Grounded Theory in Practice, Education,
and Administration
C H A P T E R
8
G
rounded theory research creates opportunities for nurses to develop substantive theories regarding phenomena important for nursing practice as well as the administrative and educative processes that are inherent to the discipline.In Chapter 7, methodological issues related to grounded theory investiga- tions were described. This chapter examines published grounded theory studies in the areas of nursing practice, education, and administration. Two important questions guided the direction of this chapter: When should grounded theory be used?andHow has the method been used to study issues in nursing education, administration, and practice?Three research studies will be reviewed using the guidelines for evaluating grounded theory research pre- sented in Box 8-1. A reprint of Bach, Ploeg, and Black’s (2009) article is provided at the end of this chapter to assist readers in understanding the cri- tiquing process. The chapter also provides readers with an overview of selected studies that highlight how nurse researchers have used grounded theory research in the investigation of phenomena important to nursing (Table 8-1).
Box 8-1
Guidelines for Critiquing Research Using Grounded Theory Method Focus/Topic
1. What is the focus or the topic of the study? What is it that the researcher is studying? Is the topic researchable? Is it focused enough to be meaningful but not too limited so as to be trivial?
2. Has the researcher identified why the phenomenon requires a qualitative format?
What is the rationale for selecting the grounded theory approach as the qualitative approach for the investigation?
Purpose
1. Has the researcher made explicit the purpose for conducting the research?
Significance
1. Does the researcher describe the projected significance of the work to nursing?
2. What is the relevance of the study to what is already known about the topic?
Method
1. Given the topic of the study and the researcher’s stated purpose, how does grounded theory methodology help to achieve the stated purpose?
2. Is the method adequate to address the research topic?
3. What approach is used to guide the inquiry? Does the researcher complete the study according to the processes described?
Sampling
1. Does the researcher describe the selection of participants and protection of human subjects?
2. What major categories emerged?
3. What were some of the events, incidents, or actions that pointed to some of these major categories?
4. What were the categories that led to theoretical sampling?
5. Did the research specify how and why participants were selected for the study?
Data Generation
1. Does the researcher describe data collection strategies?
2. Have participants been allowed to guide the direction of the inquiry?
3. How did theoretical formulations guide data collection?
Data Analysis
1. Does the researcher describe the strategies used to analyze the data?
a. Has the theoretical construction been checked against the participants’
meanings of the phenomenon?
b. Are the researcher’s views and insights about the phenomenon articulated?
c. Has the literature been related to each category that emerged in the theory?
2. Does the researcher address the credibility, auditability, and fittingness of the data?
3. Does the researcher clearly describe how and why the core category was selected?
studies should evaluate their studies according to those recommendations.
But, general guidelines can be challenging to apply, especially for novices who critique research to gain a deeper understanding of the method as well as the subject.
Therefore, specific criteria for evaluating grounded theory investigations are provided to help reviewers focus on critical elements of the method (see Box 8-1). When reviewers are critiquing any published investigation, it is important to recognize that journal restrictions, page limitations, or other external forces beyond the author’s control may have necessitated deletion of certain material, resulting in a limited critique of the research. Readers in- terested in more detailed discussion of method in a published study should contact the author.
APPLICATION TO PRACTICE
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rounded theory method offers an important opportunity for nurses interested in examining clinical practice issues and developing substan- tive theory. An example of grounded theory research related to the practice arena is the study “Nursing Roles in End-of-Life Decision Making in Critical Care Settings” by Bach et al. (2009); this is the reference for critique in this section. This study provides an example of grounded theory research in the investigation of phenomena important to nursing practice.Box 8-1 (Continued)
Empirical Grounding of the Study: Findings 1. Are concepts grounded in the data?
2. Are the concepts systematically related?
3. Are conceptual linkages described, and are the categories well developed? Do they have conceptual density?
4. Are the theoretical findings significant? If yes, to what extent?
5. Were data collection strategies comprehensive and analytical interpretations conceptual and broad?
6. Is there sufficient variation to allow for applicability in a variety of contexts related to the phenomenon investigated?
Conclusions, Implications, and Recommendations
1. How does the researcher provide a context for use of the findings?
2. Are the conclusions drawn from the study appropriate? Explain.
3. What are the recommendations for future research?
4. Are the recommendations, conclusions, and implications clearly related to the findings?
Adapted from Chiovitti, R., & Prian, N. (2003). Rigour and grounded theory research.
Journal of Advanced Nursing Practice,44(4), 427–435, and Strauss, A., & Corbin, J.
(1990). Basics of qualitative research: Grounded theory procedures and techniques.
Newbury Park, CA: Sage.
Table 8-1•Selective Sampling of Grounded Theory Research Studies Author(s)DateDomainPhenomenon of InterestSampleData GenerationFindings Crowe, V.L.H. & Bitterman, J.E.
2009PracticeDepression25 individuals who had a history of de- pression, but were not acutely depressed at the time of the inter- view. Other data sources included online information, autobiographical literature, and instru- ments developed by the researchers.
Interviews, review of online infor- mation, and quantitative data.
A theory of “Unprivitizing” was developed from the data, which involved start talking, help-finding, and self-knowing. A transition period followed, which led to “Integrating”. Integrating involved self-discovery, self-caretaking, and mean- ing making. Chiovitti, R.F.2008PracticeCaring17 Registered Nurses licensed with the College Of Nurses of Ontario
Individual inter- views which led to theoretical sampling.
A theory of “Protective em- powering” was discovered, and involves six main categories: respecting the patient, not taking the patient’s behavior person- ally, keeping the patient safe, encouraging health, authentic relating, and interactive teaching.
Wells, J.N., Cagle, C.S., Bradley, P., & Barnes, D. M.
2008PracticeCaregiving experi- ences of Mexican American Women.
34 female Mexican American family caregivers of cancer patients.
Two interviews by bilingual and bi- cultural students research assistants.
The process of caring for a family member with cancer involved becoming stronger. Subprocesses in- cluded: life restructuring, strategizing, and struggling. Hanson, K. & Stenvig, T.E.
2008EducationNeophyte baccalaureate- prepared nurses’ views of educators’ attributes.
6 RNs who completed a baccalaureate pro- gram within the 6–18 months of the interview.
Individual inter- views which were guided by open- ended questions.
Categories of positive clin- ical educator attributes were discovered: educator knowledge, interpersonal presentation, and teaching strategies. Mills, J, Francis, K. & Bonner, A.
2008EducationNurses’ experiences of mentoringNine rural nurses who had experience with mentoring others.
Eleven individual interviews, email dialogue, and situational mapping.
The overall study resulted in a theory of “cultivating and growing” rural nurses which was found to be a two part process involving getting to know a stranger and walking with another. In this paper, the re- searchers described the process of getting to know a stranger. It entailed “looking after each other, the importance of a name,and building a foundation.”
Table 8-1•(Continued) Author(s)DateDomainPhenomenon of InterestSampleData GenerationFindings
Luhanga, F., Yonge, O. & Myrick, F.
2008EducationPreceptorshipTwenty-two nurses who precepted stu- dents in their final clinical practicum.
One to one inter- views with pre- ceptors lasting 20–50 minutes.
Several student behaviors caused preceptors to deem their practice unsafe: in- ability to demonstrate knowledge and skills, atti- tude problems, unprofes- sional behavior, and poor communication skills. Reid-Searl, K, Moxham, L., Walker, S. &Happell, B.
2008EducationMedication adminis- tration errors by nurs- ing students Interviews with 28 undergraduate nurs- ing students, using open-ended questions.
Recorded and transcribed inter- views were analyzed using constant compar- ison to generate categories.
The core category was “ supervision.” The central problem was “shifting lev- els of supervision” and involved a shift from close supervision to no supervi- sion. These levels were named: being with, being over, being near, and being absent. Sherman, R.O., Bishop, M., Eggenberger, T., & Karden, R.
2007AdministrationLeadership skills and competency.Ninety-eight experi- enced nurse managers and 22 inexperienced nurse managers (n⫽120).
One-hour tran- scribed interviews which were guided by inter- view questions.
The nursing leadership competency model was developed, which included six categories: personal mastery, interpersonal ef- fectiveness, financial man- agement, human resource management, caring, and systems thinking.
Bondas, T.2009AdministrationNursing leadership Sixty-five first line nurse managersNurse managers were asked to write narrative re- sponses to open- ended questions that were coded using line by line analysis.
The core category was “Preparing the air for Nursing Care” and in- cluded two major cate- gories “Creating the direction and content ofnursing care” and “Concerned about nursing care.” McGilton, K.S., Bowers, B., McKenzie- Green, B., Boscart, V., & Brown, M.
2009AdministrationLong Term Care nurses’ understanding of the charge nurse’s role.
Individual interviews with 16 charge nurses employed at 8 facilities.
Interviews were transcribed and analyzed using line by line dimensional analysis.
The data analysis resulted in the discovery of three di- mensions of the supervisor role in long-term care: (1) Against all odds getting through the day, (2) step- ping in work, (3) leading and supporting unregu- lated care workers.
Table 8-1•(Continued) Author(s)DateDomainPhenomenon of InterestSampleData GenerationFindings
Bach et al.’s (2009) article focused on the role of the critical care nurse in end-of-life (EOL) decision making. The topic is meaningful to practicing nurses, and for those who are interested in understanding the role of the nurse in supporting families through difficult decisions. The researchers aimed to develop a conceptual framework to elucidate the process that oc- curs between nurses and clients. A qualitative approach was chosen because
“little is known about the role of nurses in EOL in the critical care setting, and therefore a grounded theory study in this area is needed to further un- derstand this important role” (p. 499). The researchers clearly identified the purpose of the study as an effort “to bring to light the role of critical care nurses in decision making at the end of life” (p. 499).
The researchers supported the need for the study through a thorough review of the extant literature. They noted that most clients spend their last days in critical care settings, and nurses play a pivotal role in supporting clients through EOL decisions. Additionally, the authors argued that critical care nurses are advocates for their patients in making their wishes known to the physician. Bach et al. (2009) stated that although some important aspects of the role of the critical nurse’s role in EOL decision making have been discussed in the literature, the processes that facilitate such discussions and ultimately decision making had not been previously studied, thereby indicating the need for their research and the grounded theory approach.
Grounded theory method is specifically aimed at discovering the processes at work in the substantive area. Thus, the method is well suited for uncovering the processes used by critical care nurses when working with clients facing EOL issues. Consistent with the Straussian grounded theory approach, the researchers stated the research question as “what role do nurses have in EOL decision making in the critical care setting?” (p. 499).
This question is both broad enough to allow key issues to emerge, yet nar- row enough to focus the research directly on a specific issue.
Because the research question focused specifically on the role of the nurse in critical care, the sample consisted of 14 registered nurses (RNs); 10 worked in the Intensive Care Unit, and 4 worked in the Cardio-Respiratory Care Unit. The sample is appropriate for gathering data relevant to the re- search question. Prior to beginning data collection, the researchers obtained approval from an ethics board. The authors also noted that the nurses re- ceived a letter outlining the purpose of the study, the research method, and assurance that they could withdraw from the study at any time.
The data were gathered through individual interviews that were guided by a written interview agenda. Questions were revised as the study progressed to clarify emerging concepts or explore new theoretical leads. The interviews were transcribed verbatim. The computer program N-VIVO was used to or- ganize and store data. The data were then analyzed using the process de- scribed by Strauss and Corbin (1998), which involved open coding, axial coding, and selective coding. Although the researchers did not specifically describe theoretical sampling, they did discuss the process of selective
coding, which is related to theoretical sampling. Selective coding entails coding for the core category, and helps the researchers determine connec- tions among the categories. Bach and colleagues explained that “through selective coding, categories were examined to discover broader relationships and identify main themes while allowing a framework to emerge and recre- ate data into a conceptual framework” (p. 501).
The overall theme that was discovered upon analysis of the data was
“Supporting the Journey.” The researchers explained that this category in- volved “all measures taken to support . . . life,” or to “decide to support the death” (p. 503). This main category explains most of the action in the sub- stantive area and conveys the nurses’ role in EOL decision making in the critical care setting. Four major themes were also discovered, including 1.
Being there, 2. A voice to speak up, 3. Enable coming to terms, and 4.
Helping to let go. These four themes explained the nurses’ roles in support- ing both the patient and the family. In describing the development of the themes, the researchers provided data to support their inclusion. Thus, the concepts are grounded in the data.
The four main concepts appear to be important dimensions of the over- arching category “Supporting the journey.” The authors stated that the four main categories were developed upon “further reflection on and analysis of the data” (p. 503). Theoretical findings presented in the results of the study are significant for practicing nurses, those developing hospital policies, and those educating the public on the role of the nurse. Applicability of the find- ings to other areas of nursing could be explored through further research.
The researchers provided a thorough discussion of the applicability of the findings for educating members of the interdisciplinary team, and family members of critically ill clients. Further, the findings “give voice” to critical care nurses who are not typically recognized for their role in EOL care. The findings confirm the vital role of the critical care nurse in provid- ing presence and support through EOL issues. Additionally, the participants, all critical care nurses who clearly address EOL issues regularly, had not received any EOL or palliative care education. Thus, the researchers con- cluded that nursing programs, and critical care orientation programs, should require education in EOL, palliative care, and bereavement.
APPLICATION TO EDUCATION
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ursing education continues to be an important area for the conduct of research and presents another context in which nurse researchers can conduct grounded theory investigations. Although relatively few grounded theory studies exist in the domain of nursing education, research studies that focus on teaching-learning offer the grounded theory researcher a rich opportunity for study. An example of the contribution grounded theory can make to nursing education is a study by Luhanga, Yonge, and Myrick (2008),“Failure to assign failing grades: Issues with grading the unsafe student.”
This article serves as the reference for critique in this section and was se- lected because it demonstrates the use of grounded theory in studying a nursing education issue. This study illustrates a good presentation of find- ings from a grounded theory investigation.
Luhanga et al. (2008) “sought to determine how preceptors teach and manage unsafe students” (p. 1). The authors explained that in Canada, where the study took place, preceptors often take responsibility for a student in the clinical setting, and faculty rely on their feedback to determine the competence of the student. The topic is relevant to nursing education, and is neither too broad nor too narrow in its scope. A qualitative approach was chosen because “to date, there is little literature regarding the process of pre- cepting students with unsafe practices” (p. 3). The researchers conducted a review of the literature which supported the need for further inquiry into the substantive area. The study was expected to provide insights into how preceptors work with students who demonstrate unsafe practice in the clin- ical arena.
Grounded theory method is useful for uncovering new dimensions of a research area, and is thereby appropriate for achieving the stated purpose of the research. The researchers did not state whether Straussian or Classic grounded theory method was chosen, and appear to mix the methods. For example, a research question was not explicitly stated, which is consistent with Classic grounded theory method, but an interview guide, based on the review of the literature was used, which is more consistent with Straussian grounded theory method. Data gathering commenced with a purposive sample. Permission was obtained from an Ethics Board prior to beginning data collection.
Participants were originally selected based on their experience with pre- cepting senior-level students who exhibited unsafe practices. As data analy- sis began, preceptors were sought who had not had experiences with unsafe students, but had nonetheless served as preceptors. The researchers ex- plained that these participants provided “negative cases,” but did not pro- vide the data or categories that led to the decision. Data were collected through individual interviews and review of documents such as preceptor guidelines. The researchers did not state whether field notes were gathered during the interviews or if the interviews were transcribed. The interview questions were altered based on the data collected during the interviews which is consistent with the method.
Data were analyzed through constant comparison, and entailed open coding, theoretical coding, and selective coding. Each of these processes was well described by the researchers. They specifically addressed the study’s rigor in terms of credibility and fittingness. The core category was identified which “tied all other categories in the theory together” (p. 5). The core cate- gory was named “promoting student learning and preserving patient safety”
and entailed five dimensions, or categories, which were empirically derived from the data. These dimensions were named: “1. hallmarks of unsafe
practice, 2. factors contributing to unsafe practice, 3. preceptors’ perceptions and feelings, 4. grading issues, and 5. strategies for managing unsafe practice”
(p. 5). In the article, the researchers chose to focus specifically on the grading issues.
The category “grading issues” included three subcategories, entitledreasons for presenting as an unsafe student,reasons for failure to fail borderline or unsafe studentsandrole of the preceptor as gatekeeper to the profession. The development of each of the subcategories was supported with data. The conceptual linkages among the core category, the category “grading issues” and its subcategories were made clear. The theoretical findings presented in the article, although mainly descriptive in nature, enhanced understanding of non-faculty involve- ment in evaluating nursing students’ performance in the clinical setting.
Variation within the data was enhanced by recruiting preceptors who had experience working with unsafe students, and those who had not.
Although the researchers recognized the importance of the role of the pre- ceptor as “gatekeepers” in disciplines other than nursing, they were careful not to make sweeping statements about the usefulness of the findings. The conclusions they drew were confined to the results of the study, and the rec- ommendations they made for nursing education were appropriate. Although they noted that preceptors’ hesitancy to assign failing grades to unsafe stu- dents has been documented in disciplines such as social work and medicine, it is not clear whether the results of Luhanga, Yonge, and Myrick’s (2008) study could be applied wholesale in other disciplines. Thus, the authors recommended the study be replicated “nationally and internationally . . . to explore the issues of professional and pedagogical accountability” (p. 12).
APPLICATION TO ADMINISTRATION
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ursing administration is an oft overlooked area of nursing practice and the extant research in this area is sparse. Few studies have explored ad- ministrative issues from a grounded theory perspective. A recent article by Sherman, Bishop, Eggenberger, and Karden (2007) provides an excellent ex- ample of the usefulness of the grounded theory approach in discovering new aspects of nursing roles. In their study, the researchers explained that the participants had “fallen into the position through assuming it as an in- terim assignment” (p. 86), conveying the lack of career planning for man- agement positions. The authors further explained that the role of the nurse manager is multi-faceted and not well defined. Their grounded theory study helped to elucidate the dimensions of the role from the perspective of those who are in the position.Sherman et al. (2007) used grounded theory method to explore the di- mensions of nursing leadership. The purpose of the study was to examine the competencies needed by contemporary nurse mangers. The focus of the study is limited enough to delineate the research area, but broad enough to be meaningful. A qualitative research approach was chosen because the