Approaches to reflexivity in qualitative research

Supporting identity and relationships amongst people with dementia through the use of technology: a qualitative interview study

Meaningful activities in dementia care can promote the co-construction of narrative identity in caregiving relationships, helping to preserve the sense of self in people with dementia.

Purpose: Informed by symbolic interactionism and Deweyan transactionalism, the aim of this study was to develop a transactional model of how narrative identity and relationships are promoted through the use of a new technological solution, SENSE-GARDEN, that uses digital technologies and multisensory stimuli to facilitate individualized, meaningful activities.

Method: We conducted a qualitative interview study to explore the experiences of people with moderate to advanced dementia and their caregivers in Norway and Portugal. After using SENSE-GARDEN for 12–16 weeks, 20 participants (7 persons with dementia and 13 caregivers) were interviewed. The interviews were analysed using reflexive thematic analysis.

Results: Three themes were generated: openness, learning, and connection. Findings suggest that SENSE-GARDEN can stimulate emotional experiences, preserve narrative identity, and foster interpersonal relationships. These findings are illustrated through a transactional model.

Conclusion: This study highlights the complex multitude of factors affecting person-environment interactions in which narrative identity and relationships are constructed. To better understand these factors, future work should adopt a holistic approach to studying new methods of creating meaningful activities in dementia care.

Clinical research associates experience with missing patient reported outcomes data in cancer randomized controlled trials

Background

Missing patient reported outcomes data threaten the validity of PRO‐specific findings and conclusions from randomized controlled trials by introducing bias due to data missing not at random. Clinical Research Associates are a largely unexplored source for informing understanding of potential causes of missing PRO data. The purpose of this qualitative research was to describe factors that influence missing PRO data, as revealed through the lived experience of CRAs.

Methods

Maximum variation sampling was used to select CRAs having a range of experiences with missing PRO data from academic or nonacademic centers in different geographic locations of Canada. Semistructured interviews were audio‐recorded, transcribed verbatim, and analyzed according to descriptive phenomenology.

Results

Eleven CRAs were interviewed. Analysis revealed several factors that influence missing PRO data that were organized within themes. PROs for routine clinical care compete with PROs for RCTs. Both the paper and electronic formats have benefits and drawbacks. Missing PRO data are influenced by characteristics of the instruments and of the patients. Assessment of PROs at progression of disease is particularly difficult. Deficiencies in center research infrastructure can contribute. CRAs develop relationships with patients that may help reduce missing PRO data. It is not always possible to provide sufficient time to complete the instrument. There is a need for field guidance and a motivation among CRAs to contribute their knowledge to address issues.

Conclusion

These results enhance understanding of factors influencing missing PRO data and have important implications for designing operational solutions to improve data quality on cancer RCTs.

What do they get out of it? Considering a partnership model in health service research

A research study to evaluate the implementation of a long-term conditions model of care provoked questions regarding the potential impact of the researcher's role in health service research. Traditional methods of qualitative interviewing require researchers to be a disembodied presence, objective, and free from bias. When health service research is conducted by health professionals, role conflict may occur if the topic is one they have expertise in, and therefore the ability to provide guidance or information. An alternative perspective to the idea of an independent and objective researcher is the notion of a partnership. In this research collaboration, participants utilised the interview process to reflect and explore different perspectives, and the researcher bracketed their own participation in the phenomenon being studied. Reflexivity was utilised by both participants and the interviewer to ensure transparency and thus bridge the gap between subjectivity and objectivity in qualitative health service research interviewing.

The current and potential role of community pharmacy in asset-based approaches to health and wellbeing: a qualitative study

Background Asset-based approaches seek to positively mobilise the strengths, capabilities, and resources of individuals and communities. To date, limited consideration has been given to the potential value of this approach in relation to community pharmacy practice, yet this is important and timely given community pharmacy's expanding role and contribution to public health initiatives. Objectives This qualitative study aimed to explore the current and potential role of community pharmacy in asset-based approaches. Methods Fifteen semi-structured telephone interviews were undertaken with community pharmacists and project leads, and public health policy and strategic leads in the UK. Transcripts were analysed using simultaneous inductive open and deductive coding using an applied Theory of Change as an illustrative lens. Results The shift towards patient-facing roles in community pharmacy was felt to offer expanded relational opportunities to engage and collaborate with individuals, communities, and other stakeholders. However, only a small number of respondents described examples of systemic asset-based working within the pharmacy sector. The adoption of asset-based approaches was challenged or enabled by several factors including the availability of protected time/resources, workplace and organisational culture/values, strategic leadership, commissioning, and funding arrangements. Conclusions The study provides valuable insights into the potential for community pharmacy, a previously unconsidered sector, to further adopt and contribute to asset-based approaches and play a more central role in the improvement of public health and reduction of health inequalities.

Perceptions of superwoman schema and stress among African American women with pre-diabetes

Three focus groups were conducted with African American women with elevated cardiometabolic risk to better understand how Superwoman Schema/the strong Black woman role influences their stress and how this cognitive-emotional aspect of health may need to be targeted in future research on cardiometabolic health disparities, such as prediabetes and diabetes. Results from this study revealed that participants' descriptions of stress and the superwoman role were consistent with the Superwoman Schema Conceptual Framework, including specific emphasis on 1) an obligation to manifest strength, 2) an obligation to suppress emotions and 3) an obligation to help others. Implications for targeting Superwoman Schema and stress as social determinants of health are described.

Methodological Socialization and Identity: A Bricolage Study of Pathways Toward Qualitative Research in Doctoral Education

Trends toward convergence on common methodologies and standardized templates restrict the diversity of qualitative methods in organizational research. Considering that graduate education is a critical process in the socialization of researchers into the norms and dominant practices of their discipline, graduate students’ socialization into research methodologies is vital for understanding methodological convergence. The purpose of our study was to understand how graduate students’ socialization shapes their methodological and paradigmatic preferences. Showcasing methodological bricolage as an alternative to qualitative templates, we constructed a research design that combined thematic, discourse, and narrative analyses to investigate graduate students’ reflections throughout a qualitative methods course introducing alternative research paradigms. Our findings highlight the role of institutional, disciplinary, and personal influences as well as identity work in researchers’ socialization and trace alternative trajectories by which socialization and methodological identity construction processes may unfold. We offer a sketch of methodological socialization and suggest that its understanding should be central to nurturing paradigmatic and methodological plurality in qualitative research. We conclude with implications for future research and for research methods training.

Artificial Intelligence in mental health and the biases of language based models

BACKGROUND

The rapid integration of Artificial Intelligence (AI) into the healthcare field has occurred with little communication between computer scientists and doctors. The impact of AI on health outcomes and inequalities calls for health professionals and data scientists to make a collaborative effort to ensure historic health disparities are not encoded into the future. We present a study that evaluates bias in existing Natural Language Processing (NLP) models used in psychiatry and discuss how these biases may widen health inequalities. Our approach systematically evaluates each stage of model development to explore how biases arise from a clinical, data science and linguistic perspective.

DESIGN/METHODS

A literature review of the uses of NLP in mental health was carried out across multiple disciplinary databases with defined Mesh terms and keywords. Our primary analysis evaluated biases within 'GloVe' and 'Word2Vec' word embeddings. Euclidean distances were measured to assess relationships between psychiatric terms and demographic labels, and vector similarity functions were used to solve analogy questions relating to mental health.

RESULTS

Our primary analysis of mental health terminology in GloVe and Word2Vec embeddings demonstrated significant biases with respect to religion, race, gender, nationality, sexuality and age. Our literature review returned 52 papers, of which none addressed all the areas of possible bias that we identify in model development. In addition, only one article existed on more than one research database, demonstrating the isolation of research within disciplinary silos and inhibiting cross-disciplinary collaboration or communication.

CONCLUSION

Our findings are relevant to professionals who wish to minimize the health inequalities that may arise as a result of AI and data-driven algorithms. We offer primary research identifying biases within these technologies and provide recommendations for avoiding these harms in the future.

"I've been to physical therapy before, but not for the knees." A qualitative study exploring barriers and facilitators to physical therapy utilization for knee osteoarthritis

BACKGROUND

Physical therapy (PT) is recommended to reduce pain and improve function. However, only 10%-15% of adults with knee osteoarthritis (OA) use PT in the United States. The purpose of this study was to explore patient-reported barriers and facilitators to PT utilization for knee OA, to understand why PT is underutilized.

METHODS

Qualitative descriptive study using semi-structured interviews was conducted, that is, one-on-one phone interviews with adults from local community centers. Participants were eligible if they were fluent in English and self-reported knee OA (1) over 45 years of age, (2) have activity-related knee pain, and (3) have no morning stiffness or morning stiffness in the knee(s) for ≤30 min. Interviews were audio-recorded and transcribed. To identify barriers and facilitators to PT utilization for knee OA, a coding framework, thematic analysis, and a constant comparative approach were used.

RESULTS

Of 22 participants with health insurance and who participated, 59% were considering PT, 23% refused PT, and 18% used PT for knee OA. Themes identified as either barriers or facilitators for participants were (1) previous experience with PT, (2) physician referral, (3) beliefs about treatment efficacy before and after knee replacement surgery, (4) insurance coverage, and (5) preference to avoid surgery.

CONCLUSION

A previous positive encounter with PT and a physician referral may facilitate PT utilization for adults with knee OA. Knowledge about and access to PT services were not identified as barriers related to PT utilization. Further research is necessary to confirm findings in a broader group of adults with knee OA.

"Finally, I belong somewhere I can be proud of" - Experiences of being a Clubhouse member in Norway

Purpose: The number of psychosocial Clubhouses is growing rapidly in Norway. However, more knowledge is needed about the subjective experience of Clubhouse members in terms of their recuperation processes and experiences in the Clubhouse context. Therefore, this qualitative study explored what it is like to be a Clubhouse member in Norway, and further discuss it in light of the theory of Salutogenesis on successful pathways to coping and well-being.Methods: Using a hermeneutic-phenomenological approach, the present study included in-depth, semi-structured individual interviews with 18 Clubhouse members from three accredited Norwegian Clubhouses. Analysis was conducted using systematic text condensation.Results: Three main themes emerged from the analysis: "Finally, I belong somewhere I can be proud of," "I feel more like an ordinary citizen, just different," and "I feel somewhat equal to others." Overall, the participants experienced improved mental and social well-being owing to their membership of a Clubhouse.Conclusions: Our findings correspond with previous international research. Owing to the positive effect participation in the Clubhouse seem to have on members' motivation, Salutogenesis might help explain helpful processes within the model. Moreover, the model might be a relevant example for policy and service development in mental health care and the labour market.

Exploring the changes of physicians' behaviour toward informal payment based on Health Transformation Plan in Iran: A qualitative study

By implementation of the Health Transformation Plan (HTP), a revised tariff system for healthcare services was executed in Iran. This study explores the changes in physicians' behaviour in facing informal payment (IP) based on HTP implementation in Iran. We conducted in-depth semi-structured interviews with 15 purposefully selected physicians and policy makers to explore the changes (positive, negative and no) in physicians' behaviours with and without the implementation of HTP. The interviews were conducted individually and face to face. The conventional content analysis for data analysis by MAXQDA ver.10 was used. Based on the results, regardless of the HTP implemented, market competitiveness could control physicians' demand for IP. However, unreal tariffs, irregular payments, inflation, expensive healthcare and comparing income with other occupations increase physicians' demand for IP as negative behaviour. This study explored three patterns of physicians' behavioural change because of HTP implementation: 1-positive behavioural change with four factors; 2-negative behavioural changes with two factors; and 3-no behavioural change with four factors. Various factors influenced physicians' behaviour towards IP with and without the HTP. To combat IP more efficiently, we recommend strengthening the HTP's positive interventions, compensation of physicians' target income, enhancing supervision, reducing the gap among various medical specialities and taking a systematic approach with law offenders.

A Mixed Methods Evaluation of a Digital Intervention to Improve Sedentary Behaviour Across Multiple Workplace Settings

BACKGROUND

Prolonged sedentary behaviour (SB) is associated with risk of chronic diseases. Digital interventions in SB require mixed method evaluations to understand potential for impact in real-world settings. In this study, the RE-AIM QuEST evaluation framework will be used to understand the potential of a digital health promotion application which targets reducing and breaking up SB across multiple workplace settings.

METHODS

Four companies and 80 employees were recruited to use a digital application. Questionnaires were used to measure SB, and additional health and work-related outcomes at baseline, one month, three month and six month follow-up. Qualitative data was collected through focus groups with employees and interviews with stakeholders. Questionnaire data was analysed using Wilcoxon Sign Rank tests and qualitative data was thematically analysed.

RESULTS

The digital application significantly increased standing time at one month for the total group and transitions per hour in one of the companies. Facilitators and barriers were identified across RE-AIM.

CONCLUSIONS

Addressing the barriers which have been identified, while maintaining the positive attributes will be critical to producing an effective digital application which also has the potential for impact in the real world.

Exploring the meaning of critical incident stress experienced by intensive care unit nurses

The complexity of registered nurses' work in the intensive care unit places them at risk of experiencing critical incident stress. Gadamer's philosophical hermeneutics (1960/2013) was used to expand the meanings of work-related critical incident stress for registered nurses working with adults in the intensive care unit. Nine intensive care unit registered nurses participated in unstructured interviews. The interpretations emphasized that morally distressing experiences may lead to critical incident stress. Critical incident stress was influenced by the perception of judgment from co-workers and the organizational culture. Nurses in this study attempted to cope with critical incident stress by functioning in 'autopilot', temporarily altering their ability to critically think and to conceal emotions. Participants emphasized the importance of timely crisis interventions tailored to support their needs. This study highlighted that critical incident stress was transformative in how intensive care unit nurses practiced, potentially altering their professional self-identity. Work-related critical incident stress has implications for nurses, the discipline, and the health care system.

After Ringing the Bell: Receptivity of and Preferences for Healthy Behaviors in African American Dyads Surviving Lung Cancer

PURPOSE

To explore receptivity of and preferences for risk-reducing health behavior changes among African American survivors of early-stage lung cancer and their family members.

PARTICIPANTS & SETTING

26 African American non-small cell lung cancer survivor-family member dyads were recruited from two cancer programs in the southeastern United States.

METHODOLOGIC APPROACH

Social cognitive theory principles guided the design and implementation of focus groups. Descriptive statistics were used to summarize the data, and thematic analysis was used to interpret the transcripts from the focus groups.

FINDINGS

The following four themes were identified.

IMPLICATIONS FOR NURSING

Participants emphasized the need for improved provider communication. Pragmatic communication interventions for providers, survivors, and family members may facilitate behavior change and improve outcomes among underserved populations.

Negotiating the Maximum-Security Offender Identity: Experiences From Incarcerated Women

The representation of women classified as maximum-security offenders continues to be a challenge due to paucity of research regarding their experiences. Generally, their stories are masked under the experiences of the other categories of incarcerated women. Drawing from a larger study conducted with incarcerated women in a South African correctional centre in Johannesburg, in this article I provide a thematic analysis of in-depth interviews on the lived experiences of negotiating the maximum-security offender identity by 13 women. The results suggest that the maximum-security offender identity is associated with rejection, dehumanisation, denial of agency, restricted movement, and labelling. The article also highlights the significance of providing agency to incarcerated women in deconstructing stereotypes that represent them as angry and uneducated with no value to society. A more balanced repositioning of their stories emerges as they get an opportunity to construct their own experiences.

Uncovering Hidden Curricula: Use of Dark Humor in Anatomy Labs and its Implications for Basic Sciences Education

Humor is subjective within most settings, but within the anatomy laboratory, it is likely to be significantly more contentious. While humor may be considered a component of the hidden curriculum of medical education, it has yet to be studied specifically from a basic sciences perspective. This study sought to understand if, when, how, and why humor may be used in anatomy labs and the implications this may have in basic sciences education. A survey consisting of demographic and qualitative items was designed to sample widely from academics, students, and health professionals with anatomy laboratory experience. A total of 185 respondents, representing 9 countries participated following purposive sampling and snowball recruitment. Findings of significance were 72% of respondents who had experienced dark humor within the anatomy lab. Themes identified from free-text pertained to the use of internal and external barometers to ascertain the appropriateness of humorous remarks and the use of humor as a mechanism for diffusing stress. Polarity in responses concerning the acceptability of dark humor and rude mnemonics was also observed. This study highlighted that while dark humor may be a perceived tension release, many individuals make use of very specific internalized gauges to determine when and what humor may be appropriate. The data emphasized the need for not only future humanistic-focused anatomy but also basic sciences, education research, to better understand and have ideal educational experiences for all. Finally, this study provided further evidence of the impact of the hidden curriculum associated with the use of humor within educational and professional settings.

Exploring factors influencing initiation, implementation and discontinuation of medications in adults with ADHD

Background

Adherence to ADHD medication is a complex phenomenon as the decision to adhere is influenced by a range of factors. To design tailored interventions to promote adherence, it is important to understand the factors that influence adherence in the context of its three phases: initiation, implementation and discontinuation.

Objective

The objective of this study was to explore the phase‐specific factors that influence adherence to medication in adults who have a diagnosis of ADHD.

Methods

Three focus groups (FGs) were conducted with twenty adults with ADHD in different metropolitan areas of Sydney, Australia. FGs were transcribed verbatim and thematically analysed.

Results

Participants’ decision to initiate medication (the initiation phase) was influenced by their perceived needs (desire to improve academic and social functioning) and concerns (fear of side‐effects) about medication following a similar process as defined by the Necessity‐Concerns Framework (NCF). The balance between benefits of medication (needs) and side‐effects (concerns) continued to determine participants’ daily medication‐taking (the implementation phase) and persistence (or discontinuation) with their medication. Forgetfulness and stigma were reported as concerns negatively impacting the implementation phase, while medication cost and dependence influenced the discontinuation phase of adherence.

Conclusions

Adults’ decision to initiate, continue or discontinue medication is influenced by a range of factors; some are unique to each phase while some are common across the phases. Participants balanced the needs for the medication against their concerns in determining whether to adhere to medication at each phase. It appears that the NCF has applicability when decision making about medication is explored at the three phases of adherence.

Nurses' perspectives on their communication with patients in busy oncology wards: A qualitative study

BACKGROUND

Despite an increase in emphasis on psychosocial care in cancer nursing, time constraints and nurses' lack of knowledge in skilled communication continue to be challenges.

AIMS

To examine how cancer care nurses view their communication with patients and how they deal with the psychosocial needs of patients in busy wards.

DESIGN

A qualitative interview study.

METHODS

Focus groups and individual interviews were conducted with eleven hospital-based cancer nurses in Hong Kong from July 2, 2017 to January 2, 2018.

RESULTS

A qualitative thematic analysis of the data identified three themes: 1. Intentional and unintentional psychosocial care that is secondary in focus; 2. Managing an emotionally challenged environment; 3. Mentoring and learning.

CONCLUSION

Oncology settings are time-constrained, emotionally charged environments for nurses, and providing psychosocial care for patients is a secondary concern. While proactive strategies can be used to avert patient complaints, being open and attending to the individual needs of patients is equally important to avoid blocking in nurse-patient communication. Despite emotional entanglement and tensions, the positive follow-up strategies used by nurses to manage the patients' emotions and provide psychosocial care reflect good practices. Leadership and support are needed to deal with the nurses' perception that their communication training has been ineffective and their ability to manage strong emotions deficient. Communication skills, honed by making continuous opportunities to communicate available, as well as an understanding of emotional labour, need to be integrated with mindfulness in the nurses' care of themselves and their patients. Notwithstanding the importance of experience in oncology care for junior nurses, it is necessary for both junior and senior nurses to learn about and reflect upon the different forms of emotional labour if value-based care is to be provided. In addition, it is essential for junior nurses to receive continuous coaching and mentoring, and to engage in reflective learning from each clinical encounter with oncology patients.

Women's Auto/Biography and Dissociative Identity Disorder: Implications for Mental Health Practice

Dissociative Identity Disorder (DID) is an uncommon disorder that has long been associated with exposure to traumatic stressors exceeding manageable levels commonly encompassing physical, psychological and sexual abuse in childhood that is prolonged and severe in nature. In DID, dissociation continues after the traumatic experience and produces a disruption in identity where distinct personality states develop. These personalities are accompanied by variations in behaviour, emotions, memory, perception and cognition. The use of literature in psychiatry can enrich comprehension over the subjective experience of a disorder, and the utilisation of 'illness narratives' in nursing research have been considered a way of improving knowledge about nursing care and theory development. This research explores experiences of DID through close textual reading and thematic analysis of five biographical and autobiographical texts, discussing the lived experience of the disorder. This narrative approach aims to inform empathetic understanding and support the facilitation of therapeutic alliances in mental healthcare for those experiencing the potentially debilitating and distressing symptoms of DID. Although controversies surrounding the biomedical diagnosis of DID are important to consider, the lived experiences of those who mental health nurses encounter should be priority.

The Social and Emotional Impact of Involving Individuals With Mental Illness in the Research Process

There is a need to involve individuals with a lived experience in health and medical research. Some organizations have developed mechanisms to seek the input of people with a lived experience. However, there are few examples of qualitative research into the impacts of participation. In this study, we investigate the social and emotional impact of participation on individuals, as well as the perceived impact on the organization, in an advisory panel at an Australian mental health research institute. In-depth qualitative interviews were conducted with 50% of the participants on the panel to understand how they conceptualized their involvement. Participants became invested in the organization and their role within it, and found it personally valuable to access diverse perspectives and discuss mental health outside a treatment context. These findings suggest that participating in the research process is beneficial to individuals with a lived experience of mental illness.

Patient readiness for risk-reduction education and lifestyle change following transient ischemic attack

PURPOSE

Patient readiness for secondary prevention and lifestyle change following transient ischemic attack is not well understood. Understanding patient perspectives about the timing and delivery of secondary prevention education is essential to promote meaningful risk factor reduction in this population.

MATERIALS AND METHODS

A single, semi-structured, telephone interview was conducted with ten individuals (7 male, 3 female) within three months following a transient ischemic attack. Interviews explored transient ischemic attack experiences and post-event education. Data were analyzed using inductive thematic analysis.

RESULTS

Individuals had a variety of experiences with secondary prevention education. Four themes emerged from these experiences including "what the hell happened?", "I mustn't have been quite ready", "what should I be doing?" and "we all see it in different ways." Individual knowledge, personal experience of transient ischemic attack, socio-environmental factors, and the format and content of education influenced patient readiness to receive secondary prevention education and adopt lifestyle changes.

CONCLUSION

Readiness for risk-reduction education and lifestyle change following transient ischemic attack is individual and complex. Logistical factors including the location, time, and cost of education, timing of education delivery, and patient perspectives should be considered in the development and delivery of secondary prevention interventions for these people. Implications for rehabilitation Risk reduction and lifestyle change following transient ischemic attack is vital to prevent recurrent stroke. Patients are ready to receive risk reduction and lifestyle advice approximately one week after their transient ischemic attack. Programs designed to provide risk reduction and lifestyle education should be informed by the unique requirements of this population. Uptake of participation in secondary prevention programs may be maximized by offering flexibility in terms of timing post-event and modes of delivery (e.g. Telehealth).

How the service delivery works in the Iranian specialised burns hospitals? A qualitative approach

As burn injuries are a major cause of death and infirmity, successful service delivery is vital in health systems. In Iran, a few specialised burns hospitals (SBHs) located in big provinces provide burn services in which burn patients with more severe conditions are referred to. However, SBHs are faced with several challenges for delivering due treatment for burn patients. So, for the first time in Iran, the main aim of the study was to identify the challenges of delivering burn services in SBHs. For this purpose, we conducted a qualitative study during February 2017 to April 2018. Key informants were purposefully selected and interviewed at national and provincial levels from the Ministry of Health, medical universities, and informants working in eight SBHs. The saturation point was reached at 21 face-to-face semi-structured interviews. A thematic analysis approach was employed to analyse transcribed documents assisted by MAXQDA Plus version 12. Our results reveal four themes and twelve subthemes on the challenges of delivering services in SBHs. Themes and (subthemes) including burn care continuum (preventive care, pre-hospital care, hospital care, follow-up, and home care), regionalisation of burning services (access to other specialties and medical services, access to specialized care in provinces without a SBH, standardised regionalisation system for burn related services (BRSs), costs of providing BRSs (expensive services and supplies and long hospitalisation), and non-compliance with standardised care (guidelines to provide burn care and physical space to provide BRSs). Results suggest that improving BRSs delivery in Iran may be reached by strengthening burn care continuum, regionalising burn care, allocating sufficient budgets to burn services and formulating burn care guidelines. These policy actions can be better addressed via intra-sectoral collaborations.

Evaluating Complex Health Interventions With Randomized Controlled Trials: How Do We Improve the Use of Qualitative Methods?

Qualitative methods are underutilized in health intervention evaluation, and overshadowed by the importance placed on randomized controlled trials (RCTs). This Commentary describes how innovative qualitative methods are being used as part of RCTs, drawing on articles included in a special issue of Qualitative Health Research on this topic. The articles' insights and a review of innovative qualitative methods described in trial protocols highlights a lack of attention to structural inequalities as a causal mechanism for understanding human behavior. We situate this gap within some well-known constraints of RCT methodologies, and a discussion of alternative RCT approaches that hold promise for bringing qualitative methods center stage in intervention evaluation, including adaptive designs, pragmatic trials, and realist RCTs. To address the power hierarchies of health evaluation research, however, we argue that a fundamental shift needs to take place away from a focus on RCTs and toward studies of health interventions.

Using Reflexive Thinking to Establish Rigor in Qualitative Research

BACKGROUND

Reflexivity can be helpful in developing the methodological rigor necessary to attaining trustworthy qualitative study results.

OBJECTIVES

The aim of this study was to evaluate strategies of critical reflexive thinking during a qualitative enquiry rooted in a mixed-methods study.

METHODS

Guided by the questions of Rolfe and colleagues from 2001 ("what," "so what," and "now what"), we applied reflexive thinking to all aspects of the investigation.

RESULTS

Critical reflexive thinking strongly supported our efforts to establish methodological rigor and helped reveal shortcomings.

DISCUSSION

Effective strategical use of reflexive thinking takes concerted effort. Both time and space are essential to applying reflexive thinking throughout the qualitative research process.

Health behavior changes in African American family members facing lung cancer: Tensions and compromises

PURPOSE

Behavioral interventions targeting cancer survivors often fail to address the clustering of unhealthy behaviors among family members and friends, and the impact of close relationships on behavior change. The study's aim was to identify factors associated with receptivity and preferences for lifestyle behavior change among family members of African-American survivors of lung cancer.

METHODS

Principles of social cognitive theory guided the design. A descriptive, qualitative study recruited 26 African-American family members of lung cancer survivors from two teaching hospitals in the southeastern United States. A 20-item Information Form collected demographic, health status, and health behavior information. Family members participated in one of three semi-structured focus group discussions.

RESULTS

Four major themes emerged: family members and survivors both resisted the caregiver role; dramatic changes evoked by the diagnosis of lung cancer were facilitators and barriers to lifestyle choices; leaning on faith was the primary source of support; and these families live with a constant threat of multiple cancers. Findings emphasize the importance of meaningful conversations among health-care providers, survivors, and family members during the time of diagnosis, treatment, and recovery, so that family members are better prepared to cope with anticipated changes.

CONCLUSIONS

This study highlights the stressors that affect family members and sheds light on their unique needs. The stressors limit their ability to change health behaviors. Family members need basic education, skills training, and support related to the lung cancer diagnosis and other cancers. Current methods to provide these services are limited in their accessibility, availability, and effectiveness.

Lung cancer screening: Practice guidelines and insurance coverage are not enough

BACKGROUND AND PURPOSE

Low-dose computed tomography (LDCT) is expected to increase early detection of lung cancer and improve survival. The growth in the number of advanced nurse practitioners (NPs) in primary care settings increases the likelihood that an NP will serve as a patient's provider. This study's purpose was to examine knowledge, attitudes, and practices regarding LDCT among NPs who work in primary care settings.

METHODS

An explanatory, sequential, mixed-method design used a 32-item questionnaire, followed by a semi-structured telephone interview. The development of the survey and interview questions were guided by a conceptual framework representing a temporal sequence for behavior change and potential barriers to guideline adherence.

CONCLUSIONS

Nurse practitioners believe that shared decision making with their high-risk patients about LDCT is within their scope of their practice. Working in time-constrained primary care settings, NPs have limited abilities to improve the uptake of LDCT. Substantial patient barriers exist that deter follow through on providers' recommendation. Disseminating guidelines and authorizing health insurance reimbursement is insufficient.

IMPLICATIONS FOR PRACTICE

Research is needed that investigates the screening process so that barriers can be closely studied. Culture change is needed where early detection has greater value for insurers, providers, and patients.

Changing status in health care: community and hospital pharmacists’ perceptions of pharmacy practice

Objectives

This study aimed to explore experienced community and hospital pharmacists’ perceptions of how their pharmacy practice and status in health care are affected by others’ views of them.

Methods

A qualitative collective case study was conducted. The primary data were 20 in-depth semistructured interviews of community and hospital pharmacists in England that were audio-recorded, transcribed and analysed thematically.

Key findings

Thematic analysis of the data identified four themes: (1) ambiguities about being professionals, (2) internal divisions, (3) medicines experts and (4) shopkeepers as healthcare providers.

Conclusions

Pharmacists want to be recognised as medicines experts in health care. They are aware that their status is assessed by the public based on their practice, which is dispensing of medicines, and that the public’s image of all pharmacists is that of ‘a typical community pharmacist’ working in a retail shop while having little experience of pharmacists in other healthcare settings. Pharmacists consider that the public does not view them as registered healthcare professionals. They mainly associate being registered professionals with being controlled from afar by their professional regulator, instead of utilising this as an enabling strategy to support their reprofessionalisation efforts. Pharmacists remain the hidden healthcare profession and need to act in practice as healthcare professionals, so the public is aware of their place and contributions in health care to maintain or enhance their status. Internal divisions between community and hospital pharmacists appear to be due to differences in practice, knowledge and aspirations having the potential to adversely affect the pharmacy profession’s status.

Dementia patient care in the diagnostic medical imaging department

INTRODUCTION

People with dementia have difficulties with memory, executive functions and behaviour which pose a challenge during diagnostic imaging. There is abundant literature on the radiographic diagnosis of dementia; however, there is little research on how to best to care for people with dementia during imaging procedures. The aim of this study is to explore the experiences of dementia care in imaging departments through the perspectives of people with dementia, carers, radiographers and student radiographers.

METHODS

This was a cross-sectional qualitative study. Four people with dementia and six carers participated in individual semi-structured interviews; eight academic radiographers and 19 student radiographers participated in focus groups. Interviews and focus groups were transcribed and thematically analysed.

RESULTS

Participants described positive and negative experiences during imaging procedures. Common themes existed among people with dementia, carers and radiographers. Findings were (1) People with dementia and carers had negative experiences such as distress and pain; radiographers experienced stigma and violence. (2) Negative experiences during imaging were associated with disrespected personhood, poor communication, insufficient knowledge of dementia, inappropriate time management, overly stimulating physical environments and exclusion of carers. (3) Departmental protocols that contributed to negative experiences included lack of preparation, lack of dementia protocols, and the use of restraints.

CONCLUSION

People with dementia and their carers can experience poor care in imaging departments and radiographers can find it difficult working with people with dementia. Radiographers need training about dementia, imaging services can improve their procedures and environment, and work in greater partnership with carers.

Exploring the need for Transition Readiness Scales within cystic fibrosis services: A qualitative descriptive study

AIMS AND OBJECTIVES

To explore healthcare professionals' and patients' perceptions of the potential use of a Transition Readiness Scale in cystic fibrosis care. This included an examination of barriers and facilitators to its implementation along with the identification of key items to include in a Transition Readiness Scale.

BACKGROUND

Due to increasing life expectancy and improved quality of life, more adolescents with cystic fibrosis are transitioning from paediatric to adult health care. To assess and correctly manage this transition, a more structured approach to transition is advocated. This can be achieved using a Transition Readiness Scale to potentially identify or target areas of care in which the adolescent may have poor knowledge. These key items include education, developmental readiness taking into account relationships, reproduction, future plans and self-management skills. Existing tools to gauge readiness concentrate mainly on education and self-care needs assessment as their key items. Currently, there is no specific cystic fibrosis Transition Readiness Scale in use in Ireland or internationally.

DESIGN

The study used a descriptive qualitative design.

METHODS

Data were collected using semi-structured interviews (n = 8) and analysed using a thematic approach.

RESULTS

The findings identified the potential benefits of this tool and second the resources which need to be in place before its development and implementation into cystic fibrosis services.

CONCLUSION

Transition Readiness Scales have substantial relevance with cystic fibrosis services emphasising the importance of establishing the necessary resources prior to its implementation. These were identified as more staff, a dedicated private space and staff training and education.

RELEVANCE TO CLINICAL PRACTICE

Significant resources are needed to fully integrate Transition Readiness Scales in practice. The study findings suggest multidisciplinary collaborations, and patient engagement is pivotal in planning and easing the transition process for adolescents with cystic fibrosis.

A nurse researcher's guide to reflexive interviewing

BACKGROUND

In a wider doctoral study related to unfavourable experiences of nursing students studying abroad, the researcher undertook a reflexive interview to reduce the potential for bias.

AIM

To discuss a method for conducting reflexive interviews and recommend their use to nurse researchers.

DISCUSSION

A reflexive interview was undertaken to reduce bias and pilot an original interview instrument. A senior researcher interviewed the researcher using original questions that would be used to interview participants in the wider doctoral study. The questions required validation and therefore the reflexive interview acted as a pilot.

CONCLUSION

This process acted as a learning opportunity for the researcher, improving interview skills such as keeping in mind the respondent's feelings, paying attention to the ratio of eye-contact to note-taking and consciously slowing the speed of asking questions. Biases were revealed through the listening guide, a reflexive method of analysis underpinned by experiential education. These included the beliefs that sending institutions insufficiently prepare nursing students to study abroad, such trips may not benefit the host locations and students study abroad merely to have an adventure.

IMPLICATIONS FOR PRACTICE

The reflexive interview exposed implicit biases and enabled the researcher to pilot an original interview instrument. The recommendation for this reflexive method is justified in that it enables introspection, reduces bias and encourages social transformation.

Planning Telehealth for Older Adults With Atrial Fibrillation in Rural Communities: Understanding Stakeholder Perspectives

Older adults with atrial fibrillation (AF) in rural communities have less access to cardiac specialty care. Telehealth offers a viable approach to provide cardiac care, yet little is known about patients’ and providers’ views on telehealth’s potential to support rural patients with AF. This qualitative descriptive study examines patient and health providers’ perspectives, an important first step in planning a telehealth initiative. Eight patients with AF, along with one partner from rural communities, were recruited through an urban-based AF clinic. Five providers were recruited through professional practice leads in the health region. Semistructured telephone interviews were conducted with both stakeholder groups. The overriding theme was variability in patient and provider receptiveness to telehealth. Receptiveness reflected differences in past experience with telehealth, in perceived adequacy of rural health services, and in perceived gaps in AF care. These are important considerations in planning effective and sustainable telehealth in rural communities.

Exploring the lived experience of gay men with prostate cancer: A phenomenological study

PURPOSE

Gay men with prostate cancer are an 'invisible species' in the research literature despite concerns that the impact of treatment may be more profound and in some ways unique compared to heterosexual men. The aim of this research is to explore the lived experience of gay men with prostate cancer.

METHOD

In-depth interviews were recorded and transcribed verbatim from a purposive sample of eight gay men treated for prostate cancer in Ireland. A qualitative methodological approach employing Giorgi's descriptive phenomenological method was used to collect and analyse data.

FINDINGS

Three key aspects emerged representing the essence of the participants lived experience; The experience of diagnosis, treatment decision making, and the impact of treatment, with sub-themes of shock of diagnosis, the generalist nature of information, sexual side effects and incontinence, and masculinity and gay identity. Secondly, the experience of the healthcare service with sub-themes of sexual orientation disclosure and communication with the healthcare team; and thirdly, sources of support and means of coping which included significant others, family & friends, cancer support groups, and gay resources and support services.

CONCLUSION

Gay men with prostate cancer have unmet information and supportive care needs throughout their prostate cancer journey, especially related to the impact of sexual dysfunction and associated rehabilitation, negatively impacting their quality of life. Issues associated with heteronormativity, minority stress, and stigma may influence how gay men interact with the health service, or how they perceive the delivery of care. Healthcare education providers should update prostate cancer education programmes accordingly.

Crossing professional cultures: A qualitative study of nurses working in a medical school

BACKGROUND

Leaving the nursing workforce is often seen as a loss. Some nurses maintain a current nursing registration and work within university schools of medicine. Little is known about their work.

AIM

To explore and describe the experiences of nurses who work in a New Zealand medical school.

DESIGN

Qualitative descriptive informed by autoethnography.

METHODS

Interviews with 14 nurses over a 12-month period in 2015. Data were inductively analysed.

RESULTS

The nurses were mid-to-late career with prior clinical experience and all held postgraduate qualifications. Five themes emerged.

CONCLUSIONS

Nurses chose to work in a medical school for a variety of reasons. They sought to maintain their nursing identity but the nursing profession often did not recognise them as nurses. Although individual colleagues recognised their value, organisationally, limited attention was afforded to the specific orientation, mentorship and development of nurses' careers within this setting.

How Can Medical Students Add Value? Identifying Roles, Barriers, and Strategies to Advance the Value of Undergraduate Medical Education to Patient Care and the Health System

PURPOSE

As health systems evolve, the education community is seeking to reimagine student roles that combine learning with meaningful contributions to patient care. The authors sought to identify potential stakeholders regarding the value of student work, and roles and tasks students could perform to add value to the health system, including key barriers and associated strategies to promote value-added roles in undergraduate medical education.

METHOD

In 2016, 32 U.S. medical schools in the American Medical Association's (AMA's) Accelerating Change in Education Consortium met for a two-day national meeting to explore value-added medical education; 121 educators, systems leaders, clinical mentors, AMA staff leadership and advisory board members, and medical students were included. A thematic qualitative analysis of workshop discussions and written responses was performed, which extracted key themes.

RESULTS

In current clinical roles, students can enhance value by performing detailed patient histories to identify social determinants of health and care barriers, providing evidence-based medicine contributions at the point-of-care, and undertaking health system research projects. Novel value-added roles include students serving as patient navigators/health coaches, care transition facilitators, population health managers, and quality improvement team extenders. Six priority areas for advancing value-added roles are student engagement, skills, and assessments; balance of service versus learning; resources, logistics, and supervision; productivity/billing pressures; current health systems design and culture; and faculty factors.

CONCLUSIONS

These findings provide a starting point for collaborative work to positively impact clinical care and medical education through the enhanced integration of value-added medical student roles into care delivery systems.

Reflexivity and the "Acting Subject": Conceptualizing the Unit of Analysis in Qualitative Health Research

The ways in which social scientists conceptualize the "reflexive" human subject have important consequences for how we go about our research. Whether and how we understand human subjects to be the authors of our own actions helps to structure what we say about health, health care, and the many other topics addressed in qualitative health research. In this article, I critically discuss assumptions of human reflexivity that are built into qualitative social science of health and medicine. I describe three alternative ways of understanding reflexive thought and human action derived from the theoretical works of Pierre Bourdieu, Bruno Latour, and George Lakoff and Mark Johnson, respectively. I then apply these three different ways of thinking about reflexivity and the acting subject to the analysis of an excerpt of participant observation data from a health services research study of transitions from hospital to home, illuminating the different kinds of analyses that arise from each perspective. I conclude with a call for social scientists to commit to the search for better ways of understanding the human subject, resisting the temptation to "settle" on theoretical statements that close down the path to more sophisticated conceptualizations of human thought and action.

Portraying Reflexivity in Health Services Research

A model is proposed for supporting reflexivity in qualitative health research, informed by arguments from Bourdieu and Finlay. Bourdieu refers to mastering the subjective relation to the object at three levels-the overall social space, the field of specialists, and the scholastic universe. The model overlays Bourdieu's levels of objectivation with Finlay's three stages of research (pre-research, data collection, and data analysis). The intersections of these two ways of considering reflexivity, displayed as cells of a matrix, pose questions and offer prompts to productively challenge health researchers' reflexivity. Portraiture is used to show how these challenges and prompts can facilitate such reflexivity, as illustrated in a research project.

The use of social environment in a psychosocial clubhouse to facilitate recovery-oriented practice

BACKGROUND

Recovery-oriented language has been widely adopted in mental health policy; however, little is known about how recovery practices are implemented within individual services, such as psychosocial clubhouses.

AIMS

To explore how recovery practices are implemented in a psychosocial clubhouse.

METHOD

Qualitative case study design informed by self-determination theory was utilised. This included 120 h of participant observation, interviews with 12 clubhouse members and 6 staff members. Field notes and interview transcripts were subject to theoretical thematic analysis.

RESULTS

Two overarching themes were identified, each comprising three sub-themes. In this paper, the overarching theme of 'social environment' is discussed. It was characterised by the sub-themes, 'community and consistency', 'participation and opportunity' and 'respect and autonomy'.

CONCLUSIONS

Social environment was used to facilitate recovery-oriented practice within the clubhouse. Whether recovery is experienced by clubhouse members in wider society, may well depend on supports and opportunities outside the clubhouse.

DECLARATION OF INTERESTS

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

A word-count approach to analyze linguistic patterns in the reflective writings of medical students

BACKGROUND

Teaching reflection and administering reflective writing assignments to students are widely practiced and discussed in medical education and health professional education. However, little is known about how medical students use language to construct their narratives. Exploring students' linguistic patterns in their reflective writings can facilitate understanding the scope and facets of their reflections and their representational or communication approaches to share their experiences. Moreover, research findings regarding gender differences in language use are inconsistent. Therefore, we attempted to examine how females and males differ in their use of words in reflective writing within our research circumstance to detect the unique and gender-specific approaches to learning and their applications.

METHODS

We analyzed the linguistic profiles of psychological process categories in the reflective writings of medical students and examined the difference in word usage between male and female medical students. During the first year of a clinical rotation, 60 fifth-year medical students wrote reflective narratives regarding pediatric patients and the psychosocial challenges faced by the patients and their family members. The narratives were analyzed using the Chinese version of Linguistic Inquiry and Word Count (CLIWC), a text analysis software program. Multivariate procedures were applied for statistical analysis.

RESULTS

Cognitive words were most pervasive, averaging 22.16%, whereas perceptual words (2.86%) were least pervasive. Female students used more words related to positive emotions and sadness than did male students. The male students exceeded the female students only in the space category. The major limitation of this study is that CLIWC cannot directly acquire contextual text meanings; therefore, depending on the research topic, further qualitative study of the given texts might be necessary.

CONCLUSIONS

To enhance students' empathy toward the psychosocial issues faced by patients and their family members, students should be encouraged to explore the domain of psychological processes by identifying and expressing their affective and perceptual experiences. Researchers in future studies should use outcome measures such as self-awareness or empathy to determine the overall effectiveness of reflective writing and how changes in linguistic patterns affect such outcomes.

Men's strategies for preserving emotional well-being in advanced prostate cancer: An interpretative phenomenological analysis

OBJECTIVE

This study explores men with advanced prostate cancers' own practices for promoting and maintaining emotional well-being using Interpretative Phenomenological Analysis.

DESIGN

Five men with advanced prostate cancer participated in face-to-face, semi-structured, in-depth interviews.

RESULTS

Within rich narratives of lost and regained well-being, two super-ordinate themes emerged--'living with an imminent and uncertain death' and 'holding on to life.' Well-being was threatened by reduced sense of the future, isolation and uncertainty. Yet, the men pursued well-being by managing their emotions, striving for the future whilst enjoying life in the present, taking care of their families and renegotiating purpose. Running through participant's accounts was a preference for taking action and problem-solving. Sense of purpose, social connectedness, and life engagement were revealed as concepts central to improving well-being, indicating areas which practitioners could explore with men to help them re-establish personal goals and life purpose.

CONCLUSIONS

The findings also add weight to the evidence base for the potential value of psychological interventions such as cognitive behaviour therapy and mindfulness in men with prostate cancer.

Assessing the knowledge of perinatal mental illness among student midwives

The experience of perinatal mental illness (mental illness occurring around the time of pregnancy) currently affect 1 in 10 women and can have adverse effects on the mother and her child (Massie and Szajnberg, 2002; O'Connor et al., 2002). The care and effective management of women experiencing perinatal mental illness is therefore an important issue for health care staff, managers, psychiatrists, commissioners and campaigners. Midwives play a significant part in caring for women throughout their pregnancies, during labour and up to the first month after birth. Midwives are in a unique position to assess a woman's well-being and to offer appropriate support. However, previous research has revealed that midwives often have poor understanding and knowledge of perinatal mental health issues and require improved training (Ross-Davie et al, 2006; McCann and Clark, 2010). This research project aims to systematically assess student midwives awareness of perinatal mental illness. The findings of this study will inform curriculum development for graduate and post-graduate midwifery students therefore improving the care and support women with mental illness receive from antenatal services. The findings from this study will also be used for the formation of an educational web-based programme for student and qualified midwives.

Service providers' perspectives, attitudes and beliefs on health services delivery for Aboriginal people receiving haemodialysis in rural Australia: a qualitative study

OBJECTIVE

Providing services to rural dwelling minority cultural groups with serious chronic disease is challenging due to access to care and cultural differences. This study aimed to describe service providers' perspectives on health services delivery for Aboriginal people receiving haemodialysis for end-stage kidney disease in rural Australia.

DESIGN

Semistructured interviews, thematic analysis

SETTING

A health district in rural New South Wales, Australia

PARTICIPANTS

Using purposive sampling, 29 renal and allied service providers were recruited, including nephrologists, renal nurses, community nurses, Aboriginal health workers, social workers and managers. Six were Aboriginal and 23 non-Aboriginal.

RESULTS

Improving cultural understanding within the healthcare system was central to five themes identified: rigidity of service design (outreach, inevitable home treatment failures, pressure of system overload, limited efficacy of cultural awareness training and conflicting priorities in acute care); responding to social complexities (respecting but challenged by family obligations, assumptions about socioeconomic status and individualised care); promoting empowerment, trust and rapport (bridging gaps in cultural understanding, acknowledging the relationship between land, people and environment, and being time poor); distress at late diagnosis (lost opportunities and prioritise prevention); and contending with discrimination and racism (inherent judgement of lifestyle choices, inadequate cultural awareness, pervasive multilevel institutionalised racism and managing patient distrust).

CONCLUSIONS

Service providers believe current services are not designed to address cultural needs and Aboriginality, and that caring for Aboriginal patients receiving haemodialysis should be family focused and culturally safer. An Aboriginal-specific predialysis pathway, building staff cultural awareness and enhancing cultural safety within hospitals are the measures recommended. Increasing patient support for home haemodialysis may improve health and the quality of care outcomes.