Conducting a Grounded Theory Study in the Wake of a Traumatic Event: A Research Protocol

Abstract

Aims

To explore the perspectives of people who worked at Whakatāne Hospital during and following a mass casualty event from the Whakaari/White Island eruption in New Zealand.

Background

The eruption of Whakaari / White Island on December 09th, 2019, significantly impacted many people in New Zealand and internationally. Whakatāne Hospital, a rural hospital in New Zealand, received a mass casualty alert in response to this event. Whakaari holds genealogical significance for Māori (Indigenous) people of the Mataatua region, the Eastern Bay of Plenty. Many local stories and waiata (songs) about this ancestral volcano are still told today.

Design

A research protocol for conducting a grounded theory study in the wake of a traumatic event.

Methods

Grounded theory (GT), a structured yet flexible methodology, is ideal for understanding a phenomenon in a research area where evidence is limited. It asserts that reality is constructed by those who experience it. In this context, recognising cultural knowledge (Mātauranga Māori) is crucial to ensure the validity of cultural inclusivity and equity in the research process and generation of data.

Conclusion

The GT developed from this study will be based on the experiences of selected participants and will also explore the importance of cultural factors, such as indigenous knowledge, in conducting research on traumatic events.

Implications for the Profession and for Patient Care

The results from this grounded theory research will provide data for healthcare practitioners in developing resources and policies to enhance health system preparedness and responsiveness to disasters, improving future crisis management protocols.

Reporting Method

EQUATOR guidelines have been adhered to Consolidated criteria for reporting qualitative research COREQ.

Public Contribution

Mr Arona Smith and Mrs TeReinga.Kingi-Chase were actively involved in the design of this study, contributing their expertise in Mātauranga Māori.

Mānawa mai te mauri nuku, Mānawa mai te Mauri rangi, Ko te mauri kei au, He mauri tipua, Ka pakaru mai te pō, Tau mai te mauri, Haumi ē, hui ē, taiki ē! 1

Gather the life force of the earth, Gather the life force of the sky, The life force within us is powerful, And shatters all darkness, It settles all within me, Bind it, come together, it is done!

What Does This Paper Contribute to the Wider Global Clinical Community?

• Developing resources and practices for providing high-quality care at different system levels in a mass casualty.

• Investigating diverse approaches to delivering healthcare during crises.

• Conducting grounded theory in the wake of traumatic events.

Introduction

Nature demonstrates its unpredictability far too frequently, as was evident in 2019 when Whakaari/White Island, New Zealand’s most active cone volcano, erupted. Whakaari has genealogical links to the Māori (indigenous) people of the Mataatua region - the Eastern Bay of Plenty. Many local stories and waiata (songs) about this ancestral volcano are still told today. On December 09th, 2019, a mass casualty alert went out to staff at Whakatāne Hospital, a rural New Zealand hospital. The eruption of Whakaari significantly impacted many people in New Zealand and internationally. The lessons learned from these experiences will be passed down as korero tuku iho (stories of the past). All korero tuku iho is considered learning and a taonga (treasure). Investigating diverse approaches to delivering healthcare during crises is crucial to gathering evidence to assist with learning from such events. To our knowledge, the record of staff’s experience from their perspective following the Whakaari eruption is limited.

Carlton and Weber (2021) acknowledge that being involved in mass casualty events can significantly impact healthcare workers. In addition, healthcare is viewed as a complex adaptive system capable of sustaining and delivering services despite unexpected circumstances (Hollnagel et al., 2019). Grounded theory is a qualitative research methodology with a structured yet flexible design ideal for understanding a phenomenon where evidence is limited, and circumstances appear complex (Charmaz, 2014; Tie et al., 2019). Grounded theory interprets the studied world from the data gathered. In this context, using grounded theory, the lead researcher chose to explore the perspectives of people who worked at Whakatāne Hospital during and following this mass casualty event. This paper describes the protocol for a grounded theory study in the wake of a traumatic event.

Method

Research Design

Grounded theory (GT) is a theoretical approach and a method for collecting and analysing data. It is a design of inquiry from sociology that sets out to generate a theory from data systematically obtained and analysed using constant comparative analysis (Charmaz, 2014; Ward et al., 2015). GT is useful for exploring a social phenomenon to construct an explanatory substantive theory of process and action or interaction grounded in the views and words of participants (Charmaz, 2014). A grounded theorist interprets the studied world from the data gathered (Tie et al., 2019). Additionally, the meaning of knowledge generated in GT is acknowledged as culturally and historically situated (Ward et al., 2015). As Charmaz (2014) described, constructivist grounded theory is a structured yet flexible design ideal for understanding a phenomenon in a research area where evidence is limited. It asserts that reality is constructed by those who experience it (Birks & Mills, 2023; Charmaz, 2016a; Tie et al., 2019). Constructivist grounded theorists seek meaning in the data that goes beyond the surface, searching and questioning for tacit meanings about values, beliefs, and ideologies and coding closer to the participants’ experiences, creating an analysis more reflective of their language (Mills et al., 2006).

Through an in-depth exploration of events that allows research participants to tell their stories, grounded theorists can examine why people do what they do and learn how research participants make sense of their experiences to explain events that occurred (Charmaz, 2014). The concept of complexity and dynamics of adaptive systems, coupled with an appropriate design for information, is ever-changing, making grounded theory a suitable research method to explore this topic. Tenets of GT include purposive sampling, theoretical sampling, constant comparative analysis, memoing, and coding to theoretical saturation, described further in the data analysis (Birks & Mills, 2023; Charmaz, 2014; Tie et al., 2019).

The research team comprises an experienced clinical registered nurse (the lead researcher/ first author) and two academic researchers with expertise in clinical and research methodologies. The lead researcher is an experienced clinical nurse specialist in critical care and resuscitation nursing with a master’s degree. The second and third authors are experienced academic and clinical nurse researchers. Additionally, the second author is an expert in grounded theory research. The research team will discuss the data contemporaneously.

The lead researcher was part of the resuscitation team the evening Whakaari erupted, with the majority of participants knowing the researcher and the objective of the research. Most participants are work colleagues, making it important to acknowledge the researcher as part of the research and identify their interests and assumptions for transparency (Tong et al., 2007). Theoretical sensitivity is an essential component of grounded theory. This increases as the study progresses and can be enhanced by reflecting on professional and personal views. Acknowledging and identifying your assumptions is essential when researching using GT methodology to ensure that theoretical sensitivity informs analysis rather than personal bias. Researchers are encouraged to articulate their assumptions in a memo at the beginning of their research and continue to memo throughout the research process (Birks & Mills, 2015).

Reflexivity

Engaging in reflexivity is an essential process of grounded theory research. Throughout the study process, reflexivity increases the researcher’s awareness of their preconceptions and the implications for their research decisions (Clarke & Charmaz, 2019). Examining the researcher’s positionality is a fundamental strategy for identifying prejudices (Charmaz, 2014; Clarke & Charmaz, 2019; Mills et al., 2006). Researchers bring their philosophical, disciplinary, theoretical, and research interests into their study. These interests can enrich the research rather than limit it when subject to rigorous critique (Charmaz, 2014; Clarke, 2003). Aburn et al. (2021) found that reflexivity helped process colleagues’ difficult experiences during interviews. In this study, reflexivity will occur from memoing and discussions with co-investigators and advisors. Memo writing and diagramming align with the reflexivity principles of constructivist GT. Charmaz and Thornberg (2021) emphasise that incorporating reflexivity into the research design is crucial for maintaining analytic integrity as the theory reflects the vantage points inherent in our varied experiences. Moreover, the lead researcher was involved in this traumatic event. Throughout analysis, diagramming and memo writing, demonstrate transparency in the research process (Ward et al., 2015).

Sample and Participants

The primary research setting of the study will be Te Whatu Ora (Health New Zealand), Hauora a Toi Bay of Plenty: Whakatane Hospital, New Zealand. Secondary settings may include other locations as some staff have since moved to new places of work. Inclusion criteria include people conversant in English who worked at Whakatāne Hospital between 14:00 hrs on December 09th, 2019 – 14:00 hours on December 10th, 2019. This may include nurses and medical and allied health staff, as described in Figure 1.

Figure 1.

Approximate staff involved during the Whakaari Island eruption. Source Bay of Plenty District Health Board Service Improvment.

At the study’s outset, purposeful sampling identifies suitable participants with specific knowledge about the studied phenomena. Thereafter, the recruitment of participants is driven by theoretical sampling to develop codes and categories (Clarke & Charmaz, 2019), which drives concurrent data collection and analysis (Tie et al., 2019). Theoretical sampling determines the sources and locations from which data will be generated (Birks & Mills, 2015). As determined by theoretical sampling processes, interviews with staff may be augmented with relevant data such as newspaper articles and televised commentary. This method involves following where the data leads to expand and refine the evolving theory during the analytical process.

Following ethical and local approval, posters were used to advertise the study in public spaces of local hospitals (cafeterias, corridors, staff rooms, staff changing rooms, ambulance bases), general medical practices, and on the hospital intranet page to allow participants to self-select. Potential participants who have subsequently left the hospital will be contacted by a service improvement team member at Whakatāne Hospital via email or social media (Facebook Messenger). In addition, as the lead researcher works at the hospital, word of mouth will be used to advertise the study. Many staff members know of this research and support it, as whanaungatanga (relationship-building and connectedness) is necessary for engagement in the research (Komene et al., 2023). The relationship through shared experiences and working together is essential for those who worked at this small rural hospital during the eruption. Potential participants will be asked to contact the lead researcher via email to signal their interest in participating.

As the lead researcher is a senior nurse, power differentials in relationships with participants can be a perceived risk. There are other challenges to be aware of and acknowledge as an insider researcher. There is a risk of assumed understanding as the lead researcher was part of the team that worked during the Whakaari disaster. Discussion with supervisors and memoing will occur throughout this process for accountability. Being aware that talking about traumatic and distressing experiences may be unsettling. However, discussing the experience in a safe environment can give participants a sense of control (Aburn et al., 2021). Aburn et al. (2021) affirm that reflective practice and memoing in grounded theory are essential to minimise such challenges for the researcher through this process.

Participation in this study is voluntary, and written informed consent will be obtained at the time of enrolment. Contact details for the lead researcher will be provided on all advertising material to enable self-enrolment in the study. Information regarding support agencies will be provided on all advertising and the participant information sheet, as any form of media may trigger unpleasant emotions and feelings. Contact information for the employee-assisted programme (EAP) and psychologist will be for employed staff of the hospital and external persons. The principle of theoretical data saturation (the point at which categories and concepts are fully explicated) in GT determines the final number of participants (Charmaz, 2014). Thus, the final sample size cannot be determined in advance. However, there are expected to be approximately 15–25 participants. Potential participants will be provided with a participant information sheet describing the study’s aims and procedures via email once they have expressed interest.

Data Collection

Interviews will be held in a private room at the Māori health building at Whakatane Hospital or a location of the participant’s choosing. In addition, Zoom or telephone interviews may be appropriate for those who have moved to other regions/countries. Data will be generated through audio-recorded, individual semi-structured interviews. Interviews will be transcribed verbatim into MSWord by the lead researcher, and details such as respondent behaviours and reactions will be memoed to help assess the questions that provoked the most robust responses. Repeat interviews are possible, as theoretical sampling occurs until theoretical saturation is reached. Therefore, this could include repeat interviews until categories are clearly articulated with sharply defined and dimensional properties (Birks & Mills, 2015; Charmaz, 2014). The lead researcher will use a conversational approach and open-ended questions (Table 1). It is estimated that each interview will be approx. 60–90 minutes.

Table 1.

Interview Question Schedule.

Main questions	Potential Prompts
What was it like the day Whakaari erupted?	• Tell me about your day the morning of the eruption. How did events unfold for you? Describe your immediate reactions to hearing about the eruption
How did you respond?	• What was your response? What made you respond to the incident? How did events unfold for you?
What was it like when you got to work?	• How did things look to you? Who was around you, and what did you talk about? How was care planned, and with whom?
How did events unfold for you while you were at work?	• What stood out to you during /after the event? How did your thoughts change over the 12 hours? What do you think went well? What didn’t?
What are your main reflections from that day?	• How can we learn from this event? What did you learn from this event? What are your enduring thoughts and feelings about working that day? What would you have told me if I had interviewed you straight after the eruption? Anything different? How would you describe that day to others that weren’t involved?

Data gathered from each participant will be de-identified for the study and used in all research findings reports to maintain confidentiality. As detailed through the participant information sheet and consent process, participants may choose to receive a copy of their transcript by email or post. They will be given the opportunity to check their transcripts for accuracy and one week to email the lead researcher any changes. Publication of findings will also be shared with participants.

Demographic data will be gathered from participants of gender, ethnic group, experience in healthcare, time in the profession, length of employment at Whakatāne Hospital, and employment status (part or full-time).

Data Analysis

Data analysis in constructivist grounded theory uses an inductive coding paradigm, leading to theory generation that explains the social processes at play during the study phenomena. Codes and categories are used to construct the theory describing participants’ experiences (Charmaz, 2014). Data analysis commences with the first interview transcript, identifying essential words, phrases, and initial constructs labelled as codes (Charmaz, 2014; Ward et al., 2015). Grounded theory is not a one-directional process, as the methods interconnect and inform the directional flow, showing recurrent elements in the research process, as outlined below (Tie et al., 2019).

Coding

Grounded theory focuses on social processes, deriving inductive coding directly from collected data (Ward et al., 2015). Coding involves taking data apart and labelling what is happening in the data. Grounded theorists create descriptive codes, or labels, as they study and interact with their data.

Constructivist grounded theory coding stages are described as initial, focused, and theoretical coding (Charmaz, 2014; Clarke & Charmaz, 2019). Initial coding occurs early in the process of engaging with and defining data. Where initial coding fractures the data, focused coding transforms primary data into more abstract explanatory concepts, allowing the development of a substantive theory explaining the phenomenon being studied (Birks & Mills, 2015; Tie et al., 2019). Moreover, it integrates and synthesises the categories derived from coding and analysis to create the theory, reflecting the participants’ experiences and perspectives (Tie et al., 2019). The lead researcher will transcribe and code each interview text line by line. The analysis begins with the first transcript.

Constant Comparative Analysis

Throughout the coding process, recognising patterns within the data generates more abstract concepts and theories. Constant comparative analysis is the inductive process of comparing data with data, data with code, code with code, code with category, a category with categories, and a category with the concept until a grounded theory is fully integrated (Birks & Mills, 2015; Charmaz, 2014).

Theoretical Saturation

Describes the point at which gathering more data about a theoretical category reveals no new properties nor yields further theoretical insights about the emerging grounded theory (Birks & Mills, 2015; Charmaz, 2014). Theoretical sampling occurs until theoretical saturation is reached. Categories are clearly articulated with sharply defined and dimensional properties (Birks & Mills, 2015; Charmaz, 2014). In addition, during analysis, theoretical sampling diminishes the potential bias of the lead researcher by intentionally seeking diverse perspectives and integrating multiple data sources, such as semi-structured interviews and additional media sources (Charmaz, 2014; Charmaz & Thornberg, 2021). Constructivist GT maintains that knowledge is co-constructed through interaction between the researcher and participants. Being involved in the event, the lead researcher is uniquely positioned to understand context and nuance, potentially leading to deeper insights (Charmaz, 2014; 2016b). Drawing upon personal experience on an ongoing basis can help develop the researchers’ theoretical sensitivity to the data (Birks & Mills, 2015).

Memo writing

The lead researcher will make field notes and memos during the interview and throughout the research. Memo writing is an analytical tool considered essential in ensuring quality in grounded theory. Tie et al. (2019) Assert that memos are the storehouse of ideas generated and documented through interacting with the data. Memo writing is a crucial method in grounded theory because it prompts the analysis of data and the development of codes into categories early in the research process (Charmaz, 2014). The lead researcher commenced memoing at the beginning of the research, as this is a fundamental process of recording thoughts, feelings, analytical insights, decisions, and ideas about the research project (Birks & Mills, 2015). Memoing has taken the form of written ideas, voice recordings, and pictures, essential constructs for her psychological safety throughout the study. These are shared with her co-investigators as reflective interpretive pieces that build an audit trail to document ideas, events, and thought processes as a strategy to assure rigour (Clarke & Charmaz, 2019; Tie et al., 2019). Reflections and memos are central tenets of grounded theory and can mitigate some of the interview challenges (Aburn et al., 2021).

Consultation and feedback will occur contemporaneously with Te Pare o Toi for cultural support. Promoting collaboration, providing hosting services, and demonstrating generosity are fundamental principles supporting a cooperative research approach. This approach encourages knowledge exchange in both directions and recognises researchers as collectors or observers of data and learners. Moreover, it eases the reciprocation process by sharing research findings and concluding a project without necessarily ending a relationship (Smith, 2006). Indigenous knowledge, languages, and cultural practices are integral to the research process (Health Research Council of New Zealand, 2010).

Ethical Considerations

Grounded theory researchers make connections between points in a process and across individual, collective, and societal levels. Research conducted ethically and meticulously will ensure quality research outcomes relevant to the practice level (Charmaz, 2014; Clarke & Charmaz, 2019; Tie et al., 2019). Māori involvement in health research is critical (Health Research Council of New Zealand, 2010), as significant health status inequities exist between Māori and other New Zealand peoples. Researchers in New Zealand must consider how they can contribute to improving health outcomes for Māori as Māori are a priority population (Health Research Council of New Zealand, 2010; Hudson & Russell, 2008). The principles of the Treaty of Waitangi/Te Tiriti o Waitangi (the founding document of New Zealand), partnership, participation, and protection guide the research process.

At the beginning and completion of each interview, mihi/karakia (welcome / prayer) will be offered to each participant. A karakia (prayer) is a cultural practice of Māori (Indigenous people of Aotearoa /New Zealand). A karakia invokes spiritual guidance and protection and settles the wairua (soul). People are transported into the spiritual world, to the domain of atua tupuna (ancestor god), rongā (traditional Māori healing) and peace. In this instance, a clearing karakia to clear the pathway for the research study. One way of extending manaakitanga (the process of showing respect and care) is by providing kai (food), which symbolises the freeing of tapu (sacred spiritual restrictions). Kai will be provided at each event, and a koha (a gift, an expression of gratitude) will be given to each participant for participating in the study. A koha is a Māori custom where gifts are given as a gesture of respect, gratitude and support. A koha of a small native tree will be gifted to each participant. This reflects manaakitanga and aroha (love) and is an essential acknowledgement of the relationship formed.

Māori beliefs and how we view the world are about tikanga (derived from the Māori word tika, meaning right or correct) - a Māori concept incorporating values and practices from mātauranga Māori (Māori knowledge) and an integral part of Māori cultural principles. Tikanga serves as a moral and ethical guide, helping individuals make decisions that align with cultural values and principles (Health Research Council of New Zealand, 2010; Keelan & Porter, 2019; Pipi et al., 2004; Smith, 2006); therefore, encompassing tikanga by incorporating this into all elements of this study design is vital to enhancing the study. An aspect of tikanga is to allow participants to invite a support person to accompany them during the interview. The researcher will not ask any questions of the support person.

Data

Locality approval from Māori Health Services Bay of Plenty has been obtained. Te Mana Raraunga (Te Mana Raraunga, 2015) will be consulted for Māori data sovereignty guidance to acknowledge that Māori data is taonga. Alongside this, Te Ara Tika: guidelines for Maori Research Ethics outlines a framework for addressing Māori ethical issues. It encompasses tikanga Māori. Tikanga guidance will primarily be with Te Pare o Toi (Hauora a Toi Bay of Plenty), especially in guiding ethical issues from a local and regional perspective. Data management will be facilitated via QRS NVivo.

Ethics has been approved by the Auckland Health Research Ethics Committee (reference number 24,970), and locality approval was also obtained. Ongoing local consultation with Te Pare o Toi (Māori Health Team) at Hauora a Toi Bay of Plenty and the executive team will occur. All recordings and transcripts will be stored on secure password-protected servers on a University of Auckland research drive. Access to data will only be granted to the primary researcher, and de-identified data will be given to co-authors. All data will be destroyed after six years. Potential participants will receive an information sheet and a written consent form.

Additionally, this will be uploaded electronically to the university research drive. At the time of the interview, the lead researcher will reiterate that data will be kept confidential and offer the opportunity for questions and clarification about the study. Each participant will be de-identified for the study, which will be used to disseminate research findings. Particular care will be taken not to reveal and potentially identify details of practices or clinicians.

Reporting

This research will be reported as a PhD thesis in peer-reviewed publications and national and international presentations. Findings will also be shared with participants through presentations at Māori Health at Whakatane Hospital, and publications will be sent to each participant.

Implications for Research

“Ehara taku toa i te toa takitahi, engari he toa takitini.”

“My strength is not mine alone; it comes from the collective.”

The above whakatauki (Māori proverb) acknowledges that a person’s success is not achieved alone but with the help and support of family, friends and colleagues, reflecting Te ao Māori (Māori worldview). Knowledge lies in the multiple social constructs, is contextually bound, and produces meaningful and relevant knowledge grounded in local experiences (Wilson et al., 2021).

Results from this research will be valuable to healthcare practitioners in developing resources and practices for providing high-quality care at different system levels in a mass casualty. “Once we see the relationship between structure and behaviour, we can begin to understand how systems work” (Meadows, 2008, p. 2). The grounded theory developed from this study will be based on the experiences of selected participants of a particular sample. It is acknowledged that others may have different experiences. However, this is balanced by acknowledging that the theory is partially grounded in the data (Birks et al., 2019). For future system design, examining what went well and why from the staff perspective on the day Whakaari erupted is crucial. Understanding what went right reminds us as clinicians that we handle dynamic situations often by constantly adapting (Lyng et al., 2022; Wiig et al., 2020). Moreover, it is valuable to consider how cultural factors such as Mātauranga Māori (knowledge) play a crucial role in undertaking this research (Aburn et al., 2020; Braithwaite et al., 2017; Wilson et al., 2021).

Conclusion

This grounded theory research will facilitate an understanding of how healthcare workers responded and how the health system adapted to the eruption of Whakaari in December 2019. The study aims to capture the perspectives of those directly involved, providing valuable insights for future crisis management protocols to enhance health system preparedness and responsiveness to natural disasters. Incorporating cultural factors in this grounded theory research recognises the validity and promotion of cultural inclusivity and equity (Macfarlane & Macfarlane, 2019).