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...

Surviving Grounded Theory Research Method in an Academic World: Proposal Writing and Theoretical Frameworks...

Naomi Elliott, Trinity College Dublin  Agnes Higgins, Trinity College Dublin Abstract Grounded theory research students are frequently faced with the challenge of writing a research proposal and using a theoretical framework as part of the academic requirements for a degree programme. Drawing from personal experiences of two PhD graduates who used classic grounded theory in two different universities, this paper highlights key lessons learnt which may help future students who are setting out to use grounded theory method. It identifies key discussion points that students may find useful when engaging with critical audiences, and defending their grounded theory thesis at final examination. Key discussion points included are: the difference between inductive and deductive inquiry; how grounded theory method of data gathering and analysis provide researchers with a viable means of generating new theory; the primacy of the questions used in data gathering and data analysis; and, the research-theory link as opposed to the theory-research link. Introduction The aim of this paper is to help grounded theory research students deal with challenges arising from doing grounded theory research within an academic context and meeting the requirements of their degree programmes. The status of grounded theory research method in academia is contested (Bryant & Charmaz, 2007); insofar as it is considered that some aspects of grounded theory method do not conform to traditional conventions of academic research. Although each grounded theory research project gives rise to a unique set of challenges, when working in an academic environment that is unfamiliar with grounded theory, there are common problems that many students and researchers experience. Two recurring problems experienced by numerous grounded theory students across Canada and Europe (Luckerhoff & Guillemette, 2011; Walls, Parahoo, & Fleming, 2010) relate to the initial literature review and use of a theoretical framework. For students, these are key issues, not only at the start of their research project, but at the end stage when defending their grounded theory thesis at final examination. Drawing from personal experiences of two PhD graduates who used classic grounded theory in two universities, one UK (Queen’s University, Belfast) and one Irish (Trinity College Dublin), this paper highlights key lessons learned that may help students who are setting out to use grounded theory method. Key discussion points are also identified that students may use when engaging with critical audiences when discussing grounded theory method with other researchers, writing up the thesis, defending at viva or doing conference presentations. Tensions between Grounded Theory and Traditional Research Approaches Since its introduction by Glaser and Strauss in 1967, grounded theory is increasingly being used as a research method in diverse areas. It provides a viable means for scholars and participants to generate a new and emic perspective, and to generate theory that is grounded in the realities of the participants’ daily life experiences. However, the hegemony of traditional research approach gives rise to difficulties for those researchers who wish to pursue an approach that is outside the traditional research conventions. Many of the tensions between grounded theory and traditional research stem from differences that are rooted in the differences between inductive and deductive enquiry. A key feature of grounded theory is it provides for inductive enquiry, a means of generating new theory and new understandings, and requires researchers to identify the research problem from the research participants’ perspectives. By contrast, traditional research provides for deductive enquiry, a means of proving or disproving existing theory and requires researchers to identify the research problem from the extant literature. ...

About the Authors

Naomi Elliott was awarded her PhD degree from Queen’s University Belfast and holds professional awards of Registered General Nurse and Registered Nurse Tutor from the Nursing and Midwifery Board of Ireland. Her integrated clinical and research expertise draws from her experience at the different levels of healthcare: from policy–making whilst working in the Irish Nursing and Midwifery Board, and with the Department of Health and Children, to the design of professional education programmes, to clinical practice in Ireland, Scotland and New Zealand, as well as a diverse range of research methods across numerous healthcare related projects. She first met Dr. Glaser in 2002 during her PhD studies and now has several publications and research presentations on grounded theory. Naomi’s current research interest is the development of new models of care delivery and quality in healthcare for major conditions such as epilepsy. Email: naomi.elliott@tcd.ie Foster Fei, Ph.D. Corresponding author (email: fosterfei@outlook.com), Fellow at Grounded Theory Institute. He has been actively involved in teaching and mentoring novice GT researchers and advocating classic GT in China. Over the years, Dr. FEI has overseen the successful completion of GT studies conducted by some highly promising researchers (Chen, 2020; Feng, 2021; Wang, 2022). He has also been working on the translation of Glaser’s texts into Chinese and organising GT seminars in China. Astrid Gynnild is Professor, PhD, at the Department for Information Science and Media Studies, University of Bergen, Norway. Her current research interests include social implications of surveillance technologies, journalism creativity, and teaching and learning activities. When onboarding as an editor of the Grounded Theory Review (2012-2018), she turned the Review into an open access, online journal with a global outreach – including a comprehensive archive of grounded theories. Mentored by Dr. Glaser, she has published several theories and taught and written extensively on the work processes of grounded theory. She co-edited the volume Grounded Theory: The Philosophy, Method, and Work of Barney Glaser (BrownWalker Press 2012) with Vivian B. Martin. She is a Fellow of The Grounded Theory Institute and a peer reviewer of The Grounded Theory Review. Senada Hajdarevic, Department of Nursing, Umeå University, Sweden. Michael Harris, University of Exeter, Exeter, United Kingdom; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.  Lars Harrysson is a senior lecturer at School of Social Work, Lund University. He has a background in economic history and his doctoral thesis in 2000 blended the fields of history, economy and social policies as the early retirement structures in Sweden were in focus. Since then, research and pedagogical development work have hit several bases; elderly care, faith, cancer rehabilitation, all methodologically, at least partly, inspired from grounded theory, as well as migration, retirement, and social and economic inequality. At the moment he is involved in collaboration with scholars in Ukraine regarding pedagogical design and reflection, and a grounded theory project inspired by story-telling in primary care. Agnes Higgins is a Professor in Mental Health Nursing at Midwifery in the School of Nursing and Midwifery in Trinity College Dublin, Ireland. She completed her PhD using grounded theory and is supervising a number of PhD students who are conducting classic grounded theory studies. Email: ahiggins@tcd.ie Robert Hoffman, Departments of Family Medicine & Medical Education, Sackler Medical School, Tel Aviv University, Israel. Kirsten Jack, RN PhD MSc BSc(Hons) PhD PGCE, Manchester Metropolitan University, is a Professor of Nursing Education in the Faculty of Health and Education at Manchester Metropolitan University. She has a clinical background in primary health care nursing, working...

From the Editor’s Desk: Remembering Barney Glaser...

It is hard to believe that nearly a year has passed since the loss of Dr. Barney G. Glaser, our dear teacher, mentor, friend, and colleague. As co-originator and constant champion of the original classic theory method, Glaser focused much of his life on teaching grounded theory and mentoring novice and experienced grounded theorists. He founded the Grounded Theory Institute, Sociology Press, and this journal, the Grounded Theory Review. He wrote or co-wrote more than 30 books and papers focused on grounded theory. He hosted innovative grounded theory seminars in the US, Europe, and Asia and mentored hundreds of PhD candidates and novice researchers through the years. In this issue, we re-publish the Glaser’s Origins and Growth of Grounded Theory, which was originally published as the first chapter in his 2016 book, Grounded Theory Perspectives: Its Origin and Growth. This chapter described Glaser’s perspective on the original method and how it was first discovered.  He also discussed how remodeling of the original method was produced by people who did not understand the basic assumptions of the method and how the method’s procedures flowed logically from these assumptions. Glaser aimed to clarify misinterpretations of the method in the many subsequent books and papers that he published. The Grounded Theory Review will remain as originally intended by Glaser—a repository of original research and other works that adhere to the classic grounded theory method. The current issue has four basic foci: an editorial on theory in general, an essay tribute to Glaser, methodological papers, original research, and a book review. In the form of a guest editorial, Kara Vander Linden tackles the question, What is ‘Theory’ in Grounded Theory.  Although theory is often discussed in relation to research, Vander Linden proposes that there is a lack of consensus on what theory is. The author briefly discusses some views of theory within sociology and the lack of consensus over what constitutes theory. This lack of consensus makes it important that grounded theorists not only explain what is meant by a theory being grounded in data but also what is meant by theory in grounded theory. Glaser was active with grounded theorists in China. In their paper, Becoming Independent: The Life-Changing Experiences of GT Researchers in China, Fei, Chen, Feng, and Wang pay tribute to Glaser. The paper lays out some life-changing experiences of these GT researchers, which ultimately led toward their academic independence. They identify three intertwining aspects of their experience with grounded theory: inspiration and empowerment of Glaser and his methodology, developing a critical mind, and growth in personal character. This issue also has two classic grounded theory methodology papers, both of which are republished with permission.  In his paper, Coding in Classic Grounded Theory, Chametzky gives novice researchers interested in the classic grounded theory design a foothold in how to do one aspect of classic grounded theory analysis: coding.  The explanation offered in this paper is based in theory and supported with practical examples. In the paper, When and How to Use Extant Literature in Classic Grounded Theory, Nathaniel weaves together Glaser’s recommendations on how, why, and when to review the literature and which literature to review. The paper includes a section debunking the no literature myth followed by descriptions of the three phases of the classic grounded theory literature review. There are four original research papers in this issue. In the paper, Transcending Inequality: A Classic Grounded Theory of Filipino Factory Workers in Taiwan, Peter Sun presents a theory that...

Origins and Growth of Grounded Theory

Barney G. Glaser PhD, Hon PhD Editor’s Note: As we continue celebrate Barney Glaser’s life, we re-publish[1] this gently edited paper about the origin and growth of grounded theory. Through the years as he noticed trends surrounding the method, Glaser codified the different elements and procedures of grounded theory and compared/contrasted them with remodeled versions.  This paper was first published as chapter 1 in Grounded Theory Perspectives: Its Origin and Growth (2016). All books mentioned in this paper can be purchased via Sociology Press at http://sociologypress.com/book.htm.   [This paper] is about the origins and growth of grounded theory (GT) as developed and written by Barney G. Glaser. It is not written to compete or compare with other QDA [qualitative data analysis] methods. The competition with other perspectives is up to the reader to write up if he so desires. My goal in this paper is to write up the GT perspective clearly and historically to date so it can be used by others in research and the rhetorical wrestle between different perspectives. As GT spreads throughout the world, a clear view of the GT perspective is constantly needed and requested from me by researchers for doing GT and for trying to explain the method to others, particularly supervisors and peer reviewers. There is an immense amount of writing on aspects of the GT perspective, often mixed with other perspectives, thus confusing its use. I trust this paper will help clarify GT with no remodeling. I am not saying that GT is better than other methodologies. I am just saying that the GT method stands on its own and produces excellent conceptual theory. Let other QDA methodologies stand on their own as they wish. This paper will just show differences in methodologies, as the reader may see. It is not written to correct other methodologies. I have written many books on the GT perspective. I trust this book will bring most of the GT perspectives under one cover. GT emerged as a fledgling methodology when analyzing the data on dying in hospitals in the book Awareness of Dying (1965). Awareness context theory took the world of research by storm. We were constantly asked how we did it. In 1967 we published our beginning formulations of GT in The Discovery of Grounded Theory: Strategies for Qualitative Research by Glaser and Strauss. It was our first attempt to write a method that closed the gap between theory and method. We focused on procedures for grounding theory not on verification of theory. We called the methodology Grounded Theory. We put to rest the 100% focus on the verifying of grand theory that was all conjectured. We discovered that GT provided us with relevant predictions, explanations, interpretations, and applications that fit. It was our explanations that were the beginning of codifying GT as a methodology. The key elements of the theory were that the concepts in the theory should have fit and relevance. So many concepts in the world of social research were conjectural, that is reified and not relevant to the area and the participants. To gain fit and be relevant the concepts had to be based on data from in the field of inquiry and be relevant to the participants. In short, they had to be grounded. They also had to be conceptual so they could be integrated by a theoretical code into a conceptual theory. What theoretical code that seemed to fit the dying data was context theory. The total product...