Resigning: How nurses work within constraints

Claire O’Donnell, University of Limerick Tom Andrews, University College Cork Abstract This study explores and explains how nurses care for patients with stroke in the acute care setting and how they process these challenges to enable delivery of care. Using a classic grounded theory methodology, 32 nurses were interviewed who cared for patients with stroke and twenty hours of observations were undertaken. Nurses’ main concern is how to work within constraints. In dealing with this challenge, nurses engage in a process conceptualised as resigning and do so through idealistic striving, resourcing and care accommodation. Resigning acts as an energy maintenance and coping strategy, enabling nurses to continue working within constraints. This theory has the potential to enhance nursing care while reducing burnout and making better use of resources, while advocating for stroke care improvements. Keywords: Care provision, constraints, classic grounded theory, nursing, resigning, stroke Introduction Quality and safety of patient care is a continued area of concern in healthcare services where constraints on health expenditure prevail (Aiken et al., 2014; Kirwan et al., 2019). Work environments influence patient outcomes where limited nursing staff and resources have a resultant negative impact on patient care outcomes (Aiken et al., 2014; Griffiths et al., 2021; Jangland et al. 2018; Rochefort & Clarke, 2010; Schubert et al., 2009). Stroke care in designated specialised stroke units is associated with improved patient outcomes (Langhorne et al., 2020) however, despite international consensus on optimum stroke care, wide variations in the delivery of stroke care across Europe persist (Stroke Alliance for Europe, 2020). Such variations in the location of stroke care adversely influence care delivery and patient mortality and morbidity (West et al., 2013; Stroke Alliance for Europe, 2020). Background    Constraints in the work environment such as reduced staff, lack of time and a lack of resources are reasons for concern regarding their negative impact on patient care delivery (Chan et al. 2013; Winsett et al., 2016; Blackman et al., 2018; Griffiths et al., 2021). Nurses caring for patients with stroke are aware of what optimum stroke care entails however, they often provide a reduced level of care due to the presence of constraints (Clarke & Holt, 2014; Seneviratne et al., 2009). One constraint commonly reported as a barrier to optimal nursing is a lack of time (Blackman et al., 2018; Chan et al., 2013; Clarke & Holt, 2014) and this includes the area of stroke care (Seneviratne et al., 2009). Reduced nurse staffing levels is another constraint associated with increased levels of mortality (Cho et al., 2015; Department of Health, 2018; Fagerström et al., 2018; Griffiths et al., 2016). Morality also increases with incidence of pressure ulcers and nosocomial infections reported when inadequate nurse staffing levels are present (Cho et al., 2015; He et al., 2016). In addition, increases in nurses’ workloads demonstrate statistically significant increase in mortality (Aiken et al., 2014; Fagerström et al., 2018). Limited availability of space, time and interprofessional support in stroke care has a similar effect (Seneviratne et al., 2009). Stroke unit care addresses all elements of the staffing and infrastructure required to create safe specialized care delivery for patients with stroke. Despite the benefits of stroke unit care, many patients continue to be cared for in the general acute setting. A national audit of stroke services in Ireland found 29% of patients were cared for on wards other than stroke units (National Office of Clinical Audit, 2020), similar to other European countries (Kings College London, 2017). Stroke care provided...

Transforming Loyalty: A Classic Grounded Theory on Growth of Self-Acceptance Through Active Parenting...

Renee Rolle-Whatley, Rolle Integrative Healing Solutions, LLC, USA Kara Vander Linden, Saybrook University, USA Abstract The experiences of parents who daily participate in the rearing of their children framed this investigation into the maturation of selflessness using Glaser’s classic grounded theory. The theory reveals vulnerabilities, lessons, and rewards gleaned from continuous immersion in parenting. Viewed as a process, transforming loyalty discloses the circuitous route parents travel as parenting experiences shift focus towards a broadened awareness about the impact of allegiance and trust in caregiving. Releasing self-interest, embracing detachment, and living nonattached define transforming loyalty. In releasing self-interest, emotional balance eases egocentric perspectives; in embracing detachment, maturing selflessness validates the autonomy of others; and in living nonattached, emotion regulation heralds a broadened self-in-relationship. As egocentricity is confronted through engaged parenting, loyalty evolves to reveal the hidden gem of the parenting process—self-acceptance­—conceptualized as a growth continuum transitioning loyalty to self into loyalty to family and onward towards a loyalty to all life. Keywords:  parenting, loyalty, self-awareness, classic grounded theory, autonomy, self-acceptance, presence Introduction The existence of Covid-19 has overwhelmed parents as they attempt to deal with an ever-expanding list of national crises (Patrick et al., 2020). For parents who are Black, indigenous, and people of color, these crises, when combined with lifetime trauma load, predispose post-traumatic-stress syndrome conditioning (Knipscheer et al., 2020). Disempowered by unpredicted unemployment, lost childcare, and potential eviction, parents have struggled to cope. But could a person effectively parent and generate family harmony when joblessness, loss of health insurance, racial tensions, and food insecurity are at all-time highs and even the air is the enemy? This research offers parents an experiential pathway that harnesses loyalty as the essential ingredient of effective daily parenting and crisis management. With evolving emotion regulation, a clarity of purpose is conferred that not only guides the prioritization of resources but also proffers an unexpected reward, namely self-acceptance. Glaser’s classic grounded theory (CGT) method provided the systematic structure through which Transforming Loyalty emerged as a pathway to reboot selfishness into selflessness through experiences of parenting.  The Basic Social Process (Bigus et al., 1982; Glaser, 1978) that arose is grounded in data, conceptualizing experiences of parents for parents. Source data included 30 items inclusive of interviews, first-person recollections from books and web pages, and audio recordings all addressing the grand tour question: “Tell me about your experiences as a parent.”   Method   The purpose was to develop a theory that offers a richer conceptual explanation, beyond the obvious rearing of offspring, for the experiences of active parenting.  A broad sampling of perspectives was gathered. Classic grounded theory was adopted for its methodical rigor, systems perspective, and ability to extract abstract conceptual theory from data involving complex social conditions (Glaser, 1978). Eligible participants were 21 years of age or older and a parent with custody of at least one child who was actively parented by the participant. Among the participants, years of parenting experience ranged from a minimum of three years to over four decades.  Study participants were also single, married, and divorced, and provided parenting in situations that included neurotypical children and children with autism spectrum disorders. In order to identify the boundaries of the theory, data collection outside the group of study (e.g., parents over 21 years of age who do not actively parent) was conducted. The foundation of this CGT’s development was conceptualization of empirical data (Holton, 2007). Focused in-depth interviews were recorded via digital sound recording software and transcribed. All study...

About the Authors

Dr. Tom Andrews, PhD, MSc; PGDE; BSc (Hons) School of Nursing & Midwifery, Brookfield, College Road, University College Cork, Cork, Ireland, although now semi-retired, has worked in Higher Education since 1991.  He has been trained in Classic Grounded Theory by Dr Barney Glaser, one of its originators.  He has supervised seven PhD students using Classic GT to successful conclusion and examined a total of twenty PhDs and two MSc by research.  He is a Fellow of the Grounded Theory Institute and on the editorial board of “The Grounded Theory Review”. He has been involved in several studies using Classic GT and has written extensively on the methodology.  He has been involved in and conducted several Grounded Theory troubleshooting seminars and has lectured extensively on the methodology.  He continues to review for several international nursing journals. Email: t.andrews@ucc.ie Emily Cashwell, Ph.D., received her doctoral degree in Psychology with a specialization in Consciousness, Spirituality, and Integrated Health from Saybrook University in Pasadena, California. She learned classic grounded theory under the mentorship of Dr. Kara Vander Linden. Currently, Emily is using classic grounded theory to expand on the theory of coming home that was developed during her doctoral research. She is a former middle school special educator and holds graduate degrees in both special education and nutrition and integrative health. Her current research is focused on the experience of becoming more authentic, particularly as it relates to individuals who identify as queer or neurodiverse. Email: dremilycashwell@gmail.com Michael Leger, PhD, MBA, BSN – University of Texas Medical Branch, School of Nursing, was introduced to Classic Grounded Theory (CGT) during his Ph.D. program under the guidance of Dr. Carolyn Phillips. He is currently an Associate Professor and Assistant Dean at the University of Texas Medical Branch (UTMB) – Galveston School of Nursing where he teaches in the graduate program and serves as a committee member for Ph.D. students using qualitative research methods, particularly CGT. Dr. Leger received his Doctor of Philosophy in Nursing from UTMB in 2016. A highlight of his research career thus far was being selected to attend Dr. Barney Glaser’s CGT Troubleshooting Seminar in May 2015. Email: jmleger@utmb.edu Elizabeth Kellogg, PhD, received her doctorate in Psychology with a specialization in Consciousness, Spirituality, and Integrated Health from Saybrook University. She is a clinician, DEI facilitator, and an adjunct professor in the Expressive Arts Therapy graduate program at Lesley University. Research interests include embodied cognition and justice, equity and inclusion. Email: ekellog2@lesley.edu Dr. Claire O’Donnell, PhD, MSc., BSc., Department of Nursing & Midwifery, Faculty of Education and Health Sciences, Health Sciences Building, North Bank Campus, University of Limerick, is 14 years working in Higher Education at the University of Limerick, Ireland, as a lecturer in nursing and midwifery and more recently in the role as the Department International Coordinator where she is the lead for Internationalisation, contributing towards managing and further developing the internationalisation agenda within the department and faculty.  Under the supervision of Dr Tom Andrews, Claire used Classic Grounded Theory as the chosen methodology for her PhD which explored the area of how nurses care for patients with stroke in the acute care setting.  Research and supervision experience to date include international and national involvement in both qualitative and quantitative projects on the areas of missed care, stroke, transcultural care, breastfeeding and internationalisation. Email: claire.odonnell@ul.ie Carolyn A. Phillips, PhD, MSN, BSN – University of Texas Medical Branch, School of Nursing and Graduate School of Biomedical Sciences, is a faculty member of the...