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...

Editorial: Perspectives on Autonomy and Control...

Astrid Gynnild, University of Bergen Can autonomy be appreciated without sufficient awareness of control? In what ways can autonomy and control be synonyms rather than antonyms? And in what ways can control that was lost be turned into processes of regaining control? Moreover: What does it mean to optimize one’s own resources under shifting conditions? And what does respect and inclusion mean to the quality of teaching? These are some of the questions that surfaced when I started recflecting on the topics of the running theoretical discussions in this issue of the Grounded Theory Review. The theories presented on the following pages are of course generated from specific substantive areas, and generalizability outside of these areas cannot be claimed. But nevertheless it seems obvious that the new concepts that are brought to light in this issue might have great value across disciplines and topics. As always, grounded concepts spark the interest for understanding more of human ways of resolving problems. In the introductory article on the ”cry for help,” Barney G. Glaser discusses problematic aspects of doing autonomous research, seen from the perspective of novice grounded theorists. As Dr. Glaser points out, ”Claiming autonomy when researching within a structure of control by superiors is problematic. Success varies from failure to get autonomy to being autonomously alone with no help.” By identifying a number of GT issues that require novices to seek methodological help, Dr. Glaser also includes a discussion of grounded theory procedures. Classic grounded theory has many procedures for generating conceptual theory that are not suitable to other methodologies. So developing research autonomy while at the same time adhering to the strict procedures of doing grounded theory might sometimes seem like a paradox to beginners. Issues of learning, autonomy, and implicit control, are brought to the fore in the new grounded theory of optimizing personal resources by Katja Hakel. She found that optimizing personal resources is a main concern of students in higher education. In order to juggle a number of course commitments and other commitments throughout a semester, students resolve their main concern by oscillating between conservation strategies and investment strategies depending on the situation. Their choice of actions stems from deliberate considerations on how to invest their time most efficiently in order to ensure a wished outcome. This new insight is valuable to teachers and professors who work to improve their own approaches to teaching and learning. In his theory of surviving situational suffering, Barry Chametzky focuses on the situation of a growing group of educators, namely contingent faculty members. In the US, part-time, adjunct educators are hired to teach a great many classes. Their main concern is maintaining employment, and they do so within a context of reduced appreciation, underutilization, and ingratitude, as pointed out by Dr. Chametzky. The theory of surviving situational suffering integrates the categories of limiting, balancing, and falling short. The theory explains and predicts costs and dilemmas of the widespread use of part-time adjunct educators, not only for contingent faculty members themselves, but also for educational environments at large. In the end, students’ learning is probably what would benefit the most from more respectful and longterm engagement with contingent faculty members by educational institutions and environments. Jumping from educational environments to a study of urine incontinence of older persons in hospitals might, at first sight, seem like a leap. Or perhaps not? The generalizability of Annemarie Dowling-Castronovo’s theory of regaining control is obvious. She found that when older persons are hospitalized...

The Cry for Help

Barney G. Glaser, PhD, Hon. PhD Classic grounded theory is being chosen as a methodology throughout the world. One result is the cry for help of many individuals with aspects of their getting the research going for their dissertation. The cry is individual, because CGT attracts on the individual level. No department has chosen it for all its candidates as an option. The novice candidate has the task of convincing his supervisor and/or department of his choice. One reason many choose using CGT is that it offers autonomy. By autonomy I mean total freedom to let the participants’ main concern or problem emerge and the conceptual variables emerge that continually resolve the main concern. Most methodologies require that the research problem and its resolving require they be preconceived before research begins. In short, CGT allows a do not know approach to full discovery. Correcting existing research conjecture is not the goal of CGT. This autonomy, which is so attractive to many novices, has many dimensions of problems. Claiming autonomy when researching within a structure of control by superiors is problematic. Success varies from failure to get autonomy to being autonomously alone with no help. Most PhD candidates have been trained in their student careers to seek genuine help and to seek an “ok” as their work proceeds. Though a big draw to using CGT going autonomous can be very frightening? “Am I using the procedures correctly that give autonomy?” is their big question. So they want help. Also many who have chosen CGT do not realize until they start research that they cannot tolerate autonomy. They need a constant “ok” and are almost paralyzed without it. They need a constant mentor to trust. Minus mentorees often have must difficulty. Thus the mixed bag of autonomy offered by CGT procedures’ varies on its proper use and is not the manifest glory it sounds like to many at first glance. CGT, when done correctly with autonomy at all stages, goes fast, less than a year to emerge a conceptual theory, yet I have talked with students who have been waiting up to five years for an “ok” of their work. Especially at the start of their research. “Am I doing it right?” and “will my supervisor approve?” are constant questions. Tolerating the beginning confusion that goes with beginning research not knowing can become intolerable autonomously. The “a-ha” eureka moment will come, but not immediately. Patience with confusion is required so the research does not become forced with existing frameworks and preconceptions. The experiential growth and clarity that come over time in doing CGT requires autonomy from routine help. Only experienced researchers with CGT are suitable to giving moments of brief help to enforce the candidate autonomy with simple realizations. The initial confusion that comes with the constant comparison of indicators before emergent conceptualization, taxes autonomy to the maximum. It is easy to use preconceptions and/or to seek authoritative help to ease the autonomous responsibility. Few can take it, many cry for help to be sure they are “doing it right.” Once concepts emerge, autonomy goes into full force. The autonomous novice researcher with a few good core concept possibilities can be told nothing to threaten his autonomy. So novices should hold on to their autonomy, it will be solidified by emergent concept. Do not out of fear give up their autonomy. Confusion and preconscious processing and constant comparisons are part of the CGT beginning process. Only a well-trained CGT researcher will...

Oscillating between Conservation and Investment: A Grounded Theory of Students’ Strategies for Optimizing Personal Resources...

Katja Hakel, Norwegian University of Science and Technology, NTNU Abstract Students’ use of time and effort during their studies has been discussed exhaustively in mass media and educational research. In most cases, researchers try to give advice to teachers on how to get their students to become more active and engaged. The grounded theory presented in this article, however, challenges this approach by focusing on the students’ point of view. When interviewing students for this study, I soon realized that students only have a limited amount of time and effort at their disposal. Optimizing these personal resources emerged as their main concern. For the students, investing resources into one study activity always means having to reduce the amount of time and effort they can spend on other activities. They resolve their main concern by oscillating between conservation and investment strategies. Their decision regarding which type of strategy to use depends strongly on the students’ evaluation of their current situation. Keywords: oscillating, optimizing, personal resources, investment strategy, conservation strategy. Introduction The theory presented in this article shows how students oscillate between conservation and investment strategies in order to optimize their personal resources. It differs from previous research in that it focuses strongly on the students’ perspective. A review of this research showed that many educational studies have a teacher-focused approach. In these studies, the researchers often provide recommendations to teachers on how to change their students’ learning approaches (Abouserie, 1995; English, Luckett, & Mladenovic, 2004; Grauerholz, 2001; Smith & Colby, 2007). Teachers must “lead students to deep learning” (Smith & Colby, 2007, p. 206). They must also “improve functioning regardless of the situation through a development of learning skills, and through an encouragement of cognitive and affective development” (Abouserie, 1995, p. 19). Only some researchers acknowledge that the students’ approaches to learning are based on how they evaluate their study situation and the demands of each specific task (English et al., 2004; Ramsden, 1992). This latter perspective is in accordance with the findings of my own study. Using the grounded theory methodology, I interviewed 13 students from language programs at a Norwegian university. I found that students experience different situations differently and that they adjust their learning strategies to each specific situation. The grounded theory presented in this article is based on the patterns that emerged from the students’ data. The theory describes how students resolve their main concern of optimizing their personal resources through oscillating between different types of strategies. Method “Remaining open to what is really going on will soon transform the researcher to going where the data takes him” (Glaser, 2012). This statement could not be any better for expressing exactly what I experienced when I started out on this grounded theory research. Originally, I had been interested in investigating students’ attitude towards the use of technology in university education. The use of grounded theory as a research method seemed to be the most suitable for me then. At that time, my knowledge of how to do research and about educational technology was close to zero. Having almost no previous knowledge meant that I had few preconceptions concerning the substantive area under study. First of all, I obtained ethical approval from the Norwegian Social Science Data Services (NSD). An interview guide that contained only the grand tour question: “Can you tell me about the use of information and communication technology in your daily study life?” was approved after I provided a detailed explanation of the grounded theory...

Surviving Situational Suffering: A Classic Grounded Theory Study of Post-Secondary Part-Time Educators in the United States...

Barry Chametzky, PhD 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 end....