2.1 Taking a social constructionist approach to draw on a relational ethics lens

In line with a social constructionist approach to grounded theory, each stage of our research process was informed by a relational ethics lens.¹⁸ A social constructionist approach to grounded theory is an appropriate methodological orientation to address the current research objective because there is a shared assumption that what can be known is constructed based on experiences and interactions with the social environment.¹⁹ Concepts of a relational ethics lens (e.g., autonomy, embodiment, trust, engagement) were thus used to sensitize the process of data creation and analysis to particular issues of interest, without any commitment to reproduce these concepts.

Relational ethics is a broad theoretical lens that draws from a recent history of critical inquiry into traditional ethical principles (i.e., autonomy, nonmaleficence, beneficence and justice).²⁰ These traditional principles are central in modern health care ethics.²¹ Many theorists argue that these principles traditionally focus too narrowly on an individual's values and priorities by conceiving an individual as independent, self-interested and separate from another.^{22, 23} By contrast, theorists propose a thoroughly relational (rather than the traditionally individualistic) orientation to reinterpret these ethical principles.^{20, 23} For example, as Baylis et al.²³ state, ‘Relational autonomy embraces (rather than ignores) the fact that persons are inherently social and politically and economically situated beings, raised in social settings, who learn to develop their interests and values in conversation with other social and politically and economically situated beings’. Relational understandings of autonomy thus encourage careful attention be paid to the context shaping a person's choices in ways that promote or undermine opportunities for autonomy.^{24, 25} Baylis et al. also stress that the context in which a person lives helps to constitute the identities that they and others regard as valuable.²⁵ In health care, a relational ethics lens has commonly been articulated through themes, such as relational autonomy, mutuality, respect, embodiment, engagement and an interdependent environment.^26-29 It has also been drawn upon to explore relational shifts between persons with chronic illness and health professionals.^{25, 30, 31}

2.2 Sample

Participants were selected from a larger sample of individuals with RA who had taken part in a randomized controlled trial (RCT).³² Participants were recruited to take part in the RCT from the Mary Pack Arthritis Programme (Vancouver Coastal Health Authority) and Fraser Health Authority in British Columbia, Canada, and study information was posted on Facebook, Twitter, Kijiji and Craigslist. To be eligible for participation in this RCT, participants had a physician-confirmed diagnosis of RA and an email address and access to the internet on a daily basis. People were excluded if they had previously used any physical activity wearable or were unsafe to be physically active without health professional supervision, as identified by the Physical Activity Readiness Questionnaire.³³ Over 8 weeks, participants used a Fitbit Flex-2 paired with a new web-based application called Fitviz to track and obtain feedback about their physical activity, received education and counselling from a study PT and received four biweekly follow-up calls from the study PT.³² Worn on the wrist of the nondominant side, the Fitbit continuously tracks steps, distance, calories burned and active minutes. It tracks progress towards a daily activity goal and can vibrate as a reminder to move if a goal has not yet been reached.

Physical activity counselling followed the Brief Action Planning approach, whereby the study PT guided individuals to set goals, develop an action plan and identify barriers and solutions.³⁴ In keeping with grounded theory methodology, sampling evolved from a purposive to a theoretical strategy as the study progressed.¹⁹ Initial purposive sampling ensured the inclusion of participants with differing ages, sex, living status and socioeconomic status. Pauses were planned after every 3–4 interviews so that ongoing analysis could inform purposive sampling and ensure that participants' experiences, which may disaffirm the evolving conceptual categories were acknowledged. Theoretical sampling was used in seeking pertinent data through follow-up interviews to check, qualify and elaborate conceptual categories as they developed through analysis, making them more robust and uncovering their complexity.

2.3 Interviews

A constructivist grounded theory approach that emphasizes participants' lived experiences as they present it informed strategies to construct and analyze data.^{19, 35} Between December 2017 to November 2019, semi-structured intensive interviews (lasting between 50 min to 3 h) were conducted in-person by J. L. at a time and location chosen by the participant (5 at home; 11 at Arthritis Research Canada offices).³⁶ The interviewer had access to a resource package, including details on how to access professional support for physical and emotional health, to share with participants as appropriate.

Concepts of the relational ethics lens were used as sensitizing concepts to inform the development of an interview guide, which was used to elicit accounts of participants' experiences and revised throughout the analysis to address evolving conceptual categories.¹⁸ Between March and July 2020, J. L. also conducted a follow-up phone interview (lasting approx. 30 min) that allowed for further elaboration and clarification to pursue developing conceptual categories in the analysis. The University of British Columbia's Clinical Research Ethics Board granted ethical approval for the study (H15-00868). Participants provided written consent and were given opportunities to withdraw at each stage of the research process. Confidentiality was assured, and participant-selected pseudonyms are used throughout.

2.4 Analysis

Interviews were audiotaped and transcribed verbatim. Transcripts were checked for accuracy against audio recordings and deidentified. Our analytic process was guided by Charmaz's constructivist application of grounded theory, whereby two trainee researchers (J. L., S. Z.) and a member of the research staff at Arthritis Research Canada first independently coded a sample of early transcripts line-by-line in a process of open or initial coding.¹⁹ No preselected codes were identified. Through discussion, we next used constant comparative techniques to sort initial codes into agreed-upon preliminary themes in a process of focused coding.¹⁹

Using QSR NVivo 12 software to organize and store the data, we confirmed, modified or disaffirmed these themes as new transcripts became available. Memo-writing was used to develop and refine key conceptual categories from these themes, outline conditions under which each category developed and analyze relationships between these key conceptual categories. It was at this stage that a relational ethics lens and fieldnotes were used purposefully to sensitize the analysis to possible concepts and aid the interpretation of conceptual categories. In line with theoretical sampling, after refining key categories, we generated new data through follow-up interviews to check, fill out and extend conceptual categories.¹⁹ Experienced qualitative researchers (C. B., L. N., A. T., L. L.) provided peer reviews during this iterative process. Through discussion, it was agreed that conceptual categories were sufficiently saturated when, as a consequence of theoretical sampling, these categories reflected enough conceptual depth and variation.^{19, 35} This model of theoretical saturation, outlined by Charmaz, fits well with the methodological orientation of this study.³⁷

3.1 Conceptual category 1: Making autonomous choices about physical activity

Participants commonly expressed a long-held belief that they should be active. Drawing from a lens of relational autonomy emphasized that this belief was intertwined with moral values placed on self-control, which participants and others (e.g., their family members) shared with wider cultural norms of their relational settings. Although participants typically did not state these shared values explicitly, they were often subtly present in the moralistic terms (such as ‘right’, ‘discipline’, ‘should’, ‘good’, ‘guilt’) used when describing their choices about physical activity (Table 2: Quotes 1–4). Being active was commonly viewed by participants to be the ‘right thing’ that they were supposed to do, requiring some degree of self-control. Inactivity, on the other hand, was associated often with personal failing, guilt or self-blame, particularly by participants who also reported feeling bad about themselves, that they were a failure or had let themselves or their family down in their PHQ-9 questionnaire (Table 2: Quotes 3–4). For instance, Anastasia's comments about her inactivity took on a confessional tone as she recounted, ‘I rest… I do that more often than I'd like to admit’.

Shared moral values placed on self-control when making choices about physical activity were also present in participants' descriptions of performing social roles in their everyday lives. For example, following her daughter's comment ‘You said you were going to ride that bike and you haven't done that yet’, Heather expressed how she felt a slight sense of shortcoming in her role as a mother. This feeling of shortcoming was underpinned by a belief that ‘I should be modelling good physical exercise behaviour’, which evokes shared moral values around what it means to be a ‘good’ mother within the relational settings in which she lives. Heather and Nikki also felt a sense of guilt from being active as they expressed that being active meant time away from their commitments to others as a mother, wife or volunteer (Table 2: Quotes 2–4). Each of these roles is heavily intertwined with their own sets of shared moral values within the relational settings in which participants live. Making choices within this complex web of shared moral values, Heather felt ‘damned if I do and damned if I don't’ whether she chose activity or inactivity. Approaching participants' descriptions through a lens of relational autonomy thus helps to foreground how their experiences of making autonomous choices about physical activity were intertwined with a complex web of (sometimes competing) moral values shared with others (e.g., family members) and wider cultural norms in their relational settings.

Many participants described how using Fitbit to self-monitor during research participation had helped them to do ‘something right’, whether the ‘something right’ was reaching their daily step goals (Table 2: Quotes 5–7) or sitting less (Table 2: Quotes 8–9). They reported checking their step count using Fitbit, which served often as a ‘gentle reminder’ to walk ‘a bit more’ towards ‘getting what I should be getting every day’ (e.g., by walking an extra lap around the block). Participants also reported setting reminders in Fitbit that would vibrate at their chosen times prompting them to stand. Nic reflected that these reminders had ‘helped train me’ to stand more often, which became a habit she continued after turning Fitbit's reminders off.

One participant (Table 2: Quote 10), however, reasoned he had enough self-control to reach his step goals anyhow and therefore did not need to self-monitor using Fitbit because it did not add value to him. Nikki similarly recounted how she sometimes did not check her step count because she knew she was being active even if she did not self-monitor using Fitbit. She commented ‘sometimes I just forget it, like oh how many steps did I do? I know I did a lot’.

Some participants, commonly those who did not meet physical activity guidelines at baseline, described circumstances in which they experienced feelings of ambivalence about making choices to reach step count goals when wearing their Fitbit. For example, due to erosion in her ankle due to RA, Anastasia had been recommended by her surgeon not to overdo her activity and therefore she felt ambivalent about whether she should or should not reach step goals when using her Fitbit to self-monitor. On days she reached step count goals, she recalled ‘wondering if that's a good thing for my ankle’ and on days when she did not meet her step goal, she felt ‘it's probably better for my ankle… it's always that opposing thought “I want to. I need to. I should be”’.

Others (Table 2: Quotes 11–12) also described experiencing ambivalence on days they had not met a step goal. They often justified it was ‘fine’ or ‘legit’, believing they had ‘good excuses’ when ‘there was nothing I could do’ to meet the step count goals when the reasons were deemed outside their control, such as illness. These feelings, however, were also mixed with guilt or disappointment, as a person living with chronic illness, ‘you haven't done enough to take care of yourself’ or, as a research participant, ‘it was going to impact my participation in a way that I couldn't control’.

Feelings of ambivalence experienced by some participants had implications for their communication with the study PT as well as their relationship with themselves (i.e., their perception of themself as a person doing ‘something right’). Jane and Sarah, neither of whom met physical activity guidelines at baseline, both wanted to justify not meeting their step count goal so that the study PT would understand they were not to blame. The wearable was thus experienced as a potential disruptor in their relationship with the study PT, which participants sought to mitigate through reaching mutual understanding. Sarah hoped for an ‘opportunity to put in a disclaimer somewhere… Being able to do that would sort of justify that I wasn't slacking off’. This finding highlights the hope of these participants for the study PT to trust they had ‘good’ intentions to do ‘something right’. It overlaps with the second category we identify in this paper, which further explores issues of trustworthiness prompted in the relationship between the participant, the study PT and the wearable.

Other participants (Table 2: Quote 13) also commented on the possibility of feeling negatively about oneself when checking Fitbit data that indicated they had not met their step count goals. To avoid feeling upset or disappointed in themselves, they highlighted it was important to choose goals that were realistic for them. Victoria, for example, recounted how she ensured she felt in control of setting goals with the study PT because ‘it just sucks when you get upset with yourself… There's a million different things that could've happened that could've affected why you didn't do what you were supposed to do’.

Regardless of whether they met physical activity guidelines at baseline, participants experienced feelings of ambivalence when Fitbit's reminders to sit less conflicted with competing priorities in their everyday lives (Table 2: Quote 14). Anastasia ignored Fitbit's reminders while she was sewing because it was what she loved to do and felt conflicted as she recounted ‘even though getting up and moving is hard on my ankle… so is sitting for eight hours and not moving… so choose your enemy… there's never a clear right or wrong’. Nic also experienced mixed feelings when receiving Fitbit reminders to move but nevertheless welcomed the reminders. She likened Fitbit to ‘your mother when you're little tells you to brush your teeth. It's annoying… in the long run I'm so glad my mom nagged me to brush my teeth because now I have all my teeth’.

Some participants, who were already meeting physical activity guidelines, were prompted to plan and reflect on choices they had made to be more active when using Fitbit to self-monitor (Table 2: Quote 15). Having received a reminder from Fitbit to stand up at an impractical time while driving, Nic told herself ‘I should make a point… to take my dog. I'm not going to just take her out around the little park tonight and do 10 minutes, we're going to do the big loop and we're going to do an hour’. Heather described how she ‘did a lot of “Well tomorrow I know I'm going on a hike so I'm going to do 20,000 steps tomorrow. What if I only do 5000 today?”’ While at the time ‘it felt fine’, she later felt guilty and regretful about not having met her daily step goal, explaining ‘if I didn't reach the goal [the next day] then I felt like I had doubly let myself down [laughs]’.

3.2 Conceptual Category 2: Negotiating mutual trustworthiness

Participants typically expressed how they felt a moral responsibility to uphold a commitment to wearing their Fitbit as a trustworthy participant during the research study so that their Fitbit data could be used for purposes that could benefit others (Table 3: Quotes 1–3). Victoria conveyed how her sense of commitment to the research team drove her to wear her Fitbit, remarking ‘I thought I must wear the thing because I promised [the research team] I would do this to the best of my ability… I like to follow up on my promises’. Sarah also expressed a sense of commitment to a wider public depending on her to wear her Fitbit, as she commented ‘other people rely on me too, for this information… potentially it will help a lot of people… I'm doing it for somebody else’. Participants' choices to wear their Fitbit during research participation therefore played a role in how they sought to maintain a sense of themselves as a person who could be trusted by the research team and a wider public who stood to benefit from the research.

There were sometimes circumstances in which participants had not continued to wear their Fitbit during research participation, which had prompted them to feel moral tension. One participant, Nic, commented on ‘a handful of times where I just didn't wear [Fitbit]’ during research participation, recalling ‘it's like just one afternoon or one evening then it's like, “Whatever, I was just sitting anyways”’. She felt morally dubious about these actions describing herself as ‘probably just a rotten person’. Another participant, Rita, felt a sense of moral tension about her decision to stop wearing her Fitbit as it kept falling off and she did not want to lose it because she ‘respected the equipment’. She recalled she ‘felt bad because I know that was part of the research… it's important for the research to go on to learn’, but the research team ‘told me not to worry’ about stopping wearing the Fitbit, thus alleviating the moral unease she felt. Through a lens of relational autonomy, these experiences had moral implications for participants' relationships with themselves (i.e., their self-perception). Wearing their Fitbit was intertwined with the desire of these participants (shaped by the cultural norms of the context in which live) to maintain a positive moral identity as a trustworthy person. Similar to findings presented in Category 1, participants conveyed a relationship between themselves and their wearable in which the wearable was afforded an agentic quality, with a degree of influence over how their moral character may be reflected.

While participants trusted the step counts recorded by their Fitbit in general, some felt their device sometimes misrepresented the intensity and time spent in their non-ambulatory activities, such as cycling or gardening (Table 3: Quotes 4–6). For some of these participants, distrust of their wearable data had implications for (1) if and how they looked at their Fitbit data during their research participation, (2) the degree to which they relied on their own memory or bodily sensations (i.e., feeling an urge to move) and/or (3) their interactions with the study PT.

Nic, for example, continued to look at wearable data throughout her research participation although she took it with ‘a grain of salt’ and checked it against her own recollections of being active. She commented ‘you're pretty sure you know but then you can [check the data] and either you agree or disagree with what it says’. By contrast, Bob stopped looking at his wearable data, having concluded his wearable was ‘not really capturing true data’ and relying primarily on his body to tell him ‘what I'm supposed to do’ in terms of being active. For Bob, not looking at his wearable data during his research participation raised moral tensions in communication with the study PT. When the study PT encouraged Bob to ‘use the [Fitbit] better’, he felt a moral imperative to ‘be grateful’ and show appreciation for her ‘trying to help’. To avoid appearing ungrateful, he told the study PT harmless ‘white lies’ that he would continue to look at his wearable data during his research participation. A lens of relational autonomy highlights how his experience raised moral issues in his relationship with himself and the study PT, as it involved him negotiating moral norms and values within the social context in which he lived to preserve a valued sense of self as a grateful person.

Among participants who generally trusted the step counts recorded by their Fitbit, Jane envisioned that her wearable data could serve to build trust in her relationship with health professionals in future. She commented ‘it's a really helpful tool for people who have chronic illness to get that data and go back to their doctors and say like, “Here's some solid, concrete evidence that this is what I'm experiencing and that it's not like all in my head that I'm exhausted all the time” … they can look at it and they can't refute it because it's right there in black and white… The Fitbit doesn't have any biases’.

3.3 Conceptual Category 3: Preserving self-respect

Before their research participation, many participants (Table 4: Quotes 1–3), especially older participants (aged 69–71 years), conveyed they had been experiencing tensions in preserving or regaining a sense of self that was valued and respected in their relational settings. For many participants, maintaining or regaining a respected sense of self as an independent or productive person (i.e., a person able to engage in everyday physical activities that were meaningful to themselves and others within their relational settings of daily life) was threatened by physical restrictions from their arthritis. These physical restrictions limited or threatened to limit their ability to do everyday activities like cooking, walking and tasks related to paid employment.

Indeed, for some of these participants (Table 4: Quotes 4–5), their decision to participate in the research study was partly driven by a want to overcome feelings of ‘uselessness’, by contributing to ‘help someone else’. These experiences were intertwined with shared moral values placed on independence, competence and productivity, the normative structures that inhabit the relational settings in which participants live (with commonly shared understandings about social obligations and appropriate, correct or respectable behaviour). Although not stated explicitly, these shared values were particularly evident in the concerns that participants conveyed about losing independence. For example, Anastasia recalled that her husband had been a ‘great caregiver’ following surgery to her ankle prior to research participation, on which she reflected guiltily ‘you just want to say, I'm sorry I'm like this… he knows it's not my fault… but it's hard not to feel responsible… creating that kind of stress on someone else’. Victoria also expressed feelings of guilt believing that ‘if I'm in pain all the time then I'm bothering other people like my family… I should be able to deal with my own things without bringing other people into it’.

For many of these participants, physical activity offered a means to preserve or regain their independence or productivity. For example, being able to do ‘the work around the house’ enabled Jane to affirm her sense of moral worth by doing ‘my share’ and keeping up ‘my end of stuff’ in her partnership with her husband. A lens of relational autonomy helps to foreground how these experiences convey shared moral values placed on choices about physical activity, which valorize ‘doing’ in performing valued social roles in relationship with others. Similar to previous categories, these experiences highlight moral issues in participants' relationships with themselves and others, which intertwine with their relational settings. They involve participants' desires (shaped by these relational settings) to maintain qualities of a positive moral identity in which independence and productivity play a role.

For many participants (Table 4: Quotes 6–7), wearable data from their Fitbit provided a new lens through which they could see concrete proof of their physical activity, prompting them to reflect on and affirm their sense of independence or productivity. Consistent with previous categories, participants conveyed a relationship between themselves and their wearable in which the wearable was afforded an agentic quality, with a degree of influence over how they reflected qualities bound up with shared understandings of a positive moral identity to themselves and others (e.g., family members). Especially at the beginning of the study, some participants were curious to ‘start knowing’ aspects of their physical activity that remained unknown or ‘invisible’ before accumulating wearable data through self-monitoring. Jane, for example, was prompted to affirm her sense of productivity, as she recounted ‘[Fitbit] actually showed me that, you know, I'm not as still as I think I am… I don't feel quite as bad about it now that I realize like how much I actually do get accomplished in a day’. By sharing her Fitbit data with her husband, her sense of productivity and independence was further validated as she commented ‘he's away most of the day and he doesn't see… it's a bit of an eye opener for him because I really am a champion coper’.

Nikki also used her wearable data strategically, using it to provide evidence that would attest to her moral worth as a ‘good mom’. She described how her sense of productivity was affirmed through sharing her Fitbit self-monitoring data with her son. She recounted ‘I want to be a good mom… As a single parent who necessarily can't work, so I can't be like, “Hey, look at my cool job, kid”. [Yet] I'm still doing things that inspire him’. One participant was encouraged to affirm her own productivity after the study PT praised her wearable data. She recalled ‘I said something about, you know, “I don't get out much” … [the physio] looked at my results… She said, “What are you talking about? You're great”… so I'm not actually a couch potato like I think I am’. Through a lens of relational autonomy, these experiences of using a physical activity wearable with others thus helped to reaffirm qualities (e.g., independence, competence, productivity) of a valued sense of self among these participants, which was deeply intertwined with shared values of the relational settings in which they live.

For one participant, however, wearable data challenged her sense of self as a productive person. Tara thought she ‘was quite an active person’ and was surprised ‘to see these slots of time where I, I would say, waste time… I knew already that I played FreeCell more than I wanted to or should and all that, but I didn't realise that I was doing it for three hours in a row’. She too viewed her wearable data with an aura of objectivity, affording it with a degree of influence in her relationship with herself, which prompted her to question if she was a ‘lazy bum’ and reflect on why she ‘would waste time’ on something ‘that makes me feel tense and guilty’. Through a lens of relational autonomy, her experience of using a physical activity wearable thus prompted tensions in preserving a valued sense of self as a productive person within the relational settings in which she lives. These tensions are evident in her questioning whether she was a lazy person. Rethinking her sense of self in this way held negative connotations as it brought on feelings of guilt expressed by the participant, which is in line with values shared within relational settings that view laziness as inappropriate or undesirable behaviour.

3.4 Summary of findings

Drawing from the three conceptual categories identified, Figure 1 summarizes issues of relational ethics experienced by participants when using a wearable during their participation in the physical activity counselling intervention study. These issues arose within and influenced the relationships that participants had with themselves, their wearable and others (i.e., the study PT, family members), as participants sought to construct a positive sense of self as a person of moral worth in the context of their everyday lives.