Embodied Revelation: A Classic Grounded Theory of Heart Failure Patient Decision Making Surrounding Primary Prevention Implantable Cardioverter Defibrillator Therapy...

Vera Barton-Caro Ph.D., Wheeling Jesuit University, USA Abstract The purpose of this classic grounded theory study was to explain the complex decision making process of heart failure (HF) patients considering primary prevention implantable cardioverter defibrillator (ICD) therapy. Sudden cardiac death (SCD) is the leading cause of death for people with HF as well as the primary cause of death in the United States (US). ICDs represent the standard of care as the only effective therapy for primary prevention of SCD. However, a significant proportion of qualifying HF patients declines this invasive, yet life-saving device. The grounded theory is of Embodied revelation. The threat of SCD for ICD candidates consists of four stages: living in conscious denial, heightening of awareness, sanctioning ICD therapy, and living in new assurance. The first stage ends abruptly with the critical juncture of grasping the threat of SCD. This grounded theory has implications for research, nursing and medical practice, as well as bioethical considerations. Keywords: Heart Failure; Implantable Cardioverter Defibrillators; Patient Decision Making. Introduction Heart failure (HF) is a severe, chronic condition characterized by high mortality and high morbidity (American Heart Association, 2010). Unlike many other cardiovascular conditions, the incidence of HF is increasing; approximately 5.8 million people in the United States (US) have HF (Mozaffarian et al., 2015). Sudden cardiac death (SCD), the result of a lethal arrhythmia, is the leading cause of death for people with HF as well as the primary cause of death in the US (Mozaffarian et al., 2015). The number of people who die each year from SCD approximates the deaths from Alzheimer’s, firearm assaults, breast cancer, cervical cancer, colorectal cancer, diabetes, HIV, house fires, motor vehicle accidents, prostate cancer and suicides combined (Sudden Cardiac Arrest Foundation, 2015). Primary prevention ICDs represents the standard of care as the only effective therapy to prevent SCD in people with HF (Bardy et al., 2005; Echt et al., 1991; Moss et al., 2002; Yancy et al., 2013). Contemporary ICDs, metallic devices similar to pacemakers, are surgically implanted underneath the skin usually in the chest area. These devices aim to detect lethal arrhythmias and emit an electrical shock that aborts the arrhythmia. Primary prevention therapies are aimed at preventing a first occurrence. Secondary prevention refers to therapies that prevent a disease or event from recurring or exacerbating (van Welsenes et al., 2011). In the case of ICDs, secondary prevention devices are implanted in patients who have already demonstrated potentially lethal ventricular arrhythmias by surviving such an event or having had an inducible ventricular arrhythmia demonstrated by an electrophysiologic study. Those patients offered a secondary prevention ICD have already survived SCD. Prior to 2002, ICDs were implanted only for secondary prevention. Based on landmark trials demonstrating significantly improved survival from SCD, ICDs now represent a class IA recommendation as primary prevention for all patients with systolic HF deemed high risk for lethal tachyarrhythmias defined as a left ventricular ejection fraction (LFEF) of 35% or less on optimal pharmacologic therapy (Bardy et al.; Duray, Israel, & Hohnloser, 2006; Moss et al., 2002). Factors influencing patient decision making about primary prevention ICDs could be significantly different than issues involving secondary devices. These patients are asked to consider a potentially burdensome, yet life-saving therapy. The problem that this investigation addresses is a significant proportion of qualifying HF patients who are at risk for life-threatening arrhythmias decline ICD therapy (Gravelin et al., 2011; Hernandez et al., 2007; Lakshmanadoss et al., 2011; LaPointe et al., 2011; Ruskin, Camm, Zipes,...

Momentary Contentment A Modern Version of an Old Survival Culture

Ulrika Sandén, Lars Harrysson, and Hans Thulesius, Lund University, Sweden Abstract This is a classic grounded theory based in longitudinal data from everyday life in an environment in Northern Norway characterized by long distances, a harsh climate and people living close to nature and each other. The place has a history of poverty and isolation. Yet, old survival strategies prevail despite modernisation. The theory reveals a culture of momentary contentment with three dimensions: Doing safety, destiny readiness and middle consciousness. This momentary contentment culture explains how the participants resolve their main concern of enjoying life. Doing safety means that common and individual acts create stability. Destiny readiness illuminates a discourse of acceptance, a way of thinking that, with the aid of linguistic strategies, prepares for life changing events. Middle consciousness shows a way of handling difficulties by dividing and separating different phenomena. Keywords: contentment, Grounded Theory, time, safety, happiness, altruism, hope Introduction How is everyday life organized in an environment characterized by long distances, harsh climate and people being close to nature and each other? The first author had moved far away to such a place in Northern Norway and was struck by the special life approach of people living there. Before the Second World War this was an isolated place and the sea route was the only way to connect with other villages. Everyday life then included fishing boats perishing in the ocean storms as well as tuberculosis and other diseases on shore. This harsh environment called for different strategies for both physical and psychosocial survival. Isolation created a need for mutual help as well as functional relationships with both internal worries and external dangers. Eventually the fishing boats got safer, tuberculosis controlled and after the war a country road was built to connect with other villages (Bottolfsen, 1995; Rortveit, 2008). Accidents and deaths decreased significantly. Even so, our data suggests that to this day, much because of nature’s capriciousness, life’s natural course is seen as unpredictable. To find out what was going on in everyday life the authors chose to do a grounded theory based on years of observations—first unstructured and later more formalized. This article is based on a master thesis done by the first author. Method and material The data consists of interviews, conversations and notes from observations of everyday life from 2010 to 2014. Before the study began, in December 2012, the notes were written in the form of diary entries and journalistic notes. The first author conducted a total of six focus groups and eight individual unstructured and semi-structured interviews that lasted between 2-6 hours each. In order to capture views of their everyday lives the informants were asked to freely talk about their experiences. In some of the later interviews, questions pertaining to the emerging theory were asked. The first author also gathered field notes from 15 conversations targeted towards the thesis and 50 informal, semi-structured conversations. In alignment with the classic grounded theory maxim “all is data” (Glaser, 2010) all research notes, diary entries and journalistic notes were discussed between the authors and included in the circular analytic process. Theoretical Sampling New decisions regarding data collection were made after each interview (Glaser, 1978). The first author started with interviewing elderly in groups of three with the only question “please tell me about your lives”. This was a way to collect data from what they said, how they said it, and what they chose not to talk about. She then went on...

Utilizing Grounded Theory to Enhance: the Education of Graduate Clinical Social Work Field Students...

J. Christopher Hall, College of Health and Human Services, University of North Carolina at Wilmington Abstract Recently, Glaser (2014) wrote that there is little in the literature regarding the varied ways in which grounded theory (GT) can be applied, stating that the exploration of the application of GT “is a vital topic for our profession and ourselves” (p. 1). This article presents the first published discussion on how GT can be used in social work field education to enhance learning and interpersonal awareness of graduate students. All is data is a well-known mantra of GT and in this research, student field journals are read monthly, coded, and themes conceptualized and shared with students to assist in joint learning and reflection of common experiences. The GT research process used for field pedagogical purposes is shared in the hopes that it may serve as a guide for others and the themes emerging from the research are presented. Keywords: Social Work Field Education, Social Work Grounded Theory, Social Work Education Research. Introduction Recently, Glaser (2014) wrote that there is little in the literature regarding the varied ways in which grounded theory (GT) can be applied, stating that the exploration of the application of GT “is a vital topic for our profession and ourselves” (p. 1). After an extensive literature review, this article presents the first published discussion on how GT can be used in field education to enhance learning and interpersonal awareness of graduate students. For the past ten years, I have been teaching clinical practice and field courses to second-year social work graduate students. For two hours each week, I meet with twelve students to discuss their field internship experiences, how they are acclimating to their agencies, their successes and challenges with clients, and how they are personally and professionally changing based on these experiences. As part of my field course they are to turn in a five to six-page journal once per month describing experiences and reflecting upon events relevant to their learning and growth as social work practitioners. The grading of these journals has always been a bit troubling to me because, when done correctly, a journal is a private place to process ideas, feeling, and events that have been personally and professionally impactful. I have felt that the process of critiquing their journals never felt right, much less helpful, and certainly got in the way of the students feeling free enough to openly process their experiences. If students are thinking about my grading when they are writing their journals, then it directly affects the expression of their real feeling and experiences. The problem for me as a professor was how to include a very pedagogically sound assignment like a field journal in the course while reviewing it in a manner that doesn’t overly influence the writer to the extent that it ceases to be a true reflection and becomes more of an exercise in telling the teacher whatever is thought will receive a good grade. After much thought, two ideas came to mind to answer this question. First, it seemed extremely helpful to student learning if my role as a professor could be to help them pull themes from their journals so that these themes could be discussed. Second, it would be helpful if the class journals could be compared and common emerging themes across all journals could be discussed. These commonly experienced themes could then be brought back to the class in a confidential way so that...

About the Authors

Tom Andrews, Ph.D., is a Lecturer in Nursing at Brookfield Health Science Complex, University of Cork, Ireland, specialising in critical care.  Andrews lectures in research methods on post-graduate courses and supervises a number of PhD students using classic GT.  He has conducted a number of classic grounded theory troubleshooting seminars alone and in collaboration. He is a fellow of the GT Institute and publishes in a number of journals. His research interests are around worsening progressions whatever the context. Email: t.andrews@ucc.ie Vera Barton-Caro, Ph,D., is an Assistant Professor of Nursing at Wheeling Jesuit University (WJU). She maintains a part time clinical practice as a nurse practitioner.  She has been a researcher and educator for the implantable cardiac device industry, and has a special interest in patient decision making.  She is a national speaker and past president of The American Association of Heart Failure Nurses.  Vera received her undergraduate and graduate degrees from WJU, and her Ph.D in nursing from West Virginia University. Academic awards include the St. Ignatious of Loyola award for outstanding alumnus from WJU, and the Anna Mary Miller Scholarship for outstanding PhD student from WVU. She was awarded the State Award for Excellence form the American Academy of Nurse Practitioners. Email: vbarton-caro@wju.edu Brett B. Chulu earned his undergraduate degree from the University of Zimbabwe and his Master of Business Administration from the National University of Science and Technology in Zimbabwe. He has practiced as a management consultant in Botswana and Zimbabwe since 2008. He worked as a senior consultant for Global Consult, a premier management consultancy firm in Botswana. He later returned to Zimbabwe to work as an independent strategy consultant. In Zimbabwe he has consulted to both for-profit and not-for profit organisations in the areas of strategy and operational systems. Brett penned over 150 articles in a weekly column for a leading Zimbabwean business weekly publication. He has a keen observer of the development and spreading of Africa’s mobile phone money transfer innovation, which he hopes to formally pursue as a Ph.D study using classic grounded theory methodology. Email: brettchulu@consultant.com Barney G. Glaser is the cofounder of grounded theory (1967). He received his PhD from Columbia University in 1961. He then went to University of California San Francisco, where he joined Anselm Strauss in doing the dying in hospitals study and in teaching PhD and DNS students methods and analysis. He published over 20 articles on this research and the dying research. Since then, Glaser has written 14 more books using and about grounded theory and countless articles. In 1998 he received an honorary doctorate from Stockholm University. Email: bglaser@speakeasy.net Christopher Hall, Ph.D., LCSW is an Associate Professor at the University of North Carolina at Wilmington where he teaches graduate social work practice, clinical lab, and field. Chris’ scholarship and research focuses on ways to enhance learning in the classroom, how to use research to inform clinical counseling, the ethics of counseling, and expanding the use of research in education. Chris has given presentations and trainings on clinical practice modalities, the client’s experience of counseling, and how counselors come to understand themselves professionally and personally. In addition to being an adjunct professor, Chris is a counselor in Wilmington, NC. Email: www.drchristopherhall.com Lars Harrysson, Ph.D., is a senior lecturer at the School of Social Work, Lund University. He has been engaged in the development of the momentary contentment theory from the start. He is currently involved in an international primary care project following the implementation of the...