Based on empirical analysis from this project, it is argued that video game and internet dependency not only deserve sociological consideration, but that a sociological analysis is vital in order to arrive at a more differentiated understanding of these complex phenomena. The debate on this new phenomenon does not however seem to do justice to its complexity. For example, the research field — as with research on mental disorders in general see Groenemeyer, — is dominated by medical-psychiatric thinking.
The prevailing psychological and neuroscientific studies focus in particular on diagnosis and epidemiology, and largely use learning theory and neurobiology models to explain the occurrence and the process of video game and internet dependency Gentile et al. Walter and Schetsche show how internet dependency as a social problem evolved historically and describe the career of problem perception. The field of video game and internet dependency is left to the more natural science and biomedicine-focused disciplines.
In a first step I want to highlight how sociologists have already looked at dependency in general. These perspectives could be fruitfully taken up also for researching this new phenomenon. These analyses show that regarding the behaviour commonly described as video game dependency VGD 3 , we are in fact dealing with a phenomenon with strong social implications which therefore deserves a sociological consideration.
But rather than presenting an established research strategy for VGD or even developing a complete sociological theory on VGD the aim of this article is to highlight empirically how the human and social sciences could contribute to a more complex description and understanding of the behaviour called VGD and to plea for more theoretical thinking and qualitative empirical research on the phenomenon. They understand dependency as a reaction to reduced chances in society strain theory or look at the close social surroundings peer and parental influence that might lead to dependency.
For example, research conducted by Norman E. He emphasizes the role of social norms, rules and rituals and thus the setting aspect. The work of well-known addiction-researcher Stanton Peele also follows this approach. For him, social structural conditions, i. Greater importance is attached to the process of how the phenomenon came to be seen and to authority of definition and evaluation; both: historically and on a microsociological level. The strength of this approach lies in its process orientation and its assumption of a contingent development rather than a deterministic one, i.
With its focus on processes and careers the labelling approach, instead, allows analysis of the interaction between the subject perspective and the structural preconditions Dollinger, and therefore allows insights into the concrete mechanisms of action. It is a doctoral project conducted as part of a study done by the Criminological Research Institute of Lower Saxony and launched in summer The reconstructive analysis attempts to supplement the purely biomedical and psychological treatment of the phenomenon with a sociological perspective and investigates the question of the evolvement of the behaviour commonly called video game dependency VGD from a social science perspective.
Starting with this curiosity the aim is to contribute to a more complex understanding of the phenomenon by taking the video gamers seriously and, in particular, placing the spotlight on the complex interrelationship between everyday life and the biography and the virtual world.
Both approaches reach way beyond paraphrasing the manifest text. What the interviewees themselves say on a manifest level, and how they interpret it, is less important than the latent functionalities of their virtual practices regarding their everyday life and biography, which they themselves might not be aware of 9.
These latent patterns are reconstructed in team sessions using a microscopic, sequential analysis and constant comparison technique for a detailed description of the procedure see Oevermann et al. In this way a database could be built up which in the end included around 1. From this pool interviewees were selected, whereby according to theoretical sampling strategy results from first data analysis influenced the selection of the next interviewees see Strauss ; Przyborski and Wohlrab-Sahr The interviews were conducted in the private setting of the interviewees or at places chosen by the interviewees.
Duration was between one and almost four hours. After describing the gaming practice, in a first step the interpretation focuses on the level of self-analysis by the interviewees with respect to their gaming behaviour. This part not only shows how uneasy the gamers feel when their gaming practices come into conflict with social norms and expectations. A second step discusses the underlying, latent motives of the gaming behaviour in the biographical context which sustain the behaviour along with the associated biographical consequences.
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He is seven years old when his parents divorce and Mathias moves with his three-year-older brother and their mother to live with her later second husband some kilometres from their home town. Their contact with their father dwindles to three or four visits a year, with Mathias always travelling to stay with his father. At around this age, Mathias has his first contact with video and computer games. He plays simple adventure games on a Commodore 16, and then goes on copying game programmes from magazines and programming his own small games. He terminates their relationship about a year and a half later.
After that, he starts to play the guitar and learns to dance. He meets his second girlfriend during his training. The video games are still part of his everyday life as they are joint activities with his girlfriend. At the end of his training, Mathias and his girlfriend study for a degree in social work.
As they start working after their introductory year, Mathias begins a second degree course and studies social sciences. After seven years in his relationship, Mathias separates from his partner and leaves the home they have shared. He begins psychotherapy to cope with depression. Once the therapy is completed, he goes to study in another European country.
Six months later, he becomes involved in an educational project. There, he meets a woman who is in a relationship with another man. They move in together and she gets pregnant. They have two sons aged three and four. Mathias is unemployed and his wife, an occupational therapist, is also at home. The family is in a difficult situation financially. Video games like the real-time browser game Farmerama and a variety of other games on an internet gaming platform play an important role in his life.
He has been playing a variety of casual games for a lot longer. These are largely skill and logic games on an internet platform where he competes against other players. He plays for money, which pushes his gaming behaviour more in the direction of gambling. His gaming practice is focused on achieving new goals. With Farmerama , it is about managing new tasks, while with the casual games it is the competition with new players.
In both cases, the other players are seen only as the measure against which to pitch his performance. Thus, although they are real people, they are exchangeable and have no relevance as individuals. This could have something to do with his experience of therapy and with his education and social science studies. With regard to his computer gaming behaviour, Mathias presents himself largely as an expert who sees through both the gaming mechanisms and his own behaviour. When looking at his biography as a whole, he identifies various phases in relation to computer gaming:.
I think, if I.. Time, money. Erm, but then there are duller times when it..
The clarity with which Mathias on a manifest level describes his behaviour contrasts with the latent message. This already becomes visible when taking a closer look at this sequence. On the one hand Mathias qualifies his gaming habits as time- and money-consuming. This is not yet problematic in itself but becomes a problem when confronted with social rules and normative expectations known and internalised by Mathias and in this situation represented by the interviewer.
He describes his day as structured by the children or, rather, by the opportunities to do something independently of the children. He claims to divide his free time into working time during the day and leisure time in the evening. But actually, playing video games turns out to be the dominant activity. In the evening, it appears as an acceptable progression from a usual, general practice of media consumption during leisure time 14 to relax from the tiring responsibilities as a father:.
The following sequence is a fitting example:. Well, when it comes to friendships and stuff And also, erm, had very different abilities to develop relationships. About one and a half years all told. I felt, well, isolated in that relationship because the clique had disbanded..
I started All those kinds of things, like. He describes himself as a lonely, neglected child — both in relation to his family and peers. His choice of words points more to situational, isolated changes which to a certain extent jump out from the loneliness, and are limited to a certain phase in his life, namely puberty. For Mathias, the ability to form a relationship seems to mean the ability to suffer. Mathias describes a significant turning point towards the positive which is linked to a withdrawal from the social circle. He now seems to seek happiness in things and in himself.
It seems as if he frees himself from the assumption of having to be socially integrated and instead pursues the things that interest him. While the first part of the biographical account was strongly characterised by passive constructions and laboured ways of expressing himself, Mathias suddenly portrays himself in a pro-active role. He formulates his words clearly and he becomes the active subject in his story. The separation from his girlfriend and the breaking apart of the clique allows Mathias to take charge of his life. On that background and given the extent of satisfactory access to informal sources, the researcher abstained from looking for official conversation partners and confined himself rather to informal communications.
Accordingly, two meetings were arranged within this framework with the goal to give the researcher both the opportunity to outline his interests and to acquire an elementary understanding of processes and problems on the field of research related criminal issues. The first meeting was organized with and by the Head of Operations of the State Office of Criminal Investigation Landeskriminalamt and six members from other departments, and the Head of Operations of the Nuremberg Office of Criminal Investigations on issues of corruption, money laundering, and economic crime.
From those two talks, more contacts by meetings, phone-calls and mail followed, in many cases conversation partners introduced the researchers to colleagues or volunteered to establish the contact in other ways. Different from tax administration, there was the clear indication that those working within the police force at any level were happy to talk about his or her work — one notable exception proving the rule was that in spite of several requests, he refused to meet and confined himself to be contacted through mails.
For talks with contacts arranged officially by the Ministry of the Interior no specific arrangements have been asked for to signify specifically those mediated informants as opposed to the informal contacts. Here, the Ministry introduced the researcher to three contact partners, from there other contacts followed. For talks with the above mentioned three contacts arranged officially by the Ministry of Justice no specific arrangements have been asked for to signify specifically those mediated informants as opposed to the informal contacts.
Due to personal recommendation, eight civil servants were contacted personally or by phone and by mail as well. It follows a list of those contacts 14 One person listed here is counted twice under Tax Auditor and Tax Consultant since he provided information both from his earlier employment at the Tax Auditing Department and from his present employment as tax consultant. Of those conversation partners, around one fifth came from Nuremberg, the remaining from Bavaria, some from other parts of Germany, mostly Berlin.
Given the importance of repeated meetings for social qualitative research cf. Accordingly, it was more important to get rather few, but cooperative conversation partners with whom complex information could be followed-up and deepened than many contacts with whom only little follow up conversation was possible and the value of provided information was rather superficial.
This attempt was successful. In about three quarters of the informants listed more than one contact could be arranged either via meetings, via telephone or mail — in a number of cases more than 10 contacts were possible, enabling even requests for assistance, proof reading or elaboration of specific expertise. In some cases information was too sensitive or for other reasons not used for quotes, but for background information only. That way the technical version documents step by step the information contributed to, and underlying, the report composition. For data-protection reasons and in the attempt to protect informants, the technical version will not be published.
Only very selected and trusted persons were given insight into excerpts of the technical version. In all departments and sections of institutions, and in all fields and categories of research the previously made experience occurred once more; not the quantity of interview partners was decisive. Many of the talks with the same person were far better than several talks with several other people. In the first interview always a lot of time needed to be spent on the research itself in order to make people understand its purpose — which left little time to make use of the remaining hour.
More the frequent meetings were the more open and differentiated information provided. Even diverging information was be helpful to clarify different versions, and to get closer to an adequate understanding of the matters at hand. For the research, and most certainly for the interested readership, the latter information was most valuable to assess what is working in accordance to the known and declares policies and what not.
Towards the end of the research, a questionnaire containing 23 Bavaria respectively 26 Federal level questions was developed arising from the insights of the research so far. The rise of this party and its popularity suggests, however, also in the light of the spread of like-minded parties in other EU states, that this party is there to stay at least for some considerable future. Both the Federal Ministries for Home Affairs and Justice and the Bavarian Ministry for Home Affair were very quick to point out that they were not the proper addressees for the questionnaire since the Ministry in charge is that of Finance.
When detailing in a second letter, that the questions addressed very well segments in their proper responsibility which has been confirmed in the replies by the Ministries of Finance, the Bavarian Minister of Home Affair also wrote a detailed reply. Peculiar was the reply by the Bavarian Ministry for Finance. The letter displayed all signs of heavy editing and it could be concluded that it was highly disputed within the ministry.
It is also significant to point out that the signatory of the letter was the lowest possible ranking civil servant for this kind of reply, while all other letters were signed by the heads of department or the Ministers themselves. When conversation partners from police and prosecution services were asked to comment on that behavior of their supreme employers and their parliamentary supervisors they only stated that of course, all excuses are sought not to answer the kind of critical questions which were put to them for comments.
A major features, they explained, of day to day political excitement is the lack of middle and long-term planning. Rather, resources are merely sent to areas where they are most urgently needed, were quick statistically proven success can be expected and where the public is involved by, e. This makes sense, because when the questionnaire was sent out, experts in Home Affairs both in ministries and in parliament were pre-occupied with issues of Neo-Nazism NSU-Enquete Commission and terrorism the Paris attacks.
In the attempt of gaining a better background understanding especially of the reply by Bavarian Ministries of Home Affair and Finance, informal conversation partners were asked to give a detailed comment on the replies from an insider point of view. Among the statements coming from representatives in the field of tax and finance it is interesting to see the difference between the Federal Ministry of Finance and the Bavarian Ministry of Finance both in terms the quantity and the quality. While the former put a lot of effort and care in the reply, the latter comes along with a rather polemic and simplified way.
Equally, the statements of representatives of political parties vary in accordance to their political values and norms, and not surprising that there is a strong difference in representatives of parties in government responsibility and those in opposition. Given the importance, those respondents have for shaping legislation in tax related issues a personal reading of the transmitted statements that is recommended.
For quantitative replies, alternatives for selecting and marking were provided.
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For the qualitative parts, open questions were asked without any prior suggestions or alternatives. The open answers sometimes essays, sometimes only sketches and catchwords were grouped into typological answers. This survey was chance-guided, i. The survey was carried out at churches or meetings. About questionnaires were returned to the project.
Since the researcher was a non-expert at the beginning and a very little literature was available for preparation, hypotheses and interests guiding the first interviews were either very general or were guided by a knowledge which was quickly replaced by more differentiating points of view on part of the interview partners. Even if a lot of time is elapsing on efforts to identify important research focal points it is of worth because this is the movement away from anticipated points of interests by the researcher to the critical issues as seen by interview partners, and accordingly, the object matters.
Building upon the talks mentioned above, the quotable public verification of information was looked for, and the context of exemplarily raised issues was examined in more details.
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However, a problem faced here is that the publications which are available publicly either from public administration or NGOs e. At times, passages from those interviewed were sent back to interviewees with the request to look over them and correct and comment on passages, were they found it to be appropriate. Henceforth, the literature could likewise be researched more down to the points under investigation.
Two examples are given below which cannot adequately be translated into English. The first example addresses the question of understaffing and whether the Ministry of Finance does enough to fill up the ranks. Denn er hat neue Stellen auf rund 1. Damit kann nicht nur jeder Beamtinnen und Beamten vorhandenen ausscheidende Mitarbeiter ersetzt werden, Planstellen. Und das sind mehr. Diese sondern die Personalsituation wird insgesamt gleichen allerdings die Stellenverluste nicht verbessert. Minister Fahrenschon hat diese Entwicklung gestoppt, abernicht umgedreht.
Insbesondere im Innendienst. In this case the author can just state that both parties disagree upon how to judge that which is de facto being undertaken. Therefore, the researcher assumes the position that both parties agree that more staff is needed, but that they disagree with a.
In one press release, the representative of the trade union argued that at least positions in the tax administration are missing, whereas, the Ministry countered that since almost positions have been created — one information not really contradicting the other. When one MP tried to seek out how big the problem is, everybody was surprised to see that it apparently did not exist. According to the Ministry, there was hardly any overwork in any local tax administration in Bavaria in Taking two examples from the region of Middle Franconia: in the tax office Nuremberg South the employees worked 0 hours overtime; at the same time, the maximum overtime occurred in the tax office Hilpoltstein with 3 hours and 5 minutes.
Es existiert die sog. Das Guthaben kann er entweder mit Minus verrechnen oder zum Ausgleich neben dem Urlaub sog. Zeitausgleichtage nehmen. Diese Zeitausgleichtage sind auf 24 Tage pro Jahr begrenzt. Wie mit den Zeitguthaben bzw. So kannz. Beim Arbeitszeitguthaben sind wir da flexibler hier gibt es einen Stichtag z. Vom Die sog. Das z. Bei diesen Kolleginnen und Kollegen reichen oft die 24 Zeitausgleichtage nicht aus. Wenn jetzt aber eine z. In some cases, the implementation of TAVI resulted in a better collaboration between both departments.
The interviews indicate that this depended on central actors, which underscores previous research [ 22 ]. Champions, eager to implement the method, facilitated the dialogue between both departments and took initiative to drive the process forward. However, if the balance of power favored the standard treatment instead of TAVI, it needed stimuli like a staff turnover to facilitate new approaches.
These findings suggest that moderation could be needed to foster the implementation process and to mediate between different interests. In all our cases, the procedure was implemented sooner or later, implying that if conflicts of interest existed, they were solved. The interviews suggest that cardiologists had more bargaining power. A reason for this could be the fact that the intervention is indicated by the cardiologists, and patients undergo surgery only if the cardiologist sees that as an option.
Another reason lies in the possibility to hire expertise from the outside, as was mentioned in one of the interviews. Even though prevailing issues have been solved in all cases, it could lead to further dissent in the future due to expanding indications, as comments regarding this conflict imply. According to the recommendations of German and international cardiac and cardiothoracic societies and associations, the decision whether TAVI is an option for the patient should be made by a heart team comprised of cardiologists, a cardiac surgeon, and anesthesiologists.
If required, this also includes other specialists such as vascular surgeons or angiologists [ 27 ]. This refers to what Greenhalgh et al. If the soft periphery, in the case of TAVI having a surgical department on site 3 , is no longer perceived as necessary, this could further increase the diffusion of the procedure.
As the respondents mentioned during the interviews and as current debates suggest, this requirement is more and more questioned. We could show that the procedure was perceived as significantly better. Still, this is only true for the current indication: older patients with severe symptomatic AS who are not suited for conventional procedures [ 10 ]. Considering the age of patients undergoing TAVI, the recommendations of the national and European cardiac and cardiothoracic societies and associations suggest a minimum age of 75 [ 10 ].
In the group of patients under the age of 75, the surgical intervention was considered superior to TAVI, although the respondents predicted changing recommendations for the near future. Even though experimenting with new techniques and procedures bears a high degree of risk, trialability can have an important impact on the adoption decision of medical devices and facilitate the uptake [ 28 ].
As pointed out by Chaudoir et al. This study raises additional questions that have to be investigated further. The ongoing debate about the indications for TAVI, as well as the requirements necessary to perform the procedure, requires more research from different angles. For instance, a discourse analysis could provide additional insights about the balance of power. This is also interesting with respect to the conflict between cardiologists and cardiac surgeons.
Further studies should focus particularly on the question of how, and in which ways, new medical devices, procedures, and their diffusion affects the collaboration and interaction of medical professionalism and work processes. From a practical point of view, different factors that were discussed within this study provide opportunities to influence the implementation and diffusion of the procedure. Moderation could be a way to support the implementation process. Focus should also be placed on conflicts about competences and responsibilities as they could lead to negative implementation outcomes and, as a worst case, cause harm to the patients.
This study focuses only on cardiologists and thoracic surgeons working in hospitals. Further interviews with administrative staff, like medical or commercial directors or nursing staff, could provide further insights into the implementation processes. This derived from the fact that we faced multiple challenges during the recruitment. Firstly, the subject of our research is considered controversial at the national and international level, which seemed to affect the willingness to participate in a negative way.
This could have caused irritation and lead some to reject participation. The respondents were also asked to recall events and discussions form the past, in some cases covering several years, which could have a negative effect on the level of detail. Even though anonymity was ensured prior to and after the interview, the answers given bear the risk of social desirability.
The respondents may have given answers that they felt were pleasing to the interviewer. This paper has, based on problem-centered interviews, illustrated factors affecting the adoption, implementation, and diffusion of TAVI within German hospitals. According to the multi-level model described by Greenhalgh et al. Summarizing the results, we found that, on the innovation level, relative advantage was not only expressed in terms of medical advantages and social prestige but reimbursement also positively affected the adoption decision.
The same is true with respect to the attribute of complexity: Even though the intervention was described as complex, this seems to have a positive rather than a negative effect on the adoption decision. According to the domain of communication and influence, opinion leader could be identified on the system level.
The implementation of the procedure was driven by champions, typically head physicians of the department of cardiology, while cardiac surgeons took the role of gatekeepers. A well-established cooperation supported the implementation process, whereas an internal conflict interrupted it. Reimbursement policies and the public debate affected the diffusion of the method as external factors.
The most dominant themes proved to be the medical advantages of the procedure, the fact that it was quite easy to have TAVI reimbursed, and the cooperation and competition between medical departments and disciplines. Interestingly, TAVI diffused relatively quickly despite major challenges and hindrances that occurred during the diffusion process. Most notably, this includes the conflict between cardiologists and cardiac surgeons regarding responsibilities and competences and, as a consequence, due to the controversial debate.
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Taking into consideration the professional discourse about TAVI, further research from different disciplines is needed not only to guarantee a safe and controlled diffusion of TAVI but also other emerging procedures and innovations. Only hospitals with more than five cases are included. Competing interests.
SM and SB conceptualized the specific research question. All authors were involved in the discussions that led to the framing and conceptualization of this paper and in data analysis and interpretation.
SM wrote the initial draft of this manuscript, and all authors provided substantive comments and edits, producing the final version. All authors read and modified drafts and approved the final manuscript. National Center for Biotechnology Information , U. Journal List Implement Sci v. Implement Sci. Published online Oct 6. Neugebauer , and Stephan von Bandemer. Edmund A. Author information Article notes Copyright and License information Disclaimer. Sebastian Merkel, Email: ue. Corresponding author. Received Dec 16; Accepted Sep This article has been cited by other articles in PMC.
Abstract Background The transcatheter aortic valve implantation TAVI , a minimally invasive surgical procedure to treat patients with severe symptomatic aortic stenosis, showed a rapid diffusion in Germany compared to the international level. Methods We conducted problem-centered interviews with cardiologists and cardiac surgeons working in German hospitals. Results Among the ten participants who were interviewed, we found both barriers and facilitators related to the innovation itself, system readiness and antecedents, communication and influence, and the outer context.
Conclusions The findings show that there are multiple factors influencing the diffusion of TAVI that go beyond the reimbursement and cost issues. Open in a separate window. Method Data collection We used the model provided by Greenhalgh et al. Sample size and recruitment While there is no general agreement regarding the sample size for the problem-centered interview, between 7 to 30 interviews is suggested based on previous research [ 26 ].
Analysis of the data Each transcript was analyzed using qualitative content analysis, which was then organized in four steps: 1 There was a familiarizations process with the data to gain a deeper understanding. Anonymization Though anonymization does not receive much attention in qualitative studies [ 21 ], it has to be seen as a central aspect and leads to multiple challenges. Results In total, we conducted ten interviews across nine sites, three of which were university hospitals.
Communication and influence The physicians referred to two main sources of information. System readiness and system antecedents Pressure for change was widely reported by the respondents. The outer context Concerning the extra-organizational context, the respondents described economic as well as social influences on the adoption decision. Recommendations for research and practice This study raises additional questions that have to be investigated further.
Limitations This study focuses only on cardiologists and thoracic surgeons working in hospitals. Conclusions This paper has, based on problem-centered interviews, illustrated factors affecting the adoption, implementation, and diffusion of TAVI within German hospitals.
Competing interests The authors declare that they have no competing interests. References 1. Explaining diffusion patterns for complex health care innovations. Health Care Manage Rev. The nonspread of innovations: the mediating role of professionals. Acad Manag J. Interlocking interactions, the diffusion of innovations in health care. Human Relations. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.