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

Int J Qual Stud Health Well-being. 2010; 5(2): 10.3402/qhw.v5i2.5146.

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

Ingrid Larsson

ⁱEnquiry and Evolution Centre, Spenshult Hospital, Oskarström, Sweden

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

Stefan Bergman

ⁱInquiry and Development Heart, Spenshult Hospital, Oskarström, Sweden

Bengt Fridlund

ⁱⁱSchoolhouse of Health Sciences, Jönköping University, Jönköping, Sweden

Barbro Arvidsson

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

⁴Faculty of Health Care and Nursing Sciences, Gjøvik University College, Gjøvik, Kingdom of norway

Abstruse

Rheumatology nursing supports patients to manage their lives and live as independently as possible without pain, stiffness and functional restrictions. When conventional drugs fail to delay the evolution of the rheumatic disease, the patient may crave biological handling such as self-administered subcutaneous anti-tumour necrosis gene (TNF) therapy. It is therefore important that the patient perspective focuses on the life-irresolute state of affairs acquired by the assistants of regular subcutaneous injections. The aim of this study was to describe variations in how patients with rheumatic diseases experience their independence of a nurse for administration of subcutaneous anti-TNF therapy. The study had a descriptive, qualitative design with a phenomenographic arroyo and was carried out past means of xx interviews. 4 means of understanding the patients' experience of their subcutaneous anti-TNF therapy and independence of a nurse emerged: the struggling patient; the learning patient; the participating patient; the independent patient. Achieving independence of a nurse for subcutaneous anti-TNF injections tin exist understood by the patients in different ways. In their strive for independence, patients progress past learning about and participating in drug treatment, later on which they experience that the injections brand them independent.

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

The intention of rheumatology nursing is to back up patients to manage their lives and live as independently as possible (Ryan & Oliver, 2002), too equally to master their disease and improve 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 harm and forestall functional damage (Bykerk & Keystone, 2005). For the last 10 years, biological medications, of which some are specifically formulated to cake the cytokine tumour necrosis gene-alfa (TNF-α), such as Remicade, Enbrel and Humira, have been used within rheumatology. These are administered either past the patient giving him/herself a subcutaneous injection or in a polyclinic by means of an intravenous infusion (Furst et al., 2010). Patients take 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 actress cost to him/her and dispensing with the need for time to visit the hospital. Self-administered subcutaneous anti-TNF injections tin can be difficult for patients whose hands are plain-featured. The pre-filled syringes lead to express flexibility in terms of dosage and thus there is a risk of not-adherence (Schwartzman & Morgan, 2004).

A goal of nursing intendance is well-informed patients who have sufficient knowledge to participate in decisions about their disease and treatment. It is important for nurses to strengthen patients' independence, thus allowing them to take responsibility for their own wellness (Hill, 2006). In a study by Larsson, Arvidsson S, Bergman, and Arvidsson B (2010), patients confirmed that information about medications provided by a nurse led to autonomy, ability and security. Furthermore, patients have differing expectations of biological medications. Their feel of anti-TNF medications is that they increment concrete and social functioning, reduce morning stiffness and pain likewise as enhancing well-being and improving quality of life, especially in relation to increased physical ability that in turn 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 equally secure, invigorating and leading to involvement. Security includes continuity, competence and information provided by a nurse. Patients study participation in the treatment as well as liberty in the sense that they do not have to attend to their medication between infusions and that the time at the hospital when the infusion is administered as invigorating equally well equally an opportunity to relax and rest in a calm environment (Larsson, Bergman, Fridlund, & Arvidsson, 2009). Due to the poor outcome of this handling, only 36% of patients still receive intravenous anti-TNF infusions after v years (Kristensen, Saxne, Nilsson, & Geborek, 2006) and many start self-administration by means of subcutaneous injections (Keystone, 2006; Laas, Peltomaa, Kautiainen, & Leirisalo-Repo, 2008). Nonetheless, some express worries virtually what is to them a new and unknown medication and almost 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 nearly 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. Loma (2007) emphasised the need to brainwash patients and increase their knowledge of the treatment. When meeting "new" patients and assisting them to administer the therapy themselves, knowledge nigh the qualitative variation in patient needs could serve equally a very powerful tool for rheumatologists and rheumatology nurses. It is therefore necessary to investigate how patients themselves sympathise the phenomenon of independence when their life state of affairs involves regular assistants of subcutaneous anti-TNF injections. Schwartzman and Morgan (2004) argued that both the quantitative and qualitative investigations are required to written report 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 cocky-assistants of subcutaneous anti-TNF injections in the field of rheumatology. A phenomeno-graphic study contributes to such noesis, equally information technology 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

Design and method description

The study employed a qualitative descriptive blueprint with a phenomenographic arroyo (Marton, 1981) in order to depict variations in conceptions of the phenomenon investigated. In order to grasp the variation in how patients feel their independence of a nurse for the assistants of subcutaneous anti-TNF injections, we demand to sympathize what they experience differently. Phenomenography, which was chosen equally the approach in this study, was developed in the early on 1970s in Sweden inside the domain of learning. It has since spread from the educational context to that of health scientific discipline research (Sjöström & Dahlgren, 2002). The intention is to identify variations in conceptions of a specific phenomenon and to describe the qualitatively dissimilar 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 idea of variations in conceptions is important, because individuals will have different experiences depending on their various relationships to the world (Marton, 1992; Wenestam, 2000). It is of import to exist enlightened of conceptions relating both to our social reality and to ourselves. These ii factors help to explain our everyday lives and the way in which we deal with them guide our opinion and direct our search for noesis (Barnard, McCosker, & Gerber, 1999). Phenomenography places the focus on the assay of the how attribute with the aim of identifying qualitatively dissimilar conceptions that cover the major part of the variation in a population. Several ways of understanding a phenomenon can be 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 organisation the relationship between an individual and the phenomenon. These descriptions form descriptive categories, which are composed of a number of aspects of that which the participants feel in relation to the phenomenon (Marton & Booth, 1997).

Context

The study was based on interviews with patients conducted at a infirmary in southern Sweden specialising in rheumatology diseases (Arvidsson et al., 2006). A nurse-led rheumatology unit 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 as well as back up, monitoring and administration of the regular intravenous infusions. Patients who have opted to administer their biological medications by means of subcutaneous injections are allocated a personal support nurse after 1 or ii months. Self-administration takes place one time 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 accord with the phenomenographic tradition, the participants were strategically selected to obtain variation (Marton & Booth, 1997) with regard to sex (10 women, 10 men), age (17–79 years), ceremonious condition (eight single, 12 married/cohabiting), instruction (three main school, 12 secondary school, v third-level education), employment status (12 employed, eight on sick leave or retired), elapsing of disease (1–42 years), length of treatment with the medication (0.25–ten years), previous treatment with intravenous infusions (vii patients) and being born outside Sweden (iii patients).

Data collection

Data drove took place in the first half of 2009. The main author (IL), who works parttime as a nurse in a rheumatology clinic contacted the nurses in the nurse-led rheumatology unit in order to identify patients who met the study 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 part 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 whatsoever time without giving an explanation and without whatever consequences for their hereafter care.

The interview started with the chief author clarifying the aim of the study. An open interview guide with opening questions was employed as a ways of ensuring that similar data 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 y'all?
How do you lot conceive the independence provided by the fact that y'all yourself tin administer subcutaneous anti-TNF injections?
How do you conceive the fact that you are not dependent on a nurse for taking your anti-TNF injections?

In guild to encourage the patient to probe more deeply into a question, he/she was asked to "tell more than", or questions such as "how do you mean?" or "what are y'all thinking of when you say…" were posed. Each interview lasted between 45 and 60 min, and was audio-taped. Two airplane pilot interviews were conducted to bank check the questions. Equally no revision was necessary, these interviews were included in the analysis.

Data analysis

The aim of the phenomenographic method is to identify diverse ways of understanding a miracle (in this case patients' independence of a nurse for the assistants of subcutaneous anti-TNF injections). The assay was performed by the principal author and the fourth writer (BA) acted every bit co-assessor. The main author transcribed the interviews equally 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 sound-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 beingness contained of a nurse for the administration of subcutaneous anti-TNF injections. Formulating a preliminary clarification of each patient'due south dominant mode of understanding his/her independence of a nurse for the administration of subcutaneous injections (Figure one). This can be illustrated past a quotation from the patient:

Dominating (+ +) and non-dominating (+) ways of agreement 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'southward fantastic not to have to travel, because it takes time. It takes simply a few minutes to brand the necessary preparations here at home. You take out the syringe, pull it down and then administer it. So there is no trouble. Otherwise y'all accept to bulldoze to the infirmary or the district nurse, although I don't know if they [district nurses] exercise things like that, well I suppose they exercise. But information technology's proficient to be spared the problem, and injecting myself is no problem.
Grouping the descriptions based on similarities and differences in meaning resulted in descriptive categories. These categories were compared in order to establish that each of them had a unique character and the aforementioned level of description. Quotations were selected in order to illustrate the connection between the participants' statements and the corresponding descriptive category.
Searching for non-ascendant means of understanding the phenomenon, i.e., statements in which the patients described other ways of understanding the phenomenon. This was undertaken to ensure that no aspect was overlooked (Figure ane). The following examples are from the same participant as above:

I had problems because we were going to South Africa and would be abroad for three weeks. And then my large problem was what to practise with these syringes because they have to be stored in a cool place?

I phone if I think that I'one thousand nearly to develop a common cold and explicate how I feel, in order to make certain about whether or non to take the shot. When you have a cold the nurses said that if the discharge is green so [ane should not take the injection], but it'due south a chip catchy to tell, equally y'all are a little afraid of doing the wrong matter. And so I have phoned on one or two occasions and sometimes I did not have the injections until I was fully recovered.
Creating a structure out of the resulting descriptive categories, i.eastward., their outcome space. Together, the descriptive categories, the outcome space, constitute the result of a phenomenograpic study, which is reported in the grade of text that is illustrated by means of anonymised quotations.
Assigning a metaphor for each descriptive category.

Ethics

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

Findings

The following metaphors emerged from the 4 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 contained patient.

The numbers inside brackets (No.) refer to a particular patient'due south statement.

The struggling patient

The patients experienced a struggle likewise as limitations in their lives due to the self-administration of the subcutaneous injections. They strived to achieve independence and described beingness restricted by the injections. They worried that the injections would go wrong and missed the contact with a nurse. There was as well a wish to exist alone when administering the injections, equally it was considered a individual affair. The injections were painful and caused bruising, but the effect was adept. They were grateful for this new, expensive medication. The subcutaneous injections meant a brake in life, equally they needed to be stored in a cool place, which created problems when travelling.

Now it'due south close in betwixt, it's every week. I don't know, it'southward hard work actually. I have only one goal in life: to manage information technology myself. I don't desire to go dependent on anyone. So I'one thousand struggling on my ain behalf. (No. 2)

The simply problem is if you are going abroad somewhere for a longer period of time you accept to bring information technology with you. That's always a problem. I was away once and brought a syringe with me but it was difficult, as information technology has to be kept absurd and that's not 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 rising to worry and influenced their motivation. There was a willingness to administer the subcutaneous injections themselves, as the effect of the medication was good, simply the discomfort it caused them made every injection a struggle between reason and emotion. "My brain wants me to do it, but not my hand". 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 administrate the injections themselves increased their knowledge and competence. The patients experienced secure with this grade of treatment, and their independence of others for the administration of their medication fabricated them grow as human beings. When they needed information, they contacted a nurse and self-administration became a habit and a routine.

It's a habit. I accept done so for many years at present. (No. 7)

I practice exactly as she (the nurse) showed me, launder and make clean it sort of. That's what I've been taught to exercise 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 way placed the emphasis on learning. They experienced increasingly secure in their self-administration of the medication, as their noesis and competence improved with the preparation that repeated injections gave them. Self-assistants became a routine and was carried out without reflection. "The things you know how to do are piece of cake". 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 part 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 add-on, correct disposal of the waste was highlighted as function of the treatment.

It feels good to be involved and not to be left out, similar when they say: "I think you should do this" only instead they said: "There is a grooming that y'all might like to consider, and if so, you can read about it and and so we can use it". For my part I think it has been super, the fact that they never said: "I recollect you should accept this", but instead: "we take this, would yous similar to think well-nigh it?" Existence given the opportunity to reflect on it. And so yous are set when it'south time. (No. eleven)

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

The focus of this descriptive category was patient participation in the course of treatment that provided independence. The most important attribute of participation was the decision to start self-administration and the applied tasks associated with the injections. Participation was interpreted every bit the opportunity to influence one's life by taking control of the administration of the injections equally well as by complying with instructions. "I instantly took the decision that I was going to self-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 treatment 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 responsibility for i's own handling and thus one'southward own life was highlighted. The injections were easy to take and user friendly.

You take a consummate new sense of freedom, you don't demand to plan journeys, y'all do it when it suits y'all and you try to inject yourself on a Sat or Sunday … It feels proficient for me considering I don't need to plan my life according to appointments with a nurse. (No. 20)

It'southward a skillful thing that yous can take the shot yourself and do information technology at home without the need to allocate extra time to become somewhere, and you lot might also practice information technology yourself every bit information technology's and then simple. (No. 15)

The conceptions in this descriptive category focused on the liberty provided by self-administration. Independence of a nurse was conceived as liberating. The patients' lives were not governed by the administration of medication, which they controlled themselves. This meant autonomy and independence, which is a matter of grade for those who do non need regular medication. "Cocky-injection makes y'all very independent; yous are free to do what you lot desire and to inject yourself at your leisure". The metaphor of the independent patient emerged.

Outcome space

The qualitative analysis describes the different means in which patients experience and manage their independence of a nurse for the administration of subcutaneous anti-TNF injections. The meaning of these dissimilar experiences can be identified past the researcher by the fact that they are related in certain ways, like the parts of a whole. Differences in the experiences of the miracle are merged together into 4 ways of understanding, which comprise the study'south outcome space. These four ways of understanding represent the variation in the phenomeno-graphic assay at a collective descriptive level and not the individual variation between patients. At that place were patients who moved betwixt different dominant ways of agreement, while others retain the same level of agreement (Effigy i). Furthermore the meaning of the variation that emerged from the qualitative analysis is described equally four unlike ways of agreement that are not hierarchically related, equally they are more or less circuitous and developed (Marton & Booth, 1997). Instead, they can be regarded as a structure for describing variation and are illustrated every bit a staircase (Effigy 2). The first way of agreement reveals how patients struggle to achieve independence of the nurse. This struggle tin affect their lives to a greater or lesser caste. The second way focuses on learning, where the patients' noesis and skills increment. The third fashion concerns participation in treatment and patient involvement that contributes to independence. The fourth style of understanding focuses on the patients' independence in the self-assistants of subcutaneous anti-TNF injections. Independence means that the patients have the ability to manage their lives and alive independently. The human relationship between the four different ways of understanding is illustrated in Figure 2.

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The issue space illustrated by a staircase, representing the collective agreement of xx patients' independence of a nurse for the administration of subcutaneous anti-TNF therapy.

Give-and-take

Independence of a nurse for regular subcutaneous anti-TNF injections tin can be understood in different means. The patients are striving for independence when learning about and participating in their treatment, and the experience of being able to administer the injections themselves leads to a sense of freedom and independence. Patients tin move between different ways of understanding as they experience various means of becoming contained in terms of their subcutaneous anti-TNF injection therapy. The way of understanding how each individual patient finds him/herself is not related to how long they have been administering the injections themselves.

The results depict patients' conceptions of their independence of a nurse for subcutaneous anti-TNF therapy. The struggling patient strives for independence of a nurse and to administer subcutaneous anti-TNF injections him/herself. These patients desire to be experts with respect to their own bodies and be respected for this. The possibility of not having to rely on other people is important for these patients, simply they have to struggle for their independence, a finding supported past Ahlmén et al. (2005). They initially experience feet well-nigh their ability to administer subcutaneous injections themselves, which is linked to their sensation of the high cost of the medication also revealed in the study by Sanderson, Calnan, Morris, Richard, and Hewlett (2009). Any problems that arise during the initial menses of cocky-administration can exist resolved with support from the nurse. While virtually patients receive such support, rheumatology clinics all the same need to develop a follow-up of cocky-administration for individual patients (Brod, Rousculp, & Cameron, 2008). Patients who have regular contact with a nurse study 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 independent 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 caused them hurting and they had to struggle to administer the subcutaneous injection. This struggle is more or less apparent for patients during their treatment. The nature of the struggle varies, from dominating the patients' lives and restricting everyday activities, to pocket-size limitations associated with keeping the syringes in a absurd identify while on holiday. The finding that the necessity to keep the medication cool restricts the patients' everyday lives is as well supported by Hiley, Homer, and Clifford (2008), who concur that patients feel more than independent and find it easier to travel when they do not have to worry most ensuring that their medications are stored in a absurd identify.

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 part of life. The patients reported that they obtained the necessary data and knowledge, and contacted the nurse at the rheumatology clinic on their own initiative when the demand arose. A competent rheumatology nurse can support the patients during their learning process (Sanderson et al., 2009), although accessibility is an of import factor (Larsson et al., 2010). Learning becomes a process in which bones knowledge is combined with bodily experience, thus leading to a development in each private patient, which Ingadottir and Halldorfsdottir (2008) likewise revealed to be relevant in the case of patients suffering from diabetes who administered subcutaneous injections on a daily basis. Regular subcutaneous injections course an integral function of the overall life state of affairs of patients who require this type of therapy. Self-administered subcutaneous injections go a habit and routine for many patients and have a relatively limited subjective impact on their everyday life, which as applies to patients suffering from HIV who also require injections on a daily basis (Cohen et al., 2003).

The participating patient takes part in his/her treatment in terms of the applied tasks involved in the administration likewise as decisions related to the therapy. The patients wish to be involved in their drug handling as supported by Chilton and Collett (2008). They should exist encouraged to participate fully in the treatment of their condition (Colina & Reay, 2002) in accordance with Kjeken et al. (2006), who revealed that patients' ability to influence medical decisions needs to exist farther developed. Participation is important for patients with a rheumatic disease, as it 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, affliction and treatment as well as providing control over the management of everyday life. Participation is characterised by respect for the individual and the fact that the patient is an active partner in planning the care (Eldh, Ekman, & Ehnfors, 2006). There were patients who rely totally on their doctor'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 as many treatment decisions as possible. When patients brand a conscious decision, they experience a sense of control and their adherence to the treatment becomes greater, fifty-fifty when the effect of the medication is not immediately apparent (Ryan, 2006). Some other gene that is of import for adherence to the administration of subcutaneous medication is the patient's motivation (Brod et al., 2008).

The contained 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'south life easier. In social club today, fourth dimension is in short supply and it is thus extremely important to be able to cope with all aspects of life in a quick and easy manner. Ease of administration is of major importance for patients suffering from a rheumatic disease who crave regular medication, which is supported past the patients in Chilton and Collett's (2008) written report. Autonomy provides a sense of freedom. Information technology is therefore vital to be contained and have self-control. The demand for independence and autonomy is closely linked to the need for support and respect from other people, but besides to responsibility and the ability to control one's handling and thus one's everyday life. The need for independence differs betwixt individuals, and therefore accessibility and sensitivity on the part of nurses are key factors for the provision of support. This also applies to other groups of patients with chronic diseases that are treated by ways of regular subcutaneous injections, for example diabetes (Ingadottir & Halldorfsdottir, 2008). Patients who feel a positive effect from their subcutaneous anti-TNF injections obtain double liberty, as they can care for themselves and are independent of a nurse. When the treatment leads to emptying of the symptoms of their disease and the patients experience fit, they also experience liberty from pain, stiffness and sleep bug. They get independent in everyday life and experience like a "normal" person with an increased power to cope with the various difficulties in life (Marshall et al., 2004). The design of the syringe makes information technology easy for the patient to administer the subcutaneous anti-TNF injections. This is in accord with Sanderson et al. (2009), who hold that patients who administer their anti-TNF medication by means of subcutaneous injection are worried that they might take to change to intravenous infusions and thus go dependent on a nurse. In dissimilarity, Larsson et al., (2009) described that patients treated by ways of intravenous anti-TNF infusions reported a sense of freedom, despite existence dependent on a nurse. In the latter case, the freedom involved not existence obliged to take responsibility and not having to think almost medication between infusion sessions (Larsson et al., 2009).

Reflection on the methodology

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

In the data collection and assay, credibility was strengthened past the use of an open interview guide, which was employed to assist 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 explicate his/her understanding in more detail. Follow-up questions were posed in order to avoid misunderstanding and the participants were encouraged to talk openly. The interview guide guaranteed that the aforementioned opening questions were posed to all participants. The interviews were conducted in an undisturbed location chosen past the participants. The main writer was familiar with the subject and conducted all the interviews. The fact that 2 pilot interviews were conducted and that no new ascendant descriptive categories emerged afterward the 16th interview besides strengthens credibility. Each conception was described by several participants, which also increases credibility. A characteristic of phenomenography is the search for variation, and every conception that emerges is relevant and of import (Marton & Booth, 1997).

Dependability was strengthened by the fact that the data analysis sought to identify patients' dominant and not-ascendant ways of understanding independence of a nurse in relation to subcutaneous anti-TNF injections. The main writer attempted to be open to all variations in conceptions that corresponded to the aim. Dependability was likewise increased by 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 terminal classification was agreed on.

Confirmability of the results is considered relevant due to the fashion in which the information were systematically and carefully handled: repeated readings, identification and reflection on the resulting conceptions. All steps of the analysis have been conscientiously reported and confirmability is enhanced by the fact that the interviews were both conducted and transcribed by the main author. The conceptions are described in every bit much particular 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 separate. The primary author's pre-agreement can influence the results, considering in her clinical work she meets patients who administer their subcutaneous anti-TNF injections themselves. An sensation of pre-understanding helped the researcher to bracket it, while the co-researchers did not possess such pre-agreement, thus the run a risk of influence was avoided. The researchers tried to exist enlightened of their attitudes and be attentive to how these might affect their own interpretations. Every bit a phenomenographic researcher, it is of import to reverberate on one's ain interpretations, perspectives and values. It also means existence open up to the research and seeing research as a learning process. In a successful phenomenographic research process, the relationship between the researcher and the phenomenon being explored too every bit the researcher'due south understanding of it develops.

In this study, transferability was strengthened past the method and recruitment process, which were intended to provide maximum information. Phenomenography is a method with loftier applicability for identifying variations in human conceptions of a miracle. In qualitative inquiry, the meaning of applicability is that the report identifies and actually investigates that which it sets out to written report. A strategic selection in line with the phenomenographic approach was fabricated with the aim of obtaining maximum variation amidst the participants (Marton & Berth, 1997). Applicability tin can exist deemed to exist ensured due to the fact that the selection took business relationship of several variables, such as sex, age, ceremonious status, educational activity, employment status, duration of disease, length of treatment with the medication, previous treatment with intravenous infusions and born exterior Sweden. A limitation of the report may be that the participants only came from one hospital in Sweden. It is possible that the results might have been different had participants from other hospitals taken role, as it is likely that all hospital activities are not structured in the aforementioned way. However, in order for the textile in a phenomenographical report to be manageable, the number of participants has to exist limited (Larsson & Holmström, 2007). In this study 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 result of this study has provided insight into life with regular subcutaneous injections without the ongoing support of a nurse. Independence of a nurse for the administration of subcutaneous anti-TNF injections tin be understood in different ways and patients can move betwixt diverse dominant ways of understanding. There is a struggle for independence, where patients improve their competence by learning and participating in drug treatment, afterwards which they feel that cocky-administration of the subcutaneous injections provides independence. This cognition tin exist used by the nurse in his/her work to support 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 exist one way of achieving security in terms of treatment. It would exist interesting to investigate whether or not patients undergoing regular anti-TNF therapy experience increased security and participation past replacing every second visit to a physician with a visit to a nurse.

Acknowledgements

This report was supported past grants from The Swedish Rheumatism Clan.

Disharmonize of interest and funding

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

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