Nursing students' learning dynamics and influencing factors in clinical contexts

Clinical placements are essential for students to develop clinical skills to qualify as nurses. However, various difficulties encountered by nursing students during their clinical education detract from developing clinical competencies. This constructivist grounded theory study aims to explore nursing students' experiences in clinical nursing education, and to identify the factors that influence the clinical education students receive. Twenty-one individual and six group semi-structured interviews were conducted with sixteen fourth year nursing students and four registered nurses. This research identified six factors that influence nursing students' clinical education: interpersonal, socio-cultural, instructional, environmental, emotional and physical factors. The research has developed a dynamic model of learning in clinical contexts, which offers opportunities to understand how students' learning is influenced multifactorially during clinical placements. The understanding and application of the model can improve nursing instructional design, and subsequently, nursing students' learning in clinical contexts.

Health care transitions for persons living with dementia and their caregivers

BACKGROUND

Persons with dementia are likely to require care from various health care providers in multiple care settings, necessitating navigation through an often-fragmented care system. This study aimed to create a better understanding of care transition experiences from the perspectives of persons living with dementia and their caregivers in Ontario, Canada, through the development of a theoretical framework.

METHODS

Constructivist grounded theory guided the study. Seventeen individual caregiver interviews, and 12 dyad interviews including persons with dementia and their caregivers, were recorded and transcribed verbatim. The data were coded using NVivo 10 software; analysis occurred iteratively until saturation was reached.

RESULTS

A theoretical framework outlining the context, processes, and influencing factors of care transitions was developed and refined. Gaining an in-depth understanding of the complex care transitions of individuals with dementia and their caregivers is an important step in improving the quality of care and life for this population.

CONCLUSION

The framework developed in this study provides a focal point for efforts to improve the health care transitions of persons living with dementia.

The capability imperative: Theorizing ableism in medical education

Medical education programs profess commitments to justice, equity, and inclusion, seeking to diversify the profession and better serve patient populations. Although disability has more recently joined recognized categories of valued diversity, significant barriers remain for disabled learners in medicine. This paper develops the concept of the capability imperative, derived from a constructivist grounded theory study examining disability inclusion at four U.S. medical schools that analyzed technical standards policies and interviews with 19 disabled students and 27 school officials (faculty and administrators). Through three motifs (the selfless superhuman; the "real world" of medicine; and the malleable student), the capability imperative enforces the characteristics of a good physician, justifies institutional arrangements, and seeks to produce a learner who can conform to these expectations. Drawing on critical disability theories of ableism and crip theory, the paper argues that the capability imperative represents a context-specific manifestation of ableism that upholds a cultural logic of compulsory hyper-ablebodiedness and mindedness. This logic is antithetical to inclusive goals. Exploration of what constitutes a physician and whom this vision serves may help to shift the professional culture towards justice and unroot disabled peoples' ongoing marginalization in the medical profession.

Patients' experiences of internet-based Acceptance and commitment therapy for chronic pain: a qualitative study

Background

Chronic pain is a globally widespread condition with complex clusters of symptoms within a heterogeneous patient group. Internet-delivered Acceptance and Commitment Therapy (IACT) has shown promising results in the treatment of chronic pain. How IACT is experienced by patients is less well known. Qualitative studies of patients’ experiences are needed to further understand factors behind both engagement and negative effects. The aim of this study was to explore how IACT was experienced by chronic pain patients who had participated in a controlled trial.

Methods

Through an open and exploratory approach this study aimed to investigate how IACT was experienced when delivered as a guided self-help program to persons with chronic pain. Eleven participants were interviewed over telephone after completing IACT.

Results

Qualitative analysis based on grounded theory resulted in 2 core categories and 8 subcategories. In treatment: Physical and cognitive restraints, Time and deadline, Therapist contact, and Self-confrontation. After treatment: Attitude to pain, Image of pain, Control or Command, and Acting with pain. Individual differences as well as specific conditions of the treatment may explain variations in how the treatment was approached, experienced and what consequences it led to. Therapist guidance and deadlines for homework play complex roles in relation to autonomy and change.

Conclusions

Adjusting treatment content and format based on participants’ characteristics, such as expectations, motivation and restraints, might positively affect engagement, autonomy and change. Further research on attrition and negative effects of treatment might clarify what enables chronic pain patients to benefit from IACT.

Trial registration

clinicaltrials.gov (NCT01603797). Registered 22 May 2012. Retrospectively registered.

Juggling identities of rheumatoid arthritis, motherhood and paid work - a grounded theory study

PURPOSE

To explore how women with rheumatoid arthritis manage their illness, motherhood, and work life.

METHODS

A constructivist, grounded theory approach based on individual interviews and participant observations with 20 women with rheumatoid arthritis who participated in work life and had children living at home or were pregnant. After initial and focused coding Goffman's concepts of social identity were applied.

RESULTS

A core category: "Juggling meaningful identities" and three conceptual categories were developed: (1) Work life as the strongest identity marker; (2) Motherhood: a two-sided act; (3) Living with rheumatoid arthritis as an identity? Paid work, motherhood, and illness are linked to the women's social identities. The women construct and change their identities in interactions with children, partners, other parents, colleagues, and employers.

CONCLUSION

The women attribute the highest priority to their professional identity, spending the majority of their time and energy in an effort to appear as "good stable workers". The disease is seen as a hindrance in this regard, and the illness identity is almost completely rejected. In motherhood, the women prioritize close interaction with their children, and deprioritize external activities. Extended outbreaks of the disease and issues regarding the children force the women to deprioritize working life. Implications for rehabilitation Juggling meaningful identities of rheumatoid arthritis, motherhood, and paid work challenge women in managing their everyday lives. Therefore, rehabilitation professionals should support individuals to develop new strategies to manage the challenges they experience regarding juggling motherhood and work ability. Work is a dominant identity marker for women with rheumatoid arthritis therefore, rehabilitation professionals have an important role to play in investigating possible ways for the individual to maintain employment or return to work. Living with rheumatoid arthritis and being a paid worker challenge women's role performance and thereby their identification as mothers. Therefore, rehabilitation professionals have to support the women and their families.

Deliberate acquisition of competence in physiological breech birth: A grounded theory study

PROBLEM

Research suggests that the skill and experience of the attendant significantly affect the outcomes of vaginal breech births, yet practitioner experience levels are minimal within many contemporary maternity care systems.

BACKGROUND

Due to minimal experience and cultural resistance, few practitioners offer vaginal breech birth, and many practice guidelines and training programmes recommend delivery techniques requiring supine maternal position. Fewer practitioners have skills to support physiological breech birth, involving active maternal movement and choice of birthing position, including upright postures such as kneeling, standing, squatting, or on a birth stool. How professionals learn complex skills contrary to those taught in their local practice settings is unclear.

QUESTION

How do professionals develop competence and expertise in physiological breech birth?

METHODS

Nine midwives and five obstetricians with experience facilitating upright physiological breech births participated in semi-structured interviews. Data were analysed iteratively using constructivist grounded theory methods to develop an empirical theory of physiological breech skill acquisition.

RESULTS

Among the participants in this research, the deliberate acquisition of competence in physiological breech birth included stages of affinity with physiological birth, critical awareness, intention, identity and responsibility. Expert practitioners operating across local and national boundaries guided less experienced practitioners.

DISCUSSION

The results depict a specialist learning model which could be formalised in sympathetic training programmes, and evaluated. It may also be relevant to developing competence in other specialist/expert roles and innovative practices.

CONCLUSION

Deliberate development of local communities of practice may support professionals to acquire elusive breech skills in a sustainable way.

Motivations for cancer history disclosure among young adult cancer survivors

PURPOSE

To gain an in-depth understanding of the motivations for cancer history disclosure and/or non-disclosure among young adult cancer survivors.

METHODS

Using a constructivist grounded theory approach, semi-structured telephone interviews were conducted with breast and testicular cancer survivors diagnosed between the ages of 18 and 39 from across Canada.

FINDINGS

Twenty-eight young adult cancer survivors (16 female; 12 male) participated in this study. Analysis of the interviews revealed two basic motivational systems for disclosure at play: approach-focused motivations geared towards a positive outcome (desire for understanding, acceptance, support and to promote cancer awareness) and avoidance-focused motivations which are geared towards avoiding a negative outcome (fear of discrimination/stigmatization, unwanted attention, pity, loss of privacy, and rejection). Those exhibiting approach-focused motivations were more likely to disclose than those expressing avoidance-focused motivations. Participants also described a series of situational/contextual factors (social/cultural context, relevance, situation/timing, person disclosing, audience/confidant, and time passed since cancer diagnosis) which had the potential to change or influence the disclosure decision despite overarching motivations to disclose or not.

IMPLICATIONS FOR CANCER SURVIVORS

Gaining a better understanding of the cancer history disclosure decision processes of young adult cancer survivors can help them to better adapt and socially reintegrate back into their pre-cancer lives after the completion of treatment. Acknowledging and understanding the disclosure decision process and communication challenges faced by young cancer survivors can also be beneficial to healthcare professionals in the development and provision of better support interventions and informational resources to help improve psychosocial well-being after cancer.

Legitimizing neglect - a qualitative study among nursing home staff in Norway

INTRODUCTION

Residents in nursing homes do not always get qualitatively good nursing care, and research shows that residents' basic care needs are sometimes neglected. Neglect in nursing homes is a challenging and complex issue, yet a preventable one. Nursing home staff are at the frontline of detecting and preventing neglect but may also be the ones causing it. It is essential to understand why and how neglect happens in order to recognize, expose, and prevent its occurrence. Our aim was to generate new knowledge on the processes leading to and allowing neglect to continue in Norwegian nursing homes, by studying how nursing home staff perceive and reflect on when nursing home residents are neglected in their daily practice.

METHODS

A qualitative exploratory design was used. The study was based on five focus group discussions (20 participants, total) and ten individual interviews with nursing home staff from 17 different nursing homes in Norway. The interviews were analysed according to Charmaz constructivist grounded theory.

RESULTS

In order to make neglect an acceptable practice, nursing home staff apply different strategies. These strategies were identified as when the staff legitimize neglect by neglecting neglect, when the staff are not recognizing their own behaviour as neglectful, as expressed in their actions and language, and normalizing missed care when resources are lacking and nursing staff are rationing care.

CONCLUSIONS

The gradual shift between judging actions as neglectful or not are made possible when nursing home staff legitimize neglect by not recognizing their practice as neglective, thus neglecting neglect or when they are normalizing missed care. Increased awareness and reflections on these processes may be a way of reducing the risk of and preventing neglect in nursing homes.

A qualitative study on gender inequality and gender-based violence in Nepal

BACKGROUND

Gender inequality and violence are not mutually exclusive phenomena but complex loops affecting each other. Women in Nepal face several inequalities and violence. The causes are diverse, but most of these results are due to socially assigned lower positioning of women. The hierarchies based on power make women face subordination and violence in Nepal. The study aims to explore participants' understanding and experience to identify the status of inequality for women and how violence emerges as one of its consequences. Furthermore, it explores the causes of sex trafficking as an example of an outcome of inequality and violence.

METHOD

The study formulated separate male and female groups using a purposive sampling method. The study used a multistage focus group discussion, where the same groups met at different intervals. Six focus group discussions, three times each with male and female groups, were conducted in a year. Thirty-six individuals, including sixteen males and twenty females, were involved in the discussions. The study used constructivist grounded theory for the data analysis.

RESULTS

The study participants identify that a power play between men and women reinforce inequality and increases the likelihood of violence for women. The findings suggest that the subjugation of women occurs due to practices based on gender differences, constricted life opportunities, and internalization of constructed differences among women. The study identifies that interpersonal and socio-cultural violence can result due to established differences between men and women. Sex trafficking, as an example of the outcome of inequality and violence, occurs due to the disadvantageous position of women compounded by poverty and illiteracy. The study has developed a concept of power-play which is identified as a cause and consequence of women's subordination and violence. This power play is found operative at various levels with social approval for men to use violence and maintain/produce inequality.

CONCLUSION

The theoretical concept of power play shows that there are inequitable power relations between men and women. The male-centric socio-cultural norms and practices have endowed men with privilege, power, and an opportunity to exploit women. This lowers the status of women and the power-play help to produce and sustain inequality. The power-play exposes women to violence and manifests itself as one of the worst expressions used by men.

The process of learning and professional development according to nursing students' experience during Covid-19: A constructivist grounded theory study

AIM

This study explored the experiences of nursing students with respect to learning processes and professional development during internships with COVID-19 patients to build a novel theoretical model.

BACKGROUND

The COVID-19 outbreak had a profound impact on the worldwide learning system and it interrupted the internship experiences of nursing students. After the second wave of COVID-19, to balance academic activities with COVID-19 containment, some Italian universities allowed nursing students' internships in COVID-19 units. This new experience may have influenced nursing students' learning processes and professional development, but this is yet to be investigated.

DESIGN

A qualitative study using a constructivist grounded theory (CGT) approach.

METHODS

Nursing students were recruited from two hospitals in northern Italy between January and April 2021. Data are gathered from interviews and a simultaneous comparative analysis were conducted to identify categories and codes, according to Charmaz's (2006) theory.

RESULTS

The sample consisted of 28 students. The results suggested the core category, that is the 'Students' sense of belonging to the nursing profession' and four main categories: (1) From knowledge to know-how, (2) A new relationship modality, (3) Sharing and socialisation and (4) Responsibilization. Finally, a premise and a corollary, respectively (5) Motivation and the (6) Circularity of the process, were identified.

CONCLUSION

Our study proposed a new theory of nursing students' learning processes in clinical contexts during internships with COVID-19 patients. Despite significant difficulties, the nursing students developed a unique learning process characterised by motivation. Therefore, our study provided insight into the learning process during a pandemic and investigated the support needed for nursing students to continue their internships.

Perceptions of illness severity in adults with drug-resistant temporal lobe epilepsy

OBJECTIVE

The purpose of this study was to explore how subjective perceptions of illness severity were described by a sample of participants with drug-resistant epilepsy (DRE) who were considering surgery.

METHODS

A qualitative methodology, constructivist grounded theory, guided all aspects of the study. Data were collected via 51 semi-structured interviews with 35 adults in our multiethnic sample. At interview, the 20 women (57%) and 15 men (43%) ranged in age from 18 to 68 years (mean = 35.6 years) and had lived with epilepsy for an average of 15.4 y (range = 2-44 years).

RESULTS

A grounded theory with four interrelated categories was developed to reflect the process by which participants arrived at an explanation of illness severity. Illness severity for participants evolved as participants reflected upon the burdensome impact of uncontrolled seizures on self and others. Epilepsy, when compared with other chronic conditions, was described as less serious, and participants imagined that other peoples' seizures were comparatively worse than their own. Illness severity was not uppermost in participants' minds but emerged as a concept that was both relative and linked to social burden. Perceptions of overall disease severity expanded upon determinants of seizure severity to offer a more complete explanation of what patients themselves did about longstanding, uncontrolled epilepsy.

CONCLUSIONS

Perceptions of illness severity played a vital role in treatment decision-making with the potential to impact the illness trajectory. How to measure components of illness severity represents a new challenge for outcomes research in DRE.

A pattern language of compassion in intensive care and palliative care contexts

BACKGROUND

Compassion has been identified as important for therapeutic relationships in clinical medicine however there have been few empirical studies looking at how compassion is expressed different contexts. The purpose of this study was to explore how context impacts perceptions and expressions of compassion in the intensive care unit and in palliative care.

METHODS

This was an inductive qualitative study that employed sensitizing concepts from activity theory, realist inquiry, phenomenology and autoethnography. Clinicians working in intensive care units and palliative care services wrote guided field notes on their observations and experiences of how suffering and compassion were expressed in these settings. Data were analyzed using constructivist grounded theory.

RESULTS

Fifty-eight field notes were generated, along with transcripts from three focus groups. Clinicians conceptualized, observed, and expressed compassion in different ways within different contexts. Patterns of compassion identified were relational, dispositional, activity-focused, and situational. A pattern language of compassion in healthcare was developed based on these findings.

CONCLUSIONS

Recognizing compassion as shifting patterns of diverse attitudes, behaviours, and relationships raises numerous questions as to how compassion can be developed, supported and recognized in different clinical settings.

Financial management roles of nurse managers in selected public hospitals in KwaZulu-Natal province, South Africa

Background

The public health sector in South Africa has been facing severe financial cutbacks and financial constraints in recent times. The nurse manager (NM) is faced with the task of managing and reducing expenditure in the nursing sector without compromising the quality care. This requires skills and understanding of financial management.

Aim

This study aimed to explore the financial management roles of NMs and to identify financial management development needs necessary for NMs’ practice.

Setting

The study was conducted in KwaZulu-Natal. A total of eight hospitals from the five health districts were included.

Methods

The study used the naturalistic paradigm with a constructivist grounded theory approach. Interviews were used to initially gather data from six NMs who were purposively selected. Theoretical sampling was used to further recruit financial managers, chief executive officers, assistant nurse managers and operational managers. The final sample consisted of 18 participants.

Results

Financial management of the hospitals is the primary function of the financial managers and the chief executive officers. However, the role of NMs extends to the performance and participation in various activities relating to the financial functioning of the hospital. These include financial planning, financial monitoring, financial decision-making and financial control.

Conclusion

Nurse managers have a financial management function in public health care organisations but lack the necessary skills, knowledge and competencies to function in this role and require additional training. Recommendations included that a competency framework be developed to improve the financial management competencies of NMs.

Patient roles in primary care interprofessional teams: a constructivist grounded theory of patient and health care provider perspectives

Health care providers are increasingly asked to work in interprofessional teams to enhance the care provided to and health outcomes of their patients. However, there is little evidence on how to include patients in meaningful roles on these teams to support their health monitoring and management. The purpose of this study was to gain insight into roles that patients can assume within their health care teams and to understand the conditions and processes required for patient roles to be enacted. Ten patients and 10 health care providers from two Family Health Teams in Southwestern Ontario, Canada, participated in individual interviews to learn about their perspectives on patient roles in teams. Data collection and analysis strategies generated theoretical concepts, and member-checking interviews provided final feedback on the framework. This study resulted in a comprehensive framework of two roles and the conditions and processes required for patient-health care provider interactions within primary care interprofessional teams. Further researchers could use this framework to build knowledge of patient roles in interprofessional teams across varying health care settings and patient populations.

The role of the intensive care nurse in the medical emergency team: A constructivist grounded theory study

BACKGROUND

Intensive care nurses are essential members of rapid response systems (RRSs) with little qualitative data available to capture what intensive care nurses do as they navigate their way around the complexity of a medical emergency call.

OBJECTIVE

The study aims to describe and explain the role of the intensive care nurse within the medical emergency team (MET) of a tertiary-level hospital to develop an understanding of the intensive care nurse role, the way it is enacted, and their responsibilities within the team.

METHOD

A constructivist grounded theory research approach collected qualitative data from intensive care nurses who had experience attending MET calls. Data were collected through participant observation (16 MET calls), followed by 12 semistructured interviews.

FINDINGS

A substantive theory was developed that 'keeping patient's safe' is a fundamental role of the intensive care nurse within the MET. This is derived from four key concepts: Systematic framework for decision making, Figuring it out, Directing care, and Patient safety. Each of these concepts was developed from categories that describe the role of the intensive care unit nurse on the MET. They include performing assessments and interventions, figuring it out, critical thinking, prioritising care, directing care, being supportive, and ensuring patient safety.

CONCLUSION

This study provides new insights into and an understanding of the ways intensive care nurses work within the MET, making a significant contribution to our existing understanding of the role.

Male nurse practice in inpatient rehabilitation. Finding a safe way: a grounded theory

BACKGROUND

Research interest in nursing's contribution to inpatient rehabilitation is growing. Nurses contribute to rehabilitation specifically by teaching patients how to care for themselves. This contribution is largely reported from a female or genderneutral perspective. Despite the work of male nurses being examined in a range of other specialities, their work within inpatient rehabilitation remains underexplored.

OBJECTIVE

To report on a grounded theory study to identify and make visible male nurse practice in inpatient rehabilitation in Australia.

DESIGN

Constructivist grounded theory informed by symbolic interactionism.

SETTING(S)

Stage 1 data were collected in locations of participants choosing throughout Australia. Stage 2 data collection centred on seven data collection sites across two specialist rehabilitation hospitals in two states of Australia.

PARTICIPANTS

Twenty-three male nurses and 15 patients participated in the study.

METHODS

Stage 1 (October 2013 to June 2014) consisted of semi-structured interviews with 11 male nurses. Stage 2 (February to April 2015) consisted of semi-structured interviews and 63.5 h of non-participant observation with 12 male nurses. Fifteen interviews with patients as recipients of male nurse care were also conducted. Data analysis included initial coding, focused coding, and theoretical coding using constant comparative methods, memo writing and diagramming.

RESULTS

Nurse participants were aware of patient perceptions about nursing being an occupation for women and male nurses being perceived as sexual threats, which led to an everyday concern of potential for misinterpretation. To address this concern, male nurses engaged in a three-phase process known as assessing and managing risk in order to minimise risk and to keep themselves safe in practice. However, two contextual conditions, type of care and urgency of care, influenced engagement in assessing and managing risk. The core category and substantive grounded theory to explain these results is finding a safe way.

CONCLUSIONS

Gender stereotypes affected the daily working lives of male nurses in inpatient rehabilitation. To counter the risk of misinterpretation male nurses used a range of strategies to address the barriers encountered daily in their working lives. However, male nurse efforts were often influenced by conditions outside of their control. In inpatient rehabilitation, male nurses practised cautiously to keep themselves safe in order to practise nursing.

"A whole other competence story": exploring faculty perspectives on the process of workplace-based assessment of entrustable professional activities

The centrality of entrustable professional activities (EPAs) in competency-based medical education (CBME) is predicated on the assumption that low-stakes, high-frequency workplace-based assessments used in a programmatic approach will result in accurate and defensible judgments of competence. While there have been conversations in the literature regarding the potential of this approach, only recently has the conversation begun to explore the actual experiences of clinical faculty in this process. The purpose of this qualitative study was to explore the process of EPA assessment for faculty in everyday practice. We conducted 18 semi-structured interviews with Anesthesia faculty at a Canadian academic center. Participants were asked to describe how they engage in EPA assessment in daily practice and the factors they considered. Interviews were audio-recorded, transcribed, and analysed using the constant comparative method of grounded theory. Participants in this study perceived two sources of tension in the EPA assessment process that influenced their scoring on official forms: the potential constraints of the assessment forms and the potential consequences of their assessment outcome. This was particularly salient in circumstances of uncertainty regarding the learner's level of competence. Ultimately, EPA assessment in CBME may be experienced as higher-stakes by faculty than officially recognized due to these tensions, suggesting a layer of discomfort and burden in the process that may potentially interfere with the goal of assessment for learning. Acknowledging and understanding the nature of this burden and identifying strategies to mitigate it are critical to achieving the assessment goals of CBME.

Overt restrictive feeding for weight management: a preliminary retrospective examination of childhood experiences

PURPOSE

Overt restrictive feeding practices (ORFP), aimed at promoting weight loss or preventing weight gain for children, are often implemented by parents with good intentions. Despite findings that indicate unintended weight and behavioral outcomes little is known about how parental ORFP are experienced by those who are subjected to them. Thus, we explored retrospective accounts of meaning making related to experiences of such practices during childhood.

METHODS

Six young adult females who experienced ORFP were interviewed. Data were analyzed using constructivist grounded theory.

RESULTS

Participants retrospectively associated experiencing ORFP with a meaning making process that involves: (a) perceiving parental motivation for ORFP and receiving messages about weight, (b) internalizing parental messages about weight, and (c) viewing self-worth as contingent on weight.

CONCLUSION

Preliminary findings suggest that parents may be reinforcing weight stigma in their children through ORFP. Results add evidence against the use of parental ORFP for childhood weight management.

LEVEL OF EVIDENCE

Level V, Descriptive study.

Perceived barriers and enablers to physical activity participation in people with Alopecia Areata: a constructivist grounded theory study

BACKGROUND

Alopecia Areata (AA) is an autoimmune disease that is characterised by hair loss. Individuals diagnosed with it often describe feelings of trauma and social rejection due to cosmetic repercussions and are at high risk of experiencing psychological distress. Physical activity (PA) participation has been associated with better mental health outcomes in diverse populations. A preliminary study of individuals with AA indicated that severe hair loss is associated with symptomatic depression, anxiety and stress, which negatively impacted PA participation. While strategies to increase PA participation in the general population have been established, little is known about PA participation in people with AA. This study aimed to understand barriers and enablers to PA participation in people with AA to inform the development of evidence-based interventions.

METHODS

The study used a grounded theory (GT) methodology, relying on an iterative and simultaneous process of data collection, coding, theory development, and data comparisons to explore the perceived barriers and enablers to PA. Data were collected through a focus group (8 participants [33.38 ± 10.81 years]) and individual telephone interviews (8 participants [33.89 ± 11.87 years]). The study was conducted in Melbourne, Australia. Interview data were recorded digitally, transcribed verbatim and analysed. Recruitment continued until theoretical saturation was achieved.

RESULTS

The constructivist grounded theory method used has assisted to develop an explanatory model which is used to explain the themes for barriers and enablers to PA participation. The four phases in the explanatory model are as follows (1) onset of AA; (2) reaction towards the condition; (3) adjustment; and (4) acceptance.

CONCLUSION

The findings highlighted perceived barriers and enablers to PA participation in people with AA. Future interventions could consider addressing these barriers specifically to maximise effectiveness and to improve mental health status based on the phases of the explanatory model.

A qualitative study examining the critical differences in the experience of and response to formative feedback by undergraduate medical students in Japan and the UK

BACKGROUND

Formative feedback plays a critical role in guiding learners to gain competence, serving as an opportunity for reflection and feedback on their learning progress and needs. Medical education in Japan has historically been dominated by a summative paradigm within assessment, as opposed to countries such as the UK where there are greater opportunities for formative feedback. How this difference affects students' interaction with feedback has not been studied. We aim to explore the difference in students' perception of feedback in Japan and the UK.

METHODS

The study is designed and analysed with a constructivist grounded theory lens. Medical students in Japan and the UK were interviewed on the topic of formative assessment and feedback they received during clinical placements. We undertook purposeful sampling and concurrent data collection. Data analysis through open and axial coding with iterative discussion among research group members was conducted to develop a theoretical framework.

RESULTS

Japanese students perceived feedback as a model answer provided by tutors which they should not critically question, which contrasted with the views of UK students. Japanese students viewed formative assessment as an opportunity to gauge whether they are achieving the pass mark, while UK students used the experience for reflective learning.

CONCLUSIONS

The Japanese student experience of formative assessment and feedback supports the view that medical education and examination systems in Japan are focused on summative assessment, which operates alongside culturally derived social pressures including the expectation to correct mistakes. These findings provide new insights in supporting students to learn from formative feedback in both Japanese and UK contexts.

Re-negotiating agency - patients using comics to reflect upon acting in situations of abuse in health care

Background

There is a growing body of international research that displays the prevalence and character of abuse in health care. Even though most of these studies are conducted from a patient perspective little is known about how patients conceptualize their agency in relation to such situations. This study aimed to explore how patients reason about their potential to act in abusive situations.

Methods

Qualitative interviews were conducted with thirteen patients in Sweden. Central in the interviews were three comics, inspired by Boal’s Forum Theatre and part of an earlier online intervention study in which the informants had participated. Each comic showed a situation in which a patient feels abused, and on the opposite side were suggestions for how the patient could act in response. Informants were asked to reflect about situations of abuse and in specific upon the comics. We used the methodology of constructivist grounded theory throughout the study, including the analysis.

Results

It appeared that the informants constantly re-negotiated their and other patients’ agency in relation to the specifics of the event, patients’ and staff’s responsibilities, and the patients’ needs and values. This process questions views of agency as fixed and self-evident, and can be understood as part of changing discourses about patients’ social role and possibilities to organize their care. Using a feminist theory of power we expected the informants to elicit instances of resistance to domination, which is central to the comics. While doing that, the informants also hinted at parallel stories of empowerment and less visible forms of agency in spite of domination.

Conclusion

The current analysis showed different ways in which the informants constantly re-negotiated their agency in potentially abusive situations. Not only did the informants engage in reflections about immediate responses to these untoward situations, they also engaged in thoughts about strategies that could protect them and counteract abuse in health care over the long-term. This opens up for future research into ways patients organize their care and identify threats and barriers to the care they need, which could be valuable knowledge for care quality improvement.

Panic or peace - prioritising infant welfare when medicating feverish infants: a grounded theory study of adherence in a paediatric clinical trial

Background

Literature on factors influencing medication adherence within paediatric clinical trials is sparse. The Paracetamol and Ibuprofen in the Primary Prevention of Asthma in Tamariki (PIPPA Tamariki) trial is an open-label, randomised controlled trial aiming to determine whether paracetamol treatment, compared with ibuprofen treatment, as required for fever and pain in the first year of life, increases the risk of asthma at age six years. To inform strategies for reducing trial medication crossovers, understanding factors influencing the observed ibuprofen-to-paracetamol crossovers (non-protocol adherence) is vital. The aim of this study was to investigate the factors influencing the decision-making process when administering or prescribing ibuprofen to infants that may contribute to the crossover events in the PIPPA Tamariki trial.

Methods

Constructivist grounded theory methods were employed. We conducted semi-structured interviews of caregivers of enrolled PIPPA Tamariki infants and healthcare professionals in various healthcare settings. Increasing theoretical sensitivity of the interviewers led to theoretical sampling of participants who could expand on the teams’ early constructed codes. Transcribed interviews were coded and analysed using the constant comparative method of concurrent data collection and analysis.

Results

Between September and December 2020, 20 participants (12 caregivers; 8 healthcare professionals) were interviewed. We constructed a grounded theory of prioritising infant welfare that represents a basic social process when caregivers and healthcare professionals medicate feverish infants. This process comprises three categories: historical, trusting relationships and being discerning; and is modified by one condition: being conflicted. Participants bring with them historical ideas. Trusting relationships with researchers, treating clinicians and family play a central role in enabling participants to challenge historical ideas and be discerning. Trial medication crossovers occur when participants become conflicted, and they revert to historical practices that feel familiar and safer.

Conclusions

We identified factors and a basic social process influencing ibuprofen use in infants and trial medication crossover events, which can inform strategies for promoting adherence in the PIPPA Tamariki trial. Future studies should explore the role of trusting relationships between researchers and treating clinicians when conducting research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03230-4.

Negotiating care in organizational borderlands: a grounded theory of inter-organizational collaboration in coordination of care

BACKGROUND

Although coordination of care and integrated care models aim to enhance patient satisfaction and perceived care quality, evidence regarding their practical implementation remains scarce. Understanding the nuances of collaboration across care providers to achieve effective coordination of care is imperative for seamless care integration. The aim of this study was to construct a grounded theory of how inter-organizational collaboration is performed to support coordination of care for patients with complex care needs.

METHODS

A qualitative design with a constructivist grounded theory approach was applied. In total, 86 participants with diverse backgrounds were recruited across multiple care settings, including hospitals, ambulance services, primary care centers, municipal home healthcare and home care services. The grounded theory was developed iteratively, based on a combination of observations and interviews, and using constant comparative analysis.

RESULTS

Coordination of care, a complex process that occurs across interconnected healthcare organizations, is manifested as "Negotiating care in organizational borderlands." Care coordination evolves through a spectrum of inter-organizational collaboration, ranging from "Dividing care by disease-specific expertise" to "Establishing paths for collaboration" and ultimately "Co-constructing a comprehensive whole." These categories highlight the challenges of coordinating care across both professional and organizational boundaries. In the multifaceted healthcare landscape, effective care coordination occurs when healthcare professionals actively bridge the divides, leveraging their collective expertise. Importantly, organizational boundaries may serve a purpose and should not be dissolved to facilitate effective care coordination.

CONCLUSIONS

The key to effective care coordination lies in robust inter-organizational collaboration. Even when patients receive integrated care, healthcare professionals may have fragmented roles. This research emphasizes the importance of clearly defined lines of accountability, reinforcing mutual responsibility and facilitating bridging of professional and organizational boundaries. Healthcare professionals and policymakers can use these insights to effectively utilize inter-organizational collaboration in supporting care coordination for patients with complex care needs.

"Just pee in the diaper" - a constructivist grounded theory study of moral distress enabling neglect in nursing homes

BACKGROUND

A growing body of evidence shows that many nursing home residents' basic care needs are neglected, and residents do not receive qualitatively good care. This neglect challenges nursing staff´s professional and personal ideals and standards for care and may contribute to moral distress. The aim of this study was to investigate how nursing staff manage being a part of a neglectful work culture, based on the research question: "How do nursing home staff manage their moral distress related to neglectful care practices?"

METHODS

A qualitative design was chosen, guided by Charmaz´s constructivist grounded theory. The study was based on 10 individual interviews and five focus group discussions (30 participants in total) with nursing home staff working in 17 different nursing homes in Norway.

RESULTS

Nursing staff strive to manage their moral distress related to neglectful care practices in different ways: by favouring efficiency and tolerating neglect they adapt to and accept these care practices. By disengaging emotionally and retreating physically from care they avoid confronting morally distressing situations. These approaches may temporarily mitigate the moral distress of nursing staff, whilst also creating a staff-centred and self-protecting work culture enabling neglect in nursing homes.

CONCLUSIONS

Our findings represent a shift from a resident-centred to a staff-centred work culture, whereby the nursing staff use self-protecting strategies to make their workday manageable and liveable. This strongly indicates a compromise in the quality of care that enables the continuation of neglectful care practices in Norwegian nursing homes. Finding ways of breaking a downward spiralling quality of care are thus a major concern following our findings.

Exploring a learning model for knowledge integration and the development of critical thinking among nursing students with previous learning: a qualitative study protocol

Students often struggle to apply their knowledge of bioscience to their care practice. Such knowledge is generally learned through remembering and understanding, but retention quickly fades. They also experience difficulty progressing to higher-order cognitive skills such as applying, analyzing, evaluating, and even creating, which are necessary to develop soft skills, such as critical thinking, in the care profession. In order to improve existing programs, there is a need to better understand students' prior learning experiences and processes. The proposed study will explore the previous learning experiences of nurses enrolled in a two-year nursing program at a Taiwan university and identify the challenges they face in integrating multidisciplinary knowledge and developing critical thinking competency. The study will adopt a constructivist grounded theory methodology to collect interview data. The findings are expected to improve higher cognitive learning performance and inform the revision of the two-year nursing curriculum.