Breaking Through the Glass Ceiling—Having <i>That</i> Conversation: A Constructivist Grounded Theory Study Exploring the Experiences of Nephrology Nurses’ Practice in Kidney Supportive Care in Canada

For nursing students

Study summary

Dialysis keeps people with kidney failure alive, but it can bring heavy physical and emotional symptom burdens. Kidney supportive care (KSC) is an approach that pairs dialysis with early attention to symptoms and quality of life, and it includes advance care planning (ACP)—the process of talking with patients about their values, wishes, and goals for future care. The problem this study addresses is that ACP is underused in dialysis settings and, when it does happen, it is often started late, sometimes only near the end of life. When nurses delay these conversations, patients can end up receiving care that does not match what they actually wanted, needed, or valued.

A team of Canadian nurse researchers, led by Jovina Concepcion Bachynski along with Lenora Duhn, Idevania G. Costa, and Pilar Camargo-Plazas, set out to understand this problem from the inside. Their purpose was to construct a substantive theory about nurses' engagement in KSC in Canadian dialysis settings.

They used constructivist grounded theory, a qualitative method developed by Kathy Charmaz. Unlike studies that test a hypothesis with numbers, grounded theory builds an explanatory theory from the ground up, out of what people actually say in interviews. The researchers recruited 23 registered nurses working in hemodialysis and peritoneal dialysis and interviewed each of them twice. Data collection and analysis happened concurrently: the team constantly compared codes across interviews, wrote memos to track emerging ideas, and practiced researcher reflexivity, reflecting on their own assumptions as they worked. They kept refining categories until they reached theoretical saturation, the point where new interviews stopped adding new insight.

From this process, the researchers constructed a substantive theory they named "Breaking Through the Glass Ceiling of Engagement—Having That Conversation." The theory identifies three stages of engagement that describe nurses' practice patterns around communicating about goals of care with patients: Transactional, Intentional, and Actional. In the Transactional stage, communication with patients tends to stay task-focused and routine. In the Intentional stage, nurses begin to recognize the importance of goals-of-care conversations and start to intend to have them. In the Actional stage, nurses actually initiate and carry these conversations through with patients. The theory also describes how this progression is modulated by a boundary of professionalism and familiarity with patients — nurses have to balance staying appropriately professional while also becoming familiar enough with a patient to have a meaningful conversation about that person's goals and values. Layered on top of this is a set of multi-dimensional contextual barriers that shape how and whether engagement happens at all.

The study's conclusion, as stated by the authors, is that nephrology nurses have a vital role in discussions about goals of care and require training to enhance their communication skills. The "glass ceiling" in the title is a metaphor for an invisible barrier that can keep nurses positioned in more transactional, task-based communication unless something helps them move toward intentional and, eventually, actional engagement with patients.

For nursing students, this study offers a useful window into how communication skills around serious illness develop in real practice, not just in theory. Having a values-based conversation with a patient facing a chronic, life-limiting illness like kidney failure is not simply a matter of knowing the correct words to use. It is a process shaped by a nurse's comfort level, the relationship built with a specific patient, the workplace context, and the training a nurse has received. On a dialysis unit, or any unit caring for people with chronic or life-limiting illness, this three-stage framework can help you notice where you personally sit in your own conversations about goals of care — transactional, intentional, or actional — and think about what might help you move forward.

A caution for readers: this is a qualitative study describing a theory built from interviews with 23 nurses in Canadian dialysis settings. It is not a large statistical study measuring how common each stage is, and the available abstract does not report detailed demographic breakdowns of the sample, specific health regions, or numeric findings. As with any grounded theory study, the resulting theory explains a process as described by the nurses studied, in the settings studied — a foundation for further research and practice change, not a final, generalized statement about all nephrology nurses everywhere. Treat the three-stage model as a starting point for reflection and further testing in other dialysis units and health systems, rather than a fixed, universal rule.

For educators

Teaching and appraisal notes

This constructivist grounded theory study by Bachynski, Duhn, Costa, and Camargo-Plazas, published in the Canadian Journal of Nursing Research, addresses a persistent gap between the value of advance care planning (ACP) in kidney supportive care (KSC) and its inconsistent uptake by nephrology nurses in dialysis settings. The authors frame the problem clearly: ACP is underused and often initiated late in the illness trajectory, which risks producing care that is discordant with patients' values, wishes, and preferences — a framing that will resonate with faculty teaching goals-of-care communication, palliative approaches to chronic illness, and person-centred care.

Methodologically, the study is a strong teaching example of Charmaz's constructivist grounded theory approach. The team recruited 23 registered nurses across hemodialysis and peritoneal dialysis settings and conducted two intensive interviews with each participant, allowing for depth and follow-up over time rather than a single snapshot. Analysis proceeded concurrently with data collection, using constant comparative analysis of codes, memo-writing, and researcher reflexivity, continuing until theoretical saturation was reached. This design is worth flagging for students: constructivist grounded theory does not aim to test a pre-existing hypothesis, but to build an explanatory theory that is co-constructed between researcher and participant, with the researcher's own positionality treated as part of the analytic process rather than a source of bias to be eliminated.

The resulting substantive theory, "Breaking Through the Glass Ceiling of Engagement — Having That Conversation," proposes three stages of nurse engagement in goals-of-care conversations: Transactional, Intentional, and Actional. This progression is modulated by a boundary of professionalism and familiarity with patients and unfolds amid multi-dimensional contextual barriers. The "glass ceiling" metaphor is a useful discussion anchor: it frames low engagement not simply as an individual skill deficit, but as a structurally and relationally constrained process that nurses move through (or get stuck in) depending on context.

For classroom use, this article pairs well with units on end-of-life and serious illness communication, chronic disease/renal nursing, and qualitative methods. Instructors can use the three-stage model as a framework for role-play or reflective practice exercises: asking students to identify where a given clinical vignette (or their own clinical experience) sits on the Transactional–Intentional–Actional continuum, and what specific barrier (professionalism/familiarity boundary, workload, role ambiguity, unit culture) might be keeping engagement transactional.

Appraisal points for a journal club: as a single-country, qualitative, interview-based study of 23 nurses, the transferability of the three-stage model to other health systems, non-Canadian contexts, or non-nephrology populations facing serious illness should be discussed explicitly with students rather than assumed. The abstract does not report participant demographics (years of experience, hemodialysis vs. peritoneal dialysis proportions, geographic region within Canada), so instructors should be transparent that these details are unavailable from the source and, if relevant to discussion, direct students to the full published paper (Canadian Journal of Nursing Research, DOI 10.1177/08445621251395378) for methodological detail not captured in the abstract. The authors' explicit conclusion — that nephrology nurses require training to enhance communication skills for goals-of-care conversations — offers a natural bridge to discussing existing communication training frameworks (e.g., structured communication skills training, simulation-based goals-of-care conversation practice) and how programs might operationalize the theory's three stages as a curricular scaffold or workplace professional-development target.