An explorative design with the grounded theory (GT) approach by Corbin and Strauss [19] was used. GT has been developed from symbolic interactionism which requires the individual to develop through social interaction and the creation of meaning [19, 20]. The main purpose of doing GT studies is to generate concepts, models or theories developed from empirical data in order to explain the phenomenon under study. Data collection and data analysis is a process that intertwines the two with each other. The collection of data begins with a purposeful sampling followed by theoretical sampling. Theoretical sampling includes both new collection of data as well as a theoretical sampling of the existing data when a theory is arising to look for aspects to confirm the arising theory or to object to the theory. The steps of data analysis are: open coding, axial coding and selective coding. Throughout the analysis process asking questions about the data and constant comparison are of importance. Questions useful to ask could be: “What is going on?” and “Who are the actors involved and what is the meaning to them?” The constant comparison means to compare each situation with other situations for similarities and differences. During the analysis process ideas, preliminary assumptions and theoretical reflection are written down in memos in order to help with the generation of a theoretical model [19].

During autumn 2009 and spring 2010, 16 informants were asked to participate in an interview and all agreed to join the study. The inclusion criteria for participation were that they were diagnosed with RA and could speak the Swedish language. To gain the variation of different ways of management, a purposeful sample was used with regard to: age, sex and disease duration. The overview of background factors (Table 1) shows that the mean age for women was 62 years (28-82) and for men 61 years (42-70). They had different levels of education and civil status. Disease duration varied between 2-42 years with a mean value of 14 years. They all were treated at a rheumatology hospital either at the day-care clinic or at the rehabilitation department and were contacted by a nurse in adjacent to their planned visit. They received written information and if willing to attend, the nurse at the hospital got in contact with the first author (UB) who contacted the informants to give more information and set the day and place for the interview. The interviews were done by the first author at the rheumatology hospital in a private room. Each interview lasted between 20 and 50 minutes and was transcribed verbatim. The interview began with the opening question, “How do you manage your rheumatic disease, RA?” Questions that followed were given in order to deepen the answers, “Can you tell me more about that?” and “What did you do then?” so as to gain rich meaning and experiences from the informants.

The informants were interviewed at one occasion but had the opportunity to contact the interviewer if further questions or comments occurred. One informant contacted the interviewer to clarify the time of diagnose of RA.

The open coding began directly with the first interview, through reading the text line by line to identify words, phrases and sentences which were then labeled with codes that captured the meaning according to the aim. By asking questions about the data this coding process moved on to the next level of analysis where these codes were clustered into higher categories (axial coding). In the axial coding process two categories were defined; making use of personal resources and grasping for support from others, as important parts of the management process. In the selective coding process the core category, striving for a good life, emerged as the overall theme. The theory arose when linking the core category with these two categories; making use of personal resources and grasping for support from others together. Through theoretical sampling in the selective coding process four dimensions of managing of RA emerged by constant comparison and asking theoretical questions to the data. Throughout the data collection and analysis the first author wrote memos according to GT methodology. After 13 interviews and analyses no more meaningful information was gained indicating theoretical saturation. An additional three interviews were conducted to ensure that the information from the patient was theory based.

The study was approved by the regional Ethics Committee at Lund University (LU-2009/391). The study was explained both verbally and in writing to informants and informed consent was obtained. They were informed that participation was voluntary and that they could withdraw without any further explanation. Confidentiality was guaranteed and it was emphasized that none of the informants would be identifiable. None of the researchers were involved in the care of the informants.

This way of managing RA was characterised by experiencing their situation in a way of acceptance. They used their personal resources, felt confident in themselves and expressed trustfulness in the support from others in their striving for a good life. Patients described personal resources, such as having a positive attitude to life and an optimistic personality, that were used as sources to manage the disease as well as other problems in life. Mastering was a way of management that could involve a long process before it was reached. A woman expressed,”…but I can’t stop and live… I have to overcome so to speak…through building up in some way a confidence in oneself, that you can fix this. I think that you can be quite capable if you focus and most things are able to be solved with a little thought.” There were patients that drafted a more direct way of mastering. A woman said, ”So, it is just so recently... but I’ve accepted it…and it’s just so nice…already from the beginning so to speak… It was just obvious that I would have medicine that would help…and it has done a great deal of good…I have all support from home... and I have been able to work... it means a great deal to not feel sick.” Patients described their need to continue with leisure-time activities and to feel that they still were in charge over their lives. In having a chronic disease with disabilities they believed and framed a need for support in everyday life, as well as quick support from healthcare providers when symptoms arose or when there were problems with the medications. Hence, the mastering way of managing RA was to put the person’s life in front of the disease and not focus on the disease. Patients showed both faith and gratitude to the support around them.

This way of managing RA in striving for a good life was depending on others and the patients experienced trustfulness in their grasping for support from healthcare providers, relatives and friends. The support from healthcare providers was equally valued as the support from relatives and friends. Patients did not mention their own capability or their own responsibility in the management of RA, but that they depended on others. They described their experience of the healthcare as good, felt secure and expressed gratitude to have access to their healthcare. Patients had experienced episodes of caring where nurses suggested helpful hints which they could not have figured out by themselves. There was also a gratitude to the medical treatment and care they were offered, but they still related some worry about the future. A man treated with an intravenous medicine each 8 weeks at the rheumatology clinic expressed, ”Some week before I come here I feel... how I start to have pain in my joints again... just a little bit, swollen up some joint like that... know that I soon am coming to the nurse (name given) and then it becomes good again. You can’t do anything about it (the disease)... it was when I received this (the medicine) then…a real miracle for me…if you don’t get this… How would it have been then?…The future, yes... that maybe you are a little worried about... regarding the medicines, if it stops working or side effects…a little worried.” Relatives were also important and often mentioned in relation to the need for more personal care or help with household work. A woman claimed, ”I have had terrifically good help…it means so much of course…so what I can’t do, he does (the husband), so I have very good help in the household and things like that... only a thing like going to the store…I can carry one or two kilograms, but that is nothing if you are going to shop for the household... and so, therefore, you are very dependent on someone else.” Accordingly, the relying way of managing RA showed that patients striving for a good life were depending on the good support they had. Their own responsibility was not in focus when expressing their ways of managing RA.

This way of managing RA was characterised by patients that were in an active role in order to gain respect, particularly from others. They expressed high self-confidence, but they were in ambivalence. In one way they wanted to look after themselves, but they were still depending on the support from others. One aspect of this struggling was described in not reaching the right support from healthcare providers. They had to fight for seeing a doctor whom they felt trust in. One man said, ”He didn’t give any confidence as a doctor should do... it became totally wrong... for me it didn’t feel right... it became so that I wasn’t welcome anymore... but I care how they treat me... it maybe is the difference in those who are 70 years old or more… I say no.” Another way of struggling was for independence. They described a strong belief in managing RA themselves with a minimum of support from others. Their personal resources were not in balance with their need of support, so they were struggling with accepting support from relatives when offered. They wanted to manage more than they could and battled with the fact that they had a chronic disease. The struggle could also incorporate different illness perceptions in relation to the healthcare system. Patients were not satisfied with how the healthcare providers expressed themselves in the encounter with the patient. A woman formulated her experience like this, ”I see myself as healthy... I consider myself to be in very good health... I am the type of person who has a difficult time in how people express themselves... it shows a lot about what kind of view of humanity a person has... I consider that everyone all around should express themselves in the right way.” Thus, the struggling way of managing RA was for the patients a battle that was hard to accept and they were fighting for respect. The outcome of the struggle was of importance when they tried to strive for a good life.

This way of managing RA expressed less of personal resources in combination with ambiguity to the support from others. Patients experienced a wish for something to happen and they did not think that they had the possibility to choose or the ability to change this on their own. Patients were describing this kind of management in the beginning of the disease and often they moved forward to another way of management, but still there were patients in this dimension a couple of years after the diagnosis. They expressed that their RA led to various types of restrictions. They could not, for example, do certain specific physical activities any longer, discussed in a way of letting the disease take a greater part in their lives and how the disease became the main focus. A woman commented,” Yes, I have adjusted my life entirely... I live through the rheumatism.” In regard to their need for support from others they expressed difficulties in being taken seriously by relatives as well as healthcare providers. Friends and relatives could have difficulties to understand the problems the disease created and that could lead to social restrictions in life. As one woman said,”What do you do all day?’ people say. They don’t understand that... that everything takes time... A person isn’t so quick and you have to take little detours. But I never can manage so much as I would like, am never finished with anything... there isn’t enough energy?”

There were also difficulties in the encounter with healthcare providers by not being taken seriously, as well as the problems reaching the rheumatologist and getting an appointment at the clinic. As a result, this way of management possessed characteristics of the patients letting the disease take a great part in life and that they felt ambiguity to the support from others they received. Their striving for a good life was sometimes not fulfilled.

The present study had a qualitative design using grounded theory as the approach to answer the research question. In order to meet the methodological considerations of data collection and analysis, the following four terms were used: applicability, reasonableness, trustworthiness and conscientiousness [31]. Applicability was addressed by using relevant method for the aim of the study, as well as using purposeful and theoretical sampling in order to obtain a good representation of informants with different experiences of everyday life with RA. Reasonableness was ensured by describing the concordance between the data collection method and the area of investigation and through continuous movement back and forth between the whole and the parts during the constant comparison analysis [19]. Trustworthiness was guaranteed by the systematic and methodical approach to data analysis and by the co-researchers who had earlier experience with this method. Conscientiousness and honesty towards the informants was important from the start of the research process, through the different stages of analysis and to the presentation of a clear and comprehensive picture. This was achieved by indentifying statements from the informants and making continuous comparisons between data, codes and categories throughout the analysis process. The informants’ integrity was respected all through the research process. A possible limitation in the study was that all interviews where done at the same hospital but the patients in the study had experiences from other settings to.