Week 8 - Grounded Theory

Grounded theory, as I have understood from this week's readings, is a research methodology that challenges qualitative researchers to gain a deeper understanding of an observed social process through the development and refinement of a theory (Streubert & Carpenter, 2011, p.129-130).  In the classical sense (Glaser & Strauss), the researcher is naive to the area of study, participants are experts and data is gathered via unstructured interviews, field notes, photos, and/or historical documents. When saturation of data is achieved, concepts are coded and theoretical connections are made to create a substantive theory about the area of study (Streubert & Carpenter, 2011, p. 127). In the Straussian sense, initial insight into an area of study is gained through literature review and a research question is framed to limit the scope of the study--the assumption is that concepts relating to the phenomenon are limited or poorly understood.  Data collection and analysis methods are similar to the classical sense, except that interviews may be structured (with open-ended questions) and the use of computer programs is an acceptable tool to analyze data. The concepts and themes that emerge are discussed in a descriptive sense, but may not lead to theory development (Streubert & Carpenter, 2011).

Working in the ICU, the article by Bach, Ploeg & Black (2009) resonated with me as end-of-life decision-making is a concept that has emotional, practical and ethical considerations. I have struggled with initiating that conversation with families; and have experienced from the patient-family perspective, having that conversation initiated with me by another nurse. It is a very delicate conversation topic, and my personal experience with it, means that I don’t enter into it lightly. My grandmother was diagnosed with pancreatic cancer over two years ago. At the time of her diagnosis, she was living independently and sought advice from her family doctor after having diffuse mild to moderate abdominal pain for the last month.  What followed over the next two weeks was an ultrasound, a CT, and an expedient consult to a surgical oncologist at Sunnybrook, where she ultimately received surgery for her pancreatic mass.  This is all to say, that as her family, because of her rushed diagnosis and treatment, we were unprepared to see her as an unwell person in the hospital.  In one of her earlier re-admissions to the ICU (postoperative GI bleed), I distinctly remember a nurse approaching me, the nurse in the family, with the subject of re-evaluating my grandmother's code status from full to DNR. At the time, I was wholly unprepared for this conversation--my grandmother's surgery had gone well! She walked into the hospital! Yes, she was intubated and on pressors, but the doctors had managed her bleeding, and she was on an upward swing.  That nurse's intention of "being real" with me, felt totally misplaced as she didn't know anything about my grandmother, only her age and diagnosis had convinced her this was an appropriate conversation. We, as her family, had been with her through her entire journey while she was hospitalized, surely we would know when to let go... My grandmother did recover, and continues to live at home independently with support and the understanding now that she would not want extreme measures if she were to fall ill again.

           I agree with Bach, Ploeg & Black's (2009) use of Straussian grounded theory to describe end-of-life decision making among critical care nurses. The authors captured the core concept well--supporting the journey and its four major themes, being there, a voice to speak up, enable coming to terms, and helping to let go.  Nurse presencing is one of the fundamental roles used to support patients and families in palliative care.  As is the balance of providing truth and hope to patients/families among the healthcare team. The authors identify the lack of palliative care education among critical care nurses.

References

Bach, V., Ploeg, J., & Black, M. (2009). Nursing roles in end-of-life decision making in critical care settings. Western Journal of Nursing Research, 31(4), 496–512. https://doi.org/10.1177/0193945908331178

Streubert, H. J., & Carpenter, D. R. (2011). Qualitative research in nursing: Advancing the humanistic imperative. (5^th ed.).  Philadelphia: Lippincott, Williams & Wilkins.