An exploration of how clinician attitudes and beliefs influence the implementation of lifestyle risk factor management in primary healthcare: a grounded theory study

Background

Despite the effectiveness of brief lifestyle intervention delivered in primary healthcare (PHC), implementation in routine practice remains suboptimal. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about the process by which clinicians' perceptions shape implementation. This study aims to describe a theoretical model to understand how clinicians' perceptions shape the implementation of lifestyle risk factor management in routine practice. The implications of the model for enhancing practices will also be discussed.

Methods

The study analysed data collected as part of a larger feasibility project of risk factor management in three community health teams in New South Wales (NSW), Australia. This included journal notes kept through the implementation of the project, and interviews with 48 participants comprising 23 clinicians (including community nurses, allied health practitioners and an Aboriginal health worker), five managers, and two project officers. Data were analysed using grounded theory principles of open, focused, and theoretical coding and constant comparative techniques to construct a model grounded in the data.

Results

The model suggests that implementation reflects both clinician beliefs about whether they should (commitment) and can (capacity) address lifestyle issues. Commitment represents the priority placed on risk factor management and reflects beliefs about role responsibility congruence, client receptiveness, and the likely impact of intervening. Clinician beliefs about their capacity for risk factor management reflect their views about self-efficacy, role support, and the fit between risk factor management ways of working. The model suggests that clinicians formulate different expectations and intentions about how they will intervene based on these beliefs about commitment and capacity and their philosophical views about appropriate ways to intervene. These expectations then provide a cognitive framework guiding their risk factor management practices. Finally, clinicians' appraisal of the overall benefits versus costs of addressing lifestyle issues acts to positively or negatively reinforce their commitment to implementing these practices.

Conclusion

The model extends previous research by outlining a process by which clinicians' perceptions shape implementation of lifestyle risk factor management in routine practice. This provides new insights to inform the development of effective strategies to improve such practices.

Communicating change in organizational restructuring: a grounded theory case study

Literature has shown that planned change is accompanied by excitement and hope. People affected by change require qualityinformation. Failure to communicate change may lead to resistance. This paper presents a change involving the amalgamation oftwo university faculties into one. Within the framework of a case study research design and the used of the ConstructivistGrounded Theory for data collection and analysis, the theme of communication during the change process is presented throughthe experiences and life accounts of faculty members involved and affected by it. The paper ends with useful suggestions forchange agents in today’s complex organization.

Board directors and conflict of interest : a study of a sport league

Conflict of interest is one aspect of governance that has the potential to damage both an organisation and those who govern that organisation. Board directors of sport organisations are faced with a number of influences particular to sport business, which can impact on the process of managing conflict of interest. This research identified processes and attributes that influence directors: selection processes, outside roles, experience, regulation, education, motivation and qualifications. Directors and CEOs drawn from a sample of five Australian Football League (AFL) clubs and members of the AFL commission were interviewed. Data analysis was undertaken using a constructivist grounded theory method, and key processes (selection processes and director education) and attributes (outside roles, experience, regulation, motivation and qualifications) of non-executive directors were identified. By better understanding the influences on board directors in sport organisations, and the impact of these on managing conflict of interest, the potential for damage to the directors and the organisation may be decreased.

Voice, post-structural representation and the subjectivity of ‘included’ students

Aligned with the broader movement from structuralism to the post-structuralisms [Lather, P. 2013. “Methodology-21: What Do We Do in the Afterward?” International Journal of Qualitative Studies in Education 26 (6): 634–645; St. Pierre, E. A. 2009. “Afterword: Decentering Voice in Qualitative Inquiry.” In Voice in Qualitative Inquiry: Challenging Conventional, Interpretive, and Critical Conceptions in Qualitative Research, edited by A. Y. Jackson and L. A. Mazzei, 221–236. London: Routledge; St. Pierre, E. A. 2013. “The Posts Continue: Becoming.” International Journal of Qualitative Studies in Education 26 (6): 646–657], research in disability studies for the past two decades has found ‘the potholes’ [Miller, L., J. B. Whalley, and I. Stronach. 2012. “From Structuralism to Poststructuralism.” In Research Methods in the Social Sciences, edited by B. Somekh and C. Lewin. London: SAGE] of disability rights scholarship. In this paper, I offer a critical research framework in the field of disability studies in education that is theoretical, political and personal. Concentrating on the positioning of disability, I draw on the methodological tools of post-structural representation, subjectivity and constructivist grounded theory to study how discursive practices within (and around) secondary schools shape ‘included’ disabled subjects. In the paper I develop this framework and then demonstrate its application in ongoing research that critically counters the conventions that marginalize particular students in schools.

Exploring the later life relationship between adults with cerebral palsy and their non-disabled siblings

 Purpose: Adults with moderate or severe cerebral palsy often require significant lifetime support from family and formal services. The aim of this study was to use a life course approach to explore how previous life experiences impact on the later life relationships of people with moderate to severe cerebral palsy aged 40 years and over and their non-disabled siblings. Method: Twelve adults with moderate to severe cerebral palsy and 16 of their non-disabled siblings were interviewed twice to explore their relationships. Constructivist grounded theory method was used to analyse the data. Results: Four themes were identified as important in understanding these later life sibling relationships: sharing childhood experiences, contact in adulthood, diminishing parental role and increasing support needs. Conclusions: The life course approach indicated that siblings' growing up together was important for the development and maintenance of emotional closeness later in life. Emotional closeness and familial obligation were important factors in motivating siblings with and without cerebral palsy to maintain or re-establish contact with each other in adulthood. Maintenance of sibling relationships in later life is dependent on health, proximity and the ability to keep in contact with each other.Implications for RehabilitationAs adults with severe cerebral palsy live longer, their relationships with non-disabled siblings often take on increased importance and particularly as their parents may be no longer able to provide support.Service providers have a role in helping ageing siblings with and without disability to maintain and build their relationships, for example, by supporting geographically distant siblings to keep in touch.Service providers have a role in supporting the person with a disability and their siblings to make plans for the future. © 2014 Informa UK Ltd.

‘It should be a big responsibility’: Separated low-income mothers’ evaluation of child support arrangements and the conduct of fathers

The Australian Child Support Scheme was established as a means of ensuring adequate financial support for children of separated parents. However, within the financial transfer of child support exist notions of ‘trust’ and ‘fairness’ based on parents navigating their changed relationship post-separation. Previous research has explored the assessment and outcomes of child support for both payee and payer parents, however little attention has been given to how women evaluate the assessment and outcomes of child support. As such, this research aimed to explore payee mothers’ evaluation of their child support experiences based on the value of their child support assessment and the extent to which these payments were received. Following the methods of constructivist grounded theory, in-depth interviews were conducted with 20 low-income single mothers. Analysis revealed that payee mothers evaluated child support based on the moral assumptions and the rationalities they perceived were underlying payer fathers’ child support compliance. While payee mothers desired arrangements that reflected joint parental financial responsibility, in reality many experienced problematic child support payments, which may ultimately undermine payee parents’ confidence in the Child Support Scheme.

Communication changes experienced by adults with cerebral palsy as they age

PURPOSE: Adults with cerebral palsy (CP) experience multiple, functional changes as they age, including changes to communication modes and methods that enable development and maintenance of relationships, communicative participation and quality-of-life. Little is known about the nature of communication changes experienced by this group. The aim of this study was to better understand how adults with CP experience changes in their communication abilities as they age and the subsequent psychosocial impact.

METHOD: Twenty adults with cerebral palsy aged 40-72 years with complex communication needs (CCN) participated in a series of in-depth interviews, framing their experiences of loss and grief throughout their lives. The impact of changing communication abilities emerged as an important area of focus. Data were analysed using constructivist grounded theory methodology.

RESULT: Themes arising from the participants' perceptions of their communication included experiencing communication change as a loss with subsequent impact on self-concept; and how communication is integral to the process of managing losses associated with older age.

CONCLUSION: Implications for speech-language pathologists working with older people with cerebral palsy and CCN include the need to understand the psychosocial impact of communication changes on social interaction, relationships and communicative participation. It is important to promote positive and meaningful communication options that maintain a coherent sense of self in addition to promoting functional communication skills and communicative participation.

Dynamic due diligence : an entrepreneurial business planning method for evaluating mergers and acquisitions: theory, case application and general implications

This paper presents a method for conducting dynamic due diligence to evaluate Mergers and Acquisitions; demonstrates its effectiveness in a particular case; and extrapolates its theoretical and practical implications to the general case. It may be called the ‘ECIPP’ method - an acronym for: Establishing mandates; Creating projections; Identifying issues; Prioritizing procedures and Performing them.

Two established alternative due diligence methods are examined. The prevailing finance-theory-based procedure has the virtues of simplicity and elegance; the vice is abstraction. The prevailing practitioner-based regime has the virtues of thoroughness and concreteness but the vices of rigidity and inefficiency. Resolving the tradeoffs inherent in both static prescriptions provides an opportunity for a dynamic, innovative approach derived from grounded theory and an application of Hindle’s (1993) theory of venture renaissance through application of an enhanced paradigm of Entrepreneurial Business Planning. The ECIPP method retains simplicity, concreteness and thoroughness but eliminates abstraction, rigidity and inefficiency.

This is demonstrated in a case. ChildCo’s CEO had only one month to complete his M&A evaluation; no expertise or previous experience; severely limited budget for the exercise and had been flatly informed by prevailing M&A experts that what he wanted could not be done. Using the ECIPP method, the CEO and the author did it: on time, within budget and to the satisfaction of a previously skeptical board of one of the world’s largest multi-national companies including arguably the world’s most professional corporate M&A division.

The replicability logic of the case research permits two generalisations. (1) ECIPP extends the range and utility of Entrepreneurial Business Planning as a management technology, well beyond the constraints to which it is usually confined. (2) The ECIPP method of dynamic due diligence is an innovation worthy of mature consideration and further investigation by theorists and practitioners in the M&A field, in the disciplines of both Finance and Entrepreneurship and, well beyond, in the realms of general management theory, methodology and practice.

Corporate social responsibility in professional team sport organisations : towards a theory of decision-making

Research question: 

Challenging the handover : recommendations for research and practice

Communicating nursing care during the patient's total hospital stay is a difficult task to achieve within the context of high patient turnover, a lack of overlap time between shifts, and time constraints. Clear and accurate communication is pivotal to delivering high quality care and should be the gold standard in any clinical setting. Handover is a commonly used communication medium that requires review and critique. This study was conducted in five acute care settings at a major teaching hospital. Using a grounded theory approach, it explored the use of three types of handover techniques (verbal in the office, tape-recorded, and bedside handovers). Data were obtained from semi-structured interviews with nurses and participant field observations. Textual data were managed using NUD-IST. Transcripts were critically reviewed and major themes identified from the three types of handovers that illustrated their strengths and weaknesses. The findings of this study revealed that handover is more than just a forum for communicating patient care. It is also used as a place where nurses can debrief, clarify information and update knowledge. Overall, each type of handover had particular strengths and limitations; however, no one type of handover was appraised as being more effective. Achieving the multiple goals of handover presents researchers and clinicians with a challenging task. It is necessary to explore more creative ways of conducting the handover of patient care, so that an important aspect of nursing practice does not get classified as just another ritual.

Guided reflection: transcending a routine approach in the management of sexually transmissible infections

This paper describes a distinctive approach to the sexually transmissible infections (STI) clinical consultation: 'the guided reflection approach'. The authors coined this term and identified the guided reflection approach through analysis of 22 in-depth interviews with practitioners who provide care for people with STI, and 34 people who had attended a healthcare facility in Australia for screening or treatment of an STI. A grounded theory method was used to collect and analyse this information. The data revealed when the STI consultation is conducted using the principles characterized by the guided reflection approach creates contexts for sexual empowerment that have the potential to effectively assist people to gain autonomy for safe sex. Routinely, most of the practitioners in this study were shown to direct the STI consultation towards risk behaviours and practices and prevention of transmission, with minimal intervention. However, this study shows that if clinical interaction is to make a difference to the patient's autonomy for sexual behaviour, two changes will be required. First, practitioners need to adopt the goal of assisting patients to attain levels of autonomy, and second, practitioners require education to assist them to develop the interactive skills needed to engage patients in dialogue and reflection about sexual behaviour.

Nurse academics meeting the challenges of scholarship and research

This research study explored nurse academics' perceptions and experiences of scholarship and research. Interviews were carried out with 20 nurse academics in four Australian states. A grounded theory approach was used to explore issues they faced. The paper discusses how academics engaged in research and scholarship integrate it into their work practices. The participants spoke of problems encountered, such as the difficulty of gaining higher degrees whilst undertaking additional research. They indicated they felt under significant pressure to publish. The organisational structures that a small number of institutions put in place to facilitate the development of a scholarly research culture are illustrated.

Recruiting in public places : A strategy to increase diversity in qualitative research samples

For some research projects, recruiting in public places is an invaluable addition to sampling strategies. It complements the more traditional recruitment strategies by providing researchers with' opportunities to include people in the research who would otherwise be excluded. One of the limitations of selective and snowball sampling is that participants often come from the same social group. Participants from these social groups often share similar experiences and ways of thinking about those experiences. The aim of recruiting in public places is to move beyond this 'in group' to ensure a wider perspective. This paper illustrates how recruiting in public places can provide greater sample diversity for theoretical strength. The paper begins with a brief overview of recruiting in public places. It then describes the theoretical considerations associated with this recruiting strategy. The paper demonstrates how recruiting in public places facilitates grounded theory by providing comparisons that are informed by diverse experiences. Using examples and a case study, we illustrate how recruiting in public places can complement selective, snowball and theoretical sampling to ensure a more comprehensive sample.