grounded theory different from other qualitative research

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Grounded theory research: A design framework for novice researchers

Ylona chun tie.

1 Nursing and Midwifery, College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia

Melanie Birks

Karen francis.

2 College of Health and Medicine, University of Tasmania, Australia, Hobart, TAS, Australia

Background:

Grounded theory is a well-known methodology employed in many research studies. Qualitative and quantitative data generation techniques can be used in a grounded theory study. Grounded theory sets out to discover or construct theory from data, systematically obtained and analysed using comparative analysis. While grounded theory is inherently flexible, it is a complex methodology. Thus, novice researchers strive to understand the discourse and the practical application of grounded theory concepts and processes.

The aim of this article is to provide a contemporary research framework suitable to inform a grounded theory study.

This article provides an overview of grounded theory illustrated through a graphic representation of the processes and methods employed in conducting research using this methodology. The framework is presented as a diagrammatic representation of a research design and acts as a visual guide for the novice grounded theory researcher.

Discussion:

As grounded theory is not a linear process, the framework illustrates the interplay between the essential grounded theory methods and iterative and comparative actions involved. Each of the essential methods and processes that underpin grounded theory are defined in this article.

Conclusion:

Rather than an engagement in philosophical discussion or a debate of the different genres that can be used in grounded theory, this article illustrates how a framework for a research study design can be used to guide and inform the novice nurse researcher undertaking a study using grounded theory. Research findings and recommendations can contribute to policy or knowledge development, service provision and can reform thinking to initiate change in the substantive area of inquiry.

Introduction

The aim of all research is to advance, refine and expand a body of knowledge, establish facts and/or reach new conclusions using systematic inquiry and disciplined methods. 1 The research design is the plan or strategy researchers use to answer the research question, which is underpinned by philosophy, methodology and methods. 2 Birks 3 defines philosophy as ‘a view of the world encompassing the questions and mechanisms for finding answers that inform that view’ (p. 18). Researchers reflect their philosophical beliefs and interpretations of the world prior to commencing research. Methodology is the research design that shapes the selection of, and use of, particular data generation and analysis methods to answer the research question. 4 While a distinction between positivist research and interpretivist research occurs at the paradigm level, each methodology has explicit criteria for the collection, analysis and interpretation of data. 2 Grounded theory (GT) is a structured, yet flexible methodology. This methodology is appropriate when little is known about a phenomenon; the aim being to produce or construct an explanatory theory that uncovers a process inherent to the substantive area of inquiry. 5 – 7 One of the defining characteristics of GT is that it aims to generate theory that is grounded in the data. The following section provides an overview of GT – the history, main genres and essential methods and processes employed in the conduct of a GT study. This summary provides a foundation for a framework to demonstrate the interplay between the methods and processes inherent in a GT study as presented in the sections that follow.

Glaser and Strauss are recognised as the founders of grounded theory. Strauss was conversant in symbolic interactionism and Glaser in descriptive statistics. 8 – 10 Glaser and Strauss originally worked together in a study examining the experience of terminally ill patients who had differing knowledge of their health status. Some of these suspected they were dying and tried to confirm or disconfirm their suspicions. Others tried to understand by interpreting treatment by care providers and family members. Glaser and Strauss examined how the patients dealt with the knowledge they were dying and the reactions of healthcare staff caring for these patients. Throughout this collaboration, Glaser and Strauss questioned the appropriateness of using a scientific method of verification for this study. During this investigation, they developed the constant comparative method, a key element of grounded theory, while generating a theory of dying first described in Awareness of Dying (1965). The constant comparative method is deemed an original way of organising and analysing qualitative data.

Glaser and Strauss subsequently went on to write The Discovery of Grounded Theory: Strategies for Qualitative Research (1967). This seminal work explained how theory could be generated from data inductively. This process challenged the traditional method of testing or refining theory through deductive testing. Grounded theory provided an outlook that questioned the view of the time that quantitative methodology is the only valid, unbiased way to determine truths about the world. 11 Glaser and Strauss 5 challenged the belief that qualitative research lacked rigour and detailed the method of comparative analysis that enables the generation of theory. After publishing The Discovery of Grounded Theory , Strauss and Glaser went on to write independently, expressing divergent viewpoints in the application of grounded theory methods.

Glaser produced his book Theoretical Sensitivity (1978) and Strauss went on to publish Qualitative Analysis for Social Scientists (1987). Strauss and Corbin’s 12 publication Basics of Qualitative Research: Grounded Theory Procedures and Techniques resulted in a rebuttal by Glaser 13 over their application of grounded theory methods. However, philosophical perspectives have changed since Glaser’s positivist version and Strauss and Corbin’s post-positivism stance. 14 Grounded theory has since seen the emergence of additional philosophical perspectives that have influenced a change in methodological development over time. 15

Subsequent generations of grounded theorists have positioned themselves along a philosophical continuum, from Strauss and Corbin’s 12 theoretical perspective of symbolic interactionism, through to Charmaz’s 16 constructivist perspective. However, understanding how to position oneself philosophically can challenge novice researchers. Birks and Mills 6 provide a contemporary understanding of GT in their book Grounded theory: A Practical Guide. These Australian researchers have written in a way that appeals to the novice researcher. It is the contemporary writing, the way Birks and Mills present a non-partisan approach to GT that support the novice researcher to understand the philosophical and methodological concepts integral in conducting research. The development of GT is important to understand prior to selecting an approach that aligns with the researcher’s philosophical position and the purpose of the research study. As the research progresses, seminal texts are referred back to time and again as understanding of concepts increases, much like the iterative processes inherent in the conduct of a GT study.

Genres: traditional, evolved and constructivist grounded theory

Grounded theory has several distinct methodological genres: traditional GT associated with Glaser; evolved GT associated with Strauss, Corbin and Clarke; and constructivist GT associated with Charmaz. 6 , 17 Each variant is an extension and development of the original GT by Glaser and Strauss. The first of these genres is known as traditional or classic GT. Glaser 18 acknowledged that the goal of traditional GT is to generate a conceptual theory that accounts for a pattern of behaviour that is relevant and problematic for those involved. The second genre, evolved GT, is founded on symbolic interactionism and stems from work associated with Strauss, Corbin and Clarke. Symbolic interactionism is a sociological perspective that relies on the symbolic meaning people ascribe to the processes of social interaction. Symbolic interactionism addresses the subjective meaning people place on objects, behaviours or events based on what they believe is true. 19 , 20 Constructivist GT, the third genre developed and explicated by Charmaz, a symbolic interactionist, has its roots in constructivism. 8 , 16 Constructivist GT’s methodological underpinnings focus on how participants’ construct meaning in relation to the area of inquiry. 16 A constructivist co-constructs experience and meanings with participants. 21 While there are commonalities across all genres of GT, there are factors that distinguish differences between the approaches including the philosophical position of the researcher; the use of literature; and the approach to coding, analysis and theory development. Following on from Glaser and Strauss, several versions of GT have ensued.

Grounded theory represents both a method of inquiry and a resultant product of that inquiry. 7 , 22 Glaser and Holton 23 define GT as ‘a set of integrated conceptual hypotheses systematically generated to produce an inductive theory about a substantive area’ (p. 43). Strauss and Corbin 24 define GT as ‘theory that was derived from data, systematically gathered and analysed through the research process’ (p. 12). The researcher ‘begins with an area of study and allows the theory to emerge from the data’ (p. 12). Charmaz 16 defines GT as ‘a method of conducting qualitative research that focuses on creating conceptual frameworks or theories through building inductive analysis from the data’ (p. 187). However, Birks and Mills 6 refer to GT as a process by which theory is generated from the analysis of data. Theory is not discovered; rather, theory is constructed by the researcher who views the world through their own particular lens.

Research process

Before commencing any research study, the researcher must have a solid understanding of the research process. A well-developed outline of the study and an understanding of the important considerations in designing and undertaking a GT study are essential if the goals of the research are to be achieved. While it is important to have an understanding of how a methodology has developed, in order to move forward with research, a novice can align with a grounded theorist and follow an approach to GT. Using a framework to inform a research design can be a useful modus operandi.

The following section provides insight into the process of undertaking a GT research study. Figure 1 is a framework that summarises the interplay and movement between methods and processes that underpin the generation of a GT. As can be seen from this framework, and as detailed in the discussion that follows, the process of doing a GT research study is not linear, rather it is iterative and recursive.

Research design framework: summary of the interplay between the essential grounded theory methods and processes.

Grounded theory research involves the meticulous application of specific methods and processes. Methods are ‘systematic modes, procedures or tools used for collection and analysis of data’. 25 While GT studies can commence with a variety of sampling techniques, many commence with purposive sampling, followed by concurrent data generation and/or collection and data analysis, through various stages of coding, undertaken in conjunction with constant comparative analysis, theoretical sampling and memoing. Theoretical sampling is employed until theoretical saturation is reached. These methods and processes create an unfolding, iterative system of actions and interactions inherent in GT. 6 , 16 The methods interconnect and inform the recurrent elements in the research process as shown by the directional flow of the arrows and the encompassing brackets in Figure 1 . The framework denotes the process is both iterative and dynamic and is not one directional. Grounded theory methods are discussed in the following section.

Purposive sampling

As presented in Figure 1 , initial purposive sampling directs the collection and/or generation of data. Researchers purposively select participants and/or data sources that can answer the research question. 5 , 7 , 16 , 21 Concurrent data generation and/or data collection and analysis is fundamental to GT research design. 6 The researcher collects, codes and analyses this initial data before further data collection/generation is undertaken. Purposeful sampling provides the initial data that the researcher analyses. As will be discussed, theoretical sampling then commences from the codes and categories developed from the first data set. Theoretical sampling is used to identify and follow clues from the analysis, fill gaps, clarify uncertainties, check hunches and test interpretations as the study progresses.

Constant comparative analysis

Constant comparative analysis is an analytical process used in GT for coding and category development. This process commences with the first data generated or collected and pervades the research process as presented in Figure 1 . Incidents are identified in the data and coded. 6 The initial stage of analysis compares incident to incident in each code. Initial codes are then compared to other codes. Codes are then collapsed into categories. This process means the researcher will compare incidents in a category with previous incidents, in both the same and different categories. 5 Future codes are compared and categories are compared with other categories. New data is then compared with data obtained earlier during the analysis phases. This iterative process involves inductive and deductive thinking. 16 Inductive, deductive and abductive reasoning can also be used in data analysis. 26

Constant comparative analysis generates increasingly more abstract concepts and theories through inductive processes. 16 In addition, abduction, defined as ‘a form of reasoning that begins with an examination of the data and the formation of a number of hypotheses that are then proved or disproved during the process of analysis … aids inductive conceptualization’. 6 Theoretical sampling coupled with constant comparative analysis raises the conceptual levels of data analysis and directs ongoing data collection or generation. 6

The constant comparative technique is used to find consistencies and differences, with the aim of continually refining concepts and theoretically relevant categories. This continual comparative iterative process that encompasses GT research sets it apart from a purely descriptive analysis. 8

Memo writing is an analytic process considered essential ‘in ensuring quality in grounded theory’. 6 Stern 27 offers the analogy that if data are the building blocks of the developing theory, then memos are the ‘mortar’ (p. 119). Memos are the storehouse of ideas generated and documented through interacting with data. 28 Thus, memos are reflective interpretive pieces that build a historic audit trail to document ideas, events and the thought processes inherent in the research process and developing thinking of the analyst. 6 Memos provide detailed records of the researchers’ thoughts, feelings and intuitive contemplations. 6

Lempert 29 considers memo writing crucial as memos prompt researchers to analyse and code data and develop codes into categories early in the coding process. Memos detail why and how decisions made related to sampling, coding, collapsing of codes, making of new codes, separating codes, producing a category and identifying relationships abstracted to a higher level of analysis. 6 Thus, memos are informal analytic notes about the data and the theoretical connections between categories. 23 Memoing is an ongoing activity that builds intellectual assets, fosters analytic momentum and informs the GT findings. 6 , 10

Generating/collecting data

A hallmark of GT is concurrent data generation/collection and analysis. In GT, researchers may utilise both qualitative and quantitative data as espoused by Glaser’s dictum; ‘all is data’. 30 While interviews are a common method of generating data, data sources can include focus groups, questionnaires, surveys, transcripts, letters, government reports, documents, grey literature, music, artefacts, videos, blogs and memos. 9 Elicited data are produced by participants in response to, or directed by, the researcher whereas extant data includes data that is already available such as documents and published literature. 6 , 31 While this is one interpretation of how elicited data are generated, other approaches to grounded theory recognise the agency of participants in the co-construction of data with the researcher. The relationship the researcher has with the data, how it is generated and collected, will determine the value it contributes to the development of the final GT. 6 The significance of this relationship extends into data analysis conducted by the researcher through the various stages of coding.

Coding is an analytical process used to identify concepts, similarities and conceptual reoccurrences in data. Coding is the pivotal link between collecting or generating data and developing a theory that explains the data. Charmaz 10 posits,

codes rely on interaction between researchers and their data. Codes consist of short labels that we construct as we interact with the data. Something kinaesthetic occurs when we are coding; we are mentally and physically active in the process. (p. 5)

In GT, coding can be categorised into iterative phases. Traditional, evolved and constructivist GT genres use different terminology to explain each coding phase ( Table 1 ).

Comparison of coding terminology in traditional, evolved and constructivist grounded theory.

Adapted from Birks and Mills. 6

Coding terminology in evolved GT refers to open (a procedure for developing categories of information), axial (an advanced procedure for interconnecting the categories) and selective coding (procedure for building a storyline from core codes that connects the categories), producing a discursive set of theoretical propositions. 6 , 12 , 32 Constructivist grounded theorists refer to initial, focused and theoretical coding. 9 Birks and Mills 6 use the terms initial, intermediate and advanced coding that link to low, medium and high-level conceptual analysis and development. The coding terms devised by Birks and Mills 6 were used for Figure 1 ; however, these can be altered to reflect the coding terminology used in the respective GT genres selected by the researcher.

Initial coding

Initial coding of data is the preliminary step in GT data analysis. 6 , 9 The purpose of initial coding is to start the process of fracturing the data to compare incident to incident and to look for similarities and differences in beginning patterns in the data. In initial coding, the researcher inductively generates as many codes as possible from early data. 16 Important words or groups of words are identified and labelled. In GT, codes identify social and psychological processes and actions as opposed to themes. Charmaz 16 emphasises keeping codes as similar to the data as possible and advocates embedding actions in the codes in an iterative coding process. Saldaña 33 agrees that codes that denote action, which he calls process codes, can be used interchangeably with gerunds (verbs ending in ing ). In vivo codes are often verbatim quotes from the participants’ words and are often used as the labels to capture the participant’s words as representative of a broader concept or process in the data. 6 Table 1 reflects variation in the terminology of codes used by grounded theorists.

Initial coding categorises and assigns meaning to the data, comparing incident-to-incident, labelling beginning patterns and beginning to look for comparisons between the codes. During initial coding, it is important to ask ‘what is this data a study of’. 18 What does the data assume, ‘suggest’ or ‘pronounce’ and ‘from whose point of view’ does this data come, whom does it represent or whose thoughts are they?. 16 What collectively might it represent? The process of documenting reactions, emotions and related actions enables researchers to explore, challenge and intensify their sensitivity to the data. 34 Early coding assists the researcher to identify the direction for further data gathering. After initial analysis, theoretical sampling is employed to direct collection of additional data that will inform the ‘developing theory’. 9 Initial coding advances into intermediate coding once categories begin to develop.

Theoretical sampling

The purpose of theoretical sampling is to allow the researcher to follow leads in the data by sampling new participants or material that provides relevant information. As depicted in Figure 1 , theoretical sampling is central to GT design, aids the evolving theory 5 , 7 , 16 and ensures the final developed theory is grounded in the data. 9 Theoretical sampling in GT is for the development of a theoretical category, as opposed to sampling for population representation. 10 Novice researchers need to acknowledge this difference if they are to achieve congruence within the methodology. Birks and Mills 6 define theoretical sampling as ‘the process of identifying and pursuing clues that arise during analysis in a grounded theory study’ (p. 68). During this process, additional information is sought to saturate categories under development. The analysis identifies relationships, highlights gaps in the existing data set and may reveal insight into what is not yet known. The exemplars in Box 1 highlight how theoretical sampling led to the inclusion of further data.

Examples of theoretical sampling.

Thus, theoretical sampling is used to focus and generate data to feed the iterative process of continual comparative analysis of the data. 6

Intermediate coding

Intermediate coding, identifying a core category, theoretical data saturation, constant comparative analysis, theoretical sensitivity and memoing occur in the next phase of the GT process. 6 Intermediate coding builds on the initial coding phase. Where initial coding fractures the data, intermediate coding begins to transform basic data into more abstract concepts allowing the theory to emerge from the data. During this analytic stage, a process of reviewing categories and identifying which ones, if any, can be subsumed beneath other categories occurs and the properties or dimension of the developed categories are refined. Properties refer to the characteristics that are common to all the concepts in the category and dimensions are the variations of a property. 37

At this stage, a core category starts to become evident as developed categories form around a core concept; relationships are identified between categories and the analysis is refined. Birks and Mills 6 affirm that diagramming can aid analysis in the intermediate coding phase. Grounded theorists interact closely with the data during this phase, continually reassessing meaning to ascertain ‘what is really going on’ in the data. 30 Theoretical saturation ensues when new data analysis does not provide additional material to existing theoretical categories, and the categories are sufficiently explained. 6

Advanced coding

Birks and Mills 6 described advanced coding as the ‘techniques used to facilitate integration of the final grounded theory’ (p. 177). These authors promote storyline technique (described in the following section) and theoretical coding as strategies for advancing analysis and theoretical integration. Advanced coding is essential to produce a theory that is grounded in the data and has explanatory power. 6 During the advanced coding phase, concepts that reach the stage of categories will be abstract, representing stories of many, reduced into highly conceptual terms. The findings are presented as a set of interrelated concepts as opposed to presenting themes. 28 Explanatory statements detail the relationships between categories and the central core category. 28

Storyline is a tool that can be used for theoretical integration. Birks and Mills 6 define storyline as ‘a strategy for facilitating integration, construction, formulation, and presentation of research findings through the production of a coherent grounded theory’ (p. 180). Storyline technique is first proposed with limited attention in Basics of Qualitative Research by Strauss and Corbin 12 and further developed by Birks et al. 38 as a tool for theoretical integration. The storyline is the conceptualisation of the core category. 6 This procedure builds a story that connects the categories and produces a discursive set of theoretical propositions. 24 Birks and Mills 6 contend that storyline can be ‘used to produce a comprehensive rendering of your grounded theory’ (p. 118). Birks et al. 38 had earlier concluded, ‘storyline enhances the development, presentation and comprehension of the outcomes of grounded theory research’ (p. 405). Once the storyline is developed, the GT is finalised using theoretical codes that ‘provide a framework for enhancing the explanatory power of the storyline and its potential as theory’. 6 Thus, storyline is the explication of the theory.

Theoretical coding occurs as the final culminating stage towards achieving a GT. 39 , 40 The purpose of theoretical coding is to integrate the substantive theory. 41 Saldaña 40 states, ‘theoretical coding integrates and synthesises the categories derived from coding and analysis to now create a theory’ (p. 224). Initial coding fractures the data while theoretical codes ‘weave the fractured story back together again into an organized whole theory’. 18 Advanced coding that integrates extant theory adds further explanatory power to the findings. 6 The examples in Box 2 describe the use of storyline as a technique.

Writing the storyline.

Theoretical sensitivity

As presented in Figure 1 , theoretical sensitivity encompasses the entire research process. Glaser and Strauss 5 initially described the term theoretical sensitivity in The Discovery of Grounded Theory. Theoretical sensitivity is the ability to know when you identify a data segment that is important to your theory. While Strauss and Corbin 12 describe theoretical sensitivity as the insight into what is meaningful and of significance in the data for theory development, Birks and Mills 6 define theoretical sensitivity as ‘the ability to recognise and extract from the data elements that have relevance for the emerging theory’ (p. 181). Conducting GT research requires a balance between keeping an open mind and the ability to identify elements of theoretical significance during data generation and/or collection and data analysis. 6

Several analytic tools and techniques can be used to enhance theoretical sensitivity and increase the grounded theorist’s sensitivity to theoretical constructs in the data. 28 Birks and Mills 6 state, ‘as a grounded theorist becomes immersed in the data, their level of theoretical sensitivity to analytic possibilities will increase’ (p. 12). Developing sensitivity as a grounded theorist and the application of theoretical sensitivity throughout the research process allows the analytical focus to be directed towards theory development and ultimately result in an integrated and abstract GT. 6 The example in Box 3 highlights how analytic tools are employed to increase theoretical sensitivity.

Theoretical sensitivity.

The grounded theory

The meticulous application of essential GT methods refines the analysis resulting in the generation of an integrated, comprehensive GT that explains a process relating to a particular phenomenon. 6 The results of a GT study are communicated as a set of concepts, related to each other in an interrelated whole, and expressed in the production of a substantive theory. 5 , 7 , 16 A substantive theory is a theoretical interpretation or explanation of a studied phenomenon 6 , 17 Thus, the hallmark of grounded theory is the generation of theory ‘abstracted from, or grounded in, data generated and collected by the researcher’. 6 However, to ensure quality in research requires the application of rigour throughout the research process.

Quality and rigour

The quality of a grounded theory can be related to three distinct areas underpinned by (1) the researcher’s expertise, knowledge and research skills; (2) methodological congruence with the research question; and (3) procedural precision in the use of methods. 6 Methodological congruence is substantiated when the philosophical position of the researcher is congruent with the research question and the methodological approach selected. 6 Data collection or generation and analytical conceptualisation need to be rigorous throughout the research process to secure excellence in the final grounded theory. 44

Procedural precision requires careful attention to maintaining a detailed audit trail, data management strategies and demonstrable procedural logic recorded using memos. 6 Organisation and management of research data, memos and literature can be assisted using software programs such as NVivo. An audit trail of decision-making, changes in the direction of the research and the rationale for decisions made are essential to ensure rigour in the final grounded theory. 6

This article offers a framework to assist novice researchers visualise the iterative processes that underpin a GT study. The fundamental process and methods used to generate an integrated grounded theory have been described. Novice researchers can adapt the framework presented to inform and guide the design of a GT study. This framework provides a useful guide to visualise the interplay between the methods and processes inherent in conducting GT. Research conducted ethically and with meticulous attention to process will ensure quality research outcomes that have relevance at the practice level.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Home » Grounded Theory – Methods, Examples and Guide

Grounded Theory – Methods, Examples and Guide

Table of Contents

Grounded Theory

Definition:

Grounded Theory is a qualitative research methodology that aims to generate theories based on data that are grounded in the empirical reality of the research context. The method involves a systematic process of data collection, coding, categorization, and analysis to identify patterns and relationships in the data.

The ultimate goal is to develop a theory that explains the phenomenon being studied, which is based on the data collected and analyzed rather than on preconceived notions or hypotheses. The resulting theory should be able to explain the phenomenon in a way that is consistent with the data and also accounts for variations and discrepancies in the data. Grounded Theory is widely used in sociology, psychology, management, and other social sciences to study a wide range of phenomena, such as organizational behavior, social interaction, and health care.

History of Grounded Theory

Grounded Theory was first introduced by sociologists Barney Glaser and Anselm Strauss in the 1960s as a response to the limitations of traditional positivist approaches to social research. The approach was initially developed to study dying patients and their families in hospitals, but it was soon applied to other areas of sociology and beyond.

Glaser and Strauss published their seminal book “The Discovery of Grounded Theory” in 1967, in which they presented their approach to developing theory from empirical data. They argued that existing social theories often did not account for the complexity and diversity of social phenomena, and that the development of theory should be grounded in empirical data.

Since then, Grounded Theory has become a widely used methodology in the social sciences, and has been applied to a wide range of topics, including healthcare, education, business, and psychology. The approach has also evolved over time, with variations such as constructivist grounded theory and feminist grounded theory being developed to address specific criticisms and limitations of the original approach.

Types of Grounded Theory

There are two main types of Grounded Theory: Classic Grounded Theory and Constructivist Grounded Theory.

Classic Grounded Theory

This approach is based on the work of Glaser and Strauss, and emphasizes the discovery of a theory that is grounded in data. The focus is on generating a theory that explains the phenomenon being studied, without being influenced by preconceived notions or existing theories. The process involves a continuous cycle of data collection, coding, and analysis, with the aim of developing categories and subcategories that are grounded in the data. The categories and subcategories are then compared and synthesized to generate a theory that explains the phenomenon.

Constructivist Grounded Theory

This approach is based on the work of Charmaz, and emphasizes the role of the researcher in the process of theory development. The focus is on understanding how individuals construct meaning and interpret their experiences, rather than on discovering an objective truth. The process involves a reflexive and iterative approach to data collection, coding, and analysis, with the aim of developing categories that are grounded in the data and the researcher’s interpretations of the data. The categories are then compared and synthesized to generate a theory that accounts for the multiple perspectives and interpretations of the phenomenon being studied.

Grounded Theory Conducting Guide

Here are some general guidelines for conducting a Grounded Theory study:

• Choose a research question: Start by selecting a research question that is open-ended and focuses on a specific social phenomenon or problem.
• Select participants and collect data: Identify a diverse group of participants who have experienced the phenomenon being studied. Use a variety of data collection methods such as interviews, observations, and document analysis to collect rich and diverse data.
• Analyze the data: Begin the process of analyzing the data using constant comparison. This involves comparing the data to each other and to existing categories and codes, in order to identify patterns and relationships. Use open coding to identify concepts and categories, and then use axial coding to organize them into a theoretical framework.
• Generate categories and codes: Generate categories and codes that describe the phenomenon being studied. Make sure that they are grounded in the data and that they accurately reflect the experiences of the participants.
• Refine and develop the theory: Use theoretical sampling to identify new data sources that are relevant to the developing theory. Use memoing to reflect on insights and ideas that emerge during the analysis process. Continue to refine and develop the theory until it provides a comprehensive explanation of the phenomenon.
• Validate the theory: Finally, seek to validate the theory by testing it against new data and seeking feedback from peers and other researchers. This process helps to refine and improve the theory, and to ensure that it is grounded in the data.
• Write up and disseminate the findings: Once the theory is fully developed and validated, write up the findings and disseminate them through academic publications and presentations. Make sure to acknowledge the contributions of the participants and to provide a detailed account of the research methods used.

Data Collection Methods

Grounded Theory Data Collection Methods are as follows:

• Interviews : One of the most common data collection methods in Grounded Theory is the use of in-depth interviews. Interviews allow researchers to gather rich and detailed data about the experiences, perspectives, and attitudes of participants. Interviews can be conducted one-on-one or in a group setting.
• Observation : Observation is another data collection method used in Grounded Theory. Researchers may observe participants in their natural settings, such as in a workplace or community setting. This method can provide insights into the social interactions and behaviors of participants.
• Document analysis: Grounded Theory researchers also use document analysis as a data collection method. This involves analyzing existing documents such as reports, policies, or historical records that are relevant to the phenomenon being studied.
• Focus groups : Focus groups involve bringing together a group of participants to discuss a specific topic or issue. This method can provide insights into group dynamics and social interactions.
• Fieldwork : Fieldwork involves immersing oneself in the research setting and participating in the activities of the participants. This method can provide an in-depth understanding of the culture and social dynamics of the research setting.
• Multimedia data: Grounded Theory researchers may also use multimedia data such as photographs, videos, or audio recordings to capture the experiences and perspectives of participants.

Data Analysis Methods

Grounded Theory Data Analysis Methods are as follows:

• Open coding: Open coding is the process of identifying concepts and categories in the data. Researchers use open coding to assign codes to different pieces of data, and to identify similarities and differences between them.
• Axial coding: Axial coding is the process of organizing the codes into broader categories and subcategories. Researchers use axial coding to develop a theoretical framework that explains the phenomenon being studied.
• Constant comparison: Grounded Theory involves a process of constant comparison, in which data is compared to each other and to existing categories and codes in order to identify patterns and relationships.
• Theoretical sampling: Theoretical sampling involves selecting new data sources based on the emerging theory. Researchers use theoretical sampling to collect data that will help refine and validate the theory.
• Memoing : Memoing involves writing down reflections, insights, and ideas as the analysis progresses. This helps researchers to organize their thoughts and develop a deeper understanding of the data.
• Peer debriefing: Peer debriefing involves seeking feedback from peers and other researchers on the developing theory. This process helps to validate the theory and ensure that it is grounded in the data.
• Member checking: Member checking involves sharing the emerging theory with the participants in the study and seeking their feedback. This process helps to ensure that the theory accurately reflects the experiences and perspectives of the participants.
• Triangulation: Triangulation involves using multiple sources of data to validate the emerging theory. Researchers may use different data collection methods, different data sources, or different analysts to ensure that the theory is grounded in the data.

Applications of Grounded Theory

Here are some of the key applications of Grounded Theory:

• Social sciences : Grounded Theory is widely used in social science research, particularly in fields such as sociology, psychology, and anthropology. It can be used to explore a wide range of social phenomena, such as social interactions, power dynamics, and cultural practices.
• Healthcare : Grounded Theory can be used in healthcare research to explore patient experiences, healthcare practices, and healthcare systems. It can provide insights into the factors that influence healthcare outcomes, and can inform the development of interventions and policies.
• Education : Grounded Theory can be used in education research to explore teaching and learning processes, student experiences, and educational policies. It can provide insights into the factors that influence educational outcomes, and can inform the development of educational interventions and policies.
• Business : Grounded Theory can be used in business research to explore organizational processes, management practices, and consumer behavior. It can provide insights into the factors that influence business outcomes, and can inform the development of business strategies and policies.
• Technology : Grounded Theory can be used in technology research to explore user experiences, technology adoption, and technology design. It can provide insights into the factors that influence technology outcomes, and can inform the development of technology interventions and policies.

Examples of Grounded Theory

Examples of Grounded Theory in different case studies are as follows:

• Glaser and Strauss (1965): This study, which is considered one of the foundational works of Grounded Theory, explored the experiences of dying patients in a hospital. The researchers used Grounded Theory to develop a theoretical framework that explained the social processes of dying, and that was grounded in the data.
• Charmaz (1983): This study explored the experiences of chronic illness among young adults. The researcher used Grounded Theory to develop a theoretical framework that explained how individuals with chronic illness managed their illness, and how their illness impacted their sense of self.
• Strauss and Corbin (1990): This study explored the experiences of individuals with chronic pain. The researchers used Grounded Theory to develop a theoretical framework that explained the different strategies that individuals used to manage their pain, and that was grounded in the data.
• Glaser and Strauss (1967): This study explored the experiences of individuals who were undergoing a process of becoming disabled. The researchers used Grounded Theory to develop a theoretical framework that explained the social processes of becoming disabled, and that was grounded in the data.
• Clarke (2005): This study explored the experiences of patients with cancer who were receiving chemotherapy. The researcher used Grounded Theory to develop a theoretical framework that explained the factors that influenced patient adherence to chemotherapy, and that was grounded in the data.

Grounded Theory Research Example

A Grounded Theory Research Example Would be:

Research question : What is the experience of first-generation college students in navigating the college admission process?

Data collection : The researcher conducted interviews with first-generation college students who had recently gone through the college admission process. The interviews were audio-recorded and transcribed verbatim.

Data analysis: The researcher used a constant comparative method to analyze the data. This involved coding the data, comparing codes, and constantly revising the codes to identify common themes and patterns. The researcher also used memoing, which involved writing notes and reflections on the data and analysis.

Findings : Through the analysis of the data, the researcher identified several themes related to the experience of first-generation college students in navigating the college admission process, such as feeling overwhelmed by the complexity of the process, lacking knowledge about the process, and facing financial barriers.

Theory development: Based on the findings, the researcher developed a theory about the experience of first-generation college students in navigating the college admission process. The theory suggested that first-generation college students faced unique challenges in the college admission process due to their lack of knowledge and resources, and that these challenges could be addressed through targeted support programs and resources.

In summary, grounded theory research involves collecting data, analyzing it through constant comparison and memoing, and developing a theory grounded in the data. The resulting theory can help to explain the phenomenon being studied and guide future research and interventions.

Purpose of Grounded Theory

The purpose of Grounded Theory is to develop a theoretical framework that explains a social phenomenon, process, or interaction. This theoretical framework is developed through a rigorous process of data collection, coding, and analysis, and is grounded in the data.

Grounded Theory aims to uncover the social processes and patterns that underlie social phenomena, and to develop a theoretical framework that explains these processes and patterns. It is a flexible method that can be used to explore a wide range of research questions and settings, and is particularly well-suited to exploring complex social phenomena that have not been well-studied.

The ultimate goal of Grounded Theory is to generate a theoretical framework that is grounded in the data, and that can be used to explain and predict social phenomena. This theoretical framework can then be used to inform policy and practice, and to guide future research in the field.

When to use Grounded Theory

Following are some situations in which Grounded Theory may be particularly useful:

• Exploring new areas of research: Grounded Theory is particularly useful when exploring new areas of research that have not been well-studied. By collecting and analyzing data, researchers can develop a theoretical framework that explains the social processes and patterns underlying the phenomenon of interest.
• Studying complex social phenomena: Grounded Theory is well-suited to exploring complex social phenomena that involve multiple social processes and interactions. By using an iterative process of data collection and analysis, researchers can develop a theoretical framework that explains the complexity of the social phenomenon.
• Generating hypotheses: Grounded Theory can be used to generate hypotheses about social processes and interactions that can be tested in future research. By developing a theoretical framework that explains a social phenomenon, researchers can identify areas for further research and hypothesis testing.
• Informing policy and practice : Grounded Theory can provide insights into the factors that influence social phenomena, and can inform policy and practice in a variety of fields. By developing a theoretical framework that explains a social phenomenon, researchers can identify areas for intervention and policy development.

Characteristics of Grounded Theory

Grounded Theory is a qualitative research method that is characterized by several key features, including:

• Emergence : Grounded Theory emphasizes the emergence of theoretical categories and concepts from the data, rather than preconceived theoretical ideas. This means that the researcher does not start with a preconceived theory or hypothesis, but instead allows the theory to emerge from the data.
• Iteration : Grounded Theory is an iterative process that involves constant comparison of data and analysis, with each round of data collection and analysis refining the theoretical framework.
• Inductive : Grounded Theory is an inductive method of analysis, which means that it derives meaning from the data. The researcher starts with the raw data and systematically codes and categorizes it to identify patterns and themes, and to develop a theoretical framework that explains these patterns.
• Reflexive : Grounded Theory requires the researcher to be reflexive and self-aware throughout the research process. The researcher’s personal biases and assumptions must be acknowledged and addressed in the analysis process.
• Holistic : Grounded Theory takes a holistic approach to data analysis, looking at the entire data set rather than focusing on individual data points. This allows the researcher to identify patterns and themes that may not be apparent when looking at individual data points.
• Contextual : Grounded Theory emphasizes the importance of understanding the context in which social phenomena occur. This means that the researcher must consider the social, cultural, and historical factors that may influence the phenomenon of interest.

Advantages of Grounded Theory

Advantages of Grounded Theory are as follows:

• Flexibility : Grounded Theory is a flexible method that can be used to explore a wide range of research questions and settings. It is particularly well-suited to exploring complex social phenomena that have not been well-studied.
• Validity : Grounded Theory aims to develop a theoretical framework that is grounded in the data, which enhances the validity and reliability of the research findings. The iterative process of data collection and analysis also helps to ensure that the research findings are reliable and robust.
• Originality : Grounded Theory can generate new and original insights into social phenomena, as it is not constrained by preconceived theoretical ideas or hypotheses. This allows researchers to explore new areas of research and generate new theoretical frameworks.
• Real-world relevance: Grounded Theory can inform policy and practice, as it provides insights into the factors that influence social phenomena. The theoretical frameworks developed through Grounded Theory can be used to inform policy development and intervention strategies.
• Ethical : Grounded Theory is an ethical research method, as it allows participants to have a voice in the research process. Participants’ perspectives are central to the data collection and analysis process, which ensures that their views are taken into account.
• Replication : Grounded Theory is a replicable method of research, as the theoretical frameworks developed through Grounded Theory can be tested and validated in future research.

Limitations of Grounded Theory

Limitations of Grounded Theory are as follows:

• Time-consuming: Grounded Theory can be a time-consuming method, as the iterative process of data collection and analysis requires significant time and effort. This can make it difficult to conduct research in a timely and cost-effective manner.
• Subjectivity : Grounded Theory is a subjective method, as the researcher’s personal biases and assumptions can influence the data analysis process. This can lead to potential issues with reliability and validity of the research findings.
• Generalizability : Grounded Theory is a context-specific method, which means that the theoretical frameworks developed through Grounded Theory may not be generalizable to other contexts or populations. This can limit the applicability of the research findings.
• Lack of structure : Grounded Theory is an exploratory method, which means that it lacks the structure of other research methods, such as surveys or experiments. This can make it difficult to compare findings across different studies.
• Data overload: Grounded Theory can generate a large amount of data, which can be overwhelming for researchers. This can make it difficult to manage and analyze the data effectively.
• Difficulty in publication: Grounded Theory can be challenging to publish in some academic journals, as some reviewers and editors may view it as less rigorous than other research methods.

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Grounded Theory

• First Online: 29 September 2022

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• Robert E. White   ORCID: orcid.org/0000-0002-8045-164X 3 &
• Karyn Cooper 4  

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Grounded theory may perhaps be one of the most widely known methodologies used to conduct qualitative research in the social sciences and beyond. Introduced by sociologists Barney Glaser and Anselm Strauss (Glaser & Strauss, 1967), grounded theory suggests that procedures once thought to be unacceptable with regards to traditional qualitative research have become perfectly acceptable, if not desirable and required. The methodology also provides justification for regarding qualitative research as a legitimate and rigorous form of inquiry (DePoy & Gitlin, 2016).

GT is multivariate. It happens sequentially, subsequently, simultaneously, serendipitously, and scheduled. Barney Glaser ( 1998 )

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Negotiating emotional order: a grounded theory of breast cancer survivors

Jennifer A. Klimek Yingling

Klimek Yingling, J. A. (2018). Negotiating emotional order: A grounded theory of breast cancer survivors. Grounded Theory Review: An International Journal 17 (1), 12-27.

In this article, classic grounded theory captures the processes of 12 women who had completed initial treatment for breast cancer. The qualitative data analysis reveals the basic social process of negotiating emotional order that describe how breast cancer survivors perceive their illness and decide to take action. From the data, five stages of the process of negotiating emotional order emerge: 1) Losing Life Order, 2) Assisted Life Order, 3) Transforming 4) Accepting, and 5) Creating Emotional Order. This study may help healthcare providers who care for breast cancer survivors understand the depth of perpetual emotional impact that breast cancer survivors endure. This study will potentially serve as a path for future research and aid in the understanding of the psychological impact that breast cancer has upon survivors.

Keywords : breast cancer, survivor, chemotherapy, emotional order

What Sparked This Research

I cared for a patient who I had gotten to know as her child often visited the emergency department due to hemophilia. She was a pleasure to work with, strong, level headed, and upbeat. On this particular day she was the patient. Her complaint was simple: a cough and she clearly wasn’t herself emotionally. I was surprised to discover, when I took her past medical history, that she was a breast cancer survivor. After I discussed her chest x-ray results I sensed she was still upset and filled with uncertainty. Then the lightbulb went on. I asked her directly if she was concerned if the cancer was recurring. She said yes and her tears flowed. I do believe if I had not dug a little deeper into her emotional state she would have left the emergency department with much of the same emotional duress that she initially had. This interaction sparked my research as it was clear that breast cancer survivors endure a process after treatment ends. For these survivors the treatment is over but the emotional aspect of breast cancer is not. It also became evident to me that health care providers need to know more about this process on order to be able to treat patients holistically.

Negotiating Emotional Order: A Grounded Theory of Breast Cancer Survivors

Breast cancer is the most prevalent cancer found in women worldwide (American Cancer Society [ACS], 2016; Ferlay et al., 2104). In the United States, it is estimated that 3.5 million women have been diagnosed with breast cancer; 245,000 will be newly diagnosed; and, approximately 40,000 women will succumb to breast cancer annually (ACS, 2016; Breastcancer.org, 2016). Early detection and improved treatment is credited to the rising population of women who are breast cancer survivors (Howlader et al., 2015; McCloskey, Lee, & Steinburg, 2011). Concerns about the psychosocial ramifications of chronic illness have a long history. The Institute of Medicine (2009), American Cancer Society (2015), and the American Society of Clinical Oncology (2015) resonate concern about psychosocial hindrances regarding cancer patients, citing them as a critical area needing improvement within the nation’s health care system.

The literature suggests breast cancer survivors endure psychological stressors after the completion of treatment including the following: loneliness (Marroquin, Czamanski-Cohen, Weihs, & Stanton, 2016; Rosedale, 2009), anxiety and depression (Walker, Szanton, & Wenzel, 2015), uncertainty (Dawson, Madsen, & Dains, 2016; Mishel et al., 2005), and fear of recurrence (McGinty, Small, Laronga, & Jacobsen, 2016). The phenomenon of breast cancer survivorship has been identified with qualitative methods, yet is lacking explanatory theory (Allen, Savadatti & Levy, 2009; Pelusi, 1997). Qualitative analysis uses inductive rather than deductive investigation of a clinical phenomenon for capturing themes and patterns within subjective perceptions to generate an interpretive account to inform clinical understanding. Inductive methods are used by the researchers to discover and generate theory (Artinian, Giske, & Cone, 2009; Glaser, 2008). Therefore, grounded theory was chosen to study the process of survivorship in women who have completed treatment for breast cancer.

A Glaserian grounded theory design was chosen to explore the process of transition survivorship in women who have completed treatment for breast cancer. Grounded theory allows the researcher to explore a phenomenon and build theory from concepts going through processes and transitions (Glaser & Strauss, 1967; Glaser, 2008). The ACS defines cancer survivor as “anyone with a history of cancer, from the time of diagnosis through the remainder of their life” (ACS, 2016, p. 3). This definition was used for inclusion criteria for this project. Prior to commencement of the research, approval from the university’s institutional review board was secured. A purposive sample was sought and participants were self-identified breast cancer survivors in a suburban community in Northeast United States. A presentation was made at a local breast cancer survivorship group. Flyers were posted in community centers, libraries, and public places including areas that reach numerous individuals. Based on these recruitment efforts, 12 women were interviewed during a four-month period.

Data Collection

All participants received written and verbal information about the study and gave informed consent. Data were collected by completing the following: a demographic data form, approximately one-hour individual in-depth interviews, observational notes, and field notes. All of the data was handled in a confidential manner. Each interview session lasted approximately one hour in length. Broad open-ended questions were used to stimulate discussion of thoughts and feelings about extended survivorship. Focused questions and prompts were used to elicit more specific information from participants about their actions to attain and maintain psychosocial health after the completion of breast cancer treatment. The focus questions also elicited information about processes used to modify and maneuver through adversities after completion of treatment. Each participant was asked to describe situations when she knew something had changed in her health and psychosocial status after the completion of treatment for breast cancer. Participants were asked to answer the questions until they felt they had no information to add to the topic.

Data Analysis

Data analysis took a Glaserian approach in which data collection, analysis, and memoing were ongoing and concurrent throughout the research. Each interview was digitally taped and transcribed. Atlas.ti software was used as a depository to code, store, and memo during analysis. Data was coded line by line to fracture the data into nouns formed from a verb or gerund. The interviews were re-coded on three different occasions. After the initial interview was coded, the second interview was coded in a similar fashion and the data were examined for common constructs that were clustered. Subsequent interviews were open-coded and compared with ideas and relationships described in the researcher’s memos. As the categories unfolded, some categories were re-coded or combined with other categories. At the conclusion of the last interview, all codes were sorted to certify fit. Once a core variable or category was identified, coding became selective. The researcher continued the interviews and coding until saturation of the core variable was achieved. On saturation, theoretical coding was used to intersect categories within the data. Exploration of the literature for substantive codes that were significant was conducted each day. Extensive memo taking was used via manual notes and also as freehand drawn visuals created by the researcher to capture the researcher’s mind set.

Trustworthiness

For the purpose of this paper, a conglomerate of trustworthiness criteria grounded from the recommendations of Glaser (1978, 1998, 2001) was employed. The researcher who conducted this study had scant exposure to extended breast cancer survivors in her personal and professional realm. Techniques to establish credibility included prolonged engagement and peer debriefing. Theoretical sampling and constant comparison took place when data, analytic categories, interpretations, and conclusions were discussed and tested with study participants throughout the interview process. Prolonged engagement developed rapport and participant trust. To address transferability, the following groups of data were included in an audit trail: 1) raw data, 2) data reduction and analysis notes, data reconstruction and synthesis products, 3) process notes, 4) materials related to intentions and dispositions, and 5) preliminary development information. The researcher kept a reflexive journal to record methodological decisions and the rationale for the decisions, the planning and management of the study, and reflection upon the researcher’s own principles, feelings, and interests. Lastly, external audits were conducted by several researchers not involved with the research process on several occasions.

The Theory of Negotiating Emotional Order

The main concern of the women is the struggle for emotional order. The meaning inherent in the basic social process of Negotiating Emotional Order is that women who have been diagnosed with breast cancer strive for emotional order by negotiating control of the negative feeling of threats to their mortality and to live their daily lives. The process described in the theory of Negotiating Emotional Order changes as the situation of the breast cancer survivors changes. As time passes, the women move from discovering an abnormality to a time after treatment ends. This process is dynamic and perpetual in nature because the threat of cancer recurrence remains until the end of the breast cancer survivor’s life. For some women, negotiating emotional order is achieved even when the cancer recurs or metastasizes.

The participants’ actions and decisions illuminate the perpetual struggle to negotiate emotional order. For some, order is compartmentalizing negative thoughts and emotions that they could not control. For others, they accept the fact that they cannot control cancer but project order onto other aspects of their lives. The struggle for emotional order is present from the time the survivor found the abnormality into long-term survivorship and at times is cyclic. Five stages of the process of negotiating emotional order emerges from the data: 1) Losing Life Order, 2) Assisted Life Order, 3) Transforming, 4) Accepting, and 5) Creating Emotional Order.

Losing Life Order

During this time period, the realization of the threat of breast cancer disrupts emotional order with intense fear and uncertainty of the future. The breast cancer survivor often makes decisions and acts on her instincts to placate the immediacy that she feels prior to starting treatment, often seeks information from the Internet, popular literature, media and from others who have experienced breast cancer. Unfortunately, their need for immediacy is often not met by the health care community, so they take matters into their own hands and act.

Many of the participants voice that this time period is difficult, as they have multifaceted family roles as wives, mothers, and children of parents of their own causing additional emotional turmoil. The participants continue or attempt to continue with their family roles by working, caring for children, and maintaining their households. The breast cancer survivors voice that they don’t have time to let cancer get in the way emotionally as they are too busy with family and work responsibilities. The participants speak of emotional duress when they see their families react to their illness and chose to protect their families by concealing their emotions. One participant talked about why she concealed her emotions: “The emotional impact it had on my family was horrible . . . I felt like I had to be strong for them . . . I would not show any emotions about being sick.”

Losing order encompasses two properties of disorder: losing emotional order and losing physical order. Upon discovering an abnormality, and then confirming breast cancer, the breast cancer survivors report loss of control of their bodies, which causes emotional duress. This stage marked the survivors’ first sense that cancer cannot be controlled. Loss of emotional order is represented by feelings of sadness, anger, immediacy, loneliness, fear, and uncertainty. This stage is hallmarked by emotional chaos and decision making. Approaches the women use in this stage are: taking matters into own hands and concealing to maintain family order.

Assisted Life Order

Surprisingly, although treatment is a physically draining endeavor, the breast cancer survivors voice that it is a time of respite when they focus on physical well-being rather than the emotional disruption that is occurring. During this phase, the women are often consumed with treatments of surgery, chemotherapy, and/or radiation. The participants state they feel proactive and protected while under the frequent care of health care providers. This participant’s narrative exemplifies the feeling of being assisted emotionally and physically by health care providers: “While you’re getting chemotherapy, you think you’re doing something to kill off any additional cancer that the surgery didn’t get. You have certain protection.”

The breast cancer survivors verbalize feeling lonely, despite having much social and family support, and purposely seek out other women who endured breast cancer for emotional support. Breast cancer survivors seek emotional support from formal and informal support persons. The participants also discuss a phenomenon where other breast cancer survivors would approach them after hearing about their diagnosis and come to their assistance to provide support. The importance of this camaraderie is evident in this narrative: “I didn’t know people that have been through this…people came out of the woodwork. People that I had known that I didn’t know that had cancer who shared their stories with me.” Some of the breast cancer survivors express the need to have a connection with someone who has experienced breast cancer. Some women seek formal support groups for this need and continue to use them after treatment is completed.

The second stage of negotiating emotional order is assisted life order that occurs when the breast cancer survivor enters treatment and focuses all of her energy into physical well-being. At the same time, survivors entrust their life order into the hands of health care providers and rely on social support to carry them through the time that they are in treatment. During this time, the breast cancer survivor keeps physically and emotionally occupied with the routine of appointments and treatment. During this time, the women feel treatment is a sanctuary and they express that during this time they feel lonely in their current experience. During the second period, they engage with others with formal training or personal experience with breast cancer to establish emotional order.

Transforming

At this stage of the process, the breast cancer survivors report a cutting point or a crossroads and make a change in thought process. They are autonomously responsible for their physical and emotional well-being. This autonomy is a sharp contrast to their behavior while in treatment, where they live day to day and do not think about the future. Once treatments end, survivors must take the wheel and navigate into their life and the future. It does appear that this cutting point is an emotionally charged timeframe: the temporary sanctuary of treatment ends and many survivors feel the need to take subjective responsibility of their emotional order. The survivors speak about the need to reach inward to claim emotional order to live their lives beyond breast cancer.

During this stage, the threat changes from the fear of the diagnosis of cancer to the fear of cancer. The fear of cancer can be recurrence of breast cancer, occurrence of a new cancer, and/or cancer metastasis. The process of beginning to move on from the emotional effects of the diagnosis of breast cancer begins shortly after the end of treatment. Fear is initially intense then becomes manageable over time for many. Several women note the recurrent fear abates somewhat after the first year and even more after five years. The fear of recurrence also can return many years after the completion of treatment. This dread is especially true if the breast cancer survivor discovers new symptoms or abnormalities that lead her to believe the cancer has returned. Often waiting for the results of diagnostics causes extreme anxiety and fear of recurrence.

The interviewed participants ranged from three months to twenty-four years post treatment. Despite the variation of time since the ending of treatment, all of the participants discussed levels of fear of recurrence. Often, the fear of recurrence affects their daily lives initially until they set cancer apart from living their present life. Several of the participants state it is not so much an inherent process rather than an active decision to take control of their feelings of fear and move onward. In this stage, the turning point is the active decision to leave breast cancer in the past and focus on the present and future. Another participant, who is thirteen years post treatment, discussed this decision: “I told myself, I have to make a move here. You can curl up in a ball and die or I can move on. I started moving on.”

When the breast cancer survivors leave treatment, they are at a crossroad in which feelings of loss and confusion are produced. After adjuvant treatment ends, the breast cancer survivors must remap their lives and begin to strive for a new normalcy in their lives. The threat at this stage changes from the diagnosis of cancer and is replaced with the fear of recurrence. The breast cancer survivors often revisit their own mortality during this time and these feelings can cause loss of emotional order. During this time the breast cancer survivor transforms, remapping their life course and also moving on from fear.

Uncertainty of the future also causes emotional distress for breast cancer survivors. The reality that none can control their own mortality, or cancer, is an aspect of the emotional trajectory that the breast cancer survivors struggle with initially. Once breast cancer survivors make this realization, they can then subjectively gain order of their emotions. This action is autonomous as no one else but the breast cancer survivor can complete this task. One participant spoke about this decision: “There are things that I can change and there are things that I am powerless over. It’s distinguishing and I do have control over what I’m thinking.”

Although the breast cancer survivor attempts to control her emotions, she often will come to the realization that she can keep her emotions in order rather than control them so that she can move on in her life and get serenity with the past diagnosis of breast cancer. Several of the participants state the turning point occurs when they realize they cannot control cancer or their feelings, and thus accept order versus control. As the threat of recurrence is no longer an issue, they accept their mortality and are living in the present day. A participant reflection on this concept: “We’ll all go some day. It’s just my time might come sooner than expected. A part of life.”

Feelings of emotional loss of control can be triggered by reminders after treatment ends. Reminders include physical reminders, body image reminders, diagnostics, and society cancer awareness. Although gaining realization of their own mortality, living with reminders forces the breast cancer survivors to cope on a daily basis with the fear of recurrence as they are reminded by physical and cognitive aftermath of breast cancer. Additionally, diagnostics and health care visits can elicit feelings of fear. Breast cancer survivors also voice that breast cancer or cancer awareness activities in the community and media also trigger feelings of fear. The impact of reminders is showcased by one participant’s remarks: “I worry about it all the time. Every ache and pain I have. When my bones hurt I wonder if it is bone cancer. Every time I have to have a mammogram, I pray it’s not there.”

Creating Emotional Order

Inherently, human beings have emotions. One of these emotions is fear in response to a threat. As the threat of cancer recurrence has a perpetual quality in women who have been diagnosed with breast cancer, the emotional aspect of cancer recurrence is long-standing. Since she cannot fully control her emotions, the breast cancer survivor will compartmentalize negative feelings of uncertainty and fear to achieve emotional order. To protect themselves emotionally, several of the participants speak about triaging these emotions to the back of their heads and putting these feelings away. One participant illustrates this behavior: “It’s probably because I pushed it to the back of my head because I don’t want to deal with those emotions.”

Once the breast cancer survivor accepts the fact that there are aspects of her life she can control and there are aspects over which she has no power, she will begin to create emotional order. Having control over actions and or parts of her life allows the breast cancer survivor to have emotional order. During times of emotional distress, they also increase their attempts to distract themselves from their emotions. This increase in activity temporarily increases with times of stress. Often, after the breast cancer survivor feels well, she redefines the actions in which she participates. Survivors express themselves by participating in activities that they enjoy or want to experience but did not have the courage to do so prior to diagnosis. Breast cancer survivors also talk about controlling their family roles and home environment. The breast cancer survivor might demonstrate control by creating a household routine or enumerating familial activities. Distracting self with other aspects of life also is a way that breast cancer survivors create emotional order. By immersing themselves back into their daily routines of work, marital, household, and family roles, survivors limit the amount of time they have available to think about the fear of recurrence, which is similar to using activity to occupy time during the assisted life order stage.

Social comparison through self-evaluations is another way that these participants achieve emotional order. Breast cancer survivors use social comparison as a method to create emotional order by viewing their experience as better than others who experienced poor outcomes. As a defense mechanism, if the breast cancer survivor views her experience as positive then she reaffirms she is a survivor. Social comparison is evident almost unanimously in the data. Participants speak often of reflecting on the experience they endured and feel lucky. While exploring this code the researcher asked the participants what they meant by luck or being lucky. Consistently the participants talk about luck as comparing outcomes as better or worse. For example, when asked what she meant by having better luck, a participant replied: “Well I was thinking someone maybe had the same surgery as me, did better than me.” Here is an example of a breast cancer survivor socially comparing her experience as worse than another person’s experience.

In addition to evaluating the actual treatment outcomes and evaluating the way that they physically dealt with treatment, the breast cancer survivors also evaluate the entire experience of breast cancer by reflection. The ability to reflect onto the past experience to find benefits and assign positive outcomes related to the cancer allow the survivor to make sense of the experience and create emotional order. In many ways, the survivors feel everything that they endured was worth what they became. Many reflect back and feel they gained knowledge of self-meaning knowing their bodies and emotions and realized they have abilities to endure adversity that they did not know before the experience of breast cancer. The breast cancer survivors reflect back in awe of the emotional stamina that they had during adversity and were proud of their accomplishments. One participant states: “It is amazing. Yeah if someone had told me I could write a book, become a massage therapist and learn the body the way I have. I would have said no way.”

“I feel like I know these people. You have been through what they have been through.” This participant’s narrative sums up the transparent common bond the participants feel with other cancer survivors. To create emotional order, the breast cancer survivors help others as a way to help themselves emotionally. Planned helpfulness allows the breast cancer survivor to create emotional order by gaining satisfaction through assisting others. Often breast cancer survivors employ ambiguousness until they are ready to disclose their survivorship status. This opacity allows them to experience empowerment and also allows them life choice—a common theme throughout the interviews. Breast cancer survivors plan and decide how they would help others; many are grateful for the acquaintance disclosure and guidance they receive early in their disease trajectory and want to pay forward some type of comfort to others who are enduring cancer.

Once survivors accept the fact that they cannot control their mortality and cancer, the breast cancer survivor creates social order to protect herself emotionally. Breast cancer survivors are acutely aware that their actions do not guarantee that cancer will not return, but in this stage they want to maintain a status of being physically and emotionally healthy. One participant communicates: “What work do I need to do. I am a survivor and want to be a survivor for a long time.” Although reminders often trigger fear, the survivors often use methods to create emotional order, to find balance and not allow feelings of fear to overcome them. Breast cancer survivors protect themselves by controlling their actions, compartmentalizing negative feelings, using social comparison and/or engaging in planned helpfulness.

Creating Emotional Order allows breast cancer survivors to transcend the fear of recurrence by controlling their actions, compartmentalizing negative feelings, and using social comparison and planned helpfulness. Although they cannot control their emotions or control cancer, they can control the way they react to emotions and take control of their life actions. Many of the participants shelve their negative emotions in order not to let the psychological aspect of breast cancer interfere in their daily lives. The participants show evidence that the survivors can regress between stages of this theory, but after their initial passage through the stages progress forward quickly and resiliently.

Limitations

There are several limitations in this research. First, the researcher attempted to recruit a variety of participants from diverse social and demographic backgrounds through flyers posted in public places. Despite this attempt to obtain a diverse population, all the participants are White and hold high school education or equivalency and most of the sample had three or more years of college education. Most of the participants are married or partnered. Economic and insurance status information is not included in the demographic data. Expanding the demographic sample might have allowed modifiability of the theory to explore additional relationships between these variables and the process of survivorship.

Finally, grounded theory analyses are population specific. This research represents the primary step in theory development. The aim of grounded theory construction is to hone and develop a theory in the attempt to produce formal theory. Testing the applicability of this theory may be appropriate in other populations who face severe illnesses, for example individuals as they face the aging process, individuals who are facing a terminal illness, veterans returning from war diagnosed with post-traumatic stress disorder, men facing prostate cancer, and/or women facing infertility.

The aim of this study is to contribute to the knowledge of breast cancer survivorship. This research contributes to the literature as a lack of holistic research exists on the process of extended survivorship that involves the fragments of the process of survivorship. Breast cancer is a significant and prominent healthcare challenge for many women in the United States. Negotiating emotional order is identified as the core category allowing women to survive emotionally after completing treatment for breast cancer. Five stages were identified including the following: Losing Life Order, Assisted Life Order, Transforming, Accepting, and Creating Emotional Order. The grounded theory of negotiating order integrates and highlights the importance of recognizing emotional health in breast cancer survivors.

This research challenges a staple in cancer survivorship literature that is reported by Mullan (1985) in several ways. First, in the current study, breast cancer survivors described the process of survivorship beginning before diagnosis with the discovery of an abnormality. This variation in the genesis of process of survivorship is different from Mullan’s (1985) model in which the process of survivorship is said to begin with diagnosis. Second, a new stage that represented transitional survivorship or Stage III: Transforming is described in the current study as the period immediately following the completion of treatment. Third, Mullan (1985) described extended survivorship as ending once the survivor enters remission. Although most breast cancer survivors interviewed for this study entered remission, several experienced recurrences or metastatic breast cancer so Mullan’s model excluded the process that these individuals endured.

Lastly, in this study extended survivorship appeared to be a continuous state rather than a conduit to permanent survivorship as Mullan (1985) described in his model. Mullan (1985) stated permanent cancer survivorship begins once the person is considered cancer free and can successfully return to their normal physical and emotional abilities prior to the cancer diagnosis. The survivors in this study describe extended survivorship to have a perpetual nature rather than being permanently cured physically or emotionally. They also challenge the fact they would return to “normal.” One of the participants states, “It was a rough road. Trying to figure out who I was, where I belong. Because they say your life goes back to normal, there is no normalcy. I don’t feel I am normal today.” This idea is significant as many breast cancer survivors may feel the need to feel “normal” due to the extensive publication of Mullan’s (1985) model. The use of Mullan’s (1985) model by many credible cancer authorities may prove to be confusing and frustrating to breast cancer survivors who lack the feeling of normalcy after treatment is completed and into extended survivorship.

The theory of Negotiating Emotional Order supports several existing theories that describe how individuals handle severe illnesses beyond cancer. This work complements several authors who described survivorship beyond the biomedical model that psychosocial and environmental factors influence (Collins, 1995; Festinger, 1954; Folkman & Greer, 2000; Taylor, 1983; Walker, Jackson, & Littlejohn, 2004).

The construct of control can be found in the literature in multiple patient populations including breast cancer (Warren, 2010), cardiac disease (Svansdotti et al., 2012), patients with obsessive compulsive disorder (Kang, Namkoong, Yoo, Jhung, & Kim, 2012), diabetes (Hughes, Berg, & Wiebe, 2012), and sexual assault (Frazier, Morlensen, & Steward, 2005). In this study, loss of emotional control is important, as it serves as a catalyst shaping the decisions and actions of the participants. Additionally, controlling actions were used later by the participants as a means to cope, thus creating emotional order. This theme is analogous with Folkman’s (1984) description of control as a dynamic coping mechanism with shifting appraisal as result of a stressful encounter or environment.

Benefit finding and planned helpfulness that are reported are consistent with Taylor’s (1983) proposed theory of cognitive adaptation in response to threatening events as both are displays of a search for meaning in the experience and attempts of mastery to restore self-esteem. It may also be noted that Taylor (1983) linked an individual’s sense of control to positive cognitive adaptation. Lastly, social comparison is evident in this group. This observation echoes Festinger’s (1954) work hypothesizing that social comparison is done to promote self-normalcy. Social comparison in this population is a mechanism to negotiate emotional order by improving the survivors’ positive perception of their situation and is consistent with the work Collins (1995) reported.

Implications for Practice

This research affords a glimpse into the experience of survivorship from the perspective of women who have completed treatment for breast cancer and how they survived emotionally from the detection of an abnormality into extended survivorship. This work aids in the development of a broad understanding of the processes that individuals endure when faced with a serious health status alteration. This information might aid health care providers to understand the immediacy that breast cancer survivors experience during the disease trajectory and the concept that the fear of recurrence can last perpetually and be an issue that is important to survivors until the end of their lives.

A lesson that can be taken away from this work is that women are continuously attempting to create emotional order and this clearly indicates they need support to continue well after treatment ends. In terms of theory, the identification of the process used by breast cancer survivors to negotiate emotional order may be helpful for health care providers who care for, educate, and design nursing interventions for this population. This study of survivorship after breast cancer establishes the beginning process of generating a formal grounded theory on survivorship that could, through further theoretical sampling, be extended beyond this patient population. Building on existing theory, this qualitative data analysis may help explain the mechanisms used by populations who have experienced a life-threatening illness personally or while supporting a loved one.

Acknowledgements

I would like to thank the breast cancer survivors who shared their personal survivorship journey for this research. I also thank Dr. Elise Lev, Dr. Karen D’Alonzo, Dr. Claudia Beckman, Dr. Louise Dean Kelly and Naomi Tobes for their encouragement and invaluable contributions to this work.

Declaration of Conflicting Interests

The author declares no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

This research is supported by the Rita C. Koph Memorial Research Award generously given by the Foundation of New York State Nurses, Cathryne A. Welch Center for Nursing Research

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White, R.E., Cooper, K. (2022). Grounded Theory. In: Qualitative Research in the Post-Modern Era. Springer, Cham. https://doi.org/10.1007/978-3-030-85124-8_9

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Qualitative study design: Grounded theory

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Theory development.

Grounded theory proposes that careful observation of the social world can lead to the construction of theory (Rice & Ezzy, 1999). It is iterative and evolving, aiming to construct new theory from collected data that accounts for those data. It is also known as the “grounded theory method”, although the terms have become interchangeable (Bryant & Charmaz, 2007).

Grounded theory characteristics include:

• Data collection and analysis occurring simultaneously, with one informing the other.
• Data grouped into concepts, categories and themes.
• A data collection process influenced by the simultaneous development of those concepts, categories and themes.

Notably, data collection is cyclical and reflective. This is different from the more linear processes occurring in other methodologies.

Theoretical sampling is a key aspect of the sampling stage of grounded theory. Recruitment continues until the sample finally represents all aspects that make up the theory the data represent (Starks & Brown Trinidad, 2007). Participants are recruited based on their different experiences of a phenomenon.

Researchers collect participant data using these methods:

• Examination of documents
• Focus groups and interviews

Focus groups and interviews are typically being more practical in health research than observation (Starks & Brown Trinidad, 2007).

After the initial phase of data collection, researchers repeat the following cycle of steps:

Researchers’ developing understanding of the concepts, categories and relationships informs their actions at each step. These elements result in a theoretical framework explaining the data. 

This cycle reflects two crucial components of grounded theory:

• The process of coding, sorting and organising data. This aims to increasingly move towards more abstract terms in order to develop a related theory for the data
• The principle of constant comparison. This refers to the process of noting issues of interest in data and comparing them to other examples to identify similarities and differences.
• Widely used across a wide range of disciplines (Bryant & Charmaz, 2007).  
• Facilitates theory construction and the construction of fresh concepts. It also avoids assuming structures are stable (Charmaz, 2017). 
• Useful for when researchers wish to explain a process, not to test an existing theory. 

Limitations

• Inherently not useful for the application of received theory. 
• Not useful for testing hypotheses. 
• Analysis of data involves elements of researcher’s own subjective judgement.

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• What are the barriers to health care access for a refugee population? 

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Attree, M. (2001). Patients' and relatives' experiences and perspectives of 'Good' and 'Not so Good' quality care . J Adv Nurs , 33(4), 456-466. doi: 10.1046/j.1365-2648.2001.01689.x 

Lingard, L., Reznick, R., Espin, S., Regehr, G., & DeVito, I. (2002). Team communications in the operating room: talk patterns, sites of tension, and implications for novices . Acad Med , 77(3), 232-237. doi: 10.1097/00001888-200203000-00013 

Pettersson, S., Ekstrom, M. P., & Berg, C. M. (2013). Practices of weight regulation among elite athletes in combat sports: a matter of mental advantage? J Athl Train , 48(1), 99-108. doi: 10.4085/1062-6050-48.1.04 

Bryant, A., & Charmaz, K. (2007). The SAGE handbook of grounded theory : SAGE Publications Ltd.

Charmaz, K. (2017). An introduction to grounded theory : SAGE Publications Ltd. 

Lingard, L., Albert, M., & Levinson, W. (2008). Grounded theory, mixed methods, and action research . BMJ , 337, a567. doi: 10.1136/bmj.39602.690162.47 

Rice, P. L., & Ezzy, D. (1999). Qualitative research methods: a health focus . South Melbourne, Australia: Oxford University Press. 

Starks, H., & Brown Trinidad, S. (2007). Choose Your Method: A Comparison of Phenomenology, Discourse Analysis, and Grounded Theory . Qualitative Health Research , 17(10), 1372-1380. doi: 10.1177/1049732307307031 

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Article Contents

Introduction, distinguishing features of grounded theory, the role and timing of the literature review.

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Grounded theory: what makes a grounded theory study?

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Carley Turner, Felicity Astin, Grounded theory: what makes a grounded theory study?, European Journal of Cardiovascular Nursing , Volume 20, Issue 3, March 2021, Pages 285–289, https://doi.org/10.1093/eurjcn/zvaa034

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Grounded theory (GT) is both a research method and a research methodology. There are several different ways of doing GT which reflect the different viewpoints of the originators. For those who are new to this approach to conducting qualitative research, this can be confusing. In this article, we outline the key characteristics of GT and describe the role of the literature review in three common GT approaches, illustrated using exemplar studies.

Describing the key characteristics of a Grounded theory (GT) study.

Considering the role and timing of the literature review in different GT approaches.

Qualitative research is a cornerstone in cardiovascular research. It gives insights in why particular phenomena occur or what underlying mechanisms are. 1 Over the past 2 years, the European Journal of Cardiovascular Nursing published 20 qualitative studies. 2–21 These studies used methods such as content analysis, ethnography, or phenomenology. Grounded theory (GT) has been used to a lesser extent.

Grounded theory is both a methodology and a method used in qualitative research ( Table 1 ). It is a research approach used to gain an emic insight into a phenomenon. In simple terms, this means understanding the perspective, or point of view, of an ‘insider’, those who have experience of the phenomenon. 22 Grounded theory is a research approach that originated from the social sciences but has been used in education and health research. The focus of GT is to generate theory that is grounded in data and shaped by the views of participants, thereby moving beyond description and towards theoretical explanation of a process or phenomenon. 23

Grounded theory as a method and methodology

One of the key issues with using GT, particularly for novices, is understanding the different approaches that have evolved as each specific GT approach is slightly different.

The tradition of GT began with the seminal text about classic GT written by Glaser and Strauss, 24 but since then GT has evolved into several different types. The approach to GT chosen by the researcher depends upon an understanding of the epistemological underpinnings of the different approaches, the match with the topic under investigation and the researcher’s own stance. Whilst GT is frequently used in applied health research, very few studies detail which GT approach has been used, how and why. Sometimes published studies claim to use GT methodology but the approaches that form the foundation of GT are not reported. This may be due to the word limit in academic journals or because legitimate GT approaches have not been followed. Either way, there is a lack of clarity about the practical application of GT. The purpose of this article is to outline the distinguishing characteristics of GT and outline practical considerations for the novice researcher regarding the place of the literature review in GT.

There are several distinguishing features of GT, as outlined by Sbaraini et al. 25 The first is that GT research is conducted through an inductive process. This means that the researcher is developing theory rather than testing it and must therefore remain ‘open’ throughout the study. In essence, this means that the researcher has no preconceived ideas about the findings. Taking an inductive approach means that the focus of the research may evolve over time as the researchers understand what is important to their participants through the data collection and analysis process.

With regards to data analysis, the use of coding is initially used to break down data into smaller components and labelling them to capture the essence of the data. The codes are compared to one another to understand and explain any variation in the data before they are combined to form more abstract categories. Memos are used to record and develop the researcher’s analysis of the data, including the detail behind the comparisons made between categories. Memos can stimulate the researcher’s thinking, as well as capturing the researcher’s ideas during data collection and analysis.

A further feature for data analysis in a GT study is the simultaneous data analysis and sampling to facilitate theoretical sampling. This means that as data analysis progresses participants are purposefully selected who may have characteristics or experiences that have arisen as being of interest from data collection and analysis so far. Questions in the topic guide may also be modified to follow a specific line of inquiry, test ideas and interpretations, or fill gaps in the analysis to build an emerging substantive theory. This evolving and non-linear methodology is to allow the evolution of the study as indicated by data, rather than analysing at the end of data collection. This approach to data analysis supports the researcher to take an inductive approach as discussed above.

Theoretical sampling facilitates the construction of theory until theoretical saturation is reached. Theoretical saturation is when all the concepts that form the theory being developed are well understood and grounded in data. Finally, the results are expressed as a theory where a set of concepts are related to one another and provide a framework for making predictions. 26 These key features of GT are summarized in Table 2 .

Distinguishing features of a GT study (adapted from Sbaraini et al. 25 )

The identification of a gap in the published literature is typically a requirement of successful doctoral studies and grant applications. However, in GT research there are different views about the role and timing of the literature review.

For researchers using classic Glaserian GT, the recommended approach is that the published literature should not be reviewed until data collection, analysis and theory development has been completed. 24 The rationale for the delay of the literature review is to enable the researcher to remain ‘open’ to discover theory emerging from data and free from contamination by avoiding forcing data into pre-conceived concepts derived from other studies. Furthermore, because the researcher is ‘open’ to whichever direction the data takes they cannot know in advance which aspects of the literature will be relevant to their study. 27

In Glaserian GT, the emerging concepts and theory from data analysis inform the scope of the literature review which is conducted after theory development. 24 This approach to the literature review aligns with the rather positivist stance of Glaser in which the researcher aims to remain free of assumptions so that the theory that emerges from the data is not influenced by the researcher. Reviewing the literature prior to data analysis would risk theory being imposed on the data. Perhaps counterintuitively, Glaser does recommend reading literature in unrelated fields to understand as many theoretical codes as possible. 28 However, it is unclear how this is different to reading literature directly related to the topic and could potentially still lead to the contamination of the theory arising from data that delaying the literature review is intended to avoid. It is also problematic regarding the governance processes around research, whereby funders and ethics committees would expect at least an overview of the existing literature as part of the justification for the study.

A study by Bergman et al. 29 used a classic Glaserian GT approach to examine and identify the motive of power in myocardial infarction patients’ rehabilitation process. Whilst the key characteristics of GT were evident in the way the study was conducted, there was no discussion about how the literature review contributed to the final theory. This may have been due to the word limit but illustrates the challenges that novice researchers may have in understanding where the literature review fits in studies using GT approaches.

In Straussian GT, a more pragmatic approach to the literature view is adopted. Strauss and Corbin 30 recognized that the researcher has prior knowledge, including that of the literature, before starting their research. They did not recommend dissociation from the literature, but rather that the literature be used across the various stages of the research. Published literature could identify important areas that could contribute to theory development, support useful comparisons in the data and stimulate further questions during the analytical process. According to Strauss and Corbin, researchers should be mindful about how published work could influence theory development. Whilst visiting the literature prior to data collection was believed to enhance data analysis, it was not thought necessary to review all the literature beforehand, but rather revisit the literature at later stages in the research process. 30

A study published by Salminen-Tuomaala et al. 31 used a Straussian GT approach to explore factors that influenced the way patients coped with hospitalization for acute myocardial infarction. The authors described a reflexive process in which the researcher noted down their preconceived ideas about the topic as part of the data analysis process. The literature review was conducted after data analysis.

The most recent step in the evolution of GT is the move towards a constructivist epistemological stance advocated by Charmaz. 32 In simple terms, this means that the underlying approach reflects the belief that theories cannot be discovered but are instead constructed by the researcher and their interactions with the participants and data. As the researcher plays a central role in the construction of the GT, their background, personal views, and culture will influence this process and the way data are analysed. For this reason, it is important to be explicit about these preconceptions and aim to maintain an open mind through reflexivity. 32 Therefore, engaging in a preliminary literature review and using this information to compare and contrast with findings from the research undertaken is desirable, alongside completing a comprehensive literature review after data analysis with a specific aim to present the GT.

A study published by Odell et al. 33 used the modified GT approach recommended by Charmaz 32 to study patients’ experiences of restenosis after Percutaneous Coronary Intervention. The authors described the different GT approaches and key features of GT methodology which clearly informed the conduct of the study. However, there was no detail about how the literature review was used to shape the data analysis process and findings.

A solution: be clear on the approach taken to the literature review and why

Despite the clear differences in the approach to the literature review in GT, there appears to be a lack of precise guidance for novice researchers regarding how in depth or exhaustive a preliminary literature review should be. This lack of guidance can lead to a variety of different approaches as evidenced in the GT studies we have cited as examples, which is a challenge for the novice researcher. This uncertainty is further compounded by the concurrent approach to data collection and analysis which allows for the research focus to evolve as the study progresses. The complexity of the research process and the role and timing of the literature review is summarized in Figure 1 .

Literature review in Grounded Theory.

Taking a pragmatic approach, researchers will need to familiarize themselves with the literature to receive funding and approval for their study. This preliminary literature review can be followed up after data analysis by a more comprehensive review of the literature to help support the theory that was developed from the data. The key is to ensure transparency in reporting how the literature review has been used to develop the theory. The preliminary literature review can be used to set the scene for the research as part of the introduction, and the more extensive literature review can then be used during the discussion section to compare the theory developed from the data with existing literature, as per Probyn et al. 34

Whilst this pragmatic approach aligns with Straussian GT and Charmaz’s constructivist GT, it is at odds with Glaserian GT. Therefore, if Glaserian GT is chosen, the researcher should be explicit about deviation and provide a rationale.

Word count for journal articles is often a limiting factor in how much detail is included in why certain methodologies are used. Submitting detail about the methodology and rationale behind it can be presented as online supplementary material, thereby allowing interested readers to access further information about how and why the research was executed.

The use of GT as a methodology and method can shed light on areas where little knowledge is already known, generating theory directly from data. The traditional format of a published article does not always reflect the iterative approach to the literature review and data collection and analysis in GT. This can generate tension between how the research is presented in relation to how it was conducted. However, one simple way to ensure clarity in reporting is to be transparent in how the literature review is used.

The authors received no financial support for the research, authorship or publication of this article.

Conflict of interest : The authors declare that there are no conflicts of interest.

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Grounded Theory: What It Is + Approach in Qualitative Research

In the realm of qualitative research, the grounded theory approach stands as a stalwart methodology that has reshaped how researchers unravel the complexities of the human experience. 

This approach, developed by Barney G. Glaser and Anselm L. Strauss in the 1960s, provides a systematic framework for generating theories from empirical data.

Grounded theory methods involve systematically deriving theories from qualitative data, facilitating a deep understanding of complex phenomena. The grounded theory method empowers researchers to construct concepts and theories directly from the data they collect, fostering a comprehensive and contextually rich analysis.

In this blog, we delve into the core principles of the grounded theory approach and explore how platforms like QuestionPro can enhance its application in qualitative research.

Understanding the Grounded Theory Approach

Grounded theory is a qualitative research methodology that involves developing theories directly from the data collected during the research process instead of relying on pre-existing theories or hypotheses. 

This approach aims to generate insights and understanding about a particular phenomenon by systematically analyzing and coding the data to uncover patterns, relationships, and concepts. 

It emphasizes research’s iterative and inductive nature, allowing theories to emerge organically from the data rather than being imposed on it. This methodology is commonly used in social sciences and other fields to explore complex social processes and generate new theories from empirical observations and interviews.

The Importance of Grounded Theory Research?

Grounded theory research is particularly well-suited for situations where you want to develop a new theory or gain a deeper understanding of a complex phenomenon that hasn’t been extensively studied before. Here are some scenarios where such theory research can be valuable:

Exploratory Studies

When you’re exploring a new area of research where little prior theory exists, it can help you generate theories and concepts directly from the data.

Complex Social Processes

It can provide insights into the underlying dynamics if you’re studying complex social processes, behaviors, interactions, or cultural phenomena.

Emergent Phenomena

When examining a relatively new or rapidly evolving phenomenon, grounded theory can help you uncover the underlying structures and trends driving its emergence.

Theory Building

If you aim to develop a new theoretical framework based on empirical evidence, it provides a systematic approach to theory building grounded in data.

Contextual Understanding

When you want to deeply understand a phenomenon within its specific context, it allows you to capture the nuances and intricacies that more hypothesis-driven methods might miss.

Understanding Participant Perspectives

It effectively captures participants’ perspectives and experiences in a detailed and nuanced manner.

Diverse Data Types

It’s useful when you’re working with diverse types of qualitative data, such as interviews, observations, field notes, or textual documents.

Challenging Assumptions

Grounded theory allows you to develop insights that contradict or expand upon established knowledge to challenge existing assumptions or theories.

Interdisciplinary Research

This can be valuable in interdisciplinary research, where you’re attempting to integrate perspectives from multiple disciplines to develop new insights.

Theory Development in Practical Fields

In fields like education, healthcare, or social work, where practical solutions are needed, it can help in developing theories that inform real-world applications.

Key steps of the grounded theory approach

The grounded theory process involves several key steps researchers follow to generate theories from empirical data systematically. While there might be variations and adaptations in different researchers’ approaches, the following steps are commonly associated with the grounded theory methodology:

Data Collection

The foundation of the constructivist grounded theory approach lies in collecting data through methods such as interviews, observations, and document analysis. This raw data serves as the bedrock for theory construction.

Open Coding

Researchers meticulously dissect the data, assigning initial codes to capture the fundamental concepts present. This stage facilitates unbiased exploration, as researchers do not force-fit data into pre-existing categories.

Axial Coding

Building upon the initial codes, researchers start categorizing and interlinking them to form more comprehensive themes. The aim is to identify connections and relationships between these categories.

Selective Coding

The process evolves further as a core category central to the phenomenon under study emerges. Researchers refine and establish links between this core category and other concepts.

Constant Comparison

Throughout the journey, researchers consistently compare new data with existing codes and categories, refining their understanding and allowing the theory to evolve organically.

Theoretical Sampling

Researchers strategically select new data sources or participants to enrich the theory’s development and validation, ensuring that the existing theory resonates with diverse perspectives.

The journey reaches its zenith with theoretical sensitivity saturation, where new data ceases to alter the theory significantly. This signifies a comprehensive understanding of the phenomenon.

Writing the Theory

Researchers compile their insights into a coherent narrative that encapsulates emerging relationships, patterns, and concepts. This narrative becomes the tangible outcome of the grounded theory study.

Advantages and disadvantages of grounded theory

Here are some advantages and disadvantages of using grounded theory:

Advantages:

• Emergent Theory: Theories are developed from data, allowing for fresh insights.
• Flexibility: Adaptable to various research contexts and dynamic phenomena.
• Holistic Understanding: In-depth immersion in data leads to comprehensive insights.
• Conceptualization: Generates new concepts and theoretical frameworks.
• Contextual Insight: Focuses on understanding phenomena within their social and cultural context.

Disadvantages:

• Time-Consuming: Iterative process requires significant time and effort.
• Subjectivity: Interpretation influenced by researcher bias.
• Lack of Reproducibility: Lack of standardized procedure can hinder replication.
• Initial Data Collection Challenges: Open-ended data collection may need clearer stopping criteria.
• Theory Ambiguity: Generated theories might be open to varied interpretations.
• Less Quantitative Emphasis: Not suitable for producing quantitative or statistical results.

QuestionPro’s role in enhancing the grounded theory approach

In their study of online community dynamics, the researchers employed grounded theory analysis to uncover emergent patterns of interaction and collaboration among participants. Platforms like QuestionPro offer a range of tools that complement and enhance the grounded theory Approach in qualitative research:

• Survey Design: Design your survey in QuestionPro to collect open-ended responses. These could be in the form of text answers, comments, or even multimedia content.
• Data Collection: Distribute the survey to your participants. You can target specific groups or populations based on your research objectives.
• Data Analysis: Once you collect the qualitative data, you can export the responses from QuestionPro. Then, you can follow the steps of the grounded theory procedures, including open coding, axial coding, and selective coding, using specialized qualitative analysis software like NVivo, Dedoose, or even manual methods.
• Theory Development: Analyze the data and identify emergent concepts and patterns. Through iterative coding and constant comparative method, you can develop grounded theory research that explains the phenomenon you’re investigating.

The grounded theory Approach remains a cornerstone in qualitative research, fostering a dynamic interplay between data and emerging theory construction. 

QuestionPro’s suite of tools lends a helping hand to researchers embarking on this journey, providing support across data collection, analysis, collaboration, and visualization. 

As the landscape of research evolves, the synergy between methodologies like the grounded theory approach and innovative platforms like QuestionPro paves the way for deeper insights into the tapestry of human experiences.

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An Overview of Grounded Theory in Qualitative Research

Using grounded theory, you can examine a specific process or phenomenon and develop new theories derived from the collected real-world data and their analysis.

Grounded theory research is an inductive approach in which a theory is developed based on data. This is the opposite of the traditional hypothesis-deductive research approaches where hypotheses are formulated and are then tried to be proved or disproved.

In grounded theory, the process of collecting data, and developing theory is a continuous one and should be incorporated in the research design. The process of collecting and analyzing data is repeated until theoretical saturation is reached or no new insights will be gained from additional data.

In Situational Analysis Extending Grounded Theory with Dr. Adele Clarke, Clarke discusses situational analysis as an extension of grounded theory for analyzing qualitative data including interview, ethnographic, historical, visual, and/or other discursive materials. Clarke describes how it is especially useful for multi-site research, feminist, and critical inquiry. To dive deeper into the messy complexities in data and understand relations among the elements constitutive of the situation, watch Clarke’s webinar Situational Analysis Extending Grounded Theory.

>> View Webinar: Situational Analysis Extending Grounded Theory

What is Grounded Theory Approach in Research?

The grounded theory approach is a qualitative research methodology that attempts to unravel the meanings of people's interactions, social actions, and experiences. In other words, these explanations are grounded in the participants' own interpretations or explanations.

In 1967, Barney Glaser and Anselm Strauss published the book, The Discovery Of Grounded Theory which introduced this method. Many disciplines have since used grounded theory, including anthropology, sociology, economics, psychology, and public health.

Qualitative research using grounded theory was regarded as being groundbreaking upon its introduction. By using the inductive methodology, data (such as interviews and observations, and on rare occasions, historical data, archival data, and more) could be analyzed as they are being collected. They sought to move away from the dominant practice in the 1950s and 60s of starting with a theoretical framework which needed to be verified. They turned that practice on its head by starting with the data to develop theory.

Grounded theory has the following salient features:

Begins with data- Researchers using the grounded theory approach typically start with a case study by observing an individual or group in action. Through an analysis of cases, researchers formulate a tentative definition of their concept. An explanation for the construct is later crafted based on this case analysis.

A personal approach- In this method, researchers study participants as they go about their daily activities, observe them interacting with others, conduct individual or group interviews, and ask participants specific questions about their observations, daily lives, experiences, or other sources relevant to the study.

The application of grounded theory qualitative research is a dynamic and flexible way to answer questions that can't be addressed by other research methods.

What is Grounded Theory in Research?

A grounded theory is often used in cases where there is no existing theory that explains the phenomenon being studied. It is also possible to use it if there is an existing theory, but it is potentially incomplete because the information wasn’t gathered from the group you intend to research.

Check out ScienceDirect's page for more examples on how grounded theory can be applied .

What are the Advantages of Grounded Theory?

Grounded theory offers various advantages.

Results reflect real-world settings

By using grounded theory, one can develop theories that are based on observations and interviews with real subjects in real situations. This results in findings that more closely reflect reality. In contrast, other types of research take place in less natural settings, such as focus groups and lab settings.

Excellent for discovering new things

The premise of grounded theory is that you discover new theories by inductive means. In other words, you don't assume anything about the outcome and aren't concerned about validating or describing it. Instead, you use the data you collect to inform your analysis and your theoretical construct, resulting in new insights.

Streamlined data gathering and analysis

Analyzing and collecting data go hand in hand. Data is collected, analyzed, and as you gain insight from analysis, you continue gathering more data. In this way, your data collection will be adequate to explain the results of your analysis.

Findings are tightly connected to the data

In grounded theory, the outcome is determined primarily by collected data, so findings are tightly tied to those data. It contrasts with other research methods that are primarily constructed through external frameworks or theories that are so far removed from the data.

Protection from confirmation bias

Because gathering data and analyzing it are closely intertwined, researchers are truly observing what emerges from data. By having a buffer, you avoid confirming preconceived notions about the topic.

Provides analysis strategies

An important aspect of grounded theory is that it provides specific strategies for analysis. Grounded theory may be characterized as an open-ended method, but its analysis strategies keep you organized and analytical throughout the research process.

Disadvantages of Grounded Theory

In addition to the multiple advantages of grounded theory listed above, there are a few disadvantages of grounded theory, and qualitative methods in general, that are important to consider.

Grounded theory is often a time-consuming process that involves collecting data from multiple sources, analyzing the data for patterns and themes, and then finally coding the data – all steps that can take significant time if not using qualitative data analysis software like NVivo.

Additional disadvantages in grounded theory include a researcher’s own biases and assumptions which may impact their data analysis and the quality of their data – whether it’s low quality or simply incomplete.

How to Use NVivo for Grounded Theory

If you’re ready to start using grounded theory, using tools like NVivo can help!

With NVivo, you can analyze interviews (and occasionally survey) data by visually exploring datasets with the Detail View feature. This ability lets you limit the amount of data you’re viewing and filter to help identify patterns in your data.

Additionally, NVivo can help with transcribing, making connections between themes and participants, and keeping your interview data organized. Learn more about how to use NVivo for interview data in Thematic Analysis of Interview Data: 6 Ways NVivo Can Help .

Learn more about how to use NVivo for grounded theory in this paper Using NVivo to Facilitate the Development of a Grounded Theory Project: An Account of a Worked Example and the video below.

Learn more about how to use NVivo for grounded theory >>

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Your complete guide to grounded theory research.

11 min read If you have an area of interest, but no hypothesis yet, try grounded theory research. You conduct data collection and analysis, forming a theory based on facts. Read our ultimate guide for everything you need to know.

What is grounded theory in research?

Grounded theory is a systematic qualitative research method that collects empirical data first, and then creates a theory ‘grounded’ in the results.

The constant comparative method was developed by Glaser and Strauss, described in their book, Awareness of Dying (1965). They are seen as the founders of classic grounded theory.

Research teams use grounded theory to analyze social processes and relationships.

Because of the important role of data, there are key stages like data collection and data analysis that need to happen in order for the resulting data to be useful.

The grounded research results are compared to strengthen the validity of the findings to arrive at stronger defined theories. Once the data analysis cannot continue to refine the new theories down, a final theory is confirmed.

Grounded research is different from experimental research or scientific inquiry as it does not need a hypothesis theory at the start to verify. Instead, the evolving theory is based on facts and evidence discovered during each stage.Also, grounded research also doesn’t have a preconceived understanding of events or happenings before the qualitative research commences.

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When should you use grounded theory research?

Grounded theory research is useful for businesses when a researcher wants to look into a topic that has existing theory or no current research available. This means that the qualitative research results will be unique and can open the doors to the social phenomena being investigated.

In addition, businesses can use this qualitative research as the primary evidence needed to understand whether it’s worth placing investment into a new line of product or services, if the research identifies key themes and concepts that point to a solvable commercial problem.

Grounded theory methodology

There are several stages in the grounded theory process:

1. Data planning

The researcher decides what area they’re interested in.

They may create a guide to what they will be collecting during the grounded theory methodology. They will refer to this guide when they want to check the suitability of the qualitative data, as they collect it, to avoid preconceived ideas of what they know impacting the research.

A researcher can set up a grounded theory coding framework to identify the correct data. Coding is associating words, or labels, that are useful to the social phenomena that is being investigated. So, when the researcher sees these words, they assign the data to that category or theme.

In this stage, you’ll also want to create your open-ended initial research questions. Here are the main differences between open and closed-ended questions:

These will need to be adapted as the research goes on and more tangents and areas to explore are discovered. To help you create your questions, ask yourself:

• What are you trying to explain?
• What experiences do you need to ask about?
• Who will you ask and why?

2. Data collection and analysis

Data analysis happens at the same time as data collection. In grounded theory analysis, this is also known as constant comparative analysis, or theoretical sampling.

The researcher collects qualitative data by asking open-ended questions in interviews and surveys, studying historical or archival data, or observing participants and interpreting what is seen. This collected data is transferred into transcripts.

The categories or themes are compared and further refined by data, until there are only a few strong categories or themes remaining. Here is where coding occurs, and there are different levels of coding as the categories or themes are refined down:

• Data collection (Initial coding stage): Read through the data line by line
• Open coding stage: Read through the transcript data several times, breaking down the qualitative research data into excerpts, and make summaries of the concept or theme.
• Axial coding stage: Read through and compare further data collection to summarize concepts or themes to look for similarities and differences. Make defined summaries that help shape an emerging theory.
• Selective coding stage: Use the defined summaries to identify a strong core concept or theme.

During analysis, the researcher will apply theoretical sensitivity to the collected data they uncover, so that the meaning of nuances in what they see can be fully understood.

This coding process repeats until the researcher has reached theoretical saturation. In grounded theory analysis, this is where all data has been researched and there are no more possible categories or themes to explore.

3. Data analysis is turned into a final theory

The researcher takes the core categories and themes that they have gathered and integrates them into one central idea (a new theory) using selective code. This final grounded theory concludes the research.

The new theory should be a few simple sentences that describe the research, indicating what was and was not covered in it.

An example of using grounded theory in business

One example of how grounded theory may be used in business is to support HR teams by analyzing data to explore reasons why people leave a company.

For example, a company with a high attrition rate that has not done any research on this area before may choose grounded theory to understand key reasons why people choose to leave.

Researchers may start looking at the quantitative data around departures over the year and look for patterns. Coupled with this, they may conduct qualitative data research through employee engagement surveys , interview panels for current employees, and exit interviews with leaving employees.

From this information, they may start coding transcripts to find similarities and differences (coding) picking up on general themes and concepts. For example, a group of excepts like:

• “The hours I worked were far too long and I hated traveling home in the dark”
• “My manager didn’t appreciate the work I was doing, especially when I worked late”
• There are no good night bus routes home that I could take safely”

Using open coding, a researcher could compare excerpts and suggest the themes of managerial issues, a culture of long hours and lack of traveling routes at night.

With more samples and information, through axial coding, stronger themes of lack of recognition and having too much work (which led people to working late), could be drawn out from the summaries of the concepts and themes.

This could lead to a selective coding conclusion that people left because they were ‘overworked and under-appreciated’.

With this information, a grounded theory can help HR teams look at what teams do day to day, exploring ways to spread workloads or reduce them. Also, there could be training supplied to management and employees to engage professional development conversations better.

 Advantages of grounded theory

• No need for hypothesis – Researchers don’t need to know the details about the topic they want to investigate in advance, as the grounded theory methodology will bring up the information.
• Lots of flexibility – Researchers can take the topic in whichever direction they think is best, based on what the data is telling them. This means that exploration avenues that may be off-limits in traditional experimental research can be included.
• Multiple stages improve conclusion – Having a series of coding stages that refine the data into clear and strong concepts or themes means that the grounded theory will be more useful, relevant and defined.
• Data-first – Grounded theory relies on data analysis in the first instance, so the conclusion is based on information that has strong data behind it. This could be seen as having more validity.

Disadvantages of grounded theory

• Theoretical sensitivity dulled – If a researcher does not know enough about the topic being investigated, then their theoretical sensitivity about what data means may be lower and information may be missed if it is not coded properly.
• Large topics take time – There is a significant time resource required by the researcher to properly conduct research, evaluate the results and compare and analyze each excerpt. If the research process finds more avenues for investigation, for example, when excerpts contradict each other, then the researcher is required to spend more time doing qualitative inquiry.
• Bias in interpreting qualitative data – As the researcher is responsible for interpreting the qualitative data results, and putting their own observations into text, there can be researcher bias that would skew the data and possibly impact the final grounded theory.
• Qualitative research is harder to analyze than quantitative data – unlike numerical factual data from quantitative sources, qualitative data is harder to analyze as researchers will need to look at the words used, the sentiment and what is being said.
• Not repeatable – while the grounded theory can present a fact-based hypothesis, the actual data analysis from the research process cannot be repeated easily as opinions, beliefs and people may change over time. This may impact the validity of the grounded theory result.

What tools will help with grounded theory?

Evaluating qualitative research can be tough when there are several analytics platforms to manage and lots of subjective data sources to compare. Some tools are already part of the office toolset, like video conferencing tools and excel spreadsheets.

However, most tools are not purpose-built for research, so researchers will be manually collecting and managing these files – in the worst case scenario, by pen and paper!

Use a best-in-breed management technology solution to collect all qualitative research and manage it in an organized way without large time resources or additional training required.

Qualtrics provides a number of qualitative research analysis tools, like Text iQ , powered by Qualtrics iQ, provides powerful machine learning and native language processing to help you discover patterns and trends in text.

This also provides you with research process tools:

• Sentiment analysis — a technique to help identify the underlying sentiment (say positive, neutral, and/or negative) in qualitative research text responses
• Topic detection/categorisation — The solution makes it easy to add new qualitative research codes and group by theme. Easily group or bucket of similar themes that can be relevant for the business and the industry (eg. ‘Food quality’, ‘Staff efficiency’ or ‘Product availability’)

Related resources

Market intelligence 10 min read, marketing insights 11 min read, ethnographic research 11 min read, qualitative vs quantitative research 13 min read, qualitative research questions 11 min read, qualitative research design 12 min read, primary vs secondary research 14 min read, request demo.

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10 Grounded Theory Examples (Qualitative Research Method)

Grounded theory is a qualitative research method that involves the construction of theory from data rather than testing theories through data (Birks & Mills, 2015).

In other words, a grounded theory analysis doesn’t start with a hypothesis or theoretical framework, but instead generates a theory during the data analysis process .

This method has garnered a notable amount of attention since its inception in the 1960s by Barney Glaser and Anselm Strauss (Corbin & Strauss, 2015). 

Grounded Theory Definition and Overview

A central feature of grounded theory is the continuous interplay between data collection and analysis (Bringer, Johnston, & Brackenridge, 2016).

Grounded theorists start with the data, coding and considering each piece of collected information (for instance, behaviors collected during a psychological study).

As more information is collected, the researcher can reflect upon the data in an ongoing cycle where data informs an ever-growing and evolving theory (Mills, Bonner & Francis, 2017).

As such, the researcher isn’t tied to testing a hypothesis, but instead, can allow surprising and intriguing insights to emerge from the data itself.

Applications of grounded theory are widespread within the field of social sciences . The method has been utilized to provide insight into complex social phenomena such as nursing, education, and business management (Atkinson, 2015).

Grounded theory offers a sound methodology to unearth the complexities of social phenomena that aren’t well-understood in existing theories (McGhee, Marland & Atkinson, 2017).

While the methods of grounded theory can be labor-intensive and time-consuming, the rich, robust theories this approach produces make it a valuable tool in many researchers’ repertoires.

Real-Life Grounded Theory Examples

Title: A grounded theory analysis of older adults and information technology

Citation: Weatherall, J. W. A. (2000). A grounded theory analysis of older adults and information technology. Educational Gerontology , 26 (4), 371-386.

Description: This study employed a grounded theory approach to investigate older adults’ use of information technology (IT). Six participants from a senior senior were interviewed about their experiences and opinions regarding computer technology. Consistent with a grounded theory angle, there was no hypothesis to be tested. Rather, themes emerged out of the analysis process. From this, the findings revealed that the participants recognized the importance of IT in modern life, which motivated them to explore its potential. Positive attitudes towards IT were developed and reinforced through direct experience and personal ownership of technology.

Title: A taxonomy of dignity: a grounded theory study

Citation: Jacobson, N. (2009). A taxonomy of dignity: a grounded theory study. BMC International health and human rights , 9 (1), 1-9.

Description: This study aims to develop a taxonomy of dignity by letting the data create the taxonomic categories, rather than imposing the categories upon the analysis. The theory emerged from the textual and thematic analysis of 64 interviews conducted with individuals marginalized by health or social status , as well as those providing services to such populations and professionals working in health and human rights. This approach identified two main forms of dignity that emerged out of the data: “ human dignity ” and “social dignity”.

Title: A grounded theory of the development of noble youth purpose

Citation: Bronk, K. C. (2012). A grounded theory of the development of noble youth purpose. Journal of Adolescent Research , 27 (1), 78-109.

Description: This study explores the development of noble youth purpose over time using a grounded theory approach. Something notable about this study was that it returned to collect additional data two additional times, demonstrating how grounded theory can be an interactive process. The researchers conducted three waves of interviews with nine adolescents who demonstrated strong commitments to various noble purposes. The findings revealed that commitments grew slowly but steadily in response to positive feedback, with mentors and like-minded peers playing a crucial role in supporting noble purposes.

Title: A grounded theory of the flow experiences of Web users

Citation: Pace, S. (2004). A grounded theory of the flow experiences of Web users. International journal of human-computer studies , 60 (3), 327-363.

Description: This study attempted to understand the flow experiences of web users engaged in information-seeking activities, systematically gathering and analyzing data from semi-structured in-depth interviews with web users. By avoiding preconceptions and reviewing the literature only after the theory had emerged, the study aimed to develop a theory based on the data rather than testing preconceived ideas. The study identified key elements of flow experiences, such as the balance between challenges and skills, clear goals and feedback, concentration, a sense of control, a distorted sense of time, and the autotelic experience.

Title: Victimising of school bullying: a grounded theory

Citation: Thornberg, R., Halldin, K., Bolmsjö, N., & Petersson, A. (2013). Victimising of school bullying: A grounded theory. Research Papers in Education , 28 (3), 309-329.

Description: This study aimed to investigate the experiences of individuals who had been victims of school bullying and understand the effects of these experiences, using a grounded theory approach. Through iterative coding of interviews, the researchers identify themes from the data without a pre-conceived idea or hypothesis that they aim to test. The open-minded coding of the data led to the identification of a four-phase process in victimizing: initial attacks, double victimizing, bullying exit, and after-effects of bullying. The study highlighted the social processes involved in victimizing, including external victimizing through stigmatization and social exclusion, as well as internal victimizing through self-isolation, self-doubt, and lingering psychosocial issues.

Hypothetical Grounded Theory Examples

Suggested Title: “Understanding Interprofessional Collaboration in Emergency Medical Services”

Suggested Data Analysis Method: Coding and constant comparative analysis

How to Do It: This hypothetical study might begin with conducting in-depth interviews and field observations within several emergency medical teams to collect detailed narratives and behaviors. Multiple rounds of coding and categorizing would be carried out on this raw data, consistently comparing new information with existing categories. As the categories saturate, relationships among them would be identified, with these relationships forming the basis of a new theory bettering our understanding of collaboration in emergency settings. This iterative process of data collection, analysis, and theory development, continually refined based on fresh insights, upholds the essence of a grounded theory approach.

Suggested Title: “The Role of Social Media in Political Engagement Among Young Adults”

Suggested Data Analysis Method: Open, axial, and selective coding

Explanation: The study would start by collecting interaction data on various social media platforms, focusing on political discussions engaged in by young adults. Through open, axial, and selective coding, the data would be broken down, compared, and conceptualized. New insights and patterns would gradually form the basis of a theory explaining the role of social media in shaping political engagement, with continuous refinement informed by the gathered data. This process embodies the recursive essence of the grounded theory approach.

Suggested Title: “Transforming Workplace Cultures: An Exploration of Remote Work Trends”

Suggested Data Analysis Method: Constant comparative analysis

Explanation: The theoretical study could leverage survey data and in-depth interviews of employees and bosses engaging in remote work to understand the shifts in workplace culture. Coding and constant comparative analysis would enable the identification of core categories and relationships among them. Sustainability and resilience through remote ways of working would be emergent themes. This constant back-and-forth interplay between data collection, analysis, and theory formation aligns strongly with a grounded theory approach.

Suggested Title: “Persistence Amidst Challenges: A Grounded Theory Approach to Understanding Resilience in Urban Educators”

Suggested Data Analysis Method: Iterative Coding

How to Do It: This study would involve collecting data via interviews from educators in urban school systems. Through iterative coding, data would be constantly analyzed, compared, and categorized to derive meaningful theories about resilience. The researcher would constantly return to the data, refining the developing theory with every successive interaction. This procedure organically incorporates the grounded theory approach’s characteristic iterative nature.

Suggested Title: “Coping Strategies of Patients with Chronic Pain: A Grounded Theory Study”

Suggested Data Analysis Method: Line-by-line inductive coding

How to Do It: The study might initiate with in-depth interviews of patients who’ve experienced chronic pain. Line-by-line coding, followed by memoing, helps to immerse oneself in the data, utilizing a grounded theory approach to map out the relationships between categories and their properties. New rounds of interviews would supplement and refine the emergent theory further. The subsequent theory would then be a detailed, data-grounded exploration of how patients cope with chronic pain.

Grounded theory is an innovative way to gather qualitative data that can help introduce new thoughts, theories, and ideas into academic literature. While it has its strength in allowing the “data to do the talking”, it also has some key limitations – namely, often, it leads to results that have already been found in the academic literature. Studies that try to build upon current knowledge by testing new hypotheses are, in general, more laser-focused on ensuring we push current knowledge forward. Nevertheless, a grounded theory approach is very useful in many circumstances, revealing important new information that may not be generated through other approaches. So, overall, this methodology has great value for qualitative researchers, and can be extremely useful, especially when exploring specific case study projects . I also find it to synthesize well with action research projects .

Atkinson, P. (2015). Grounded theory and the constant comparative method: Valid qualitative research strategies for educators. Journal of Emerging Trends in Educational Research and Policy Studies, 6 (1), 83-86.

Birks, M., & Mills, J. (2015). Grounded theory: A practical guide . London: Sage.

Bringer, J. D., Johnston, L. H., & Brackenridge, C. H. (2016). Using computer-assisted qualitative data analysis software to develop a grounded theory project. Field Methods, 18 (3), 245-266.

Corbin, J., & Strauss, A. (2015). Basics of qualitative research: Techniques and procedures for developing grounded theory . Sage publications.

McGhee, G., Marland, G. R., & Atkinson, J. (2017). Grounded theory research: Literature reviewing and reflexivity. Journal of Advanced Nursing, 29 (3), 654-663.

Mills, J., Bonner, A., & Francis, K. (2017). Adopting a Constructivist Approach to Grounded Theory: Implications for Research Design. International Journal of Nursing Practice, 13 (2), 81-89.

Chris Drew (PhD)

Dr. Chris Drew is the founder of the Helpful Professor. He holds a PhD in education and has published over 20 articles in scholarly journals. He is the former editor of the Journal of Learning Development in Higher Education. [Image Descriptor: Photo of Chris]

• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd/ 5 Top Tips for Succeeding at University
• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd/ 50 Durable Goods Examples
• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd/ 100 Consumer Goods Examples
• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd/ 30 Globalization Pros and Cons

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What is Grounded Theory in Qualitative Research?

• April 15, 2022

You may have come across the term “ grounded theory ” in qualitative and quantitative research. Typically, grounded theory is discussed in academic research, though as market researchers, we find that we often use this framework when developing studies. In this post, we’ll try to break grounded theory down for market research usage and help provide an understanding of how impactful this mode of framing research can be for B2B and B2C studies.

First off, what is grounded theory – in real-speak?

Let’s explain grounded theory in non-academic jargon to make this simple to digest:

Use grounded theory methods when you’re not sure what you’re looking for in a study or there is no clear theory as to why certain behaviors or patterns are occurring.

Or to make it even more clear:

Use grounded theory methods when you don’t know what you don’t know.

In typical research methods (both quantitative and qualitative), teams come together with a clear hypothesis about what they’re studying.

For example, “When travelers are booking flights online, they will go for the best prices and flight times.”

That’s a clear hypothesis, likely based on previous data and studies. The research team may be tasked with investigating this hypothesis further and adding more details to it – or even disproving it, to uncover whether there are other factors at play in how people choose and book airline flights. To test the hypothesis, the research team would design a user experience study, where they observe how people book flights online (with screensharing), while asking them questions as the traveler goes through the process. This will help gather essential data that can be analyzed, thematically, to further prove or disprove the initial hypothesis.

However, that’s not what grounded theory would do, because in this case we just described, the hypothesis was set from the beginning.

What if, however, the researchers instead had a situation such as this: A product team wants to understand how people react to working from home exclusively during the pandemic so that they can develop software tools for remote teams.

In this example, the team doesn’t have a clear hypothesis to work from. For this specific case, the study question was posed in early 2020, when working from home for entire teams was new. The pandemic situation was unprecedented in the modern tech age, so the development team wasn’t sure exactly what hypothesis question to pose – or, to put it more simply – they didn’t know what they were looking for exactly, but they did know that there were likely software tools they could develop that could be helpful for remote teams.

This is a perfect example of when to apply grounded theory research. Let’s explore this example further, through the lens of grounded theory.

How to set up a grounded theory study

When you’re not sure exactly what you’re looking for, using grounded theory methods helps you explore themes, in an iterative research style.

So let’s go back to our remote-team software example.

Because the research team wasn’t sure exactly how people were adapting to at-home work, they first assembled a small sample to study. Using mobile ethnographies , the team had a sample of at-home workers record their daily work patterns. They were asked more general questions about highs and lows, efficiencies, and inefficiencies, and where they were feeling frustrated or lost by not having in-person collaboration. They also explored “workarounds” that teams were doing to stay productive.

Once they received the data back and did follow-up in-depth interviews with the participants, the team then sorted the themes into “codes.” Codes essentially sum up patterns in the data that are reoccurring. For example “ workers are less efficient when brainstorming new creative ideas” was a code that came out of the initial round.

From the initial round, some ideas started to take place and patterns emerged. The research team realized they needed to expand their participant pool to also include in-house designers, and not just product managers. The research team then devised a second round of research, also using mobile ethnographies and in-depth interviews, but this time with in-house designers and product managers.

After this second round, even more themes and codes emerged, and the product design team felt like they were getting closer to specific issues that they could develop software to address.

But they needed more data.

After analyzing the second round, the research team decided to hone in on a specific topic: in this case, how to improve brainstorming and enhance the creative process for remote teams. So they developed a third round of research, and they pulled in creative design teams, product managers, and upper-level managers.

The questions the researchers posed in this third round were now quite specific, and they designed exercises around remote creative brainstorming (also using mobile ethnographies and in-depth interviews). This round was especially illuminating because they now were much closer to proving and disproving new hypotheses that had emerged from the initial research rounds.

After analyzing the third round, the product team felt ready to design software prototypes that would address some of the issues they found in the exploratory research phases. In short: They had come up with a hypothesis, which was “Remote teams are struggling to collaborate creatively using their current software.” Now they had a hypothesis (a problem statement) and a mission for their software design work.

Let’s now break down that case study to uncover the steps of grounded theory research

We just took you through a real-world example of using grounded theory research methods to uncover patterns and arrive at a hypothesis. Grounded theory, as you can see from this example, is the opposite of typical research projects, where teams know what they’re looking for, so they recruit participants, design specific questions and exercises, and then spend the bulk of the research proving or disproving the hypothesis they’re testing.

In grounded theory, it’s exploratory, from the very beginning. Teams start with some initial ideas, recruit samples to test, and from the early tests, start to see patterns. They then may have to shift and recruit different personas and start to ask questions specific to the themes from the first round of research. In each subsequent round of research, the team uncovers ideas and then tests and poses hypotheses based on what they’re learning.

Grounded theory is a great method for specific types of research issues

Grounded theory is best applied when research teams come into a problem with uncertainty about the full landscape and situation. Because it requires multiple rounds of research, it’s more costly and time-consuming than studies where the hypothesis and testing is clear, from the very beginning. However, hopefully as the example we used illustrated, it’s a fantastic method to generate new product ideas. The key is to have an open mind and be able to first cast a wide net of ideas, before narrowing down on emerging themes to test.

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Grounded Theory: Approach And Examples

Grounded theory is a qualitative research approach that attempts to uncover the meanings of people’s social actions, interactions and experiences….

Grounded theory is a qualitative research approach that attempts to uncover the meanings of people’s social actions, interactions and experiences. These explanations are called ‘grounded’ because they are grounded in the participants’ own explanations or interpretations.

Barney Glaser and Anselm Strauss originated this method in their 1967 book, The Discovery Of Grounded Theory . The grounded theory approach has been used by researchers in various disciplines, including sociology, anthropology, psychology, economics and public health.

Grounded theory qualitative research was considered path-breaking in many respects upon its arrival. The inductive method allowed the analysis of data during the collection process. It also shifted focus away from the existing practice of verification, which researchers felt didn’t always produce rigorous results.

  Let’s take a closer look at grounded theory research.

What Is Grounded Theory?

How to conduct grounded theory research, features of grounded theory, grounded theory example, advantages of grounded theory.

  Grounded theory is a qualitative method designed to help arrive at new theories and deductions. Researchers collect data through any means they prefer and then analyze the facts to arrive at concepts. Through a comparison of these concepts, they plan theories. They continue until they reach sample saturation, in which no new information upsets the theory they have formulated. Then they put forth their final theory.

  In grounded theory research, the framework description guides the researcher’s own interpretation of data. A data description is the researcher’s algorithm for collecting and organizing data while also constructing a conceptual model that can be tested against new observations.

  Grounded theory doesn’t assume that there’s a single meaning of an event, object or concept. In grounded theory, you interpret all data as information or materials that fit into categories your research team creates.

  Now that we’ve examined what is grounded theory, let’s inspect how it’s conducted. There are four steps involved in grounded theory research:

• STAGE 1: Concepts are derived from interviews, observation and reflection
• STAGE 2: The data is organized into categories that represent themes or subplots
• STAGE 3: As the categories develop, they are compared with one another and two or more competing theories are identified
• STAGE 4: The final step involves the construction of the research hypothesis statement or concept map

Grounded theory is a relatively recent addition to the tools at a researcher’s disposal. There are several methods of conducting grounded theory research. The following processes are common features:

  Theoretical Memoing

  compile findings.

Data collection in the grounded theory method can include both quantitative and qualitative methods.

By now, it’s clear that grounded theory is unlike other research techniques. Here are some of its salient features:

It Is Personal

It is flexible, it starts with data, data is continually assessed.

Grounded theory qualitative research is a dynamic and flexible approach to research that answers questions other formats can’t.

Grounded theory can be used in organizations to create a competitive advantage for a company. Here are some grounded theory examples:

• Grounded theory is used by marketing departments by letting marketing executives express their views on how to improve their product or service in a structured way
• Grounded theory is often used by the HR department. For instance, they might study why employees are frustrated by their work. Employees can explain what they feel is lacking. HR then gathers this data, examines the results to discover the root cause of their problems and presents solutions
• Grounded theory can help with design decisions, such as how to create a more appealing logo. To do this, the marketing department might interview consumers about their thoughts on their logo and what they like or dislike about it. They will then gather coded data that relates back to the interviews and use this for a second iteration

These are just some of the possible applications of grounded theory in a business setting.

Its flexibility allows its uses to be virtually endless. But there are still advantages and disadvantages that make the grounded theory more or less appropriate for a subject of study. Here are the advantages:

• Grounded theory isn’t concerned with whether or not something has been done before. Instead, grounded theory researchers are interested in what participants say about their experiences. These researchers are looking for meaning
• The grounded theory method allows researchers to use inductive reasoning, ensuring that the researcher views the participant’s perspectives rather than imposing their own ideas. This encourages objectivity and helps prevent preconceived notions from interfering with the process of data collection and analysis
• It allows for constant comparison of data to concepts, which refines the theory as the research proceeds. This is in contrast with methods that look to verify an existing hypothesis only
• Researchers may also choose to conduct experiments to provide support for their research hypotheses. Through an experiment, researchers can test ideas rigorously and provide evidence to support hypotheses and theory development
• It produces a clearer theoretical model that is not overly abstract. It also allows the researcher to see the connections between cases and have a better understanding of how each case fits in with others
• Researchers often produce more refined and detailed analyses of data than with other methods
• Because grounded theory emphasizes the interpretation of the data, it makes it easier for researchers to examine their own preconceived ideas about a topic and critically analyze them.

As with any method, there are some drawbacks too that researchers should consider. Here are a few:

• It doesn’t promote consensus because there are always competing views about the same phenomenon
• It may seem like an overly theoretical approach that produces results that are too open-ended. Grounded theory isn’t concerned with whether something is true/false or right/wrong
• Grounded theory requires a high level of skill and critical thinking from the researcher. They must have a level of objectivity in their approach, ask unbiased, open-minded questions and conduct interviews without being influenced by personal views or agenda.

While professionals may never have to conduct research like this themselves, an understanding of the kinds of analytical tools available can help when there are decisions to be made in the workplace. Harappa’s Thinking Critically course can help with just this. Analytical skills are some of the most sought-after soft skills in the professional world. The earlier managers can master these, the more value they’ll bring to the organization. With our transformative course and inspiring faculty, empower your teams with the ability to think through any problem, no matter how large.

Explore Harappa Diaries to learn more about topics such as Meaning Of Halo Effect , Different Brainstorming Methods , Operant Conditioning Theory of learning and How To Improve Analytical Skills to upgrade your knowledge and skills.

• Open access
• Published: 25 April 2024

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study

• Hilda Bø Lyng 1 ,
• Eline Ree 1 ,
• Torunn Strømme 1 ,
• Terese Johannessen 2 ,
• Ingunn Aase 1 ,
• Berit Ullebust 3 ,
• Line Hurup Thomsen 4 ,
• Elisabeth Holen-Rabbersvik 2 , 5 ,
• Lene Schibevaag 1 ,
• David W. Bates 6 &
• Siri Wiig 1  

BMC Health Services Research volume  24 , Article number:  528 ( 2024 ) Cite this article

Metrics details

Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes.

This study is based on an exploratory qualitative methodology. The empirical data was collected through the ‘Improving Quality and Safety in Primary Care – Implementing a Leadership Intervention in Nursing Homes and Homecare’ (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory.

Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing.

This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

Peer Review reports

Quality in healthcare services is a subject in need of continuous attention [ 1 ]. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments [ 2 , 3 , 4 ]. Nevertheless, despite the number of initiatives and QI programmes aiming to increase quality of care, quality of healthcare has still not improved correspondingly [ 5 ].

Programmes for QI usually involve the translation of new knowledge into practice alongside the following implementation and adoption, which is not a straightforward process [ 6 ]. Cresswell et al. [ 7 ] found implementation processes to be associated with four different contextual factors: technical aspects, social aspects, organizational aspects, and wider socio-political aspects, all influential for the implementation efficiency. This means that to ensure successful implementation, understanding the context specificity, where enablers and barriers for one type of setting not necessarily provide the same type of impact in a different setting, is important [ 6 , 8 ]. This leads to a need for adapting implementation processes to the situational context [ 9 , 10 ].

Studies on implementation of QI programmes are still scarce in nursing homes and home care settings. Equally, there is a gap in research concerning similarities and differences of different types of implementation processes, like internally and externally initiated implementation processes. Calls have therefore been raised in literature for future studies to explore contextual aspects in terms of specific types of implementation processes [ 11 , 12 , 13 ].

Implementation science has gained increasing focus in health service research, due to the need for understanding the critical role of implementation processes for QI. However, overlapping theories of implementation as well as ambiguous definitions and terminology still challenge the implementation research field [ 14 ]. To integrate important contributions, Damschroder et al. [ 14 ] in a meta-analysis, proposed five key elements for implementation; Characteristics of the actual intervention/ QI programme, Outer context, Inner context, Individuals involved, and the Implementation process. In a systematic review of barriers and enablers for the implementation of interventions in primary care, Lau et al. [ 11 ] presented a conceptual framework displaying influencing key factors for different levels of the implementation process: Intervention/ QI programme factors, Professional factors, Organizational factors, and External context. The understandings provided by Damschroder et al. [ 14 ] and Lau et al. [ 11 ] display similarities between these frameworks, and their relatedness for this study will be further discussed in terms of the inductive findings of this study in the context of two different implementation processes taking place in nursing homes and homecare services in Norway.

Aim and research question

This study aims to contribute understanding of two different implementation processes in Norwegian nursing homes and home care services. The first implementation setting (external case) refers to an externally driven implementation process where a researcher group facilitated meetings, material, assignments, monitoring of the process, and follow up. The second implementation setting (internal case) refers to an internally driven implementation process, where the organization itself had decided to implement a specific QI programme, and where the organization was responsible for the full implementation process. The following research questions guided the study:

What type of enablers and barriers are found important for implementation processes in nursing homes and home care services?

And secondly, are identified enablers and barriers different or similar across externally and internally driven implementation processes?

Based on the exploratory nature of the aim and research questions, we opted for a qualitative methodology [ 15 ]. The empirical data were collected through the ‘Improving Quality and Safety in Primary Care – Implementing a Leadership Intervention in Nursing Homes and Homecare’ (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI implementation processes in primary care in Norway [ 16 ].

Contextual setting

A large externally driven QI (leadership guide) implementation study was supplemented with a tracer project [ 17 ] involving an internally driven QI implementation to understand the differences and similarities of implementation processes in primary care. Primary care refers to nursing homes and home care services in this study. In Norway, primary care is the responsibility of municipalities. To frame this responsibility there is a regulation stating the requirement of continuously improving quality and patient safety in primary healthcare [ 18 , 19 ]. This regulation inserts a need for leaders to plan, implement, and evaluate output from QI implementation processes. Leaders are therefore key actors for quality and safety improvements. As such, this study used leaders as informants for developing understanding of QI implementations in a Norwegian primary care setting. Based on the consensus of the importance of context for implementation processes [ 8 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ] this project provides a way of understanding and comparing healthcare implementation processes through two different approaches. However, both implementation processes share similarities, as both are seeking to implement a QI programme, both are within primary care, informants in both cases are leaders, and both are within the Norwegian primary care context. The split of the cases into an externally driven approach and an internally driven approach are not totally binary but represents the main tendency of their approach. However, the external case had to arrange for the homework internally, and the internal case engaged in an externally facilitated day of formal training provided by someone outside their organisation.

Internal case

Implementation for the internal case took place as an internally driven process in home care. The chosen QI programme was a competence improvement program focusing on observational competence, and included formal teaching of new knowledge, skills training, simulation training of new procedures and measurements, and new practical equipment. Formal teaching involved a day of teaching organized by the county’s Centre for Development of Institutional and Home Care Services (USHT), while the remining was up to the organization to facilitate and organize for (training, simulation, equipment, monitoring, and follow-up) [ 28 ]. USHT set the researchers in contact with two different home care districts who had chosen to initiate this specific QI program.

Data collection

The data collection informing this study was based on individual interviews after the implementation of the competence improvement program, to explore how the implementation process was experienced and evaluated. Only interviews of leaders and professional development nurses (nurses responsible for the professional development within the organization and as such hold an informal leader role) ( n  = 8) were included in the dataset, to ensure credibility in the cross-case comparison, see Table  1 . Researcher TS performed all interviews, following a semi- structured interview guide (supplementary file). All interviews were recorded and transcribed verbatim.

External case

The external case concerned the implementation of a QI programme (SAFE-LEAD) developed by the researcher group aimed at leaders in primary care (nursing homes and home care services) [ 16 , 29 ]. The QI programme consisted of a leadership guide to support leaders in their QI work. The leadership guide was based on the QUASER hospital guide [ 6 ], which was translated and adapted to the Norwegian primary care context [ 29 ]. The QI programme included three steps with associated workshops, facilitated by the research group, and with following “homework” for the participants to perform between each workshop. The first workshop aimed at identifying challenges within the organization. “Homework” involved an evaluating and scoring system to formalise challenges of the organization to work on. The second workshop included the development of different objectives for improvement on identified challenges. “Homework” at the second step concerned the development of formalized objectives. At the third workshop, the focus was on the development of action plans in each organization. “Homework” after the third workshop was for leaders to translate action plans into practise. The “homework” sessions provided the participants time to work with the material introduced in the workshop. As such, “homework” was a way to provide ownership to the QI programme by translating the content of the leadership guide to their context specific understanding, setting strategies and objectives for their unit.

The researcher group facilitated the implementation process through workshops focusing on self-diagnosis of the organisation, goal settings, and action plans. The workshops included presentations and knowledge sharing of upcoming tasks, monitoring of progress, discussions, and homework review. The participants were leaders from eight units (4 nursing homes and 4 home care services) in five municipalities, within three Norwegian counties. The researcher group (ER, TJ, IA, BU, LHT, EHR, TS, LS and SW) responsible for the workshops were also performing the interviews. The empirical data used for this study totalled 13 interviews (10 focus group interviews and 3 individual interviews) ( n  = 26) with leaders in all 8 units during a one-year period (April 2018 – March 2019), see Table  1 . A semi-structured interview guide was used for the interviews and all interviews were recorded and transcribed verbatim (supplementary file).

Data analysis

Due to the explorative nature of the research questions, an inductive approach was found most appropriate to explore emerging themes from the empirical data, as existing frameworks describing differences and similarities between internally driven and externally driven implementation processes in older adult care were not identified. This gap in literature informed an inductive approach. The analytical process followed a grounded theory methodology [ 30 , 31 ] where empirical data from the two cases were first inductively analysed individually, followed by a second step of cross-comparison. Grounded theory is described as a valuable approach for theory development and as such a way to address the theoretical gap described in the above [ 30 ]. The NVivo 1.7 software was used to support the analysis and for documentation of findings. Figure  1 illustrates the inductive data structure from the analysis, following the grounded theory framework by Gioia et al. [ 30 ]. The data structure includes a first inductive step of identifying 1st order codes emerging directly from the data. These 1st order codes were aggregated into 2nd order themes, and later on into more abstract 3rd order dimensions [ 30 ]. As such, 1st order codes display manifest meanings from the dataset. The researcher (HBL) identifying the 1st order codes had not been part of the data collection, workshops, or the QI programme development and was therefore able to keep an inductive approach throughout the analysis. 2nd order themes and 3rd order dimensions were agreed upon by all authors. All authors have expert competence in qualitative inductive research. A summative analysis of the results from the matrix were used to identify enablers and barriers occurring in the dataset.

Data structure model based on Gioia et al. [ 30 ]

The analysis revealed 1845 references which were coded over 284 different inductive 1st order codes emerging from the internal dataset and 3286 references coded at 190 different 1st order codes from the external dataset. A matrix where crosstabulations between successful and unsuccessful outcomes (1st order codes) in each case and the total number of codes provided the association of enablers and barriers displayed in Fig.  1 .

Successful outcomes referred to factors, resources, activities, and practices reported to have a positive impact on the implementation process. Unsuccessful outcomes referred to the opposite, where factors, resources, activities, and practices, were reported to have a negative impact on the implementation process. Successful outcomes for the internal case disclosed 122 occurrences and 115 occurrences for the external case. Unsuccessful outcomes for the internal case totalled 110 occurrences and 94 occurrences for the external case.

As displayed in Fig.  1 , some 1st order codes were coincident for both the internal and external case, while others were of a more situation specific nature. As 1st order codes emerged inductively and were analysed separately within the two different cases and furthermore at different points in time, 1st order codes might therefore be named differently, like e.g., dedication and ownership (internal case) and engagement (external case) but with similar underlying meaning. The identified barriers and enablers of the two cases were in a second step put in a Venn diagram to explore and illustrate cross-case similarities and differences (see Figs.  2 and 3 ).

Enabler’s relatedness to externally and internally driven implementation processes. Learning includes both the continuous learning and knowledge transfer enablers

Barrier’s relatedness to externally and internally driven implementation processes

Table  2 illustrates the findings, in terms of different codes and the number of occurrences, according to RQ 1. The data structure model and the following result section describe successful and unsuccessful outcomes, focusing on most present occurrences within the dataset for each case to align with the first research question of identifying enablers and barriers of the implementation (Fig.  1 ; Table  2 ).

In the following different enablers, illustrated in Table  2 ; Fig.  1 , will be described in more detail.

Continuous learning, simulation training and knowledge sharing

The importance of continuous learning was emphasized in the internally driven implementation process. A continuous focus of learning was needed to ensure ownership of the QI programme, and for making new practices and knowledge an integrated part of the culture and everyday work. Leaders, through their decision to engage and to coordinate training, were found important for facilitating this continuity of focus. As such, having weekly simulation training was perceived more favourable than having yearly seminars for the staff. Continuous learning was also of importance for the external case, yet in a lesser degree due to having visits from researchers that provided reflexive spaces and learning at predefined points in time.

“I’m so happy we engaged into this project, which gave us the results I expected. Yet, there is something that comes with this (the QI programme). We can’t stop with simulation training, as this needs to be of focus always.” (Internal implementation process).

As the quote above states, simulation training was not a one-off activity, but needed to be put in a system of repeated and continuous exposure to be beneficial. However, when simulation training firstly was introduced to the staff, it was met with high levels of resistance. Simulation training made the staff feeling exposed and evaluated, which again made them feel insecure. As time went by and the staff got more familiar with simulation training, they changed their opinion of simulation training as they discovered its value, relevance, and the inherent flexible ability to illustrate everyday issues.

Simulation training was found a pillar for the internal case but was not a part of the external implementation process, which explains this difference of occurrences across cases. However, aspects of knowledge and learning were similarly found to be of highly importance for the externally driven implementation process. Knowledge sharing for the externally driven implementation process was mainly organized in inter-organizational workshops facilitated by the researchers. As such, these workshops acted as means to develop relations between leaders across different parts of the organizations and furthermore a way to learn from each other’s successes and mistakes when organizing for QI.

“We know that A (home care department), which previously were a part of B (another home care department), has very good experience in initiating socio-professional evenings, which were very well attended. But, we (B) have struggled to make this happen. We are now planning to develop a culture for this (socio-professional evenings). We will therefore try to learn from their experiences. This is a way of using experiences from other organizations to make changes. Learning from the positive culture of other organizations” (External case).

Other dimensions of knowledge sharing highlighted in the external case were having access to meeting arenas, to facilitate knowledge sharing across organizations, providing a direction of focus for the implementation. Furthermore, receiving feedback from different actors, both vertical (different levels) and horizontal (different departments) provided a more holistic understanding and knowledge of the contextual situation for the leaders.

Perceived relevance

Willingness to put in necessary time and effort into the implementation process, relied on a perception of the outcomes to be relevant for their organization. The perceived relevance of the QI programme was found key for engagement and dedication in both cases. For the externally driven implementation it was not enough to just have motivated external researchers on visits to facilitate workshops, the motivation had to be present within the organization. Relevance in terms of quality further involved the development of a shared understanding of quality among healthcare professionals and their leaders. Hence, reflections over the meaning of quality were perceived as a valuable exercise.

“Often, they (front-line staff) say: “We need more people at work”. Based on front-line staff, this is kind of the solution for everything. However, this is not the case. I mean, we can provide quality in a good way, even though our time is limited, by providing good quality in what we do. And by having good procedures”. (External case).

Perceived relevance was also important for the internal implementation, even though this was raised in a lesser degree as the internal QI programme itself was specifically chosen by the leader for its relevance to their service.

Dedication, ownership, and engagement

Dedication, ownership, and engagement was found enabling in both cases. Engagement was crucial for the ownership of new procedures and perspectives. For the external case, the informants highlighted a need for leaders to develop a firm ownership of the implementation, as explained in the following quote:

“We had kind of decided this. We are a group that like to carry out things in clinical practice, not just making plans, but to actually realize them. I believe this is something we all are interested in. Therefore, it is important to make a plan, because it (the leader guide) needs to be anchored in management, and then we all have to work further to spread it (in practise). This is not something that can be done in 5 minutes, we must work with it (the leader guide) over time. And because this is something we have all agreed on, we will manage”. (External case).

For the internal implementation process, ownership was associated with the adoption of new procedures. Learning new procedures and measures, made especially individuals with a lower level of formal education feel safer when making decisions, resulting in a reduced need for contacting nurses, physicians, and emergency departments to get advice and supervision. Furthermore, in situations where there existed a need for contacting other healthcare professions (like physicians and emergency departments), the new knowledge allowed healthcare professionals to concretize their information, making it easier for physicians and emergency departments to target their advice. This can be exemplified by the following quote.

“They (health workers with lower formal education or no education) have evolved so much and have become so much more confident. They are the ones who have developed the most from this (the QI programme). And they have enjoyed it. And now they come back (to the home care central) and proudly stats: “I participated to a hospitalization”. This is so nice for us all to observe. (Internal case).

Technology and tools

Having access to appropriate tools, technology, and simulation equipment, were found enabling for implementation in both cases. It is important to notice, at this point, that technology and tools also were reported as a barrier. Meaning that technology and tools need to be accessible, easy to use, providing an overview, and easing information transfer to act as an enabler, if not, they may end up as a barrier. As such, the digital version of the leadership guide in the external case acted as an enabler providing accessibility to the learning resources, but also as a barrier if challenges in its use emerged.

One of the most important resources provided within the internal QI programme, was found to be the simulation equipment. Even though staff were reluctant to engage in simulations at first, they started to increasingly value this form of training as they got more familiar with simulation training. Findings showed that by only providing staff new tools (e.g., oximeters and blood pressure monitors) to not be sufficient to improve practises unless staff got properly trained in using them. Facilitating simulation training to ensure the correct use of new equipment was therefore enabling for internalization of new practices, as exemplified in the following quote.

“We found it necessary to include certain procedures in the simulation sessions. We then discovered that some people measured blood pressure incorrectly, and that some measured temperature incorrectly. Respiration was not always measured correctly, and not always the pulse. Therefore, even though we have been providing training, we still need to repeat the training over and over”. (Internal case).

Systematic approach and coordination

A systematic approach provided continuity of the implementation process and furthermore acted as a support structure for both cases. For the internal case a systematic approach was needed to coordinate training of all staff in new procedures and measures.

“Having a systematic plan for simulation training and lists of who is to be participating or not, has worked really well. And also, giving staff the responsibility for their own equipment, like the equipment bags, has also worked well”. (Internal case).

While the internal case had to coordinate the full implementation process themselves, participants in the external case were given “homework” by the external facilitators to perform between each pre-set meeting. Systematization in terms of coordination of the homework was found highly enabling for the external case. Systematization and coordination of the implementation approach are therefore highly related aspects in this study. To provide ownership for participants in the external case, self-organization in the coordination of homework, like in defining of goals and the initiation of action plans, was found enabling as a way to align the implementation process to their specific context.

In the following different barriers, illustrated in Table  2 ; Fig.  1 , are described in more detail.

Workload, turnover, coping with given responsibilities, staff variety and challenges in coordination

There was consensus across cases on the influence of workload as a barrier for implementation. The daily and already busy workload for health care professionals meant that the implementation of new QI programmes put on extra strains and responsibilities for the participants and the organization. Coping with these extra responsibilities was found challenging for the participants even if they perceived the implementation to be highly valuable for quality.

“They sent us to the course, which was nice. But suddenly I was responsible for all the simulation training, without being familiar with it. And I didn’t even want it….How was I to cope with this in daily practice, when I didn’t even have knowledge of it (simulation training)” (Internal implementation).

The same holds for the externally driven implementation process where they were given “homework” to perform between workshops. This was perceived as extra work to be performed on top of their already busy schedule.

“I remember well when it (the leader guide) was provided to us. And then I thought – how exiting. Really exciting. But then it (the leader guide) kind of got lost in everything else. The institutional leader quit her job at the same time, which also impacted us…However, to be able to have more focus on these things (quality improvement) would have been amazing” (External implementation).

The quote above further points to another emerging code, turnover, which was perceived as an important barrier. For the internal case, the training of new staff in the QI programme practices was experienced as time consuming and the overall implementation process therefore got negatively affected by turnover, as described in the quote below. For the external case, turnover of key personnel during the implementation process was found to be a barrier as it was difficult to find replacements to take over as implementation agents, as described in the quote above. This reflects the importance of continued engagement of the implementation process to facilitate for the development of ownership and internalisation.

“Barriers are typically turnover. And when training people in home care practices, there is a lot to teach them. It takes a really long time before you as a nurse or skilled health worker get hold of all the little things that we do here. So, this is difficult” (Internal case).

Healthcare workers in primary care are a diverse group, with variations in formal education, experiences, and contextual knowledge. This means that the implementation process needed to be aligned to the receiver, something leaders at times found challenging due to the staff variety (competence, perspectives, experience, education), reflected in the quote below.

“There are so many who should be seen and heard and all that. But I think this (QI programme) is important, especially for skilled health workers, it is important that they are lifted, and receive feedback on what they do well. Because there is a bit of rivalry between the professional nurses and the skilled health workers. Some professional nurses react when I praise them, because they feel this is only what should be expected. While others…It is difficult to applaud too much because you never know how it is received” (Internal case).

Technology and Tools

Technology and tools were found to possess a dual role as both enabler and barrier. When technology and tools were acting as a barrier it was caused by limited accessibility, compatibility, and output. The leadership guide in the externally driven implementation process was provided to the participants in both a paper version and as a digital website version. Most participants preferred the digital version due to accessibility. However, some elements of the digital version were perceived challenging by the participants, like the storing of the results, and as such a barrier for progress with the “homework”.

Lack of appropriate competence and knowledge sharing

The large variety in terms of formal education and contextual experiences meant that some employees felt that they were missing the appropriate competence to perform some specific practices. Like in the internal case where some of the simulation facilitators were unfamiliar with what they were expected to learn to their colleagues. As such, some facilitators needed more knowledge and training themselves before having to initiate training for others.

Some of the professional content has been very difficult, since I’ve not previously worked with this stuff. Among this, the use of the elevator. We have worked with a scenario of falls. I know falls very well, but I cannot use the elevator. And suddenly I’m supposed to teach the others in how to use the elevator”. (Internal case)

Knowledge sharing was also found to possess a dual role as both enabler and barrier, which reflects the importance of knowledge sharing for implementation. For the external case, lack of knowledge sharing was related to a lack of suitable arenas for knowledge sharing. Formalized meeting arenas were limited, which often resulted in a need to share knowledge, and to receive feedback, of more or less everything within the same meeting. As such, raised topics were only dealt with superficially.

“We have discussed this a bit between us. We want to have a forum. Yes, a forum for adverse events where we can air adverse events on a general basis” (External case ).

Standardizations not aligned with work and extensive documentation

Standardizations were perceived as counterproductive for quality improvement if the standardizations and routines were not properly aligned with daily work. The informants also reported that the number of standardizations, guidelines, and routines to be implemented made them less compliant to keep up with them all.

“I’m much less compliant to standardizations from the government, and the municipality, of what is of importance at the moment. This has nothing to do with quality, it is about logistics, so let us instead focus on quality.” (External case).

The same also holds for documentation. If standardizations, guidelines, and procedures required extensive documentation, then health care professionals were more reluctant to engage. A consistent problem in home care services was the use of computers. Healthcare professionals only had access to I Pads when visiting patients, meaning that they had to wait until they were back at the home care central to perform reporting and documentation. Another problem was the limited number of computers available at the home care central, meaning that they sometimes had to que up for reporting and documenting. The number of different software to enter for reporting and documenting, with corresponding passwords, was also perceived a barrier for compliance.

“The staff do not sit in front of a computer. It is very difficult to get them to use the computer, using their e-mail, and all this. It is a big challenge because they are not using the computer unless when they are writing up the report” (External case).

Cross-case analysis

In accordance with RQ2 the results described above were structured in terms of coinciding and context specific factors, for which the visual result provides us some new understanding, see Figs. 2 and 3 . It is important to notice that all factors influenced the implementation process, and each other, in rich and complex ways. For enablers, most factors were found coinciding across the cases. This means that the identified coinciding factors, were important for succeeding with healthcare implementation and should be of focus for leaders, facilitators, and implementation agents.

However, when identified barriers were structured across cases in a similar diagram, an opposite pattern surfaced. Workload was the only coincident factor across the cases, and the other factors were found more context specific. This pattern provides the understanding that workload is a common and important barrier, that needs to be of focus in all implementation processes. Yet, to circumvent barriers, contextual knowledge of the implementation setting, and furthermore characteristics of the QI programme, are necessary to understand contextual barriers for implementation. By having contextual knowledge, leaders, facilitators, and implementation agents can work to align the implementation process to the situational context, like available resources, level of competence, turnover, staff variety, technology, and the appropriate level of documentation and standardization.

We performed a qualitative study in nursing homes and home care services and identified enablers and barriers for externally and internally driven QI implementation processes. We found that technology and tools, ownership, and learning were coinciding enablers, while workload was a common barrier across the implementations processes. We also identified several barriers and enablers that differed between the externally and internally driven implementation processes. In the following we discuss these and relate them to previous research and especially the conceptual and layered framework of Lau et al. [ 11 ] focusing on intervention characteristics, external, organisational, and professional factors to understand success and failure in QI implementation processes. The frameworks by Lau et al. [ 32 ] and Damschroder et al. [ 33 ] have a different focus of study and the relatedness to these frameworks were therefore only identified after the indictive data analysis was completed.

Conceptual framework for enablers and barriers of healthcare implementations

The findings illustrate diverse enablers and barriers for externally driven and internally driven implementations. Exploring the results from this study in relation to the framework by Lau et al. [ 11 ], the following categorization depicted in Fig.  4 can be developed. Each level (external, organisational, professional, intervention) influences the others, meaning that the different levels are interdependent elements of implementation processes and need to be understood as a contextualized entirety. Each level will be described in more detail in the following.

Enablers and barriers from both cases in relation to the intervention, and professional, organizational, and external factors. Green text refers to enablers and red text refers to barriers.

Adapted from Lau et al. (2015)

Factors concerning the intervention/QI programme

Factors associated with the nature of the intervention/ QI programme itself refer to the identified enabling factor of perceived relevance. Relevance aligns with what Lau et al. [ 11 ] identified in their review on the importance of relevance, clarity, and practicality, all pointing to a need for the QI programme to provide benefits for practice, economy, patient safety, and efficiency. Efforts to make the QI programme perceived as relevant, relied on a fit between the situational context and the QI programme, thereby highlighting a need for user involvement during QI programme development. This finding is echoed in Cresswell et al. [ 7 ] where an alignment to the organizational context is not perceived as satisfactory unless the QI programme is aligned with clinical needs as well. Lau et al. [ 11 ] furthermore points to a need for leaders and implementation agents to clearly state the relevance of the QI programme in early phases of the implementation process, to provide willingness of staff to engage. This was also present in the external case where the researchers had to highlight the relevance of the QI programme for the participants to raise engagement and ownership [ 34 , 35 ]. Damschroder et al. [ 14 ] and Ree et al. [ 35 ] reports adaptability of the QI programme as a key factor for ensuring fit to the situational context. This is also reflected in our study where outcomes of the QI programme, in terms of quality, needed to be adapted to their specific context to be classified as relevant. Granja et al. [ 3 ] in a literature review found perceived quality for healthcare to be the most mentioned category for success, relating quality to contributions for professional performance standards and clinical practice.

Technologies (digital version of the leadership guide in the external case) and tools (clinical equipment in the internal case) were also part of the QI programme itself and could introduce both positive (accessibility and improved practices) and negative impact (software challenges and lack of appropriate competence) to the implementation process, as described in the result section.

Professional factors

Moving to the next circle of professional factors, which refers to influence, competence, and self-efficacy [ 11 ]. Professional factors encompass several findings within this study; enabling factors include ownership and engagement, simulation training and knowledge sharing, and barriers refer to a lack of appropriate competence and knowledge sharing, coping with given responsibilities, and staff variety. The marked role of knowledge sharing is evident through its position, as both an enabler and, if missing, a barrier. Knowledge sharing is essential for the dissemination of information, knowledge, and experience in both formal and informal channels throughout the implementation process. Furthermore, a lack of appropriate knowledge was also found hindering. This is reflected in the internal case where the staff variety made knowledge transfer more difficult, as they held different levels of competence and experience and thus required different resources for learning and training. This corresponds with Lau et al. [ 11 ] stating that adequate competence act as a facilitator for implementation success. Furthermore, Cresswell et al. [ 7 ] describe actors in possession of appropriate knowledge to be more positive towards new technology and services, than actors without appropriate training. The authors also describe a need for tailoring the training and to make it close to practise, which provides understanding to the importance of simulation training for the internal case [ 7 ].

Ownership was found of influential in both the internal and external implementation process. This corresponds with Lau et al. [ 11 ] who emphasize motivation and attitudes as enabling for change. For the external case, having the opportunity to adapt the implementation process to their setting was key for developing motivation. This issue of self-organization was not raised in the internal case as they by definition were responsible for the organization of the implementation. Greenhalgh et al. [ 10 ] describe ownership and adoption as a process, needing time to develop. Facilitators for this process were described to be appropriate knowledge of the output of the innovation/ QI programme (perceived relevance and appropriate competence), continuous access to information (continuous learning), ability for contextual adaptation, and to receive adequate feedback (knowledge sharing). These findings from Greenhalgh et al. [ 10 ] illustrate interdependencies of their findings and furthermore the findings of our study, pointing to the need for keeping a holistic perspective of barriers and enablers.

Organizational factors

Continuity in learning enabled implementation, as in the internal case where continuous learning ensured ownership by repeated focus over time until new knowledge and procedures were internalized in form of routines and thought worlds. Other aspects of continuity, like in the external case where leadership turnover resulted in a disruption of the implementation process, also acted as a barrier for the implementation process. This echoes Damschroder et al. [ 14 ] who described continuity and stability of staff as facilitative for implementation success. Leadership is also highlighted in Lau et al. [ 11 ] study, as means to identify champions, drive change, and for the communicating of objectives for the implementation process. The authors further report that early engagement by leaders as valuable for the adoption of the QI programme. This understanding is echoed in this study in relation to leaders’ dedication and engagement to the implementation process.

Another factor that acted as both an enabler and a barrier was coordination. Well organized and structured plans for the implementation process were found facilitative. Allowing participants autonomy and room for self-organization were emphasized as a way of adapting the implementation process to front-line work in our study, similarly to Cresswell et al. [ 7 ]. This refers to what is described by Greenhalgh et al. [ 10 ] as fuzzy boundaries, where innovations in services organizations, like healthcare, includes a hard core of fundamental elements that need to be unaltered to maintain the purpose of the innovation, and a soft periphery providing adaptation to the context [ 8 , 12 , 27 ]. This is further echoed in this study where QI programmes involved a fundamental hard core (different measurements and procedures to perform/leadership guide with assignments) and a soft periphery (how, when, where, and with whom, learning and homework are performed).

However, coordination also acted as a barrier, put forward due to the complexity in care and the huge variety in training and education among staff. This understanding is also mirrored in the description by Lau et al. [ 11 ] on how skill mix issues may impede coordination of responsibilities and roles. Related to coordination, was also the enabler of having a systematic approach. Systematization of the implementation process was perceived as a support structure, as it eased the overview of the training process and furthermore provided an ability to monitor progress. This means that the flexibility to adapt and translate the QI programme, described facilitative in the above, needs to be accompanied with some support structures, like infrastructure and planning to ease the implementation process [ 7 ].

Workload was heavily reported as a barrier in this research, where limited time and effort to engage into the implementation resulted in a lack of ownership and engagement. Workload as a barrier for implementation is previously described in various research. Granja et al. [ 3 ] found workload to be overrepresented as a barrier within their systematic review, and Carlfjord et al. [ 2 ] describe workload to reduce the ability to engage into the implementation process. The implementation of new QI programmes therefore needs to align adoption efforts to workload, or else the implementation process may end up as a burden for healthcare workers already in a pressed and hectic work situation [ 36 ]. Bates and Singh [ 1 ] describe workarounds, for time saving purposes, as outcomes if the QI programme and implementation process are not aligned with workload.

External factors

Nursing homes and home care services are the responsibilities of Norwegian municipalities. However, even if this structure allows for local decisions and prioritizations concerning quality improvement, the municipalities still need to align to national regulations, guidelines, and external factors. External factors found to influence the implementation were technology and tools, standardizations not aligned with work, and extensive documentation. Technology and tools therefore acted as both an enabler and a barrier for the implementation cases in this study. This is in line with Greenhalgh et al. [ 10 ] arguing that when tools are perceived as easy to use, the potential for successful implementation increases. Furthermore, appropriate, and useful knowledge for how to use technology and tools need to be present, findings which are echoed in Cresswell et al. [ 7 ].

When not perceived as accessible and useful for daily practise, technology and tools introduced a lack of motivation and workflow, thereby reducing the perceived incentives of engagement. Disruption of workflow was a significant finding in Granja et al. [ 3 ] due to a gap between the technology and the context. As a barrier for implementation, technology and tools are related to extensive documentation, referring to a lack of compliance to demands of documentation due to insufficient compatibility in technological systems, increased workload, limited resources, and poor functionality. This is furthermore mirrored in Lau et al. [ 11 ], stating that infrastructure, technology advances, and a lack of clear incentives are important external factors of implementation. Standardization and documentation, not aligned with work, are factors mostly initiated and decided upon externally, like from the specific QI programme itself, and from regulations and guidelines from the national level. However, even if decided outside of the organization, it is to be performed by individuals and teams within the organization. This means that some room for adaptability to context need to be present, if not they may act as a bottleneck for efficiency.

The Norwegian government has initiated a regulation stating the need for healthcare leaders in nursing homes and homecare services to ensure continuous quality improvement within their respective organizations. As such, there are formalised requirements for primary care leaders to take on different quality improvement interventions. However, which type of interventions to implement will often be up to the primary care leaders to decide upon, except for national programs where all units are to engage. The guidelines for which type of approach to use for the implementation process are also formed with flexibility for leaders to decide, based on what is most appropriate for their organization. Awareness of enablers and barriers for different approaches can potentially be of support for leaders in their quality improvement work. Furthermore, our findings display the benefit of providing flexibility for local adjustment of the intervention and implementation process which can inform policy makers to provide a room for adjustments in national programs.

Strengths and limitations

This study has some limitations. First, as in all qualitative research the findings from this study are not transferable. Second, it may be considered a limitation that the internal and the external case implemented different QI programmes. However, a principle for the overall study was to allow the internal case to choose their own QI programme and furthermore to implement the QI programme on their own without any impact from the researchers. Third, it is relevant to mention that the internal case only included home care services, while the external case included both nursing homes and home care services. Forth, only interviews of leaders and professional nurses were included as empirical data for this study to explore the perspective of the implementation agents and to make the empirical foundation more similar across the cases. Other findings may therefore have emerged if the dataset also incorporated employee interviews and observation notes. New studies should therefore seek to perform similar studies informed by both leaders and employees. Fifth, the data collection in the external case included both individual and focus group interviews, while the internal case included only individual interviews. For the external case, the two individual interviews were chosen due to the geographical distance of this nursing home. Furthermore, the two leaders were not located in the same unit so individual interviews were found more convenient. The choice of using individual or focus group interviews have both pros and cons, where focus group interviews allow for more discussion and as such a way to generate more ideas, while individual interviews provide psychological safety as what is reported is only between the researcher and the informant [ 37 , 38 ]. An additional factor to balance was the use of the leader’s time to conduct the interview. The interviews were therefore performed at the leader’s location which made it necessary to allow for both focus group interviews and individual interviews [ 39 ].

The major strength for this study is the comprehensive dataset, including several municipalities and institutions. The data was collected over time, providing credibility to the study. Additionally, the focus of leaders in both cases provides the ability for cross-comparison of the different implementation processes.

The aim for this study was to explore enablers and barriers of two different implementation processes of QI programmes in nursing homes and home care services, where the implementation in one case entailed an externally driven process, while the second case entailed an internally driven implementation process. As such this study theoretically contributes to calls for research on different contextual settings of healthcare implementations and further to calls for implementation studies to take place in primary care settings.

This study shows that workload acted as the main barrier for implementation in both externally and internally driven implementation processes. Based on the current state of primary care with burnout, stress, and lack of qualified healthcare professionals causing a mismatch of demands and capacity in healthcare services, implementation of QI programmes needs to be aligned with their everyday work to not be perceived an extra burden [ 36 ].

Other barriers and enablers in need of extra focus in implementation processes are factors that acted as both barriers and enablers, like technology and tools, continuity in learning and staff (turnover), and coordination. Tightly monitoring these factors throughout the implementation process may provide a positive impact.

Dedication, engagement, and ownership are other factors which need to be emphasized. These enablers were raised in both cases. However, the influence of other enablers and barriers to facilitate or hamper the development of dedication, engagement and ownership leaves these factors of importance for implementation processes.

Future studies should seek to explore similar phenomena in different countries and at different parts of healthcare services, to develop an understanding of the findings in different contexts. Furthermore, future studies should also explore implementation of different QI programmes and compare different types of implementation processes in terms of timespan, level of change introduced by the QI programme, and alternative ways of facilitating the implementation process, like having mixed externally and internally processes, as well as front-line initiated and government-initiated QI programmes.

Data availability

The datasets used and analysed during this study are available from the corresponding author on reasonable request.

Abbreviations

• Quality improvement

Improving Quality and Safety in Primary Care – Implementing a Leadership Intervention in Nursing Homes and Homecare

Centre for Resilience in Healthcare, Faculty of Health Sciences

Centre for Development of Institutional and Home Care Services

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Acknowledgements

The authors would like to thank all participants in the involved nursing homes and home care services for participating in the study.

Open access funding provided by University of Stavanger & Stavanger University Hospital. The work is part of the Improving Quality and Safety in Primary Care – Implementing a Leadership Intervention in Nursing Homes and Homecare’ (SAFE-LEAD) project, which has received funding from the Research Council of Norway’s program HELSEVEL (grant agreement no. 256681/H10), and the University of Stavanger. The funding body played no role in the design of the study, data collection, analysis, or in writing the paper.

Open access funding provided by University of Stavanger & Stavanger University Hospital

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Department of Health and Nursing Sciences, Faculty of Health and Sports Science, University of Agder, Kristiansand, N-4604, Norway

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Sunnfjord municipality, Førde, N-6802, Norway

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Contributions

HBL and SW advanced the initial idea for the article. TS introduced and contributed to the discussion of data/results according to the framework of Lau et al. (2015). ER, TS, TJ, IA, BU, LHT, EHR, LS and SW performed the data collection. HBL led the analysis, and all authors contributed to the steps of the analysis and agreed on the final results. HBL drafted the manuscript with significant contributions from ER, TS, TJ, IA, BU, LHT, EHR, LS, DWB and SW. All authors have read and approved the final manuscript.

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Correspondence to Hilda Bø Lyng .

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The Norwegian Regional Committees for Research Ethics considered this study not to be governed by the Health Research Act. The Norwegian Agency for Shared Services in Education and Research approved ethical data management for the study in two phases (Phase 1: NSD, ID 52324; Phase 2: NSD, ID 54855). The study followed the Helsinki Declaration. All participants gave individual informed written consent to take part in the study and were informed that they at any point were free to redraw their participation.

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Lyng, H.B., Ree, E., Strømme, T. et al. Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study. BMC Health Serv Res 24 , 528 (2024). https://doi.org/10.1186/s12913-024-10985-2

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Received : 14 March 2023

Accepted : 11 April 2024

Published : 25 April 2024

DOI : https://doi.org/10.1186/s12913-024-10985-2

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