Undergraduate dental students' perceptions of dental pain in children - A grounded theory study.

INTRODUCTION: There is an underuse of pain management strategies in dental care for children, possibly owing to perceived stress and discomfort when treating children, which has also been reported by dental students. The aim of this study was to explore how undergraduate dental students experience and understand pain related to dental treatment in children. MATERIALS AND METHODS: Interviews were held with 21 Swedish dental students, from 3 dental schools, all in their final 2 years of education. The interviews were transcribed verbatim and analysed according to Grounded Theory. RESULTS: A core category, seeking guidance to avoid pain, was identified and related to 6 conceptual categories. The students used different strategies to manage pain prevention in child dentistry and to become skilled dentists. They described high levels of stress, as well as having high expectations on themselves when treating children. The stress led to a surface learning approach, something the students were not fully aware of. CONCLUSION: All children should have the right to be ensured optimal pain prevention in dental care. The basis for this is laid during undergraduate education. Thus, pain management in child dentistry is an area in need of special attention in this respect. The academic staff has an important role in supporting their students in their process to gain an identity as professional dentists. To ensure that students incorporate an understanding of the importance of pain prevention when treating children there is a need to create more integration between theory and clinical training in undergraduate education.

A grounded theory study on Swedish 10 to 16-year-olds' perceptions of pain in conjunction with orthodontically indicated tooth extraction.

OBJECTIVE: Children frequently experience pain and/or discomfort during dental treatment. Still, pain research in dentistry has mainly been performed on adults using quantitative methods while research on the child's perspective is scarce. This study aims to explore and describe children's experiences and/or thoughts regarding pain in conjunction with tooth extraction. MATERIAL AND METHODS: Interviews were carried out with twelve Swedish 10-16-year-olds who had recently undergone tooth extractions due to orthodontic reasons. Interviews were transcribed verbatim and analysed according to grounded theory. RESULTS: A core category was identified and named 'handling the unavoidable unknown'. The informants recalled experiences of pain and discomfort during extractions. However, instead of focussing on pain, they described an urge for more information about the procedure and what to expect in terms of pain and/or discomfort, during and/or after treatment. They stated that the levels of pain/discomfort were manageable, while the lack of information negatively affected their coping abilities, causing feelings of unease. CONCLUSIONS: To improve patients' ability to deal with pain in conjunction with dental extraction, the dental team should ensure better and individually tailored information about the treatment. Thus, the use of psychological techniques is a cornerstone in pain management and must be reflected in clinical guidelines.

Parenting a Child with Juvenile Idiopathic Arthritis, Orofacial Pain, and Dysfunction: A Qualitative Study.

AIMS: To deepen knowledge of how parents of children diagnosed with juvenile idiopathic arthritis (JIA) perceive the orofacial manifestations of the disease, its treatments, and their encounters with dental care providers. METHODS: A total of 15 interviews with parents of JIA patients (3 to 16 years old) with orofacial pain were analyzed according to classic grounded theory. RESULTS: The main problem was identified as controlling an unpredictable life situation that includes a child with JIA. To solve this main problem, the parent was trying to comprehend, help, and speak for the child with disability, a solution that permeated their life situation. This was therefore identified as the core category, and the other categories (ie, ways parents responded to their situation) were reflecting on and re-evaluating the life situation, monitoring the child's symptoms and treatments, adapting everyday routines, seeking doctors and information, influencing school and society, and managing job and family finances. The main problem and the various categories formed a model reflecting how parents of children diagnosed with JIA act and think. CONCLUSION: It is extremely important for caregivers to understand the complexity of the life situation for parents whose children have been diagnosed with JIA. They must facilitate the parent's understanding of how this disease can influence the orofacial area and day-to-day care.

Taking care of oneself by regaining control - a key to continue living four to five decades after a suicide attempt in severe depression.

BACKGROUND: Depression is a strong risk factor for suicide and suicide attempt. Several studies have examined the pathway to suicide attempt, but few studies have considered aspects important for overcoming being suicidal. The aim of the present study was to examine personal strategies to continue living after a suicide attempt. METHODS: A qualitative grounded theory approach was used. Thirteen former inpatients diagnosed with severe depression (1956-1969) participated in a follow-up 42-56 years after their last suicide attempt, which occurred between the ages of 21 and 45. They were interviewed on one occasion between June 2013 and January 2014, using semi-structured interviews. RESULTS: The pathway to a suicide attempt was defined as 'being trapped in an overwhelming situation'. Three categories described the recovery process: 'coming under professional care', 'experiencing relief in the personal situation', and 'making a decision to continue living'. These categories emerged in a core category, labelled 'taking care of oneself by regaining control'. Overcoming being suicidal occurred regardless of recovering from depression. CONCLUSION: In the very long-term course following a suicide attempt, the process of recovery is multi-dimensional and fluctuating, and includes appropriate treatment, connecting with others, decision making, and overcoming existential issues.

Perceived Oral Health and Care of Children with Juvenile Idiopathic Arthritis: A Qualitative Study.

AIMS: To increase knowledge about how children diagnosed with juvenile idiopathic arthritis (JIA) perceive their oral health and dental care. METHODS: Fifteen interviews with children diagnosed with JIA, aged 6 to 16 years, were analyzed according to classical grounded theory. RESULTS: The children's main concern about their oral health was identified as creating a positive identity after being diagnosed with JIA and learning to live with oral health problems. While attempting to cope with this concern, the children often endured in silence, the core category in the analysis. A variety of aspects were found of this core coping strategy, which were categorized as differentiating from the disease, working on personal caretaking and positive attitude, fighting fears and sadness, control of professional aid, and building supportive relationships. The results emphasize the importance for caregivers to show empathy and interest in the child as a person, to ask precise questions when taking case histories so the child does not remain silent, to provide psychosocial support and suggest positive coping strategies, to describe and administer treatments, and to give hope for the future. CONCLUSION: Awareness of the social interaction between a child diagnosed with JIA and health professionals as well as awareness of how to approach a child with longstanding illness are crucial for disclosing and treating the child's orofacial symptoms.

Living with extended-spectrum ß-lactamase: a qualitative study of patient experiences.

BACKGROUND: Extended-spectrum ß-lactamase (ESBL) is an enzyme that conveys resistance to most ß-lactam antibiotics. Infections caused by bacteria producing ESBL are often difficult to treat because of general multiresistance, and hospital care may be necessary even for nonserious infections. METHODS: The aim of this study was to increase our understanding of how infected individuals perceive their situation as "carriers" of multiresistant bacteria. A modified version of grounded theory was used to analyze 7 open interviews. RESULTS: The analysis resulted in the core category Being thrown into the scary and unknown without a map and compass. All informants thought they had received no or insufficient information about ESBL from the health care providers. Informants who had been given some information still had many unanswered thoughts and reflections. Health care staff were lacking in knowledge about ESBL and their own fears that led to the use of extreme hygiene measures, which increased the stigma for the patient. CONCLUSION: To manage their life situation, it is important that persons diagnosed as carriers of ESBL-producing bacteria receive adequate information from the attending doctor.

Processes of enhanced self-understanding during a counselling programme for parents of children with disabilities.

BACKGROUND: The stress and burden on parents of children with disabilities are well documented, and the parents' way of handling the situation is crucial to the health and well-being of all family members, including the child with special needs. We conducted a group-based counselling programme for parents, based mainly on Gestalt education and personal construct theories, aiming at increasing the parents' ability to handle the situation. AIMS: To explore the parents' experiences from processes of change after the counselling programme. METHOD DESIGN: This qualitative study is based on modified grounded theory. METHOD: The study conducted in Norway examines the experiences of 67 parents (of whom 29 fathers) of children with disabilities. Information was collected through focus group discussions after finishing their sessions of the counselling programme. FINDINGS: From the parents' experiences, the following categories were developed: feeling motivated to communicate, describing oneself in new words, being inspired to experience one's own emotions, being more present and in charge and making a difference by taking new steps. The core category in our analysis turned out to be Improved handling of the situation by enhanced self-understanding. The parents seemed to redevelop their self-understanding through new experiences of themselves. They emphasized the importance of a secure setting of peers with similar experiences and skilled counsellors to feel free to explore one's own emotions with connecting thoughts and bodily reactions. Discussion of existential issues as one's own values also contributed to enhanced self-understanding, which strengthened the parents to find new possibilities and priorities in handling the situation. CONCLUSIONS: The parents described subjective processes of awareness and self-reflection as important for being able to start a process towards enhanced self-understanding, which helped to detect one's own values and new ways of acting. These experiences may be relevant for the parents and for the conduction of future counselling.

Daily life impact of malocclusion in Swedish adolescents: a grounded theory study.

OBJECTIVE: To explore how malocclusions affect daily life in adolescents and how adolescents cope with malocclusion-related distress. MATERIALS AND METHODS: Twelve strategically selected teenagers, seven girls and five boys aged 13-14 years, participated in this study. Open, tape-recorded in-depth interviews based on Focus Group Discussions (FGD) were performed using a theme guide and analyzed according to the qualitative method of classic grounded theory (GT). RESULTS: A core category was identified and named 'Repeatedly reminded of the malocclusion'. Associated to the core category, five categories were generated and labeled 'Being directed by the media's ideal image', 'Monitoring others' teeth', 'Struggling with low self-esteem', 'Hiding one's teeth' and 'Striving for cure'. Low self-esteem appeared to be frequently reinforced through the concerns for the malocclusion and handled via different coping strategies, such as hiding the teeth and striving to receive orthodontic treatment. Such processes were further enforced through the influence of media. Low self-esteem could be associated to a visible malposition of teeth, according to the informants. Having to wait for orthodontic treatment was frustrating the adolescents. CONCLUSIONS: Adolescents with malocclusion are often reminded of their condition, which can lead to avoiding strategies to minimize the negative feelings associated with the teeth and low self-esteem. Clinicians may therefore need to be aware of potential irrational behaviors when interacting with adolescents with malocclusions. The findings also suggest that there might be a discrepancy of attitudes between professionals focusing on oral health aspects of malocclusions and the adolescents focusing on esthetic aspects.

Facing a moral dilemma--introducing a dental care insurance within the public dental service.

Through the reform entitled "Dental care insurance-dental care at a fixed price", patients are offered a dental insurance, a capitation plan, that ensures that they can visit the dentist regularly during a period of three years at a fixed price per month (Frisktandvård).This insurance may be offered to all patients. The aim of this study was to generate a theory explaining the main concern for the staff at the public dental service when they have to introduce and advocate dental care insurance to patients. Interview data from 17 persons, representing different professions within the public dental service, were collected and analyzed simultaneously in line with guidelines for grounded theory. The results indicated that dentists/dental hygienists experienced several difficult standpoints concerning the implementation of the dental insurance, somewhat of a moral dilemma. The staff generally had a "cautiously positive attitude" to the forthcoming dental care insurance, but had perceptions how and when the patients should be offered the insurance and what that may mean to the clinic.The respondents reflected about the economic aspects for the clinic and how the oral health may be affected over time for the patients.

Oral health -- not a priority issue a grounded theory analysis of barriers for young patients with disabilities to receive oral health care on the same premise as others.

Oral health problems are reported more frequently in children with disabilities, but the reasons for this are not fully known. The present study was conducted to illuminate and to gain a deeper understanding of the possible barriers preventing children with disabilities from receiving oral health care on the same premise as others. Transcribed in-depth interviews with 65 informants (14 parents, 18 dental health-care professionals, 17 medical health-care professionals, and 16 individuals with disabilities) were analysed in open, axial, and selective coding processes according to Grounded Theory. The results showed that no-one seems to take an overriding responsibility for the oral health of young patients with disabilities. This was described in a formal theory showing that defective knowledge about importance of oral health, limited ability to focus on oral health, and uncertainty in treating the unknown in patients, family, and dental and medical health-care professionals result in a situation in which oral health is left out in young patients with disabilities; it is not a priority issue.

Grounded theory on factors involved in the decision-making processes of patients treated with implant therapy.

PURPOSE: The aims of this research were to describe the process leading to desire for implant treatment, describe how patients missing teeth gained information about implant treatment, identify gatekeeping factors for implant treatment, and note experiences in changes in oral health-related quality of life. MATERIALS AND METHODS: The constant comparative method for a grounded theory was used in collecting and analyzing data. Ten informants participated in the study, all of whom were treated with implant-supported fixed dentures during the past year. RESULTS: The emerging core category was that participants experienced a journey from social stigma to exhilaration. This process ended in the perspective that the participants' new lives with dental implants were very good and meant an end to their social stigma, but gatekeeping factors before treatment, such as cost and dental anxiety, were noted. The dentist's opinion and suggestions were the most decisive part of the decision-making process, and trust in the dentist and dental team was crucial in the decision to undergo treatment and in the overall treatment experience. Great improvement in oral health-related quality of life was noted. CONCLUSION: This qualitative study gives as the core category and main finding the importance of patients' trust and confidence in the dentist and his/her staff in the process of transforming desire for dental implant treatment into demand and also in making it more likely for patients to be satisfied with treatment regardless of complications.

Increased self-awareness in the process of returning to work.

BACKGROUND: A group of employees on sick leave, living in the Oslo area, Norway, was offered participation in a counselling programme, based on Gestalt theory, mindfulness and phenomenological understanding of the body. AIMS: To explore the participants' processes of change related to their increased ability to work. METHOD DESIGN: This qualitative study is based on modified grounded theory. METHOD: A total of 12 female employees, all who had increased work ability 1 year after the programme, participated in open focus-group interviews at the end of the programme. FINDINGS: The participants' experiences from processes of change are described through the following categories: becoming more aware of one's own thoughts, emotions and bodily reactions; taking oneself seriously and accepting oneself; being secure enough to face being challenged; realizing new possibilities and choices and trying out new ways of acting. The participants further described what had been helpful in these processes. Experience of a secure setting and open-minded listening seemed important for getting the courage to open up to all reactions. Then, they could explore new ways of thinking, communicating and behaving. Discussing existential issues such as their core values was important. This, together with being allowed to take their own emotions seriously and being challenged by the counsellors, had encouraged the processes of change. CONCLUSIONS: The women described how experiences of increased awareness contributed to reconstruction of their self-understanding and opened up for new possibilities. This seemed to have provided them with new ways of communicating and acting, which enhanced participation in work. The context of the learning programme, the existential issues and counselling challenges appeared as essential in these processes of change. The findings give insights into aspects that may be important when designing rehabilitation programmes.

Parenting an overweight or obese child: a process of ambivalence.

Childhood overweight represents a health problem, and research points towards parents as key players. The aim of this study was to deepen the knowledge of how parents of children who are overweight or obese experience their parenthood. Focus group discussions with 17 parents were analysed according to the qualitative method of modified grounded theory. The results expressed the parents' ambivalence between preventing the child's overweight and not negatively affecting the child's self-esteem. The most important issue seemed to be their concern about the child's construction of self-understanding and experiences in interaction with the environment. The parents had become uncertain of their responsibility, priorities and how to act. In conclusion, parenting a child with weight issues could be a process of loving the child the way he/she is while still wanting changes for improved health, resulting in ambivalence. In addition to traditional advice about lifestyle, many parents seem to need counselling assistance with respect to their parental role.

Uncertainty is a major concern for patients with implantable cardioverter defibrillators.

OBJECTIVE: The study objective was to explore the main concern of individuals living with an implantable cardioverter defibrillator (ICD) and how they handle this in daily life. For improved management and follow-up, it is important to understand how the ICD affects the recipient's daily life. METHODS: A grounded theory method was used. Sixteen Swedish recipients (9 men) living with an ICD for 6 to 24 months were interviewed. RESULTS: The core category labeled, "Incorporating uncertainty in daily life," illuminates the main concern. To handle uncertainty, recipients used the following strategies: restricting activities, distracting oneself, accepting being an ICD recipient, and reevaluating life. CONCLUSION: Recipients were not paralyzed by uncertainty. Instead, they incorporated uncertainty in life by using strategies to handle their daily life. Questions, comments, and plans for supportive communication were provided, which can be used by healthcare professionals in cardiac rehabilitation.

Living with Crouzon syndrome: how do young adults with Crouzon syndrome handle their life situation?

BACKGROUND: Recent research has been focused on those attributes that appear to buffer a person against the stresses and strains of living with a visible difference. AIM: To provide some insight on how young adults with Crouzon syndrome handle their life. DESIGN: Telephone interviews were carried out with eight Crouzon syndrome individuals (six males, two females, mean age 25.4 years) and data were analysed according to the qualitative method of grounded theory. RESULTS: The informants' main concern was to make the best of their situation, showing that even in adverse conditions, as in Crouzon syndrome, several individuals do find ways to live with their difference and to succeed in various aspects of life, using strategies they construct. Such strategies, as identified from the present investigation, were labelled: committed to an engaging activity, avoiding exposed situations, actively launching oneself, struggling with normalizing facial appearance, and lowering the expectations of finding a love partner. CONCLUSIONS: The adaptation of successful coping strategies seemed to be crucial in the quest of attainment of higher self-esteem. The more the participants in the study used the coping strategies they had developed over time, the better they handled their life situation, which led to enhanced well-being.

Being a messenger of life-threatening conditions: experiences of pediatric oncologists.

BACKGROUND: A nationwide population-based study with questionnaires involving 90 pediatric oncologists was performed in Sweden in 2006/2007. On the basis of this quantitative study, a qualitative study was performed. The aim of this qualitative study was to focus on the main concern of these physicians facing malignant disorders, psychosocial issues, and existential provocation. Furthermore, the strategies for handling these challenges were also studied. METHOD: Interviews were conducted in 2007 with ten physicians of both genders, with more than 10 years' experience, who were active and previously active in pediatric oncology, and were working at academic and non-academic medical centers. The interviews were analyzed according to the inductive general research method of classical grounded theory. Every oncologist was selected from the nationwide study. RESULTS: A core category, that is, their main concern, labeled being a messenger of life-threatening conditions, was identified. To manage this difficult task of acting like a messenger breaking bad news, five handling categories were used: obtaining knowledge and information, saving one's strength and resources, building a close relationship, avoiding identification, and dealing with one's attitude to central life issues. All the categories and strategies used are described in the text. CONCLUSIONS: The challenge of making difficult decisions and delivering difficult news is an inevitable part of the patient-physician relationship in pediatric oncology. This qualitative study highlights the psychological aspects of being a pediatric oncologist. The study presents some practical implications in the daily work and physician-related recommendations on how to overcome the demanding role of messenger.