Realist Approach to Qualitative Data Analysis.

BACKGROUND: A realist approach has gained popularity in evaluation research, particularly in understanding causal explanations of how a program works (or not), the circumstances, and the observed outcomes. In qualitative inquiry, the approach has contributed to better theoretically based explanations regarding causal interactions. OBJECTIVE: The aim of this study was to discuss how we conducted a realist-informed data analysis to explore the causal interactions within qualitative data. METHODS: We demonstrated a four-step realist approach of retroductive theorizing in qualitative data analysis using a concrete example from our empirical research rooted in the critical realism philosophical stance. These steps include (a) category identification, (b) elaboration of context-mechanism-outcome configuration, (c) demi-regularities identification, and (d) generative mechanism refinement. RESULTS: The four-step qualitative realist data analysis underpins the causal interactions of important factors and reveals the underlying mechanisms. The steps produce comprehensive causal explanations that can be used by related parties-especially when making complex decisions that may affect wide communities. DISCUSSION: The core process of realist data analysis is retroductive theorizing. The four-step qualitative realist data analysis facilitates this theorizing by allowing the researcher to identify (a) patterns, (b) fluctuation of patterns, (c) mechanisms from collected data, and (d) to confirm proposed mechanisms.

Nurse's, physician's and family member's experiences of withholding or withdrawing life-sustaining treatment process in an intensive care unit.

AIMS: To explore nurse's, physician's and family member's experiences of withholding or withdrawing life-sustaining treatment in an intensive care unit. BACKGROUND: In South Korea, withholding or withdrawing life-sustaining treatment is legalised by the enforcement of the Hospice, Palliative Care and Life-sustaining Treatment Decision-making Act (2018). The Act (2018) is the first legal ground for making decisions regarding life-sustaining treatment in South Korea. DESIGN: Focused ethnography. The standards for reporting qualitative research checklist is used. METHODS: Interview data are collected between August 2018 and January 2019 using semi-structured interviews with 23 nurses, 10 physicians and four family members in a South Korean intensive care unit. The interview data are analysed following the thematic analysis of Braun and Clarke. RESULTS: An overarching theme of 'constructing death' is identified from the experiences of nurses, physicians and family members regarding withholding or withdrawing life-sustaining treatment in a South Korean intensive care unit. Family members had the strongest power in the withholding or withdrawing life-sustaining treatment process whilst the process had to be based on medical consideration. All the research participants shared the purpose and motivation of withholding or withdrawing life-sustaining treatment as the dying patient's dignity. Due to the South Korean national health insurance system, the relationships between medical staff and family members were driven by customer ideology. CONCLUSION: The impact and linkage of the context of familism culture and health insurance with the process of withholding or withdrawing life-sustaining treatment in South Korea are shown in this research. The findings of this research inspire future studies to uncover the impact of the cultural context in the decision-making process of a patient's death, to explore the dynamics of family members under cultural values and to explore the influence of the healthcare system and medical costs on the relationships between medical staff and family members. RELEVANCE TO CLINICAL PRACTICE: By integrating the experiences of nurses, physicians and family members, the findings of this study inform the shared values in the context of familism culture and the health insurance system. In particular, understanding family dynamics when a patient's dying and death as a result of withholding or withdrawing life-sustaining treatment informs nurses to provide quality of care in the intensive care setting. Therefore, the findings of this research contribute to distinguishing the priority in care when withholding or withdrawing life-sustaining treatment, rapidly changing the aims of care from the patient's recovery to a dignified death.

Ambiguous loss in organ donor families: A constructivist grounded theory.

AIMS AND OBJECTIVES: Explore families' experiences when being approached for organ donation authorisation after brainstem death. BACKGROUND: The complexities of potential organ donor families' experiences include challenges related to emotional distress, coping with the loss and the organ donation decision-making process, and support needed. A lack of conceptual clarity was found concerning families' experiences when being approached for organ donation authorisation, which guided the study. DESIGN: Constructivist grounded theory. METHODS: Seventy-one participants, including healthcare professionals and families, were recruited from two large hospitals in Chile between 2017 and 2019. Field notes, documents (n = 80), interviews (n = 27) and focus groups (n = 14) were collected and analysed following Charmaz's constructivist grounded theory principles and practices until theoretical saturation was reached. The study is reported using the COREQ checklist. RESULTS: A third type of ambiguous loss of bereaved families' experience was developed as a fourfold process: (1) impending loss, (2) confirming loss, (3) ambiguous loss and organ donation decision-making and (4) organ donation as a third type of ambiguous loss. This grounded theory expands the concepts of ambiguous loss by Boss, dying by Glaser and Strauss and grief by Brinkmann, enabling explanation of families' experiences. CONCLUSION: Families of potential organ donors develop a highly complex grieving process, which may play a significant role in the organ donation decision-making process. Ambiguity is embedded in how donor families reframe the existence of the donor through the act of giving life. RELEVANCE TO CLINICAL PRACTICE: The findings shed light on families' experiences on the organ donation process after brainstem death. The study can be used in nursing practice, education and to inform policy nationally and globally, mainly due to the current focus on quantitative measures and legislative changes fostering individual decision-making. PATIENT OR PUBLIC CONTRIBUTION: Families contributed through their first-hand experiences of the organ donation process.

Emergency department nurses' role transition towards emergency nurse practitioner: A realist-informed review.

BACKGROUND: The integration of emergency nurse practitioner (ENP) services in emergency departments (EDs) has been well established, especially in high-income countries such as the United Kingdom, the United States and Australia. Different types of reviews, including integrative, literature and systematic, have been carried out to examine evidence regarding the impact of ENPs on the quality of ED services. Unfortunately, there is still limited explanation of the influencing factors that may result in a successful transition process from Registered Nurse to Emergency Nurse Practitioner. This review aims to understand these factors. METHODS: A realist approach (RAMESES) guided this review. CINAHL Plus, MEDLINE, PsycINFO, EMBASE and Web of Science databases were searched to capture studies from 1990 to 2020, combined with policy documents from professional bodies and government websites and relevant references from identified sources. Realist data analysis was carried out on the included articles to understand how context, mechanism and outcomes related to the ED nurses' role transition. RESULTS: Forty-eight articles were included. There were differences in preparatory education and scope of practice of the role. The review configured various contexts, mechanisms and outcomes of the role transition along with their interactions. CONCLUSION: The findings provide a comprehensive understanding regarding the emergency nurses' role transition, with a view to providing better insights and explanations to interested parties who would like to integrate the ENP service in their ED.

Edgework emotion management: A constructivist grounded theory of organ donation nurses' experiences and practices.

AIMS AND OBJECTIVES: To explore nurses' experiences when approaching families for organ donation authorisation to guide nursing practice. BACKGROUND: Organ donation after brainstem death implies that bereaved families are approached to discuss organ donation authorisation, and in many countries, specialist nurses do this approach. The literature describes the social, psychological and emotional challenges of health professionals in this role. However, lack of conceptual clarity regarding nurses' experiences on approaching families to guide nursing practice was found. DESIGN: Constructivist grounded theory. METHODS: Between October 2017 and July 2019, seven months of observations were conducted across two large public hospitals in Chile. Field notes, documents (n = 80), interviews (n = 27) and focus groups (n = 14) with 71 participants (51 healthcare professionals and 20 bereaved families) were included. Data collection and analysis followed the principles and practices of Charmaz' constructivist grounded theory. The COREQ checklist was followed in reporting the study. RESULTS: Edgework emotion management of organ donation nurses was developed as a threefold process: 1) being present to recognise inner and family emotions, 2) being on an emotional edge when approaching families and 3) extending the emotional edge to make sense of their experiences. The grounded theory was conceptualised using edgework emotion management by Lois (2003), which allowed to elucidate organ donation nurses' experiences and practices on managing their emotions. CONCLUSIONS: Organ donation nurses develop a sophisticated and complex emotional regulation process to approach and care for families when negotiating organ donation authorisation for transplantation. RELEVANCE TO CLINICAL PRACTICE: The experiences of specialist organ donation nurses entail a sophisticated emotion management process, which may explain the complexities of a critical role within healthcare institutions. Findings can be locally and internationally used to understand, educate and guide nursing practice, in an area of increasing specialisation and staffing shortages such as organ donation and transplantation.

Family INvolvement in inTensive care: A qualitative exploration of critically ill patients, their families and critical care nurses (INpuT study).

AIMS AND OBJECTIVES: To understand the different factors that impact on the involvement of adult family members in the care of critically ill patients from the perspective of patients, families and nurses, with the aim to inform the enactment of a patient- and family-centred care intervention to support the patient-family-nurse partnership in care involvement. BACKGROUND: Existing evidence lacks theoretical underpinning and clarity to support enactment of patient- and family-centred care and involvement of families in the care of the critically ill patient. DESIGN: Qualitative exploratory design using thematic analysis. METHODS: This study was conducted at two adult intensive care units in two tertiary university hospitals in the central belt of Scotland. Between 2013-2014, we conducted semi-structured interviews with critically ill survivors (n = 19) and adult family members (n = 21), and five focus groups with nurses (n = 15) across both settings. Data were digitally recorded, transcribed verbatim, and uploaded in NVivo 10. Data were analysed thematically using a constructivist epistemology. Ethical approval was obtained prior to data collection. Data are reported according to the Consolidated Criteria for Reporting Qualitative Research checklist. RESULTS: Family's situational awareness; the perceived self in care partnership; rapport and trust; and personal and family attributes were the main factors that affected family involvement in care. Two key themes were identified as principles to enact patient- and family-centred care in adult intensive care units: "Need for 'Doing family'" and "Negotiations in care involvement." CONCLUSIONS: Negotiating involvement in care requires consideration of patients' and family members' values of doing family and the development of a constructive patient-family-nurses' partnership. RELEVANCE TO CLINICAL PRACTICE: Future policy and research should consider patients' and family's needs to demonstrate family bonds within a negotiated process in care participation, when developing tools and frameworks to promote patient- and family-centred care in adult intensive care units.

Delivering direct patient care in the haemodialysis unit: a focused ethnographic study of care delivery.

BACKGROUND: Direct patient care is a term used within nursing and healthcare to help quantify and qualify care delivery. Direct patient care time is considered as a valuable measure by healthcare providers to indicate efficiency and to quantify nursing work, however little is understood of the patient experience and care delivery in haemodialysis settings. AIM: The aim of this study was to gain an understanding of patients' and nursing staff perceptions and experiences of 'direct patient care' within one haemodialysis unit. METHODS: A focused ethnographic approach utilised participant observations, informal questioning, photographs and 27 semi-structured interviews of registered nurses, clinical support workers and patients. Observation notes and interviews were transcribed and thematically analysed. RESULTS: The key finding was the construction and reconceptualisation of care delivery in this setting. Care was identified to be delivered in two distinct ways, both of which allowed patients to feel cared for. 'Active care' where patients feel cared for when they are being dealt with directly by staff and 'Passive care' where patients feel cared for through staff availability and visibility. CONCLUSION: Developing this understanding of patient care delivery in this specialism has highlighted some important aspects to the way care can be delivered which challenges current traditional understandings of direct patient care. Time spent with a patient is not the only important consideration to patient experience in haemodialysis. This understanding of passive care could improve care experiences in this setting.

The role of specialist nurses for organ donation: A solution for maximising organ donation rates?

AIMS AND OBJECTIVES: To explore the role that Donor Transplant Co-ordinators have played and the future potential of Specialist Nurses for Organ Donation (SN-ODs), within organ donation strategies in the UK and other countries. BACKGROUND: Organ donation and transplantation rates vary extensively around the world. However, there is a universal shortage of deceased donors, prompting different approaches to increase transplantation rates. Within the UK, the Clinical Lead for Organ Donation and Specialist Nurse in Organ Donation undertake a key role in the implementation of the Organ Donation Strategy. The Human Transplantation (Wales) Act 2015 is a recent development which facilities a deemed (presumed) consent approach to organ donation, the Specialist Nurse in Organ Donation undertakes a major role identifying the potential donor in this situation by confirming the deemed consent status of the donor and supporting bereaved relatives. UK governments in England and Scotland are currently seeking legislative changes to an opt-out system of organ donation, in line with the Wales change. DESIGN: This discursive paper explores the role from Donor Transplant Co-ordinator to Specialist Nurse in Organ Donation (SN-OD) within organ donation policy in different settings, but with a specific focus on the UK. The paper clarifies the current and future potential of nurses working with bereaved families when requesting authorisation for donation. IMPLICATIONS FOR NURSING: The current scope and future potential of Donor Transplant Co-ordinator and Specialist Nurse in Organ Donation roles need better recognition. Little empirical data exist about the key role that these nurses play in the organ donation process, especially in relation to gaining authorisation to proceed to donation. CONCLUSION: There is a need to clarify the role of the Specialist Nurse in Organ Donation and their impact on improving rates of organ donation.

Understanding nurses' decision-making when managing weaning from mechanical ventilation: a study of novice and experienced critical care nurses in Scotland and Greece.

AIM AND OBJECTIVES: To examine how nurses collect and use cues from respiratory assessment to inform their decisions as they wean patients from ventilatory support. BACKGROUND: Prompt and accurate identification of the patient's ability to sustain reduction of ventilatory support has the potential to increase the likelihood of successful weaning. Nurses' information processing during the weaning from mechanical ventilation has not been well-described. DESIGN: A descriptive ethnographic study exploring critical care nurses' decision-making processes when weaning mechanically ventilated patients from ventilatory support in the real setting. METHODS: Novice and expert Scottish and Greek nurses from two tertiary intensive care units were observed in real practice of weaning mechanical ventilation and were invited to participate in reflective interviews near the end of their shift. Data were analysed thematically using concept maps based on information processing theory. Ethics approval and informed consent were obtained. RESULTS: Scottish and Greek critical care nurses acquired patient-centred objective physiological and subjective information from respiratory assessment and previous knowledge of the patient, which they clustered around seven concepts descriptive of the patient's ability to wean. Less experienced nurses required more encounters of cues to attain the concepts with certainty. Subjective criteria were intuitively derived from previous knowledge of patients' responses to changes of ventilatory support. All nurses used focusing decision-making strategies to select and group cues in order to categorise information with certainty and reduce the mental strain of the decision task. CONCLUSIONS: Nurses used patient-centred information to make a judgment about the patients' ability to wean. Decision-making strategies that involve categorisation of patient-centred information can be taught in bespoke educational programmes for mechanical ventilation and weaning. RELEVANCE TO CLINICAL PRACTICE: Advanced clinical reasoning skills and accurate detection of cues in respiratory assessment by critical care nurses will ensure optimum patient management in weaning mechanical ventilation.

Difficult to wean patients: cultural factors and their impact on weaning decision-making.

AIMS AND OBJECTIVES: To examine the elements of the intensive care environment and consider the impact on nurses' involvement in decision-making when weaning from mechanical ventilation. BACKGROUND: Optimal management of difficult to wean patients requires the dynamic collaboration of all clinicians and the contribution of their knowledge and skills. The introduction of weaning protocols has increased nurses' input in decision-making, but there are various elements of the decision environment that impact on their involvement, which have been given little consideration. DESIGN: Ethnography was used as the research design for this study. METHODS: Fieldwork took place in two tertiary hospitals in Greece and Scotland for five months each to unveil clinicians' behaviour and interactions during the weaning practice. Observation was based on the weaning process of 10 Scottish and 9 Greek long-term ventilated patients. Semi-structured interviews followed with nurses (n = 33) and doctors (n = 9) in both settings to understand nurses' perceived involvement in weaning decision-making. Thematic analysis of interviews and field notes followed using the Qualitative Data Analysis software NVivo. Clinicians' participation was voluntary. RESULTS: The main themes identified were the (1) organisation of the units (time and structure of the ward rounds, staff levels and staff allocation system), (2) the inter- professional relationships, (3) the ownership and accountability in weaning decision-making and (4) the role of the weaning protocols. These elements described the culture of the ICUs and defined nurses' role in weaning decision-making. CONCLUSIONS: Clinical decision-making is a multi-dynamic process specifically in complex clinical situations such as weaning from mechanical ventilation. This paper suggests that weaning practice should be considered in relation to the elements of the clinical environment to provide an individualised and patient-centred weaning approach. RELEVANCE TO CLINICAL PRACTICE: Methods to enhance nurses' role in teamwork and collaborative decision-making are suggested.

A multi-disciplinary approach to medication safety and the implication for nursing education and practice.

BACKGROUND: Medication management is a complex multi-stage and multi-disciplinary process, involving doctors, pharmacists, nurses and patients. Errors can occur at any stage from prescribing, dispensing and administering, to recording and reporting. There are a number of safety mechanisms built into the medication management system and it is recognised that nurses are the final stage of defence. However, medication error still remains a major challenge to patient safety globally. OBJECTIVES: This paper aims to illustrate two main aspects of medication safety practices that have been elicited from an action research study in a Scottish Health Board and three local Higher Education Institutions: firstly current medication safety practices in two clinical settings; and secondly pre and post-registration nursing education and teaching on medication safety. METHOD: This paper is based on Phase One and Two of an Action Research project. An ethnography-style observational method, influenced by an Appreciative Inquiry (AI) approach was adapted to study the everyday medication management systems and practices of two hospital wards. This was supplemented by seven in-depth interviews with nursing staff, numerous informal discussions with healthcare professionals, two focus-groups, one peer-interview and two in-depth individual interviews with final year nursing students from three Higher Education Institutions in Scotland. RESULT: This paper highlights the current positive practical efforts in medication safety practices in the chosen clinical areas. Nursing staff do employ the traditional 'five right' principles - right patient, right medication, right dose, right route and right time - for safe administration. Nursing students are taught these principles in their pre-registration nursing education. However, there are some other challenges remaining: these include the establishment of a complete medication history (reconciliation) when patients come to hospital, the provision of an in-depth training in pharmacological knowledge to junior nursing staff and pre-registration nursing students. CONCLUSION: This paper argues that the 'five rights' principle during medication administration is not enough for holistic medication safety and explains two reasons why there is a need for strengthened multi-disciplinary team-work to achieve greater patient safety. To accomplish this, nurses need to have sufficient knowledge of pharmacology and medication safety issues. These findings have important educational implications and point to the requirement for the incorporation of medication management and pharmacology in to the teaching curriculum for nursing students. There is also a call for continuing professional development opportunities for nurses working in clinical settings.

Expectations and experiences of open abdominal aortic aneurysm repair patients: a mixed methods study.

AIMS AND OBJECTIVES: To establish what patients' expectations of postoperative pain were when undergoing open surgical repair of abdominal aortic aneurysm. A review of the relevant literature highlighted the fact that there had been no such studies conducted within a similar such homogenous group. Therefore, this study aimed to explore pain expectations prospectively and then compare these with the patients' actual experiences. BACKGROUND: It has long been established that high levels of satisfaction with pain management are very often reported in patients despite suffering from severe to moderate levels of pain. The reasons for these high satisfaction levels are not always as clear, although it is suggested that patients have an expectation of postoperative pain. DESIGN: The study set out to establish what expectations of pain patients had and the factors that might influence them within the abdominal aortic aneurysm subject group. A mixed methods approach was used. METHOD: Pain expectations were gathered preoperatively using a Likert scale of pain scoring. These were then compared with the recorded postoperative pain scores. This was followed by a semi-structured interview. RESULTS: The study illustrated that patients expected to have postoperative pain as a natural consequence of their operations. Patients appeared to draw upon their previous experiences. Pain expectation levels were statistically significant, 60% of patients expected to have pain postoperatively. CONCLUSION: This study demonstrated that patients expect to have postoperative pain. Such expectations might influence the individual's relationship and experience of their postoperative management. RELEVANCE TO CLINICAL PRACTICE: The study highlights the need for nurses to evaluate the preoperative information given to patients and to listen to expectations they voice. Patient expectations of pain are sometimes that they expect to have pain, and it is the management of this pain that makes a difference to them.

The experience of interdisciplinary peer-assisted learning (PAL).

BACKGROUND: The importance and benefits of interdisciplinary practice in health care have been well documented. Despite this, few medical schools have developed formal curriculum opportunities for interdisciplinary teaching. Here, as an example of medical and nursing students teaching and learning together, we describe a novel approach to interdisciplinary peer-assisted learning led by students on fluid and electrolyte balance. METHODS: Teaching sessions were developed and led by a collaborative group of fourth-year medical and nursing students, under the supervision of teaching staff. Each session had different stations aimed at encouraging interdisciplinary discussion between students. A pre- and post-event questionnaire was used to determine students' views on interdisciplinary learning and teaching. RESULTS: All students felt that they benefited from the interdisciplinary format of the sessions, and would recommend the sessions to other students. Furthermore, both nursing and medical students reported improvements in their confidence relating to several key domains of managing fluid balance. DISCUSSION: The sessions described provide opportunities for collaboration between medical and nursing students in the planning and delivery of teaching sessions. There are doubtless many other ways in which such interdisciplinary learning could occur, but to date very few have been described in the literature. This example is offered to encourage others to experiment in this important area, to share their experiences and approaches, and to stimulate further debate on the place of interdisciplinary learning and working in undergraduate health care curricula.

Pain management and satisfaction in postsurgical patients.

AIMS AND OBJECTIVES: To examine the relationship between patient satisfaction and the incidence of severe and enduring pain through a health board wide hospital satisfaction questionnaire. BACKGROUND: The incidence and management of acute postoperative pain and its relationship to patient satisfaction have been of great interest to clinicians over the last 20 years. Evidence suggests that despite many moves to address this problem with the advent of acute pain nurse specialists and dedicated pain teams, severe and enduring pain continues to be a problem. However, patients appear to report high satisfaction levels. DESIGN: The study design was a postal questionnaire the results of which were analysed statistically. METHODS: The postal questionnaire was sent to patients who had been discharged from acute hospitals in one health board in the previous two weeks. A total of three large acute hospitals were included. The data were analysed to produce descriptive statistics for all patients on the pain questions and then for patients with severe and enduring pain on the variables of age, gender, ethnic group, responses to pain questions and type of admission. RESULTS: Twenty-six percent of patients reported having pain all or most of the time. Patients suffering from severe and enduring pain were younger females. CONCLUSION: Acute postoperative pain continues to be a problem, although patients continue reporting moderate satisfaction levels. RELEVANCE TO CLINICAL PRACTICE: Acute postoperative pain is an ongoing issue for postsurgical patients. It is crucial to understand and recognise issues that can adversely contribute to increased pain severity.

Routines and rituals: a grounded theory of the pain management of drug users in acute care settings.

AIM: This study reviewed the perceptions and strategies of drug users and nurses with regard to pain management in acute care settings. BACKGROUND: Drug users present unique challenges in acute care settings with pain management noted to be at best suboptimal, at worst non-existent. Little is known about why and specifically how therapeutic effectiveness is compromised. DESIGN: Qualitative: constructivist grounded theory. METHOD: A constructivist grounded theory approach incorporating a constant comparative method of data collection and analysis was applied. The data corpus comprised interviews with drug users (n = 11) and five focus groups (n = 22) of nurses and recovering drug users. RESULTS: Moral relativism as the core category both represents the phenomenon and explains the basic social process. Nurses and drug users struggle with moral relativism when addressing the issue of pain management in the acute care setting. Drug users lay claim to expectations of compassionate care and moralise via narration. Paradoxically, nurses report that the caring ideal and mutuality of caring are diminished. Drug users' individual sensitivities, anxieties and felt stigma in conjunction with opioid-induced hyperalgesia complicate the processes. Nurses' and hospitals' organisational routines challenge drug user rituals and vice versa leading both protagonists to become disaffected. Consequently, key clinical issues such as preventing withdrawal and managing pain are left unaddressed and therapeutic effectiveness is compromised. CONCLUSION: This study provides a robust account of nurses' and drug users' struggle with pain management in the acute care setting. Quick technological fixes such as urine screens, checklists or the transient effects of (cognitive-based) education (or training) are not the answer. This study highlights the need for nurses to engage meaningfully with this perceptibly 'difficult' group of patients. RELEVANCE TO CLINICAL PRACTICE: The key aspects likely to contribute to problematic interactions with this patient cohort are outlined so that they can be prevented and, or addressed.