On-the-Job Ethics – Proximity Morality Forming in Medical School: A grounded theory analysis using survey data...

Hans O. Thulesius, MD, Ph.D. Abstract On-the-job-ethics exist in all businesses and can also be called proximity morality forming. In this paper we propose that medical students take a proximity morality stance towards ethics education at medical school. This means that they want to form physician morality “on the job” instead of being taught ethics like any other subject. On-the-job-ethics for medical students involves learning ethics that is used when practicing ethics. Learning ethics includes comprehensive ethics courses in which quality lectures provide ethics grammar useful for the ethics practicing in attitude exercises and vignette reflections in tutored group discussions. On-the-job-ethics develops professional identity, handles diversity of religious and existential worldviews, trains students described as ethically naive, processes difficult clinical experiences, and desists negative role modeling from physicians in clinical or teaching situations. This grounded theory analysis was made from a questionnaire survey on attitudes to ethics education with 409 Swedish medical students participating. We analyzed over 8000 words of open-ended responses and multiplechoice questions using classic grounded theory procedures, but also compared questionnaire data using statistics such as multiple regression models. The paper gives an example of how grounded theory can be used with a limited amount of survey data. Background Medical ethics is different from other subjects taught at medical school and the importance of formal ethics courses has been questioned (Hafferty & Franks, 1994). Some medical schools combine instruction in bioethical principles with teaching of humanities programs (Andre, Brody, Fleck, Thomason & Tomlinson, 2003). The teaching of ethics varies in Swedish medical schools from interspersed lectures to formal ethics courses. We designed a questionnaire survey in order to elucidate how Swedish medical students view the ethics education in medical schools (Thulesius, Sallin, Lynöe & Löfmark, 2007; Lynöe, Löfmark & Thulesius, 2008). Many students gave input to the ethics course curriculum: Should ethics be taught in lectures or learned through group discussions? Should the ethics course be a separate course among others, or should it be part of other courses with lectures and group discussions interspersed? Should it come early or late in the medical school curriculum? Should the literature be specific ethics literature or novels and short stories with relevant ethical content? From multiple-choice responses we found that strong ethics interest was associated with frequent experiences of physician teachers as good role models and an absence of poor role models (Lynöe et al., 2008). In the present study we wanted to explore what was going on in medical schools regarding the medical ethics education by analyzing open-ended survey responses together with response data from multiplechoice items. Method We constructed a survey on attitudes towards the medical ethics education during 2005 as a request from the delegation of medical ethics of the Swedish Society of Medicine. Swedish medical students from the 1st, 5th and 11th (last) term participated. The survey consisted of 14 items, of which 10 had a total of 59 multiple-choice response options and generous space for open-ended comments, and 4 items were open-ended only, see Table 1. The overall response rate to the questionnaire survey was 36%, and varied between different centers from 13% to 83%, with a total of 409 respondents, 308 women (75%) and 101 men (25%). More than half (220/409) of the respondents gave one or more written open comments amounting to >8000 words. These comments were transcribed into Word from handwritten text. “Walking survey” data from informal interviews with four physicians, of which two has been teaching medical ethics at...

Unprivatizing: A bridge to learning

Virginia Leigh Hamilton Crowe, RN, MS, Ed.D. Jeanne Ellen Bitterman , MA, MA, Ed.D. Abstract Depression is a complicated condition situated in a cultural environment that often impedes learning. The purpose of this grounded theory study was to better understand depression from the perspective of those who are living with depression. Data were collected from many sources including document review and autobiographical literature; however, the primary data were collected through in-depth interviews. Fifteen individuals, thirteen women and two men, who felt they had learned both about and from their depression volunteered to participate in the primary interview process. Analysis of the data generated categories, properties and the core concept of unprivatizing. Through theoretical coding a process of learning about one’s depression emerged which suggests that learning about one’s depression can be experienced as a transitional and meaningmaking process that occurs over an extended period of time and facilitates development. Background The disease of depression remains a great mystery. It has yielded its secrets to science far more reluctantly than many of the other major ills besetting us. (Styron, 1990, p. 11) Depression, or depressive illness, is often referred to as a constellation of disorders that depict a condition or disease which disrupts a person’s mood, behavior, physical well-being, and thought (National Institute of Mental Health Depression Brochure, 2000; O’Connor, 1997; Thompson, 1996). Depressive illness is most often attributed to a complex interaction between physiological, psychological, and sociocultural factors (Mazure, Keita, & Blehar, 2002; Murthy, 2001; Surgeon General’s Report on Mental Health, 1999). Depression is not a rare phenomenon nor is it without significant cost. According to the National Institute of Mental Health (NIMH) (2000), in any given 1-year period, 9.5% of the population will suffer from a depressive illness. The World Health Organization (WHO) notes that major depression presents the greatest burden of disease for women and is a leading cause of disability globally for both males and females (Lopez et al., 2006; Murthy, 2001). In the United States, Major Depressive Disorder (MDD) is a leading cause of disability and produces one of the highest medical costs of all behavioral conditions (Goldman, Nielson, & Champion, 1999; Hasin, Goodwin, Stinson, & Grant, 2005). It is most difficult to calculate the significant personal and family costs associated with depressive illness, specifically given that one of the most indefinable and devastating of these costs is suicide (Dumais et al., 2005; Goldman, Nielson, & Champion, 1999). The Surgeon General’s Report on Mental Health (1999) states that more than 80% of people with depression can be treated successfully with medication, mental health therapy or a combination of both (Goldman, Nielson, & Champion, 1999; Mazure, Keita, & Blehar, 2002; Murthy, 2001; O’Connor, 1997). The difficulties dealing with depression include the underdiagnosis and cultural stigma associated with mental illness; the complex interaction between physiological, psychological, and sociocultural factors; and the numerous yet often elusive and compounding contributors and triggers to depressive episodes. Thus, to become aware of, acknowledge, and continue learning about depression and how it interacts with one’s life are daunting tasks (Beck, Tush, Shaw, & Emery, 1979; Burns, 1999; O’Connor, 1997). And while much is known about what the experts believe is important to teach the depressed individual (Beck, Tush, Shaw, & Emery 1979; Burns, 1999; O’Connor, 1997), little is known or understood about the essential process of learning about depression from the perspective of those living with and learning about their own depression. The purpose of this study was to explore the experiences...

The Constant Comparative Method of Qualitative Analysis...

[This paper was originally published in Social Problems, 12(1965), pp. 436-45 and later as Chapter V in Glaser, B.G. & Strauss, A.L. (1967). The Discovery of Grounded Theory: Strategies fro qualitative research. New York: Aldine DeGruyter.] Barney G. Glaser, Ph.D. Currently, the general approaches to the analysis of qualitative data are these: 1.) If the analyst wishes to convert qualitative data into crudely quantifiable form so that he can provisionally test a hypothesis, he codes the data first and then analyzes it. He makes an effort to code “all relevant data [that] can be brought to bear on a point,” and then systematically assembles, assesses and analyzes these data in a fashion that will “constitute proof for a given proposition.”i 2.) If the analyst wishes only to generate theoretical ideasnew categories and their properties, hypotheses and interrelated hypotheses- he cannot be confined to the practice of coding first and then analyzing the data since, in generating theory, he is constantly redesigning and reintegrating his theoretical notions as he reviews his material.ii Analysis with his purpose, but the explicit coding itself often seems an unnecessary, burdensome task. As a result, the analyst merely inspects his data for new properties of his theoretical categories, and writes memos on these properties. We wish to suggest a third approach to the analysis of qualitative data- one that combines, by an analytic procedure of constant comparison, the explicit coding procedure of the first approach and the style of theory development of the second. The purpose of the constant comparative method of joint coding and analysis is to generate theory more systematically than allowed by the second approach, by using explicit coding and analytic procedures. While more systematic than the second approach, this method does not adhere completely to the first, which hinders the development of theory because it is designed for provisional testing, not discovering, of hypotheses.iii This method of comparative analysis is to be used jointly with theoretical sampling, whether for collective new data or on previously collected or compiled qualitative data. Systematizing the second approach (inspecting data and redesigning a developing theory) by this method does not supplant the skills and sensitivities required in generating theory. Rather, the constant comparative method is designed to aid the analyst who possesses these abilities in generating a theory that is integrated, consistent, plausible, close to the dataand at the same time is in a dorm clear enough to be readily, if only partially, operationalized for testing in quantitative research. Still dependent on the skills and sensitivities of the analyst, the constant comparative method is not designed (as methods of quantitative analysis are) to guarantee that two analysts working independently with the same data will achieve the same results; it is designed to allow, with discipline, for some of the vagueness and flexibility that aid the creative generation of theory. If a researcher using the first approach (coding all data first) wishes to discover some or all of the hypotheses to be tested, typically he makes his discoveries by using the second approach of inspection and memo-writing along with explicit coding. By contrast, the constant comparative method cannot be used for both provisional testing and discovering theory: in theoretical sampling, the data collected are not extensive enough and, because of theoretical saturation, are not coded extensively enough to yield provisional tests, as they are in the first approach. They are coded only enough to generate, hence to suggest, theory. Partial testing of theory, when necessary, is...

Anticipatory Caring

[This paper was originally published as Sandgren, A., Thulesius, H., Petersson, K. & Fridlund, B. (2007). Doing good care ? A study of palliative home nursing care. International Journal of Qualitative Studies on Health and Well-Being, 2:4, 227-235 and is reprinted here with the permission of the publisher] Anna Sandgren, RN, MSc, PhD Candidate; Hans Thulesius, MD, PhD; Kerstin Petersson, RNT, PhD; Bengt Fridlund, RNT, PhD Abstract Today, more and more people die in own homes and nursing homes, which fundamentally affects community nursing. The aim of this study was to develop a grounded theory of palliative home nursing care and we analyzed interviews and data related to the behavior of community nurses caring for palliative cancer patients. Doing Good Care emerged as the pattern of behavior through which nurses deal with their main concern, their desire to do good care. The theory Doing Good Care involves three caring behaviors; anticipatory caring, momentary caring and stagnated caring. In anticipatory caring, which is the optimal caring behavior, nurses are doing their best or even better than necessary, in momentary caring nurses are doing best momentarily and in stagnated caring nurses are doing good but from the perspective of what is expected of them. When nurses fail in doing good, they experience a feeling of letting the patient down, which can lead to frustration and feelings of powerlessness. Depending on the circumstances, nurses can hover between the three different caring behaviors. We suggest that healthcare providers increase the status of palliative care and facilitate for nurses to give anticipatory care by providing adequate resources and recognition. Introduction The demographics of dying have changed with more people dying at home or in nursing homes. The number of hospital beds has declined and homecare has increased, and more own home deaths are expected in the future (Burge, Lawson & Johnston, 2003; Higginson, Astin & Dolan, 1998; Socialstyrelsen, 2006). The extension of palliative care varies in different parts of Sweden (Socialstyrelsen, 2006) and fewer hospital beds increases the strain for both acute hospital care and homecare (Fürst, 2000). The acute hospital care has a high pace and a “culture of quickness” (Andershed & Ternestedt, 1997) and this high pace was found to be one explanation to why nurses suffered emotional overload while caring for palliative cancer patients in acute hospitals (Sandgren, Thulesius, Fridlund & Petersson, 2006). In the contrast to the high pace in the acute hospitals, the hospice philosophy has a “culture of slowness” (Andershed & Ternestedt, 1997) and it has thus been suggested that the hospice philosophy should be spread to all care settings with dying people (Clark, 1993). At the same time, it has been proposed that palliative care should be available wherever the patient is. In addition, the patients and their families should receive the same standard of care irrespective of domicile and source of service delivery (Dunne, Sullivan & Kernohan, 2005; SOU, 2001). In homecare, the community nurses have a central position (Wright, 2002), but their work is in a way an invisible work, predominantly conducted in the patients’ homes (Goodman, Knight, Machen & Hunt, 1998; Luker, Austin, Caress & Hallett, 2000). Community nursing has shown to offer stimulation and appreciation, especially from patients and relatives, but also a possibility for nurses to use all their professional skills (Dunne et al., 2005; Goodman et al., 1998). However caring for palliative cancer patients in their homes has also been shown to be stressful (Berterö, 2002; Dunne et al., 2005), emotionally...

Navigating New Experiences: A basic social process...

Kara L. Vander Linden, Ed.D. Abstract This grounded theory study was initiated to discover the process adult learners go through when engaging in new learning experiences. Data came from 12 open-ended intensive interviews with adult learners involved in various educational endeavors. Theoretical sampling led to several additional interviews with individuals not engaged in post-secondary education but more generally in new learning experiences. The basic social process of navigating explains three cyclical stages of behaviors used to successfully traverse new experiences. The stages are Mapping, Embarking, and Reflecting. Mapping consists of three behaviors: locating, assessing one’s location in relation to the goal; surveying, gathering information; and plotting, creating a plan. Embarking involves engaging in normalizing and strategizing behaviors to guide one’s self through the experience while encountering unexpected factors that influence one’s course and progress. Reflecting techniques and approaches are discussed in the third stage. Although providing an understanding of the process and behaviors used by adult learners, the theory is also applicable in other settings. Introduction One cannot go through life without encountering new experiences. While at times people find themselves in experiences of no choice of their own, many new experiences are entered voluntarily. One such experience is adults returning to college classrooms to continue their education. Today, more than at any other time in history, adults are returning to the college classroom to continue their education. These adult learners are referred to as “nontraditional” and are characterized by “one or more of the following characteristics: not a high school graduate; did not enroll in an institution of higher education directly after high school; are attending part-time; are working full-time; or are financially independent, married, or have dependents” (Wolanin, 2003, p 7). While adult learners have prior experience in education, many factors and conditions of adult life make the experience very different than their earlier experiences. These factors and conditions also contribute to lower retention rates. As Bosworth et al. (2007) reported, “Financially independent, working full time, with dependents and family responsibilities to juggle, and back in school after an extended time out—adult learners are at great risk of not achieving their postsecondary education goals” (p. 8) . There is substantial research and numerous theories and models on adult education and learning. Research repeatedly categorizes the challenges faced by adult learners into four general categories: accessibility, affordability, lack of time and other responsibilities, such as family and/or job responsibilities (Merriam, S. & Caffarella, R., 1999; Bosworth et al., 2007). Research has also suggested and studied strategies to increase learner retention and degree achievement. These strategies primarily address the issues of accessibility and affordability. While education institutions are making strides in these areas, there is a dearth of research on strategies for addressing the categories of lack of time and other responsibilities faced by adult learners. Although outside the control of educational institutions, these issues still affect adult learners’ success in reaching their goals. As an instructor and mentor of adult learners, I have little control over the four categories of factors that affect the retention and degree achievement of adult learners. Despite this lack of control over, part of my job is to help adult learners be successful. Often this means helping them succeed in spite of these factors. A desire to understand the learning experiences of adults and the challenges they face from their perspective provided the original area of interest and starting point for this study which was conducted for my dissertation. Classic grounded theory (GT)...