Meaning of spirituality: implications for nursing practice

Background. This research outlines some preliminary findings emerging from a grounded theory investigation into the ‘meaning of spirituality’. These initial results raise some important questions about the terminology and language that nurses use regarding the term spirituality. It seems that many of the policy directives and statutory guidelines make two major assumptions regarding ‘spirituality’. Firstly, patients and nurses are aware and understand the concept, and secondly, patients may require their spiritual needs to be met. These preliminary findings suggest that a dichotomy is emerging between professional assumption and patient expectation regarding the meaning of spirituality. Aim. The study had one broad research aim, to gain a deeper insight into how patients, nurses, and people from the major world religions understand the concept of ‘spirituality’. Design. A qualitative research design was used involving a grounded theory method of inquiry. It was felt that this qualitative method would aid the investigation of this subjective dimension of peoples’ existence, enabling existing theoretical constructs and arguments to be tested. Methods. The constant comparative method was used throughout the data collection and analysis. Analysis was undertaken at two levels, ‘overview analysis’ and ‘line‐by‐line analysis’. This enabled the creation of categories and central themes. Results. Constant comparative analysis resulted in the formation of several categories and central themes. Two categories presented and discussed in detail are ‘definitions of spirituality’, and ‘diverse perceptions of spirituality’. Conclusion. It would seem that there is now an urgent need for nursing to evaluate and perhaps adjust its vision regarding what constitutes spirituality. Such an approach may serve to reduce the gap between policy and public expectation. Relevance to clinical practice. It seems that there may be no ‘precise’ terminology associated with the language used to define spirituality, raising possible implications for nursing practice and nurse education.     

Dancing with data: an example of acquiring theoretical sensitivity in a grounded theory study

Glaser suggested that the conceptual route from data collection to a grounded theory is a set of double back steps. The route forward inevitably results in the analyst stepping back. Additionally sidestepping through, leading participants down lines of inquiry and following data threads with other participants, is also characteristic of acquiring theoretical sensitivity, a key concept in grounded theory. Other ways of acquiring theoretical sensitivity comprise: reading the literature, open coding, category building, reflecting in memos followed by doubling back on data collection once further lines of inquiry are opened up. This paper describes how we 'danced with data' in pursuit of heightened theoretical sensitivity in a grounded theory study of information use by nurses working in general practice in New Zealand. Providing an example of how analytical tools are employed to theoretically sample emerging concepts.     

Professional identity of Japanese nurses: bonding into nursing

Abstract The purpose of this study was to explore the process of establishing the professional identity of Japanese nurses. Following a grounded theory design, data were generated by interviews, multisite participant observations and theoretical memos. Eighteen Japanese nurses who were selected by theoretical sampling were formally interviewed. Data were analyzed using methods of constant comparative analysis.
Six categories emerged from the data: (i) learning from working experiences; (ii) recognizing the value of nursing; (iii) establishing one's own philosophy of nursing; (iv) gaining influence from education; (v) having a commitment to nursing and (vi) integrating a nurse into self. The core category, 'bonding into nursing', incorporated the relationship between and among all categories and explained the process of establishing the professional identity of Japanese nurses. 'Bonding into nursing' was described as an initial substantive theory, which is defined as the process by which each nurse established her/his professional identity as a nurse.     

The structure of contraceptive education and instruction within nurse led family planning clinics: a grounded theory study

Aims. This study aimed to explore and analyse how nurses instruct women in contraceptive use during consultations in family planning clinics to produce a grounded theory of contraceptive education. Background. Nurses play a key role in instructing women how to use contraception in family planning clinic consultations. These one‐to‐one situations are encounters where women are taught how to use contraceptive methods effectively. However, very little is known about the nature of these consultations. Design. A qualitative study using a grounded theory approach was used. Results. Three linked ‘core categories’ emerged from the data analysis. Firstly, women are educated about their body and how it responds to contraception: ‘reproductive education’. This core category is closely linked to ‘surveillance’ where women are taught to monitor their reproductive health and to ‘contraceptive regimen’ where women are instructed in techniques to successfully use a contraceptive method. Together these three core categories present a grounded theory of ‘contraceptive education’. Conclusions. Nursing practice in this important area of women’s health care is complex and requires skilled practitioners. This study presents unique empirical data into how nurses conduct one‐to‐one consultations with women – providing a novel insight into how contraception is explained in clinical situations. Key issues for practice from the data were the lack of a balance when discussing side effects, the rigidity of some instructions and the lack of recognition of risk from sexually transmitted infection. Relevance to clinical practice. Nurses working in sexual health need to ensure that women understand the often complex instructions they provide and that rigid instruction be occasionally amended to enable some flexibility. The manner in which side‐effects are discussed should also be balanced. Nurses need to address the risk of sexually transmitted infections more substantially in contraceptive discussions.     

Grounded theory research: literature reviewing and reflexivity

AIM: This paper is a report of a discussion of the arguments surrounding the role of the initial literature review in grounded theory. BACKGROUND: Researchers new to grounded theory may find themselves confused about the literature review, something we ourselves experienced, pointing to the need for clarity about use of the literature in grounded theory to help guide others about to embark on similar research journeys. DISCUSSION: The arguments for and against the use of a substantial topic-related initial literature review in a grounded theory study are discussed, giving examples from our own studies. The use of theoretically sampled literature and the necessity for reflexivity are also discussed. Reflexivity is viewed as the explicit quest to limit researcher effects on the data by awareness of self, something seen as integral both to the process of data collection and the constant comparison method essential to grounded theory. CONCLUSION: A researcher who is close to the field may already be theoretically sensitized and familiar with the literature on the study topic. Use of literature or any other preknowledge should not prevent a grounded theory arising from the inductive-deductive interplay which is at the heart of this method. Reflexivity is needed to prevent prior knowledge distorting the researcher's perceptions of the data.     

Using a synthesised technique for grounded theory in nursing research

Aims. To introduce a synthesised technique for using grounded theory in nursing research. Background. Nursing increasingly uses grounded theory for a broadened perspective on nursing practice and research. Nurse researchers have choices in how to choose and use grounded theory as a research method. These choices come from a deep understanding of the different versions of grounded theory, including Glaser’s classic grounded theory and Strauss and Corbin’s later approach. Design. Grounded theory related literature review was conducted. Methods. This is a methodological review paper. Results. Nursing researchers intent on using a grounded theory methodology should pay attention to the theoretical discussions including theoretical sampling, theoretical sensitivity, constant comparative methods and asking questions, keeping memoranda diagramming, identification of a core category and a resultant explanatory theory. A synthesised approach is developed for use, based on Strauss and Corbin’s style of sampling and memoranda writing, but selecting theoretical coding families, that differ from the paradigm model of Strauss and Corbin, from the wide range suggested by Glaser. This led to the development of a multi‐step synthesised approach to grounded theory data analysis based on the works of Glaser, Charmaz and Strauss and Corbin. Conclusions. The use of this synthesised approach provides a true reflection of Glaser’s idea of ‘emergence of theory from the data’ and Strauss and Corbin’s style of sampling and memoranda writing is employed. This multi‐step synthesised method of data analysis maintains the philosophical perspective of grounded theory. Relevance to clinical practice. This method indicates how grounded theory has developed, where it might go next in nursing research and how it may continue to evolve.     

Steering a course towards advanced nurse practitioner: a critical care perspective

Aim: This article is a report of a study of the experiences of expert critical care nurses in their transition to the role of advanced nurse practitioner within an intensive care unit (ICU) setting. Background: The advanced nurse practitioner role was developed to support the ICU team and to undertake many of the roles traditionally associated with junior medical staff in this specialized area. The impetus for this study therefore was generated from the need to explore the role development experiences of trainee advanced nurse practitioners to inform future developments and practice. Methods: This study used grounded theory methodology to conduct and analyse data from 25 participants. The data were collected between March 2010 and August 2010, using interview format. Data collection and analysis was conducted simultaneously using methods associated with grounded theory, theoretical sampling and the constant comparative method. Results: ‘Staying the course to advanced nursing practice’ emerged as the core category, with four related major categories and substantive codes. In conjunction, the substantive theory explaining the essential processes involved comprised of three inextricably linked processes: situational, development and conceptual meaning. The developed conceptual model captures the unique experiences of expert critical care nurses during their transition to confident and competent advanced nurse practitioners. Conclusion: This study provides an account of the role transition from expert critical care nurse to advanced nurse practitioner, specifically the synthesis of expert nursing practice with traditional medical values. The conceptual model has the potential to be utilized as a framework for others embarking upon similar projects, informing advanced nurse practitioner roles within and out with critical care settings.     

The role of community mental health nurses caring for people with schizophrenia in Taiwan: a substantive grounded theory

Aim and objectives. The aim was to develop a practice theory that can be used to guide the direction of community nursing practice to help clients with schizophrenia and those who care for them. Design. Substantive grounded theory was developed through use of grounded theory method of Strauss and Corbin. Methods. Two groups of participants in Taiwan were selected using theoretical sampling: one group consisted of community mental health nurses and the other group was clients with schizophrenia and those who cared for them. The number of participants in each group was determined by theoretical saturation. Semi‐structured one‐to‐one in‐depth interviews and unstructured non‐participant observation were utilized for data collection. Data analysis involved three stages: open, axial and selective coding. During the process of coding and analysis, both inductive and deductive thinking were utilized and the constant comparative analysis process continued until data saturation occurred. To establish trustworthiness, the four criteria of credibility, transferability, dependability and confirmability were followed along with field trial, audit trial, member check and peer debriefing for reliability and validity. Results. A substantive grounded theory, the role of community mental health nurses caring for people with schizophrenia in Taiwan, was developed through utilization of grounded theory method of Strauss and Corbin. Conclusion. In this paper, results and discussion focus on causal conditions, context, intervening conditions, consequences and phenomenon. Relevance to clinical practice. The theory is the first to contribute knowledge about the field of mental health home visiting services in Taiwan to provide guidance for the delivery of quality care to assist people in the community with schizophrenia and their carers.     

From special hospital to regional secure unit: a qualitative study of the problems experienced by patients

For those patients in the United Kingdom who are compulsorily detained in a special hospital the most common route of release is via other psychiatric hospitals, especially regional secure units That a large percentage of these patients are subsequently readmitted (43% in this study) indicates that they experience problems within the regional secure unit A grounded theory approach was used to investigate this experience from the patients' perspective by interviewing a sample of 14 patients who had been readmitted to one special hospital Data analysis can prove difficult in grounded theory and the approach that was used — a variant of the constant comparative method — is described A number of inductively developed categories were generated from the interview data and one category is reported here From these categories a theory of'failure' is postulated that, it is contended, both describes and explains the process of readmission Finally, the implications for practice in terms of the preparation of patients for transfer are addressed     

A qualitative analysis of how advanced practice nurses use clinical decision support systems

PURPOSE: The purpose of this study was to generate a grounded theory that will reflect the experiences of advanced practice nurses (APNs) working as critical care nurse practitioners (NPs) and clinical nurse specialists (CNS) with computer-based decision-making systems. DATA SOURCES: A study design using grounded theory qualitative research methods and convenience sampling was employed in this study. Twenty-three APNs (13 CNS and 10 NPs) were recruited from 16 critical care units located in six large urban medical centers in the U.S. Midwest. Single-structured in-depth interviews with open-ended audio-taped questions were conducted with each APN. Through this process, APNs defined what they consider to be relevant themes and patterns of clinical decision system use in their critical care practices, and they identified the interrelatedness of the conceptual categories that emerged from the results. Data were analyzed using the constant comparative analysis method of qualitative research. CONCLUSIONS: APN participants were predominantly female, white/non-Hispanic, had a history of access to the clinical decision system used in their critical care settings for an average of 14 months, and had attended a formal training program to learn how to use clinical decision systems. "Forecasting decision outcomes," which was defined as the voluntary process employed to forecast the outcomes of patient care decisions in critical care prior to actual decision making, was the core variable describing system use that emerged from the responses. This variable consisted of four user constructs or components: (a) users' perceptions of their initial system learning experience, (b) users' sense of how well they understand how system technology works, (c) users' understanding of how system inferences are created or derived, and (d) users' relative trust of system-derived data. Each of these categories was further described through the grounded theory research process, and the relationships between the categories were identified. IMPLICATIONS FOR PRACTICE: The findings of this study suggest that the main reason critical care APNs choose to integrate clinical decision systems into their practices is to provide an objective, scientifically derived, technology-based backup for human forecasting of the outcomes of patient care decisions prior to their actual decision making. Implications for nursing, health care, and technology research are presented.     

Coaching patients to self-care: a primary responsibility of nursing

Aim.  To explore the process nurses use to guide and support patients to actively re-establish self-care.
Background.  The movement of hospitalized patients from less to more independence is primarily a nursing responsibility. Studies of nursing practice in inpatient rehabilitation settings have begun to shed some light on this, but as yet there is limited understanding of the actual skills nurses use to support patients to re-establish self-care.
Method.  This study used grounded theory. Microanalysis and constant comparative analysis of data collected during interviews with, and observation of, registered and enrolled nurses during everyday nursing practice in five inpatient rehabilitation units facilitated open, axial and selective coding. Relevant literature was woven into the final theory.
Findings.  To facilitate patient transition from the role of acute care patient to rehabilitation patient actively reclaiming self-care, nurses engaged in a three-phase process known as coaching patients to self-care. The three phases were: easing patients into rehabilitation, maximizing patient effort and providing graduated assistance.
Conclusion.  Coaching patients to self-care is a primary activity and technology of rehabilitation nursing.
Relevance to clinical practice.  Patients in a variety of settings would benefit from nurses incorporating coaching skills into their nurse–patient interactions.     

Influencing factors of community mental health nurses caring for people with schizophrenia in Taiwan

The purpose of this study was to explore the influencing factors in the substantive theory of home care for people with schizophrenia in Taiwan. The grounded theory of Strauss and Corbin approach was used. Semi-structured one-to-one in-depth interviews were utilized to collect data. Constant comparative analysis continued during the open, axial and selective coding processes until data saturation occurred. Participants were selected using theoretical sampling, and the final sample in this study consisted of a total of 29 community nurses (18 public health nurses and 11 home health nurses) who provided community mental health home-visiting services. The public health nurses and home health nurses both conducted a total of 16 (eight carers and eight clients) home visits. Four categories and 12 subcategories of influencing factors were identified; these factors have both positive and negative effects on nursing roles and the functions of public health nurses in the mental health home-visiting service in Taiwan. The influencing factors identified support the importance of home care services.     

Nurse educators and student nurses’ perspectives on ways to improve implementation of simulation-based education in Lesotho

BackgroundIn order to ensure an effective health system, there is a need to recruit, train and deploy a competent nursing workforce. A competent workforce can be made possible by integrating simulation into the curriculum. Implementation of simulation-based education in Lesotho is facing a number of challenges as the country has limited resources.ObjectivesThis study aimed to describe nurse educators and students’ perspectives on ways to improve implementation of simulation-based education in Lesotho.MethodA qualitative study was conducted. A total of 24 students, 24 nurse educators and 4 principals who were purposely selected participated in the study. Focus group discussions as one of the data collection methods were used to collect data from the nurse educators and students whilst in-depth, unstructured individual interviews were used with the principals. Data were analysed following the Corbin and Strauss grounded theory approach where similar codes were categorised together as part of open coding, and axial coding was conducted by refining the codes and organising them into categories and subcategories.ResultsTwo categories emerged from the areas where improvement is required: resources to support simulation. Resources emerged as playing a major role in ensuring quality simulation. The teaching and learning process emerged as collaborative in nature with all key players ensuring that they meet their responsibilities in order to ensure effective simulation-based learning.ConclusionThe study revealed that there are limited numbers of simulation facilitators and this hinders effective implementation of simulation. Students are concerned about the comments of educators during simulation, as some of the comments are belittling.     

Shifting roles in nursing – does role extension require role abdication?

Aims and objectives. To discuss findings relating to role extension and loss of nursing care to auxiliary nurses. Background. There is ongoing discussion in the literature about what nurses’ roles may be and how the extension of role affects patient care. Various models have been devised to measure outcomes and the value of nursing to patients. However, there are limited data on the views of nurses themselves in terms of what they perceive their role to be and what they feel about role change. Design. A qualitative approach was used with the help of the elements of grounded theory. Methods. Data were analysed using a constant comparative method with core categories identified. The study described in this paper was the final of three. The first two studies involved student nurses and through theoretical sampling, the third sample was chosen to expand the data gained from the students. Results. The findings from the student studies indicated concern that the nursing role was being undertaken by auxiliary nurses. The results of the final study, as discussed in this paper, confirmed this. However, one main difference was that qualified nurses were not necessarily unhappy about auxiliary nurses’ role expansion but were concerned that the role of the nurse was moving away from the bedside. Conclusions. The data suggest that nurses’ roles may be hard to define. An abdication of role, as opposed to delegation of role, seems to be occurring. Critical thinking is needed to ensure this is a decision advocated by clinical nurses. Relevance to clinical practice. Nurses need to be explicit about what their clinical roles are. This study provides data expressing the views of clinical nurses about role expansion and role abdication and corresponding feelings about it.     

Therapeutic interventions associated with seclusion of acutely disturbed individuals

The use of seclusion - i.e. placing an individual in a specially designed room with a locked option in the management of mentally ill individuals whose behaviour is acutely disturbed, and who pose a personal and/or environmental threat. In a grounded theory study of psychiatric nurses' use of seclusion in two closed wards in a metropolitan teaching hospital in Australia, intervening and mainstreaming are the categories that describe nursing interventions developed from constant comparison of the data collected. Details of these interventions are presented, with reference to the skills that participants describe as necessary in the care of a mentally ill patient being secluded and then being re-integrated into ward life. Considerations for further study on the topic of seclusion are presented.     

How people construct their experience of living with secondary lymphoedema in the context of their everyday lives in Australia

Purpose

The purpose of this work was to explore how men and women construct their experiences living with lymphoedema following treatment for any cancer in the context of everyday life.

Methods

The design and conduct of this qualitative study was guided by Charmaz’ social constructivist grounded theory. To collect data, focus groups and telephone interviews were conducted. Audiotapes were transcribed verbatim and imported into NVivo8 to organize data and codes. Data were analyzed using key grounded theory principles of constant comparison, data saturation, and initial, focused, and theoretical coding.

Results

Participants were 3 men and 26 women who had developed upper- or lower-limb lymphoedema following cancer treatment. Three conceptual categories were developed during data analysis and were labeled “accidental journey,” “altered normalcy,” and “ebb and flow of control.” “Altered normalcy” reflects the physical and psychosocial consequences of lymphoedema and its relationship to everyday life. “Accidental journey” explains the participants’ experiences with the health care system, including the prevention, treatment, and management of their lymphoedema. “Ebb and flow of control” draws upon a range of individual and social elements that influenced the participants’ perceived control over lymphoedema. These conceptual categories were interrelated and contributed to the core category of “sense of self,” which describes their perceptions of their identity and roles.

Conclusions

Results highlight the need for greater clinical and public awareness of lymphoedema as a chronic condition requiring prevention and treatment, and one that has far-reaching effects on physical and psychosocial well-being as well as overall quality of life.     

An exploratory model of advance care planning clinical training for oncology nurses: A constructivist grounded theory study

AimThe purpose of this study was to explore and construct the ACP clinical training model for oncology nurses to provide the theoretical references for nursing educators to develop ACP clinical training program for oncology nurses.BackgroundOncology nurses are the primary forces of advance care planning (ACP) clinical practice. However, the systematic ACP clinical training for clinical nurses, especially oncology nurses, is still not visible in mainland China.DesignA constructivist grounded theory study.SettingsThis study included participants from three tertiary hospitals in northeastern China.ParticipantsA total of 23 oncology nurses who directly care for cancer patients.MethodsA constructivist grounded theory approach was adopted to explore the ACP clinical training model for oncology nurses. Semi-structured interviews were completed to collect qualitative data for constructing the theoretical model. A three-level coding procedure with continuous comparisons was adopted to analyze the qualitative data.ResultsAs a result of the study, a total of 32 open coding categories and 13 axial coding categories were extracted and four selective coding categories were formed, namely, external driving forces, self-development, training needs and training key elements. Based on the above categories, the demand-driven ACP clinical training model for oncology nurses was finally developed.ConclusionsOncology nurses have a strong desire for ACP clinical training and their ACP training needs are diverse. The ACP clinical training model provide the theoretical references for nursing educators to develop ACP clinical training programs for oncology nurses to promote high-quality ACP clinical practice.     

Implementation of the care coordinator role: A grounded theory approach

The purpose of this study was to explore the process of implementing a new care coordinator role on a medical-surgical unit. Qualitative data were collected from employees and patients during a 3-month period; data analysis occurred concurrently. Using the constant comparative method, a grounded theory was developed to explain the initial process of implementation of the clinical nurse III (CNIII) role. The basic social psychological problem associated with implementation was role ambiguity. The basic social psychological process used to resolve this problem was "making the role of the CNIII". Making the role involves the following four strategies, which may occur simultaneously: communicating the vision, gaining new knowledge, accessing resources, and defining boundaries. Communicating the vision refers to efforts to articulate the role before and during the implementation process. Gaining new knowledge includes participating in educational workshops and acquiring new skills. Accessing resources refers to development of new relationships and acquisition of office space and equipment. Defining boundaries includes determining the scope of responsibilities and differentiating the role from other roles. This theory may be useful to researchers, educators, and administrators interested in role implementation.