what can a healthcare provider do to help a patient remain independent

Int J Qual Stud Health Well-being. 2010; v(two): 10.3402/qhw.v5i2.5146.

Patients' independence of a nurse for the administration of subcutaneous anti-TNF therapy: A phenomenographic report

Ingrid Larsson

¹Enquiry and Development Centre, Spenshult Hospital, Oskarström, Sweden

²School of Wellness Sciences, Jönköping University, Jönköping, Sweden

Stefan Bergman

¹Inquiry and Development Heart, Spenshult Infirmary, Oskarström, Sweden

Bengt Fridlund

ⁱⁱSchool of Health Sciences, Jönköping University, Jönköping, Sweden

Barbro Arvidsson

³Schoolhouse of Social and Health Sciences, Halmstad University, Halmstad, Sweden

⁴Faculty of Wellness Intendance and Nursing Sciences, Gjøvik University College, Gjøvik, Kingdom of norway

Abstract

Rheumatology nursing supports patients to manage their lives and alive as independently as possible without hurting, stiffness and functional restrictions. When conventional drugs fail to delay the evolution of the rheumatic disease, the patient may require biological treatment such as self-administered subcutaneous anti-neoplasm necrosis factor (TNF) therapy. It is therefore important that the patient perspective focuses on the life-changing situation caused past the administration of regular subcutaneous injections. The aim of this study was to describe variations in how patients with rheumatic diseases feel their independence of a nurse for assistants of subcutaneous anti-TNF therapy. The study had a descriptive, qualitative design with a phenomenographic approach and was carried out by ways of 20 interviews. 4 ways of understanding the patients' feel of their subcutaneous anti-TNF therapy and independence of a nurse emerged: the struggling patient; the learning patient; the participating patient; the contained patient. Achieving independence of a nurse for subcutaneous anti-TNF injections can exist understood by the patients in different ways. In their strive for independence, patients progress by learning about and participating in drug treatment, after which they experience that the injections make them independent.

Keywords: Independence, patient, phenomenography, rheumatology nurse, cocky-administration, subcutaneous anti-TNF therapy

The intention of rheumatology nursing is to back up patients to manage their lives and live as independently equally possible (Ryan & Oliver, 2002), as well as to master their affliction and meliorate their quality of life. The treatment of patients with inflammatory rheumatic diseases is intended to minimise joint pain and swelling in order to reduce the risk of permanent joint damage and prevent functional impairment (Bykerk & Keystone, 2005). For the terminal 10 years, biological medications, of which some are specifically formulated to block the cytokine neoplasm necrosis factor-alfa (TNF-α), such equally Remicade, Enbrel and Humira, accept been used within rheumatology. These are administered either by the patient giving him/herself a subcutaneous injection or in a polyclinic by means of an intravenous infusion (Furst et al., 2010). Patients have a preference when it comes to administration method and should be given an opportunity to participate in such decisions. Subcutaneous anti-TNF therapy allows the patient to control his/her injections without extra cost to him/her and dispensing with the need for time to visit the hospital. Self-administered subcutaneous anti-TNF injections can be hard for patients whose easily are deformed. The pre-filled syringes atomic number 82 to limited flexibility in terms of dosage and thus there is a adventure of non-adherence (Schwartzman & Morgan, 2004).

A goal of nursing care is well-informed patients who have sufficient noesis to participate in decisions well-nigh their affliction and treatment. It is of import for nurses to strengthen patients' independence, thus allowing them to take responsibility for their own wellness (Hill, 2006). In a study by Larsson, Arvidsson Southward, Bergman, and Arvidsson B (2010), patients confirmed that data about medications provided by a nurse led to autonomy, power and security. Furthermore, patients accept differing expectations of biological medications. Their feel of anti-TNF medications is that they increase physical and social functioning, reduce morning time stiffness and pain equally well as enhancing well-being and improving quality of life, especially in relation to increased physical ability that in plow leads to independence in everyday life (Davis, van der Heijde, Dougados, & Woolley, 2005; Marshall, Wilson, Lapworth, & Kay, 2004). The intravenous infusions involve regular contact with a nurse, which is conceived as secure, invigorating and leading to interest. Security includes continuity, competence and information provided past a nurse. Patients report participation in the treatment equally well as freedom in the sense that they do not have to nourish to their medication between infusions and that the time at the hospital when the infusion is administered equally invigorating equally well as an opportunity to relax and balance in a calm environs (Larsson, Bergman, Fridlund, & Arvidsson, 2009). Due to the poor consequence of this handling, merely 36% of patients yet receive intravenous anti-TNF infusions afterward 5 years (Kristensen, Saxne, Nilsson, & Geborek, 2006) and many start self-administration by means of subcutaneous injections (Keystone, 2006; Laas, Peltomaa, Kautiainen, & Leirisalo-Repo, 2008). Nevertheless, some limited worries about what is to them a new and unknown medication and virtually administering the injections themselves (Marshall et al., 2004).

When developing the rheumatology intendance of those who are treated with biological medications, patients' needs should be the about important aspect. Jacobi, Boshuizen, Rupp, Dinant, and van den Bos (2004) emphasised the importance of the patient perspective for improving and adapting the intendance to patients' needs. Hill (2007) emphasised the demand to brainwash patients and increase their knowledge of the treatment. When meeting "new" patients and assisting them to administer the therapy themselves, noesis about the qualitative variation in patient needs could serve every bit a very powerful tool for rheumatologists and rheumatology nurses. Information technology is therefore necessary to investigate how patients themselves empathise the phenomenon of independence when their life situation involves regular administration of subcutaneous anti-TNF injections. Schwartzman and Morgan (2004) argued that both the quantitative and qualitative investigations are required to study the two methods of administering anti-TNF medication. A literature review revealed no study that explored patients' conceptions of their independence of a nurse due to self-assistants of subcutaneous anti-TNF injections in the field of rheumatology. A phenomeno-graphic study contributes to such noesis, equally it produces a variation in patient conceptions. Accordingly, the aim of this report was to describe variations in how patients with rheumatic diseases conceive their independence of a nurse for the administration of subcutaneous anti-TNF therapy.

Method

Blueprint and method clarification

The written report employed a qualitative descriptive blueprint with a phenomenographic approach (Marton, 1981) in order to describe variations in conceptions of the phenomenon investigated. In guild to grasp the variation in how patients experience their independence of a nurse for the administration of subcutaneous anti-TNF injections, we need to empathise what they experience differently. Phenomenography, which was chosen as the arroyo in this report, was adult in the early 1970s in Sweden within the domain of learning. It has since spread from the educational context to that of health scientific discipline enquiry (Sjöström & Dahlgren, 2002). The intention is to identify variations in conceptions of a specific phenomenon and to describe the qualitatively different ways in which a group of people makes sense of, experiences and understands the phenomenon in the world around them (Marton, 1981; Marton & Booth, 1997). The thought of variations in conceptions is of import, because individuals volition take unlike experiences depending on their diverse relationships to the world (Marton, 1992; Wenestam, 2000). It is of import to exist aware of conceptions relating both to our social reality and to ourselves. These two factors help to explain our everyday lives and the fashion in which nosotros deal with them guide our opinion and straight our search for noesis (Barnard, McCosker, & Gerber, 1999). Phenomenography places the focus on the analysis of the how aspect with the aim of identifying qualitatively unlike conceptions that cover the major function of the variation in a population. Several ways of agreement a phenomenon can exist institute in a group of people. Descriptions of what and how an individual conceives a phenomenon are not psychological or physical in nature, but business organization the human relationship between an private and the miracle. These descriptions form descriptive categories, which are equanimous of a number of aspects of that which the participants experience in relation to the miracle (Marton & Berth, 1997).

Context

The study was based on interviews with patients conducted at a hospital in southern Sweden specialising in rheumatology diseases (Arvidsson et al., 2006). A nurse-led rheumatology unit of measurement handles parenteral biological medications for 225 patients who are prescribed subcutaneous handling and 140 patients who receive intravenous infusions. The nurses provide patients with information about both subcutaneous and intravenous medications besides as support, monitoring and administration of the regular intravenous infusions. Patients who accept opted to administrate their biological medications by means of subcutaneous injections are allocated a personal back up nurse later on 1 or two months. Self-administration takes place once in a week or every other week depending on the medication prescribed.

Participants

The participants comprised of 20 patients undergoing self-administered subcutaneous anti-TNF therapy. In accordance with the phenomenographic tradition, the participants were strategically selected to obtain variation (Marton & Booth, 1997) with regard to sexual practice (10 women, 10 men), age (17–79 years), ceremonious status (8 single, 12 married/cohabiting), educational activity (3 primary school, 12 secondary school, five third-level pedagogy), employment status (12 employed, eight on sick exit or retired), duration of disease (1–42 years), length of treatment with the medication (0.25–10 years), previous treatment with intravenous infusions (vii patients) and beingness born outside Sweden (three patients).

Data drove

Data collection took place in the first half of 2009. The main writer (IL), who works parttime as a nurse in a rheumatology dispensary contacted the nurses in the nurse-led rheumatology unit in order to place patients who met the report criteria. The patients selected for inclusion were asked whether they were willing to participate, and the nurses provided them with oral and written information about the aim of the study. When the patient had agreed to take office and signed the consent form, a time and place for the interview was decided upon in consultation with him/her. The patients were guaranteed confidentiality and informed that they could withdraw at any time without giving an explanation and without whatever consequences for their hereafter intendance.

The interview started with the master author clarifying the aim of the written report. An open interview guide with opening questions was employed as a means of ensuring that similar information were gathered from all patients (Kvale & Brinkmann, 2009). The following opening questions were used:

What does the administration of subcutaneous anti-TNF injections involve for you lot?
How practice you conceive the independence provided by the fact that you yourself can administer subcutaneous anti-TNF injections?
How do you excogitate the fact that you are not dependent on a nurse for taking your anti-TNF injections?

In lodge to encourage the patient to probe more securely into a question, he/she was asked to "tell more", or questions such as "how do you hateful?" or "what are you lot thinking of when you say…" were posed. Each interview lasted betwixt 45 and lx min, and was audio-taped. Two pilot interviews were conducted to check the questions. As no revision was necessary, these interviews were included in the assay.

Data analysis

The aim of the phenomenographic method is to identify diverse ways of agreement a miracle (in this instance patients' independence of a nurse for the administration of subcutaneous anti-TNF injections). The analysis was performed by the chief author and the fourth author (BA) acted as co-assessor. The main author transcribed the interviews as verbatim. The data analysis was performed in 7 steps (Larsson & Holmström, 2007).

Reading the whole text several times, on the first few occasions in conjunction with listening to the audio-taped interviews.
Rereading the whole text, this fourth dimension identifying and marking conceptions that corresponded to the aim of the study.
Searching for conceptions of what patients focus on and how they described their experiences of being independent of a nurse for the administration of subcutaneous anti-TNF injections. Formulating a preliminary description of each patient'due south dominant way of understanding his/her independence of a nurse for the administration of subcutaneous injections (Figure 1). This tin can be illustrated by a quotation from the patient:

Dominating (+ +) and non-dominating (+) ways of understanding how 20 patients with cocky-administered subcutaneous anti-TNF therapy experience their independence of a nurse. Figures in brackets: duration of subcutaneous anti-TNF injection (years).

Information technology's fantastic not to have to travel, because information technology takes time. Information technology takes just a few minutes to make the necessary preparations hither at home. You take out the syringe, pull it downwards and and so administrate it. And then at that place is no problem. Otherwise you lot accept to bulldoze to the hospital or the district nurse, although I don't know if they [commune nurses] do things like that, well I suppose they practise. But it's good to be spared the trouble, and injecting myself is no trouble.
Grouping the descriptions based on similarities and differences in meaning resulted in descriptive categories. These categories were compared in club to plant that each of them had a unique graphic symbol and the aforementioned level of description. Quotations were selected in order to illustrate the connection between the participants' statements and the respective descriptive category.
Searching for non-dominant ways of agreement the phenomenon, i.e., statements in which the patients described other ways of agreement the phenomenon. This was undertaken to ensure that no aspect was overlooked (Effigy 1). The following examples are from the same participant every bit above:

I had problems because we were going to Due south Africa and would be away for three weeks. And and so my big problem was what to practice with these syringes because they take to be stored in a cool place?

I phone if I recollect that I'm about to develop a cold and explicate how I feel, in order to brand sure about whether or non to take the shot. When y'all have a cold the nurses said that if the belch is greenish and so [1 should not take the injection], only it'south a scrap catchy to tell, as you are a picayune afraid of doing the wrong thing. So I take phoned on one or 2 occasions and sometimes I did not take the injections until I was fully recovered.
Creating a structure out of the resulting descriptive categories, i.east., their outcome space. Together, the descriptive categories, the outcome infinite, constitute the result of a phenomenograpic written report, which is reported in the form of text that is illustrated by ways of anonymised quotations.
Assigning a metaphor for each descriptive category.

Ethics

The study adhered to the four main requirements on research: information, consent, confidentiality and use (The Swedish Research Council, 2002). The participants were informed of their right to withdraw at any time and given the opportunity to discuss whatsoever feelings and thoughts that had arisen during the interview. The regional Ethics Committee at Lund University approved the written report (Grant No. 594/2008).

Findings

The following metaphors emerged from the four ways of agreement the patients' experiences of their subcutaneous anti-TNF therapy and independence of a nurse: the struggling patient; the learning patient; the participating patient; and the independent patient.

The numbers within brackets (No.) refer to a item patient's statement.

The struggling patient

The patients experienced a struggle also as limitations in their lives due to the self-assistants of the subcutaneous injections. They strived to achieve independence and described being restricted past the injections. They worried that the injections would go incorrect and missed the contact with a nurse. At that place was as well a wish to be lone when administering the injections, as it was considered a private affair. The injections were painful and acquired bruising, only the effect was skilful. They were grateful for this new, expensive medication. The subcutaneous injections meant a restriction in life, as they needed to be stored in a absurd place, which created bug when travelling.

Now it'south shut in between, information technology'south every week. I don't know, it's hard work actually. I have only 1 goal in life: to manage information technology myself. I don't want to get dependent on anyone. So I'm struggling on my own behalf. (No. 2)

The only problem is if you lot are going away somewhere for a longer flow of time you have to bring information technology with you. That's ever a trouble. I was abroad once and brought a syringe with me just it was hard, as it has to be kept cool and that's non always easy when you are travelling. (No. 4)

In this descriptive category, the conceptions were focused on the striving for independence. Injecting a medication into their own torso and the pain involved gave rise to worry and influenced their motivation. At that place was a willingness to administer the subcutaneous injections themselves, as the result of the medication was good, but the discomfort it caused them fabricated every injection a struggle between reason and emotion. "My encephalon wants me to practise it, but non my paw". The metaphor of the struggling patient emerged.

The learning patient

The patients experienced that self-administration of the subcutaneous injections was a learning process. Learning to administer the injections themselves increased their knowledge and competence. The patients experienced secure with this grade of treatment, and their independence of others for the assistants of their medication fabricated them grow as man beings. When they needed data, they contacted a nurse and self-administration became a habit and a routine.

Information technology's a addiction. I have done so for many years at present. (No. 7)

I do exactly as she (the nurse) showed me, wash and clean it sort of. That'south what I've been taught to practice and I don't exercise anymore than that. (No. 6)

Patients who described their independence of a nurse in the administration of subcutaneous injections in this style placed the emphasis on learning. They experienced increasingly secure in their self-assistants of the medication, as their knowledge and competence improved with the training that repeated injections gave them. Self-assistants became a routine and was carried out without reflection. "The things y'all know how to practice are easy". The metaphor of the learning patient emerged in this descriptive category.

The participating patient

Patients experienced control over their lives by administering the subcutaneous injections themselves. They took function in the treatment past self-assistants and adhering to the prescription. Their involvement provided security both in terms of the treatment and their ain decisions. They emphasised the importance of flexibility. Prescriptions and purchase of the medication required planning. In addition, correct disposal of the waste was highlighted equally function of the treatment.

It feels good to be involved and not to be left out, like when they say: "I retrieve you should do this" but instead they said: "At that place is a preparation that y'all might similar to consider, and if then, y'all tin read about it and then we can apply it". For my office I think information technology has been super, the fact that they never said: "I think you should accept this", but instead: "we have this, would you like to call up well-nigh it?" Being given the opportunity to reflect on information technology. And so you are ready when it's time. (No. 11)

That I myself am involved, contribute to and influence how I feel. That'due south the implication of taking the shots because if I don't, I feel most unwell. (No. 10)

The focus of this descriptive category was patient participation in the form of handling that provided independence. The most of import aspect of participation was the decision to get-go self-administration and the practical tasks associated with the injections. Participation was interpreted as the opportunity to influence one's life by taking control of the administration of the injections also as past complying with instructions. "I instantly took the decision that I was going to cocky-inject". The metaphor of the participating patient emerged.

The independent patient

Patients experienced that they could manage their lives and live independently by administering the subcutaneous injections themselves. They stressed that managing the handling gave them a feeling of freedom, which included independence of other people and not having to plan their lives according to appointments with a nurse. The responsibleness for i's own handling and thus ane'due south own life was highlighted. The injections were easy to have and user friendly.

You have a consummate new sense of freedom, you don't demand to plan journeys, yous do information technology when information technology suits y'all and y'all try to inject yourself on a Saturday or Dominicus … It feels good for me because I don't need to program my life according to appointments with a nurse. (No. twenty)

Information technology's a expert thing that you can accept the shot yourself and do it at dwelling house without the need to allocate actress fourth dimension to go somewhere, and you might as well do it yourself as it's so uncomplicated. (No. fifteen)

The conceptions in this descriptive category focused on the freedom provided by self-administration. Independence of a nurse was conceived as liberating. The patients' lives were not governed past the administration of medication, which they controlled themselves. This meant autonomy and independence, which is a matter of course for those who exercise non demand regular medication. "Cocky-injection makes you very contained; you are free to practice what you want and to inject yourself at your leisure". The metaphor of the contained patient emerged.

Issue space

The qualitative analysis describes the dissimilar ways in which patients experience and manage their independence of a nurse for the administration of subcutaneous anti-TNF injections. The pregnant of these unlike experiences can be identified by the researcher by the fact that they are related in certain ways, like the parts of a whole. Differences in the experiences of the phenomenon are merged together into four ways of understanding, which comprise the written report's outcome infinite. These four ways of agreement represent the variation in the phenomeno-graphic assay at a collective descriptive level and non the individual variation between patients. There were patients who moved between unlike ascendant means of understanding, while others retain the same level of understanding (Figure ane). Furthermore the meaning of the variation that emerged from the qualitative analysis is described as four different ways of understanding that are not hierarchically related, as they are more or less complex and developed (Marton & Berth, 1997). Instead, they tin can be regarded as a structure for describing variation and are illustrated equally a staircase (Figure 2). The start way of understanding reveals how patients struggle to achieve independence of the nurse. This struggle can bear on their lives to a greater or lesser caste. The second way focuses on learning, where the patients' knowledge and skills increase. The third fashion concerns participation in handling and patient involvement that contributes to independence. The 4th way of understanding focuses on the patients' independence in the self-assistants of subcutaneous anti-TNF injections. Independence means that the patients have the power to manage their lives and alive independently. The human relationship between the four different ways of understanding is illustrated in Figure ii.

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The result infinite illustrated by a staircase, representing the collective understanding of xx patients' independence of a nurse for the administration of subcutaneous anti-TNF therapy.

Word

Independence of a nurse for regular subcutaneous anti-TNF injections can be understood in unlike means. The patients are striving for independence when learning most and participating in their handling, and the experience of beingness able to administer the injections themselves leads to a sense of freedom and independence. Patients tin move between different means of understanding as they experience various ways of becoming contained in terms of their subcutaneous anti-TNF injection therapy. The way of agreement how each individual patient finds him/herself is non related to how long they take been administering the injections themselves.

The results describe patients' conceptions of their independence of a nurse for subcutaneous anti-TNF therapy. The struggling patient strives for independence of a nurse and to administrate subcutaneous anti-TNF injections him/herself. These patients want to be experts with respect to their own bodies and be respected for this. The possibility of non having to rely on other people is of import for these patients, but they accept to struggle for their independence, a finding supported by Ahlmén et al. (2005). They initially feel feet well-nigh their ability to administrate subcutaneous injections themselves, which is linked to their awareness of the high cost of the medication also revealed in the study by Sanderson, Calnan, Morris, Richard, and Hewlett (2009). Any bug that arise during the initial menses of self-assistants can exist resolved with support from the nurse. While most patients receive such support, rheumatology clinics nevertheless need to develop a follow-up of self-administration for individual patients (Brod, Rousculp, & Cameron, 2008). Patients who have regular contact with a nurse report a sense of security due to receiving support from him/her (Arvidsson et al., 2006; Larsson et al., 2009). Security evaporates when the patient becomes contained of the nurse and administers the medication him/herself. Thus, for patients, independence can also involve insecurity. The patients in our study described missing the contact with a nurse, when injecting themselves acquired them pain and they had to struggle to administer the subcutaneous injection. This struggle is more or less credible for patients during their treatment. The nature of the struggle varies, from dominating the patients' lives and restricting everyday activities, to minor limitations associated with keeping the syringes in a cool place while on holiday. The finding that the necessity to keep the medication cool restricts the patients' everyday lives is also supported by Hiley, Homer, and Clifford (2008), who concur that patients feel more contained and find information technology easier to travel when they do not have to worry well-nigh ensuring that their medications are stored in a absurd place.

The learning patient increases his/her knowledge and competence, and learns how to manage a life that involves subcutaneous anti-TNF injections. The injections become a routine and thus a office of life. The patients reported that they obtained the necessary information and knowledge, and contacted the nurse at the rheumatology clinic on their own initiative when the need arose. A competent rheumatology nurse can support the patients during their learning procedure (Sanderson et al., 2009), although accessibility is an important factor (Larsson et al., 2010). Learning becomes a process in which bones cognition is combined with actual feel, thus leading to a development in each individual patient, which Ingadottir and Halldorfsdottir (2008) as well revealed to be relevant in the example of patients suffering from diabetes who administered subcutaneous injections on a daily basis. Regular subcutaneous injections form an integral part of the overall life situation of patients who crave this blazon of therapy. Self-administered subcutaneous injections become a habit and routine for many patients and accept a relatively express subjective impact on their everyday life, which equally applies to patients suffering from HIV who likewise require injections on a daily basis (Cohen et al., 2003).

The participating patient takes part in his/her handling in terms of the practical tasks involved in the administration equally well as decisions related to the therapy. The patients wish to exist involved in their drug handling as supported by Chilton and Collett (2008). They should exist encouraged to participate fully in the handling of their condition (Hill & Reay, 2002) in accordance with Kjeken et al. (2006), who revealed that patients' power to influence medical decisions needs to be farther developed. Participation is important for patients with a rheumatic disease, as information technology contributes to security and control in their striving for a normal life (Sällfors & Hallberg, 2009). The level of participation varies and implies the need for trust, understanding and knowledge of their bodies, disease and treatment too equally providing control over the management of everyday life. Participation is characterised past respect for the individual and the fact that the patient is an agile partner in planning the care (Eldh, Ekman, & Ehnfors, 2006). There were patients who rely totally on their dr.'s knowledge and for them participation is of the greatest importance in decisions related to everyday life (Neame, Hammond, & Deighton, 2005). It is essential to encourage the patients to participate in every bit many handling decisions as possible. When patients make a witting decision, they feel a sense of command and their adherence to the treatment becomes greater, even when the issue of the medication is non immediately apparent (Ryan, 2006). Some other gene that is important for adherence to the assistants of subcutaneous medication is the patient's motivation (Brod et al., 2008).

The independent patient is capable of managing his/her life and medication. The freedom to care for him/herself and be independent of other people makes the patient'due south life easier. In society today, time is in curt supply and it is thus extremely important to exist able to cope with all aspects of life in a quick and easy mode. Ease of administration is of major importance for patients suffering from a rheumatic disease who require regular medication, which is supported by the patients in Chilton and Collett's (2008) study. Autonomy provides a sense of freedom. It is therefore vital to be independent and accept cocky-control. The demand for independence and autonomy is closely linked to the demand for back up and respect from other people, just also to responsibility and the ability to control 1'due south treatment and thus one's everyday life. The need for independence differs betwixt individuals, and therefore accessibility and sensitivity on the part of nurses are cardinal factors for the provision of support. This likewise applies to other groups of patients with chronic diseases that are treated past ways of regular subcutaneous injections, for example diabetes (Ingadottir & Halldorfsdottir, 2008). Patients who experience a positive upshot from their subcutaneous anti-TNF injections obtain double liberty, as they can care for themselves and are contained of a nurse. When the treatment leads to emptying of the symptoms of their disease and the patients experience fit, they also experience freedom from pain, stiffness and sleep problems. They become independent in everyday life and feel like a "normal" person with an increased ability to cope with the diverse difficulties in life (Marshall et al., 2004). The blueprint of the syringe makes information technology easy for the patient to administer the subcutaneous anti-TNF injections. This is in accordance with Sanderson et al. (2009), who concur that patients who administrate their anti-TNF medication past means of subcutaneous injection are worried that they might take to change to intravenous infusions and thus become dependent on a nurse. In contrast, Larsson et al., (2009) described that patients treated by means of intravenous anti-TNF infusions reported a sense of freedom, despite being dependent on a nurse. In the latter case, the liberty involved not being obliged to take responsibility and not having to retrieve nigh medication between infusion sessions (Larsson et al., 2009).

Reflection on the methodology

According to Polit and Beck (2010), the results of a qualitative study are assessed past means of four quality criteria: credibility, dependability, confirmability and transferability.

In the data collection and analysis, credibility was strengthened by the utilise of an open interview guide, which was employed to assistance the participant to reflect on the phenomenon of the independence of a nurse for the self-administration of anti-TNF injections from his/her own perspective. The main researcher asked the participant to reflect on his/her experience of the object of study and each participant was invited to explain his/her understanding in more than particular. Follow-upward questions were posed in order to avert misunderstanding and the participants were encouraged to talk openly. The interview guide guaranteed that the same opening questions were posed to all participants. The interviews were conducted in an undisturbed location chosen by the participants. The master author was familiar with the subject area area and conducted all the interviews. The fact that two pilot interviews were conducted and that no new dominant descriptive categories emerged after the 16th interview also strengthens brownie. Each conception was described by several participants, which as well increases brownie. A characteristic of phenomenography is the search for variation, and every conception that emerges is relevant and important (Marton & Berth, 1997).

Dependability was strengthened past the fact that the information assay sought to place patients' dominant and non-ascendant ways of agreement independence of a nurse in relation to subcutaneous anti-TNF injections. The primary author attempted to exist open to all variations in conceptions that corresponded to the aim. Dependability was also increased past the fact that the co-researchers were familiar with the method and that the researchers engaged in on-going discussions. The conceptions were compared and revised until the final classification was agreed on.

Confirmability of the results is considered relevant due to the way in which the data were systematically and advisedly handled: repeated readings, identification and reflection on the resulting conceptions. All steps of the analysis take been conscientiously reported and confirmability is enhanced by the fact that the interviews were both conducted and transcribed past the main writer. The conceptions are described in every bit much item equally possible and quotations strengthen and elucidate their content. The results reveal that, although the descriptive categories are positioned at the same contextual level, their meanings are conspicuously carve up. The main writer's pre-understanding can influence the results, because in her clinical work she meets patients who administer their subcutaneous anti-TNF injections themselves. An awareness of pre-understanding helped the researcher to subclass it, while the co-researchers did non possess such pre-understanding, thus the risk of influence was avoided. The researchers tried to be aware of their attitudes and exist attentive to how these might affect their own interpretations. Equally a phenomenographic researcher, information technology is important to reflect on 1's own interpretations, perspectives and values. It as well means being open to the research and seeing research as a learning procedure. In a successful phenomenographic enquiry process, the relationship between the researcher and the miracle existence explored every bit well as the researcher's understanding of it develops.

In this study, transferability was strengthened by the method and recruitment process, which were intended to provide maximum information. Phenomenography is a method with high applicability for identifying variations in human conceptions of a phenomenon. In qualitative inquiry, the meaning of applicability is that the study identifies and actually investigates that which it sets out to report. A strategic pick in line with the phenomenographic arroyo was made with the aim of obtaining maximum variation among the participants (Marton & Booth, 1997). Applicability can be deemed to be ensured due to the fact that the selection took account of several variables, such as sex activity, age, civil status, educational activity, employment status, duration of disease, length of treatment with the medication, previous handling with intravenous infusions and born outside Sweden. A limitation of the written report may be that the participants but came from 1 hospital in Sweden. It is possible that the results might take been different had participants from other hospitals taken part, as it is probable that all hospital activities are not structured in the same way. However, in order for the fabric in a phenomenographical study to be manageable, the number of participants has to be limited (Larsson & Holmström, 2007). In this written report 20 participants were relevant because the material was manageable and provided variation in conceptions. The results can be transferred to a wider group, provided that the strategic selection in this study represents the variation in the grouping and that patients at other hospitals are not in regular contact with a nurse for subcutaneous anti-TNF treatment.

Conclusion

The event of this study has provided insight into life with regular subcutaneous injections without the ongoing back up of a nurse. Independence of a nurse for the administration of subcutaneous anti-TNF injections can exist understood in unlike ways and patients can move between various dominant means of understanding. There is a struggle for independence, where patients amend their competence past learning and participating in drug handling, after which they experience that self-administration of the subcutaneous injections provides independence. This cognition can be used past the nurse in his/her piece of work to back up patients. The opportunity for regular contact with a nurse in the class of a nurse-led clinic for patients undergoing regular subcutaneous anti-TNF therapy might be one way of achieving security in terms of treatment. It would exist interesting to investigate whether or non patients undergoing regular anti-TNF therapy experience increased security and participation by replacing every second visit to a doctor with a visit to a nurse.

Acknowledgements

This study was supported by grants from The Swedish Rheumatism Association.

Disharmonize of interest and funding

The authors had no disharmonize of interest. The authors alone are responsible for the content and writing of the paper.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899748/