Wounded healer nurses: a qualitative content analysis of the positive traits of nurses affected by chronic cardiovascular disease

This research utilized a qualitative content analysis design. These types of studies aim to discover and understand phenomena, processes, or the perspectives, points of view, and worldviews of the people involved [15]. This study aimed to address the research gap in exploring the positive traits of nurses as wounded healers by identifying and understanding the positive traits exhibited by nurses with chronic cardiovascular illnesses who provide care to patients with similar conditions. The study adhered to the Standards for Reporting Qualitative Research (SRQR) reporting guidelines [16] (Additional file 1).

This study was conducted within hospitals in Tehran, Iran, between November 2023 and March 2024. Twenty-three participants, comprising 16 females and 7 males, with a mean age of 45.6 ± 10.9 years (range 26–62) and work experience of 20.1 ± 8.4 years (range 4–32), participated in the interviews (Table 1).

Sampling was conducted using a purposive sampling method in accordance with the study objectives and inclusion criteria [17]. The inclusion criteria for participants to be included in the study were as follows: (i) aged > 22 years; (ii) held a nurse certificate; (iii) had chronic cardiovascular disease; and (iv) accepted and adapted to the disease (we used self-reported measures of acceptance and adherence from participants, along with objective indicators of disease control). The exclusion criterion for the study was the participant’s unwillingness to complete the interview. Participant selection was conducted by trained research team members (MNF and ZAD), who distributed invitations to nurses either face-to-face or via telephone. The researchers explained the study’s purpose, precautions, and confidentiality principles to potential participants through telephone or face-to-face conversations. Participation in the study was voluntary, and all participants provided written informed consent before participation. Nurses with chronic cardiovascular diseases were selected as the specific population due to their unique perspective and first-hand experience living with chronic illness while providing care to patients with similar conditions. Additionally, the research focused on nurses afflicted with chronic cardiovascular conditions due to the elevated prevalence of cardiovascular diseases among nurses and their accessibility. This selection provides valuable insights into the positive traits that may emerge from such shared experiences. Sampling continued until data saturation was achieved. Data saturation was achieved when no new information or categories emerged from the interviews, indicating that a comprehensive exploration of the positive traits had been achieved. The saturated sample size of 23 participants in this study aligns with similar studies and descriptions [18]. After completing the interviews with the initial 20 participants, additional interviewees were recruited to ensure genuine data saturation, aiming for the highest level of comprehensiveness and quality in the study. Notably, 27 individuals were invited to participate in this study, but 4 of them declined due to personal reasons.

To develop the interview guide as recommended by Kallio et al. [19], a five-step process was followed: (i) identifying the prerequisites for using semi-structured interviews, which involved determining the suitability and relevance of this method for the research context; (ii) gathering and utilizing existing knowledge; (iii) drafting the preliminary semi-structured interview guide; (iv) conducting a pilot test of the guide; and (v) finalizing and presenting the complete semi-structured interview guide. Initially, an interview framework was created based on the research objectives and a thorough review of the relevant literature. This was followed by pre-interviews with two nurses, which, after a group discussion, led to the establishment of the final interview framework. Two researchers (MNF and ZAD) then separately conducted the trial runs with two additional nurses who were not part of the main study. These pre-interviews informed the refinement and finalization of the formal interview framework.

Data collection was conducted through semi-structured face-to-face interviews using a semi-structured topic guide (Table 2). This method allows researchers to delve deeply into conversations and responses, exploring them in depth and multidimensionally [20, 21]. The location and timing of the interviews were coordinated with the participants based on their preferences. Most of the interviews were conducted in the staff room after their shifts, and some were conducted in the hospital’s coffee shop. Initially, interviews began with general questions such as “Can you describe a typical day in your role as a nurse?” Subsequently, based on the participants’ responses, more detailed questions were asked, such as “What qualities do you believe distinguish you from other nurses after being diagnosed with your illness?” Exploratory questions such as “what” and “how” were used to gather further information. The duration of the interviews ranged from 30 to 60 min, depending on the interview circumstances. When needed, the interviewer utilized questioning, rhetorical questioning, and repetition methods to validate the participants’ answers and ensure comprehension. During the interviews, the main researcher (MNF) conducted each interview while actively observing, listening, and recording the interviewees’ expressions, voices, and intonation. Additionally, any uncertain information was clarified and verified to enhance the accuracy of the data. The interview guide comprised open-ended questions, enabling participants to fully articulate their viewpoints, perceptions, and experiences. At the onset of each interview, the participants were requested to provide their information, educational degree, and work experience. Throughout the interviews, the researcher (MNF) maintained a linguistically and nonjudgmentally neutral stance to facilitate observation and recording. All interviews were recorded using an audio recording device and transcribed by the MNF after completion of the interview.

This study used conventional inductive content analysis to explore and understand the positive traits exhibited by nurses afflicted with chronic cardiovascular illnesses while simultaneously accepting and adapting to their conditions and presently delivering care to patients with similar ailments. This approach involves systematically coding and identifying patterns in textual content without consideration of the methods of data collection. This type of data interpretation aids in achieving a deep understanding of human experiences and perceptions [22]. The unit of analysis consisted of recorded interview transcripts. MNF, ZAD, and MZ meticulously read through the interview text multiple times to immerse themselves in the data. To conduct content analysis, the steps outlined by Elo and Kyngäs were followed, including creating codes, subcategories, generic categories, and main categories [23]. All these steps were individually performed by three researchers, MNF, ZAD, and MZ, and after completing the individual analyses, a consensus meeting was held to organize the data. MAXQDA v20 software was utilized to facilitate the analysis process.

In the initial phase, researchers MNF, MZ, and ZAD meticulously reviewed the recorded data multiple times, thoroughly examined the transcribed text, and identified any transcription errors for prompt rectification. This process involved extracting pertinent content from the transcript and annotating the interviewer’s expressions in brackets based on the participants’ verbatim statements. Subsequently, meaningful units were distilled from the transcribed text by condensing and summarizing recurring words or sentences as appropriate, employing inductive analysis by MNF, ZAD, and MZ. Following the completion of open coding, MNF, ZAD, and MZ compiled a list of subcategories and generic categories. This was followed by a comprehensive review of all codes, subcategories, and generic categories by the researchers, as emerged from the transcripts. Given the differing perspectives among team members, the iterative process continued until a consensus was reached. The findings of the content analysis process are reported in Table 3 (Additional file 2).

In line with Guba and Lincoln’s [24] criteria for trustworthiness in qualitative research, this study employed various strategies to establish credibility, dependability, confirmability, and transferability. The researchers’ preunderstanding influenced the data collection and analysis, guiding the development of the research questions and data interpretation. To mitigate bias and ensure rigor, they maintained a reflexive journal, used triangulation by involving multiple researchers, and conducted member checking with participants to confirm findings.

Credibility was ensured through member checking and triangulation of the data sources. Comprehensive descriptions were provided to mitigate the risk of overlooking vital information, thus enhancing the meaningful interpretation of the data. Additionally, a member-check process was conducted, wherein participants received interview transcripts and extracted codes for comparison with the researchers’ interpretations, providing valuable feedback. Triangulation, involving independent analysis by three researchers (MNF, ZAD, and MZ), was another method used to ensure trustworthiness. Furthermore, peer checking was employed to enhance credibility, with codes and categories evaluated by ShGh, an experienced qualitative researcher [25].

To establish dependability, an audit trail was meticulously maintained, documenting all stages of the research process, from data collection to analysis and interpretation. The study methodology was comprehensively described, aiming to facilitate replication by other researchers. By maintaining detailed records and providing clear methodological descriptions, the study sought to enhance the dependability of its findings.

Confirmability was achieved by maintaining reflexivity and acknowledging the researchers’ potential biases throughout the study. This ongoing reflection ensured transparency and minimized the influence of subjective biases on the research process and findings. Additionally, transferability was addressed through the provision of rich, detailed descriptions of the research context, methods, and findings. By presenting a comprehensive understanding of the phenomenon under investigation, readers could assess the applicability of the findings to their own contexts. This approach facilitated comparison and extrapolation of the research findings to similar situations, thereby enhancing the study’s transferability and overall credibility [26]. By adhering to these principles, we aimed to enhance the trustworthiness and credibility of our research findings.

This study was conducted in accordance with the Helsinki Declaration [27]. The Research Ethics Committee of the Faculty of Nursing and Midwifery at Tehran University of Medical Sciences approved this study (ethical code: IR.TUMS.FNM.REC.1402.064). The researchers explained the study’s purpose, precautions, and confidentiality principles to the participants. All participants were informed about the study details, and informed consent was obtained from them. Participants had the option to withdraw from the study at any time they desired. Participant anonymity was ensured by removing any identifying information, such as names or specific locations, during the transcription and analysis phases. Additionally, during the preparation of this manuscript, all identifying details that could compromise anonymity were either removed or generalized to ensure confidentiality. To preserve participant privacy, interview audio files are encrypted and stored with the principal researcher, and after a specified period, the audio records are deleted. Participants were informed that their decision to participate in this research would have no effect on them. Additionally, protective measures to maintain their privacy were described to them before the beginning of the interview. Participants did not receive any financial compensation or other benefits for participating in the study. The decision to participate was voluntary, and participants were informed that their involvement would solely contribute to advancing research in the field.