratives that injected hope into what was a childhood replete with criticism and scrutiny. Ultimately, participants came to their identities through balancing a desire for authenticity with demands of necessity--meaning that they weighed their internal gender experience with considerations about their available resources, coping skills, and the consequences of gender transitions. The implications of these findings are considered in terms of their contribution to gender theory, research, and clinical support for transgender clients.

The experiences of underrepresented minority faculty in schools of medicine

INTRODUCTION

Faculty of color in schools of medicine play an essential role in addressing health disparities, increasing diversity in healthcare, and improving health professions education. Yet inadequate progress has been made in increasing the numbers of faculty of color in medical schools. The reasons for this gap, and ways to address it, are poorly understood.

METHODS

We conducted a grounded theory study of 25 of faculty from groups historically underrepresented in academic medicine at 17 schools in the United States. Faculty were interviewed in person (n=4, 16%) and by telephone (n=21, 84%).

RESULTS

We identified two processes that contribute to a greater understanding of the experiences of faculty of color: patterns of exclusion and control, and surviving and thriving. We also identified one outcome - faculty of color having influence.

CONCLUSIONS

Strong support from leaders, mentors, and peers to nurture and protect faculty of color in schools of medicine is needed to counteract the negative effects of racism and to promote the positive effects this group has on diversity and excellence in medical education. Specific strategies for survival and success are described.

The process of recovery in women who experienced psychosis following childbirth

BACKGROUND

Psychosis following childbirth affects 1-2 mothers per 1000 deliveries. Onset is rapid and functioning is severely affected. Although prognosis in terms of symptom remission is generally good, long-term disability can persist. The study's aim was to develop a theoretical understanding of recovery from psychosis following childbirth.

METHODS

Semi-structured interviews were conducted with 12 women with experience of psychosis following childbirth. Interview transcripts were analysed using grounded theory methodology.

RESULTS

A theory of four superordinate themes was developed from the data, including: (i) the process of recovery; (ii) evolving an understanding; (iii) strategies for recovery; and (iv) sociocultural context. The process of recovery and women's understanding of their experience were conceptualised as parallel processes, which informed one another. Women found that a diagnosis facilitated their use of particular strategies.

CONCLUSIONS

This study highlighted a complex and ongoing process of recovery from psychosis following childbirth. Sensitivity to a woman's position in the process of recovery has the potential to facilitate professionals in assessing readiness for different interventions which will be likely to result in women feeling more understood, accepted and supported.

Relieving my discomforts safely: the experiences of discontinuing HRT among menopausal women

AIM AND OBJECTIVES

To generate a descriptive theoretical framework about the experiences of women who discontinued hormone replacement therapy.

BACKGROUND

Some menopausal women would depend on hormone replacement therapy for relieving their menopausal symptoms. However, most of them feared of hormone replacement therapy's side effects and tried to discontinue hormone replacement therapy immediately. How did these women self-manage their discomforts without using dependent medicine--hormone replacement therapy? There are few studies conducted on this issue.

DESIGN

A grounded theory research was applied.

METHODS

Nineteen Taiwanese women discontinuing hormone replacement therapy for three months, aged 45 to 67 years, participated in face-to-face audio-taped interviews. Data collection, and coding of interviews, and data analysis occurred simultaneously. All conversations were audio-recorded and then transcribed as verbatim text. The constant comparative method was used to analyse the interview data.

RESULTS

'Relieving my discomforts safely' was the core theme for describing and guiding the process of discontinuing hormone replacement therapy. 'Immediately discontinuing hormone replacement therapy--it would hurt my body' was identified as the antecedent condition. Analyses showed five dimensions to the women's relieving my discomforts safely: (1) symptoms bothered me again, (2) negative emotions, (3) learning to let it go, (4) trying to use nonhormone replacement therapy or products and (5) choosing safely therapies as first priority. Finally, some women would choose their suitable nonhormone replacement therapy way, and some women would reuse hormone replacement therapy cautiously.

CONCLUSIONS

'Relieving my discomforts safely' was the first-priority consideration for the menopausal women discontinuing hormone replacement therapy. It is the challenge to establish the health programme or management for helping these women felt safety and security to relieve their menopausal symptoms by using hormone replacement therapy or nonhormone replacement therapy.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers need to empower women the rights of decision-making of using hormone replacement therapy and assist them in monitoring their health status to reduce their fear and uncertainty.

Visible and invisible caring in nursing from the perspectives of patients and nurses in the gerontological context

AIM

Just as in many countries all over the world, the number of older people in Italy has increased rapidly. Consequently, an increasing number of nurses are engaged in the care of older patients. However, due to a lack of understanding of how nurses and patients perceive caring, nursing care may be compromised. The aim of this study is to explore, describe and compare the perceptions of gerontological nurses and patients related to the dimensions of caring in nursing in an Italian hospital setting.

METHODS

In this qualitative descriptive study, a variety of analytic techniques were used to analyse semi-structured interview data from a purposeful sample of 20 nurses and 20 patients from geriatric units in two different Italian hospitals.

FINDINGS

Although both nurses and patients gave rich descriptions of caring experiences, patients described features of caring in nursing that were visible (including nurses' caring gestures, giving attention and being competent) while nurses predominantly emphasised aspects of caring that were relatively invisible (such as reflecting on the patient's past needs, evaluating the nursing care rendered, planning for more appropriate future nursing care, taking multiple complex contextual factors into account to protect the patient and being competent).

CONCLUSION

Our data revealed more nuanced insight into the meaning of invisible and visible caring in nursing within the gerontological context than has been previously reported in the literature. This has implications for nursing education and practice because it may help nurses meet the actual needs of older patients in hospital settings.

Healing and recovering after a suicide attempt: a grounded theory study

AIMS AND OBJECTIVES

To explore the healing and recovery process following a suicide attempt over 12 months ago.

BACKGROUND

Literature has explored the process leading up to attempted suicide. However, there is a lack of information exploring the healing and recovery process after a suicide attempt.

DESIGN

Qualitative research using the grounded theory approach.

METHODS

Data were collected during 2010-2011 from the psychiatric outpatient's centre in Taiwan. Interviews were conducted with people who had attempted suicide more than 12 months prior to data collection and had not reattempted since that time (n = 14). Constant comparison analysis was used to scrutinise the data.

RESULTS

Findings demonstrated that healing and recovering evolved in five phases: (1) self-awareness: gained self-awareness of their responsibilities in life and their fear of death; (2) the inter-relatedness of life: awareness of the need to seek help from professionals, friends and family for support; (3) the cyclical nature of human emotions: reappearance of stressors and activators causing psyche disharmony; (4) adjustment: changes in adjustment patterns of behaviour, discovering and owning one's own unique emotions, deflecting attention from stressors and facing reality and (5) acceptance: accepting the reality of life and investing in life.

CONCLUSION

The healing and recovery process symbolises an emotional navigation wheel. While each phase might follow the preceding phase, it is not a linear process, and patients might move backwards and forwards through the phases depending on the nursing interventions they receive coupled with their motivation to heal. It is important for nurses to use advanced communication skills to enable them to co-travel therapeutically with patients.

RELEVANCE TO CLINICAL PRACTICE

Listening to patients' voices and analysing their healing and recovery process could serve as a reference for psychiatric nurses to use to inform therapeutic interventions.

Failing to fail: clinicians' experience of assessing underperforming dental students

INTRODUCTION

Anecdotal evidence within a UK dental school indicated that staff's grading did not always match their evaluation of students' clinical proficiency. The invalid assessment of underperforming students, which has considerable ramifications, has been reported internationally for students of nursing and medicine, but a database search revealed no accounts for dental education.

AIM

To develop an understanding of clinicians' approaches to assessing underperforming dental students.

METHODOLOGY

Seventeen clinical staff were interviewed (eleven females, six males). Interviews were recorded and transcribed verbatim. A grounded theory methodology was used, with simultaneous data collection and analysis. The main analytical technique was constant comparison.

FINDINGS

Participants' shared basic problem was Assessing undergraduate students, expressed as how they evaluated and used the assessment system or perceived others to do so. The core category, which explains what clinical staff do to manage their difficulties with assessment, was identified as Failing to Fail and has three subcategories: Evaluating the Assessment System, Shielding the Student and Protecting Myself.

CONCLUSION

This study has substantiated the complexity of failing to fail and confirmed that some causes are shared across healthcare professions, although insufficient staff discussion, the avoidance of confrontation and the impact of negative student attitude are not reported elsewhere or are minor findings. It is recommended that clinical staff receive additional training in assessment and that they are made more aware of their learning needs, their attitudes and beliefs. Increased discussion between staff about assessment and about students known to be in difficulty is essential.

The importance of optimism in maintaining healthy aging in rural Alaska

Many Alaska Native Elders attended government-run boarding schools as children, were forbidden to speak their native language, and were forced to abandon their traditional subsistence lifestyle, yet they maintained an optimistic outlook on life and continued to age well. The Explanatory Model Interview Protocol was adapted to interview a purposive sample of Alaska Native Elders (n = 26) and grounded theory was used to develop a model of successful aging for Alaska Native Elders in Bristol Bay, Alaska. The theme of optimism was significant in the findings and was also found in each of the elements of successful aging, which were spirituality, emotional well-being, community engagement, and physical health. These four elements served as the foundation of the Model of Successful Aging. The Elders believed they were able to age successfully because they continued to be optimistic despite the challenges they faced (and are currently facing) in their communities.

Coronary heart disease patients transitioning to a normal life: perspectives and stages identified through a grounded theory approach

AIMS AND OBJECTIVES

To explore how Iranian patients with coronary heart disease experience their lives.

BACKGROUND

Coronary heart disease is a leading cause of death in Iran and worldwide. Understanding qualitatively how patients experience the acute and postacute stages of this chronic condition is essential knowledge for minimising the negative consequences of coronary heart disease.

DESIGN

Qualitative study using grounded theory for the data analysis.

METHODS

Data for this study were collected through individual qualitative interviews with 24 patients with coronary heart disease, conducted between January 2009 and January 2011. Patients with angina pectoris were selected for participation through purposive sampling, and sample size was determined by data saturation. Data analysis began with initial coding and continued with focused coding. Categories were determined, and the core category was subsequently developed and finalised.

RESULTS

The main categories of the transition from acute phase to a modified or 'new normal' life were: (1) Loss of normal life. Experiencing emotions and consequences of illness; (2) Coming to terms. Using coping strategies; (3) Recreating normal life. Healthcare providers must correctly recognise the stages of transition patients navigate while coping with coronary heart disease to support and educate them appropriately throughout these stages.

CONCLUSION

Patients with coronary heart disease lose their normal lives and must work towards recreating a revised life using coping strategies that enable them to come to terms with their situations.

RELEVANCE TO CLINICAL PRACTICE

By understanding Iranian patients' experiences, healthcare providers and especially nurses can use the information to support and educate patients with coronary heart disease on how to more effectively deal with their illness and its consequences.

Mothers going to war: the role of nurse practitioners in the care of military mothers and families during deployment

PURPOSE

Many military women are being called to separate from their children to go to war. Most previous research has focused upon paternal, rather than, maternal, separation. The purpose of this article is to describe the experience of military mothers and their children during wartime deployments with clinical implications for nurse practitioners (NPs) in military or community settings.

DATA SOURCES

Using grounded theory methods, 37 active duty and reserve component military women participated in a one-time interview. Included were women who deployed for at least 4 months to Iraq or Afghanistan and had at least one child under the age of 12 during the separation.

CONCLUSIONS

Military families present unique challenges for NPs. Mother deployments offer opportunities for intervention and anticipatory guidance across the trajectory of the separation. Military women's emotional and physical health must be supported before, during, and following deployment.

IMPLICATIONS FOR PRACTICE

NPs are ideally positioned to support military families. During deployment, the NP's focus may shift to care of the children and their caregiver. Before and at reintegration, NPs are in a key position to intervene early for posttraumatic stress and support family readjustment.

Patients' perceptions of waiting for bariatric surgery: a qualitative study

BACKGROUND

In Canada waiting lists for bariatric surgery are common, with wait times on average > 5 years. The meaning of waiting for bariatric surgery from the patients' perspective must be understood if health care providers are to act as facilitators in promoting satisfaction with care and quality care outcomes. The aims of this study were to explore patients' perceptions of waiting for bariatric surgery, the meaning and experience of waiting, the psychosocial and behavioral impact of waiting for treatment and identify health care provider and health system supportive measures that could potentially improve the waiting experience.

METHODS

Twenty-one women and six men engaged in in-depth interviews that were digitally recorded, transcribed verbatim and analysed using a grounded theory approach to data collection and analysis between June 2011 and April 2012. The data were subjected to re-analysis to identify perceived health care provider and health system barriers to accessing bariatric surgery.

RESULTS

Thematic analysis identified inequity as a barrier to accessing bariatric surgery. Three areas of perceived inequity were identified from participants' accounts: socioeconomic inequity, regional inequity, and inequity related to waitlist prioritization. Although excited about their acceptance as candidates for surgery, the waiting period was described as stressful, anxiety provoking, and frustrating. Anger was expressed towards the health care system for the long waiting times. Participants identified the importance of health care provider and health system supports during the waiting period. Recommendations on how to improve the waiting experience included periodic updates from the surgeon's office about their position on the wait list; a counselor who specializes in helping people going through this surgery, dietitian support and further information on what to expect after surgery, among others.

CONCLUSION

Patients' perceptions of accessing and waiting for bariatric surgery are shaped by perceived and experienced socioeconomic, regional, and waitlist prioritization inequities. A system addressing these inequities must be developed. Waiting for surgery is inherent in publicly funded health care systems; however, ensuring equitable access to treatment should be a health system priority. Supports and resources are required to ensure the waiting experience is as positive as possible.

The transition of childbirth practices among tribal women in Gujarat, India - a grounded theory approach

BACKGROUND

Under the National Rural Health Mission, the current emphasis is on achieving universal institutional births through incentive schemes as part of reforms related to childbirth in India. There has been rapid progress in achieving this goal. To understand the choices made as well as practices and perceptions related to childbirth amongst tribal women in Gujarat and how these have been influenced by modernity in general and modernity brought in through maternal health policies.

METHOD

A model depicting the transition in childbirth practices amongst tribal women was constructed using the grounded theory approach with; 8 focus groups of women, 5 in depth interviews with traditional birth attendants, women, and service providers and field notes on informal discussions and observations.

RESULTS

A transition in childbirth practices across generations was noted, i.e. a shift from home births attended by Traditional Birth Attendants (TBAs) to hospital births. The women and their families both adapted to and shaped this transition through a constant 'trade-off between desirable and essential'- the desirable being a traditional homebirth in secure surroundings and the essential being the survival of mother and baby by going to hospital. This transition was shaped by complex multiple factors: 1) Overall economic growth and access to modern medical care influencing women's choices, 2) External context in terms of the international maternal health discourses and national policies, especially incentive schemes for promoting institutional deliveries, 3) Socialisation into medical childbirth practices, through exposure to many years of free outreach services for maternal and child health, 4) Loss of self reliance in the community as a consequence of role redefinition and deskilling of the TBAs and 5) Cultural belief that intervention is necessary during childbirth aiding easy acceptance of medical interventions.

CONCLUSION

In resource poor settings where choices are limited and mortality is high, hospital births are perceived as increasing the choices for women, saving lives of mothers and babies, though there is a need for region specific strategies. Modern obstetric technology is utilised and given meanings based on socio-cultural conceptualisations of birth, which need to be considered while designing policies for maternal health.

A Roy model study of adapting to being HIV positive

Roy's adaptation model outlines a generic process of adaptation useful to nurses in any situation where a patient is facing change. To advance nursing practice, nursing theories and frameworks must be constantly tested and developed through research. This article describes how the results of a qualitative grounded theory study have been used to test components of the Roy adaptation model. A framework for "negotiating uncertainty" was the result of a grounded theory study exploring adaptation to HIV. This framework has been compared to the Roy adaptation model, strengthening concepts such as focal and contextual stimuli, Roy's definition of adaptation and her description of adaptive modes, while suggesting areas for further development including the role of perception. The comparison described in this article demonstrates the usefulness of qualitative research in developing nursing models, specifically highlighting opportunities to continue refining Roy's work.

Promoting an equal and healthy environment: Swedish students' views of daily life at school

Education is an important factor in health equity, but many students still do not complete high school. A focus on the school context rather than on individual problems might help to create a supportive environment for health and learning. In this study we explored factors that promote health and learning from the perspective of vocational and low-achieving high school students in Sweden. We used grounded theory with a constructivist orientation, informed and sensitized by the concept of salutogenesis. Students from a school in a mid-sized municipality in Sweden participated, and we collected data using the photovoice method and interviews. Students identified general factors as significant to their well-being and success in school. The main theme, "promoting driving forces for health and learning," emerged from the categories "longing to be seen by teachers," "longing for support," and "longing for recuperation."

The interaction between the patient and nurse anesthetist immediately before elective coronary artery bypass surgery

PURPOSE

Establishing a purposive interaction with a patient who is in a vulnerable situation before coronary artery bypass graft (CABG) surgery poses a challenge for the nurse anesthetist. The aim of this study was to identify and describe the interaction between the patient and the nurse anesthetist immediately before elective CABG surgery.

DESIGN

An observational study using a grounded theory design was used.

METHODS

A theoretical selection of patients and nurse anesthetists was made. A total of 11 situations of patient/nurse anesthetist interaction were observed. The data were analyzed using the constant comparative method.

FINDINGS

A core category of reassurance emerged from other categories of continuity, confirmation, and control. Continuity was characterized by expedient anesthesia nursing of high quality, confirmation was related to communication in a trusting atmosphere, and control was associated with skilled nursing interventions in the thoracic operating theatre.

CONCLUSIONS

Reassurance can be achieved through a well-structured anesthesia nursing performance in the thoracic operating theatre, and by focusing on the patient and continuously giving him/her information during the preoperative preparation phase.

Perceptions of living with a device-based treatment: an account of patients treated with deep brain stimulation for Parkinson's disease

OBJECTIVES

Deep brain stimulation (DBS) is an established treatment for Parkinson's disease. Little is known about patients' own perceptions of living with the implanted hardware. We aimed to explore patients' own perceptions of living with an implanted device.

MATERIALS AND METHODS

Semistructured interviews with open-ended questions were conducted with 42 patients (11 women) who had been on DBS for a mean of three years. The questions focused on patients' experiences of living with and managing the DBS device. The interviews were transcribed verbatim and analyzed according to the difference and similarity technique in grounded theory.

RESULTS

From the patients' narratives concerning living with and managing the DBS device, the following four categories emerged: 1) The device-not a big issue: although the hardware was felt inside the body and also visible from outside, the device as such was not a big issue. 2) Necessary carefulness: Patients expressed the need to be careful when performing certain daily activities in order not to dislocate or harm the device. 3) Continuous need for professional support: Most patients relied solely on professionals for fine-tuning the stimulation rather than using their handheld controller, even if this entailed numerous visits to a remote hospital. 4) Balancing symptom relief and side-effects: Patients expressed difficulties in finding the optimal match between decrease of symptoms and stimulation-induced side-effects.

CONCLUSIONS

The in-depth interviews of patients on chronic DBS about their perceptions of living with an implanted device provided useful insights that would be difficult to capture by quantitative evaluations.

Nurses' perspectives on the intersection of safety and informed decision making in maternity care

OBJECTIVE

To explore maternity nurses' perceptions of women's informed decision making during labor and birth to better understand how interdisciplinary communication challenges might affect patient safety.

DESIGN

Constructivist grounded theory.

SETTING

Four hospitals in the western United States.

PARTICIPANTS

Forty-six (46) nurses and physicians practicing in maternity units.

METHOD

Data collection strategies included individual interviews and participant observation. Data were analyzed using the constant comparative method, dimensional analysis, and situational analysis (Charmaz, 2006; Clarke, 2005; Schatzman, 1991).

RESULTS

The nurses' central action of holding off harm encompassed three communication strategies: persuading agreement, managing information, and coaching of mothers and physicians. These strategies were executed in a complex, hierarchical context characterized by varied practice patterns and relationships. Nurses' priorities and patient safety goals were sometimes misaligned with those of physicians, resulting in potentially unsafe communication.

CONCLUSIONS

The communication strategies nurses employed resulted in intended and unintended consequences with safety implications for mothers and providers and had the potential to trap women in the middle of interprofessional conflicts and differences of opinion.

Perspectives on medicine adherence in service users and carers with experience of legally sanctioned detention and medication: a qualitative study

AIM

To explore and analyze perceptions of service users and caregivers on adherence and nonadherence to medication in a mental health care context.

BACKGROUND

Mental health medication adherence is considered problematic and legal coercion exists in many countries.

DESIGN

This was a qualitative study aiming to explore perceptions of medication adherence from the perspective of the service user (and their caregiver, where possible).

PARTICIPANTS

Eighteen mental health service users (and six caregivers) with histories of medication nonadherence and repeated compulsory admission were recruited from voluntary sector support groups in England.

METHODS

Data were collected between 2008 and 2010. Using qualitative coding techniques, the study analyzed interview and focus group data from service users, previously subjected to compulsory medication under mental health law, or their caregivers.

RESULTS

The process of medication adherence or nonadherence is encapsulated in an explanatory narrative. This narrative constitutes participants' struggle to negotiate acceptable and effective routes through variable quality of care. Results indicated that service users and caregivers eventually accepted the reality of their own mental illness and their need for safety and treatment. They perceived the behavior of professionals as key in their recovery process. Professionals could be enabling or disabling with regard to adherence to medication.

CONCLUSION

This study investigated service user and caregiver perceptions of medication adherence and compulsory treatment. Participants described a process perceived as variable and potentially doubly faceted. The behavior of professionals was seen as crucial in collaborative decision making on medication adherence.

Effortless awareness: using real time neurofeedback to investigate correlates of posterior cingulate cortex activity in meditators' self-report

Neurophenomenological studies seek to utilize first-person self-report to elucidate cognitive processes related to physiological data. Grounded theory offers an approach to the qualitative analysis of self-report, whereby theoretical constructs are derived from empirical data. Here we used grounded theory methodology (GTM) to assess how the first-person experience of meditation relates to neural activity in a core region of the default mode network-the posterior cingulate cortex (PCC). We analyzed first-person data consisting of meditators' accounts of their subjective experience during runs of a real time fMRI neurofeedback study of meditation, and third-person data consisting of corresponding feedback graphs of PCC activity during the same runs. We found that for meditators, the subjective experiences of "undistracted awareness" such as "concentration" and "observing sensory experience," and "effortless doing" such as "observing sensory experience," "not efforting," and "contentment," correspond with PCC deactivation. Further, the subjective experiences of "distracted awareness" such as "distraction" and "interpreting," and "controlling" such as "efforting" and "discontentment," correspond with PCC activation. Moreover, we derived several novel hypotheses about how specific qualities of cognitive processes during meditation relate to PCC activity, such as the difference between meditation and "trying to meditate." These findings offer novel insights into the relationship between meditation and mind wandering or self-related thinking and neural activity in the default mode network, driven by first-person reports.

Practical support aids addiction recovery: the positive identity model of change

BACKGROUND

There is a need for studies that can highlight principles of addiction recovery. Because social relationships are involved in all change processes, understanding how social motivations affect the recovery process is vital to guide support programs.

METHODS

The objective was to develop a model of recovery by examining addicted individuals' social motivations through longitudinal assessment of non-professional support dyads. A qualitative, longitudinal study design was used, combining focus groups and in-depth interviews with addicted individuals and their sponsors. Data were analyzed using the principles of grounded theory: open coding and memos for conceptual labelling, axial coding for category building, and selective coding for theory building. The setting was an addiction recovery social support program in Oslo, Norway. The informants included nine adults affected by addiction, six sponsors, and the program coordinator. The participants were addicted to either alcohol (2), benzodiazepines (1), pain killers (1) or polydrug-use (5). The sponsors were unpaid, and had no history of addiction problems.

RESULTS

Support perceived to be ineffective emerged in dyads with no operationalized goal, and high emotional availability with low degree of practical support. Support perceived to be effective was signified by the sponsor attending to power imbalance and the addict coming into position to help others and feel useful.

CONCLUSIONS

The findings appear best understood as a positive identity-model of recovery, indicated by the pursuit of skill building relevant to a non-drug using identity, and enabled by the on-going availability of instrumental support. This produced situations where role reversals were made possible, leading to increased self-esteem. Social support programs should be based on a positive identity-model of recovery that enable the building of a life-sustainable identity.

Professionals' perceptions of the effect of pornography on Swedish adolescents

OBJECTIVE

The aims were to gain a deeper understanding of how personnel, who work with adolescents, reason about the effect of pornography and its spread in the media, and to explore how well prepared they consider themselves to be in addressing sexual health and gender equality.

DESIGN AND SAMPLE

An inductive, exploratory, qualitative study with focus group discussions was selected. Seventeen participants with different professions were invited into five heterogeneous groups.

MEASURES

Data were analyzed according to grounded theory.

RESULTS

Conflicting messages about sexuality became the core category. Participants were of the opinion that pornography conveyed a contradictory message compared with national public health goals, societal laws, and regulations. They believed that young people use pornography as a source of information and stimulation. Furthermore, they thought that pornography contributed to norm-creating ideals and a demanding sexuality, thus, confirming the traditional gender order. The participants opined that a professional approach was required when addressing sexuality and gender equality issues and requested better training tools and more cultural competence.

CONCLUSIONS

Professionals working with adolescents perceived that pornography conveys a conflicting message about sexuality. They expressed a need for adequate tools for improving education on health and sexuality, including gender equality aspects and critical media analysis.

Women's decision making and experience of subsequent pregnancy following stillbirth

INTRODUCTION

This study sought to increase understanding of women's thoughts and feelings about decision making and the experience of subsequent pregnancy following stillbirth (intrauterine death after 24 weeks' gestation).

METHODS

Eleven women were interviewed, 8 of whom were pregnant at the time of the interview. Modified grounded theory was used to guide the research methodology and to analyze the data.

RESULTS

A model was developed to illustrate women's experiences of decision making in relation to subsequent pregnancy and of subsequent pregnancy itself.

DISCUSSION

The results of the current study have significant implications for women who have experienced stillbirth and the health professionals who work with them. Based on the model, women may find it helpful to discuss their beliefs in relation to healing and health professionals to provide support with this in mind. Women and their partners may also benefit from explanations and support about the potentially conflicting emotions they may experience during this time.

Exploring the process of women's infant feeding decisions in the early postbirth period

Research indicates that multiple factors are associated with decisions women make about infant feeding, yet few studies have explored the decision-making process. In this article, we present the analysis that produced the core category "deconstructing best," previously reported as part of a grounded theory exploring 37 Australian women's infant feeding experiences and decisions in the first 6 weeks postbirth. We expand on the previous article by detailing and discussing the phases of the infant feeding decision-making process in relation to decision-making theory. Analysis demonstrates the importance of these early weeks in shaping women's infant feeding trajectories. Findings illustrate that information gathering encompassing multiple factors occurred at this time, and that complex and often competing goals were involved in the women's decisions. We suggest that acknowledging and assisting women to meet alternate goals in the postbirth period might help them meet their breastfeeding goals.

Health effects of digital textbooks on school-age children: a grounded theory approach

This qualitative study used the grounded theory approach to analyze digital textbook-related health experiences of school-age children. In-depth interviews were held with 40 elementary school students who had used digital textbooks for at least a year. Data analysis revealed a total of 56 concepts, 20 subcategories, and 11 categories related to digital textbook health issues, the central phenomena being "health-related experiences." Students' health-related experiences were classified into "physical" and "psychological" symptoms. Adverse health effects related to digital textbook usage were addressed via both "student-led" and "instructor-led" coping strategies. Students' coping strategies were often inefficient, but instructor-led strategies seemed to prevent health problems. When health issues were well managed, students tended to accept digital textbooks as educational tools. Our findings suggest that students can form healthy computer habits if digital textbook usage is directed in a positive manner.

Development of an instrument to measure the degree of critical patient's satisfaction with nursing care: research protocol

AIM

To investigate and understand patient's satisfaction with nursing care in the intensive care unit to identify the dimensions of the concept of 'satisfaction' from the patient's point of view. To design and validate a questionnaire that measures satisfaction levels in critical patients.

BACKGROUND

There are many instruments capable of measuring satisfaction with nursing care; however, they do not address the reality for critical patients nor are they applicable in our context.

DESIGN

A dual approach study comprising: a qualitative phase employing Grounded Theory and a quantitative and descriptive phase to prepare and validate the questionnaire.

METHODS

Data collection in the qualitative phase will consist of: in-depth interview after theoretical sampling, on-site diary and expert discussion group. The sample size will depend on the expected theoretical saturation n = 27-36. Analysis will be based on Grounded Theory. For the quantitative phase, the sampling will be based on convenience (n = 200). A questionnaire will be designed on the basis of qualitative data. Descriptive and inferential statistics will be used. The validation will be developed on the basis of the validity of the content, the criteria of the construct and reliability of the instrument by the Cronbach's alpha and test-retest approach. Approval date for this protocol was November 2010.

DISCUSSION

Self-perceptions, beliefs, experiences, demographic, socio-cultural epistemological and political factors are determinants for satisfaction, and these should be taken into account when compiling a questionnaire on satisfaction with nursing care among critical patients.

I've lost the person I used to be--experiences of the consequences of fatigue following myocardial infarction

Fatigue has been found to be the most frequent and bothersome symptom after myocardial infarction (MI), influencing health-related quality of life negatively. Moreover, fatigue after MI has been described as incomprehensible due to its unpredictable occurrence and lack of relationship to physical effort. The aim of this study is therefore to explore persons’ experiences of consequences of fatigue and their strategies for dealing with it 2 months after MI. In total, 18 informants, aged 42–75 years, participated in the study. Interviews were conducted and analysed using constructivist grounded theory methodology. Grounded in the data, the main consequence of fatigue, as illustrated in the core category, was: I’ve lost the person I used to be. It indicates a sense of reduced ability to manage daily life due to experiences of fatigue. The core category was developed from the four categories: involuntary thoughts, certainties replaced with question marks, driving with the handbrake on and just being is enough. Furthermore, attempts to relieve fatigue were limited. These findings indicate that patients with symptoms of fatigue should be supported in developing relief strategies, for example, rest and sleep hygiene as well as physical activity. In conclusion, the results show that fatigue can be understood in light of the concepts “comprehensibility” and “manageability.” They also indicate that, working from a person-centered perspective, health-care professionals can support patients experiencing post-MI fatigue by giving them opportunities to straighten out the question marks and by inviting them to discuss involuntary thoughts and feelings of being restricted in their daily life functioning.

Diagnosis of dementia as a turning point among Finnish families: a qualitative study

The experiences of receiving a diagnosis of dementia from the viewpoint of people with dementia and their family members were explored in this study. Purposive sampling was used to recruit people with newly-diagnosed dementia (n = 8) and their family members (n = 8) from a university hospital's memory clinic in northern Finland. Data were collected using low-structured interviews, and analyzed using the stages of grounded theory. The diagnosis of dementia was a mutual turning point in the family, and it was experienced and responded to in shared processes within the family. In a changing life situation, close ones became a significant resource, and focus on the present day was emphasized. Individuals with dementia and their family members aimed to live meaningful lives by being active agents. Understanding the individual and shared experiences of both those with dementia and their family members can help health professionals design and carry out tailored early psychosocial interventions for families to assist them to create a shared understanding of living with dementia.

Nutritional rehabilitation after ICU - does it happen: a qualitative interview and observational study

AIMS AND OBJECTIVES

To compare and contrast current nutritional rehabilitation practices against recommendations from National Institute for Health and Excellence guideline Rehabilitation after critical illness (NICE) (2009, http://www.nice.org.uk/cg83).

BACKGROUND

Recovery from critical illness has gained increasing prominence over the last decade but there is remarkably little research relating to nutritional rehabilitation.

DESIGN

The study is a qualitative study based on patient interviews and observations of ward practice.

METHODS

Seventeen patients were recruited into the study at discharge from the intensive care unit (ICU) of a large teaching hospital in central Scotland in 2011. Semi-structured interviews were conducted on transfer to the ward and weekly thereafter. Fourteen of these patients were followed up at three months post-ICU discharge, and a semi-structured interview was carried out. Observations of ward practice were carried out twice weekly for the duration of the ward stay.

RESULTS

Current nutritional practice for post-intensive care patients did not reflect the recommendations from the NICE guideline. A number of organisational issues were identified as influencing nutritional care. These issues were categorised as ward culture, service-centred delivery of care and disjointed discharge planning. Their influence on nutritional care was compounded by the complex problems associated with critical illness.

CONCLUSIONS

The NICE guideline provides few nutrition-specific recommendations for rehabilitation; however, current practice does not reflect the nutritional recommendations that are detailed in the rehabilitation care pathway.

RELEVANCE TO CLINICAL PRACTICE

Nutritional care of post-ICU patients is problematic and strategies to overcome these issues need to be addressed in order to improve nutritional intake.

From risky to safer home care: health care assistants striving to overcome a lack of training, supervision, and support

Patients receiving home care are becoming increasingly dependent upon competent caregivers’ 24-h availability due to their substantial care needs, often with advanced care and home care technology included. In Sweden, care is often carried out by municipality-employed paraprofessionals such as health care assistants (HC assistants) with limited or no health care training, performing advanced care without formal training or support. The aim of this study was to investigate the work experience of the HC assistants and to explore how they manage when delivering 24-h home care to patients with substantial care needs. Grounded theory methodology involving multiple data sources comprising interviews with HC assistants (n=19) and field observations in patients’ homes was used to collect data and constant comparative analysis was used for analysis. The initial analysis revealed a number of barriers, competence gap; trapped in the home setting; poor supervision and unconnected to the patient care system, describing the risks associated with the situations of HC assistants working in home care, thus affecting their working conditions as well as the patient care. The core process identified was the HC assistants’ strivings to combine safe home care with good working conditions by using compensatory processes. The four identified compensatory processes were: day-by-day learning; balancing relations with the patient; self-managing; and navigating the patient care system. By actively employing the compensatory processes, the HC assistants could be said to adopt an inclusive approach, by compensating for their own barriers as well as those of their colleagues’ and taking overall responsibility for their workplace. In conclusion, the importance of supporting HC assistants in relation to their needs for training, supervision,and support from health care professionals must be addressed when organising 24-h home care to patients with substantial care needs in the future.

Understanding palliative care on the heart failure care team: an innovative research methodology

CONTEXT

There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team.

OBJECTIVES

To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team.

METHODS

This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams.

RESULTS

We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps.

CONCLUSION

We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

Seeking life balance: the perceptions of health of Cambodian women in resettlement

This grounded theory study in California, United States was an inquiry into the perceptions of health of Cambodian women in resettlement. The sequelae of significant life trauma on the health of women who escaped political conflict have received little attention in the nursing literature. Thirty-nine Cambodian women were recruited through a social service organization and verbal referrals. Open-ended questions and a conversational approach to dialogue and data gathering facilitated the interview process. Women were interviewed at home or the local temple. Seeking life balance emerged as the core perspective of this study. The relationships between thematic categories of seeking life balance, patterns of knowing, and caring for self were salient. Outcomes of these interrelationships further moved women's health toward disharmony or harmony. The findings of this study are limited by sampling participants in a tightly networked community and may serve as a pilot for future research.

Navigating hardships in old age: exploring the relationship between spirituality and resilience in later life

Research suggests that spirituality is important to a large percentage of the older adult population and serves as a promoter of healthy aging. In this qualitative research I conducted and analyzed multiple interviews with 6 women aged 80 and older. Using multiple in-depth interviews I explored the interplay between spirituality and resilience over the life course. A grounded theory analysis of the 30 interviews was performed. The major finding is that participants used their spirituality as a tool to promote and maintain resilience in later life. I present the results as an interpretation of the participants' perceptions of their spirituality, and indicate their reliance on spirituality to overcome hardship over the life course. In addition, I discuss the connections between spirituality and resilience. The roles these two constructs play in the lives of older adults are considered.

Motivational journey of Iranian bachelor of nursing students during clinical education: a grounded theory study

This study explored how nursing students can be kept motivated throughout their clinical education. Motivation is a key issue in nursing clinical education for student retention. The study was conducted using grounded theory methods, which are appropriate when studying process in a social context. Sixteen students and four instructors, who were purposefully selected, participated in semistructured interviews. Data were analyzed using the constant comparative method. Students' motivational journey occurred in three steps: (i) social condition; (ii) encountering the clinical education challenges; and (iii) looking for an escape from nursing, or simply tolerating nursing. Struggling with professional identity emerged as the core variable. Iran's social context and many other conditions in the clinical education setting affect students' motivation. Identifying motivational process might assist educational authorities in offering solutions to promote motivation among students.

The process of community health nursing clinical clerkship: A grounded theory

BACKGROUND

The performance of the community health nurse depends on a combination of scientific and practical competencies acquired by educational experiences during the nursing course. Curriculum planners of nursing education need to understand nursing education to train professional and community-oriented nurses. The aim of this article is to explore the experiences of nursing students during their community health nursing clinical clerkship courses.

MATERIALS AND METHODS

A grounded theory approach was used to conduct this study. Twelve nursing students, 13 health-care staff members, and 10 nursing instructors were interviewed individually in 2011-2012. The interviews were tape-recorded and later transcribed verbatim. The transcriptions were analyzed using the method of Strauss and Corbin.

RESULTS

AMBIVALENCE OF MOTIVATION WAS THE MAIN CATEGORY AND INCLUDED FIVE SUBCATEGORIES: Professional identity, educational atmosphere, educational management, motivation-based approaches, and inadequate productivity. This paper presents the aspects of the community health nursing clerkship course from the viewpoint of students in areas such as the role of the community health nurse, attitude toward the course, medical orientation, prerequisite skills/knowledge, poor administrative planning, rotation of students, insufficient activity for students, passiveness, providing service to clients, responsibility, and inproductivity. These categories could explain the nature of the community health nursing clerkship of the Mashhad Faculty of Nursing and probably others in Iran.

CONCLUSIONS

The findings revealed inadequate productivity of the community health nursing education; so, it is suggested to define a position for nurses in this setting and remove barriers and provide conditions for them to play more important roles in the promotion of community health.

A grounded theory approach to understand the process of decision making on fertility control methods in urban society of Mashhad, Iran

BACKGROUND

More than 30% of pregnancies in Iran are unintended and most of them happen among the women who use various contraceptive methods. Results of Integrated Monitoring and Evaluation System (IMES) showed that the rate of innovative contraceptive use in Mashhad has been 41.5%-57% in different urban areas. This study was conducted to explore the process of making decision toward using family planning methods in women of reproductive age in urban society of Mashhad, Iran.

MATERIALS AND METHODS

In this grounded theory study, semi-structured interviews were conducted with 45 purposefully selected participants including 28 women and 17 key informants including family health providers and managers, and participants' mothers and husbands, who lived in urban society of Mashhad, Iran, in 2011-2012. Participants' recruitment continued until data saturation occurred. Data were analyzed using Strauss and Corbin's mode of analysis through constant comparative method, applying levels of open, axial, and selective coding with MAXqda software. Study rigor was confirmed through prolonged engagement, member check, expert debriefing, and thick description of the data.

RESULTS

The core category of "caring the comprehensive health of my family," which emerged from the data, described the process of couples' decision making toward using family planning methods in this study. Other developed categories which were presented into a theoretical scheme consisted of 1) shaping the ideas of fertility control, 2) developing cognition about the fertility control methods, 3) appraising available choices and choosing the most appropriate one, 4) managing the course of using methods, and 5) realizing the fertility intentions.

CONCLUSION

It is important that family planning providers understand the motivations, perceptions, and knowledge of women about contraceptive methods in their contextual situation, which illustrates their mode of interaction in the arenas of family planning decision making.

Living fully in the shadow of mortal time: psychosocial assets in advanced cancer

OBJECTIVE

This study aimed to characterize the strategies and psychosocial conditions that influence how resilient people live in the face of advanced cancer.

METHODS

Grounded theory interviews and a survey of 10 resilient people with advanced cancer were collected and analyzed.

FINDINGS

Personal assets - including positive relationships, purpose in life, faith, and mastery--contributed to living fully in mortal time. Strategies included embracing paradox, reframing time, deepening connections, and aligning actions with priorities. Open-ended interviews yielded rich illness and life stories; many participants requested a copy of the transcript.

CONCLUSION

Resilient people use a range of strategies to thrive in the face of advanced cancer.

Preparing culture change agents for academic medicine in a multi-institutional consortium: the C - change learning action network

INTRODUCTION

Research suggests an ongoing need for change in the culture of academic medicine. This article describes the structure, activities and evaluation of a culture change project: the C - Change Learning Action Network (LAN) and its impact on participants. The LAN was developed to create the experience of a culture that would prepare participants to facilitate a culture in academic medicine that would be more collaborative, inclusive, relational, and that supports the humanity and vitality of faculty.

METHODS

Purposefully diverse faculty, leaders, and deans from 5 US medical schools convened in 2 1/2-day meetings biannually over 4 years. LAN meetings employed experiential, cognitive, and affective learning modes; innovative dialogue strategies; and reflective practice aimed at facilitating deep dialogue, relationship formation, collaboration, authenticity, and transformative learning to help members experience the desired culture. Robust aggregated qualitative and quantitative data collected from the 5 schools were used to inform and stimulate culture-change plans.

RESULTS

Quantitative and qualitative evaluation methods were used. Participants indicated that a safe, supportive, inclusive, collaborative culture was established in LAN and highly valued. LAN members reported a deepened understanding of organizational change, new and valued interpersonal connections, increased motivation and resilience, new skills and approaches, increased self-awareness and personal growth, emotional connection to the issues of diversity and inclusion, and application of new learnings in their work.

DISCUSSION

A carefully designed multi-institutional learning community can transform the way participants experience and view institutional culture. It can motivate and prepare them to be change agents in their own institutions.

'Working behind the scenes'. An ethical view of mental health nursing and first-episode psychosis

The aim of this study was to explore and reflect upon mental health nursing and first-episode psychosis. Seven multidisciplinary focus group interviews were conducted, and data analysis was influenced by a grounded theory approach. The core category was found to be a process named 'working behind the scenes'. It is presented along with three subcategories: 'keeping the patient in mind', 'invisible care' and 'invisible network contact'. Findings are illuminated with the ethical principles of respect for autonomy and paternalism. Nursing care is dynamic, and clinical work moves along continuums between autonomy and paternalism and between ethical reflective and non-reflective practice. 'Working behind the scenes' is considered to be in a paternalistic area, containing an ethical reflection. Treating and caring for individuals experiencing first-episode psychosis demands an ethical awareness and great vigilance by nurses. The study is a contribution to reflection upon everyday nursing practice, and the conclusion concerns the importance of making invisible work visible.

Adolescent boys with asthma - a pilot study on embodied gendered habits

Purpose

Asthma is a common chronic disease with gender differences in terms of severity and quality of life. This study aimed to understand the gendered practices of male asthmatic adolescents in terms of living with and managing their chronic disease. The study applied a sociological perspective to identify the gender-related practices of participants and their possible consequences for health and disease.

Patients and methods

The study used a combined ethnomethodology and grounded theory design, which was interpreted using Bourdieu’s theory of practice. We aimed to discover how participants interpreted their social worlds to create a sense of meaning in their everyday lives. The study was based on multistage focus group interviews with five adolescent participants at a specialist center for asthmatic children and youths. We took necessary precautions to protect the participants, according to the principles of the Declaration of Helsinki. The study protocol was approved by the Regional Committee for Medical Research Ethics and the hospital’s research department.

Results

The core concept for asthmatic male adolescents was being men. They were focused on being nonasthmatic, and exhibited ambivalence towards the principles of the health services. Physical activity supported their aim of being men and being nonasthmatic, as well as supported their treatment goals. Being fearless, unconcerned, “cool,” and dependent also supported the aim of being men and being nonasthmatic, but not the health service principle of regular medication. Occasionally, the participants were asthmatic when they were not able to or gained no advantages from being nonasthmatic. Their practice of being men independently of being asthmatic emphasized their deeply gendered habits.

Conclusion

Understanding gender differences in living with and managing asthma is important for health workers. Knowledge of embodied gendered habits and their reproduction in social interactions and clinical work should be exploited as a resource during the supervision of asthmatic adolescent boys.

Exploring transitions within a project-based Housing First setting: qualitative evaluation and practice implications

The Housing First (HF) approach is a model of housing that entails the provision of immediate, permanent, low-barrier, supportive housing to chronically homeless individuals either in separate apartments within a larger community (known as scattered-site HF) or in a single building (known as project-based HF). One recent innovation is the application of project-based HF with chronically homeless individuals with alcohol problems. Although initial studies have shown its effectiveness, there is currently no research on residents' and staff 's experiences living and working in a project-based HF program. The purpose of this article was to document these experiences and highlight strengths and challenges of project-based HF programs. Using data collected from naturalistic observations, agency documentation, one-on-one resident interviews, and a staff focus group, we delineated transitional periods, including moving into project-based HF, community-building, managing day-to-day, and transitions from project-based HF. Findings are interpreted to help health care policymakers and providers envision the role of project-based HF in comprehensive public health efforts and to integrate lessons learned into their own clinical practice.

How do surgeons decide to refer patients for adjuvant cancer treatment? Protocol for a qualitative study

BACKGROUND

Non-small cell lung cancer, breast cancer, and colorectal cancer are commonly diagnosed cancers in Canada. Patients diagnosed with early-stage non-small cell lung, breast, or colorectal cancer represent potentially curable populations. For these patients, surgery is the primary mode of treatment, with (neo)adjuvant therapies (e.g., chemotherapy, radiotherapy) recommended according to disease stage. Data from our research in Nova Scotia, as well as others', demonstrate that a substantial proportion of non-small cell lung cancer and colorectal cancer patients, for whom practice guidelines recommend (neo)adjuvant therapy, are not referred for an oncologist consultation. Conversely, surveillance data and clinical experience suggest that breast cancer patients have much higher referral rates. Since surgery is the primary treatment, the surgeon plays a major role in referring patients to oncologists. Thus, an improved understanding of how surgeons make decisions related to oncology services is important to developing strategies to optimize referral rates. Few studies have examined decision making for (neo)adjuvant therapy from the perspective of the cancer surgeon. This study will use qualitative methods to examine decision-making processes related to referral to oncology services for individuals diagnosed with potentially curable non-small cell lung, breast, or colorectal cancer.

METHODS

A qualitative study will be conducted, guided by the principles of grounded theory. The study design is informed by our ongoing research, as well as a model of access to health services. The method of data collection will be in-depth, semi structured interviews. We will attempt to recruit all lung, breast, and/or colorectal cancer surgeons in Nova Scotia (n ≈ 42), with the aim of interviewing a minimum of 34 surgeons. Interviews will be audiotaped and transcribed verbatim. Data will be collected and analyzed concurrently, with two investigators independently coding and analyzing the data. Analysis will involve an inductive, grounded approach using constant comparative analysis.

DISCUSSION

The primary outcomes will be (1) identification of the patient, surgeon, institutional, and health-system factors that influence surgeons' decisions to refer non-small cell lung, breast, and colorectal cancer patients to oncology services when consideration for (neo)adjuvant therapy is recommended and (2) identification of potential strategies that could optimize referral to oncology for appropriate individuals.

Teleconferencing as a source of social support for older spousal caregivers: initial explorations and recommendations for future research

Teleconferencing is increasingly being used as a medium of delivering social support for dementia caregivers. Further direction is required from pilot studies before the optimal clinical service can be delivered. Following a 6-week pilot support group for spousal caregivers, delivered via teleconferencing software, we interviewed 8 participants for their feedback. Semi-structured interviews were conducted and analyzed using grounded theory analysis. Themes of "group processes" and "barriers," containing subcategories of "functions of the group," "responsibilities of facilitators," and "barriers to communication" were discussed. According to caregivers, successful teleconferencing support groups should acknowledge the caregiver as the dementia expert, allow participants to meet before the deployment of the support group, provide active facilitation and leadership via the researcher, employ user-friendly technologies, and facilitate for the group to self-maintain following the pilot deployment period. These issues should be taken into consideration when designing future teleconferencing applications for caregivers.

'Expanding your mind': the process of constructing gender-equitable masculinities in young Nicaraguan men participating in reproductive health or gender training programs

Background

Traditional forms of masculinity strongly influence men's and women's wellbeing.

Objective

This study has two aims: (i) to explore notions of various forms of masculinities in young Nicaraguan men participating in programs addressing sexual health, reproductive health, and/or gender equality and (ii) to find out how these young men perceive their involvement in actions aimed at reducing violence against women (VAW).

Design

A qualitative grounded theory study. Data were collected through six focus groups and two in-depth interviews with altogether 62 young men.

Results

Our analysis showed that the informants experienced a process of change, labeled ‘Expanding your mind’, in which we identified four interrelated subcategories: The apprentice, The responsible/respectful man, The proactive peer educator, and ‘The feminist man’. The process showed how an increased awareness of gender inequities facilitated the emergence of values (respect and responsibility) and behavior (thoughtful action) that contributed to increase the informant's critical thinking and agency at individual, social, and political levels. The process was influenced by individual and external factors.

Conclusions

Multiple progressive masculinities can emerge from programs challenging patriarchy in this Latin American setting. The masculinities identified in this study show a range of attitudes and behaviors; however, all lean toward more equitable gender relations. The results suggest that learning about sexual and reproductive health does not directly imply developing more gender-equitable attitudes and behaviors or a greater willingness to prevent VAW. It is paramount that interventions to challenge machismo in this setting continue and are expanded to reach more young men.

Joint action between child health care nurses and midwives leads to continuity of care for expectant and new mothers

Reduction of the duration of postpartum hospital stay in western countries highlights the need for better support and continuity of care for expectant and new mothers. The aim of this study was to investigate strategies to improve continuity of care for expectant and new mothers. The study also aimed to elaborate on a preliminary substantive grounded theory model of "linkage in the chain of care" that had been developed earlier. Grounded theory methodology, which involved multiple data sources comprising structured interviews with midwives and child healthcare nurses (n=20), as well as mothers (n=21), participant observation, and written material, was used. Comparative analysis was used to analyse the data. To achieve continuity, three main strategies, transfer, establishing and maintaining a relation, and adjustment, were identified. These strategies for continuity formed the basis of the core category, joint action. In all the strategies for continuity, midwives and child healthcare nurses worked together. In addition, mothers benefited from the joint action and recognized continuity of care when strategies for continuity were implemented. The results are discussed in relation to the established concepts of continuity.

Experiences of low back pain in adolescents in relation to physiotherapy intervention

The aim of this study was to generate a substantive theory, based on interviews with children and adolescents with low back pain (LBP), explaining how they manage their main concerns in daily life. Tape-recorded open interviews were conducted with 14 boys and girls with LBP, aged 12-18 years, who participated in a 12-week physical therapy intervention. The grounded theory was used for analyzing the transcribed interviews. A core category, mobilizing own resources, emerged from the analysis, describing how adolescents with LBP succeed in managing their main concern, gaining body confidence, in daily life. The core category was divided into four categories labelled: coaching from the physiotherapist, seeking for information, compliance with physiotherapy and gaining energy from pain-free moments. The categories formed a substantive theory, illuminating how young people with LBP experienced physical therapy intervention. The theory explains and provides a deeper understanding of the main concerns of these adolescents and their strategies in managing their life situation.