Connectivity: Person-Centred Research Principles to Inform Constructivist Grounded Theory

Introduction

A rigorous person-centred research and evidence-based foundation is vital to understanding what underpins best practice surrounding person-centred care (Dewing et al., 2021; Jacobs et al., 2017; McCormack et al., 2017; McCormack & McCance, 2021; van Leishout & Peelo-Kilroe, 2021; WHO, 2015). As a well-renowned proponent of person-centred practice and research, McCormack has long contended that applying the principles of person-centredness is essential when conducting research that aims to understand nursing practice (McCormack, 2003; McCormack et al. 2017, 2021). Critical to current healthcare research is ensuring the centrality of the voices of people accessing (and providing) healthcare. These voices inform the “humanising” of healthcare and create a greater understanding of the current experiences of those involved in this complex and challenging arena. While there are no singular person-centred research methodologies, certain principles guide a “value-led and multilayered approach” (van Lieshout & Peelo-Kilroe, 2021, p. 80) to person-centred research.

To add to this discourse, the aim of this paper is to explore how the principles of person-centred research intersect with constructivist grounded theory (CGT) as a contemporary approach to healthcare research, further evolving CGT methodology with the use of person-centredness as an underpinning philosophy. Using person-centred principles as researchers engaging in a constructivist grounded theory study is a novel approach and we consider the synergies and connections, considerations, and possibilities within this paper.

Background

The Focus of Our Research Study

The research study we are undertaking aims to improve understanding of the person-centred process of engaging authentically within the nurse-patient relationship from both the nurses and the patient’s perspectives. This study is ongoing and taking place in an Australian regional hospital setting, with nurses from this setting and adults who have recently been inpatients invited to participate. Engaging authentically is one of five key processes in mid-range theories on person-centred nursing and person-centred healthcare practice (McCormack et al., 2021; McCormack & McCance, 2010, 2017, 2019). Person-centred Practice and Nursing frameworks have been developed, refined, and utilised in different care settings and by researchers in various disciplines and contexts (McCormack & McCance, 2021; see also https://www.cpcpr.org/). Within the person-centred nursing framework are nursing processes that focus on the nurses’ actions and interactions, demonstrating person-centred practice (McCance & McCormack, 2017). (See Figure 1: The Person-centred Nursing Framework). Though defined by McCormack and McCance, the person-centred process of engaging authentically has yet to be central in research focussing on the nurse-patient relationship (Pratt et al., 2020). Further understanding and clarification of this person-centred process from the perspectives of both the nurse and the person being cared for are essential to enhance person-centred nursing practice. In exploring methodologies suited to the research question posed, we selected constructivist grounded theory as this supported the explicatory aims of the research (Charmaz, 2014).OPEN IN VIEWER

Constructivist Grounded Theory

Grounded theory is a recognised research methodology spanning over half a century, and multiple variants have been introduced over time as researchers advance their understandings and positions (Apramian et al., 2017; Kelle, 2019; Timonen et al., 2018). Charmaz (2006) reinterpreted grounded theory through a constructivist lens and considered grounded theory to be both a method and a methodology. CGT differs from Glaser and Strauss (1967) approach underpinned by objectivist epistemological foundations. Constructivist grounded theorist’s ontological and epistemological positions recognise the subjectivities that exist in a world of multiple realities, where "generalisations are partial, conditional, and situated in time, space, positions, action, and interactions” (Charmaz, 2014, p. 236). Understanding, therefore, is interpretive and contextual (Charmaz, 2008b).

Furthermore, Charmaz (2014) describes the influences of the pragmatist Chicago School underpinnings in CGT where openness and curiosity of the world are nurtured, and empathy is used to understand participant’s experiences of their worlds. The importance of the relationship between the researcher and the participants during CGT research supports an “aim to enter the studied phenomenon and view it from the inside” (Charmaz, 2008a, p. 133). Enhancing relationships increases the researcher’s understanding of the different perspectives and experiences of the participant’s shared realities (Charmaz, 2004).

Grounded theorists recognise a “constellation of methods” (Charmaz, 2014, p. 14) which are shared principles of theory development, theoretical sampling, progression of abstraction in coding, constant comparison, and memoing (Bowers & Creamer, 2020, p. 4). Though all grounded theory research share methods, Charmaz’s constructivist approaches differ in how the above principles and specific methods are used. To this end the constructivist approach “treats research as a construction but acknowledges that it occurs under specific conditions-of which we may not be aware and which may not be of our choosing” (Charmaz, 2014, p. 13). These specific conditions are contextual, and relate to time, culture, and place, recognising the social construction of reality and that we know the world around us by establishing mutual awareness through interacting with others (Gardner et al., 2012). Participants’ understandings of their worlds and the language they use to describe their experiences become evidence of their realities (Charmaz, 2014). Charmaz, as a social researcher, sees the researchers’ relationship to the research participants, the data, and the data analysis as integral to the approach. This methodology, therefore, relies on the co-construction of experience and meaning in the area of inquiry with the participants, pursuing and presenting the “participant’s views and voices as integral to the analysis” (Charmaz, 2014, p. 236). The creation of shared, constructed reality informs the development of the grounded theory, hence it is “grounded in the data” (Timonen et al., 2018, p. 8).

Charmaz (2008b) encourages CGT researchers to re-examine their epistemic knowledge, research approaches, and methods to ensure they remain open in their perception of what the data is revealing. Charmaz also contends that the researcher is very much part of the CGT research and must be aware of their values and behaviours and evaluate their own underlying beliefs and research methods (Charmaz, 2017). This recognition that researchers come with their values, beliefs, and pre-conceived understandings of the world that inform the interpretation of the data means reflexivity is a fundamental principle embedded throughout research processes (Charmaz, 2014). This strong emphasis on reflexivity indicates that exploration of the impacts of researcher positionality on the relationships, analysis, and conceptualisation is included in the grounded theory and informs research credibility (Charmaz, 2014).

CGT principles highlight the importance of relationships with the research participants and the centrality of their voices to the co-construction of the grounded theory. This importance is also echoed in person-centred research principles, which see values such as “respect, reciprocity, mutuality and self-determination” (Jacobs et al., 2017, p. 52) as central to creating an environment where research enriches lives. Considerable attention is given to how the researcher acts and interacts in person-centred research, embodying person-centred ways of being and supporting the aim of flourishing for all (Dewing et al., 2021). Working in person-centred ways as researchers support Charmaz’s considerations for relational approaches to research participants and the careful and methodical analysis and representation of information which is key to CGT studies. Charmaz mirrors many person-centred values and qualities in her writing and approaches to research. Synergies and connections were noted when investigating person-centred research principles and the CGT approach, as further explored below. We also present considerations in using this approach and the possibilities for others when undertaking research.

Constructivist Grounded Theory and Person-Centred Research Principles: Synergies and Connections, Considerations, and Possibilities

As our research takes place within a healthcare setting, discovering aspects of the nurse-patient relationship and the process of engaging authentically, we will explore the interactions, communications, actions, and behaviours perceived by both cohorts that are significant to them. This research is about a social process, and we contend that the use of CGT fits well. Considering the shared and multiple realities, the social structures and interactions and the care environment will provide context to this exploration.

This research area is multilayered, multifaceted, and complex, where participant experiences and perspectives must be valued, and shared meanings are negotiated and co-constructed with care (Charmaz, 2014). Understanding the socio-political and cultural contexts of care will also play a role (Charmaz, 2014). We recognise the possible impacts of working and being cared for in current healthcare environments. The Covid-19 pandemic placed an extra burden on nurses in an already burgeoning health system and is still contributing to impacts on their health and well-being (Mannix, 2021). A person-centred, compassionate stance when engaging with research participants, including “loving kindness” in approaches (van Lieshout & Peelo-Kilroe, 2021, p. 73), supports the participants as explored further below.

Jacobs et al., (2017) describe the core person-centred research principle as one of connectivity; the being, doing, and knowing of the researcher throughout the research. Connectivity encompasses the “efforts to connect with oneself, other persons and contexts and which is expressed in the way one does the research (doing), talks about it (knowing), and is as a researcher and person (being)” (Jacobs et al., 2017, p. 53). The importance of relationships when working together to enable new knowledge is central to the principle. Included are the related principles of attentiveness and dialogue, empowerment and participation, critical reflexivity (Jacobs et al., 2017), and, more recently, “loving kindness” (van Lieshout & Peelo-Kilroe, 2021, p. 73). These reflect the person-centred approaches used throughout the research, connecting respectfully and empathetically with everyone involved. Enabling dialogue that is open and supportive of others is vital to respected and valued relationships, providing a research environment where ideas are shared, knowledge is created, and human flourishing can occur (Jacobs et al., 2017).

Charmaz has emphasised “flexible guidelines, not methodological rules, recipes, and requirements” in CGT studies (2014, p. 16). Using these flexible guidelines to work in person-centred ways means incorporating the above person-centred principles of attentiveness and dialogue, empowerment and participation, critical reflexivity, and loving kindness (Jacobs et al., 2017; van Lieshout & Peelo-Kilroe, 2021) into our research. Undertaking research that supports the ability to connect with others to learn about their experiences and perspectives meant we wanted to gain an understanding of the healthcare environments (in the context of our research) and to hear from nurses and people who had been cared for in recent times. As an illustration, we included overt observation using a person-centred observational tool, the Workplace Culture Critical Analysis Tool Revised (WCCAT^R) (Wilson et al., 2020), and intensive interviewing in our research design. For us as researchers, a period of observation using the WCCAT^R aims to support a greater understanding of current contexts of care and to note “daily workplace happenings and situations by seeing, hearing and perceiving what is going on” (Wilson et al., 2020, p. 5). For this study, the tool is utilised explicitly relating to the person-centred processes between nurses and the people they are caring for, observed in the context of the care environment. Interacting with the nursing staff during this time of observation also allows them to explore aspects of their work and to share their thoughts with the researcher, inviting reflection and insights into their practice. Being attentive to practice realities during the observational period helps to inform the researcher’s understandings of current practice and provides avenues to explore in subsequent intensive interviews with participants.

Exploring the Person-Centred Principles and Constructivist Grounded Theory

Possibilities

We contend that using the person-centred principles discussed above whilst undertaking this research will give voice to both nurses and people who access healthcare to enhance understanding of the care experience at the interface of care. This knowledge about nursing practice and, significantly, what patients experience and expect will, we hope, give rise to some evaluation of current practice by clinicians and others involved in healthcare provision. Allowing nurses and healthcare users to share what is important to them will enable them to feel empowered and heard.

Considerations

Aiming to use person-centred approaches in a CGT study authentically has challenged us. We have wondered whether further explicating the person-centred process of authentic engagement using the constructivist lens and grounded theory methods supports the person-centred research aim of human flourishing for all. Different definitions of human flourishing abound in the literature but perhaps “enabling helpful, supportive relationships based on mutual trust and understanding that empower others to grow and develop, as well as sharing knowledge” (McCormack & Titchen, 2006, in Jackson et al., 2021, p. 237) is a practical way of considering this in person-centred research. Dewing et al., (2021, p. 8), note that person-centred research is not rigid in terms of methodologies but asks for “new weavings of principles for understanding persons, environment, health, and nursing”. We contend that working in person-centred ways in CGT studies is possible for researchers. It is in consideration of the methods used to engage with research participants that challenges may occur, as engagement and learning opportunities need to be present (Dewing et al., 2021). Titchen et al. (2017, p. 33) propose a framework for person-centred research including the prerequisites: “knowing self, clarity of values and beliefs, professionally competent, developed interpersonal, facilitation and research skills, and commitment to the research”. These prerequisites illuminate the essential skills, knowledge, and attitudes of a person-centred researcher. This informs what shape the research will take, and perhaps begins to highlight the difference between person-centred research and other research, where all these essentials are not seen as necessary. The emphasis on a values-driven, person-centred, reflexive approach in person-centred research, means “values are central, are explicit, are considered and are acted upon, and this condition makes explicit the need for considering the values held by all participants in research decision-making” (van Dulmen et al., 2017, p. 211). As researchers, we believe it is possible to strengthen CGT research with these facilitative, values-based approaches, informed by our own explicitly known values and beliefs and supported by a philosophy of person-centredness and recognition of personhood. Underpinning the research with these approaches, alongside the CGT methods for concurrent information gathering and analysis as outlined, will add credibility to our study. Research rigour is discussed further below.

Supporting the researcher’s ability to flourish as well as research participants is undoubtedly an incentive for person-centred researchers. Bringing ourselves into the research in this authentic way shapes the research and supports the flourishing of the research participants and us. However, as Dewing et al., (2021) advise, person-centred research is a challenging option and needs careful consideration.

When considering person-centred philosophy and principles; we have given careful thought to the design and conduct of our CGT research to ensure we are able to maintain a person-centred approach. Our traditional grounded theory research and the observational and interviewing methods of data collection and CGT analysis needed to incorporate the person-centred principles discussed in this article. As person-centred researchers, it is perhaps more in the way the constructivist grounded theory data collection and analysis methods are used, rather than the need for different approaches. We have not discovered any CGT studies using a person-centred approach, but as Charmaz (2014, p. 27) notes “just as the methods we choose influence what we see, what we bring to the study influences what we can see”. Creating safe spaces by incorporating person-centred ways of working, with respect, authentic presence and care, and reflexivity, will support the person-centred research outcomes in all aspects of our CGT research (Jacobs et al., 2017; Titchen et al., 2017). As healthcare continues to be driven by humanist approaches to care, we invite healthcare researchers to look closely at their own lens and ways of being in all aspects of research.

Considering Personhood and Person-Centredness as a Standpoint for Constructivist Grounded Theory

We have presented the overarching person-centred research principle of “connectivity” to inform the being, doing and knowing of the person-centred researcher and the research (Jacobs et al., 2017, p. 52). Importantly, person-centred research is informed by having clarity on person-centredness and understanding “what a person is” (Dewing et al., 2021, p. 2), and this philosophical paradigm could be a standpoint for CGT studies. When underpinning CGT with person-centred philosophy, an epistemological and ontological framework has been presented by Titchen et al., (2017) that includes the research environment and processes, prerequisites for person-centred research, and the outcomes. It is contended that this framework can be used across different worldviews, from the practical to the transformational, always considering the “person-centred values of respect, reciprocity, mutuality and self-determination in every aspect of the research” (Titchen et al., 2017, p. 42).

Charmaz (2014), from her interpretive worldview, sees pragmatism and symbolic interactionism as antecedents of the theoretical perspective of CGT. Charmaz does not see symbolic interactionism as the only theoretical perspective for constructivist grounded theorists however, she also encourages other stances. In her early writings on her work, she acknowledges, “my application of grounded theory derives from a symbolic interactionist perspective tempered by Marxism and phenomenology” (Charmaz, 1990, p. 1161). More recently, she has noted feminist theory and intersectionality (Roschelle & Kaufman, 2004; cited in Charmaz, 2014), and social justice and critical inquiry researchers (Charmaz, 2020) utilising CGT as a methodological approach. Though Charmaz does not appear to have explored personhood in depth in her writings, she does recognise and consider personhood and the valuing of persons in her work. She has, for example, applied Gadow's (1982) conceptual framework for understanding the body-self relationship in her major study on chronic illness and identity (Charmaz, 1995). She agrees with Gadow, who “assumes that the human existence essentially means embodiment and that the self is inseparable from the body” and sees this as important in her conceptualisation and subsequent grounded theory (Charmaz, 1995, p. 659). Carl Rogers and his humanistic approaches are also embraced by Charmaz (2014), ensuring the participant experiences are empathetically recognised and valued during the research processes. Charmaz (2014) sees CGT as a flexible, interpretive approach to qualitative research and encourages innovation in the use of CGT guidelines. Seeking to underpin CGT studies with person-centred philosophy is, we believe, a legitimate and feasible proposition, and will add to the possibilities for person-centred research. In our research, CGT methodology informed by person-centred research principles of connectivity and critical reflexivity provides an opportunity to transform understandings of the nurse-patient relationship and the person-centred process of engaging authentically.

Empowerment and Participation-Creating Spaces and Places for Participants in Constructivist Grounded Theory

As a principle of “connectivity” in person-centred research, considerations of empowerment and participation must be incorporated into research design and methods. Jacobs et al. (2017) describe the need to combine forces and work together to achieve change as ways to be empowered to participate in person-centred research, addressing the possible hierarchical power imbalances between researchers and participants. There are considerations to this person-centred approach in our CGT research, as research design contemplates how participant realities are interpreted and presented by CGT researchers and what part they may play in theory construction. Critical reflexivity supports the systematic approaches required to evidence research quality throughout from both person-centred and constructivist grounded theory perspectives (Charmaz, 2014; Jacobs et al., 2017). Critical reflexivity is also an important principle to ensure actions and interactions are underpinned by the values of person-centredness that safeguard empowerment and participation (Jacobs et al., 2017).

Using the more traditional qualitative research data collection methods such as observation and interviewing (as we are) may pose problems when evidencing this principle in the forms of negotiation and decision-making by research participants. As many research studies use these methods, consideration of the approaches researchers use to invite participants to co-construct information and the kind of dialogue undertaken is essential. As outlined above, Charmaz (2014) stresses the importance of forming effective relationships with participants to ensure an environment where shared meaning is developed. In CGT studies, the methods for data analysis involve the researcher working closely with the information provided by participants with initial word-by-word or line-by-line coding and then seeking further clarification of ideas in subsequent interviews (Charmaz, 2014). Gaining additional input from previous participants can be included in the research design, and conducting follow-up interviews or focus groups adds to participant opportunities to contribute to initial concepts and later theoretical categories, further empowering participants (Charmaz, 2014). Dewing et al. (2021, p. 10), however, challenge traditional member-checking activities, and premise the inclusion of “dynamic peer review” to be a valuable inclusion in person-centred research. Including activities that provide learning opportunities and active engagement for participants are key processes in person-centred research, and these, of course, can be included in CGT research design.

Dewing et al. (2021, p. 9) note that whatever the methods employed, “the experience of being involved in person-centred research must feel different”. The question of how the experience enhances connectivity, and ultimately flourishing, and therefore feels different needs to be central to all decisions made throughout the research, and this may be hard to evaluate. Dewing et al. (2021, p. 162) note that this is “primarily an ontological process”, where personhood is the crucial and over-arching consideration. Researchers are invited to create their own conditions for person-centred research, providing firm foundations to underpin studies and demonstrating new perspectives to frame person-centred research.

Demonstrating Rigour in Constructivist Grounded Theory Research Informed by Person-Centred Research Principles

We aim to provide a quality research study, working with nurses and recent in-patients to explicate further engaging authentically as a process, how it is defined, the enablers and the challenges and barriers to it in this study. Charmaz (2014) has presented criteria for evaluating rigour in CGT studies. These criteria fit the constructivist methodological stance, where the importance of abstract understanding, recognition of subjectivity and contexts is recognised. Charmaz (2006, 2014) suggests that researchers should prioritise credibility, originality, resonance, and usefulness. She has presented a helpful series of questions and guidelines to support constructivist grounded theorists to consider the quality and rigour of their studies (see Charmaz, 2014, pp. 337–338; Charmaz & Thornberg, 2021, pp. 321–322). However, she advises caution in using lists of criteria as a “methodological crutch” that decreases the ability to engage deeply in the research study (Charmaz & Thornberg, 2021, p. 321). Evaluating rigour in person-centred research requires additional differing considerations, underpinned by understandings of personhood and informed by methodological principles. Dewing et al., (2021, pp. 10–11) suggest informed flexibility, sympathetic presence, negotiation, mutuality and transparency as criteria for research rigor in person-centred research, linking this example to conditions for person-centred research established by McCormack in 2003 and included in Dewing et al., (2021, p. 6). These key conditions relate to being person-centred as a researcher and working with the values of person-centred practice. The core value of “respect for the person” (McCormack et al., 2021, p. 15) is, of course, necessary for the ethical conduct of all research, however in person-centred research, this value (and others related to authenticity, shared autonomy and mutuality) must be clearly articulated. Ensuring the values of person-centredness ground all aspects of the research requires relational approaches that support all to feel well-supported and empowered.

Conclusion

Considering the current important worldwide aim of humanising healthcare for all, we have presented an exploration of the relationships and possibilities between person-centred research principles and a CGT approach. Gaining further perspectives around the experience of care using person-centred research principles in CGT studies is very useful and should be embraced by researchers. Applying the philosophy of person-centredness to a CGT research study as a starting point and stance to conduct research would add value to research exploring nursing and healthcare phenomena now and into the future. Using the principles for person-centred research outlined in this article will enable an approach that encourages flourishing for all, the ultimate aim for person-centred research and researchers.

We would like to pay tribute to the late Professor Jan Dewing who was a much respected and important leader of person-centred healthcare research and practice. Her knowledge and wisdom was immense and she was very generous in sharing her understandings with us over the years. Jan has contributed in many ways to the flourishing of healthcare students, academics, researchers, and practitioners and is sadly missed.