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Pluralistic task shifting for a more timely cancer diagnosis: A grounded theory study from a primary care perspective...
Hans Thulesius, Ulrika Sandén, Davorina Petek, Robert Hoffman, Tuomas Koskela, Bernardino Oliva-Fanlo, Ana Luisa Neves, Senada Hajdarevic, Lars Harrysson, Berit Skjodeborg Toftegaard, Peter Vedsted, Michael Harris,The Örenäs Research Group, Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland [1] Key words: Cancer, diagnosis, primary care, grounded theory, screening, qualitative data Abstract Objective: To explore how cancer could be diagnosed in a more timely way. Design: Classic grounded theory analysis of primary care physicians’ free text survey responses to: “How do you think the speed of diagnosis of cancer in primary care could be improved?” and secondary analysis of primary care physician interviews, survey responses, literature. Setting: Primary care in 20 European Örenäs Research Group countries. Subjects: Primary care physicians: 1352 survey respondents (2013-2016), 20 Spanish and 7 Swedish interviewees (2015-2019). Main outcome measures: Conceptual explanation of how to improve timeliness of cancer diagnosis. Results: Pluralistic task shifting is a grounded theory of a composite strategy. It includes task sharing – among nurses, physicians, nurse assistants, secretaries and patients – and changing tasks with cancer screening when appropriate or cancer fast-tracks to accelerate cancer case finding. A pluralistic dialogue culture of comprehensive collaboration and task redistribution is required for effective pluralistic task shifting. Pluralistic task shifting relies on cognitive task shifting, which includes learning more about slow analytic reasoning and fast automatic thinking initiated by pattern recognition; and digital task shifting, which by use of eHealth and telemedicine bridges time and place and improves power symmetry between patients, caregivers and clinicians. Financial task shifting thatinvolvescost trackingfollowed byreallocation of funds is necessary for the restructuring and retraining required for successful pluralistic task shifting. A timely diagnosis reduces expensive investigations and waiting times. Also, late-stage cancers are costlier to treat than early stage cancers. Timing is central to cancer diagnosis: not too early to avoid overdiagnosis, and never too late. Conclusions: We present pluralistic task shifting as a conceptual summary of strategies needed to optimise the timeliness of cancer diagnosis. Key Points Cancer diagnosis is under-researched in primary care, especially theoretically. Thus, we analysed and conceptualised the field using classic grounded theory: Pluralistic task shifting is a conceptual explanation of how the timeliness of cancer diagnosis could be improved, with data derived mostly from primary care physicians. This includes task sharing and changing tasks including screening and cancer fast-tracks to accelerate cancer case finding, and requires cognitive task shifting emphasising learning, and digital task shifting involving the use of eHealth and telemedicine. Financial task shifting with cost tracking and reallocation of funds is eventually necessary for successful pluralistic task shifting to happen. Introduction Diagnosing cancer is heterogeneous, in that it depends on disease type, age, gender, socioeconomic and geographical context, and type of healthcare system (1-3). Some cancers, such as breast cancer, colorectal cancer and prostate cancer, may be detected by screening in an early asymptomatic phase of the disease (4). However, the majority of cancers are discovered by case finding: symptoms and signs of the cancer are assessed through consultations with health care professionals (5) and most cancer patients are first seen by a primary care physician (1,2). Work-up of a cancer diagnosis often requires several different assessment methods, which may or may not include a physical examination (5). These are followed by technical procedures which include diagnostic imaging techniques and blood tests (2). A histological examination of body tissue or cells ultimately confirms the cancer diagnosis, except for some late-stage cancers, often in the elderly, which may only be discovered by diagnostic imaging or at autopsy (6). Many countries have introduced fast-track systems for detecting cancer that...De-shaming for believability: A Grounded Theory of physicians’ communication with patients about adherence to HIV medication in San Francisco and Copenhagen...
Toke S. Barfod, MD PhD [1] Abstract To be “adherent” to a medication means to take the medicine as agreed upon. Poor adherence is the main barrier to the effectiveness of HIV medication. Communication between patient and physicians is a major factor in adherence. We found that this communication is very often awkward and superficial, if not completely lacking. According to the proposed theory, it is a core determinant of adherence communication whether or not physicians use a “de-shaming” communication strategy. When physicians do not, they receive answers with low believability, and may even abstain from exploring the possibility of non-adherence. Furthermore, physicians have difficulty in handling low believability of patient statements, and their more or less beneficial strategies may have negative consequences for the relation between patient and physician, and for the patient’s adherence. The here proposed theory “de-shaming for believability” suggests that communication with patients about adherence can be understood as four steps governed mainly by three factors. The four steps are: deciding whether to ask about adherence or not, pre-questioning preparations, phrasing the question, and responding to the patient’s answer. The three factors/determinants are: the communicator’s perceptions of adherence, awkwardness, and believability. Introduction Background: HIV Treatment and Adherence When patients take their medication as agreed upon, they are said to “have good adherence” (Osterberg & Blaschke, 2005). However, patients often have poor adherence (Osterberg & Blaschke, 2005), and especially in HIV treatment, it is one of the main causes of treatment failure (Osterberg & Blaschke, 2005; Wood, et. al, 2004; Dybul et.al., 2002). HIV treatment requires good adherence in order to maintain maximum treatment efficacy and avoid that the HIV virus mutates and becomes resistant to treatment (Osterberg & Blaschke, 2005; Wood, et. al, 2004; Dybul et.al., 2002). Still, around one fourth of patients have poor adherence to HAART (Wood et. al., 2004; Barfod et.al., 2005). Several factors are related to poor adherence, especially patient-related factors such as depression, abuse, and weak social support, but also regimen complexity, patient’s lack of trust in the treatment, and poor patient-physician relations (Barfod et.al., 2005; Fogarty et. al., 2002). When looking at physician factors, we find that experienced physicians achieve better patient adherence (Delgado et.al., 2003), and that trusting patient-physician relations (Heckman et.al., 2004; Mostashari et. al., 1998) and open communication (Schneider et. al., 2004) are associated with better adherence to HAART. In interviews, patients also stress that communication with physicians is important in maintaining adherence to HAART (Roberts, 2002) as well as other diseases (Osterberg & Blaschke, 2005; Cox et. al., 2004). Accordingly, guidelines for treating patients with HAART recommend that adherence be addressed at all follow-up visits to prevent treatment failure (Dybul et.al., 2002; Poppa et. al., 2004). The majority of physicians dealing with HIV also report that they do so (Roberts & Volberding, 1999; Gerbert et.al., 2000; Roberts, 2000; Golin et.al., 2004). Physicians’ communication with patients about adherence to HAART can, however, be problematic. In descriptive questionnaire and interview studies physicians have identified lack of time and resources, as well as their own lack of training as the main barriers to their communication with HIV-positive patients about adherence (Gerbert et.al., 2000; Roberts, 2000; Golin et.al., 2004). Furthermore, a recent systematic review has concluded that two-way discussions and partnership in treatment decisions regarding medicine-taking in general most likely seldom take place(Cox et. al., 2004). To our knowledge, no observational study exploring physicians’ communication with patients about adherence to HAART has been done and no analytical...Surviving Situational Suffering: A classic grounded theory study of post-secondary part-time educators in the United States...
Barry Chametzky Abstract Administrators at post-secondary institutions in the United States hire contingent faculty members to teach a great many classes. It is therefore valuable to understand what the issues are for these on-demand, non-tenured faculty members. The theory of surviving situational suffering explains how part-time adjunct educators in the United States resolve their main concern—maintaining employment—within a context of reduced appreciation, underutilization, and ingratitude. Just as with various historical events now considered discriminatory, the theory explores a form of bias and intolerance in higher education that needs to be openly discussed and addressed. The theory consists of three broad categories: (a) limiting, (b) balancing conflict, and (c) falling short. Though the substantive area is post-secondary educational institutions, the ideas presented in this paper are easily generalizable to other areas in life whenever someone is trying to survive situational anxieties. Introduction As an on-demand faculty member at a post-secondary school, I knew that when I started this research, the topic would hit close to home. I also realized that I had preconceptions and feelings stemming from my educational experiences as a part-time adjunct educator. Yet, by being true to the tenets of classic grounded theory, I treated those positive and negative feelings as additional elements of data (Glaser, 2007). Numerous reasons exist to explain why some people choose to work as contingent adjunct educators. For some people, being an adjunct is convenient, as they need to be able to deal easily with family or personal issues. Because of this flexibility, the idea to keeping a professional foothold in education has value and appeal. Other instructors, including this researcher, enjoy bonding with learners inside and outside of the class environment and feel that they are making an impact. Still other people feel that teaching is more than a job; it is a calling. For many people, being an educator is a privilege of which the students are the most important part. There exists nothing higher than to be able to influence the course learners and how they perceive the subject. While these worthwhile reasons are noble, a darker side exists to being a part-time adjunct educator. The purpose of this classic grounded theory study is to examine what it is like being an on-demand instructor at post-secondary U.S. schools. According to one participant, this research is “a conversation that needs to be had.” Data Gathering and Analysis In order to “instill a spill” (Glaser, 2009, p. 22), I conducted interviews with 11 participants (three male, eight female) and asked the following grand tour question (Spradley, 1979): What is it like being an on-demand adjunct in the US? Through the iterative classic grounded theory process of coding, memoing, sorting, conceptualization, and constant comparison (Glaser, 1965), and with suspended preconception (to the extent possible [Simmons, 2011]), I discovered the theory of surviving situational suffering; it explains how contingent educators resolve their main concern—maintaining employment—within a context of reduced appreciation, underutilization, and ingratitude. No theory exists in isolation. It was important, therefore, to situate it within the context of extant literature. As such, when I explained the theory, I was able to use extant literature to support its key elements. The Theory of Surviving Situational Suffering The theory of surviving situational suffering consists of three categories: limiting, balancing conflict, and falling short. Because of the continual cause-effect and conditional relationship that exists in the theory, the categories have a strong interdependency that permits people to move from the beginning to...‘The system was blinking red’: Awareness Contexts and Disasters
Vivian B. Martin, Central Connecticut State University, USA Abstract The awareness context has been a source of inspiration for grounded theories for more than 50 years; yet little has been done to extend the theory beyond nursing and the medical field, and a few works on identity. This paper extends the awareness context by examining its role in several high-profile disasters, natural and man-made, where gaining a clear sense of what was going on was often blocked by poor information flow and general communication failures, interpersonal and technological. Selective coding and the introduction of new concepts after analyzing hundreds of pages of documents issued by special commissions in the aftermath of the 9/11 attacks, Hurricane Katrina, the Deepwater Horizon oil spill in the Gulf, and the Sago Mine Disaster not only explain various processes around awareness in the midst of crisis, but also illuminate pre-crisis patterns that, if attended, could have mitigated the impact of the disasters. Keywords: Awareness context, crisis communication, sociology of disaster, situational awareness, 9/11 attacks, Hurricane Katrina, Deepwater Horizon explosion, Sago Mine Disaster. Introduction Whether it is in personal interactions, professional life, or community activities, we are always communicating and processing information. Some of this information is innocuous and of no immediate consequence, while other information may have direct bearing on our wellbeing, that of our families, or colleagues. In such high stakes situations, it is important to have immediate access to information that is complete and credible. Seen from this perspective, Glaser and Strauss’s awareness context (1964, 1965) addresses a fundamental communication process of everyday life. We move in and out of awareness contexts throughout daily life. The identification of a typology of awareness in which interactions among health professionals and patients are shaped by whether a patient is aware of a terminal diagnosis was a critical intervention in nursing and medical studies, and continues to be a starting point for much research (Andrews & Nathaniel, 2010). The subject—dying—and discipline in which this theory has been embedded and extended across numerous illnesses and concerns may mask the essential work of the awareness context as a theory about the managing and sharing of information, a concern throughout organizations and institutions. Of course, the awareness context has not been limited to health issues. The role of identity and the interactions that occur when people are uncertain of the identify of another is highlighted in the American Sociological Review article Glaser and Strauss (1964) published prior to the release of Awareness of Dying; Ekins’s (1997) work on cross-dressing is a successful extension of the awareness context into this realm. But awareness as a concept offers many more possibilities for explaining phenomena that impede the distribution of critical communication across many spheres. This paper extends the awareness context by examining its role in several high-profile disasters, natural and man-made, where gaining a clear sense of what was going on was often blocked by poor information flow and general communication failures, interpersonal and technological. Selective coding and the introduction of new concepts from analyzing hundreds of pages of documents issued by special commissions in the aftermath of the 9/11 attacks, Hurricane Katrina, the Deepwater Horizon oil spill in the Gulf, and the Sago Mine Disaster not only explain various processes around awareness in the midst of crisis, but also illuminate pre-crisis patterns which, if attended, could have mitigated the crises. The awareness context becomes an important contribution to crisis communication and organizational communication. Concepts such as abridging...A Novice Researcher’s First Walk Through the Maze of Grounded Theory: Rationalization for Classical Grounded Theory...
Gary L. Evans, Liverpool John Moores University Abstract Being new to grounded theory the onus to understand the methodology and the various versions can be daunting. Learning and understanding the differences between grounded theories methodologies can be as much a learning of one’s own research philosophy and this philosophy is often the deciding factor in methodology selection. Learning the different methodologies is a difficult journey as terminology often sounds similar to the novice researcher, but only by exploring the differences can the researcher rationalize their own choice. This paper offers the new researcher a view into the confusing world of grounded theory, where common terms are used but the secret lies in understanding the philosophy of the researcher and the topic of discovery. Glaser was correct, the answer is in the data, but you need to understand the philosophy of the method and if it matches your philosophy of research. Theoretical Framework Grounded theory, developed by Barney Glaser and Anselm Strauss in the early 1960s, is a methodology for inductively generating theory (Patton, 1990). Glaser’s definition of grounded theory is “a general methodology of analysis linked with data collection that uses a systematically applied set of methods to generate an inductive theory about a substantive area” (Glaser, 1992, p. 16). While this definition is accepted by researchers, the approach and rigor in the data collection, handling and analysis created differences between Glaser and Strauss. Strauss developed a more linear approach to the research methodology (Strauss & Corbin 1990). Grounded theory is not new to business research and Mintzberg emphasized the importance of grounded research for qualitative inquiry within organization settings: “measuring in real organizational terms means first of all getting out, into real organizations. Questionnaires often won’t do. Nor will laboratory simulations… The qualitative research designs, on the other hand, permit the researcher to get close to the data, to know well all the individuals involved and observe and record what they do and say” (Mintzberg, 1979, p. 586). As grounded theory became more popular for researchers, the substantial divide between the creators of the methodology was apparent. The two original authors reached a diacritical juncture on the aims, principles, and procedures associated with the implementation of the method. Two paths emerged, and these are marked by Strauss and Corbin’s 1990 publication, Basics of Qualitative Research: Grounded Theory Procedures and Techniques, towhich Glaser responded harshly with accusations of distortion of the central objectives of parsimony and theoretical emergence (Glaser, 1992). Glaser’s views were supported by other grounded theory researchers who agreed that the late Strauss’ 1990 publication was an erosion of the original 1967 methodology (Stern, 1994). During the years since the opening of the debate on grounded theory, a number of researchers have firmly supported the classic grounded theory methodology CGT (Bowen 2005; Clark & Lang 2002; Davis 1996; Efinger, Maldonado & McArdie 2004; Holton 2007; Schreiber 2001). Various scholars have put forward a range of strategies and guidelines for the coding process (Charmaz 2006; Goulding 2005; Partington 2002; Patton 2002; Strauss & Corbin 1990, 1998). The process and methods for coding have created the highest level of debate for users of grounded theory. Some researchers have combined quantitative and qualitative forms of data collection when using grounded theory. And while nothing prohibits such combination, the purpose needs to be clear, otherwise a muddling of the methodology will occur (Baker, West & Stern 1992; Wells, 1995). While the coding process is an important part of grounded theory, over-rigid...