Saturation in qualitative research: exploring its conceptualization and operationalization

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation—as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

Using Grounded Theory Method to Capture and Analyze Health Care Experiences

OBJECTIVE

Grounded theory (GT) is an established qualitative research method, but few papers have encapsulated the benefits, limits, and basic tenets of doing GT research on user and provider experiences of health care services. GT can be used to guide the entire study method, or it can be applied at the data analysis stage only.

METHODS

We summarize key components of GT and common GT procedures used by qualitative researchers in health care research. We draw on our experience of conducting a GT study on amyotrophic lateral sclerosis patients' experiences of health care services.

FINDINGS

We discuss why some approaches in GT research may work better than others, particularly when the focus of study is hard-to-reach population groups. We highlight the flexibility of procedures in GT to build theory about how people engage with health care services.

CONCLUSION

GT enables researchers to capture and understand health care experiences. GT methods are particularly valuable when the topic of interest has not previously been studied. GT can be applied to bring structure and rigor to the analysis of qualitative data.

The physician's experience of changing clinical practice: a struggle to unlearn

BACKGROUND

Changing clinical practice is a difficult process, best illustrated by the time lag between evidence and use in practice and the extensive use of low-value care. Existing models mostly focus on the barriers to learning and implementing new knowledge. Changing clinical practice, however, includes not only the learning of new practices but also unlearning old and outmoded knowledge. There exists sparse literature regarding the unlearning that takes place at a physician level. Our research objective was to elucidate the experience of trying to abandon an outmoded clinical practice and its relation to learning a new one.

METHODS

We used a grounded theory-based qualitative approach to conduct our study. We conducted 30-min in-person interviews with 15 primary care physicians at the Cleveland VA Medical Center and its clinics. We used a semi-structured interview guide to standardize the interviews.

RESULTS

Our two findings include (1) practice change disturbs the status quo equilibrium. Establishing a new equilibrium that incorporates the change may be a struggle; and (2) part of the struggle to establish a new equilibrium incorporating a practice change involves both the "evidence" itself and tensions between evidence and context.

CONCLUSIONS

Our findings provide evidence-based support for many of the empirical unlearning models that have been adapted to healthcare. Our findings differ from these empirical models in that they refute the static and unidirectional nature of change that previous models imply. Rather, our findings suggest that clinical practice is in a constant flux of change; each instance of unlearning and learning is merely a punctuation mark in this spectrum of change. We suggest that physician unlearning models be modified to reflect the constantly changing nature of clinical practice and demonstrate that change is a multi-directional process.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Understanding 'energy insecurity' and why it matters to health

Energy insecurity is a multi-dimensional construct that describes the interplay between physical conditions of housing, household energy expenditures and energy-related coping strategies. The present study uses an adapted grounded theory approach based on in-depth interviews with 72 low-income families to advance the concept of energy insecurity. Study results illustrate the layered components of energy insecurity by providing rich and nuanced narratives of the lived experiences of affected households. Defined as an inability to adequately meet basic household energy needs, this paper outlines the key dimensions of energy insecurity-economic, physical and behavioral- and related adverse environmental, health and social consequences. By thoroughly examining this understudied phenomenon, this article serves to raise awareness of an increasingly relevant issue that merits more attention in research and policy.

Perceptions of successful aging among diverse elders with late-life disability

PURPOSE

Researchers often use the term "successful aging" to mean freedom from disability, yet the perspectives of elders living with late-life disability have not been well described. The purpose of this study was to explore the meaning of successful aging among a diverse sample of community-dwelling elders with late-life disability.

DESIGN AND METHODS

Using qualitative grounded theory methodology, we interviewed 56 African American, White, Cantonese-speaking Chinese, and Spanish-speaking Latino disabled elders who participate in On Lok Lifeways, a Program of All-inclusive Care for the Elderly. Through semi-structured interviews with open-ended questions, we explored the elders' perceptions of what successful aging and being old meant to them.

RESULTS

Despite experiencing late-life disability, most participants felt they had aged successfully. An overarching theme was that aging results in Living in a New Reality, with two subthemes: Acknowledging the New Reality and Rejecting the New Reality. Participants achieved successful aging by using adaptation and coping strategies to align their perception of successful aging with their experiences. Themes were common across race/ethnic groups but certain strategies were more prominent among different groups.

IMPLICATIONS

Across race and ethnic groups, most of these participants with late-life disability felt they had aged successfully. Thus, successful aging involves subjective criteria and has a cultural context that is not captured in objective measurements. Understanding elders' perception will help establish common ground for communication between clinicians and elders and identify the most appropriate interventions to help elders achieve and maintain the experience of successful aging.

Psychedelic microdosing benefits and challenges: an empirical codebook

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

How nursing home residents develop relationships with peers and staff: a grounded theory study

Social support and social relationships have been repeatedly identified as essential to nursing home resident quality of life. However, little is known about ways residents develop relationships with peers or staff.

OBJECTIVE

This study was conducted to explore the ways resident develop relationships with peers and staff in nursing homes.

DESIGN AND METHODS

Fifteen cognitively intact nursing home residents from two facilities were interviewed for this grounded theory study. Sampling, interviewing, and analysis occurred in a cyclical process with results at each stage of the study informing decisions about data collection and analysis in the next. Unstructured interviews and field observations were conducted. Data were analyzed with open, axial, and selective coding.

RESULTS

Residents developed relationships with peers and staff largely as an unintended consequence of trying to have a life in the nursing home. Having a life was a two-step process. First, life motivations (Being Self and Creating a Positive Atmosphere) influenced resident preferences for daily activities and interaction goals and subsequently their strategies for achieving and establishing both. Second, the strategies residents used for achieving their required daily activities (Passing Time and Getting Needs Met) and interaction goals then influenced the nature of interaction and the subsequent peer or staff response to these interactions. Residents defined relationships as friendly or unfriendly depending on whether peers or staff responded positively or negatively. There was considerable overlap in the ways peer and staff relationships developed and the results highlight the role of peer and staff responsiveness in relationship development.

IMPLICATIONS

The results provide possible explanations for the success of interventions in the literature designed to improve staff responsiveness to residents. The results suggest that adapting these kinds of interventions for use with peers may also be successful. The conceptual model also presents a number of opportunities for developing interventions for residents.

Finessing incivility: The professional socialisation experiences of student nurses' first clinical placement, a grounded theory

BACKGROUND

Clinical practice is where student nurses are socialised into a professional role and acquire the distinct behaviour, attitudes and values of the nursing profession. Getting it right at the outset can maximise the development of a professional identity and the transmission of robust value systems.

OBJECTIVES

To explore the impact of the first clinical placement on the professional socialisation of adult undergraduate student nurses in the United Kingdom.

DESIGN

Data of a longitudinal qualitative nature were collected and analysed using grounded theory.

SETTINGS

First year student nurses in hospital ward placements comprising a rural District General Hospital and a large inner city Hospital kept daily unstructured diaries for six weeks.

PARTICIPANTS

A total of 26 undergraduate adult student nurses were purposefully sampled between 2008 and 2010 before undertaking their initial clinical placement.

METHODS

Data collection and analysis used grounded theory and the key question asked of the diarists 'tell me what it is like to be a first year nurse on a first placement' was theoretically adjusted during constant comparison and as the theory emerged. Ethical approval and consent was obtained.

RESULTS

The theory of finessing incivility comprises a conceptual framework depicting how student nurses deal with professional incivility during their initial clinical placement and sustain a student identity. Being disillusioned with their role as worker rather than learner yields a sense of 'status dislocation'. Despite needing professional benevolence, they remain altruistic and seek recompense from significant others to negotiate for learning opportunities and relocate their student status.

CONCLUSIONS

Despite the stressful transition into clinical practice rather than 'fit in', the student nurses want to belong as learners. His or her own resilience to learn nursing and be a professional student maintains their resolve, their altruism and strengthens their existing values to be benevolent towards an indifferent profession. This behaviour ultimately mirrors the social nature of the practice community.

Building healthcare provider relationships for patient-centered care: A qualitative study of the experiences of people receiving injectable opioid agonist treatment

BACKGROUND

Injectable opioid agonist treatment (iOAT) was designed as a pragmatic and compassionate approach for people who have not benefitted from medication assisted treatment with oral opioids (e.g., methadone). While, a substantial body of clinical trial evidence has demonstrated the safety and effectiveness of iOAT, considerably less is known about the patient-centered aspects of this treatment and their role in self-reported treatment goals and outcomes. The aim of this study was to explore participants' experiences in iOAT as they broadly relate to the domains of patient-centered care. A secondary goal was to explore how these experiences affected participants' self-reported treatment outcomes.

METHODS

A qualitative methodology, and constructivist grounded theory approach, was used to guide sampling, data collection and analysis. A total of 30 in-depth interviews were conducted with people receiving iOAT in North America's first clinic. Audio-recordings for each semi-structured interview were transcribed and read repeatedly. The strategy of constant comparison was used through iterative stages of line-by-line, focused and theoretical coding until theoretical saturation was achieved.

RESULTS

"Building healthcare provider relationships for patient-centered care in iOAT" was the emergent core concept. Healthcare provider relationships were established through two interrelated processes: 'Opening up' was attributed to the positive environment, and to feeling understood and supported by healthcare providers. 'Being a part of care' emerged as participants felt safe to ask for what was needed and had opportunities to collaborate in treatment decisions. These processes established a foundation in which participants experienced care that was responsive to their individual dose, health and psychosocial needs.

CONCLUSIONS

The core concept suggested that therapeutic relationships were fundamental to experiences of patient-centered care in iOAT. When relationships were respectful and understanding, participants received individualized and holistic care in iOAT. These findings offer a valuable example of how therapeutic relationships can be strengthened in other substance use treatment settings, particularly when responding to the diverse treatment needs of clients.

What constitutes a health-enabling neighborhood? A grounded theory situational analysis addressing the significance of social capital and gender

Variations in health between neighborhoods are well known and the conceptualization of social capital has contributed to an understanding of how contextual factors influence these differences. Studies show positive health-effects from living in high social capital areas, at least for some population sub-groups. The aim of this qualitative study was to understand what constitutes a 'health-enabling' neighborhood. It follows up results from a social capital survey in northern Sweden indicating that the health effects of living in a high social capital neighborhood is gendered in favor of women. A grounded theory situational analysis of eight focus group discussions--four with men and four with women--illustrated similar and different positions on how neighborhood characteristics influence health. A neighborhood, where people say hi to each other ("hi-factor") and where support between neighbors exist, were factors perceived as positive for health by all, as was a good location, neighborhood greenness and proximity to essential arenas. Women perceived freedom from demands, feeling safe and city life as additional health enabling factors. For men freedom to do what you want, a sense of belonging, and countryside life were important. To have burdensome neighbors, physical disturbances and a densely living environment were perceived as negative for health in both groups while demands for a well styled home and feeling unsafe were perceived as negative for health among women. Neighborhood social capital, together with other elements in the living environment, has fundamental influence on people's perceived health. Our findings do not confirm that social capital is more important for women than for men but that distinctive form of social capital differ in impact. Investing in physical interventions, such as planning for meeting places, constructing attractive green areas, and making neighborhoods walking-friendly, may increase human interactions that is instrumental for social capital and is likely to have health promoting effects for all.

Young Adults on the Autism Spectrum: The Struggle for Appropriate Services

In the United States, young adults with an autism spectrum disorder (ASD) lose federally mandated supports upon leaving high school. To arrange adult services, families must prove their young adult's eligibility and find competent service providers. National-level statistics regarding receipt of appropriate adult services are discouraging, but little is known about families' lived experience with regard to services. Therefore, qualitative interviews focused on the search for and satisfaction with adult services were conducted with parents of young adults with ASD, then analyzed using the constant comparative method. Emergent themes included Bureaucracy and Fighting for Access, Staffing Issues, Program Suitability, and "Doing It Yourself." The need to improve service access and delivery is discussed, as are issues facing specific ASD subgroups.

Letting go: How newly graduated registered nurses in Western Canada decide to exit the nursing profession

BACKGROUND

The Canadian Nurses Association (CNA) estimates a nursing shortage in Canada will rise to 60,000 registered nurses by 2022. Further compounding this crisis is the approximate 14-61% of new nursing graduates who will change nursing roles or exit the profession.

AIM

To explore the factors and basic psychosocial process involved in the decisions of newly graduated registered nurses in Western Canada who permanently exit the nursing profession within five years.

DESIGN

Data was collected through unstructured and semi-structured interviews using the Glaserian grounded theory method.

FINDINGS

Participants were found to be in a process of letting go of nursing that commenced as students and continued as they entered practice as registered nurses. Four major themes were identified. 1) Navigating constraints of the healthcare system and workplace: participants encountered difficulties adjusting to shiftwork and workload. 2) Negotiating social relationships, hierarchies, and troublesome behaviors; specifically hierarchal and horizontal violence. 3) Facing fears, traumas and challenges. 4) Weighing competing rewards and tensions which resulted in leaving the nursing profession.

CONCLUSION

Students and subsequently new nursing graduates require a variety of supports to establish a nursing identity and remain in the profession. These supports include a manageable workload; meaningful orientation; interprofessional teamwork; and engagement within transformational and authentic leadership constructs. New nurses require a sense of being welcomed, valued, respected and accepted into the workplace environment, as well as constructive feedback, emotional support and debriefing to face workplace challenges.

Burnout and resilience in critical care nurses: A grounded theory of Managing Exposure

BACKGROUND

Many critical care nurses experience burnout; however, resilience shows promise as a potential solution to burnout. This study was conducted to better understand nurse burnout and resilience in response to workplace adversity in critical care.

DESIGN

A grounded theory investigation, using the Corbin and Strauss methodology. Participants engaged in qualitative, open-ended interviews about burnout and resilience.

SETTING

A multi-site, urban, teaching hospital in Canada.

PARTICIPANTS

11 female critical care nurses, with 1-30+ years of critical care experience.

FINDINGS

Burnout and resilience can be understood as indicators in a process of responding to workplace adversity. Workplace adversity can take many forms and has a negative impact on nurses. Nurses must be aware of this impact to take action. The process of Managing Exposure is how nurses address workplace adversity, using variety of techniques: protecting, processing, decontaminating, and distancing. The indicators of this process for nurses are thriving, resilience, survival and burnout. Organisational policies can impact on this process.

CONCLUSIONS

Resilience and burnout are connected, as indicators of the same process for critical care nurses. Nurse leaders can intervene throughout this process to reduce workplace adversity and support resilience among nurses.

Cultural Identity Among Afghan and Iraqi Traumatized Refugees: Towards a Conceptual Framework for Mental Health Care Professionals

Cultural identity in relation with mental health is of growing interest in the field of transcultural psychiatry. However, there is a need to clarify the concept of cultural identity in order to make it useful in clinical practice. The purpose of this study is to unravel the complexity and many layers of cultural identity, and to assess how stress and acculturation relate to (changes in) cultural identity. As part of a larger study about cultural identity, trauma, and mental health, 85 patients from Afghanistan and Iraq in treatment for trauma-related disorders were interviewed with a Brief Cultural Interview. The interviews were analysed through qualitative data analysis using the procedures of grounded theory. The analysis resulted in three domains of cultural identity: personal identity, ethnic identity and social identity. Within each domain relationships with stress and acculturation were identified. The results offer insight into the intensity of changes in cultural identity, caused by pre-and post-migration stressors and the process of acculturation. Based on the research findings recommendations are formulated to enhance the cultural competency of mental health workers.

Understanding why people do or do not engage in activities following total joint replacement: a longitudinal qualitative study

OBJECTIVE

Numerous studies report large and significant improvements in basic mobility and activities of daily living following total hip or knee replacement (TJR). Nevertheless, quantitative research has shown minimal increase in participation in activities that benefit overall health. This study explored why people do or do not engage in activities following hip or knee TJR.

METHOD

This was a longitudinal qualitative study. Sampling was guided by constructivist grounded theory and data collected using open-ended, semi-structured interviews. Participants were recruited using maximum variation sampling based on age, sex and joint replaced (hip or knee). Data were analysed using a constant comparative approach and coded for thematic patterns and relationships from which overarching themes were constructed.

RESULTS

Twenty-nine patients participated in interviews prior to, and 8 and 18 months post following TJR. A high degree of variability with regard to participants' return to activities was found and five emergent themes were identified that accounted for this variability. These themes highlight the importance of issues beyond medical factors alone, such as socio-cultural factors that partially determine participants' participation in activity following TJR.

CONCLUSION

Findings suggest that multi-faceted experiences impact participation in activity following TJR. These experiences include changes in identity and lifestyle that preclude a 'return to normal'. There is an urgent need for supports to increase people's activity post-TJR in order to facilitate enhancement of post-surgery levels of engagement. Approaches that take into consideration more personalized interventions may be critical to promoting healthy aging in people with TJR.

A grounded theory study of 'turning into a strong nurse': Earthquake experiences and perspectives on disaster nursing education

BACKGROUND

While Asia has the dubious distinction of being the world's most natural disaster-prone area, disaster nursing education and training are sparse in many Asian countries, especially China where this study took place.

OBJECTIVE

To explore the earthquake disaster experiences of Chinese nurses and develop a substantive theory of earthquake disaster nursing that will help inform future development of disaster nursing education.

DESIGN

A qualitative study employing grounded theory, informed by symbolic interactionism.

PARTICIPANTS AND SETTING

Fifteen Chinese registered nurses from five hospitals in Jiangxi Province who undertook relief efforts after the 2008 Wenchuan Earthquake.

METHODS

Data were collected in 2012-2013 in digitally-recorded, semi-structured, in-depth interviews and reflective field notes, and analyzed using Glaser's grounded theory method.

RESULTS

Participants were unprepared educationally and psychologically for their disaster work. Supporting the emergent theory of "working in that terrible environment", was the core category of "turning into a strong nurse", a process of three stages: "going to the disaster"; "immersing in the disaster"; and "trying to let disaster experiences fade away". The participants found themselves thrust in "terrible" scenes of destruction, experienced personal dangers and ethical dilemmas, and tried the best they could to help survivors, communities and themselves, with limited resources and confronting professional work.

CONCLUSIONS

Our rich findings confirm those of other studies in China and elsewhere, that attention must be paid to disaster education and training for nurses, as well as the mental health of nurses who work in disaster areas. Emergent theory helps to inform nurse educators, researchers, leaders and policy makers in China, and elsewhere in developing strategies to better prepare nurses for future disasters, and assist communities to prepare for and recover after earthquake disasters.

Grounded theory: what makes a grounded theory study?

Grounded theory (GT) is both a research method and a research methodology. There are several different ways of doing GT which reflect the different viewpoints of the originators. For those who are new to this approach to conducting qualitative research, this can be confusing. In this article, we outline the key characteristics of GT and describe the role of the literature review in three common GT approaches, illustrated using exemplar studies.

Exploring patient perception of success and benefit in self-management of breast cancer-related arm lymphoedema

PURPOSE

The aim of this study was to identify factors influencing patient perception of success and benefit with self-management of breast cancer-related lymphoedema (BCRL) and explore how patients decide whether their swollen limb has improved or deteriorated.

METHODS

This qualitative study used a Grounded Theory approach. Twenty-one women in the BCRL self-management phase participated in one in-depth interview exploring their experience and perspective on self-managing their BCRL.

FINDINGS

Seven enablers and blocks to self-management were identified: routine, recognising benefit of self-management and consequences of non-treatment, owning treatment, knowledge and understanding, problem-solving, time required for treatment and aesthetics of hosiery. Women determined treatment outcome by monitoring size, appearance, texture and internal sensations within the affected arm.

CONCLUSIONS

Women who participated in this study showed varying degrees of acceptance and adjustment to life with lymphoedema. This appears to directly impact their ability to self-manage lymphoedema. Lymphoedema practitioners and oncology nurses have a valuable role providing knowledge and support to patients transitioning to independent self-care. A better understanding of factors facilitating patients to become experts in their condition may improve longer term outcomes and reduce cost pressures on lymphoedema services.

How older adults with mild cognitive impairment relate to technology as part of present and future everyday life: a qualitative study

BACKGROUND

Existing everyday technology as well as potential future technology may offer both challenges and possibilities in the everyday occupations of persons with cognitive decline. To meet their wishes and needs, the perspective of the persons themselves is an important starting point in intervention planning involving technology. The aim of this study was to explore how persons with mild cognitive impairment relate to technology as a part of and as potential support in everyday life - both present and future.

METHODS

Qualitative in-depth interviews with six participants aged 61-86 were conducted and analyzed, using a grounded theory approach.

RESULTS

The findings describe the participants' different ways of relating to existing and potential future technology in everyday occupations as a continuum of downsizing, retaining, and updating. Multiple conditions in different combinations affected both their actions taken and assumptions made towards technology in this continuum. Both when downsizing doing and technology use to achieve simplicity in everyday life and when striving for or struggling with updating, trade-offs between desired and adverse outcomes were made, challenging take-off runs were endured, and negotiations of the price worth paying took place.

CONCLUSIONS

Our findings suggest that persons with mild cognitive impairment may relate to technology in various ways to meet needs of downsized doing, but are reluctant to adopt video-based monitoring technology intended to support valued occupations. Feasibility testing of using already-incorporated everyday technologies such as smartphones and tablets as platforms for future technology support in everyday occupations is suggested.

Adherence to adjuvant endocrine therapy among breast cancer survivors: a systematic review and meta-synthesis of the qualitative literature using grounded theory

PURPOSE

Numerous studies have examined non-adherence to adjuvant endocrine therapy in women recovering from breast cancer, but none provides a comprehensive theory to explain the challenges of long-term medication taking and resilience needed to continue. The aim of this study was to source, appraise, and synthesize data from existing qualitative studies to develop an in-depth explanatory model of non-adherence and discontinuation of hormonal medication among breast cancer survivors.

METHODS

A comprehensive search of databases and the literature identified 24 eligible qualitative studies published 2010-2019. Quotations (n = 801) listed within these papers and the original author interpretations were synthesized using NVivo, and grounded theory methodology.

RESULTS

At the beginning, knowledge about adjuvant endocrine therapy, trust in doctors, and worries and expectations, mean agreeing to medication is the only viable option, akin to a Hobson's choice. Thereafter, women's ability to deal with medication side-effects, knowledge and support received affect their decision to continue, akin to a horned dilemma where giving up the medication risks cancer recurrence and continuing means reduced contentment. Women stopping medication altogether question treatment necessity, search for normalcy and prioritize quality of life.

CONCLUSION

Shared experiences and understandings were uncovered by examining commonalities in existing publications. The core category explained the difficulties women face with the initial decision to accept long-term endocrine therapy and then the everyday challenges of continuing or deciding to stop treatment early. An educational tool to inform survivors and health professionals about these challenges could potentially improve women's experience on treatment and in turn their adherence.

Midwifery students learning experiences in labor wards: a grounded theory

BACKGROUND

The labor ward is an important and challenging learning area for midwifery students. It is there the students learn in authentic complex situations, in intimate situations, with potential risk for the life and health of mothers and their babies.

OBJECTIVE

The aim of this study was to explore the main concern expressed by midwifery students in labor wards and how they handled this concern.

DESIGN

A longitudinal study based on grounded theory methodology was used. The participants were 10 postgraduate midwifery students, from a University College in Norway. Data were gathered and analyzed throughout the 2-year postgraduate program, in the students first, third and fourth semesters. Every student was interviewed three times in a total of 15 single and three focus-group sessions.

FINDINGS

The grounded theory of "building relationships" explains how students dealt with their main concern: "how to gain access to learning experiences". This theory consisted of three strategies; a) controlling vulnerability, b) cultivating trust and c) obtaining acceptance.

CONCLUSION

Clarifying discussions involving midwives and students may facilitate the process of building relationships and contribute to confident learning. Students appreciate it when the midwives initiate discussions about acute situations and state that a novice may perceive labor and childbirth as more frightening than an experienced midwife would.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Experiences and responses of second victims of patient safety incidents in Korea: a qualitative study

BACKGROUND

Healthcare professionals who experience trauma due to patient safety incidents can be considered second victims, and they also suffer from various difficulties. In order to support second victims, it is necessary to determine the circumstances of the incidents in question, along with the symptoms that the victims are experiencing and the support they require. A qualitative study on healthcare professionals of various occupations, such as physicians and nurses working in Korea, was conducted, and the experiences and response methods and processes of second victims were examined.

METHODS

In-depth interviews were conducted with 16 healthcare professionals (six physicians, eight nurses, and two pharmacists) who had experienced a patient safety incident. All interviews were recorded and transcribed, and the data analysis was conducted in accordance with Strauss and Corbin's grounded theory. Both open coding and axial coding were performed. Consolidated criteria for reporting qualitative research (COREQ) were applied in this study.

RESULTS

The results of the open coding demonstrated that the experiences of second victims can be categorized into "the reactions of the first victim and surrounding people after the incident," "Influence of factors aside from the incident," "the initial complex responses of the participants to the incident," "open discussion of the incident," "the culture in medical institutions regarding early-stage incident response," "the coping responses of the participants after incidents," and "living with the incident." Then, the seven categories in the open coding stage were rearranged according to the paradigm model, and the reaction process of the second victims was analyzed through process analysis, being divided into the "entanglement stage," "agitating stage," "struggling stage," "managing stage," and "indurating stage."

CONCLUSIONS

This research is significant because it provides a comprehensive understanding of second victims' experiences in the eastern region of Korea, by obtaining data using a qualitative research method. The findings of the study also highlight the five stages of the second victim response process, and can be used to design a specialized second victim support program in Korea.

Navigating cancer using online communities: a grounded theory of survivor and family experiences

PURPOSE

People affected by cancer often have unmet emotional and social support needs. Online cancer communities are a convenient channel for connecting cancer survivors, allowing them to support one another. However, it is unclear whether online community use makes a meaningful contribution to cancer survivorship, as little previous research has examined the experience of using contemporary cancer communities. We aimed to explore the experiences of visitors to online cancer communities.

METHODS

Twenty-three in-depth interviews were conducted with online cancer community visitors, including cancer survivors (n = 18), family members (n = 2), and individuals who were both a survivor and family member (n = 3). Interviews were analysed using a grounded theory approach.

RESULTS

A theory developed explaining how individuals 'navigated' the experience of cancer using online cancer communities. Online advice and information led participants on a 'journey to become informed'. Online friendships normalised survivorship and cast participants on a 'journey to recreate identity'. Participants navigated a 'journey through different worlds' as they discovered relevant and hidden communities.

CONCLUSIONS

This theory highlights virtual paths people affected by cancer can take to self-manage their experience of the disease. Online community experiences can be improved by promoting online evaluation skills and signposting visitors to bereavement support.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors can benefit through both lurking and posting in online communities. However, individuals risk becoming distressed when they befriend individuals who may soon die. Additionally, people affected by rarer cancers can struggle to find shared experiences online and may need to look elsewhere for support.