{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,14]],"date-time":"2025-12-14T08:40:15Z","timestamp":1765701615436,"version":"3.48.0"},"reference-count":55,"publisher":"BMJ","issue":"5","license":[{"start":{"date-parts":[[2025,5,27]],"date-time":"2025-05-27T00:00:00Z","timestamp":1748304000000},"content-version":"unspecified","delay-in-days":26,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,5,7]]},"published-print":{"date-parts":[[2025,5]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Proper positioning in trauma care is essential to prevent associated complications by stabilising haemodynamics, preserving the spine, securing the airway and protecting skin integrity. Motor vehicle crashes are the leading cause of traumatic brain injury (TBI) in Pakistan, necessitating rigorous safety measures and high-quality care due to their severe impact and high mortality rates. Resource-limited settings face significant challenges in providing adequate neurosurgical services. Moreover, there is a notable gap in the existing literature regarding effective care of patients with TBI. This study aims to address a gap in neurosurgical nursing research by exploring how nurses\u2019 interactions and behaviors during positioning interventions contribute to the cultural understanding of nursing care strategies and how the specific cultural context of the neurosurgical ward shapes and informs these interactions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>The current study will use a focused ethnography design. Patients with TBI, along with nurses and doctors, will be purposively selected from the neurosurgical wards of two tertiary care hospitals in Islamabad, Pakistan, based on set eligibility criteria. Data will be collected through participant observation, semistructured interviews and analysis of documents and artefacts to ensure diversity and trustworthiness. Braun and Clarke\u2019s Reflexive Thematic Analysis approach will be used for data analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>This study has been approved by the institutional review boards (IRBs) of Shifa Tameer-e-Millat University (IRB# 125\u201324) and the Pakistan Institute of Medical Sciences (No. f.1.1\/215\/ERB\/SZABMU\/1298). Potential ethical concerns will be addressed by protecting the rights of participants including avoiding harm, ensuring privacy and confidentiality and obtaining informed consent. In line with ethnography guidelines, this study adopted the process-informed consent to ensure informed and autonomous involvement. The study results will be shared with key stakeholders and published in scientific journals and presented at conferences.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2024-092232","type":"journal-article","created":{"date-parts":[[2025,5,28]],"date-time":"2025-05-28T02:20:22Z","timestamp":1748398822000},"page":"e092232","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Focused ethnography of nurses\u2019 interactions and behaviours in the therapeutic positioning of patients with traumatic brain injury in Pakistan: study protocol"],"prefix":"10.1136","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-8997-609X","authenticated-orcid":false,"given":"Naveeda","family":"Iqbal","sequence":"first","affiliation":[{"name":"Faculty of Nursing and Midwifery, Shifa Tameer-e-Millat University, Islamabad, Pakistan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Reema","family":"Safadi","sequence":"additional","affiliation":[{"name":"Faculty of Nursing and Midwifery, Shifa Tameer-e-Millat University, Islamabad, Pakistan"},{"name":"University of Jordan, School of Nursing, Amman, Jordan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9262-5304","authenticated-orcid":false,"given":"Nafisa","family":"Bardaie","sequence":"additional","affiliation":[{"name":"Faculty of Nursing and Midwifery, Shifa Tameer-e-Millat University, Islamabad, Pakistan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Amir","family":"Waheed","sequence":"additional","affiliation":[{"name":"Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad, Pakistan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Erika S","family":"Froelicher","sequence":"additional","affiliation":[{"name":"Faculty of Nursing and Midwifery, Shifa Tameer-e-Millat University, Islamabad, Pakistan"},{"name":"Department of Physiological Nursing, School of Nursing, and Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,5,27]]},"reference":[{"key":"2025121400371361000_15.5.e092232.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.mcna.2019.11.001"},{"key":"2025121400371361000_15.5.e092232.2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1476-4431.2010.00527.x"},{"key":"2025121400371361000_15.5.e092232.3","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1089\/neu.2022.0068","article-title":"Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature","volume":"40","author":"Allen","year":"2023","journal-title":"J Neurotrauma"},{"key":"2025121400371361000_15.5.e092232.4","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-045816","article-title":"EXperienceS and aTtitudes towards Agitated behaviours in Traumatic brain injury in the Intensive Care unit patients (EXSTATIC): a protocol for an interprofessional mixed-method study","volume":"11","author":"Saavedra-Mitjans","year":"2021","journal-title":"BMJ Open"},{"key":"2025121400371361000_15.5.e092232.5","doi-asserted-by":"publisher","DOI":"10.1097\/MCC.0000000000000285"},{"key":"2025121400371361000_15.5.e092232.6","doi-asserted-by":"publisher","DOI":"10.1016\/s1474-4422(22)00309-x"},{"key":"2025121400371361000_15.5.e092232.7","doi-asserted-by":"publisher","DOI":"10.1097\/JNN.0b013e3181ce5b8a"},{"key":"2025121400371361000_15.5.e092232.8","first-page":"227","article-title":"Effect of semi-Fowler\u2019s position on oxygenation and hemodynamic status among critically ill patients with traumatic brain injury","volume":"4","author":"Abd El-Moaty","year":"2017","journal-title":"Int J Novel Res Healthc Nurs"},{"key":"2025121400371361000_15.5.e092232.9","doi-asserted-by":"crossref","first-page":"794","DOI":"10.1227\/01.NEU.0000298908.94129.67","article-title":"The role of postoperative patient posture in the recurrence of traumatic chronic subdural hematoma after burr-hole surgery","volume":"61","author":"Abouzari","year":"2007","journal-title":"Neurosurgery"},{"key":"2025121400371361000_15.5.e092232.10","doi-asserted-by":"publisher","DOI":"10.4103\/2152-7806.139612"},{"key":"2025121400371361000_15.5.e092232.11","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1111\/fare.12122","article-title":"Promoting resilience following traumatic brain injury: application of an interdisciplinary, evidence\u2010based model for intervention","volume":"64","author":"Godwin","year":"2015","journal-title":"Fam Relat"},{"key":"2025121400371361000_15.5.e092232.12","first-page":"143","article-title":"The importance of correct patient positioning in theatres and implications of mal-positioning","volume":"20","author":"Adedeji","year":"2010","journal-title":"J Perioper Pract"},{"key":"2025121400371361000_15.5.e092232.13","doi-asserted-by":"crossref","first-page":"744","DOI":"10.1007\/s12028-022-01551-x","article-title":"Determinants of Adherence to Best Practice in Severe Traumatic Brain Injury: A Qualitative Study","volume":"37","author":"Gantner","year":"2022","journal-title":"Neurocrit Care"},{"key":"2025121400371361000_15.5.e092232.14","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1097\/01376517-200410000-00007","article-title":"Effect of backrest position on intracranial pressure and cerebral perfusion pressure in individuals with brain injury: a systematic review","volume":"36","author":"Fan","year":"2004","journal-title":"J Neurosci Nurs"},{"key":"2025121400371361000_15.5.e092232.15","article-title":"Elevation of the head during intensive care management in people with severe traumatic brain injury","volume":"12","author":"Alarcon","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"key":"2025121400371361000_15.5.e092232.16","doi-asserted-by":"crossref","first-page":"1","DOI":"10.5294\/aqui.2019.19.4.9","article-title":"Nursing interventions for patients with intracranial hypertension: integrative literature review","volume":"19","author":"de Almeida","year":"2019","journal-title":"Aquichan"},{"key":"2025121400371361000_15.5.e092232.17","doi-asserted-by":"publisher","DOI":"10.5430\/ijhe.v6n5p26"},{"key":"2025121400371361000_15.5.e092232.18","first-page":"1","article-title":"Research paradigms: researchers\u2019 worldviews, theoretical frameworks and study designs","volume":"4","author":"Shah","year":"2013","journal-title":"Arab World Engl J"},{"key":"2025121400371361000_15.5.e092232.19","first-page":"1","article-title":"Symbolic interactionism","volume":"1","author":"Carter","year":"2015","journal-title":"Sociopedia"},{"key":"2025121400371361000_15.5.e092232.20","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/S0163-2396(08)32005-5","volume-title":"Studies in symbolic interaction","volume":"Vol 32","author":"Charmaz","year":"2008"},{"key":"2025121400371361000_15.5.e092232.21","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1177\/104649647600700101","article-title":"Introduction: symposium on interaction in laboratory and field settings","volume":"7","author":"Bales","year":"1976","journal-title":"Small Group Behavior"},{"key":"2025121400371361000_15.5.e092232.22","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1037\/a0013495","article-title":"The influential role of relational messages in group interaction","volume":"13","author":"Keyton","year":"2009","journal-title":"Group Dyn Theory Res Pract"},{"key":"2025121400371361000_15.5.e092232.23","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1016\/j.afjem.2012.04.005","article-title":"Orientation among multiple truths: an introduction to qualitative research","volume":"3","author":"Erlingsson","year":"2013","journal-title":"Afr J Emerg Med"},{"key":"2025121400371361000_15.5.e092232.24","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1017\/S0317167100016280","article-title":"Improving information provision for neurosurgical patients: a qualitative study","volume":"41","author":"Bramall","year":"2014","journal-title":"Can J Neurol Sci"},{"key":"2025121400371361000_15.5.e092232.25","unstructured":"Creswell JW , Poth CN . Qualitative inquiry and research design: choosing among five approaches. 4th edn. Sage Publications, 2018."},{"key":"2025121400371361000_15.5.e092232.26","first-page":"63","article-title":"Using focused ethnography in nursing research","volume":"10","author":"Crawford","year":"2019","journal-title":"Kaitiaki Nurs Res"},{"key":"2025121400371361000_15.5.e092232.27","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2013-002335"},{"key":"2025121400371361000_15.5.e092232.28","unstructured":"Howarth E , Devers K , Moore G , et al . Contextual issues and qualitative research. In: Challenges, solutions and future directions in the evaluation of service innovations in health care and public health. NIHR Journals Library, 2016."},{"key":"2025121400371361000_15.5.e092232.29","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.321.7273.1400"},{"key":"2025121400371361000_15.5.e092232.30","doi-asserted-by":"publisher","DOI":"10.1080\/13814788.2017.1375091"},{"key":"2025121400371361000_15.5.e092232.31","first-page":"1921","article-title":"Guidance on performing focused ethnographies with an emphasis on healthcare research","volume":"26","author":"Higginbottom","year":"2021","journal-title":"Qual Rep"},{"key":"2025121400371361000_15.5.e092232.32","doi-asserted-by":"crossref","first-page":"00149","DOI":"10.15406\/bbij.2017.05.00149","article-title":"Sampling and sampling methods","volume":"5","author":"Etikan","year":"2017","journal-title":"BBIJ"},{"key":"2025121400371361000_15.5.e092232.33","first-page":"11","article-title":"Does sample size matter in qualitative research?: a review of qualitative interviews in is research","volume":"54","author":"Marshall","year":"2013","journal-title":"J Comput Inf Syst"},{"key":"2025121400371361000_15.5.e092232.34","doi-asserted-by":"crossref","first-page":"607","DOI":"10.4300\/JGME-D-21-00752.1","article-title":"Beyond the Guise of Saturation: Rigor and Qualitative Interview Data","volume":"13","author":"LaDonna","year":"2021","journal-title":"J Grad Med Educ"},{"key":"2025121400371361000_15.5.e092232.35","doi-asserted-by":"publisher","DOI":"10.7748\/nr2004.07.12.1.7.c5927"},{"key":"2025121400371361000_15.5.e092232.36","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1080\/14780887.2022.2090469","article-title":"Participatory thick descriptions: a collaborative and reflective approach","volume":"20","author":"Sankofa","year":"2023","journal-title":"Qual Res Psychol"},{"key":"2025121400371361000_15.5.e092232.37","doi-asserted-by":"crossref","unstructured":"Delamont S . Ethnography and participant observation. In: Seale C , ed. Qualitative research practice. London: SAGE Publications, 2004: 205\u201317.","DOI":"10.4135\/9781848608191.d19"},{"key":"2025121400371361000_15.5.e092232.38","doi-asserted-by":"crossref","first-page":"22","DOI":"10.7748\/nr.2017.e1506","article-title":"Shared worlds: multi-sited ethnography and nursing research","volume":"24","author":"Molloy","year":"2017","journal-title":"Nurse Res"},{"key":"2025121400371361000_15.5.e092232.39","doi-asserted-by":"crossref","unstructured":"Moeran B . From participant observation to observant participation. In: Ybema S , Yanow D , Wels H , et al , eds. Organizational ethnography: studying the complexity of everyday life. London: SAGE Publications, 2009: 139\u201355.","DOI":"10.4135\/9781446278925.n8"},{"key":"2025121400371361000_15.5.e092232.40","doi-asserted-by":"publisher","DOI":"10.1177\/107780049700300402"},{"key":"2025121400371361000_15.5.e092232.41","doi-asserted-by":"publisher","DOI":"10.1177\/0894318412466742"},{"key":"2025121400371361000_15.5.e092232.42","doi-asserted-by":"crossref","unstructured":"Braun V , Clarke V , Hayfield N , et al . Doing reflexive thematic analysis. In: Knight C , Turner L , eds. Supporting research in counselling and psychotherapy: qualitative, quantitative, and mixed methods research. Cham: Springer International Publishing, 2023: 19\u201338.","DOI":"10.1007\/978-3-031-13942-0_2"},{"key":"2025121400371361000_15.5.e092232.43","doi-asserted-by":"crossref","unstructured":"Roper JM , Shapira J . Ethnography in nursing research. Thousand Oaks: Sage, 2000.","DOI":"10.4135\/9781483328294"},{"key":"2025121400371361000_15.5.e092232.44","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.a1020","article-title":"Qualitative research methodologies: ethnography","volume":"337","author":"Reeves","year":"2008","journal-title":"BMJ"},{"key":"2025121400371361000_15.5.e092232.45","doi-asserted-by":"publisher","DOI":"10.1002\/capr.12360"},{"key":"2025121400371361000_15.5.e092232.46","unstructured":"Guba EG , Lincoln YS . Competing paradigms in qualitative research. In: Denzin NK , Lincoln YS , eds. Handbook of qualitative research. Thousand Oaks (CA): Sage Publications, 1994: 105\u201317."},{"key":"2025121400371361000_15.5.e092232.47","first-page":"435","article-title":"Trustworthiness in Qualitative Research","volume":"25","author":"Connelly","year":"2016","journal-title":"Medsurg Nurs"},{"key":"2025121400371361000_15.5.e092232.48","doi-asserted-by":"crossref","unstructured":"Roshan A , Elhami A . Ethnographic research methods and the role of reflexivity in qualitative research. In: Principles of conducting qualitative research in multicultural settings. Hershey (PA): IGI Global, 2024: 1\u201314.","DOI":"10.4018\/979-8-3693-3306-8.ch001"},{"key":"2025121400371361000_15.5.e092232.49","unstructured":"Buscatto M . Practising reflexivity in ethnography. In: Silverman D , ed. Qualitative research. London: Sage, 2016: 137\u201351."},{"key":"2025121400371361000_15.5.e092232.50","doi-asserted-by":"crossref","first-page":"S403","DOI":"10.2105\/AJPH.2015.302551","article-title":"Cultural reflexivity in health research and practice","volume":"105 Suppl 3","author":"Aronowitz","year":"2015","journal-title":"Am J Public Health"},{"key":"2025121400371361000_15.5.e092232.51","doi-asserted-by":"crossref","unstructured":"Madden R . Being ethnographic: a guide to the theory and practice of ethnography. 2nd edn. London: Sage, 2017.","DOI":"10.4135\/9781529716689"},{"key":"2025121400371361000_15.5.e092232.52","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1080\/10508422.2022.2152339","article-title":"Confidentiality, informed consent, and multiple relationships in four emerging regions","volume":"33","author":"Akhurst","year":"2023","journal-title":"Ethics Behav"},{"key":"2025121400371361000_15.5.e092232.53","unstructured":"Huber E , Imeri S . Informed consent in ethnographic research: a common practice facing new challenges. In: Smith A , Johnson B , eds. Ethics in qualitative research: contemporary issues. London: Academic Press, 2023: 45\u201360."},{"key":"2025121400371361000_15.5.e092232.54","doi-asserted-by":"crossref","first-page":"795","DOI":"10.1177\/14687941211014366","article-title":"Implementing continuous consent in qualitative research","volume":"22","author":"Klykken","year":"2022","journal-title":"Qual Res"},{"key":"2025121400371361000_15.5.e092232.55","doi-asserted-by":"crossref","first-page":"43","DOI":"10.29045\/14784726.2022.09.7.2.43","article-title":"Identity, positionality and reflexivity: relevance and application to research paramedics","volume":"7","author":"Wilson","year":"2022","journal-title":"Br Paramed J"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2024-092232","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,14]],"date-time":"2025-12-14T08:37:29Z","timestamp":1765701449000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2024-092232"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5]]},"references-count":55,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2025,5,27]]},"published-print":{"date-parts":[[2025,5]]}},"alternative-id":["10.1136\/bmjopen-2024-092232"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2024-092232","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"type":"print","value":"2044-6055"},{"type":"electronic","value":"2044-6055"}],"subject":[],"published":{"date-parts":[[2025,5]]}}}