Transcending Taboos in Medical Ethics

Hans Thulesius, Lund University, Sweden The following is perhaps what Glaser would call a “theory bit” (1) from a write up of memos inspired by interview data leading up to a grounded theory of De-tabooing Dying Control (2). This conceptualization of what goes on in medical ethics is the product of the analysis of data from two sources. It is the write-up of memos arising from the secondary analysis of the interview data tht initially led to a grounded theory of De-tabooing Dying Control. It is also the product of the analysis of field notes of talks, chats, and discussions which took place at the Swedish Society of Medicine’s medical ethics delegation from 2005 – 2009. Specifically, the data were collected from meetings of physicians engaged in ethical rumination for the purpose of providing statements of opinions on government reports and official documents. During my years in the Swedish Society of Medicine’s medical ethics delegation, I discovered that transcending taboos conceptualized the medical ethics discourse. Taboo is, by Oxford dictionaries, defined as something “prohibited or restricted by social custom” or “designated as sacred and prohibited”. To manage taboo topics thus explains what is going on when sensitive issues regarding life, death, and sexuality are managed. The task of the ethics delegation is to scrutinize and vet governmental and other official reports on health issues from a medical ethics perspective. Medical ethics deals with what is acceptable and unacceptable behavior in the medical field, especially for health care professionals: What is right or wrong? What is forbidden or unacceptable is often connected with the big taboo subjects—sex, money, death, and dying. What is politically correct (PC) may set the agenda for what is taboo and what is not. Political correctness changes over time and so do taboo topics and issues. It seems that political correctness aligns itself with what is taboo—to be politically incorrect could therefore be seen as a property of de-tabooing, i.e. acting or talking in such a manner that a taboo is being challenged or transcended. To be PC regarding medical ethics is a necessity for someone who wants to work in health care and be considered respectable. To go against what is PC is a risky endeavor and therefore transcending the taboo is seldom done in the open. Transcending dying taboos Legal abortion is time framed, meaning that it is conditioned primarily by time; it has a time window within which it is sanctioned by law to terminate a pregnancy, in other words eliminate the existence of a future human being to some people and a present human being to others. To terminate the existence of a human being is taboo in most cultures with the exception of the death penalty and situations of self-defense and war. So, with abortion being another exception to the commandment “Thou shalt not kill” it is connected with the taboo of death and dying and thus one could talk about legal abortion being a time framed death taboo transcendence in the first months of human life. Abortion issues were not commonly discussed in the medical ethics delegation in the 2000s with the exception of sex selective abortions that were somewhat taboo at the time. To decide upon the sex of the fetus within the free abortion time window was not considered a good thing to do—it was indeed not PC to hold this position. Yet, a significant number of people used and still use this opportunity of selective family planning....

Grappling with the Suicidal Monster: A Grounded Theory of how Parents Experience Living with Suicidal Distress...

Erica Delaney, Evelyn Gordon, Dublin City University, Ireland Background Suicidal behaviour is a significant public health concern given the strong association between acts of self-injury and death by suicide—particularly among young people where rates of self-injury are steadily increasing (National Suicide Research Foundation, 2017). Furthermore, carers including parents, relatives, and significant others are being allocated increasing responsibility in assisting mental health care services in the early detection and management of family members at risk of suicide (Chiang, Lu, Lin, Lin, & Sun, 2015). Thus, it is essential to understand how this vital role is experienced by parents in order to ensure that sufficient supports are made available to them.  However, there is a paucity of literature relating to this phenomenon. This grounded theory (Glaser & Strauss, 1967) study generated a substantive theory about how parents experience living with young adults who are in suicidal distress. The main concern The main concern, keeping my child alive, describes the sole focus of the parents throughout the young persons’ suicidal distress. Parents’ thoughts, fears, and imaginations act as driving forces where they become preoccupied regarding the dangers to which their children may succumb because of their suicidality, rendering a “monster” to be reckoned with for a sustained period in their lives. The core category/theory: Grappling with the suicidal monster Grappling with the suicidal monster offers a novel theoretical understanding of the three-staged psychosocial process participating parents undergo to resolve their core concern. It describes how they struggle to understand the suicidal distress that their adult children are experiencing and the various protective actions they take to address this issue. While each progressive stage lessens in intensity and worry for parents, the experience has a profound and prolonged impact on their overall functioning and well-being. Unmasking the monster The first stage of grappling with the suicidal monster is unmasking the monster, which describes the processes the parents engage in as they begin to suspect that something might be wrong with their child. They notice changes in their child’s behaviour, which lead them to feel increasingly on edge and concerned for their child’s welfare, while not wholly understanding what they are witnessing. They endeavour to communicate with their child about what is happening and become preoccupied with how they might protect them from this new and uninvited intruder into their lives. Living with the monster The next phase, living with the monster, reflects how the parents, consumed by their need to keep their child safe, enter a prolonged state of heightened fear. Due to this intense focus on their children, daily routines become less important to uphold, with some parents unable to concentrate on tasks, such as working or engaging in activities outside the home. The parents also withhold expressing their own feelings and monitor how they interact with their child for fear of inadvertently making the situation worse. Being continuously on guard results in sleep deprivation and a decline in their own mood. While seeking support for themselves is not a priority, some parents find support in their significant others, specialty programmes, or through creative relaxation exercises. Surviving the monster The final phase, surviving the monster, describes how, as the suicidal distress of their child begins to dissipate, the parents struggle to leave this traumatic experience behind and return to life as they had previously known it. Application of the theory to mental health practice The substantive theory, grappling with the suicidal monster, offers a theoretical framework for mental health practitioners to understand...

Caring with Honor: A Grounded Theory of Caring for Veterans within the Veterans Health Administration...

Alvita K. Nathaniel, West Virginia University School of Nursing, USA, Lisa Hardman, Women’s Health Services Veterans Health Administration Abstract Veterans comprise a unique culture. Through their military experience, Veterans become ingrained with shared values, beliefs and attitudes that characterize their everyday existence. Health care providers must take into consideration that culture impacts health care seeking behaviors.  The theory of Caring with Honor is emerging through the classic GT method.  A team of investigators within the VA health care system gathered data from 19 health care professionals via one-on-one interviews.  The emerging theory, Caring with Honor, represents an amplifying process whereby health care professionals engage with Veterans through a process of enculturating, witnessing, connecting, honoring, and caring with purpose. Keywords: Veterans, military, grounded theory The U.S. Department of Veterans Affairs (VA) provides eligible Veterans needed hospital and outpatient health care in one of its more than 1,700 sites (U.S. Department of Veterans Affairs, 2017).  This paper provides a glimpse at the emerging theory of Caring with Honor that focuses on those who care for patients within the VA system.  The theory provides a powerful look at the psychosocial and social cultural processes within the VA health care system.  Following is a background of Veterans’ health care and a snapshot of the theory and one of the categories that has emerged from interviews with a variety of Veteran and non-Veteran health care professionals who work within the VA health system. Background In fiscal year 2015, 44% of all Veterans used at least one VA benefit or service (U.S. Department of Veterans Affairs & National Center for Veterans Analysis and Statistics, 2015a, 2015b). When caring for Veterans, VA employees must go beyond providing traditional health care required by non-Veteran patients.  Veterans’ health care must also address Veteran-specific health care issues such as post-traumatic stress disorder, traumatic brain injury, spinal cord injury, military sexual trauma, readjustment difficulties, and war-related illness and injury. Veterans comprise a unique cultural group. Through their military experience, Veterans share values, beliefs and attitudes that characterize their everyday existence. Characteristics seen within the cultural group include positive qualities such as a strong sense of duty, honor, loyalty and commitment to fellow soldiers. Other less positive characteristics of Veterans include hesitance to seek health care (Malmin, 2013; Denneson, et al., 2015); debilitating feelings of guilt and shame (Denneson, 2015); feeling of loss of sense of self (Johnson et al.; Demers, 2011); reluctance to report physical and mental health concerns that may bring embarrassment and stigma (Malmin, 2013; Simmons & Yoder, 2013); and feelings of weakness for experiencing mental and physical needs (Malmin, 2013). Health care providers must take into consideration that culture influences health seeking behaviors and that understanding cultural aspects will allow care that effectively meets the unique needs of the Veteran population. Even though Veterans have a high acuity of complex physical and mental health concerns that could make health care delivery challenging, many VA employees find satisfaction with their work. The Department of Veterans Affairs Federal Employee Viewpoint Survey Results (2015) indicates that 72% of VA employees responding to the survey feel their work gives them a sense of personal accomplishment; 92% are constantly looking for ways to do a better job; 84% identify their work is related to the VA’s goals and priorities, and 94% rated that the work they do is important. The theory of caring with honor The theory of Caring with Honor represents an amplifying process whereby health care professionals engage with the...

Grounding Anger Management

Odis E. Simmons, PhD, USA One of the things that drew me to grounded theory from the beginning was Glaser and Strauss’ assertion in The Discovery of Grounded Theory that it was useful as a “theoretical foothold” for practical applications (p. 268). From this, when I was a Ph.D student studying under Glaser and Strauss in the early 1970s, I devised a GT based approach to action I later came to call “grounded action.” In this short paper I’ll present a very brief sketch of an anger management program I developed in 1992, using grounded action.          I began my research by attending a two-day anger management training workshop designed for training professionals in the most commonly used anger management model. Like other intervention programs I had seen, this model took a psychologizing and pathologizing approach to the issue. Following this, I sat through the full course of an anger management program that used this model, observing the reactions of the participants and the approach of the facilitator. Following each session I conducted open-ended interviews with most of the participants, either individually or in groups of two or three. I had also done previous research in counseling and social work contexts that turned out to be very relevant to an anger management program design. In analyzing my notes, several things stood out. One was that the conventional anger management approach not only didn’t work particularly well, but it was actually counterproductive because it unknowingly replicated the conditions that my observations and interviews revealed as the key anger variables. Almost all of the participants whom I interviewed expressed close versions of what one participant said when I asked for his thoughts about the experience, “I’m more pissed off now than I was when I started!” Some participants stayed mum during the sessions because they were court ordered and feared a negative report about their participation. Several participants reported feigning buy-in. A few, who had not been court ordered, sincerely bought in. And several, attempting to preserve their dignity, took the risk of pushing back. These approaches paralleled those I had seen in other contexts. Most participants clearly didn’t like the program’s approach. When I asked them what it was they didn’t like about it, their responses revealed their main concerns, which I termed “Rodney Dangerfielding.” For those who are not familiar with him, Rodney Dangerfield was a now deceased standup comedian and later comic actor whose catch-phrase was, “I don’t get no respect.” What I discovered was that from their point of view, the anger that put them in their current situation was a consequence of the paucity of respect and power in their daily lives which led to “things never going my way.” Although they were willing to accept what they viewed as their “fair share” of responsibility for anger situations, they resented what they viewed as the “unfairness” of always being the bad guy when others involved were seen as their innocent victims. The interviews indicated that they thought the program was just one more experience of these things. The extent to which their views were or weren’t accurate didn’t change the fact that an effective anger management program needed to address these main concerns. Knowing this, I developed an eight-week program of weekly 2 ½-hour evening sessions that focused on their main concerns.  Before the first session, intake materials indicated that all of the initial participants had been through at least one prior anger management program, although not...

Growing Grounded Theory: Doing my Bit

Helen Scott, PhD, United Kingdom In Glaser’s recent book, The Grounded Theory Perspective: Its Origin and Growth (2016), Glaser writes of how he recorded and explicated the grounded theory perspective and disseminated the perspective as the grounded theory general method of research, over a period of 50 years. During this period he has monitored its use, embracing procedural developments (e.g. Nilsson, 2011; Scott, 2011), whilst vigorously defending and differentiating the grounded theory perspective from adaptions (e.g. Glaser, 1992, 2002). A scholastic endeavour of monumental proportions. Over the decades, his key tools in achieving the phenomenal worldwide growth of grounded theory[1] are his books and troubleshooting seminars. In this way, he empowers an army of PhD students to spread the use of grounded theory wider still. The result is the continuing diffusion of the grounded theory method geographically and across disciplines including medicine, business, technology, journalism, psychology, international relations, and education and many more substantive areas of interest, including construction, caring professions, careers advice, prison life, de-radicalisation, living on a volcano and so on. Since learning how to do grounded theory is best achieved by experiencing the method, a key teaching technique used in both books and seminars is “exampling”. In his readers, Barney publishes grounded theories that represent the current frontier in grounded theory research. Novices are encouraged to read the theories to develop understandings about how grounded theory studies are conducted and constructed i.e. to identify the theoretical code(s) which model the substantive codes and to experience how the theoretical codes shape the presentation of the theory. In seminars, exampling helps the novice GT researcher envision the trajectory of their own grounded theory by working with other grounded theories at later stages in the development process. Additionally, in hearing of the procedural issues of other participants, novices are able to anticipate or notice their own procedural issues. In discussion, novices also learn how the procedures support the grounded theory perspective and how modifying procedures can, wittingly or unwittingly, compromise the grounded theory perspective. Encouraged by Glaser, several of his troubleshooting alumni now also publish books (e.g. Gynnild & Martin, 2011; Holton & Walsh 2016) and run seminars: Hans Thulesius and Anna Sandren run troubleshooting seminars in Sweden; Foster Fei runs seminars in China and Tom Andrews and I run seminars in Ireland, the UK, Malta, and Australia. One of my problems when learning grounded theory was that coming fresh to grounded theory as a novice PhD student from a department dominated by quantitative methods, much of what I read in Glaser’s writings was telling me what grounded theory was not: the issues that were being defended or differentiated were not my issues. I needed to know what grounded theory is. This has led me, in my methodological mentoring work to focus on the grounded theory research process. This approach works well and has supported my mentees in their development of some truly excellent grounded theories (Krieger, 2014; Stevens, 2015). My natural style is one of facilitation rather than teaching and I prefer to model grounded theory practices. If a mentee feels a need to compromise a procedure (such as using a structured interview design for collecting data at interview) I take care to explain how that will inhibit development of their grounded theory and example how I would approach the issue. I focus on practical matters of progress. Previously I have had little patience with what Glaser (1998) terms the “rhetorical wrestle” (p. 35) preferring to focus on...

The Discovery Power of Staying Open

Judith A. Holton, Mount Allison University, Canada Glaser (1978) emphasized three foundational pillars of GT that must be respected: emergence, constant comparison, and theoretical sampling.  While many qualitative researchers who claim to employ GT will assert their use of constant comparison and theoretical sampling, there is much less clarity around claims to respecting GT’s emergent nature.  Emergence necessitates that the researcher remains open to what is discovered empirically in the data “without first having them filtered through and squared with pre-existing hypotheses and biases” (Glaser, 1978, p. 3) or theoretical frameworks drawn from extant theory.  In many qualitative studies, however, emergence is restricted to the analysis phase (e.g., Corley & Gioia, 2004) and with data collection framed through an initial review of the literature (e.g., Partington, 2000), articulation of specific research questions or interview protocols for “consistency” (Xiao, Dahya, & Lin, 2004, p. 43). Staying open to emergent patterns in data offers surprising and exciting theoretical discoveries—what Glaser has termed the Eureka moment.  Even in studies otherwise framed with some level of preconception, as typical of most qualitative research studies, it is possible to remain open to such discoveries.  This was the case in a research study conducted in 2010-2011. The focus of this study was a leadership development needs analysis for a health services organization where leadership was aligned with fostering a healthy workplace.  The intent of the study was to explore the perspectives of middle managers regarding the overall organizational climate and their leadership development needs.  A qualitative approach was adopted with semi-structured interviews to elicit a variety of experiences, directly and indirectly related to leadership development needs.  Thirty-two middle managers participated in the interviews. Detailed findings were shared with the organization and also published (Grandy & Holton, 2013a, 2013b). As a grounded theorist and a co-investigator in this study, what interested me most as the interviews progressed were moments of self-reflection in which verbal confessions and body language revealed a growing discomfort and realization of disconnect between espoused corporate messages about a healthy workplace, their experience of the organizational culture, and their own realized unhealthy work practices.  While the organization and we as researchers were focused on identifying key leadership development needs, the grounded theorist in me recognized that this felt disconnect—not leadership development—was the main concern of these middle managers.  I wanted to explore this idea further. Following completion of the initial study, we went back and selectively coded the data to better understand this discovered main concern, subsequently developing the concept voiced inner dialogue to explain how managers are able to surface and process the disconnects they experience between the espoused goals of the organization and their own lived experiences of those goals. We identified and elaborated voiced inner dialogue as a three-stage process: Reacting, not reflecting Reacting, not reflecting wherein managers simply react in accordance with organizational norms and espoused values without stopping to reflect on the appropriateness or feasibility of such norms and values, particularly when attempting to demonstrate leadership in a context of constant crisis and “putting out fires” typical of most health care organizations.  These “go, go, go” cultures are reactive, not proactive; there is no catching up, no opportunity to be strategic; timelines are short and imposed deadlines unreasonable.  In reacting, not reflecting managers assume responsibility for this disconnect by questioning their own competence as effective leaders. “I find the more I model this go, go, go, go they [subordinates] pick up on it …. I shouldn’t underestimate the...

Intellectual Autonomy of PhD Researchers who use the Grounded Theory Methodology...

Andy Lowe, PhD, Thailand Abstract The decision to choose the grounded theory methodology (GT) for one’s PhD research should never be done lightly, as outlined in Glaser (2015).  The emergence of a researcher’s own intellectual autonomy is often of more importance than the research itself. Intellectual autonomy can be fostered perpetually and spasmodically. Keywords: intellectual autonomy, grounded theory, perpetual fostering, investigating, negotiating. Perpetual fostering Intellectual autonomy can be fostered perpetually in three main ways; discovery of “voice”, investigating, and negotiating. Intellectual autonomy involves the discovery of one’s own “voice” without arrogance but with humility. The PhD researcher should never bury missteps in the PhD thesis.  Instead write about them and explain how they arose and then the means with which they were dealt.  The formal acknowledgement of these errors is always an indicator for the PhD committee that researcher’s intellectual autonomy has emerged. The process of intellectual autonomy begins when the researcher starts understanding, by discovering his own “voice”, by critically reading the published works of others.  The researcher has to delve beyond the descriptive narrative and begin to tease out the more fundamental deep-seated concepts that underpin the research of others.  This approach will also reveal the line of argument being used by various authors.  Glaser (1978) emphasized the importance of the GT researcher being able to develop theoretically sensitivity.  Put very simply, this means that the researcher has to go directly to the ideas and concepts that underpin the research. Investigating Before embarking on any PhD research, it is the researcher’s task to demonstrate his intellectual autonomy by using due diligence. It is the duty and responsibility of the researcher to choose the location where the GT PhD will be registered.  This issue is not just administrative; this is because the researcher should be cautious of naively assuming that all research environments are likely to be equally competent and intellectually stimulating. Find a university that is tolerant of an inductive research design. The dominant research paradigm in academia is the deductive hypothesis approach.  Many universities automatically assume that all PhDs will always follow this path.  This has the potential to be problematic for the GT PhD researcher because GT research is principally an inductive research method. An online research will reveal the attitude of different universities to inductive research based PhDs.  Be wary of universities who compel PhD researchers to use the identical chapter headings and structure regardless of the type of research method being employed.  Do remember that what is considered to be the appropriate structure of a PhD is highly variable even at the same university.  If a PhD researcher is already signed up to a university with an inflexible system, it still might be possible to do a GT PhD.  The workaround is called “the retro fitted PhD”.  Here the GT PhD researcher faithfully follows the tenets of the authentic GT research method that will result in a robust core variable.  Then return to the rigid PhD structure that the university has imposed on the research and repackage the legitimate GT PhD research into the thesis format retrospectively.  However, what frequently happens is that when the supervisors read the GT research they often are so impressed by the research that they find ways in accepting the authentic GT PhD structure. The Conventional full-time PhD Younger novice researchers may wish to opt for a PhD process that pays the annual registration fee as well as income from teaching at a university. Apart from the obvious...

Rethinking Applied Economics by Classic Grounded Theory: An Invitation to Collaborate...

Olavur Christiansen, University of Faroe Islands Introduction The heading of this paper refers to an issue that so far remains unaddressed by classic grounded theory (CGT) researchers. The aim of this paper is to take a closer look at the accordance between the CGT methodology and the field of applied economics (economic policy-making). The goal is NOT to present a finished theory; the purpose is to briefly discuss the main concern and to suggest some possible properties of the recurrent solution of the main concern (the core variable) within the field of applied economics. The paper is based on some open coding of sampled data. These data came from interviews with leading politicians with economic responsibilities, memoirs, and published diaries of leading economic politicians, and a selection of popular books written by leading economists. The procedure of memo writing has been used to a limited extent, but no sorting of memos has been made. Selective coding has not yet begun. This means that the work is far from finished. It has hardly begun. Thus, it is far from possible to present an entire classic grounded theory. I can only present some initial theory bits that relate to the discovered main concern. This paper is also an invitation to collaborate, see the epilogue. Two most different methodological approaches The methodological approach of generating and presenting economic theory by classic grounded theory (CGT) is very different from the conventional economic approach. Neoclassic and keynesian economics are both normative. These approaches focus on what should be done, and how. Mainstream economics is based on the assumption that the behaviour of economic agents follows the rule of “rational choice” (optimizing), and that the actual behavior of economic agents should follow this rule. CGT methodology on the other hand is not normative in the same sense. Use of the CGT methodology means that focus will be on actual behavior (what people actually do) and how to explain this actual behavior. No apriori assumptions are made regarding this actual behavior. Discoveries regarding this actual behavior that are grounded in the data may be used at a later stage as a guideline for problemsolving within the field of study (i.e., as “grounded action”). “Schools” of economics A distinction can be made between present-day mainstream economics (typically neoclassic and neoclassic-keynesian synthesis) and different smaller schools of what we can call “minorstreams economics”. These “streams” can typically be identified by the journals, where the respective research is published. One illustrative example of such a “minorstream” is the approach of Daniel Bromley (2006).  Bromley challenges the prevailing economic assumption of “rational choice” of economic agents (optimization), and he offers an alternative evolutionary model of pragmatic human action, where individuals “work out” their desired choices and actions, as they learn what choices are available. Bromley’s methodological perspective of “volitional pragmatism” builds on the work of Charles Sanders Peirce and his abductive approach. For Bromley (2006), the most fundamental human need is not eating, drinking or obtaining shelter, but concerns “what to believe” (Ibid). Nevertheless, Bromley’s approach just replaces the “rational” choice assumption with the assumption of “volational pragmatism” – i.e. so far, the methodology is not so different from the mainstream. Methodologies: Better or worse? Despite this difference of methodological approaches, it would be too brash to claim that the CGT approach is better or worse compared to other approaches. CGT is just different. From the perspective of a CGT researcher, CGT also becomes justified because it is “different”. That...