Leveraging qualitative approaches to guide sustainable international research collaborations.

Qualitative research approaches were used to launch an international research collaboration between the U. S. and Cambodia. Cambodian officials requested assistance in learning qualitative approaches to complement the research skills of Cambodian mental health providers. This article provides a description of how U. S. researchers responded to that request and engaged with Cambodian psychiatrists to explore mental health needs and interventions in both countries and initiate a sustainable relationship. The early focus on qualitative research methodologies may be an avenue that mitigates some of the challenges that can characterize international research. In this study, early communications involved developing a plan to teach qualitative methods while also collecting and analyzing data in both countries that would address the mental health concerns experienced by respective care providers. A case study exemplar was embedded with a scripted focus group guide to collect data from U. S. focus groups, then share with Cambodian psychiatrists. Components of hermeneutic phenomenological interviewing and descriptive content analysis were used to simultaneously teach and enact the research methods, gather data in both countries to analyze, and inspire participants to replicate the methods in their ongoing work. Cambodian psychiatrists were able to demonstrate competence in facilitating focus groups after being participant-observers. Researcher/practitioners from both U. S. and Cambodian teams gained new understandings about the mental health needs of their patients. The mutual engagement of a research focus is an effective way to establish cross-cultural relationships. The challenges of staying with stable teams over times remain, but the content shared and learned in a participatory structure yields understandings that cross cultural boundaries. Anticipated and unexpected challenges may be offset by an intention of reciprocity and mutual engagement. The use of qualitative methodologies, early and repeatedly, can facilitate relational understanding.

Adolescents Concerned about Climate Change: A Hermeneutic Study.

Climate change is a public health threat on a global scale. Over the last two decades, research has uncovered the myriad health effects of climate change and its associated costs. The literature is also beginning to show the direct and indirect effects of climate change to be an indicator of increased adverse mental health outcomes including excessive worry, anxiety, grief, and post-traumatic stress disorder. The development of scales to measure some of these effects in adult populations has shown the critical need to understand the various ways climate change affects mental well-being in adolescent populations who are at a critical juncture in psychological development. The purposes of this study were to understand the lived experience of adolescents who are concerned about climate change and uncover the meaning of climate change concern for adolescents as informed by emerging patterns. This study utilized Hermeneutic Phenomenology as a philosophical foundation and methodological approach for data retrieval and analysis. An interview-based approach with a purposeful sample (n = 11, aged 12-17 years) revealed the multi-layered elements of climate change concern and its effects. Three patterns emerged: Climate Change as a Temporal Threat and Pressure, Awareness and Concern as a Continuum, and Experiencing Concern and Making Meaning. These findings may now inform interdisciplinary knowledge on upstream mitigation efforts and the promotion of positive outcomes relating to climate change. The need for focused educational attention to adolescent behaviors and concerns is explicated and exemplified.

For the Good of the People: an interpretive analysis of Chinese volunteerism in the critical matter of care at the start of the pandemic.

PURPOSE: China employed a unique volunteerism system where health care providers outside of Hubei Province, the epicentre, travelled to reverse the devastation wrought by coronavirus disease 2019 (COVID-19) at its global onset. The aim is to study the unique circumstances of Chinese volunteerism in the context of continuing pandemic threats, specifically exploring the experiences of 20 Chinese nurse and physician volunteers fighting COVID-19 during the outbreak. METHODS: Interviews were done through video calling. RESULTS: Using content analysis with a hermeneutic perspective, emerging patterns showed the ways in which China's particular manifestation of volunteerism teaches us how to engage global threats of this nature. The overarching lesson, For the Good of the People, was manifested in several dynamic and overlapping themes: 1) Reaching for Professional Standards Even in Crisis; 2) Constantly Caring Through Failures and Successes; and 3) Holding Fast to the Common Good. The devastation was met by the resilience of volunteers, who overcame profound challenges managing patient care. CONCLUSIONS: Volunteerism required sacrifice and tremendous support in the form of training and administrative direction, family support, and peer collaboration. Volunteers' physical and psychosocial wellbeing was a priority. Recognizing the representative themes can help societies plan for continuing and future events.

Protocol for a randomized controlled trial in Cambodian individuals with PTSD: Trauma-Informed Treatment Algorithms for Advancing Novel Outcomes (Project TITAN).

INTRODUCTION: Low- and middle-income countries shoulder a disproportionate burden of mental health disorders with limited resources to support the provision of care using culturally relevant, evidence-based interventions. This is particularly true in Cambodia where the population continues to confront traumatic consequences of the Khmer Rouge genocide that targeted educated people, including treatment providers. Trauma-Informed Treatment Algorithms for Advancing Novel Outcomes (Project TITAN) will examine proof of concept and preliminary efficacy of culturally tailored interventions for symptoms of post-traumatic stress (PTS) among Cambodian adults. METHODS: A stepped care randomized controlled trial enrolling people seeking mental health treatment and priority populations with high rates of trauma exposure, including female entertainment and sex workers and sexual and gender minorities. In total, 160 participants with symptoms of PTS are randomized to Stabilization Techniques or Behavioral Activation plus Stabilization Techniques, implemented within a culturally relevant framework. Individuals who do not demonstrate a reduction in symptoms of PTS after six treatment sessions receive Eye Movement Desensitization and Reprocessing therapy. PTS, depression, anxiety, and substance use are assessed at baseline and two and four months post-randomization. PLANNED ANALYSES: The percentage of individuals achieving reductions in symptoms of PTS after four months is the primary outcome. Secondary outcomes are depression, anxiety, and substance use over four months. Finally, machine learning analyses will be conducted to identify features at baseline and during treatment that predict outcomes. DISCUSSION: Findings will guide future development and implementation of interventions to improve mental health conditions among individuals in Cambodia and other resource-limited settings.

"No matter what, we just work with the trauma ": Mental Health Therapists' Care of Diverse Sexual and Gender Identity Citizens in Cambodia.

The convergence of trauma symptomatology, mental health symptoms, family and social difficulties, and intersectionality of diverse sexual and gender minority (SGM) individual issues is complex, multi-faceted, and challenging for the individuals in Cambodia who suffer them and for the therapists in Cambodia who meet individuals in treatment. We documented and analyzed the perspectives of mental health therapists in the context of a randomized control trial (RCT) intervention within the Mekong Project in Cambodia. The research questions explored perceptions of therapists' care of mental health clients, therapist wellbeing, and experiences of navigating within a research environment in which SGM citizens with mental health concerns receive treatment. The larger study enrolled 150 Cambodian adults, among which 69 identified as SGM. Three key patterns emerged across our interpretations. Clients seek help when symptoms interfere with daily life, therapists care for clients and themselves, and integrated research and practice is integral yet sometimes paradoxical. Therapists did not identify differences in terms of how they work with SGM clients compared with non-SGM clients. Future studies are warranted to examine a reciprocal academic-research partnership in which we examine therapists' work alongside rural community members, evaluate the process of embedding and fortifying peer supports within educational systems, and study the wisdom of traditional and Buddhist healers to address the discrimination and violence that citizens who identify as SGM disproportionately suffer. National Library of Medicine (U.S.). (2020). Trauma Informed Treatment Algorithms for Novel Outcomes (TITAN). Identifier NCT04304378.

Immobility and the High Risk of Not Recovering Function in Older Adults: A Focused Ethnography.

PURPOSE: The objective of the study was to explore the experiences of older adults with immobility posthospitalization. DESIGN: We conducted a focused ethnography qualitative study. METHODS: Data collection included in-depth interviews with 10 individuals ages 69-82 years who had been hospitalized for at least 1 week, field notes, and observations of mobility. An inductive approach was used to analyze the data. FINDINGS: Older adults believe mobility is a central element in their life. Hospitalizations lasting 1 week or longer often result in a loss of the older adult's ability to function as before, a pattern that we identified as The Crushing Assault: Consequences of Immobility. Rehabilitation involves a Rocky Road to Regaining Mobility that is challenging but possible. CONCLUSIONS: Immobility after hospitalization has unexpected and profound consequences that are life-changing and distressing for older adults at home. Recovering function is prolonged and difficult. An individualized training program that includes flexibility and progressive resistance exercises is recommended over longer periods and with extended medical follow-up. CLINICAL RELEVANCE: Lingering problems with immobility at home are frequently overlooked. Active programming promoting preservation of function and an optimistic attitude as well as focusing on milestones to reach are key to optimal function.

The "seeing place": Teaching nurse practitioners about cultural difference through dramatization.

BACKGROUND: The use of dramatization in health professional education is one method to teach students about implicit bias and cultural difference, yet it has not been widely studied among graduate students of nursing. OBJECTIVES: The purpose of this article is to present a qualitative analysis of data regarding doctoral nursing students' responses to a new dramatic exercise as part of a funded project to facilitate cultural learning in a diversity-enhanced nursing curriculum. DESIGN: We employed a cross-sectional posttest design with qualitative data collection and hermeneutic analysis. Setting and. PARTICIPANTS: Subjects were students from two cohorts in a Doctor of Nursing Practice program at a large metropolitan university in the Midwestern United States (n = 136). METHODS: Following a dramatic exercise facilitated by a local theatre group, students debriefed and provided feedback via paper-based surveys collected by their instructor. The research team reviewed and analyzed student feedback with an eye toward new learning or insights around cultural difference. RESULTS: Students rated the dramatic exercise highly. Their written feedback provided for a deeper exploration of how they internalized messages about cultural difference. These experiences were thematized in the following way: (a) Awareness is facilitated through integrating nonverbal (kinesthetic) and verbal encounters, (b) Hesitancy to participate in unfamiliar activities creates tension, and (c) Safety is a foundational aspect of learning sensitive issues. CONCLUSION: Dramatization of culturally sensitive scenarios for advanced practice nurses can lead to new understanding. Educators who understand the need for thoughtful introduction of dramatization experiences can better prepare nurses for interaction in cross-cultural clinical environments.

Identifying the Complexity of Diagnosing Bipolar Disorder: A Focused Ethnography.

Purpose: To identify and describe the complexity of diagnosing bipolar disorder, including the diagnostic process and patient experiences of being newly diagnosed with bipolar disorder. Design: A mixed-methods focused ethnography was conducted, grounded in a post-positivist foundation. Methods: Medical records (n = 100) of patients whose diagnosis had been switched to bipolar disorder were examined. Six weeks post-hospitalization, ten outpatients with the diagnosis of bipolar disorder underwent an in-depth interview. Findings: Four diagnostic processes were identified during the retrospective record review. Two patterns and five themes were identified from the interviews. The first pattern, living with undiagnosed bipolar disorder, demonstrated common experiences of distinguishing impulsive moods and behavior, suffering life challenges, and seeking relief. The second pattern, acclimating to a new diagnosis of bipolar disorder, demonstrated participants' ways of understanding the diagnosis and reconciling the diagnosis. Patterns in the interviews corroborated data from the record review. Conclusions: The rendering of an appropriate diagnosis is key. Many participants' lives were significantly improved when diagnosis was made, and treatment recommendations for bipolar disorder (BPD) were initiated. These findings offer clinicians and researchers new ways to think about the complexity of the diagnosis of BPD including contrasting decision-making outcomes along a screening, diagnosis, and treatment continuum, as well as using the diagnostic event to instigate meaningful life change in the patient.

The Compelling and Persistent Problem of Bipolar Disorder Disguised as Major Depression Disorder: An Integrative Review [Formula: see text].

BACKGROUND: Up to 40% of patients with bipolar disorder are misdiagnosed, usually with major depression disorder. OBJECTIVE: The purpose was to describe the current state of the science of the misdiagnosis of bipolar disorder, with the ultimate goal of improving psychiatric diagnostic workups including screening. DESIGN: An integrative review was conducted using standard criteria for evaluating research articles. RESULTS: Forty-nine articles met the eligibility criteria. Articles explored patient-related and health care provider-related factors contributing to the misdiagnosis of bipolar disorder as well as consequences of misdiagnosis. Clinically oriented, reliable, and valid screening tools for bipolar disorder also were reviewed. CONCLUSIONS: Awareness of multiple, challenging patient-related factors and more comprehensive assessment and screening by health care providers may reduce misdiagnosis.

Seeking Chronic Pain Relief: A Hermeneutic Exploration.

BACKGROUND: In the United States, chronic pain is experienced by over 39.4 million adults, many of whom are treated with opioid pain medications. AIM: This research presents an interpretation of the experience of seeking pain relief for a group of people taking opioid pain medications whose pain is not adequately controlled. METHODS: A concurrent embedded mixed-methods design was used, including a Heideggerian hermeneutic qualitative approach that focuses on the participants' perceptions as a vehicle for understanding the phenomenon of seeking pain relief with descriptive quantitative data in a supporting role. Thirteen interviews and 15 surveys were analyzed, all of which met the following criteria: (1) self-reported chronic pain (persistent pain lasting a minimum of six months), (2) current use of prescription opioid medications, (3) pain not successfully controlled. RESULTS: The analysis revealed a paradox, which we describe as being lost/finding myself in the health care system. This paradox became the overarching pattern of experience that subsumed several dynamic, overlapping practices described in the patterns: (1) seeking relief as suffering; (2) being classified as an addict but not an addict; (3) living with pain as remembering; and (4) experiencing treatment modalities as fickle possibilities. CONCLUSION: Explication of and interpretive commentary on these patterns shift the focus from drug seeking to pain relief seeking behaviors in chronic pain sufferers. Such a shift could change the manner in which providers work with chronic pain sufferers to find appropriate treatment modalities.

Relational Health and Recovery: Adolescent Girls in Chemical Dependency Treatment.

Adolescent substance use (SU) endures as a priority concern to communities. The increasing risk of SU in young women has been a rising concern, and the needs of young women may be unique. The importance of relationships and "connectedness" as aberrant behavior protective factors has been validated extensively in the literature of several disciplines over the past decade. Less well described are the components and qualities of relational engagement among adolescents involved in SU treatment. This multimethod study was a broad analysis of the nature of relational health in adolescent girls, so as to determine whether understanding components of relational health could inform SU treatment options. The survey tool, the Relational Health Indices (Liang et al., 2002), was used to measure dimensions and domains of relational health in adolescent girls and informed qualitative methods in the study. It is clear from this research that adolescent girls in SU treatment care deeply about but are confused regarding their relationships with others, particularly their romantic partners and their mothers. They have a desire to help others, specifically their siblings and others struggling with addiction. This article describes the multimethod study and implications for treatment, research, and education.

Data Collection via In-Depth Email Interviewing: Lessons From the Field.

This methods article is a reflection on the use of in-depth email interviewing in a qualitative descriptive study. The use of emailing to conduct interviews is thought to be an effective way to collect qualitative data. Building on current methodological literature in qualitative research regarding in-depth email interviewing, we move the conversation toward elicitation of quality data and management of multiple concurrent email interviews. Excerpts are shared from a field journal that was kept throughout one study, with commentary on developing insights. Valuable lessons learned include the importance of (a) logistics and timing related to the management of multiple concurrent email interviews, (b) language and eliciting the data, (c) constructing the email, and (d) processing text-based data and preparing transcripts. Qualitative researchers seeking deeply reflective answers and geographically diverse samples may wish to consider using in-depth email interviews.

Relational Health in Transitions: Female Adolescents in Chemical Dependency Treatment.

BACKGROUND: Adolescent substance use (SU) remains a serious problem. Inpatient, primary care, and self-treatment models for chemical dependency (CD) yield varying degrees of success impacting the sequelae of chronic or episodic SU. Relational engagement among adolescent substance users is a long known influential factor in the development, maintenance and transformation of addictive behaviors. OBJECTIVES: Following tenets of Relational-Cultural Theory and using the Relational Health Indices for Youth (RHI-Y), a validated survey tool for adolescents, we sought to measure relational health (RH) during times of transitions during CD treatment. This article addresses use of the tool and its potential for improving addictions research and practice. METHODS: During 2015-2017 we explored differences in RH scores in adolescent girls entering inpatient CD treatment at three points: 51 at admission, 39 at discharge, and 13 at 3 months post-discharge. Data were analyzed using a generalized linear mixed model to compare changes in domain scores of RH. RESULTS: Changes in RH scores were significant in the friend domain, but not the mentor and community domains. The RHI-Y shows promise in discerning RH change during transitions in CD treatment.

"Can you keep it real?" : Practical, and culturally tailored lifestyle recommendations by Mexican American women diagnosed with type 2 diabetes: A qualitative study.

BACKGROUND: The purpose of this article is to engage clinicians in a dialogue about ideas on how to provide more specific, contextually relevant, practical and culturally tailored diabetes self-management recommendations as suggested by Mexican-American women diagnosed with type 2 diabetes. Current diabetes self-management recommendations, targeting Mexican Americans in particular, remain largely broad ("reduce your calorie intake" or "cut back on carbs"), overly ambitious ("stop eating tortillas"), and relatively ineffective (Svedbo Engström et al., BMJ Open 6(3):e010249, 2016; Johansson et al., Int J Qual Stud Health Well-being 11, 2016; Oomen et al., The Diabetes Educ 25:220-225, 1999; Franek, Ont Health Technol Assess Ser 13(9):1-60, 2013; Purnell et al. Patient 9:349, 2016). METHODS: A secondary and focused analysis (N = 12) was performed on data gathered from a larger qualitative study (N = 16), which explored diabetes among Mexican-American women residing in rural South Texas. RESULTS: Findings from the secondary analysis were that study informants elicited more realistic or contextually relevant, specific self-management strategies that reflected the cognitive, emotive, and behavioral areas but were reframed within the context of the Mexican-American culture. Self-management strategies fell into the categories of: (a) environmental controls, (b) avoiding overeating, (c) lifestyle changes, (d) cooking tips, and (e) active self-management. CONCLUSIONS: Diabetes remains a serious health threat to Mexican Americans, women in particular. Few individuals attain glycemic control, likely due in part to the disconnect between global and non-contextual self-management recommendations offered by health care providers and the need for more detailed and realistic guidance required for the day-to-day self-management of diabetes.

Experiences of RNs Who Voluntarily Withdraw From Their RN-to-BSN Program.

BACKGROUND: The number of RN-to-baccalaureate nursing (BSN) programs is increasing; however, nurses continue to voluntarily withdraw at higher rates than expected. METHOD: A Heideggerian hermeneutic approach was used to interpret the meaning of the experience of RNs, who voluntarily withdraw from their baccalaureate nursing programs. The research aims were to generate a comprehensive understanding of (a) the experiences of RN-to-BSN noncompleters, (b) the meaning noncompleters ascribe to the experience of dropping out, and (c) the interplay between factors that influence dropout decisions. RESULTS: Two overarching patterns of understanding emerged: Withdrawing as Revisiting Failure, and Withdrawing as Impasse: On One Side of the Divide. The factors that influence whether an RN finishes a baccalaureate nursing program are many, but the effect on dignity and well-being are immeasurable. CONCLUSION: Voluntary withdrawal from an RN-to-BSN program leaves nurses professionally place-bound, affecting not only the individual nurse but also the profession. [J Nurs Educ. 2017;56(5):260-265.].

Grand Multiparous Mothers' Embodied Experiences of Natural and Technological Altered Births.

In-depth interviews of a purposive sample (n = 14) of grand multipara mothers (five or more births) was conducted to investigate the mothers' embodied experiences of natural, technologically altered births and oxytocin inductions in U.S. hospitals from 1973 to 2007. A comprehensive secondary analysis of the lived experiences of natural birth and the high use of technology and oxytocin during birth, which was found in an original theme of a previous study, was explored. An overarching theme emerged of Embodiment of Birthing in U.S. Hospitals. Two patterns: Embodied Technological Altered Natural Births and Embodied Technologically Altered Induced Births were uncovered. Childbirth educators, doulas, and nurses are an integral part of creating changes in hospital settings, which discourage nonmedically indicated inductions and encourages changes in hospitals.

Qualitative Methods in Patient-Centered Outcomes Research.

The Patient-Centered Outcomes Research Institute (PCORI), created to fund research guided by patients, caregivers, and the broader health care community, offers a new research venue. Many (41 of 50) first funded projects involved qualitative research methods. This study was completed to examine the current state of the science of qualitative methodologies used in PCORI-funded research. Principal investigators participated in phenomenological interviews to learn (a) how do researchers using qualitative methods experience seeking funding for, implementing and disseminating their work; and (b) how may qualitative methods advance the quality and relevance of evidence for patients? Results showed the experience of doing qualitative research in the current research climate as "Being a bona fide qualitative researcher: Staying true to research aims while negotiating challenges," with overlapping patterns: (a) researching the elemental, (b) expecting surprise, and (c) pushing boundaries. The nature of qualitative work today was explicitly described and is rendered in this article.

Preserving Self: Medication-Taking Practices and Preferences of Older Adults With Multiple Chronic Medical Conditions.

PURPOSE: To examine the experiences of older adults with multiple chronic medical conditions when a new medication was added to their existing multiple medication regimen. DESIGN: A multimethod qualitative design was used. Thirty adults 60 years of age with (a) at least three chronic medical diagnoses, (b) at least five medications at baseline, and (c) a new medication prescription were enrolled in a prospective study of 30 days duration, participating from their homes. METHODS: In-depth hermeneutic interviews (2 per 15 participants) and self-assessment diaries recorded on electronic tablets (daily per 30 participants) were completed. Transcribed interviews and self-recorded survey data were analyzed using hermeneutical analysis and ecological momentary assessment and content analysis, respectively. FINDINGS: Common reasons participants did not take medications as prescribed included tolerability, transportation, access to medications, and forgetting. The overarching pattern, "preserving self," was supported by two patterns that subsumed several themes: (a) engaging the powerful hold of my illness, and (b) engaging providers in visioning health. CONCLUSIONS: A deeper understanding of the impact of receiving a new prescription and of managing medication reveals the challenges patients experience in preserving a sense of self. Healthcare providers of all disciplines should understand the meaning of medication prescribing and medication taking to ameliorate medication-taking difficulties. CLINICAL RELEVANCE: The provider-patient relationship is often cited as an area that needs to be addressed in healthcare practice. Our study emphasized the patients' voices and their profound needs around medication management. The emphasis on preservation of self is an important finding that focalizes the concern.

A demonstration of mixed-methods research in the health sciences.

Background The growth of patient, community and population-centred nursing research is a rationale for the use of research methods that can examine complex healthcare issues, not only from a biophysical perspective, but also from cultural, psychosocial and political viewpoints. This need for multiple perspectives requires mixed-methods research. Philosophy and practicality are needed to plan, conduct, and make mixed-methods research more broadly accessible to the health sciences research community. The traditions and dichotomy between qualitative and quantitative research makes the application of mixed methods a challenge. Aim To propose an integrated model for a research project containing steps from start to finish, and to use the unique strengths brought by each approach to meet the health needs of patients and communities. Discussion Mixed-methods research is a practical approach to inquiry, that focuses on asking questions and how best to answer them to improve the health of individuals, communities and populations. An integrated model of research begins with the research question(s) and moves in a continuum. The lines dividing methods do not dissolve, but become permeable boundaries where two or more methods can be used to answer research questions more completely. Rigorous and expert methodologists work together to solve common problems. Conclusion Mixed-methods research enables discussion among researchers from varied traditions. There is a plethora of methodological approaches available. Combining expertise by communicating across disciplines and professions is one way to tackle large and complex healthcare issues. Implications for practice The model presented in this paper exemplifies the integration of multiple approaches in a unified focus on identified phenomena. The dynamic nature of the model signals a need to be open to the data generated and the methodological directions implied by findings.

Prolonged Distress of Parents After Early Preterm Birth.

OBJECTIVE: To examine how parents describe the distress of early preterm birth in the months and years after the infant's hospital discharge. DESIGN: Discourse analysis of in-depth interviews and photo elicitation. SETTING: Homes or cafés in the Pacific Northwest United States. PARTICIPANTS: Parents of premature infants born between 24 and 30 weeks gestation (N = 10) who experienced significant distress in and out of the hospital. Parents participated in the study when their children were between 15 months and 8 years old. METHODS: Participants described dealing with prematurity, emotional distress, and parenting in individual interviews and returned for second interviews in which they further described their distress using photographs. Data were analyzed using discourse analysis. RESULTS: Parents described preterm birth, hospitalization, and the aftermath as ongoing traumatic events. Discourses of distress included the Perfect Child, the Good Mother, and the Good Father. Parents used these discourses to reconcile the loss of an idealized birth and parenting after the birth of a premature child. Isolation and Medicalized Parenting were used to explain how parents struggled to interact within their social networks and to parent under challenging circumstances. CONCLUSION: Participants described their trauma and distress in ways not captured by psychiatric diagnoses such as depression and anxiety. Findings may help nurses be aware of the negative effects of preterm birth and respond to parents' emotional needs.