Recovery experience of older adults with COVID-19: A grounded-theory study

1. Study Design

The authors complied with consolidated criteria for reporting qualitative research (COREQ) guidelines. This qualitative study employed Corbin and Strauss’s [12] methodology for grounded theory qualitative research, to describe the relationships between concepts that constitute the phenomenon and investigate the recovery process of older adults with a history of COVID-19. Through examining and exploring various perspectives on individuals’ behaviors, researchers can scrutinize these behaviors and develop a comprehensive, situation-specific theory. Through a grounded theoretical approach, the researcher can develop a theory that can explain complex and multi-dimensional situations by exploring the experiences of older adults with a history of COVID-19.

2. Setting and Sample

A total of 15 participants were recruited based on purposive and snowball sampling. The recruitment was conducted in a way that previously recruited participants recommended subsequent participants. A total of 10 participants were recruited based on verbal referrals from participants who had previously been recruited, and the other five participants were subsequently recruited based on the recommendation of G wellness centers’ staff members.

In grounded theory, participant selection is an important procedure achieved through theoretical sampling that deliberately selects appropriate study participants. Theoretical sampling is a process for researchers to determine data to collect based on analyzing prior data to decide the next collection target within a particular context [11]. According to theoretical sampling methods, subsequent data were determined based on the analysis of the characteristics, and quality of previous data. By analyzing samples intentionally collected based on concepts, researchers can discover common core concepts by extracting attributes from study participants [11,12].

Afterward, analyzed data were theoretically saturated based on continuous comparative analysis of information until new meaningful information was no longer yielded. Theoretical saturation occurs when the development of all paradigm categories becomes densely woven, and no new or related data emerges. At this stage, relationships between categories are well-established, and new meaningful information is no longer yielded [12]. We reached theoretical saturation after analyzing data up to the 15th participant, where the data no longer yielded new concepts or themes.

Inclusion criteria included older adults aged 60 and above who had recovered and could truthfully describe their experience of being quarantined due to COVID-19. We included participants who could reflect on their experience and signed the consent form. Based on considering the recovery from traumatic experiences, we recruited participants who have been maintaining their daily lives without problems for at least one year after being quarantined [13,14]. Accordingly, we recruited participants who had been forced to quarantine due to COVID-19 from January 2021 to August 2021. In addition, we conducted a psychological test in advance provided by G wellness center to include participants for those who fall within the normal range [15]. Exclusion criteria included those with cognitive impairment or a diagnosis of post-traumatic stress disorder (PTSD) due to psychiatric stress caused by COVID-19.

3. Ethical Considerations

This study was reviewed and approved by the Ethics Committee of Kyungpook National University (IRB No. 2022-0320). The researchers explained the study’s purpose, methods, and their right to stop participating at any time without disadvantages to the participants. Their willingness was confirmed by obtaining their signatures on informed consent forms. The recorded data were kept in a password-protected file and paper-based documents in a locked cabinet.

4. Data Collection

Data collection was conducted from September 12, 2022 to February 27, 2023, by using face-to-face, individual, semi-structured interviews. As the potential risks of quarantine experiences were weighed carefully against possible distress, we interviewed three older adults with a history of COVID-19 for pilot testing in August. Previous studies have reported that PTSD related to COVID-19 can cause past trauma to suddenly appear. In addition, it causes abnormal symptoms such as suffocation [8]. All interviews were conducted in the counseling room within the hospital affiliated with the G wellness center where medical treatment was available in the event of an emergency to alleviate COVID-19-related risks. Multidisciplinary experts (nursing professors and psychologist) participated in discussions to determine the research participants. First, background information—living situations, patient history, the status of physical and mental health—was assessed to determine the study participants’ availability of interviews.

Next, to build a rapport, researchers were introduced, psychological support guidelines were provided, participants’ written consent was obtained, and interviews were scheduled at their convenience. Interviews (up to three sessions lasting 60 to 90 minutes per person) were conducted complying with COVID-19 safety guidelines by the research member who previously worked in a COVID-19 ward—wearing masks and temperature checks.

The researchers began the interviews by empathically asking open-ended questions and ended them by expressing appreciation for the participants’ engagement. The main interview questions were “What have you been through sequentially after the infection?” and “What are your coping strategies?”, “What was the most difficult part of the COVID-19 infection period?”, and “What change did you feel through the COVID-19 experience?”. The frequently used facilitation question was “Is there anything else you want to talk about regarding COVID-19 experience? If so, “please tell us?” All interviews were audio recorded. The interviewer summarized the content, asked the participants to confirm it, and made debriefing notes after each interview. Psychological guidance materials were sent after the interview to assess participants’ mental states, and if applicable, post-interviews were implemented to reduce potential trauma risks.

5. Data Analysis

To identify and classify similarities and differences in data and extract distinct categories for interpretation, researchers use the constant comparison method.

First, the outline centered on psychological pain among adults with a history of COVID-19 who had been quarantined was formulated after several readings of the interviews, excluding researchers’ prejudices. Transcripts were returned to participants for comment and correction. Data analysis was conducted based on Corbin and Strauss’s qualitative research methodology with a grounded theory approach [12]. Thereafter, interviewers reviewed all the transcripts using the QSR NVivo11 program for open coding [16]. In data analysis, codification procedures, such as simple word-by-word and line-by-line coding, were also implemented.

Open coding is an analytical approach that involves naming and categorizing phenomena during the initial phase of coding through close data examination. This process involved carefully reviewing and re-reviewing the raw data multiple times. Open coding enables in-depth analysis by deriving categories through event-to-event and object-to-object comparisons, along with the use of theoretical comparison techniques. Similar or different concepts were compared to derive a particular category, find and classify differences in their attributes using theoretical comparison techniques. This allowed us to group similar concepts, forming broader categories. Through open coding, specific concepts (codes, sub-themes, themes) emerged from the raw data, revealing their properties and dimensions.

In axial coding, the process involved reassembling previously distinct concepts and categories that had been derived through open coding to construct a structural framework. This framework was developed to provide a more detailed and comprehensive explanation of the phenomenon under study. Axial coding involves connecting categories through a paradigm model, including crucial elements such as causal conditions and consequences.

A causal condition refers to an event that triggers or facilitates a particular phenomenon. Contextual conditions refer to the set of circumstances or environments in which a particular phenomenon is situated. Intervening conditions within a specific context can either facilitate or inhibit the effectiveness of action/interaction strategies. Action/interaction strategies involve addressing, controlling, executing, and responding to a phenomenon. Consequences refer to the results that stem from the action/interaction strategies.

In the selective coding phase, the content at the descriptive level was developed to an abstract level. We identified a core category that represents concepts and categories. All categories were integrated around the core category using selective coding. We used this core category as the foundation to create a theory, focusing on the recovery process of older adults with COVID-19 in our study.

Afterward, process analysis was conducted to understand how participants’ experiences evolved over time. A process analysis involves linking stages sequentially over time. This approach enables us to comprehend how the process evolves under the influence of variables to lead to an outcome.

6. Rigor

To enhance rigor, Guba and Lincoln’s [17] criteria of truth value, applicability, consistency, and neutrality were used. Truth value was confirmed through repeated checks and interpretations for accuracy. The interview transcripts were analyzed, and their accuracy was strengthened by obtaining the participants’ reaffirmation. Applicability of the results was established by obtaining confirmations from three participants and three non-participants to enhance authenticity so that the results could be applied to a wider range of situations. Consistency was determined by theoretical comparisons. Throughout the analysis, the data and coding were regularly checked by researchers, nursing professors, and a psychologist. Neutrality was maintained by avoiding involvement/interactions between the researchers and participants. To exclude prejudices, all reflections were recorded, and the research process was noted, which helped to avoid biases.

1. Casual Condition: Potential Threats to Wellbeing

Older patients who were infected with COVID-19 faced a growing sense of anxiety about their physical and mental well-being due to the effects of confinement. Those who were isolated in hospitals witnessed COVID-19-related deaths, which made them more aware of the severity of the infection. They expressed a sense of emotional despair because they had nowhere to turn for straightforward guidance on what to do next, and they lacked outlets for emotional support. Amidst the confusion during confinement, participants were worried about the prospect of returning to society and resuming their usual lives.

2. Contextual Condition: Lack of Support Systems

Many people found themselves spending time in self-isolation, using COVID-19 self-test kits to determine if they were positive or negative. The limitations on social interactions during isolation also resulted in unavoidable financial losses. When trying to access economic assistance, they mentioned that the government’s eligibility criteria were complicated, making it challenging to qualify. Moreover, government guidelines have undergone frequent changes, and officials in charge have often been unreachable by phone. It was common that temporary support was sometimes offered but then abruptly disappeared. Older patients, in particular, required more support than younger individuals, yet aside from isolation, they received minimal assistance.

3. Central Phenomenon: A Life Shattered Amidst COVID-19-Related Helplessness

Participants expressed stress during their COVID-19 recovery period, which lasted for more than a month. The majority of participants reported that they had to comply with a hierarchical quarantine policy that just required acceptance within a confined environment, limiting freedom of expression. Some participants mentioned experiencing extreme stress and suicidal impulses because of the adverse situation they experienced due to COVID-19. Participants reported experiencing personality changes in a negative direction. They also faced a lack of interpersonal relationships, along with damaging rumors and stigmatization related to COVID-19. The social stigma associated with contracting COVID-19 led to feelings of insignificance and a loss of confidence, contributing to participants’ sense of alienation from acquaintances after their release from quarantine.

4. Intervening Condition: Rebound for Change

Support and encouragement from religion and family have been instrumental in their lives, serving as strong pillars and sources of motivation. They’ve also come to rely on external support, which has strengthened their belief that they can overcome challenges. Due to their old age, some participants made financial arrangements to prepare for the potential worsening of their health. They also devised temporary solutions in anticipation of health decline. They focused on healing their minds and souls while taking care of their physical and mental well-being as part of their journey to recover from the consequences of the COVID-19 infection.

5. Action/Interaction Strategies: Development of Efficient Coping Strategies

Through the experiences they’ve had in life, the participants have fluently developed effective strategies for dealing with difficult situations. They found a sense of purpose and belonging through volunteer activities and charitable contributions after being infected with COVID-19 to overcome feelings of helplessness. Additionally, during the quarantine period, they engaged in indoor exercises, sought online counseling to relieve anxiety and loneliness, and explored various activities like internet searches, and music via their smartphones. Some even reached out to mental health professionals through online. Joining online forums to ask health-related questions and seek answers became a common practice.

6. Consequences: Fostering Resilience After Life-Threatening Incidents

The COVID-19 crisis experience has brought about a shift in thinking, allowing individuals to discover positive aspects even within the crisis itself. They also experienced the satisfaction of persevering and achieving something even in the face of adversity.

7. Process Analysis

The core category revealed was turning crisis into opportunities throughout making meaning of living in the time of COVID-19. Although time cannot heal all wounds, it allows participants to experience events, form new perspectives, and reorient for the future. Participants reflected on their lives and became stronger by enduring various aspects of pain related to COVID-19. Acknowledging the unavoidable and reorienting to changes were identified as the core categories, with the strategic coping process comprising three stages: recognition of crisis, seeking a way out, and fostering resilience (Figure 1).

Figure 1.

Turning crisis into opportunities throughout making meaning of living in the time of COVID-19 pandemic.