Selecting a Grounded Theory Approach for Nursing Research

Lost and changed meaning in life of people with Long Covid: a qualitative study

Long Covid (LC) has been called the greatest mass-disabling event in human history. For patients, LC not only has implications for quality of life but also for meaning in life: how one's life and the world are understood and what is seen as valuable in one's life. This qualitative empirical study used a Constructivist Grounded Theory approach to investigate the meaning in life of people struggling with LC through ten patient interviews. This study shows that patients lose their prior understanding of life and come to a changed meaning in life, in part due to the experienced (social) isolation and loss of (both physical and cognitive) abilities caused by LC. Moreover, patients struggled with acceptance, uncertainty, and the inherent incomprehensibility and uncontrollability that living with LC entails, though this simultaneously co-existed with hope, optimism and acceptance. Additionally, dimensions of meaning intersect; a patient having some understanding of their illness (dimension of meaning: comprehension) required an understanding Other (dimension of meaning: connection). Emerging from lockdown brought the challenge and isolation of adjusting to chronic illness in society as usual (albeit divided about COVID-19 measures). This study thus offers novel insights regarding changed, present, and sought meaning in life for LC patients.

Making Conscientious Decisions: Engaging in Venous Leg Ulcer Self-Management Following Nurse-Led Patient Education

Venous leg ulcers (VLUs) provoke multiple symptoms and impact individuals and society as a whole. Their treatment and prevention strategies require individual's involvement in self-management strategies. Insufficient knowledge with regard to prevention, management, and treatment has been identified as a critical factor related to VLUs and their recurrence. Therapeutic patient education (TPE) proposed as part of a management strategy for this population provides unclear benefits regarding wounds healing or prevention of recurrence. The aim of the study was to develop a theory explaining how individuals with a VLU experience an individualized nurse-led TPE program regarding self-management strategies. The constructivist approach of Charmaz to the grounded theory method was used to develop the theory. A total of 26 individuals contributed to the co-construction of the theory through face-to-face or telephone semi-structured interviews. Data analysis and data collection occurs simultaneously with a comparative process to reveal the conceptual categories, apply theoretical sampling, and define theoretical saturation. The theory of "Conscientiously Engaging in Self-Management" was co-constructed with the participants encapsulating four categories: "Being influenced by my own story," "Being personally informed," "Making conscientious decisions to engage in self-adapted management strategies," and "Integrating a conscientious way of living." This theory highlights individuals' voices and stories toward their journey of VLU self-management taking contextual factors into consideration. This new theory offers new knowledge about implementation of self-management strategies for individuals living with a VLU and will inform clinical practice and contribute to the development of targeted interventions.

The four Cs of physician leadership: A key to academic physician success

Leadership is increasingly recognized as important in medicine. Physician leadership impacts healthcare delivery and quality. Little work has been done to determine how physician leadership in practice aligns with established models in leadership theory. We conducted 40 semi-structured, 50-minute interviews of physicians who had achieved the rank of professor in our school of medicine and were serving, or had served, in leadership positions. We used an inductive content analysis approach to identify content categories, with leadership emerging as one such category. Subsequently, for the present study, we performed a secondary analysis of the data. To do this, we reviewed all transcripts, seeking to identify if and how participants discussed leadership in relation to success in academic medicine. Following identification of sub-categories related to leadership, we performed qualitative content analysis. We then used a deductive content analysis approach to determine how participants' discussions of leadership aligned with major leadership theories. Then, the principal investigator conducted a secondary inductive content analysis revealing leadership themes that were synthesized into a new model of physician leadership. Twenty-nine participants spontaneously discussed leadership and leadership-related topics as important to their own academic success and comprised the present study cohort. Participants identified contributors to leadership success that aligned with multiple major leadership theories, including leadership traits, skills, behaviors styles, and situational leadership. None of the leadership theories aligned completely with our physician leaders' discussions, suggesting an alternate leadership framework was operating. Further analysis revealed a new model of leadership comprised of the "Four Cs of Physician Leadership": character, competence, caring, and communication. Our participant group of academic physicians identified leadership capabilities as being important in their academic success. While they discussed leadership in ways that fit to varying degrees with the major leadership theories, their discussions revealed a novel, more holistic leadership framework. Further work will be beneficial to determine if this model of leadership is specific to physicians or is more generalizable.

The Lived Experiences of Pregnant and Parenting Women in Recovery Toward Medication Treatment for Opioid Use Disorder

BACKGROUND

Maternal misuse of prescription opioids and illicit drugs such as, heroin and non-pharmaceutical fentanyl analogs has increased in the last 2 decades and one in 5 women reported misuse of opioids. Medications for opioid use disorder (MOUD) are recommended for treating pregnant women with opioid use disorder (OUD). MOUD is effective in reducing cravings and negative outcomes, yet treatment is underutilized and varies in integration and intensity of resources across health systems. Exploring perceptions of MOUD delivery among pregnant/parenting women promises to uncover and address the underlying challenges to treatment, a perspective that may be different for providers and stakeholders. Therefore, our main purpose is to elicit patients' experiences and perceptions of MOUD, associated access to treatment, and availability of supportive resources during pregnancy/postpartum to inform OUD treatment.

METHODS

Through a qualitative research approach we gathered data from individual interviews/focus group discussions for this pilot study. Pregnant and postpartum parenting women (n = 17) responded to questions related to perceptions of MOUD, access to treatment, and availability of social and psychosocial resources. Data were collected, transcribed, and coded (by consensus) and emerging themes were analyzed using grounded theory methodology.

RESULTS

Emerging themes revealed positive uptake and perceptions of MOUD, continuing gaps in knowledge, negative impact of stigmatization, and limited access to programs and resources. Supportive relationships from family, peers, healthcare providers and child welfare staff, and co-located services were perceived as positive motivators to recovery.

CONCLUSIONS

Through the unique lenses of women with lived experience, this study revealed several themes that can be transformative for women. Overall perceptions of MOUD were positive and likely to facilitate uptake and promote positive recovery outcomes. Bridging knowledge gaps will reduce anxieties, fears about neonatal opioid withdrawal syndrome and adverse maternal outcomes. Additionally, a deeper understanding of stigmatization and relationships can inform an integrated patient-centered approach to OUD treatment.

Classic grounded theory: identifying the main concern

Grounded theory comprises a family of research approaches designed to support the generation of a theory explaining a phenomenon experienced by a group of participants. One style of grounded theory, Classic grounded theory, is used less often than other types of grounded theory. The less frequent use of Classic grounded theory may be attributed to the limited availability of clearly articulated processes for conducting this method. Particularly important within Classic grounded theory, and not used in other forms of grounded theory, is identifying the participants' main concern. Identifying the participants' main concern is a signature feature of Classic grounded theory and is a prerequisite for ascertaining the core category and subsequent discovery of theory. In this article we provide a detailed explanation of how to identify the participants' main concern, and in so doing, we offer an exemplar to illustrate the process involved.

Inpatient pain assessment and decision-making in internal medicine and general surgery residents: A qualitative analysis

Background

Understanding physician approaches to pain treatment is a critical component of opioid and analgesic stewardship. Practice patterns learned in residency often persist longitudinally into practice.

Objective

This study sought to identify salient factors and themes in how resident physicians assess and manage pain.

Methods

Video-recorded focus groups of internal medicine and general surgery residents were conducted via videoconferencing software. Data were analyzed using a ground theory approach and constant comparative method to identify themes and subthemes. Focus groups occurred in September and October 2020.

Results

10 focus groups including 35 subjects were conducted. Four general themes emerged: (1) Assessment considerations; (2) Education & Expectations; (3) Systems Factors; and (4) Management considerations. Participants indicated that while it is important to treat pain, its inherently subjective nature makes it difficult to objectively quantify it. The 0-10 numeric rating scale was problematic and infrequently utilized. Patient expectations of no pain following procedures was viewed as particularly challenging. The absence of formal best practices to guide pain assessment and management was noted in every group. Management approaches overall very highly variable, often relying on word-of-mouth relay of the preferences of specific attending physicians.

Conclusions

Pain is highly nuanced and resident physicians struggle to balance pain's subjectivity with a desire to quantify and appropriately treat it. The 0-10 numeric rating pain scale, though ubiquitous, is problematic. Priority areas of improvement identified include education for both patients and physicians, functional pain scales, and expansion of existing effective resources like the nursing pain team.

The Ethics of Electronic Tracking Devices in Dementia Care: An Interview Study with Developers

Wandering is a symptom of dementia that can have devastating consequences on the lives of persons living with dementia and their families and caregivers. Increasingly, caregivers are turning towards electronic tracking devices to help manage wandering. Ethical questions have been raised regarding these location-based technologies and although qualitative research has been conducted to gain better insight into various stakeholders' views on the topic, developers of these technologies have been largely excluded. No qualitative research has focused on developers' perceptions of ethics related to electronic tracking devices. To address this, we performed a qualitative semi-structured interview study based on grounded theory. We interviewed 15 developers of electronic tracking devices to better understand how they perceive ethical issues surrounding the design, development, and use of these devices within dementia care. Our results reveal that developers are strongly motivated by moral considerations and believe that including stakeholders throughout the development process is critical for success. Developers felt a strong sense of moral obligation towards topics within their control and a weaker sense of moral obligation towards topics outside their control. This leads to a perceived moral boundary between development and use, where some moral responsibility is shifted to end-users.

Palliative care physicians' decision-making about palliative sedation for existential suffering: A Belgian nationwide qualitative study

OBJECTIVES

This study aims to provide an in-depth understanding of the content and process of decision-making about palliative sedation for existential suffering (PS-ES) as perceived by Belgian palliative care physicians.

METHODS

This Belgian nationwide qualitative study follows a grounded theory approach. We conducted semistructured interviews with 25 palliative care physicians working in 19 Belgian hospital-based palliative care units and 4 stand-alone hospices. We analyzed the data using the Qualitative Analysis Guide of Leuven, and we followed the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ).

RESULTS

Analysis of the data identified several criteria that physicians apply in their decision-making about PS-ES, namely, the importance of the patient's demand, PS-ES as a last resort option after all alternatives have been applied, the condition of unbearable suffering combined with other kinds of suffering, and the condition of being in a terminal stage. Regarding the process of decision-making itself, physicians refer to the need for multidisciplinary perspectives supported by an interpretative dialogue with the patient and all other stakeholders. The decision-making process involves a specific temporality and physicians' inner conviction about the need of PS-ES.

SIGNIFICANCE OF RESULTS

Belgian palliative care physicians are not sure about the criteria regarding decision-making in PS-ES. To deal with complex existential suffering in end-of-life situations, they stress the importance of participation by all stakeholders (patient, relatives, palliative care team, other physicians, nurses, social workers, physiotherapists, occupational therapists, chaplains, etc.) in the decision-making process to prevent inadequate decisions being made.

The Judiciarization of People Living with Mental Illness: A Grounded Theory on the Perceptions of Persons Involuntary Admitted in Psychiatric Institution

The involvement of people living with mental illness in the judicial process, whether in civil or criminal justice system, is a growing phenomenon that can be defined as judiciarization. Such over-representation of people with mental illness in the justice system is related to several issues, including stigma, experienced coercion, loss of autonomy and social isolation. To explore this understudied phenomenon in nursing research, we conducted a study to better understand how judiciarization affects people living with mental illness. The specific objectives were: 1) to understand how insertion into a judicial process affects people living with mental illness; 2) to explore the perception of these people and their lived experience within the judicial trajectory. For the methodology, grounded theory was used as a research model. The theoretical framework of the total institution, proposed by Erwin Goffman, was used conceptually. Participants were recruited from a university-affiliated hospital. Hospitalized persons who had been involved in the justice system were interviewed (n = 10). Three conceptualizing categories were identified through the analyzed data: 1) Diversity of Judicial Trajectories; 2) Involuntary Psychiatric Admission Process; 3) Judiciarization Lived as a Complex Experience. The results of this research can be used to better inform nurses, clinicians, and policy makers about the impacts of the judiciarization of mental illness, and how clinical practices can be better adapted to populations with very complex health needs.

"Balancing two worlds": a constructivist grounded theory exploring distributed/decentralised nursing education in rural and remote areas in Canada and Norway

A challenge confronting northern nursing is delivery of equitable and culturally competent nursing education. Advances in technology support distributed approaches for decentralised learning and enhance the feasibility of nursing education in rural and remote regions. However, there is limited scholarship on distributed/decentralised technologies in nursing education, particularly in northern and circumpolar regions. The purpose of this constructivist grounded theory research was to develop an enhanced understanding of the unique experiences of students, faculty and administrators who use distributed/decentralised methods and technology. Open-ended interviews were completed in 2015-17 with nursing students (n = 8), faculty and administrators (n = 6) at two universities using distributed/decentralised educational strategies in northern and circumpolar regions. Interviews, journal entries, field notes and memos, were analysed using grounded theory procedures. Findings indicated that distributed/decentralised programs offered rural and remote students educational possibilities that "fit" which would not have otherwise existed. However, Balancing Two Worlds created a collision of roles resulting in the potential loss of balance. Students rectified the Fear of "Falling Off" of their program through four subprocesses: Being Disciplined, Having Realistic Expectations, Planning Ahead and Staying Motivated which provided structure and predictability. Findings support the development of empirical knowledge regarding distributed/decentralised technologies in nursing education and a foundation for future research.

A Mixed-Method Social Network Analysis of Low-Income Diverse Older Volunteers

Although volunteering has been associated with numerous social benefits for diverse older adults, there is little information on how they establish relationships within a multicultural volunteering program outside of their co-ethnic communities. This convergent mixed-method social network study adopts the bonding and bridging social capital theory to explore the structures and dynamics of social interactions within a multicultural volunteer program. Low-income Russian, Khmer, Somali, Nepali, and English-speaking older volunteers in the Senior Companions Program (SCP) in a Midwest metropolitan (N = 83) participated in the surveys and focus groups. Homophily coefficients (r) show that the SCP volunteers mostly interacted with people who identified with the same nationality (r = .86), race (r = .87), and gender (r = .50). Qualitative results suggested that volunteers strengthened their social networks through within-cultural social bonding while appreciating opportunities for cross-cultural social bridging. Compared with within-cultural social bonding, cross-cultural social bridging in multicultural volunteer programs require intentional facilitation, resources, and organizational commitment.

Thriving psychological well-being in undergraduate nursing student: a grounded theory study with the life grid approach

BACKGROUND

Psychological well-being (PWB) plays a vital role in successful adaptation to the Bachelor of Nursing journey and affects career development. However, there is little known about the functional and social processes associated with enhancing well-being specific to the subjective perspective of nursing students.

AIM

To investigate how nursing students promote their psychological well-being to conceptualize thriving psychological well-being.

METHOD

This qualitative study analyzed and reviewed a life grid and semi-structured in-depth interviews of 20 Chinese Nursing graduates by investigators and participants, following Charmaz's constructivist grounded theory. The constant comparative method was used to analyze data. This study took place between 2020 and 2022.

RESULTS

All participants experienced fluctuations in psychological well-being. This study identified a new understanding of how nursing students enhance their psychological well-being. Thriving awareness was co-constructed as the core category and based on the relationship with a supportive environment, the thriving psychological well-being of nursing students is conceptualized.

CONCLUSIONS

It is imperative to enhance the psychological counseling and support for nursing students during their clinical placements, during the period just entering university as well as after repeated outbreaks of COVID-19. Nursing educators and administrators could develop appropriate educational programs and interventions based on the theoretical model-Thriving psychological well-being.

Perceptions of racism in a children's psychiatric inpatient unit: A qualitative study of entrenching and uprooting factors

WHAT IS KNOWN ON THE SUBJECT?: The impacts of racism on health are well documented and are greater for mental than for general health. Mental health professionals are well positioned to help dismantle racism and structural barriers compromising optimal patient care.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

We describe a systematic and orderly way to identify factors that contribute to entrenching racism as the status quo or that help to uproot it. By incorporating a racial equity lens, we can better understand daily racism and inform the optimal antiracist actions most relevant to an inpatient psychiatric setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our two-domain/six-theme model may serve as a rubric for individuals to engage in structured self-reflection, for organizations in auditing or programmatic evaluation, or as scaffolding for difficult but frequently elided conversations. The unique strengths of a mental health environment can be harnessed toward the elimination of racism and racist practices in clinical care and in the workplace ABSTRACT: INTRODUCTION: It is well documented that racism plays a role in health care access and outcomes. However, discussions about racism in the inpatient psychiatric workplace are generally avoided. To address this gap, we incorporated a racial equity perspective into a qualitative study to better understand daily racism, its impact on patients and staff, and to inform optimal antiracist actions most relevant to inpatient psychiatric settings.

AIM/QUESTION

We sought to identify factors that may contribute to or deter from racism to inform interventions to sustain a psychologically supportive environment for patients and staff.

METHODS

We conducted semistructured interviews using a purposive sample of 22 individuals in an acute child psychiatric inpatient service. We analysed transcripts using thematic analysis guided by a constructivist grounded theory conceptual framework.

RESULTS

We identified two countervailing processes: (1) Entrenching-factors that sustain or increase racism: Predisposing, Precipitating, and Perpetuating and (2) Uprooting-factors that rectify or reduce racism: Preventing, Punctuating, and Prohibiting. We organized each of the elements into a '6P' model along a temporal sequence around sentinel racist events. For each of the six components we describe: Contributing Factors, Emotional Reactions, and Behavioural Responses as reported by participants.

IMPLICATIONS FOR PRACTICE

Identifying factors that entrench or uproot racism can inform specific steps to improve the care of all children and families on an inpatient child psychiatry unit. The two-domain/six-theme model we developed can serve as a rubric for individuals or milieu-based inpatient settings serving patients of any age to engage in structured self-reflection, auditing, program evaluation, or as scaffolding for difficult but frequently elided conversations.

Public health nurses experience of mental health encounters in the context of primary health care: a constructivist grounded theory study

BACKGROUND

In primary health care people with mental health needs are often overlooked or masked with physical complaints. It has been suggested that public health nurses lack sufficient knowledge when encountering people with mental health problems. Low levels of mental health literacy among professionals are associated with negative patient outcome. There is a need to understand public health nurses process and strategies used when encountering a person with mental health problems in order to promote mental health. This study aimed to construct a theory that explains the process of public health nurses experience when encountering people with mental health problems based on their knowledge, attitudes, and beliefs about mental health.

METHODS

A constructivist grounded theory design was used to meet the aim of the study. Interviews were conducted with 13 public health nurses working in primary health care between October 2019 and June 2021, and the data analysis was performed according to the principles of Charmaz.

RESULTS

The core category, "Public health nurses as a relationship builder - to initiate the dialogue" reflected the process while the main categories "Being on your own", "Being on top of things- knowing your limits", and "Professional comfort zone" reflected conditions that were decisive for initiating a dialogue.

CONCLUSION

Managing mental health encounters in primary health care was a personal and complex decision-making process that depends on the public health nurses' professional comfort zone and acquired mental health literacy. Narratives of the public health nurses helped to construct a theory and understand the conditions for recognizing, managing and promoting mental health in primary health care.

Explaining the process of formation of ageism among the iranian older adults

BACKGROUND

Ageism is considered as one of the consequences of the industrialization of societies, which appears in various forms in different cultures. This study aimed to explain the process of formation of ageism among the older adults people.

METHODS

The research was conducted using grounded theory method. Data were collected from 28 participants using in-depth semi-structured interviews and field notes. Data were analyzed using open, axial, and selective coding.

RESULTS

Fear of loneliness and rejection striving to tackle ageism "was identified as the core category of the study. Concepts such as "family context" and "cultural context" were relevant. After identifying the strategies used by the older adults in response to the context ("maintaining integrity", "socio-cultural care" and "proper health care", "striving to tackle ageism") was the most important process in ageism by the Iranian older adults.

CONCLUSION

Findings of this study indicated that individual, family and social factors play an important role in the process of ageism among the older adults. These factors sometimes exacerbate or moderate the process of ageism. By recognizing these factors, various social institutions and organizations (including the health care system and the national media (radio and television)) can help the older adults achieve successful aging by emphasizing the issues related to the social aspect.

Analysis of network public opinion on COVID-19 epidemic based on the WSR theory

Objective

To obtain the influencing factors of public opinion reactions and to construct a basic framework of the factors causing the occurrence of online public opinion in the epidemic area.

Methods

The hot news comments on microblogs during the epidemic in Shanghai were collected and analyzed with qualitative analysis, grounded theory, and the "Wuli-Shili-Renli" (WSR) methodology as an auxiliary method.

Results

(1) Three core categories of the Wuli system, the Shili system, and the Renli system, 15 main categories, and 86 categories that influence the development of network public opinion are obtained. (2) WSR Elements Framework Of Network Public Opinion (WSR-EFONPO) is established. (3) The WSR-EFONPO is explained.

Conclusion

The framework of factors for the occurrence of network public opinion is proposed, and the development process of network public opinion under COVID-19 is sorted out, which is of great theoretical value in guiding the public in the epidemic area to form reasonable behavior.

Fostering Hope: Comprehensive Accessible Mother-Infant Dyad Care for Neonatal Abstinence (CAIN)

Hospital and community healthcare providers have expressed concerns around the continuity and quality of care for infants with neonatal abstinence syndrome (NAS) during hospitalization and transition home. This qualitative study explored the experiences of hospital and community-based healthcare providers and identified themes related to the management of NAS for mothers and infants. Healthcare providers that cared for women with substance use disorders and/or cared for newborns with NAS in a large urban setting in Canada met inclusion criteria for this study and were interviewed in groups or as individuals. Interview transcripts were reviewed iteratively using inductive thematic analysis to identify an overarching theme linked with primary themes. In total, 45 healthcare providers were interviewed. Qualitative analysis of their experiences derived the overarching theme of hope with five primary themes being: mother/infant, mental health, system, judgement, and knowledge. The study identified gaps in NAS care including fear, stigma, and language. This research demonstrates that programs and interventions that work with mothers and newborns with NAS must foster hope in mothers, families, and in the extended care provider team and improve communication between hospital and community networks.

Parents' process of recognition and response to clinical deterioration of their children with medical complexity at home: A grounded theory

AIM

To explore the process of recognition and response to clinical deterioration of children with medical complexity at home by their parents.

BACKGROUND

Children with medical complexity are characterised by known chronic conditions associated with frailty and functional limitations, dependence on healthcare services and high use of technology and resources. Their medical complexity often leads to the onset of complications. Targeted care ensures timely recognition and response to clinical deterioration at home, thus avoiding serious sequelae, inappropriate hospitalisations and improving quality of life. Evidence on parents' process of the recognition and response to clinical deterioration at home is limited.

DESIGN

Qualitative study using a Grounded Theory methodology.

METHOD

Seven online focus groups were conducted with parents and healthcare providers experienced in their care. The interviews were transcribed verbatim and analysed through open, axial and selective coding, using a constant comparative iterative method. The COREQ guidelines guided the reporting of this work.

RESULTS

Four categories and one core category were identified: (1) Awareness of the unique and shared characteristics of children with medical complexity; (2) Parents' care maintenance and management; (3) Parents' care monitoring; (4) Parents' response to clinical deterioration and (5) Seeking the Shift of Agency, the core category as the foundation of the Process of Recognition and rEsponse of PAREnts to Deterioration (PRE-PARE-D) theory.

CONCLUSION

The role of parents of children with medical complexity is evolving into active care leaders, by developing care management and care monitoring competences and negotiating care with healthcare providers.

RELEVANCE TO CLINICAL PRACTICE

The shift of agency from healthcare providers to parents requires education and counselling pathways to promote the development of parent's self-efficacy, competencies and empowerment in the care management of their children. Home care delivery for children with medical complexity should aim at sustaining this partnership between healthcare providers and parents.

Navigating asthma-the immigrant child in a tug-of-war: A constructivist grounded theory

BACKGROUND

Avoidable hospitalisation rates for Indian immigrant children with asthma is high in New Zealand and other Western countries. Understanding how children and their carers manage asthma may lead to a reduction in hospitalisation rates. The topic of asthma and Indian immigrant children's perspectives has not been investigated. Most studies on the topic focus on the experiences of family carers and health professionals. Practice cannot be advanced in the child's best interests unless the child's asthma experiences are explored. The following research addressed this gap by upholding Article 12 of the United Nations Convention on the Rights of the Child, thereby giving Indian immigrant children a voice in describing their asthma experiences.

DESIGN

Constructivist grounded theory.

METHODS

Intensive interviews were conducted with ten family carers and nine children (eight to 17 years old). Child-sensitive data collection techniques such as drawing, and photography were used to facilitate interviewing children younger than 14 years. The COREQ guidelines guided the reporting of this study.

RESULTS

The theory, navigating asthma: the immigrant child in a tug-of-war, is the resulting grounded theory with the tug-of-war being the basic social process. This theory comprises three main categories: being fearful, seeking support and clashing cultures. The data reflected two types of tug-of-war: one between two cultures, the native Indian and the host New Zealand culture and another between family carers' and children's preferences.

CONCLUSION

Acculturation and sociocultural factors may significantly influence the asthma experiences of Indian immigrants.

RELEVANCE TO CLINICAL PRACTICE

The theory may assist healthcare practitioners to better comprehend Indian immigrants' asthma experiences within their wider sociocultural context. Our research indicates the need for healthcare practitioners to work in partnership with Indian immigrant families to implement culturally safe asthma management strategies.

'Weighing up risks': a model of care home staff decision-making about potential resident hospital transfers

Background

care home staff play a crucial role in managing residents’ health and responding to deteriorations. When deciding whether to transfer a resident to hospital, a careful consideration of the potential benefits and risks is required. Previous studies have identified factors that influence staff decision-making, yet few have moved beyond description to produce a conceptual model of the decision-making process.

Objectives

to develop a conceptual model to describe care home staff’s decision-making when faced with a resident who potentially requires a transfer to the hospital.

Methods

data collection occurred in England between May 2018 and November 2019, consisting of 28 semi-structured interviews with 30 members of care home staff across six care home sites and 113 hours of ethnographic observations, documentary analysis and informal conversations (with staff, residents, visiting families, friends and healthcare professionals) at three of these sites.

Results

a conceptual model of care home staff’s decision-making is presented. Except in situations that staff perceived to be urgent enough to require an immediate transfer, resident transfers tended to occur following a series of escalations. Care home staff made complex decisions in which they sought to balance a number of potential benefits and risks to: residents; staff (as decision-makers); social relationships; care home organisations and wider health and social care services.

Conclusions

during transfer decisions, care home staff make complex decisions in which they weigh up several forms of risk. The model presented offers a theoretical basis for interventions to support deteriorating care home residents and the staff responsible for their care.

Exploring the Nursing Care Process for Patients with COVID-19: A Grounded Theory Study

Introduction:

A specific model and process of nursing care for patients with COVID-19 has yet to be developed. However, nurses are navigating how to care for patients and themselves in a novel and stressful work environment. A care process is needed that promotes effective nursing for patients’ health and well-being.

Objective:

This study aimed to explore the current nursing care process for patients with COVID-19.

Methods:

The present qualitative study used a grounded theory approach. Participants included 23 nurses working in a hospital COVID-19 ward who were selected through purposive sampling. Semi-structured interviews were conducted with nurses, and data were simultaneously analyzed using MAXQDA software to code the data. Grounded theory with a storyline approach was used to categorize codes to elucidate themes from interviews and check for data saturation. This consists of several steps, including open coding, developing concepts in terms of their properties and dimensions, analyzing data for context, bringing the process into the analysis, and integrating categories.

Results:

Data analysis revealed seven main categories to describe nurses’ conceptions of the care process for COVID-19 patients: ‘patients’ complicated condition’, ‘severe nursing staff shortage’, ‘nursing professionalism’, ‘treatment team collaboration’, ‘work and environmental pressure’, ‘efficacy of care’ and ‘care deficit’. The category of ‘nursing professionalism’ was determined to be the core concept that nurses used to describe their care process.

Conclusion:

Though nurses think highly of their efficacy of care for patients with COVID-19, they face many challenges in their care process that lessen the care they are able to provide for patients and themselves. These include the complex health status of patients, shortage of staff, environmental stresses such as becoming infected, and lack of resources in the hospital. The results of the present study can be used for planning in various fields of nursing, including management, education and clinical training.

Ethics of sedation for existential suffering: palliative medicine physician perceptions - qualitative study

OBJECTIVES

Palliative sedation for existential suffering (PS-ES) is considered a controversial practice to control refractory suffering at the end of life. This study aims to explore Belgian palliative care physicians' perceptions regarding the ethics of PS-ES.

METHODS

This nationwide qualitative study follows a Grounded Theory approach. We conducted semistructured interviews with 25 palliative care physicians working in 23 Belgian hospitals and hospices (Flanders, Brussels, Wallonia). We analysed the data using the Qualitative Analysis Guide Of Leuven and we followed the Consolidated Criteria for Reporting Qualitative Research guidelines.

RESULTS

The data revealed that Belgian palliative care physicians have difficulty characterising ES and distinguishing it from other types of suffering. They express mixed attitudes towards PS-ES and employ a wide range of ethical arguments in favour and against it, which are mainly linked to the four principles of biomedical ethics.

CONCLUSION

Since there is a lack of consensus among Belgian palliative care physicians about PS-ES, further research is needed to clarify their attitudes. A better understanding of physicians' underlying presuppositions can provide more insight into their perceptions of ES and PS-ES and provide further insight for establishing good practices in ES management at the end of life.

Being Uncertain: Rural-Living Cardiac Patients' Experience of Seeking Health Care

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality worldwide. Secondary prevention strategies reduce disease progression to heart failure. Rural cardiac patients typically have less access to health care resources to support them in managing secondary prevention, and services to improve quality of life tend to be lacking in rural settings. The study aim was to examine the process that rural cardiac patients go through to access health care and cardiac rehabilitation (CR) following myocardial infarction (MI). In-depth interviews with 11 post-MI participants using Straussian grounded theory were undertaken. Analysis revealed a linear process from hospital discharge to maintaining health. There were five elements: comfort with health information, relationship with health care providers, social support, taking ownership, and availability of/for CR. The core category was "being uncertain." Findings can be used to identify ways to improve access and address uncertainty stemming from a lack of perceived information and supports following discharge.

Perceptions of traditional Chinese medicine doctors about using wearable devices and traditional Chinese medicine diagnostic instruments: A mixed-methodology study

Objective

This study aimed to investigate the perceptions of traditional Chinese medicine doctors about wearable devices and diagnostic instruments and explore the factors that influence them.

Methods

Data on the perceptions of the traditional Chinese medicine doctors in Hangzhou, China, about wearable devices and diagnostic instruments were collected through face-to-face semi-structured interviews. The author coded the interview responses using grounded theory. A cross-sectional survey was conducted in four traditional Chinese medicine hospitals in Hangzhou, China. The responses of 385 traditional Chinese medicine doctors were considered valid. Descriptive statistics and binary logistic regression models were used for analysis.

Results

This study categorized the perceptions of traditional Chinese medicine about wearable devices and traditional Chinese medicine diagnostic instruments under convenience, reliability, suitable population, machine usage scenario, and the integration of traditional Chinese medicine and information communication technology. Convenience encompassed portability and the convenience of carrying instruments or wearing the devices and operating them and the human-device interface. Reliability encompassed the underlying principles, accuracy, durability, and reference to diagnosis. Suitability for people encompassed age distinction and disease differentiation. Machine usage scenarios included use in daily life, educational institutions, and primary medical institutions. The combination of traditional Chinese medicine and information communication technology encompassed the integration of traditional Chinese medicine and wearable functions and diagnostic interpretation. The perceptions of traditional Chinese medicine doctors were affected by age, title, type of hospital, and specialty.

Conclusions

The use of wearable devices and traditional Chinese medicine diagnostic instruments has gradually been accepted by traditional Chinese medicine doctors. Traditional Chinese medicine doctors need to improve their knowledge and skills for information communication technology integration, and their standardized training should incorporate information communication technology and digital health.

Neonatologists' Resuscitation Decisions at Birth for Extremely Premature Infants. A Belgian Qualitative Study

OBJECTIVE

Deciding whether initiating or withholding resuscitation at birth for extremely preterm infants (EPIs) can be difficult due to uncertainty on outcomes. Clinical uncertainty generates ethical uncertainty. Thus, physicians' attitudes and perspectives on resuscitation of EPIs might influence resuscitation decisions. We aimed at understanding how neonatologists make clinical-ethical decisions for EPI resuscitation and how they perceive these decisions.

METHODS

We performed a qualitative study using a constructivist account of grounded theory. Face-to-face, semi-structured in-depth interviews with neonatologists comprised data collection. For data analysis, we used the Qualitative Analysis Guide of Leuven.

RESULTS

We interviewed 20 neonatologists working in 10 hospitals in Belgium. Participants' decision-making can be described as consensus-based, gestational age-based, contextualized, progressive, and shared. All participants agreed on the importance of using the consensus expressed in guidelines as a guidance for the decision-making, i.e., consensus-based. Consequently, all 20 participants use GA thresholds indicated in the guidelines, i.e., GA-based. However, they use these thresholds differently in their decisions. Few participants rigidly follow established thresholds. The vast majority reported using additional contextual factors as birthweight or parents' wishes in the decision-making, rather than only the EPIs' GA, i.e., contextualized. All participants agreed on the importance of involving the parents in the decision-making, i.e., shared, and indeed parents' wishes were among the most valued factors considered in the decision-making. However, the extent to which parents were involved in the decision-making depended on the infant's GA. Participants described a gray zone in which parents' were viewed as the main decision-makers due to the high clinical uncertainty. This mean that participants tend to follow parents' request even when they disagree with it. Outside the gray zone, physicians were viewed as the main decision-makers. This mean that, although parents' wishes were still considered, counseling was more directive and the final decision was made by the physician.

CONCLUSION

Although an EPI's GA remains the main factor guiding neonatologists' resuscitation decisions, other factors are seriously considered in the decision-making process. All neonatologist participants agreed on the importance of involving parents in the decision-making. However, they involve parents differently depending on the EPI's GA.

Neonatologists' decision-making for resuscitation and non-resuscitation of extremely preterm infants: ethical principles, challenges, and strategies-a qualitative study

Background

Deciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists’ clinical–ethical decision-making for resuscitation of EPIs.

Methods

We conducted a qualitative study in Belgium, following a constructivist account of the Grounded Theory. We conducted 20 in-depth, face-to-face, semi-structured interviews with neonatologists. Data analysis followed the qualitative analysis guide of Leuven.

Results

The main principles guiding participants’ decision-making were EPIs’ best interest and respect for parents’ autonomy. Participants agreed that justice as resource allocation should not be considered in resuscitation decision-making. The main ethical challenge for participants was dealing with the conflict between EPIs’ best interest and respect for parents’ autonomy. This conflict was most prominent when parents and clinicians disagreed about births within the gray zone (24–25 weeks). Participants’ coping strategies included setting limits on extent of EPI care provided and rigidly following established guidelines. However, these strategies were not always feasible or successful. Although rare, these situations often led to long-lasting moral distress.

Conclusions

Participants’ clinical–ethical reasoning for resuscitation of EPIs can be mainly characterized as an attempt to balance EPIs’ best interest and respect for parents’ autonomy. This approach could explain why neonatologists considered conflicts between these principles as their main ethical challenge and why lack of resolution increases the risk of moral distress. Therefore, more research is needed to better understand moral distress in EPI resuscitation decisions.

Clinical Trial Registration: The study received ethical approval from the ethics committee of UZ/KU Leuven (S62867). Confidentiality of personal information and anonymity was guaranteed in accordance with the General Data Protection Regulation of 25 May 2018.

Exploring the Process of Spiritual Health of the Elderly Living in Nursing Homes: A Grounded Theory Study

BACKGROUND

Spiritual health is one of the important dimensions of the elderly's health, which plays an important role in other dimensions of their health. This study aimed to explain the process of spiritual health of the elderly living in nursing homes.

METHODS

This grounded theory study was conducted in 4 nursing homes in the city of Arak Iran between October 2019 and September 2020. The participants were 24 elderly people living in nursing homes, two health care providers, one nurse and one family member, first selected through purposive sampling and then, through theoretical sampling. The data were collected through semi-structured interviews and field notes. All the interviews were transcribed verbatim and analyzed based on Strauss and Corbin approach (2008).

RESULTS

Six main categories were identified, including helplessness, inefficient supportive environment, spiritual distress, seeking support, relative improvement of spiritual health and factors affecting spiritual health, each of which explains a part of the whole process of spiritual health of the elderly living in nursing homes.

CONCLUSION

Supporting the elderly living in nursing homes is necessary in order to meet their spiritual needs and preserve and promote their spiritual health.

A qualitative examination of the current management of opioid use disorder and barriers to prescribing buprenorphine in a Canadian emergency department

Background

Emergency departments (EDs) across Canada are increasingly prescribing buprenorphine for opioid use disorder (OUD). The objective of this study was to identify the current knowledge, attitudes, and behaviours of ED physicians on the management of OUD in the ED, including barriers and facilitators to prescribing buprenorphine.

Methods

We purposefully selected emergency physicians from one ED in Toronto which had recently received education on OUD management and had a new addiction medicine follow-up clinic, to participate in semi-structured interviews. We used semi-structured interviews to explore experiences with patients with OUD, conceptions of role of the ED in addressing OUD, and specifically ask about perceptions and experience on using buprenorphine for opioid withdrawal. Our analysis was informed by constructivist grounded theory to help uncover contextualized social processes and focus on what people do and why they do it. Two researchers independently coded transcripts using an iterative constant comparative and interpretative approach.

Results

Results fell broadly into facilitators and barriers. Generally, management of OUD in the ED varied significantly. Physician-level facilitators to treating opioid withdrawal with buprenorphine included: knowledge about OUD an7d buprenorphine, positive experiences with substitution therapy in the past, and the presence of physician champions. Systems-level facilitators included timely access to follow-up care and pre-printed order sets. Barriers included provider inexperience, lack of feedback on treatment effectiveness, limited time to counsel patients, and pressure to discharge patients quickly. Additional barriers included concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes.

Conclusion

This study describes barriers and facilitators to addressing OUD and prescribing buprenorphine in a Canadian ED. These findings suggest a role for additional provider education, involvement of allied health professionals in counseling, and mentorship by physician champions in the department.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00443-1.

Opioid use disorder in pregnancy: leveraging provider perceptions to inform comprehensive treatment

BACKGROUND

Medications for opioid use disorder (MOUD) are recommended with adjuvant behavioral therapies, counseling, and other services for comprehensive treatment of maternal opioid use disorder. Inadequate access to treatment, lack of prescribing providers and complex delivery models are among known barriers to care. Multi-disciplinary provider input can be leveraged to comprehend factors that facilitate or inhibit treatment. The objective of this study is to explore provider perceptions of MOUD and factors critical to comprehensive treatment delivery to improve the care of pregnant women with opioid use disorder.

METHODS

A qualitative research approach was used to gather data from individual provider and group semi-structured interviews. Providers (n = 12) responded to questions in several domains related to perceptions of MOUD, treatment delivery, access to resources, and challenges/barriers. Data were collected, transcribed, coded (by consensus) and emerging themes were analyzed using grounded theory methodology.

RESULTS

Emerging themes revealed persistent gaps in treatment and challenges in provider, health systems and patient factors. Providers perceived MOUD to be a "lifeline" to women.

CONCLUSIONS

Inconsistencies in treatment provision, access and uptake can be improved by leveraging provider perceptions, direct experiences and recommendations for an integrated team-based, patient-centered approach to guide the care of pregnant women with opioid use disorder.

Acquired Brain Injuries and Intimate Partner Violence: A Situational Analysis of Help Seeking Barriers in Rural Northern New England

Nurses care for women experiencing non-fatal strangulation and acquired brain injuries whether or not it is disclosed. Situational analysis was used to analyze 23 interviews from Northern New England with survivors, healthcare workers, and violence/legal advocates to explore overlapping relationships between violence, acquired brain injuries, non-fatal strangulation, and seeking care. Findings included the concepts of paying social consequences and the normalization of violence. Non-fatal strangulation was described as increasingly related to violence and other areas. Repetitive acquired brain injuries can impair functioning needed to address violence and healthcare providers and advocates are generally unaware of the impact of acquired brain injuries. A lack of resources, training, and tools for acquired brain injury screening were barriers in recognizing and responding to it, causing hidden symptoms. This study adds to the literature examining intimate partner violence in rural areas; specifically intimate partner violence-related acquired brain injuries in rural areas.

Patients' and family members' perspectives on the benefits and working mechanisms of family nursing conversations in Dutch home healthcare

The aim of this study is to propose a model of the benefits and working mechanisms of family nursing conversations in home healthcare from the perspective of participating patients and their family members. Family nursing conversations in this study are intended to optimise family functioning, improve collaboration between family and professional caregivers and ultimately prevent or reduce overburden of family caregivers. In a qualitative grounded theory design, data were collected in 2017 using intensive interviewing with participants of family nursing conversations in home healthcare. A total of 26 participants (9 patients and 17 family members) from 11 families participated in a family nursing conversation and the study. Seven nurses who received extensive education in family nursing conversations conducted them as part of their daily practice. Interviews occurred 4-6 weeks after the family nursing conversation. The model that was constructed in close collaboration with the families consists of three parts. The first part outlines working mechanisms of the conversation itself according to participants, i.e. structured and open communication about the care situation and the presence of all of the people who are involved. The second part consists of the benefits that participants experienced during and immediately after the conversation - an increased sense of overview and improved contact among the people involved - and the related working mechanisms. The last part consists of benefits that emerged in the weeks after the conversation - reduced caregiver burden and improved quality of care - and the related working mechanisms. Insight into the benefits and working mechanisms of family nursing conversations may assist healthcare professionals in their application of the intervention and provides directions for outcomes and processes to include in future studies.

Experiences of Venous Leg Ulcer persons following an individualised nurse-led education: protocol for a qualitative study using a constructivist grounded theory approach

INTRODUCTION

Venous leg ulcers are slow-healing wounds with a high risk of recurrences. To prevent recurrences and promote healing, different nurse-led educational interventions have been developed. The impact of these interventions on self-management is ambiguous. Also, how persons with a venous leg ulcer experiences these educational sessions are poorly described.

AIM

This study protocol presents the methodology to provide a comprehensive explanation of participants' journeys-of how they experience their individualised education sessions concerning self-management.

METHODS AND ANALYSIS

A constructivist grounded theory approach according to Charmaz involving 30 participants will be used. Data will be collected through semistructured face-to-face interviews. Interviews will be transcribed verbatim and analysed with initial and focus coding using MAXQDA. Data collection and data analysis will occur iteratively, focusing on constant comparison to obtain well-developed categories. Categories will be reinforced using existent literature.

ETHICS AND DISSEMINATION

This pre-results study is embedded in a clinical trial (NCT04019340) and approved by ethical committee of the canton of Geneva (CCER: 2019-01964). A theory will emerge from participants' journeys informing future education sessions for patients with venous leg ulcers. The findings will be disseminated through peer-reviewed publications and communications.

Human-centred leadership in health care: A contemporary nursing leadership theory generated via constructivist grounded theory

AIM

To generate a unique and contemporary leadership theory reflecting the essence of nursing within a complex health care environment.

BACKGROUND

As health care faces unprecedented change and increasing complexity, a nursing leadership theory embedded within complexity science is vital for teams to be innovative, nimble and focused on human-centred care.

METHODS

Constructivist grounded theory framed exploration of human issues embedded in nursing leadership. The constructivist approach sought thematic and theoretical sensitivity through the rich co-creative experience of participants, researchers, literature and data. Focus groups were convened over 18 months with 39 nurse leaders from bedside to boardroom.

RESULTS

Constant comparative methods resulted in 15 attributes. Advanced coding positioned the 15 attributes into constructs: Awakener, Connector and Upholder. Definitions emerged through the constructivist process organically connecting attributes and constructs to the potential outcomes identified in the theory as cultures of excellence, trust and caring.

CONCLUSIONS

The final constructivist process revealed a nursing-specific theory: human-centred leadership in health care uniquely suited to assist leaders in addressing structure, process and outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

Efforts by nurse leaders to test the theory with metrics related to nursing excellence will result in validation of the theory and validation of the proposed sustained culture change.

How young children learn independent asthma self-management: a qualitative study in Malaysia

OBJECTIVE

We aimed to explore the views of Malaysian children with asthma and their parents to enhance understanding of early influences on development of self-management skills.

DESIGN

This is a qualitative study conducted among children with asthma and their parents. We used purposive sampling and conducted focus groups and interviews using a semi-structured topic guide in the participants' preferred language. All interviews were audio-recorded, transcribed verbatim, entered into NVivo and analysed using a grounded theory approach.

SETTINGS

We identified children aged 7-12 years with parent-reported, physician-diagnosed asthma from seven suburban primary schools in Malaysia. Focus groups and interviews were conducted either at schools or a health centre.

RESULTS

Ninety-nine participants (46 caregivers, 53 children) contributed to 24 focus groups and 6 individual interviews. Children mirrored their parents' management of asthma but, in parallel, learnt and gained confidence to independently self-manage asthma from their own experiences and self-experimentation. Increasing independence was more apparent in children aged 10 years and above. Cultural norms and beliefs influenced children's independence to self-manage asthma either directly or indirectly through their social network. External influences, for example, support from school and healthcare, also played a role in the transition.

CONCLUSION

Children learnt the skills to self-manage asthma as early as 7 years old with growing independence from the age of 10 years. Healthcare professionals should use child-centred approach and involve schools to facilitate asthma self-management and support a smooth transition to independent self-management.

TRIAL REGISTRATION NUMBER

Malaysian National Medical Research Register (NMRR-15-1242-26898).

"Doing" Intergenerational Friendship: Challenging the Dominance of Age Homophily in Friendship

This article challenges the dominance of age homophily in the literature on friendship. Using findings from a recent study on intergenerational friendship, we put forward a new conceptualization of a homophily of doing-and-being in friendships between adults who are of different generations. This research took a qualitative approach using constructivist grounded theory methodology. Homophily of doing-and-being has three components: being "friends in action" (pursuing interests and leisure activities, or simply spending time together), being "not only old" (sharing identities beyond age), and sharing attitudes and approaches to friendship and life. Additionally, "differences" were an important element of interest between the intergenerational friends. Our discovery of the centrality of doing-and-being, and the relative insignificance of age homophily, constitute a novel way of looking at friendship, and a new way of conceptualizing how and why (older) adults make and maintain friendships.

Hunting to Feel Human, the Process of Women's Help-Seeking for Suicidality After Intimate Partner Violence: A Feminist Grounded Theory and Photovoice Study

Women reach out to health care providers for a multitude of health problems in the aftermath of intimate partner violence, including suicidality; however, little is known about how they seek help. The purpose of this study was to explore how women seek help for suicidality after intimate partner violence using a feminist grounded theory and photovoice multiple qualitative research design. Interviews were conducted with 32 women from New Brunswick, Canada, and seven from this sample also participated in five photovoice meetings where they critically reflected on self-generated photos of their help-seeking experiences. Data were analyzed using the constant comparative analysis of grounded theory. Hunting to Feel Human involves fighting for a sense of belonging and personal value by perceiving validation from health care providers. Women battled System Entrapment, a feeling of being dehumanized, by Gauging for Validation and Taking the Path of Least Entrapment. Implications for health care providers include prioritizing validating interactions and adopting a relational approach to practice.