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Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 19-22

A grounded theory pilot study: Exploring the perceptions of patient advocacy in a Saudi Arabian critical care context

1 Adult Critical Care Unit, King Fahad Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Faculty of Nursing and Midwifery, Mahsa University, Kuala Lumpur, Malaysia
3 Nursing Studies, University of Malaya, Kuala Lumpur, Malaysia

Date of Web Publication8-Jan-2018

Correspondence Address:
Manfred Mortell
King Fahad Hospital, KAMC, Riyadh
Saudi Arabia
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DOI: 10.4103/jhs.JHS_86_17

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Aim: The purpose of this pilot study was to determine the applicability, feasibility and practicality of a constructivist-grounded theory design to explore the perceptions of patient advocacy amongst Saudi Arabian Intensive Care Unit (ICU) nurses and to assess the effectiveness of the data collection methodology.
Background: Patient advocacy for all patients in a critical care setting is essential as a component of patient safety. However, data, information and knowledge pertaining to Saudi Arabian ICU nurses' perceptions of patient advocacy in the critical care setting are currently non-existent.
Methods: The pilot study used a constructionist-grounded theory approach with a purposive sample of five Saudi Arabian ICU nurses. The data were collected using single participant semi-structured interviews which were guided by the individual participant's responses. A reflective participant journal and a follow-up focus group interview were also employed.
Results: The findings of the study confirmed that a constructivist-grounded theory design was a feasible and logical approach to explore the perceptions of patient advocacy amongst Saudi Arabian ICU nurses. It also highlighted important implications for all Saudi Arabian nurses and their indigenous patients, which would ultimately enhance patient outcomes and safety. The pilot study also validated the efficacy of the data collection strategies, with the participants' approval that data collection transpired without prompting or forcing the data by the researcher.
Conclusions: As novice researcher, the pilot study provided a discerning introduction to grounded theory as a research methodology. It also confirmed that a grounded theory approach was apt to explore the perceptions of patient advocacy amongst Saudi Arabian ICU nurses, in addition to being an effective participant recruitment strategy and a data collection and analysis tool.

Keywords: Advocacy, critical care, grounded theory, nursing, Saudi Arabia

How to cite this article:
Mortell M, Ahmad C, Abdullah KL. A grounded theory pilot study: Exploring the perceptions of patient advocacy in a Saudi Arabian critical care context. J Health Spec 2018;6:19-22

How to cite this URL:
Mortell M, Ahmad C, Abdullah KL. A grounded theory pilot study: Exploring the perceptions of patient advocacy in a Saudi Arabian critical care context. J Health Spec [serial online] 2018 [cited 2020 Jul 7];6:19-22. Available from: http://www.thejhs.org/text.asp?2018/6/1/19/222466

  Introduction Top

It remains essential in most research methods that a pilot study be conducted before a full study aimed at finalising the approach before entering the field for data collection. Despite the fact that no references are made to the benefits of a pilot study, Glaser and Strauss,[1] did imply that a single study can reveal a conceptual category with related properties which may be verified by follow-up analyses. Therefore, this pilot study will test the data collection and analysis methodology, in addition to identifying unanticipated issues before the commencement of a primary study.

This pilot study had several objectives. The first was to determine the feasibility and practicality to explore the topic of interest, patient advocacy. The second was to establish whether the perceptions of patient advocacy amongst Saudi Arabian Intensive Care Unit (ICU) nurses were unique, in comparison to western perceptions. The third was to assess the effectiveness of the triangulation of data collection methodology, which included single and focus group interviews and a reflective journal.


The role of a patient advocate, as a moral obligation, is considered an ethical ideal for professional nurses based on the notion that nurses provide continuity of care and therefore have a greater intimacy with the patient.[2],[3] This is an ideal which is supported and endorsed by numerous international nursing codes of practice (CNA 2010 and CACCN 2012).[4],[5],[6]

The dilemma, however, for Saudi Arabian ICU nurses, is multi-dimensional, in that the concept of patient advocacy has been derived primarily from the perspective of Western cultures. Furthermore, from the Western literature which is readily accessed electronically on the internet and obtainable in all Saudi Arabian nursing universities and colleges, English language, written with Western standards, idioms, values and ethics, repeatedly dominates the nursing literature.[7] An additional factor to consider is the impact which Western nurses employed in Saudi Arabia have on Saudi Arabia nurses as role models.

Consequently, patient advocacy in an indigenous, Islamic culture such as Saudi Arabia may be comparative to their societal and religious contexts, where dimensions such as virtuousness and compassion are countered by immorality and unkindness. Such a situation would not only influence perceptions of patient advocacy but also cause the perceived perceptions by Saudi Arabian ICU nurses to be multifaceted and therefore possibly more complex.

Literature review

Previous and limited qualitative research pertaining to perceptions of patient advocacy by ICU nurses;[8] have been Western in their cultural orientation. The participants sampled for this patient pilot study were Saudi Arabian ICU nurses, of which there are currently no data available in the global nursing or healthcare literature which explore their perceptions of patient advocacy. Therefore, a grounded theory research design would be an advantageous approach to explore the concept of patient advocacy in the Saudi Arabian critical care context and how it was comprehended by Saudi Arabian ICU nurses.

  Methodology Top


A constructionist grounded theory design was selected for this pilot study to determine the feasibility to explore the perceptions of patient advocacy amongst Saudi Arabian intensive care nurses and to evaluate the efficacy of the data collection methodology. The essential elements included theoretical sampling, constant comparative technique, coding and categorising and memo writing, all of which generated data, which construct insight into the phenomenon of patient advocacy.[9]

Setting of the study

The location of this pilot study was set in an academic hospital in Riyadh in the Kingdom of Saudi Arabia. The academic hospital is a 1400-bedded teaching tertiary care centre, which has been accredited by the Joint Commission International since 2006. This hospital employs more than 3500 nursing staff. The specific location for the commencement of the study was a general adult ICU.

The patients cared for in this ICU are admitted due to illness or injury which requires nurses to provide continuous invasive hemodynamic monitoring, intravenous high-dose vasopressor and inotropic medications, high-flow oxygen therapy administration, invasive and non-invasive mechanical ventilation, continuous renal replacement therapy and occasionally venous-venous extracorporeal membrane oxygenation therapy. As the study advanced, theoretical sampling was employed, and the setting of the study did invariably change to include trauma ICU, cardiac surgical ICU, medical cardiac ICU and neurology ICU.


The participants were practising registered Saudi Arabian ICU nurses and were selected based on the following criteria: (a) being Saudi Arabian registered nurse; (b) being proficient in English; (c) being an ICU nurse working in a critical care setting and (d) being willing to participate in this study.

All five participants in the study were contacted individually and provided with a participant booklet, which included invitation letter, information sheet, informed consent form and purpose and significance of the study. Following confirmation of their interest to participate in the study, the researcher met with all five participants as they were recruited and explained their role as participants in the study in more detail.

Data collection

The data collection process consisted of digitally recorded single participant and focus group, semi-structured interviews approximately 45–60 min in duration. The rationale for their employment was to trial both the individual- and group-interviewing approaches and techniques which would be utilised in the major study.

Interview questions were generated from the grounded theory recommendations.[9] Therefore, each interview commenced with the broad open-ended question, about patient advocacy: 'What do you understand by the concept of patient advocacy?' During each interview, memos were written directly onto the participant interview sheets. According to Glaser,[10]'Memos are the theorizing write-up of ideas about codes and their relationships as they strike the researcher'. As a result, writing memos prompted the researcher to be more reflective and insightful while constantly comparing the data being collected and analysed from the Saudi Arabian ICU nurses.[1],[9],[10]

Following each interview, the participants were asked to provide feedback regarding the structure and implementation of the interview process and the questions that were created based on their responses to previous questions. Participants were also provided with a reflective journal which was a triangulation strategy for data collection.[11],[12]

Ethical considerations

Ethical approval to commence the research study was obtained from the Ethics Committee of both MASHA University, the participating organisation, and King Abdullah International Medical Research Centre. In accordance with ethical approval requirements, each participant was asked to sign informed consent form which included authorisation that allowed the use of transcripts for publication. The participants were also informed that all names and identifiable data would be changed within the transcript to ensure confidentiality and anonymity and that all data collected were confidential. They were also informed that their participation was really appreciated, but that it was purely voluntary, and that they could withdraw from the study at any time, without any explanation.

Data analysis

All interviews were transcribed verbatim, immediately after each interview, to identify themes in the participant's contextual experience which led to the creation of codes and categories. This transcription process was extremely time-consuming but also enriching as it provided the researcher with an opportunity to recall and re-experience the participant's situation. The coding process was divided into two phases; the initial phase and the subsequent focused theoretical phase.[9],[10] The initial coding phase required to analyse the 'raw' data 'line by line' after each interview, to explore all the participants' conceivable beliefs, thoughts, impressions or feelings that were being revealed. As recommended by the grounded theory academics, the initial codes were then grouped into categories as repetitive patterns, similarities and relationships emerged.[1],[9],[13]


The four criteria employed to validate rigour in this qualitative grounded theory study were: uniqueness;[9] trustworthiness also referred to as credibility,[9],[14] usefulness or transferability and fittingness and quality also known in the literature as resonance.[9]

  Results Top

Objective A

The first objective of this pilot study was to determine the feasibility and practicality to explore the topic, of patient advocacy from the perspective of Saudi Arabian ICU nurses, and to provide insight as to whether their perceptions would be unique, in comparison to Western perceptions.


The participants endorsed this research project because of the implications for all Saudi Arabian nurses, especially nursing students, interns and residents in the universities and healthcare organisations. They stated that Saudi nurses are ill-informed about patient advocacy which sustains ignorance which results in ineffectual preparation to meet the role if required. In addition to that, the research topic and the subsequent findings would promote understanding of the role in the context of Saudi Arabian nursing, which would narrow the theory-practice gap and subsequently improve patient outcomes and safety. As the data were collected and concurrently analysed, several interesting themes pertaining to patient advocacy began to emerge, utilising the constant comparison method. These themes were subsequently sorted and labelled into codes and categories. The codes that were generated were being vulnerable and at risk, or being like a family member, or a religious person, or being culturally sensitive, and being a good human being. The participants' narrations generated codes and categories and identified the core theme, being a good human being.

'Vulner-acy' which combines the terms vulnerable and advocacy emerged as a category from the participants' codes which included the patient as defenceless and the nurse being a defender, protector or standing-in as a protector or undertaking or speaking on behalf of the patient who cannot, such as the elderly or incapacitated. They believed that it was their responsibility to protect their patients from potential harm.

'Family-acy' which combines the terms family and advocacy introduced a theme of family values and ideals which participants' believed incorporated both patient-focused care and family-centred care which was important to implement the advocacy role effectively.

'Religious-acy' which combines the terms religion and advocacy specified that the participants believed that the religion of Islam influences how a Muslim is required to behave; especially with those who are less fortunate, or those who are unwell or injured, or those people who are in need, requiring comfort, support or assistance.

'Culture-acy' which combines the terms culture and advocacy spoke to the participants' awareness, sensitivity and competence of the patient's culture, which is inclusive of their indigenous language, spirituality, faith, beliefs and activities of daily living.

'Human-acy' which combines the terms humanity and advocacy incorporated all the advocacy codes and categories which identified it as a potential core category. They believed that being a human being meant that a person was perceived as good, moral and ethical, kind-hearted, compassionate and caring person, which also required, the application of family values, cultural competence and religious sensitivity to protect a vulnerable patient.

Objective B

The second objective was to assess the effectiveness of the triangulated data collection strategies, which consisted of single and focus group interviews and a reflective participant journal. The feedback that the participants provided validated that the interview methodology used in the pilot study was an effective approach to collect data for the major study. All the five participants agreed that the open-ended questioning method was appropriate because it allowed the participants' to autonomously guide, expand and elaborate on the analysis in their personal direction without prompting or forcing the data by the researcher.[1] As a data triangulation method, the participants also endorsed the value of the reflective journal which allowed them to reflect in privacy about their thoughts in relation to recollections after each interview.[11],[15]

  Discussion Top

Despite the reality, that this pilot study was a trial for the major study. It did confirm that the efficacy of a constructionist-grounded theory approach was the appropriate choice [9] to investigate the topic of interest. It also demonstrated that the data collection methodology was effective to identify themes and generate codes and categories, which provided unique data. It is also noteworthy to consider that the Saudi Arabian ICU nurse participants in this pilot study may not have a standardised perception of what patient advocacy involves, which therefore requires further exploration.

Issues identified

Overall, the pilot study did not entertain any real issues; however, it did highlight the importance of preparation, having patience and being thoughtful and caring to the participants as keys for success. Yet, it was inevitable that there were issues despite meticulous planning of meetings and effective communication with the participants. For example, events such as an epidemic of Middle Eastern Respiratory Syndrome-Corona Virus which required the ICU nurses as participants to be rescheduled for interviews because they were deployed to meet patient-care requirements.

  Conclusions Top

From a learning perspective, this pilot study has provided me with an insightful approach to interview participants in a non-threatening, accessible and productive manner. It also offered the opportunity to test the theoretical sampling methodology as a participant recruitment strategy and a data collection and analysis tool. The knowledge and understanding that were acquired during this pilot study have been invaluable and will hopefully avert problems and/or delays that may not have been anticipated. The pilot study also highlighted the importance of being adaptable, accommodating and to be prepared for the unexpected complexities that could be encountered during the research process.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine; 1967.  Back to cited text no. 1
Matthews JH. Role of professional organizations in advocating for the nursing profession. Online J Issues Nurs 2012;17:3.  Back to cited text no. 2
Selanders LC, Crane PC. The voice of Florence Nightingale on advocacy. Online J Issues Nurs 2012;17:1.  Back to cited text no. 3
California Nurses Association/National Nurses Organizing Committee. Code of Ethics for Registered Nurses; 2010. Available from: http://www.nationalnursesunited.org. [Last accessed on 2014 Sep 20].  Back to cited text no. 4
American Nurses Association. Scope and Standards of Practice. 2nd ed. Silver Spring: American Nurses Association; 2010.  Back to cited text no. 5
Canadian Association of Critical Care Nurses. Shattering the Silence: Voices of Advocacy in Critical Care Nursing; 2012. Available from: http://www.caccn.ca/en/pdfs/CACCN%20Dynamics%202013%20FINAL1.pdf. [Last accessed on 2016 Sep 20].  Back to cited text no. 6
Wujcik DM. How culturally competent are you? ONS Connect 2011;26:5.  Back to cited text no. 7
Breeding J, Turner de S. Registered nurses' lived experience of advocacy within a critical care unit: A phenomenological study. Aust Crit Care 2002;15:110-7.  Back to cited text no. 8
Charmaz K. Constructing Grounded Theory: A Practical Guide, Through Qualitative Analysis. London: Sage; 2006.  Back to cited text no. 9
Glaser BG. Theoretical Sensitivity: Advances in Methodology of Grounded Theory. Mill Valley CA, USA: Sociology Press; 1978.  Back to cited text no. 10
Bodrick MM. The Role of the Middle Eastern Liaison Nurse in the Ambulatory Care Context of a Middle Eastern Teaching Hospital: A Practice Model. Doctoral Thesis. University of the Witwatersrand, Johannesburg; 2011.  Back to cited text no. 11
McGhee G, Marland GR, Atkinson J. Grounded theory research: Literature reviewing and reflexivity. J Adv Nurs 2007;60:334-42.  Back to cited text no. 12
Corbin J, Strauss A. Basics of Qualitative Research. 3rd ed. London: Sage Publications; 2008.  Back to cited text no. 13
Leed P, Ormrod J. Practical Research: Planning and Design. 10th ed. Sydney: Pearson; 2013.  Back to cited text no. 14
Taylor BJ. Reflective Practice: A Guide for Nurses and Midwives. 2nd ed. Maidenhead: Open University; 2006.  Back to cited text no. 15


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