Qualitative Descriptive Methods in Health Science Research

OBJECTIVE

The purpose of this methodology paper is to describe an approach to qualitative design known as qualitative descriptive that is well suited to junior health sciences researchers because it can be used with a variety of theoretical approaches, sampling techniques, and data collection strategies.

BACKGROUND

It is often difficult for junior qualitative researchers to pull together the tools and resources they need to embark on a high-quality qualitative research study and to manage the volumes of data they collect during qualitative studies. This paper seeks to pull together much needed resources and provide an overview of methods.

METHODS

A step-by-step guide to planning a qualitative descriptive study and analyzing the data is provided, utilizing exemplars from the authors' research.

RESULTS

This paper presents steps to conducting a qualitative descriptive study under the following headings: describing the qualitative descriptive approach, designing a qualitative descriptive study, steps to data analysis, and ensuring rigor of findings.

CONCLUSIONS

The qualitative descriptive approach results in a summary in everyday, factual language that facilitates understanding of a selected phenomenon across disciplines of health science researchers.

Conducting qualitative interviews by telephone: Lessons learned from a study of alcohol use among sexual minority and heterosexual women

This study explored effective interviewer strategies and lessons-learned based on collection of narrative data by telephone with a sub-sample of women from a population-based survey, which included sexual minority women. Qualitative follow-up, in-depth life history interviews were conducted over the telephone with 48 women who had participated in the 2009-2010 National Alcohol Survey. Questions explored the lives and experiences of women, including use of alcohol and drugs, social relationships, identity, and past traumatic experiences. Strategies for success in interviews emerged in three overarching areas: 1) cultivating rapport and maintaining connection, 2) demonstrating responsiveness to interviewee content, concerns, and 3) communicating regard for the interviewee and her contribution. Findings underscore both the viability and value of telephone interviews as a method for collecting rich narrative data on sensitive subjects among women, including women who may be marginalized.

On Your Own: Older Adults' Food Choice and Dietary Habits

The United Kingdom, in common with many countries, has an ageing demographic. Changes accompanying ageing can influence food choice and dietary habits. This study explored older adults’ perceptions and practices related to dietary behaviour and the factors influencing their food choice in later life. Semi-structured focus-group discussions were conducted with 30 individuals (aged 63–90 years) in a UK city. An inductive thematic approach was adopted for data analysis, and 4 themes and 12 sub-themes emerged: age-related changes (lower appetite, food changes, declining physical function); food access (food cost, support with food, maintaining independence); on your own (cooking for one, eating alone, shopping for one); and relationship with food (food variety, eating what you want, dieting). These influenced participants’ food acquisition, food preparation and cooking, as well as eating habits. Living alone and its substantial influence, as well as associated social isolation and loneliness, were highlighted in many of the discussions. Given the possible implications for nutritional intake, further work is recommended in this area. Likewise, steps should be taken to improve food access, increase opportunities for commensal eating and, fundamentally, address social isolation and loneliness in the older population.

'It's nice to have something to do': early-onset dementia and maintaining purposeful activity

As the global focus on dementia care increases due to the demand on health, social, legal and financial services, it is imperative to further understand the experience of those living with a diagnosis of dementia. There is a particular lack of research focused on younger people (under the age of 65 years) with dementia and virtually none focuses on the experience of the family unit. The literature suggests that periods of transition place significant stressors on families living with dementia. One such transition is the transition out of perceived purposeful activity, be this employment or voluntary work. This transition was explored during the course of a qualitative repeated interview study with younger people with dementia and their families. Nine families (20 participants) took part in semi-structured research interviews that were transcribed and analyzed using a Framework approach to qualitative analysis. Meaningful Activity emerged as a major theme through this analysis. Two subthemes also emerged: (1) the traumatic cessation of work; and (2) the need for purposeful activity. These themes have significant clinical implications as maintaining a purposeful role through high-quality, age-specific dementia services may decrease the direct and indirect costs of dementia to global economies.

Influences on Dietary Choices during Day versus Night Shift in Shift Workers: A Mixed Methods Study

Shift work is associated with diet-related chronic conditions such as obesity and cardiovascular disease. This study aimed to explore factors influencing food choice and dietary intake in shift workers. A fixed mixed method study design was undertaken on a convenience sample of firefighters who continually work a rotating roster. Six focus groups (n = 41) were conducted to establish factors affecting dietary intake whilst at work. Dietary intake was assessed using repeated 24 h dietary recalls (n = 19). Interviews were audio recorded, transcribed verbatim, and interpreted using thematic analysis. Dietary data were entered into FoodWorks and analysed using Wilcoxon signed-rank test; p < 0.05 was considered significant. Thematic analysis highlighted four key themes influencing dietary intake: shift schedule; attitudes and decisions of co-workers; time and accessibility; and knowledge of the relationship between food and health. Participants reported consuming more discretionary foods and limited availability of healthy food choices on night shift. Energy intakes (kJ/day) did not differ between days that included a day or night shift but greater energy density (ED_energy, kJ/g/day) of the diet was observed on night shift compared with day shift. This study has identified a number of dietary-specific shift-related factors that may contribute to an increase in unhealthy behaviours in a shift-working population. Given the increased risk of developing chronic diseases, organisational change to support workers in this environment is warranted.

Strengthening mental health nurses' resilience through a workplace resilience programme: A qualitative inquiry

WHAT IS KNOWN ON THE SUBJECT?: Mental health nurses are affected by interpersonal, practice-related and organizational factors that can increase workplace stress and reduce their physical and mental health and well-being. Resilience programmes are a strength-based preventative approach to supporting individuals to overcome workplace adversities. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This qualitative inquiry is the first study to report mental health nurses' perspectives and experiences on a workplace resilience programme. Strengthening mental health nurses' resilience through a resilience programme involved a process of understanding resilience, and applying resilience strategies such as positive self-talk, managing negative self-talk, detaching from stressful situations, being aware of and managing emotions, and showing more empathy, to address workplace challenges. To address the range of resources needed to support mental health nurses' resilience, a social-ecological approach to workplace resilience can be used to promote resource provision at individual, work unit, organizational and professional levels. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Resilience programmes are one resource for addressing the impacts of workplace stressors on mental health nurses. Organizational barriers and risks to staff well-being need to also be addressed to build a resilient workforce. Incorporating resilience strategies into clinical supervision or reflective practice models may help sustain beneficial outcomes following a resilience programme and support resilient practice. ABSTRACT: Introduction Mental health settings are potentially high-stress workplaces that can lead to nurses' poorer health and well-being. Resilience programmes are a strengths-based preventative approach for promoting mental health and well-being in the face of adversity; however, there is no prior research on mental health nurses' perspectives on resilience programmes. Aim To explore the perspectives of mental health nurses participating in a mental health service-initiated resilience programme (Promoting Adult Resilience). Method An exploratory qualitative inquiry was undertaken. Multiple qualitative data: open-ended responses and semi-structured interviews and focus groups, were thematically analysed. Results Twenty-nine registered nurses from a metropolitan mental health service participated. Four main themes were as follows: being confronted by adversity; reinforcing understandings of resilience; strengthening resilience; and applying resilience skills at work. Discussion This is the first study to report mental health nurses' perspectives on a resilience programme. Resilience programmes can help improve nurses' self-efficacy and ability to realistically appraise stressful situations and to moderate their emotional responses to others. Implications for practice It is recommended resilience programmes are provided to promote nurses' well-being and resilient practices. To build a resilient workforce, the wider barriers and risks to staff well-being need to be addressed at a unit, organizational and professional level.

Towards a Critical Health Equity Research Stance: Why Epistemology and Methodology Matter More Than Qualitative Methods

Qualitative methods are not intrinsically progressive. Methods are simply tools to conduct research. Epistemology, the justification of knowledge, shapes methodology and methods, and thus is a vital starting point for a critical health equity research stance, regardless of whether the methods are qualitative, quantitative, or mixed. In line with this premise, I address four themes in this commentary. First, I criticize the ubiquitous and uncritical use of the term health disparities in U.S. public health. Next, I advocate for the increased use of qualitative methodologies-namely, photovoice and critical ethnography-that, pursuant to critical approaches, prioritize dismantling social-structural inequities as a prerequisite to health equity. Thereafter, I discuss epistemological stance and its influence on all aspects of the research process. Finally, I highlight my critical discourse analysis HIV prevention research based on individual interviews and focus groups with Black men, as an example of a critical health equity research approach.

From Challenge to Opportunity: Virtual Qualitative Research During COVID-19 and Beyond

COVID-19 has required researchers to adapt methodologies for remote data collection. While virtual interviewing has traditionally received limited attention in the qualitative literature, recent adaptations to the pandemic have prompted increased discussion and adoption. Yet, current discussion has focussed on practical and ethical concerns and retained a tone of compromise, of coping in a crisis. This paper extends the nascent conversations begun prior to the pandemic to consider the wider methodological implications of video-call interviews. Beyond the short-term, practical challenges of the pandemic, these adaptations demonstrate scope for longer-term, beneficial digitalisation of both traditional and emergent interview methods. Updating traditional interview methods digitally has demonstrated how conversion to video interviewing proves beneficial in its own right. Virtual focus-group-based research during COVID-19, for example, accessed marginalised populations and elicited notable rapport and rich data, uniting people in synchronous conversation across many environments. Moreover, emergent interview methods such as the Grid Elaboration Method (a specialised free-associative method) demonstrated further digitalised enhancements, including effective online recruitment with flexible scheduling, virtual interactions with significant rapport, and valuable recording and transcription functions. This paper looks beyond the pandemic to future research contexts where such forms of virtual interviewing may confer unique advantages: supporting researcher and participant populations with mobility challenges; enhancing international research where researcher presence or travel may be problematic. When opportunities for traditional face-to-face methods return, the opportunity for virtual innovation should not be overlooked.

Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives

BACKGROUND

Service users wish to be involved in care planning but typically feel marginalized in this process. Qualitative explorations of the barriers and enablers of user involvement in mental health care planning are limited.

QUESTION

How is user involvement in care planning conceptualized by service users and how can meaningful involvement be instilled in the care planning process?

METHODS

In 2013, we conducted five focus groups (n = 27) and 23 individual interviews with current or recent adult users of secondary care mental health services (n = 27) in England. Eight users participated in both. Data were analysed using Framework Analysis. Results Ten themes emerged from the data: these themes encompassed procedural elements (connection; contribution; currency; care consolidation; and consequence), service user characteristics (capacity and confidence) and professional enablers (consultation; choice; and clarity of expression). Procedural elements were discussed most frequently in service user discourse.

DISCUSSION

The process of care planning, centred on the user-clinician relationship, is key to user involvement.

IMPLICATIONS FOR PRACTICE

Users describe a common model of meaningful involvement in care planning. Their requests, summarized through a 10C framework of care planning involvement, provide clear direction for improving service users satisfaction with care planning and enhancing the culture of services.

#Online harms or benefits? An ethnographic analysis of the positives and negatives of peer-support around self-harm on social media

BACKGROUND

There is emerging evidence of the potentially detrimental impact of social media on young people's mental health. Against this background, online self-harm content has been a recent focus of concern across academia, policy and the media. It has been argued to encourage or even cause acts such as self-cutting through mechanisms of contagion. However, little is known about why a young person might engage with such content or about its impact on behaviour or well-being.

METHODS

Online ethnographic observation of interactions around self-harm on Twitter, Reddit and Instagram: collection and analysis of 10,169 original posts and 36,934 comments, both written and pictorial, at two time-points in 2018 and 2019. Ten in-depth semi-structured interviews exploring engagements with self-harm content on social media.

RESULTS

Our data show that peer support is the central component of online interactions around self-harm. Young people accessing such content are likely to already be self-harming; they may turn to social media to understand, and seek help for, their actions and feelings in a context of offline stigma and service support gaps. This paper engages with the mechanisms, complexities and impact of this peer-support, reflecting on the benefits and dangers to caring for oneself and others through social media.

CONCLUSIONS

Self-harm content is a fraught issue at the centre of current debates around risks and opportunities for child and adolescent mental health in the digital age. Whilst the importance of supporting young people's online safety is clear, moves to eradicate self-harm content must be undertaken with caution so as not to cause unintentional harm. Our research highlights a need to think beyond a model of contagion, instead attending to other mechanisms of harm and benefit. In so doing, it challenges prevailing attitudes towards online communication about self-harm and accepted approaches to managing this.

A qualitative study of perceived responsibility and self-blame in type 2 diabetes: reflections of physicians and patients

BACKGROUND

Despite new treatment therapies and the emphasis on patient activation, nearly 50 % of diabetes patients have hemoglobin A(1c) levels above target. Understanding the impact of unmet treatment goals on the physician-patient relationship is important for maintaining quality care in clinical practice.

OBJECTIVE

To explore physicians' and type 2 diabetes patients' views of patients' difficulty achieving diabetes treatment goals.

DESIGN

Qualitative study using in-depth interviews with a semi-structured interview guide.

PARTICIPANTS

Nineteen endocrinologists and primary care physicians and 34 patients diagnosed with type 2 diabetes at least two years prior.

MAIN MEASURES

In-depth interviews with physicians and patients. A multidisciplinary research team performed content and thematic analyses.

KEY RESULTS

Qualitative analysis revealed two main findings, organized by physician and patient perspectives. Physician Perspective: Physicians' Perceived Responsibility for Patients' Difficulty Achieving Treatment Goals: Physicians assumed responsibility for their patients not achieving goals and expressed concern that they may not be doing enough to help their patients achieve treatment goals. Physicians' Perceptions of Patients' Reactions: Most speculated that their patients may feel guilt, frustration, or disappointment when not reaching goals. Physicians also felt that many patients did not fully understand the consequences of diabetes. Patient Perspective: Patients' Self-Blame for Difficulty Achieving Treatment Goals: Patients attributed unmet treatment goals to their inability to carry out self-care recommendations. Most patients blamed themselves for their lack of progress and directed their frustration and disappointment inwardly through self-depreciating comments. Patients' Perceptions of Physicians' Reactions: Several patients did not know how their physician felt, while others speculated that their physicians might feel disappointed or frustrated.

CONCLUSIONS

Physicians' perceived responsibility and patients' self-blame for difficulty achieving treatment goals may serve as barriers to an effective relationship. Physicians and patients may benefit from a greater understanding of each other's frustrations and challenges in diabetes management.

A Bridge Over Turbulent Waters: Illustrating the Interaction Between Managerial Leaders and Facilitators When Implementing Research Evidence

BACKGROUND

Emerging evidence focuses on the importance of the role of leadership in successfully transferring research evidence into practice. However, little is known about the interaction between managerial leaders and clinical leaders acting as facilitators (internal facilitators [IFs]) in this implementation process.

AIMS

To describe the interaction between managerial leaders and IFs and how this enabled or hindered the facilitation process of implementing urinary incontinence guideline recommendations in a local context in settings that provide long-term care to older people.

METHODS

Semistructured interviews with 105 managers and 22 IFs, collected for a realist process evaluation across four European countries informed this study. An interpretive data analysis unpacks interactions between managerial leaders and IFs.

RESULTS

This study identified three themes that were important in the interactions between managerial leaders and IFs that could hinder or support the implementation process: "realising commitment"; "negotiating conditions"; and "encouragement to keep momentum going." The findings revealed that the continuous reciprocal relationships between IFs and managerial leaders influenced the progress of implementation, and could slow the process down or disrupt it. A metaphor of crossing a turbulent river by the "building of a bridge" emerged as one way of understanding the findings.

LINKING EVIDENCE TO ACTION

Our findings illuminate a neglected area, the effects of relationships between key staff on implementing evidence into practice. Relational aspects of managerial and clinical leadership roles need greater consideration when planning guideline implementation and practice change. In order to support implementation, staff assigned as IFs as well as stakeholders like managers at all levels of an organisation should be engaged in realising commitment, negotiating conditions, and keeping momentum going. Thus, communication is crucial between all involved.

How does gender influence immigrant and refugee women's postpartum depression help-seeking experiences?

The number of migrants arriving in Canada from non-European countries has grown significantly over the past three decades. How best to assist these escalating numbers of immigrant and refugee women to adapt to their new environment and to cope with postpartum depression (PPD) is a pressing issue for healthcare providers. Evidence has shown that immigrant and refugee women experience difficulties in accessing care and treatment for PPD. This qualitative study was conducted with 30 immigrant and refugee women using in-depth interviews to obtain information about the women's PPD experiences. The primary aim was to explore how cultural, social, political, historical and economic factors intersect with race, gender and class to influence the ways in which immigrant and refugee women seek help to manage PPD. Results reveal that immigrant and refugee women experience many complex gender-related challenges and facilitators in seeking equitable help for PPD treatment and prevention. We will demonstrate that (a) structural barriers and gender roles hinder women's ability to access necessary mental healthcare services and (b) insecure immigration status coupled with emotional and economic dependence may leave women vulnerable and disadvantaged in protecting themselves against PPD.

"Catching your tail and firefighting": The impact of staffing levels on restraint minimization efforts

WHAT IS KNOWN ON THE SUBJECT?: Mental health nursing in the UK and other countries faces an acute workforce crisis. Safe staffing levels are called for, and in some jurisdictions have been legislated for. The evidence base linking staffing levels and patient outcomes is limited. Staffing levels are implicated in adverse experiences of service users and staff within mental health ward settings, and they might contribute to levels of violence and aggression and the application of restrictive practices, such as physical restraint but there is limited research evidence to support this. Programmes such as Safewards, No Force First, the Engagement Model and the Six Core Strategies can reduce the use of restrictive practices. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Staffing levels on acute mental health wards appeared crucial in the implementation of a restraint minimization project. Both staff and service users implicate insufficient staffing for deficiencies in the relational elements of care, such as lack of face-to-face contact between nurses and service users. Similarly, staffing levels are associated with perceived problems in the cause of violence and aggression and responses to it. Despite successes in minimizing restrictive practices in this project, difficulties implementing alternative forms of practice that would reduce use of physical restraint, such as de-escalation, were also attributed to staffing levels. There is an irony that a project concerned with safety itself provoked concern over safe staffing levels. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Efforts to reduce restrictive practices will be hampered without adequate staffing levels. Restrictive practices may justifyably be framed as an employment relations matter. Organisations and policy makers ought to address environmental, contextual and resourcing factors, rather than identify problems exclusively in terms of perceived aberrant behaviour of staff or service users. ABSTRACT: Introduction Safe staffing and coercive practices are of pressing concern for mental health services. These are inter-dependent, and the relationship is under-researched. Aim To explore views on staffing levels in a context of attempting to minimize physical restraint practices on mental health wards. Findings emerged from a wider data set with the broader aim of exploring experiences of a restraint reduction initiative. Methods Thematic analysis of semi-structured interviews with staff (n = 130) and service users (n = 32). Results Five themes were identified regarding how staffing levels impact experiences and complicate efforts to minimize physical restraint. We titled the themes-"insufficient staff to do the job"; "detriment to staff and service users"; "a paperwork exercise: the burden of non-clinical tasks"; "false economies"; and, "you can't do these interventions." Discussion Tendencies detracting from relational aspects of care are not independent of insufficiencies in staffing. The relational, communicative and organizational developments that would enable reductions in use of restraint are labour intensive and vulnerable to derailment by insufficient and poorly skilled staff. Implications for practice Restrictive practices are unlikely to be minimized unless wards are adequately staffed. Inadequate staffing is not independent of restrictive practices and reduces access to alternative interventions for reducing individuals' distress.

System-Level Barriers and Facilitators for Foregoing or Withdrawing Dialysis: A Qualitative Study of Nephrologists in the United States and England

BACKGROUND

Despite a growing body of literature suggesting that dialysis does not confer morbidity or mortality benefits for all patients with chronic kidney failure, the initiation and continuation of dialysis therapy in patients with poor prognosis is commonplace. Our goal was to elicit nephrologists' perspectives on factors that affect decision making regarding end-stage renal disease.

STUDY DESIGN

Semistructured, individual, qualitative interviews.

METHODOLOGY

Participants were purposively sampled based on age, race, sex, geographic location, and practice type. Each was asked about his or her perspectives and experiences related to foregoing and withdrawing dialysis therapy.

ANALYTICAL APPROACH

Interviews were audiotaped, transcribed, and analyzed using narrative and thematic analysis.

RESULTS

We conducted 59 semistructured interviews with nephrologists from the United States (n=41) and England (n=18). Most participants were 45 years or younger, men, and white. Average time since completing nephrology training was 14.2±11.6 (SD) years. Identified system-level facilitators and barriers for foregoing and withdrawing dialysis therapy stemmed from national and institutional policies and structural factors, how providers practice medicine (the culture of medicine), and beliefs and behaviors of the public (societal culture). In both countries, the predominant barriers described included lack of training in end-of-life conversations and expectations for aggressive care among non-nephrologists and the general public. Primary differences included financial incentives to dialyze in the United States and widespread outpatient conservative management programs in England.

LIMITATIONS

Participants' views may not fully capture those of all American or English nephrologists.

CONCLUSIONS

Nephrologists in the United States and England identified several system-level factors that both facilitated and interfered with decision making around foregoing and withdrawing dialysis therapy. Efforts to expand facilitators while reducing barriers could lead to care practices more in keeping with patient prognosis.

Investigating the needs and concerns of lesbian, gay, bisexual, and transgender older adults: the use of qualitative and quantitative methodology

Extensive research on the specific needs and concerns of lesbian, gay, bisexual, and transgender (LGBT) older adults is lacking. This article describes the results of both quantitative studies (i.e., LGBT Elders Needs Assessment Scale) and qualitative studies (i.e., focus groups and in-depth interviews with lesbian, gay, or bisexual [LGB] older adults and LGB grandparents) that specifically sought to investigate the unique needs and concerns of LGBT elders. The results identified 7 areas (medical/health care, legal, institutional/housing, spiritual, family, mental health, and social) of concern and the recognition that the needs and concerns of LGBT older adults be addressed across multiple domains, rather than in isolation.

Service user involvement enhanced the research quality in a study using interpretative phenomenological analysis - the power of multiple perspectives

AIM

The aim of this study was to examine how service user involvement can contribute to the development of interpretative phenomenological analysis methodology and enhance research quality.

BACKGROUND

Interpretative phenomenological analysis is a qualitative methodology used in nursing research internationally to understand human experiences that are essential to the participants. Service user involvement is requested in nursing research.

DESIGN

We share experiences from 4 years of collaboration (2012-2015) on a mental health promotion project, which involved an advisory team.

METHODS

Five research advisors either with a diagnosis or related to a person with severe mental illness constituted the team. They collaborated with the research fellow throughout the entire research process and have co-authored this article. We examined the joint process of analysing the empirical data from interviews. Our analytical discussions were audiotaped, transcribed and subsequently interpreted following the guidelines for good qualitative analysis in interpretative phenomenological analysis studies.

RESULTS

The advisory team became 'the researcher's helping hand'. Multiple perspectives influenced the qualitative analysis, which gave more insightful interpretations of nuances, complexity, richness or ambiguity in the interviewed participants' accounts. The outcome of the service user involvement was increased breadth and depth in findings.

CONCLUSION

Service user involvement improved the research quality in a nursing research project on mental health promotion. The interpretative element of interpretative phenomenological analysis was enhanced by the emergence of multiple perspectives in the qualitative analysis of the empirical data. We argue that service user involvement and interpretative phenomenological analysis methodology can mutually reinforce each other and strengthen qualitative methodology.

Sexuality and Intimacy in Assisted Living: Residents' Perspectives and Experiences

The assisted living industry provides residential, medical, nutritional, functional, and social services for approximately 1 million older adults in the United States. Despite their holistic approach to person-centered care and their emphasis on a consumer-empowered, social environment, assisted living providers pay scant attention to clients' sexual needs. In this article, the authors discuss the realities of sex and intimacy in assisted living from the perspectives of residents, families, managers, and staff, exploring the discourse of sexuality, the impact of institutional structure and the role of oversight on sexual attitudes and behaviors, and the relationship of assisted living industry values to residents' sexual expression. Also presented are practical recommendations and policy implications for addressing the sexual and intimacy needs of current and future cohorts of assisted living residents. Data for this article were drawn from 3 National Institute on Aging-funded ethnographic studies conducted in 13 assisted living settings over 9 years.

Mental health inpatients' and staff members' suggestions for reducing physical restraint: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Restraint has negative psychological, physical and relational consequences for mental health patients and staff. Restraint reduction interventions have been developed (e.g., "Safewards"). Limited qualitative research has explored suggestions on how to reduce physical restraint (and feasibility issues with implementing interventions) from those directly involved. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper explores mental health patients' and staff members' suggestions for reducing physical restraint, whilst addressing barriers to implementing these. Findings centred on four themes: improving communication and relationships; staffing factors; environment and space; and activities and distraction. Not all suggestions are addressed by currently available interventions. Barriers to implementation were identified, centring on a lack of time and/or resources; with the provision of more time for staff to spend with patients and implement interventions seen as essential to reducing physical restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Improving communication and relationships between staff/patients, making staffing-related changes, improving ward environments and providing patient activities are central to restraint reduction in mental healthcare. Fundamental issues related to understaffing, high staff turnover, and lack of time and resources need addressing in order for suggestions to be successfully implemented.

ABSTRACT

Introduction Physical restraint has negative consequences for all involved, and international calls for its reduction have emerged. Some restraint reduction interventions have been developed, but limited qualitative research explores suggestions on how to reduce physical restraint (and feasibility issues with implementation) from those directly involved. Aims To explore mental health patients' and staff members' suggestions for reducing physical restraint. Methods Interviews were conducted with 13 inpatients and 22 staff members with experience of restraint on adult mental health inpatient wards in one UK National Health Service Trust. Results Findings centred on four overarching themes: improving communication and relationships between staff/patients; making staff-related changes; improving ward environments/spaces; and having more activities. However, concerns were raised around practicalities/feasibility of their implementation. Discussion Continued research is needed into best ways to reduce physical restraint, with an emphasis on feasibility/practicality and how to make time in busy ward environments. Implications for Practice Improving communication and relationships between staff/patients, making staffing-related changes, improving ward environments and providing patient activities are central to restraint reduction in mental healthcare. However, fundamental issues related to understaffing, high staff turnover and lack of time/resources need addressing in order for these suggestions to be successfully implemented.

Adolescents' and parents' views of Child and Adolescent Mental Health Services (CAMHS) in Ireland

Service user involvement is essential for quality care in the Child and Adolescent Mental Health Services (CAMHS). This study was conducted to explore adolescents' and parents' experiences of CAMHS in relation to accessibility, approachability and appropriateness. This study used a descriptive qualitative design, and focus groups and single interviews were conducted with adolescents (n = 15) and parents (n = 32) from three mental health clinics. Data were analysed using thematic analysis. Accessing mental health services was a challenging experience for many parents and adolescents due to knowledge deficit, lack of information and limited availability of specialist services. Some parents and adolescents reported positive experiences while others reported negative experiences. They expressed a need for more information, involvement in decision making, flexible scheduling of appointments, school support and parent support groups. The nature and quality of the relationship with staff was critical to positive experience with the service; therefore, frequent changes of medical staff was disruptive. Mental health nurses can play a vital role in ensuring continuity, assessing adolescents' participation preferences and advocating for their information needs with other members of the interdisciplinary team.

Auditory hallucinations as a personal experience: analysis of non-psychiatric voice hearers' narrations

This exploratory research investigates the phenomenon of non-psychiatric auditory hallucinations from the perspective of the voice hearer, evaluating the possibility that this experience can contribute the maintenance and adaptation of the hearer's personal identity system. A semi-structured interview was administered to 10 Italian voice hearers, six men and four women, aged 18-65 years, who had never been in contact with any mental health services because of the voices, even though some of them had been hearing voices for decades. Participants were not distressed or worried about the voices; on the contrary they developed their own understanding, personal coping resources and beliefs in relation to the positive functions of the voices. These results indicate that voices cannot be considered merely as symptoms, but may be seen also as adaptation systems. Consequently, we should avoid trying to helping voice hearers to eliminate or deny voices, and rather we should help them to feel allowed to preserve them.

Older African American women's lived experiences with depression and coping behaviours

Little is known about older African American women's lived experiences with depression. What does depression mean to this group? What are they doing about their depression? Unfortunately, these questions are unanswered. This study examined older African American women's lived experiences with depression and coping behaviours. The common sense model provided the theoretical framework for present study. Thirteen community-dwelling African American women aged 60 and older (M = 71 years) participated. Using qualitative phenomenological data analysis, results showed the women held beliefs about factors that can cause depression including experiences of trauma, poverty and disempowerment. Results also indicated the women believed that depression is a normal reaction to life circumstances and did not see the need to seek professional treatment for depression. They coped by use of culturally sanctioned behaviours including religious practices and resilience. It appears these women's beliefs about depression and use of culturally sanctioned coping behaviours might potentially be a barrier to seeking professional mental healthcare, which could result in missed opportunities for early diagnosis and treatment of depression among this group. Implications for research, educational and clinical interventions are discussed.

A framework for capturing the interactions between laypersons' understanding of disease, information gathering behaviors, and actions taken during an epidemic

This paper provides a description of a methodological framework designed to capture the inter-relationships between the lay publics' understanding of health-related processes, information gathering behaviors, and actions taken during an outbreak. We developed and refined our methods during a study involving eight participants living in severe acute respiratory syndrome (SARS)-affected areas (Hong Kong, Taiwan, and Toronto). The framework is an adaptation of narrative analysis, a qualitative method that is used to investigate a phenomenon through interpretation of the stories people tell about their experiences. From our work, several hypotheses emerged that will contribute to future research. For example, our findings showed that many decisions in an epidemic are carefully considered and involve use of significant information gathering. Having a good model of lay actions based on information received and beliefs held will contribute to the development of more effective information support systems in the event of a future epidemic.

The Process of Patient Empowerment in Integrative Health Coaching: How Does it Happen?

Emerging healthcare delivery models suggest that patients benefit from being engaged in their care. Integrative health coaching (IHC) is designed to be a systematic, collaborative, and solution-focused process that facilitates the enhancement of life experience and goal attainment regarding health, but little research is available to describe the mechanisms through which empowerment occurs in the health coaching process. The purpose of this qualitative study is to describe apparent key components of the empowerment process as it actually occurs in IHC. A sample of 69 recorded health coaching sessions was drawn from 12 participants enrolled in a randomized controlled study comparing two different methods of weight-loss maintenance. Two researchers coded the word-for-word transcripts of sessions focusing on the structure of the sessions and communication strategies used by the coaches. Three basic sections of a coaching session were identified, and two main themes emerged from the communication strategies used: Exploring Participant's Experience and Active Interventions. In IHC, health coaches do not direct with prefabricated education based on the patient's presenting problem; rather, they use a concordant style of communication. The major tenets of the health coaching process are patient-centeredness and patient control focused around patient-originated health goals that guide the work within a supportive coaching partnership. As the field of health coaching continues to define itself, an important ongoing question involves how the structure of the provider-patient interaction is informed by the role of the healthcare provider (eg, nurse, therapist, coach) and in turn shapes the empowerment process.

Recruitment Strategies to Optimize Participation by Diverse Populations

The authors describe the methodological strategies used to effectively recruit a diverse sample of nurses in a qualitative study. Adequate representation of diverse populations is necessary to advance science and health equity. A multimodal research approach (research team composition, flyers, social media, and purposive sampling) was used. When undertaking research with underrepresented groups, recruitment efforts should begin in the early phases of study planning with research team development that can assist in employing multiple recruitment strategies accordingly.