For this Assignment, be sure to view this week’s Qualitative Research Design PowerPoint webinar and pay close attention to its content on the basic elements of qualitative research methods (e.g., sample selection, data collection, plans for interpretive analysis). Then, review the two research studies presented in this week’s resources for this assignment.

Note: While not a required resource, you might find the definitions in the Encyclopedia of Nursing Research helpful for this assignment.

This assignment involves identifying and describing different elements of the research method used in the Walsh et al. (2015) article.

· Focus on the research design, sample selection, data collection methods, and plan for data analysis as discussed in the Walsh et al. (2015) article.

Create 2 pages to Identify at least two strengths and two weaknesses of the article’s research method based on trustworthiness. You must provide support for your explanation with citations from additional sources.

· Use the Journal Club Template for Qualitative Research located in this week’s resources.

Qualitative Health Research
2015, Vol. 25(4) 527 –539
© The Author(s) 2014
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/104973231455245

6

qhr.sagepub.com

Article

Mothers play a vital role in providing healthy food
choices for their young children. The complexity of this
role has increased over the last few decades. Mothers are
now making food choices in an environment that is con-
sidered obesogenic or obesity-producing. This environ-
ment has contributed to a rapid increase in the number of
Canadian children becoming overweight and obese
(Canadian Population Health Initiative [CPHI], 2004),
constituting a critical public health issue in Canada.

Since the late 1970s the prevalence of childhood over-
weight and obesity in Canada has risen (Shields, 2006).
Using the 2004 age-/sex-specific body mass index (BMI)
classification cut-offs established by the International
Obesity Task Force (IOTF), 26% of Canadian children
and youth are overweight or obese (Statistics Canada,
2004). This prevalence rate increases when using the more
recent 2007 World Health Organization (WHO) age-/sex-
specific BMI classification cut-offs for children and ado-
lescents (de Onis et al., 2007). The WHO growth charts
estimate that 31.5% of Canadian children aged 5 to 17
years are overweight or obese (Statistics Canada, 2012).

Compared with their normal-weight peers, overweight
and obese children suffer disproportionately from a num-
ber of chronic conditions such as type 2 diabetes, heart
disease, bone and joint problems, and sleep apnea
(Lobstein, Baur & Uauy, 2004; Public Health Agency of
Canada [PHAC], 2011). These children report poorer
health-related quality of life, intense stigmatization,
lower self-esteem, and increased loneliness as their

ability to move freely, play sports, and engage with peers
is affected (Institute of Medicine [IOM], 2004; Lobstein
et al., 2004). In addition, obesity-related health problems
place a tremendous strain on present and long-term
Canadian health care costs (Kuhle et al., 2011; PHAC,
2011). Kuhle et al. found that obese children living in
Nova Scotia had significantly higher health care costs,
more physician visits, and more specialist referrals than
their normal-weight peers.

Feeding one’s family is work taken on primarily by
mothers. Its gendered nature is well noted in the literature
(Attree, 2005; Spitzer, 2005; Travers, 1996). On a daily
basis, mothers generally make their young children’s food
choices (Lindsay, Sussner, Kim, & Gortmaker, 2006;
Statistics Canada, 2010a). Although seemingly simple,
because much of the work involved is not visible to others
(DeVault, 1991), making food choices is a complex social
practice determined by many factors and their interactions
(Delormier, Frohlich, & Potvin, 2009; Furst, Connors,
Bisogni, Sobal, & Falk, 1996). Contextual factors such as
social, economic, political, and environmental conditions
can limit one’s agency and consequent capacity to make

552456QHRXXX10.1177/1049732314552456Qualitative Health ResearchWalsh et al.
research-article2014

1Cape Breton University, Sydney, Nova Scotia, Canad

a

2Dalhousie University, Halifax, Nova Scotia, Canada

Corresponding Author:
Audrey Walsh, Cape Breton University, 1250 Grand Lake Rd.,
Sydney, Nova Scotia, Canada B1P 6L2.
Email: audrey_walsh@cbu.ca

Persistent Optimizing: How Mothers
Make Food Choices for Their Preschool
Children

Audrey Walsh1, Donna Meagher-Stewart2, and Marilyn Macdonald2

Abstract
Mothers’ ability to provide healthy food choices for their children has become more complex in our current obesogenic
environment. We conducted a total of 35 interviews with 18 mothers of preschool children. Using constructivist
grounded theory methods, we developed a substantive theory of how mothers make food choices for their
preschoolers. Our substantive theory, persistent optimizing, consists of three main integrated conceptual categories:
(a) acknowledging contextual constraints, (b) stretching boundaries, and (c) strategic positioning. Implications to
improve mothers’ ability to make healthy food choices that reduce their children’s risk of becoming overweight or
obese are discussed.

Keywords
children; grounded theory; health promotion; mothers; mothering; obesity / overweight

mailto:audrey_walsh@cbu.ca

http://crossmark.crossref.org/dialog/?doi=10.1177%2F1049732314552456&domain=pdf&date_stamp=2014-09-25

528 Qualitative Health Research 25(4)

healthy choices. Therefore, it is important to examine the
role that personal and environmental circumstances play
when exploring how mothers make food choices for their
children.

In this article, we report on a research project in which
we explored the individual, interpersonal, and socioenvi-
ronmental factors and conditions that constrained moth-
ers’ ability to make preferred food choices for their
preschool-aged children, and the strategies that mothers
used to push back against these constraints. We present a
theoretical understanding of the process in which mothers
engaged while making food choices for their preschool-
aged children. This research was carried out by the first
author as part of her PhD work and was guided by her
supervisors, who are the coauthors.

Contextual Factors Influencing
Mothers’ Food Choices

A complex and interacting set of social, economic, cul-
tural, technological, and environmental factors and con-
ditions contributes to the problem of childhood overweight
and obesity (Eriksen, Lyn, & Moore, 2010; PHAC, 2011).
Combined, many of these factors and conditions create an
environment that is obesogenic. An obesogenic or obe-
sity-producing environment was defined by Swinburn,
Egger, and Raza (1999) as “the sum of influences that the
surroundings, opportunities or conditions of life have on
promoting obesity in individuals or populations” (p. 564).
This obesity-producing environment is the backdrop
against which mothers are expected to make food choices
that promote and protect their children’s health.

The literature contains descriptions of the many fac-
tors at different levels of influence that affect mothers’
ability to make healthy food choices for their children.
On an individual level, a child’s food preferences might
pose a barrier. Mothers are frequently challenged to pro-
mote nutritious food choices because children’s prefer-
ences are often for energy-dense foods and drinks that are
high in sugar (Dwyer, Needham, Simpson, & Heeney,
2008; Holsten, Deatrick, Kumanyika, Pinto-Martin, &
Compher, 2012).

A mother’s income, race, and education play a signifi-
cant role. In Canada, single mothers with children and
individuals living on social assistance are among the
groups that experience the highest rates of food insecurity
(Health Canada, 2006; McIntyre & Rondeau, 2009).
Aboriginal women experience greater levels of poverty
and therefore endure higher levels of food insecurity than
non-Aboriginals (Health Canada; Power, 2008). Single-
parent households, low-income households, and those
with two working parents more often report having less
time to prepare nutritious meals made from whole foods.
They consequently rely on convenience foods that are

less costly, quicker, and easier to prepare, but higher in fat
and sodium (Broughton, Janssen, Hertzman, Innis, &
Frankish, 2006; Raine, 2005). Homes of parents with
higher levels of education tend to purchase healthy food
on a more frequent basis (Cribb, Jones, Rogers, Ness, &
Emmett, 2011; Ricciuto, Tarasuk & Yatchew, 2006).

At the interpersonal level, the mother–child relation-
ship is an important factor in determining the foods that
mothers select for their children. Although most studies
indicate that mothers’ food choices are motivated mainly
by their concern for their children’s health, many of these
studies highlight inconsistencies between motivation and
behavior as mothers engage in practices such as offering
unhealthy foods to motivate their children’s eating behav-
iors (Slater, Sevenhuysen, Edginton, & O’Neil, 2012;
Tucker, Irwin, He, Bouck, & Pollett, 2006). Brewis and
Gartin (2006) found that although parents wanted their
children to eat low-sugar, low-fat foods, many children
were consuming calorie-dense foods even when directly
supervised by parents. In addition, children often vetoed
their mother’s healthier food choices for foods that were
lower in nutritional value and higher in calories, fat, and
salt (Colapinto, Fitzgerald, Taper, & Veugelers, 2007;
Slater et al., 2012).

On a community level, features of the physical envi-
ronment influence mothers’ food choices. Families that
live in rural or deprived communities in North America
often have less access to large supermarkets that provide
variety and lower-priced healthy foods. Williams (2009)
reported that the average monthly cost of a basic nutri-
tious diet in rural Nova Scotia was greater compared to
those in urban areas. In addition, rural and less-affluent
communities are less conducive to maintaining a healthy
weight (Oliver & Hayes, 2005) because they often lack
resources such as safe and attractive trails, parks, and rec-
reational facilities for indoor sports and activities
(Dehghan, Akhtar-Danesh, & Merchant, 2005).

Finally, societal and political factors influence moth-
ers’ food choices. Invasive marketing practices and cam-
paigns strongly sway the decisions made by the uncritical
consumer (Nestle, 2006; Winson, 2004). According to
Winson, the foods most heavily promoted, marketed, and
prominently placed in grocery stores were those that
yielded the greatest margin of profit. In particular, these
products included “pseudo foods,” or foods that were
highly processed and high in sugar and/or fat and calo-
ries, and low in nutrients. The types of foods that were
made available, marketed, and advertised influenced
individuals’ preferences, purchases, and children’s
requests (Gantz Schwartz, Angelini, & Rideout, 2007;
Hastings et al., 2003; Taylor, Evers, & McKenna, 2005;
Winson).

This overview of the literature provides valuable insight
into the constraining factors from different levels of

Walsh et al. 529

influence that challenge mothers in their attempts to make
healthy food choices for their children. Notably absent in
the literature were findings on the process mothers use to
make their food choices in the face of all these factors. This
gap in the research was the focus of our study.

Methods

We used a constructivist grounded theory methodology
(Charmaz, 2002, 2006) to better understand the actions,
interactions, or the process in which mothers engage
when making food choices for their preschool-aged chil-
dren. According to Charmaz (2005), a constructivist
grounded theory demands going deeper into the phenom-
enon itself and its situated location in the world. In con-
structivist grounded theory, the researcher creates the
data and ensuing analysis with the participants and reality
arises from the interactive process and its temporal, cul-
tural, and structural contexts (Charmaz, 2002, 2006).

Constructivist grounded theorists enter the field with a
set of guideposts or sensitizing concepts based on extant
literature or past experiences (Blumer, 1969; Charmaz,
2006). Consistent with the literature and our public health
nursing backgrounds and beliefs, we used sensitizing
concepts from the multifactoral socioen-vironmental
health promotion (SEHP) perspective (Cohen, 2012;
Labonte, 1993). Our knowledge of the SEHP perspective
sensitized us to be alert to multiple-level factors and
underlying conditions that perpetuate differences between
people and limit their ability to make healthy choices
(Charmaz, 2006; Labonte). It is important to stress that
sensitizing concepts were used to assist us in asking ques-
tions and approaching the data with greater consideration
of the background issues. Sensitizing concepts were not
used to force a preconceived framework onto the data.

Recruitment and Sampling

Mothers with children between the ages of 3 and 5 were
invited to take part in this study. Study participants were
recruited from a variety of settings that provided services
to preschool-aged children in a large municipality in east-
ern Canada. Upon receiving required research ethics
board approval, mothers were recruited from settings that
included public health services, family place resource
centers, and early childhood centers.

Participants included 18 mothers with children
between the ages of 3 and 5, who did not have any dietary
restrictions and represented a range of economic, educa-
tional, cultural, and geographical backgrounds. Mothers
ranged in age from 23 to 48 years, with an average age of
30 years. All mothers except one with twins had one pre-
schooler at home. Eleven mothers were married or living
in common-law marriages. Fourteen had a high school

education or higher, 12 were unemployed, 10 had incomes
below the Statistics Canada Low Income Cut-Off (LICO)
rate (Statistics Canada, 2010b), and 8 had incomes above
the LICO rate. Fourteen mothers resided in a city or town
and 4 resided in a rural setting. Sixteen mothers were
White, and 2 were Mi’kmaq (First Nations people indig-
enous to Canada).

In keeping with Morse’s (2007) recommendation to
begin with a demographically homogeneous sample, we
started with a sample of participants whose estimated
before-tax yearly family income was below Statistics
Canada’s LICO rate (Statistics Canada, 2010b). To add
dimension to our emerging theory, once we heard the
same central concerns from these mothers we expanded
our sample to include mothers whose incomes were
above the LICO rate.

Data Collection

The primary source of data collection was an initial face-
to-face, semistructured interview followed by a second
telephone or face-to-face interview. In addition, over the
16- month period of data collection, mothers brought to
our attention issues such as child-focused product place-
ment in grocery stores and increased pricing for products
with cartoon or celebrity figures on the package. To
obtain a clearer picture of the settings and situations
described by mothers in their interviews, we made obser-
vations in local grocery stores and restaurants. These
observations allowed us to create additional question
probes to add to our interviews. All field notes were con-
sidered data and were analyzed using grounded theory
methods.

All interviews followed a semistructured approach to
allow each participant greater control over the inquiry
process. Initial questions were broad and open-ended; as
we interacted with the data and as categories were cocon-
structed, we adjusted the range of topics to gather more
specific data to develop our theoretical framework. For
example, each time a mother introduced a new topic or
idea such as money, time, interpersonal conflict, or
unique strategies, we added this insight to future inter-
views to see if it was common for other mothers. Data
analysis began with the first interview.

Typed transcripts of the initial interviews were pre-
pared and mailed to participants to read and verify.
Following receipt of the transcript, we conducted a fol-
low-up recorded interview with 17 of the 18 original par-
ticipants. In the follow-up interviews, mothers were
invited to discuss and provide further examples of find-
ings that could be used to modify and saturate categories.
Data collected during follow-up interviews were used to
supplement those gathered from the initial narrative
accounts.

530 Qualitative Health Research 25(4)

The question of how mothers make food choices for
their children was a clear and obvious one. The mothers
who participated in this study were willing to share their
stories and provide extensive and detailed data. For this
study, 35 interviews with 18 participants was a sufficient
number to build robust theoretical categories and thus
reach saturation.

Data Analysis

Consistent with grounded theory methodology, data col-
lection, coding, and analysis occurred concurrently
(Glaser & Strauss, 1967). We used QSR International’s
(2008) NVivo 8 qualitative software to sort and code
data. We followed the two main grounded theory coding
phases described by Charmaz (2002, 2006) that consist of
an initial phase and a focused, selective phase. Theoretical
coding followed the selective phase.

In the initial or open coding phase, we read each tran-
script and asked questions of the data to identify pieces of
data such as words, lines, or incidents to determine their
analytical significance. In the second or focused selective
coding phase, we took the most significant or frequently
appearing initial codes to use in sorting and synthesizing
larger segments of data. We used focused coding to
develop categories, and like codes were subsumed into
categories. For example, a number of initial codes per-
tained to a variety of strategies that some mothers used to
better afford healthier foods; these were grouped together
as a focused code, economizing. Other codes referred to
strategies that mothers used to gain more time and to be
better prepared to make healthier food choices; these
were grouped together under enhancing time and effort.
Both of these focused codes were subsumed under the
category, managing resources.

Theoretical coding, as described by Charmaz (2006),
is a sophisticated level of coding that suggests relation-
ships between the categories developed during the selec-
tive phase of analysis. It is a process of coding that yields
the conceptual relationship between categories and their
properties (Glaser, 1978). For example, the managing
resources category referred to a previously described set
of strategies that mothers used to counteract contextual
constraints. Two other categories, namely advancing
healthy food choices and minimizing societal deterrents,
also described different strategies that mothers used to
moderate constraints. Three of these categories were sub-
sumed under the major conceptual category, stretching
boundaries. Coding was accompanied by writing and
sorting memos, which assisted us in exposing the connec-
tions between categories, better defining subcategories,
and recognizing the core category. The core category that
captured our overall understanding of how mothers were
making food choices for their children was identified

during this phase of research and was named persistent
optimizing.

Findings

The central problem affecting mothers in this study was
facing numerous interpersonal, social, economic, and
environmental factors that constrained their ability to
make healthy food choices for their preschool-aged chil-
dren. To overcome this problem and to reach their goal of
providing preferred food choices to their children on a
more consistent basis, mothers used a multidimensional
process called persistent optimizing. Optimizing, as used
in this study, refers to mothers’ persistent efforts at nego-
tiating the abovementioned factors to more consistently
make the best food choices for their children in each food
choice situation. Persistent optimizing consists of three
main integrated, conceptual categories constructed from
the data: acknowledging contextual constraints, stretch-
ing boundaries, and strategic positioning. The central
process of persistent optimizing is depicted in Figure 1.

Overview of Persistent Optimizing

As reflected in Figure 1, the persistent optimizing graphic
representation depicts a spiral that denotes the persistent
forward motion of mothers in making their preferred food
choices for their children. Mothers entered the spiral with
the intention of making food choices that promoted their
children’s health. To reach this goal they moved through
the three main conceptual categories: (a) acknowledging
contextual constraints, (b) stretching boundaries, and (c)
strategic positioning. The categories, although depicted
separately, were interactive and interrelated.

Persistent optimizing was not an orderly, sequential
process; rather, it describes a somewhat messy, complex
process of how mothers dealt with a variety of competing
constraints to make healthy food choices for their chil-
dren. Mothers’ success in each conceptual category
helped propel them toward making the best possible food
choice in a given situation. The spiral represents the
building of mothers’ awareness, knowledge, successful
strategizing, and subsequent agency to procure preferred
food choices on a more consistent basis.

Acknowledging Contextual Constraints

Mothers set out to make food choices consistent with their
feeding goals for their children. All mothers expressed
that their overall intention was to provide their children
with healthy food choices. They acknowledged various
competing contextual constraints at multiple levels of
influence that hindered their ability to make their intended
food choices. Acknowledged constraints were subsumed

Walsh et al. 53

1

under three subcategories: (a) relational conflicts: discern-
ing food values of self and significant others; (b) restrained
resources: recognizing individual and structural realities
that constrain choice; and (c) societal deterrents: discover-
ing the unaccommodating food environment.

Relational conflicts: Discerning food values of self and signifi-
cant others. In making food choices for their preschool-
ers, mothers acknowledged relational conflicts with their
child, their partner, extended family, or friends. One pro-
fessionally employed mother described trying to make

I

Compromising

Invisible Balancing

Reflecting Critically

Advancing Healthy Food Choices

Managing Resources

Minimizing

Societal Deterrents

Relational Conflicts

Restrained Resources

Societal Deterrents

Mothers’ best food choice at that time

Mothers’ intention to provide food choices
that promote health

1

Increasing dissonance

6

cctttttsssssttttt

111111111111111

a

STRATEGIC
POSITIONING

ACKNOWLEDGING
CONTEXTUAL
CONSTRAINTS

STRETCHING BOUNDARIES

Increasing reactivity

Increasing reflectivity

Figure 1. Persistent optimizing graphic representation.

532 Qualitative Health Research 25(4)

healthy food choices as a battle. She struggled with main-
taining control over her children’s food choices when
they were around other children:

It’s hard, too, when there are other kids [children] around,
because if they have it, and typically, like I said, we’re not
terrible. If they’re having a treat, then I will let them have it,
but if another one comes out and another one. But it’s so
hard, because the other kids are eating it, and I’m saying,
“No, you’ve had enough.”

When asked what it would take to make the food
choices that she would like to make, she replied, “If
everyone would listen and the kids would eat healthy.”
Another mother, whose child visited her grandparents
regularly, highlighted the challenges of dealing with well-
meaning extended family members whose views on giv-
ing junk foods were different from hers:

She [mother-in-law] is a huge influence on their life, and she
kind of takes over. She hadn’t seen them in a week, so she
wanted to pick them up the other night, and when she came
home, she didn’t just have a treat of a chocolate bar for them,
she had bought them six bars. I was like, “They don’t need
that,” but she’s so influencing that way.

Restrained resources: Recognizing individual and structural
realities that constrain choice. Mothers in this study
acknowledged restrained resources such as money, time,
and cooking ability. Those who lived below the Statistics
Canada LICO rate (Statistics Canada, 2010b) frequently
described not having enough money to make preferred
food choices for their children. One mother was not able
to afford on a regular basis the salads her son enjoyed.
She said, “To buy a salad that’s not cheap, and it’s one
meal, and it’s like seven dollars [Canadian] for one meal,
and it’s only a side of a meal, so it doesn’t happen very
often.”

Lack of time to prepare healthy meals was another
constraint that mothers acknowledged. For almost all
mothers, life did not allow time to cook nutritious meals
every day. This was true both for working mothers and
for mothers who stayed at home caring for their young
children. For example, a mother with an income below
the LICO rate noted,

Lengthy meals are very, very hard. Like last week I made
cabbage rolls and it took hours and hours before I even got
them in the oven. Like something that would have taken me
normally an hour probably took me four, just because of
having to take care of the baby at the same time.

Food marketing practices directed toward children: Discourag-
ing health. Mothers acknowledged societal deterrents in
the form of counterproductive food-marketing practices.

Mothers were challenged to provide healthy food choices
for their children because of the way foods were dis-
played in the grocery stores. All mothers described gro-
cery stores as being designed to encourage children to ask
for less-healthy, often more expensive foods. Such foods
were displayed at children’s eye level and with cartoon
figures that their children recognized from TV advertise-
ments. Pestering was a serious issue that all mothers
encountered while they were shopping with their chil-
dren. Similar to other mothers, one mother noted how her
child always noticed the big bin of chocolate bars that
was located next to the checkout counter. She com-
mented, “So she sees it no matter what, because when
you go to the checkout, there’s the big bin. And then she
just starts asking for them. Every time; it never fails.”

The multiple competing, interpersonal, and socioenvi-
ronmental factors or conditions that mothers recognized
as contextual constraints heightened their feelings of dis-
sonance and motivated them to devise strategies to reach
their goal of choosing healthier foods for their children.
Mothers who wanted to severely restrict their children’s
access to unhealthy foods experienced more dissonance
than mothers who allowed their children to eat varying
amounts of such foods. Mothers with more restrictive
feeding goals described their feeding work as “a battle,”
“a lot of work.” Mothers moved from acknowledging
contextual constraints to the other categories of stretching
boundaries and strategic positioning. Here they enacted a
variety of moderating and optimizing strategies to negoti-
ate the constraints that deterred them from providing pre-
ferred food choices for their children.

Stretching Boundaries

Stretching boundaries was characterized by increasing
levels of reaction or reactivity. Many of the healthier food
choices preferred by mothers appeared at first glance to
be out of bounds. Mothers were bounded or constrained
by many factors, such as their children’s food prefer-
ences, money, or the time they had to shop or prepare
meals. Reacting to the dissonance they experienced in
acknowledging contextual constraints, mothers con-
structed and employed a series of moderating strategies
to stretch the boundaries of their capacity to make healthy
food choices for their children. These strategies were sub-
sumed under the subcategories of (a) advancing healthy
food choices; (b) managing resources: mothers’ income,
time, ability, and effort; and (c) minimizing societal
deterrents.

Advancing healthy food choices. According to most moth-
ers in this study, their children’s food preferences often
tended toward less-healthy foods. As a strategy to get
their children to make different choices, mothers stretched

Walsh et al. 533

the boundaries of the number of food options from which
their children could choose. In these ways, children’s
exposure to less-healthy foods was limited. Mothers cre-
atively prepared healthy foods, created diversions that
encouraged their children to eat healthier foods, regulated
food rewards and treats, and found ways to reconcile con-
flicting food values of family and friends. All mothers
described using tricks such as hiding vegetables or meat
in mashed potatoes. One mother who lived below the
LICO rate commented, “I’ll take all of her food, and I’ll
mix it up into one if I’m having potatoes, because she just
thinks she’s eating potatoes, and she doesn’t know the
meat is in there.”

Mothers attempted to limit the number of treats or
reward foods filled with empty calories. A strategy used
was to hide these foods and eat them after their children
went to bed. One mother reported that she and her hus-
band often bought and then hid snacks such as chips and
soda pop. She commented, “We will hide our chips so
that he doesn’t see it. Or the pop, we will hide it where he
can’t see it. And then when he’s asleep, that’s when we’ll
have our snack.”

Sometimes a mother’s desire to give her child nutri-
tious foods was thwarted by her partner, the child’s grand-
parents, or by her friends. This was a cause of dissension
for the mother when others wanted to give the child
unhealthy foods more often than she felt was appropriate.
Mothers strategized to find ways to reconcile these differ-
ences. A mother spoke about her partner’s tendency to be
more lenient in offering unhealthy snacks to their child,
and noted, “I have to speak to him sometimes because we
have to be on the same ground [regarding giving junk
food to child]: ‘We can’t give in. If I put my foot down,
don’t let her [child] run to you.’” Some mothers limited
their time spent with family members or friends who
offered too many unhealthy food choices. Another mother
countered this problem by sending healthy food when her
child went to visit her grandparents:

So it is kind of a bit of a treat day if she does go. But I do
offer suggestions to my mother. And sometimes I will send
out some of her favorite foods with her and tell her, “This is
for you and Nanny to share.” It kind of gives them an
opportunity then to have what I want them to have, and have
it be a treat like fresh strawberries, fresh peaches, or some
fresh grapes.

Mothers enacted many strategies for dealing with family
and friends and were placed in the difficult position of
maintaining family harmony while also attempting to
promote their children’s health.

Managing resources: Mothers’ income, time, ability, and
effort. The amount of money and time mothers had

available greatly affected the food choices they were able
to make for their children. All mothers worked to secure
healthier choices whenever possible. Mothers with a lim-
ited income searched for discounts on healthier food
items. This took a great deal of effort because unhealthy
foods were on sale more frequently. Mothers with a
higher income had greater selection because they could
afford more. Generally, all mothers struggled with a lack
of time to prepare preferred meals.

To manage their resources, mothers economized to
stretch their food dollars and tried to maximize their time
and energy when feeding their children. Mothers found,
collected, and used coupons to save money on preferred
purchases. As illustrated by one mother, some were more
adept at finding and using coupons: “Oh, I live on cou-
pons. I get them off the computer—save.ca and through
fliers.” Characteristically, mothers who lived below the
LICO rate planned ahead and exercised patience; for
instance, one waited a month to buy the oil she needed to
make a carrot cake after being given extra carrots at the
food bank the month before. In addition, mothers exer-
cised ingenuity by substituting less-expensive items for
more-expensive ones. One mother stated,

Yeah, sometimes the ingredients are just too expensive.
Sometimes I try to substitute it with cheaper. Like most
recipes, you can substitute with a cheaper no-name version.
No-name is my friend. There are certain things that I won’t
eat no-name because they don’t taste as good.

Mothers with an income below the LICO rate had to
work harder to acquire and prepare sufficient nutritious
foods to feed their children. In addition, all mothers strat-
egized to save time in preparing healthy meals. Mothers
described planning ahead, such as preparing meals the
night before or making extra on weekends to use during the
week. Some mothers were able to share the workload with
their partner. Mothers’ efforts at moderating time con-
straints helped to stretch the boundaries or increase their
capacity to make healthy food choices for their children.

Minimizing societal deterrents. Mothers used strategies to
counteract persuasive food-marketing practices. Some
mothers prevented their children from making unhealthy
food requests by avoiding the junk food aisles in grocery
stores. Notably, navigating away from the junk food
aisles did not stop children’s requests for child-oriented
food items dispersed throughout the store. One mother
stated, “I try to avoid the junk food aisle. If they go down
that aisle, I try to trick them, saying, ‘Oh, look at this.
This is nicer.’” A few mothers avoided conflict with their
children by using a tactic we describe as stealth. When a
child asked for an item that the mother did not want to
buy, she put it in the cart, and when the child was not

534 Qualitative Health Research 25(4)

watching, she removed the item. A mother who lived
below the LICO rate noted,

Mother (M): Pick, pick, and then sometimes, I’ll hide it.
Interviewer (I): What do you mean by hiding it? Do you

mean when you get home?
M: No, when I’m not going to buy it, I’ll put it back on the

shelf when they’re not looking.…I don’t have to hear her
yelling, no temper tantrums.

To avoid a public confrontation with their preschool-
aged child, some mothers simply gave in and let the child
have the item or left the store without finishing their
shopping. Mothers tended to view the grocery store as a
potential battlefield, and they created multiple strategies
to keep the peace.

Overall, the strategies that mothers employed to mod-
erate contextual constraints helped to stretch the boundar-
ies of the food options available to them, thus enhancing
their agency in making preferred choices. Once mothers
exhausted their use of moderating strategies they were
left with making their food choices from the options
available to them.

Strategic Positioning

With strategic positioning, mothers demonstrated increas-
ing levels of reflection. They reflected on the success of
the moderating strategies they had used and employed
optimizing strategies to position them closer to making
the best food choice in a given situation. Optimizing
strategies included: (a) compromising, (b) invisible bal-
ancing, and (c) reflecting critically.

Compromising. Mothers generally had to make compro-
mises among the food options available. They attempted
to take action consistent with their personal standards and
make choices that enhanced their satisfaction with the
food they offered their children. Mothers had to consider
their children’s needs and wants; their own income, time,
and energy; and keeping peace in the family. Mothers
with an income below the LICO rate were often forced to
compromise between a more-expensive, healthier food
and a less-expensive, less-healthy choice. To illustrate,
one mother remarked,

It’s really hard for me to shop healthy because of the cost. If
you do the comparisons, if you get just white plain bread to
whole wheat bread, whole wheat bread would be more. I
would rather buy white bread.

Time scarcity also compelled mothers to compromise;
in the end, making sure their child had food was the prior-
ity. One mother offered unhealthy foods on occasion
because of the convenience: “They certainly get more

junk than I would like them to get, and that’s from me as
well—sometimes, like I said, because of convenience and
whatnot.” In other situations, mothers felt compelled to
compromise their child’s nutrition for a brief period to
keep peace with a family member. To counteract compro-
mised food choices that were inconsistent with their feed-
ing goals, mothers immediately started preparing for
future food choices that would balance out their child’s
health over a period of time. There was fluidity around
choice making. Many choices over a period of time con-
tributed to a mother’s goal of getting her child to eat
healthy foods on a more consistent basis.

Invisible balancing. In invisible balancing, mothers stayed
alert and prepared so that if an optimal food choice or
situation presented itself they would be able to take
advantage of it. Mothers used resources wisely to find
ways of acquiring and presenting healthier food options
to their preschoolers. They looked at the big picture to
ensure that, over a particular period of time, the healthier
foods their children consumed outweighed the less-
healthy ones. A mother remarked,

I would say over a couple of days, simply because some days
she simply doesn’t eat a whole lot, and other days she’ll eat
everything. So I’m more concerned with over a few days. If
she doesn’t eat her entire lunch one or two days, but I know
she’s having a good supper that night, then I’m okay with that.

Mothers were vigilant and always thinking forward to the
next choice in an effort to balance the healthfulness of
their children’s food choices.

Reflecting critically. Finally, by reflecting critically, a few
mothers in this study were able to examine their situation
through a broader, more critical lens. These mothers
inquired and reflected more critically on the power rela-
tionships and underlying social structures that affected
their ability to make their preferred food choices. Taking
a futuristic view, these mothers planned for their chil-
dren’s future health; they wanted to teach them healthy
eating habits that would endure. One mother stated, “If
you teach them early to eat the better stuff, make sure
they get their fruit and stuff, they are more likely to keep
that when they get older, instead of going to the junk all
the time.” Possessing a higher level of literacy or income
than did their parents, some mothers attempted to recreate
themselves, making different food choices than the ones
they were given as children. A mother commented,

My mother didn’t know, and she still doesn’t know. She
thinks that she is doing the kids a favor by giving them Froot
Loops [a sugary breakfast cereal], and it’s hard to convince
her that it’s not. She feels that they would be deprived if they
lived in a world without Froot Loops or bologna.

Walsh et al. 535

Other mothers recognized their need to learn more
about feeding issues so that they could provide age-
appropriate, healthy foods for their children on a more
consistent basis. One mother who was a teenager when
she had her first child stated that at that time she knew
very little about feeding her infant and managing money.
She considered herself fortunate that she was able to take
advantage of the services offered by the local family
resource center. She stated,

Family Resource.…They’re my lifeline. They taught me a
lot. I was nineteen when I had my son, and I didn’t really
know too much. So I take as many courses there as I can, and
they answer all my questions for me and help me be the best
parent I can be.…They also helped with meal planning and
stuff. I took a couple of courses that helped me with that.

Another mother was critical of the financial structures
that restrained her food choices. She pointed out the dis-
parity between health messages that recommended what
her children should eat and constraints such as grocery
store pricing and social assistance allowances that kept
her from buying these foods. She questioned why the
healthy options were the most difficult to afford: “They
got to price it up so much because they know you got to
buy it. Just like with milk. Like they know that you need
it. But they price it right up. You still got to buy it.”

This overview of persistent optimizing shows how a
mothers’ ability to make food choices in any situation
was conditioned by the identified constraints and her
agency to counteract these constraints. Mothers were not
always successful at making their preferred food choices,
but they persisted, choice by choice, day by day, and even
week by week to increase their ability to make such
choices. Mothers’ agency was influenced by their life cir-
cumstances; the amount of money, time, and energy they
possessed at any one moment was prone to change, as
were the contextual constraints mothers encountered.

In this regard, no one set of strategies was exclusively
successful; mothers generally had to revise and refine old
strategies and develop new ones. They also often had to
use strategies in layers; for example, following moderat-
ing strategies with compromising strategies, and follow-
ing compromising strategies with strategies to balance
their children’s health. By employing these strategies to
overcome contextual constraints, mothers developed new
knowledge and skills that enhanced their ability to make
preferred food choices.

Discussion

The substantive theory, persistent optimizing, integrates
the voices, values, and perspectives of 18 mothers of pre-
school-aged children. It represents the process of how

mothers responded to a variety of constraining factors
and conditions from multiple levels of influence and
enhanced their ability to make healthier food choices for
their children. Most studies exploring the food-choice
decision process concentrate on how adults make food
choices for themselves (Connors, Bisogni, Sobal, &
Devine, 2001; Falk, Bisogni, & Sobal, 1996; Furst et al.,
1996; Sobal, Bisogni, Devine, & Jastran, 2006); they do
not account for the complexities involved in making food
choices for others and the intricacies of the mother–child
feeding relationship.

Studies that have explored how mothers make food
choices for their children generally focus on a specific
influencing factor and the strategies mothers use to
respond to this factor. Some of these factors include
parental feeding styles and cultural influences (Clark,
Goyer, Bissell, Blank, & Peters, 2007; Patrick, Nicklas,
Hughes, & Morales, 2005; Ventura, Gromis, & Lohse,
2010), income (Attree, 2005; McIntyre & Rondeau,
2009; Raine, 2005), time (Bava, Jaeger, & Park, 2008;
Jabs et al., 2007; Wethington & Johnson-Askew, 2009),
education (Cribb et al., 2011; Ricciuto et al., 2006), and
food marketing practices (Hastings et al., 2003; Winson,
2004).

Persistent optimizing shares some similarities with
Gillespie and Gillespie’s (2007) conceptual framework
that identified four stages in the family food decision-
making process. Unlike persistent optimizing, in Gillespie
and Gillespie’s decision-making framework, mothers
were not singled out but were part of the family in the
food decision-making process. Families in their study
consisted of any configuration of people who regularly
ate together, shared household food resources, and who
mutually influenced decisions about food. The particular
makeup of each family studied was not described, and
preschool-aged children were not mentioned. Persistent
optimizing, by focusing on mothers and preschool-aged
children, extends and enhances Gillespie and Gillespie’s
framework.

Persistent optimizing lends support for Giddens’
(1984) structuration theory, wherein capacity is under-
stood as being limited by structural constraints that come
about through the agency–structure interplay. In this
study, the capacity of mothers to recognize and respond
to socioenvironmental constraints in food choice situa-
tions was significantly influenced by the resources avail-
able to them. Delormier et al. (2009) borrowed notions
from Giddens’ structuration theory to develop a concep-
tual framework that explores eating as a social practice.
Focusing on family feeding practices, these authors noted
that the conditions under which food choices are made
are structured by “rules and resources” (Giddens) that
limit an individual’s range of options. Persistent optimiz-
ing, as an explanation of how mothers make food choices,

536 Qualitative Health Research 25(4)

supports Delormier et al.’s (2009) structuration analysis
of family feeding practices, because mothers’ agency to
make preferred food choices for their children was influ-
enced by contextual factors and conditions that could be
subsumed under Giddens’ rules and resources.

Persistent optimizing is original because it considers
factors from all levels of influence and the interaction
between these factors to explain how mothers make food
choices for their preschool-aged children. In this study,
mothers’ food choices were constrained by multiple com-
peting interpersonal and structural constraints. Furst et al.
(1996) contended that people’s perceptions of what is
available to them demarcate their boundaries in food
choice situations. In this study, mothers developed and
enacted a variety of moderating strategies to stretch the
boundaries of the food choices that were available to
them at first glance. They worked to increase their agency
to make preferred choices.

Many of the moderating strategies in persistent opti-
mizing are supported by the literature. Freeman, Ekins,
and Oliver (2007), Noble, Stead, Jones, McDermott, and
McVie (2007), and Tucker et al. (2006) described a vari-
ety of strategies that mothers use to enhance the quality
and quantity of their children’s food choices. Bevan and
Reilly (2011), Brewis and Gartin (2006), Noble et al., and
Slater et al. (2012) described mothers accommodating the
food preferences or needs of other family members over
their own, and trying to keep peace within the family.
Notably, the need to maintain peace with extended family
and friends, which mothers in this study encountered,
was not strongly identified in most studies that were
reviewed. This finding extends and adds nuance to the
literature in this area.

Strategies to manage resources, such as stretching a
meager income (Attree, 2005; Devault, 1991; Travers,
1996) and maximizing time (Bava et al., 2008; Bevan &
Reilly, 2011; Jabs et al., 2007; Wethington & Johnson-
Askew, 2009), were also noted. In addition, mothers in
this study created strategies to deal with their children’s
demands for less-healthy, often more-costly foods that
were designed to attract and tempt children. Pestering,
according to McDermott, O’Sullivan, Stead, and Hastings
(2006), directly influences mothers to buy foods that are
less healthy and that increase children’s risk of becoming
overweight.

Notably, the findings of the present study extend some
results found in the literature, add depth and understand-
ing to others, and add nuance to what is already known.
Many of the strategies that mothers used in this study
were previously described in the literature. Persistent
optimizing adds an original way of looking at these strat-
egies, to view them as moderating strategies that help to
lessen the impact of negative forces on mothers’ capacity
to make healthy food choices.

Mothers used these strategies to stretch the boundaries
of the food choices available to them, enhancing their
agency by placing them in a stronger position to make
preferred food choices for their children. Their success
with using moderating strategies provided them with
their range of choices. For example, the mother who took
time on the weekend to prepare and freeze meals was bet-
ter positioned to offer a healthy meal during the week
when evening schedules did not permit this option,
Mothers living below the LICO rate who closely moni-
tored their food supplies, shopped for bargains, used cou-
pons, and stocked up on sale items had more money to
make preferred food choices than mothers who did not
use these strategies. Without these daily moderating strat-
egies, a mother’s agency to make choices was more
limited.

In strategic positioning, mothers were more reflective,
enacting a variety of optimizing strategies to make the
best choice from among the range of existing options.
Consistent with other findings, mothers used a variety of
compromising strategies (Bava et al., 2008; Connors et
al., 2001; Furst et al., 1996; Slater et al., 2012; Sobal et
al., 2006; Sobal & Bisogni, 2009). Mothers followed
compromised food-choice situations with strategies that
allowed them to balance their children’s health over a
period of time. Balancing as a strategy used to resolve
food-choice value conflicts is noted in the literature
(Connors et al., 2001; Falk et al., 1996; Furst et al.;
Gillespie & Gillespie, 2007).

All mothers in this study acknowledged the contextual
factors and conditions that limited their ability to make
preferred, healthier food choices for their children. A few
mothers were able to go beyond these constraints to view
more critically some of the invisible forces that created
and sustained these barriers. These mothers described the
food environment as one designed more toward making a
profit than promoting health. Mothers enacted strategies
to assist their preschool-aged children in developing good
food habits at an early age, so that they would be better
able to resist a food environment that promotes unhealthy,
obesogenic food choices in the future.

Persistent optimizing highlights the relentless reflec-
tive work that mothers engaged in on a daily basis to
increase their ability to make preferred food choices for
their children. A strength of persistent optimizing is that it
makes visible the dynamic process of mothers’ feeding
work, including the many dimensions and strategies that
are frequently invisible. It highlights the repertoire of
strategies that mothers employed to push back against the
contextual conditions and factors that constrained their
ability to make preferred, healthy food choices.

In conclusion, persistent optimizing captures and
organizes the many aspects of mothers’ food-choice prac-
tices that must be in place for them to be successful. It

Walsh et al. 537

emphasizes that much work is needed to increase the
opportunities for mothers to make preferred food choices
for their children on a more consistent basis. Helping
mothers to make healthy food choices that minimize their
children’s risk of becoming overweight or obese will
require collective action from multiple levels of influ-
ence, including policy-level changes that address the
socioenvironmental determinants of health to supporting
individuals and families to make healthier food choices
on a more consistent basis.

Further studies in this area are needed to emphasize
repeatedly that contextual constraints must be altered to
create the socioenvironmental conditions that allow all
mothers to make preferred, healthier food choices for
their children. In this way, the burden that mothers face
will be diminished, children’s risk of becoming over-
weight or obese will be reduced, and opportunities for
children to grow into healthy adults will be improved.

Authors’ Note

Portions of this article were presented at the 3rd International
Public Health Nursing Conference, August 27, 2013, in
Galway, Ireland, and at the 19th Annual Qualitative Health
Research Conference, October 29, 2013, in Halifax, Nova
Scotia, Canada.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding

The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Support was received through a Nova Scotia Health Research
Foundation Doctoral Student Research Award.

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Author Biographies

Audrey Walsh, PhD, RN, is an associate professor at the Cape
Breton University Department of Nursing in Sydney, Nova
Scotia, Canada.

Donna Meagher-Stewart, PhD, RN, is a retired associate pro-
fessor, Dalhousie University School of Nursing, Halifax, Nova
Scotia, Canada.

Marilyn Macdonald, PhD, RN, is the associate director of
graduate studies and an associate professor at Dalhousie
University School of Nursing, Halifax, Nova Scotia, Canada.

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http://www.feednovascotia.ca/images/ns_food_costing_2009

http://www.feednovascotia.ca/images/ns_food_costing_2009

Global Qualitative Nursing Research
1 –11
© The Author(s) 2015
DOI: 10.1177/2333393615582036
gqn.sagepub.com

Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 3.0 License
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permission provided the original work is attributed as specified on the SAGE and Open Access page (http://www.uk.sagepub.com/aboutus/openaccess.htm).

Article

Patient or client-centered care (CCC) has been widely
accepted as an essential component of health care delivery in
many countries. Thousands of articles have been published
on the subject in the last decade. Similar to any developing
subject, there are many names (e.g., person-, patient-, client-,
family-centered care) and even more new definitions and
conceptualizations of this idea (Abdelhadi & Drach-Zahavy,
2012; Bamm & Rosenbaum, 2008; Bechtel & Ness, 2010;
Bertakis & Azari, 2011). Although they might differ slightly
in how the concepts are operationalized, essentially all
describe care

. . . that establishes a partnership among practitioners, patients,
and their families (when appropriate) to ensure that decisions
respect patients’ wants, needs, and preferences and that patients
have the education and support they need to make decisions and
participate in their own care. (National Research Council, 2001,
p. 41)

The preferences of patients and caregivers in different health
care settings have also been explored. Consistently, the most
important characteristics of CCC are described as information
provision, good communication, accessibility, continuity, coor-
dination, empowerment, and emotional support (Bechtel &

Ness, 2010; Dancet et al., 2012). Several studies have also
looked at the roles that clients would like to assume in the inter-
action with health care providers (HCPs), and interestingly the
results differed across settings and countries. On one hand,
people living with a chronic condition or caring for a person
with a chronic condition were interested in developing partner-
ships with HCPs by participating in decision making about
their care (Bechtel & Ness, 2010). Similarly, clients of infertil-
ity care clinics across Europe were interested in active partici-
pation (Dancet et al., 2012). On the other hand, Aro, Pietilä,
and Vehviläinen-Julkunen (2012) reported that involvement in
decision making and involvement of family and friends were
less important for patients of Estonian intensive care units (Aro
et al., 2012). Given these variations, different models of client/
patient-centered care have been developed and empirically
tested in different settings and disciplines (Abley, 2012;
Rathert, Williams, McCaughey, & Ishqaidef, 2015).

582036GQNXXX10.1177/2333393615582036Global Qualitative Nursing ResearchBamm et al.
research-article2015

1McMaster University, Hamilton, Ontario, Canada

Corresponding Author:
Elena L. Bamm, School of Rehabilitation Science, McMaster University,
1400 Main Street West, IAHS 402, Hamilton, Ontario, Canada L8S 1C7.
Email: bamme@mcmaster.ca

Exploring Client-Centered Care
Experiences in In-Patient Rehabilitation
Settings

Elena L. Bamm1, Peter Rosenbaum1, Seanne Wilkins1,
Paul Stratford1, and Nadilein Mahlberg1

Abstract
Patient or client-centered care has been widely accepted as an essential component of health care delivery in many countries.
Few studies explore actual implementation of client-centered principles and clients’ and health care providers’ (HCPs)
experiences with these approaches. Our objective was to explore current models of delivery of rehabilitation services from
the perspectives of patients, families, and HCPs. We conducted semistructured interviews with patients, families, and HCPs
of one of four rehabilitation facilities in South-Central Ontario, Canada. Being on common grounds/Working toward client set
goals was the main category identified by both clients and HCPs. Although successful partnerships were created, the majority
of clients assumed a passive position. Clients needed more information about the rehabilitation progression and alternative
treatment options. The results of the study suggest that we need to encourage and educate clients to become motivated,
well-informed, proactive participants in their care.

Keywords
client-centered care; quality of care; relationships, patient-provider; stroke, partnerships

Received December 10, 2014; revised February 24, 2015; accepted March 24, 2015

mailto:bamme@mcmaster.ca

http://crossmark.crossref.org/dialog/?doi=10.1177%2F2333393615582036&domain=pdf&date_stamp=2015-04-15

2 Global Qualitative Nursing Research

Few studies explore actual implementation of client-cen-
tered principles and HCPs’ experiences with these approaches
(Bright, Boland, Rutherford, Kayes, & McPherson, 2012;
Nieuwenhuijsen, 2009). In Canada, patient care or CCC is
inherent to the health care system, being one of the main foci
of every hospital and health care center’s mission statement
(Government of Saskatchewan, 2008; Ontario Medical
Association, 2010). Because the idea has been around for
some time, it is a good time to stop and reflect on what is
working and what still requires further attention.

The objective of this study was to explore current models
of delivery of rehabilitation services from the perspectives of
both patients and families (collectively the “client”) and
health care professionals (HCPs). To develop a conceptual-
ization of client-centered principles in stroke rehabilitation,
we explored the following broad questions:

•• How do patients, families, and HCPs see their role in
the interaction? Are clients interested in assuming an
active role?

•• How do clients perceive family involvement in
rehabilitation?

•• What are clients’ priorities for communication with
HCPs, and for information?

•• What are some challenges (e.g., respecting wishes,
taking preferences into account) when there are more
than two parties involved, and what are the ways to
deal with them?

•• Do HCPs feel supported and encouraged by their
superiors and colleagues when practicing client/fam-
ily-centered care, and in what ways (available
resources, incentives, education, etc.)?

•• What pros and cons do they perceive from practicing
CCC?

In our work we have defined our concept as client-cen-
tered care, where client stands for the patients and family
(when the latter are involved). The broad topics for the pres-
ent study were guided by the client and family-centered
framework developed by the CanChild Centre for Childhood
Disability Research (2003). The core concepts of the frame-
work are Enabling and Partnership, Providing General
Information, Providing Specific Information, Coordinated
and Comprehensive Care, and Respectful and Supportive
Care. The applicability of the framework for adult health
care has been previously supported (Bamm & Rosenbaum,
2008; Dancet et al., 2012; Schoot, Proot, ter Meulen, & de
Witte, 2005). The distinctiveness of this study involved
interviewing both clients (patients and families) and HCPs of
the in-patient rehabilitation units in which people were
recovering after a stroke. This allowed for the input of all
stakeholders to be considered when developing an under-
standing of processes of care as experienced from all sides of
the relationship.

Method

We conducted a grounded theory study that involved semis-
tructured interviews over a 10-month period in 2011. We
invited all patients and families receiving care for at least 2
weeks in one of four rehabilitation facilities in South-Central
Ontario, Canada, to participate. Participants were excluded if
they did not speak English or were diagnosed with severe
cognitive impairment as assessed by the Montreal Cognitive
Assessment (MoCA ≥ 19) or the Mini-Mental State
Examination (MMSE ≥ 21; outcome measures routinely
used by stroke centers). In cases where no cognitive score
was available, the decision of eligibility was left to the judg-
ment of the clinical staff working with the patients.

Potential participants were identified and the study intro-
duced by a health practitioner (nurse or social worker) from
the patient’s direct circle of care. The participants were
selected based on the previously completed survey, the
Measure of Processes of Care for Adults (MPOC-A), a mea-
sure of client-centeredness of care adapted for adult health
care settings (results reported elsewhere). To represent varied
perspectives, interviewees were selected based on their varied
perceptions of client-centeredness as assessed by MPOC-A,
ensuring variation across participants (the perspectives of
people who rated the services as highly client-centered might
differ substantially from those whose needs are not being met
by their service providers). In addition, as the interviews pro-
gressed, we looked for clients of different ages and both gen-
ders, and clinicians from different disciplines (theoretical
sampling; Strauss & Corbin, 1998). A research assistant con-
tacted consenting participants to collect demographic and
contact information. The interviews took place in a venue
comfortable for participants. All but one were conducted by
the first author in participants’ homes (the exception was con-
ducted at the public library) approximately 2 to 3 months after
discharge. The interviews lasted 30 to 60 minutes.

All HCPs who have been practicing in one of the four
rehabilitation units for at least 3 months (to ensure familiar-
ity with the unit culture) were invited to participate. Lunch-
and-learn sessions were presented at each site to inform the
clinicians about the study and invite participation, following
which information packages were left in the units. Interviews
were conducted at the hospitals. Similar to clients, the selec-
tion of the HCPs for interviews was done based on their
responses to the Measure of Processes of Care for Service
Providers working with Adults (MPOC-SP(A)), a compan-
ion measure of client-centeredness of care for clinicians.

Analysis and Rigor

To explore processes of client–health care professional inter-
action in the rehabilitation settings, the Grounded Theory
approach developed by Strauss and Corbin (1998) was
adopted. This approach was particularly suitable to answer

Bamm et al. 3

the questions presented by this study for several reasons.
First, the phenomenon under study is the process: The desired
outcome of the study is developing a clear understanding of
personal, organizational, and contextual factors and the
interaction among them. Second, little is known about the
current state of client-centeredness in rehabilitation from
either the clients’ or clinicians’ perspectives. The systematic
examination of the topic and creation of the model will allow
better understanding of the supports and barriers to imple-
mentation of client-centered principles in adult rehabilitation
(Strauss & Corbin, 1998).

To help organize and analyze the data, the qualitative data
analysis computer software package NVivo, Version 9, was
used (QSR International Pty Ltd., 2011). The interviews
were transcribed and two researchers (E.L.B. and N.M.) car-
ried out initial analysis independently. We started the analy-
sis with line-by-line reading of the transcripts and breaking
the data into codes (open coding). We then compared our
findings. Disagreements were resolved through extensive
discussions. Then the many open codes were collapsed into
categories and subcategories to begin the process of refining
our data. The properties and dimensions of the categories
were further developed with every new interview, helping to
relate the major categories to the subcategories (axial cod-
ing). Constant comparison of the properties and dimensions
of the emerging categories along with multiple viewpoints
presented by patients, families, and HCPs helped us to main-
tain objectivity during analysis. The analytic thoughts and
discoveries were recorded in the theoretic memos that also
helped with further development of each category. Diagrams
helped to ensure clear relationships between and among the
categories and identify categories that were poorly defined.
When all categories were well defined and no new concepts
or dimensions were emerging, no further interviews were
undertaken. Finally, the central categories were integrated to
create the representation of the process or the model (selec-
tive coding; Strauss & Corbin, 1998).

In addition to following grounded theory methods noted
above, rigor was also ensured through a decision trail to track
changes in codes and categories over the course of the proj-
ect. Also ongoing discussions with the supervisory commit-
tee offered peer review opportunities. Reflexivity through
journaling was used to highlight team and professional pre-
conceptions and their impact on the process of analysis. The
results of selective coding were presented to the participants
and their feedback was invited.

Ethical considerations. The protocol of the study was approved
by McMaster University’s Research Ethics Board and all
participating sites’ ethics committees.

Results

Eight patients and four family members from four rehabilita-
tion units were interviewed. Patients ranged in age from 19 to

86, five were women, three of four family members were
spouses (two women, one man), and one was the mother of the
youngest participant. Fifteen HCPs from four hospitals partici-
pated in the interviews. Several disciplines were represented:
Five physiotherapists, four occupational therapists, three social
workers, two nurses, and one physician were interviewed.

We focused our interviews on experiences related to the
intake to rehabilitation and actual rehabilitation. Five major
categories were extracted and are discussed below. The cat-
egories are supported by anonymized quotes from interviews
with patients (P), family members (F), and HCPs.

Category I: Working Toward Goals Set by the
Client/Being on Common Ground

This main category is in fact a combination of several
threads. Participants described the importance of working
toward client set goals (goals set jointly by the client and the
therapists). We defined compliance as a patient’s and fami-
ly’s acceptance of treatment without them being interested in
voicing an opinion (i.e., passive attitude). We also were inter-
ested in exploring whether the clients felt on equal ground
with the hospital staff in making decisions—position of
power; and how they interacted with the staff during therapy
or any situation when confused or angry. Did they make
themselves heard—speaking up?

Working toward client set goal. Clients and clinicians having
similar goals and understandings of the outcomes have been
mentioned as important aspects of health care professional/
client interaction at the beginning of all interviews. Building
a good rapport and working together on a goal not only
improves the day-to-day experiences of both clinicians and
clients but also advances clients’ outcomes: “We can’t get
them motivated to participate in therapy unless we are work-
ing on something that they want” (HCP).

We talked about what my goals were and we worked towards
them . . . It was very much a joint—I don’t know what the point
is if the other person is not going to do what you ask them to do.
If you’re not going to do the exercises. They always explained
why they were doing stuff, which was important for me, and for
me to be successful I had to agree to what they wanted me to do
and why they wanted me to do it. (P)

Clinicians would like to work in partnerships with both
the patients and families where there is mutual respect, trust,
honesty, and ongoing communication. Partnerships in care
also resulted in better organized and efficient care, decreas-
ing the load and the stress on the staff. Some commented on
CCC being time-consuming but described it as time well
spent to ensure that engaged and educated clients will be
ready for discharge with less effort and stress.

Compliance and position of power. Although all patients and
family members felt comfortable asking questions, the

4 Global Qualitative Nursing Research

majority did not consider intervening in day-to-day deci-
sions. One couple stated,

. . . if he [patient] had wanted to ask questions, I think that would
have been okay. Certainly I felt that the doctor was kind of open
to, you know, questions and things. You just basically were in
there with a problem and you were just complying with what
was being said to do and working to get out, basically. (F)

It seems that as long as the rehabilitation plan did not
clash with clients’ beliefs they would not interfere, although
most clients had an impression that they would be able to
challenge the staff should they feel strongly about some-
thing. This idea was confirmed in several more interviews: “I
just feel they [HCP] are there and they know what is, you
know, best for you” (P).

Speaking up. Clients also have to ask questions, and question
the process; this not only keeps the therapist up to date but
also helps clients to direct their own care. Clients are not
only the experts on their previous conditions but also on
what they need to cope and return to their life. They need to
understand what is going on and provide the clinicians with
information about what their needs and goals are. Clinicians
highlighted the importance of clients taking charge early in
their recovery, feeling that this will make it easier for them to
take care of themselves after they leave the hospital: “. . . we
do say to them, ‘This is your therapy so without you we
wouldn’t be here. You are actually the most important mem-
ber of our team’” (HCP). Some clinicians suggested that
poor health literacy prevents clients from active participa-
tion, and being informed will empower the client and encour-
age control and participation. Some clients did not raise their
voice for fear of being called noncompliant or difficult. The
older clients did not want to “offend” anybody by speaking
their mind:

That’s the way I approach life. I don’t speak up unless it’s really
important. I want people to know that when I speak up, I really
mean it. It seems to me that some people are always complaining
and always saying things, you know, and the other people tune
out. (P)

On the contrary, one of the younger patients felt more
confident about voicing his wishes and expectations; he
wanted to be involved in decisions about therapies, alterna-
tive treatment providers, and overall plans of action.
However, he felt that he was being perceived as “whiny” and
a “complainer.”

Category II: Support

As the patient and the family were going through very diffi-
cult times, they needed all the support that was available not
only from within the family unit but also from the staff,
extended family, friends, and family doctor.

Family. Family involvement in care and decision making
improved both patients’ and families’ experiences of reha-
bilitation. Especially for patients whose speech was affected
(aphasia) it was very important to have somebody to voice
their questions and concerns: “My husband [the caregiver].
Oh yes. He was very good at asking lots and lots and lots of
questions. He was asking the questions . . . he thought he
knew I wanted answers to” (P).

This incredible support comes through during the inter-
views with two participants affected with aphasia: In each
case, the family member encouraged the participant to take
the time and answer the questions, at the same time trying to
guess where they were going and offer some choices, but
never talking for them. One of the participants commented
that being in a somewhat unstable and confused state, she
was happy to have her husband on her side to help her under-
stand and follow what was going on. Family was also provid-
ing additional care and therapy: “. . . I think between my son
and the therapist, that’s when we started to see the movement
coming back” (F).

Family members also reflected that being present for most
of the time during the rehabilitation contributed to the posi-
tive experience that they all had with the hospital stay. They
also commented on always being welcome to be there,
invited to the therapy sessions and social events. Being pres-
ent during the day, they were able to ask all their questions
and did not require any special meetings with the staff:

I found—I know some people have complained because they
don’t get answers and this and that and everything else. I think
that ties in with their overall involvement. How do you get
answers if you are not really there, if you’re not involved, if you
don’t ask the questions? (F)

The outcomes of rehabilitation often depend on family
readiness (physical, mental, and emotional) to provide sup-
port: “I find the patients that do the best are the ones who
have active family member involvement all the way through
. . .” (HCP). It is beneficial for the family to be present for
therapy sessions to see the progress and learn how to assist
the patient with exercises and day-to-day activities. Family
also acts as a cheerleader for a patient’s successes, and
becomes an active participant of the caring team. This not
only gives them confidence and decreases stress but also
improves family dynamics.

Health care professionals. Clinicians’ attitudes also helped to
shape the experience for the clients. Having a positive atti-
tude, being caring, outgoing, enthusiastic, committed,
knowledgeable, and approachable were repeatedly named as
very important personal attributes of the clinicians. For the
most part, the experiences were very positive, with therapists
and nurses creating positive and supportive environment.
However, based on her experience, one participant wanted to
highlight the importance of the staff focusing on clients’

Bamm et al. 5

abilities versus what they cannot do. Although this was her
only negative encounter with the therapists, she wanted it to
be heard:

I thought that [the therapist] was detrimental to my recovery. She
was so negative. My very first time I met her, she sat in that chair
and I was sitting there and she spent an hour talking about all the
things that I could not do. My first day home from a hospital.
Couldn’t ride a bike. You can’t run. You can’t do this. You can’t
do that. It was because I was feeling so good about my recovery,
she just couldn’t—I don’t know. Every time she came, it was so
focused on what I couldn’t do instead of what I could do. (P)

Clinicians described stroke as a life-changing experience,
with clients going through the steps of grieving and accep-
tance, and different challenges for both the patient and the
family at different stages of rehabilitation. Often, it is their
first experience with a major illness that adds tremendous
emotional, social, and financial burdens. These can be espe-
cially difficult for younger clients who have different family
roles and are still working. The clients go through learning
and adjusting processes to take control over what is going to
happen next. They might present as confused, impractical, or
depressed.

Family doctor. More than half of participants would have
liked to see their family doctor as part of the hospital team.
They felt that having the doctor involved would not only pro-
vide additional support and information source but also
improve continuity of care after discharge. One participant
felt that her doctor did not have all the information about her
condition and progress, and it affected her care, especially
given the complications that were mostly resolved in the hos-
pital but still required follow-up. Other participants described
often not knowing what questions to ask at the time. They
believed that family doctors would have been able to explain
things better and describe what was going to happen next.

Organizational support. The context of practice was also
described as important in supporting the developing model of
care. All participants described their hospitals encouraging the
clients and clinicians to work together in partnership. Updating
hospital mission statements, educational sessions for clinicians,
posters, and clients’ education are just some of the strategies
used. However, there is still a need for more practical education
about actual implementation of CCC principles:

I think people get [CCC] in theory. I just don’t think we all do a
very good job of implementing it—like from everyone across
the board versus me in physio and her in OT and him in SLP or
whatever it is. (HCP)

Category III: Communication

All participants described the importance of good communi-
cation among all the partners: the units of the hospital, the

staff members, staff and clients, and also patients and their
families.

HCPs and clients. For the most part, there was good commu-
nication when the clients were transferred from unit to unit
or among the staff of the rehabilitation ward. However, when
something was not done properly or recommendations were
not recorded, the clinicians turned to the patients with their
questions (i.e., why is the walker the wrong height, why are
you taking certain medications, why is your urine a certain
color, etc.):

They would ask me questions . . . And I found that very
frustrating because I couldn’t answer these questions, and then it
started me worrying because if they didn’t know then you know
maybe something was wrong. It was everywhere. (P)

Different personalities tend to voice their concerns differ-
ently. In one instance, the patient was walking on a broken
foot because the staff was not attentive to his quiet com-
plaints. On another occasion, the patient and her husband had
repeatedly requested to be seen by a doctor to address the
other chronic conditions that she was managing. Clients felt
that more often the staff was focused on the immediate prob-
lem (i.e., stroke), ignoring the overall package of issues that
the client brought with them.

Navigating the new system was very challenging and it
was important for the clients to have a person to whom they
could always turn with questions and concerns. It was not
necessarily a formal caseworker, but rather any clinician who
had a trusting relationship and was helpful and willing to
guide the client. Many continued relying on their caseworker
long after being discharged from the hospital: “. . . when
there are changes when you are not well, you need somebody
there to lead you through. To help you realize the different
changes” (P).

Clinicians described having different strategies that help
them to get everybody on the same page. In general, it is
important to create a supportive environment with open and
honest communication, focusing on the achievements and
not on negative aspects. Education and information for both
the patient and the family were mentioned by all the partici-
pants as the main strategies to help them develop a clear
understanding of their condition and prognosis. Other tactics
included problem solving—breaking the long-term goal into
smaller, manageable short-term goals that still work toward
the client’s ultimate goal (explaining this to the client), let-
ting the client try the activity and discuss the results, involv-
ing the family in goal setting and discussions, and working as
a team to maintain consistency:

And so it’s all a form of education ultimately but try to take the
patient together with their family and me to problem solve, you
know, can we attain this goal? . . . let’s get your ability to sit
unsupported for a little bit before we work on standing and then
walking. (HCP)

6 Global Qualitative Nursing Research

Among HCPs. Another frequently mentioned issue was the
communication between the therapists and the nursing staff
about patient progress. For example, many functional
achievements could have been reinforced had the nurses sup-
ported the clients in doing things the same way as they were
done during therapy sessions.

Patient and family. Interestingly, the communication between
the patients and their families was also not always success-
ful. Some had memory or communication problems, whereas
others were just confused. The spouse of one of the partici-
pants remembers,

No I would ask him, when he would say, “Oh the doctor was in
today” I would say, “Well what did they say?” and he would give
me a couple of things and I would say, “Well did you ask him
about this and did you” and of course he forgot quite a bit. (F)

Category IV: Information

Not surprisingly, the issue of information was identified as
one of the important attributes of good quality care. The staff
(mainly nurses, therapists, and social workers) was described
as being the main source of information during the hospital
stay. Following discharge, support groups, friends, and fam-
ily also played an important part in educating the clients
about treatment options and supports available in the com-
munity. Clients also described that having written informa-
tion (pamphlets, handouts, and brochures) was helpful;
however, it could not replace the one-on-one information
provided by the clinicians. Hence, the majority of clients
who were admitted to the rehabilitation unit on Friday com-
plained about not getting enough personal information until
after the weekend (because most hospitals do not have regu-
lar therapy sessions during the weekends).

All participants agreed that when a direct question was
asked, clear and detailed information was provided. However,
many felt overwhelmed by their condition, and did not know
what questions to ask at the moment. After the fact, they
thought that clinicians, having the experience, could have
foreseen what information would be useful for the clients in
their particular situation: “If I asked specific questions, I was
always given the answer if they could, you know? That was
just fine. [But] things weren’t forthcoming, I think” (P). “. . .
the information was only provided if I asked” (P).

Timeliness of the information was mentioned repeatedly
by the participants. They felt that the majority of information
was concentrated around transition periods (intake and dis-
charge), and they would have liked to have the information
spread out over their stay. Participants were well aware that
it was impossible for the clinicians to give them specific
timelines of their recovery. However, having at least tenta-
tive ranges based on previous experiences would have been
greatly appreciated. It would also have made planning ahead
easier: “Yeah, well I would have liked to have known more

or been told more there, because really a lot of the time we
didn’t know what was going to happen next” (F).

Another suggestion was to provide written materials
about the rehabilitation unit prior to transfer, when the client
is still on the acute ward. This would give the clients more
time to learn about new rules and routines, and make the
transition less stressful:

I got pamphlets, but as I said, three days after I got to rehab. It
would have even been nice if they’d given it to me before when
they decided I was going to go. When I was still on surgery but
I was going to go down to rehab. I would have read it all and
known what was going on. (P)

Clients would also have liked to know more about alter-
native, affordable, or private treatment options both during
their stay at rehabilitation and after discharge. It was espe-
cially important for clients with a specific problem that was
more pronounced than others (i.e., speech impairments,
physical limitations) and who wanted to supplement the
amount of treatment provided by the hospital: “. . . they
didn’t really give me a choice about other options available.
I’m not sure if there are other options available to me” (P).

Several successful strategies to improve CCC have been
introduced in different hospitals: writing a family note (a
summary that is given to the family) at the family meeting,
appointing a contact person/therapy leader for each client,
improving continuity and coordination of care through inter-
disciplinary collaborations, having the same staff working
with the client, providing written materials (binder or stroke
passport—a booklet including all the information pertaining
to the patient’s rehabilitation: that is, goals and progress,
important information regarding procedures, assistance, dis-
charge, etc.), creating flexible environments and educational
sessions for patients and families, and organizing discharge.

Overall, the majority of participants felt that they were
well equipped, both physically and with information prior to
discharge.

Category V: Hospital Experiences

Positive features. The overall hospital experiences were also
mentioned by all the participants as important attributes in
shaping their satisfaction with their stay. All participants
reflected on the helpfulness and kindliness of the auxiliary
staff (kitchen and cleaning staff, and other services) and
nurses and therapists: “Cleaning staff. They always came in
with a smile on their face, so that was nice” (P).

Surprisingly, over half of the participants found meals and
especially the way they were provided in a common area as
one of the best experiences: “Meals honestly are one of the
high points of the day [laughs]” (P). They also commented
on the organization of therapy sessions and the helpfulness
of having the schedule written on the notice board. This
allowed the clients to plan their day and also organize visits

Bamm et al. 7

from family and friends. Some rehabilitation units also
encouraged their clients to dress in their home clothes. Many
participants found it very uplifting: “I liked the fact that you
got dressed every day. You didn’t feel you were sick of hos-
pital gowns [laughs]” (P).

Weekend passes were also mentioned by several clients
and HCPs as an important event. It provided an anchor for
both the patient and family on the progress and special needs,
and highlighted the areas that needed to be addressed before
final discharge.

Negative features. There were several areas in which clients
would like to see changes. Probably one of the most fre-
quently mentioned was being admitted on the weekend (Fri-
day). Participants felt that they were just left there to fend for
themselves until the Monday when the therapy resumed.
This brought up another point of worrying and uncertainty
that many participants experienced near transition times (i.e.,
from unit to unit, going home) and which was increased by
inadequate support when the transition happened before the
weekend:

The one thing I really didn’t like was the fact I was moved to that
[rehab] floor on a Friday afternoon and it was such a deadly
weekend, even though I had visitors for myself but there was
nothing going on the weekend. It honestly was depressing. It
was depressing. The second weekend it was okay because I
knew what to expect but that first weekend, it was very
depressing. (P)

All HCPs described that being short staffed and having to
combine several responsibilities (i.e., primary contact clini-
cian organizing discharge) do not allow them to perform to
the best of their abilities, and add stress to the staff. Many felt
that there was too much demand on their time: “I feel some-
times that client-centered care needs to be supported by hav-
ing the appropriate amount of staff. Having the ability for a
person to be able to do the productivity within a stress-free
environment” (HCP).

Understaffing also results in staff having to prioritize
dealing with the problematic cases, and not providing enough
support and education to the clients who are “coping well.”
Not having enough time with each client was also described
by all as a barrier to CCC. The clinicians also wished for
more flexibility in the clients’ length of stay, and felt that not
having to transfer the clients to a different rehabilitation
facility would have eased the stress of the adjustment for an
already vulnerable population.

Discharge planning. Discharge can be a challenging time for
the clients, so providing education and coordinating services
and supports in the community are the key for stress-free
experiences. Participants commented that having a desig-
nated discharge planner improves the process of transition
for the clients and decreases the load on the therapists.

Having a community care representative participating in
planning also improves the coordination and provides bridg-
ing to the community care.

Discussion

The aim of the study was to explore current client-centered
processes of care from clients’ and clinicians’ perspectives
using in-patient rehabilitation units as our settings. Unlike pre-
vious studies that reported some discrepancies in clients’ and
clinicians’ experiences, in the current study, there were clear
parallels between the identified categories that allowed cre-
ation of a uniform model (Figure 1) to describe processes of
care (Berglund, Westin, Svanstrom, & Sundler, 2012;
McCance, Slater, & McCormack, 2009; Rosewilliam, Roskell,
& Pandyan, 2011; Tutton, Seers, & Langstaff, 2008).

The central category from both clients’ and HCPs’ per-
spective was the importance of the whole team having mutual
goals and understanding of the outcomes: “Being on com-
mon ground” runs as the main thread throughout all the inter-
views. Both clients and HCPs described successful
partnerships in goal setting; however, similar to other stud-
ies, the participation of the clients in other decisions, includ-
ing day-to-day decisions about the amount and type of
therapy, length of stay, and conditions of discharge, varied
significantly based on their age and assertiveness. Older cli-
ents tended to assume a passive role, rarely voicing their
opinions and preferences (Chung, Lawrence, Curlin, Arora,
& Meltzer, 2012; Moreau et al., 2012), whereas younger cli-
ents faced additional challenges due to unclear diagnoses,
and due to the multiple roles they were fulfilling in their pre-
stroke lives. Although clinicians were striving to create a
flexible environment, there still seemed to be set routines
and procedures in rehabilitation processes. The amount of

Figure 1. Theoretical model of processes of care.
Note. HCPs = health care providers.

8 Global Qualitative Nursing Research

therapy could not always be adjusted to specific needs of the
client. It was often limited by the understaffing of different
disciplines. In addition, there were few options available to
focus the treatment on specific therapy (i.e., speech language
pathology or physiotherapy) for clients with severe limita-
tions that would affect their postdischarge life. As stroke is
increasingly affecting younger people (Kissela et al., 2012),
the processes will have to be adjusted to better address
unique needs and expectations of younger clients.

Any critical illness is a stressful, life-changing event for
the entire family. It is also new ground for the clients where
they might feel powerless, depressed, and unsure about any
decisions. To help clients get some control over their situa-
tion, clinicians employed different strategies, including edu-
cation and information provision, joint problem solving,
weekend passes, and focusing on achievements. Several
studies in different settings described that client education
and information provision helped in setting more realistic
goals for rehabilitation and also improved outcomes for both
the patient and the family (Foster et al., 2012; Hunt, Moore,
& Sherriff, 2012; Kergoat et al., 2012; Leach, Cornwell,
Fleming, & Haines, 2010; Levack, Siegert, Dean, &
McPherson, 2009). In their report on patients’ experiences on
an experimental stroke unit, Lewinter and Mikkelsen (1995)
described that changing the environment during weekend
visits at home was having a therapeutic effect on their recov-
ery (Lewinter & Mikkelsen, 1995).

To create productive partnerships, the importance of
teamwork was highlighted by all participants. All clinicians
described the patient and family as central members of the
rehabilitation team. However, they would have liked the
clients to be more proactive in seeking information, asking
questions and participating in decision making. Most cli-
ents were happy with their role during their rehabilitation.
Although they felt that they were listened to, and free to ask
questions, they did not perceive themselves capable of
making medical decisions. The above ideas were also
described by previous studies with stroke survivors and
general patients (Chung et al., 2012; Ellis-Hill et al., 2009).
Similar to other studies, early family involvement was
found to benefit all the team members’ experiences and out-
comes (Foster et al., 2012; Levack et al., 2009; Mitchell &
Chaboyer, 2010; Pellerin, Rochette, & Racine, 2011; Tutton
et al., 2008). Clinicians were described as fulfilling multi-
ple roles, advocating for clients’ best interests, educating,
and providing support. Positive attitudes of HCPs were
extremely important in creating pleasant experiences.
Inclusion of family physicians into the rehabilitation team
was seen as beneficial but was, unfortunately, not practical
given the political constraints regarding hospital privileges.
In the study by Wachters-Kaufmann, Schuling, The, and
Meyboom-de Jong (2005), nearly half of the stroke survi-
vors and their caregivers would prefer their general practi-
tioners to be their main source of information, due to
long-term trusting relationships and follow-up care that

they provide. However, the therapists were found to pro-
vide most information (Wachters-Kaufmann et al., 2005).

Both the clients and HCPs agreed that efficient communi-
cation among all the team members and provision of timely
and forthcoming information required further improvement.
Importantly, these two main domains of CCC have been
found deficient by previous studies (Arnold, Coran, &
Hagen, 2012; Peoples, Satink, & Steultjens, 2011; Sinfield,
Baker, Agarwal, & Tarrant, 2008; VisserMeily, van Heugten,
Post, Schepers, & Lindeman, 2005; Wachters-Kaufmann
et al., 2005). Peoples et al. (2011) conducted a systematic
review of qualitative studies that explored stroke survivors’
experiences of rehabilitation. They highlighted the impor-
tance of sufficient information for improving partnerships in
care, and lack of information resulting in patients’ assuming
a passive role (Peoples et al., 2011).

The main barriers to implementation of CCC identified by
all participants were poor health literacy, lack of time, under-
staffing, and organizational culture. Poor health literacy
affects clients’ ability to participate actively in their care by
preventing them from asking questions and making deci-
sions. According to the Canadian Council on Learning
(2007), 60% of Canadians have poor health literacy.
Considering clients’ literacy and educating them accordingly
is essential if active partnership in care is desired (Levasseur
& Carrier, 2010).

Without exception, participants described CCC as requir-
ing more time than medically focused care. This idea is
indeed supported by the literature (Bright et al., 2012; Dilley
& Geboy, 2010; Hunt et al., 2012; Leach et al., 2010; Saha &
Beach, 2011). However, all agreed that it was time well
spent. It allowed timely education for both the patient and
family, increased clients’ participation, and consequently
ownership over their condition, and resulted in improved
outcomes. As stated in Bright et al. (2012), “. . . you do not
have time not to do it” (p. 1001).

Understaffing can directly affect time available for each
client, and indirectly increase stress levels and burnout of
clinicians, resulting in decrease in empathy and client-cen-
tered communication (Bombeke et al., 2010; Passalacqua &
Segrin, 2012). Organizational culture also has significant
effects on implementation of CCC. Similar to previous stud-
ies, clinicians described the need for education, ongoing
feedback, and a general organizational atmosphere that is
supportive of client-centered behaviors. In turn, HCPs also
reported increased job satisfaction and motivation, and better
understanding of their professional identity (Dilley & Geboy,
2010; Kjörnsberg, Karlsson, Babra, & Wadensten, 2010;
Perry, 2009; Rozenblum et al., 2013).

Finally, we would also like to highlight several minor, but
no less important, points that were identified by the clients
from different hospitals. Positive attitudes and helpfulness of
the auxiliary staff (technical support, janitors, kitchen staff,
etc.) made it easier to bear the long-term stay at the rehabili-
tation unit. Being dressed in regular clothes decreased the

Bamm et al. 9

feelings of depression and sickness that hospital gowns often
bring to people. However, being admitted on the weekend (or
on Friday) left clients to adjust to the new environment with-
out sufficient support and information from the therapists.

Some of the limitations of the current study include the
relatively small number of participants. However, we felt
that we gained sufficient depth and breadth in the qualitative
interviews (saturation), and no new categories were emerg-
ing at the time we concluded interviewing. The study was
conducted in in-patient rehabilitation units in Canada, and
caution must be exercised when applying the results in dif-
ferent health care settings and countries. Many of the identi-
fied categories, however, were supported by international
literature, and we feel that the results might be of high inter-
est to any health care institution that has adopted, or plans to
adopt, CCC as their philosophy of care.

Conclusions and Implications

The results of the current work suggest that clinicians have a
clear understanding of the principles of CCC and are work-
ing in partnerships with the clients to achieve their goals.

Regardless of age, all participants reflected on the impor-
tance of working toward goals that were meaningful and
important for the client. However, some clients tend to have
passive attitudes to day-to-day decisions and their prefer-
ences should be respected and supported. Clients rely on a
support group that includes family, friends, staff, and family
physicians. Efficient communication among all the parties is
paramount. We need to encourage and educate clients to
become motivated, well-informed, proactive participants in
their care. Health education should begin as early as the
school years to empower clients to participate in planning
and decision making about their care.

Acknowledgments

We thank all frontline clinicians and research assistants who helped
with recruitment and data collection. We are especially grateful to
Mrs. McNicoll-Whiteman for ongoing support and commitment.
We are also grateful to all participants for providing their time and
sharing their unique experiences.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for
the research, authorship, and or publication of this article: The
study was supported by the Ontario Stroke System (OSS) Research
Program (Grant OSN0912-000103). The first author was sup-
ported by the Frederick Banting and Charles Best Canada Graduate
Scholarships—Doctoral Award, Canadian Institutes of Health
Research (CIHR).

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Author Biographies

Elena L. Bamm, PT, is a PhD graduate from the School of
Rehabilitation Science, McMaster University, Hamilton, Ontario,
Canada.

Peter Rosenbaum, MD, FRCP(C), is a developmental pediatri-
cian, professor of pediatrics, and cofounder of CanChild Centre for
Childhood Disability Research, McMaster University, Hamilton,
Ontario, Canada.

Seanne Wilkins, OT, PhD, is professor emeritus at the School of
Rehabilitation Science, McMaster University, Hamilton, Ontario,
Canada.

Paul Stratford, PT, MSc, is a professor in the School of
Rehabilitation Science and an associate member in the Department
of Clinical Epidemiology and Biostatistics at McMaster University,
Hamilton, Ontario, Canada.

Nadilein Mahlberg, MSc, is a graduate student in the Health
Research Methodology Program, and research assistant at the
CanChild Centre for Childhood Disability Research, McMaster
University, Hamilton, Ontario, Canada.