Dynamic Health Care Environment

1.0 Introduction 1.         INTRODUCTION In today's dynamic health care environment, it is important that nursing practice is based on sound scientific knowledge.  Recent professional publications highlight the crucial role of nursing research.  There is increasing awareness that many conventional nursing practices are not underpinned by sound evidence (Parahoo & McKenna 1999)  and that only a moderate number of nurses use research as a basis for practice (Mulhall 1998) Through research, knowledge is developed to underpin the provision of safe and effective patient care and develop evidence-informed policy. Nursing strategies endorsed by the UK governments specify that nursing practice should be underpinned by the best available evidence and make explicit the requirement to undertake nursing research (Royal College of Nursing 2004). The NMC (2004) make it clear that nurses are accountable for their practice, and that they should not work outside their scope of practice.  The need for nurses to use evidence based practice is largely documented and has led to much prominence being placed on clinical research and audit. Therefore the provision of high quality evidence based practice is of extreme interest to the researcher and was one of the motivating factors for choosing definition of faecal incontinence as a research topic.     Nursing research is beneficial to nurses by methodically looking for and authenticating knowledge (Polit & Hungler 1999).  Parahoo (1997) suggests that nurses should be able to understand and carry out research relating to their area of practice and should be aware of the importance and relevance to practice thereby improving patient care.  According to NICE guidelines (2007), faecal incontinence denotes a common condition that may affect up to 10 percent of adults, thus having a negative impact of lifestyle, physical and psychological health of individuals suffering from the condition.  Faecal Incontinence causes severe social restriction and tends to be a hidden problem, with many feeling ashamed to admit such symptoms to healthcare professionals, family and friends.   2.0 Aim RESEARCH AIMS The aim of the study is to discover whether a universal definition of faecal incontinence would improve assessment of faecal incontinence. The main objective of the study is to determine whether such a universal definition of FI will assist nurses in realizing their professional role within basis of evidences in such practices to be recognized and be acquired by the nurses involved in such case. 2.1 Objectives OBJECTIVES The initial objectives can be that: To acquire ample application of FI in terms of determining such universal definition for purpose of assessing improvement of faecal incontinence To execute good research posits towards the development of a better nursing practice along with such process relating to FI's universal definition Then, to make certain of FI information be available to nursing practice and its related research and design ideal interview questionnaire for nurses. 3.0 Research Design RESEARCH APPROACH OR DESIGN Research Design refers to a systematic plan to coordinate research to ensure the efficient use of resources and to guide the research according to scientific methods (Hopkins 2000).  The complex approach underpinning nursing has led to the implementation of methodologies which can be divided into qualitative and quantitative research (Martin & Thompson 2000). Qualitative research is an established method of investigation in nursing research. This method of research seeks to understand motivations of people (Porter 1999).  This method can be contrasted with quantitative approaches; which identifies and deals with facts.  Therefore, qualitative researchers highlight the significance of subjective knowledge whilst to quantitative researchers; objective knowledge is of paramount importance.   Qualitative and quantitative methods of research are not mutually exclusive; at times both schools of thought merge (Porter 1999) and researchers use features of both. Carter (1996) posits that each method make a valuable contribution to nursing and the selection of either qualitative or quantitative approach will depend on the topic being investigated, the aim of the research and the state of existing knowledge.  The descriptive method of research is to be used in this study.  Creswell (1994) defines descriptive method of research as gathering information about present existing conditions.  The emphasis is on describing rather than judging or interpreting.  The aim of descriptive research is to verify formulated hypotheses that refer to present situations in order to clarify it.  The descriptive approach is quick, practical and cost effective.  Moreover, this method allows a flexible approach, thus when important new issues and questions arise during the study, further investigations may be conducted.  This method can use either qualitative or quantitative data or both, allowing the researcher greater options when selecting the instrument for data gathering (Saunders, Lewis & Thornhill, 2003).   Quantitative data collection methods are centred on the determination of the weighted mean of the given statements. When these methods are used, the researcher is usually detached from the study and the final output is context free. Measurement, numerical data, and statistics are the main substance of quantitative instruments (Saunders, Lewis & Thornhill, 2003). With these instruments, an explicit description of data collection and analysis of procedures are necessary. The quantitative approach is more on the detailed description of phenomenon. It basically gives a generalization of the gathered data with tentative synthesized interpretations.   Quantitative approach is useful as it helps the researcher to prevent bias in gathering and presenting research data. Quantitative data collection procedures create epistemological (epistemology is a branch of philosophy that investigates the origin, nature, methods, and limits of human knowledge) postulations that reality is objective and unitary, which can only be realized by means of transcending individual perspective. This phenomenon in turn should be discussed or explained by means of data analysis gathered through objective forms of measurement. The quantitative data gathering methods are useful especially when a study needs to measure the perception of respondents regarding a topic. The purpose of quantitative approach is to avoid subjectivity by means of collecting and exploring information which describes the experience being studied (Gall, Gall & Borg, 2003). In other words, subjectivity of judgment can be avoided through quantitative methods. Thus, conclusions, discussion, and experimentation involved in the process are more objective. Variables, both dependent and independent, that are needed in the study are clearly and precisely specified in a quantitative study. In addition, quantitative method enables longitudinal measures of subsequent performance of the respondents. It has been noted that qualitative researchers aim to decode, describe, analyze, and interpret accurately the meaning of a certain phenomena happening in their customary social contexts. The focus of the researchers utilizing the framework of the interpretative paradigm is on the investigation of authenticity, complexity, and contextualization, mutual subjectivity of the researcher and the respondent as well as the reduction of illusion.   Quantitative research can be divided into either experimental or non-experimental designs (Watson 1999). Experimental research is aimed at exploring cause and effect, whilst non-experimental research designs construct a picture of a phenomenon or explore events, people or situations as they naturally occur (LoBiondo-Wood & Haber 1998).   In descriptive research, the identification of relationships between variables serves to generate hypothesis for further exploration. A descriptive study collects, organise and review information about the matter being studied (Punch 2000). Collected data can be used to make plans for improving care (Carter ). Parahoo & McKenna (1999) consider that survey is the most suitable method to use when descriptive data are required. Survey research makes it possible to gather data from a large sample of subjects drawn from a defined population. In summary, therefore, the writer intends to carry out a quantitative, descriptive survey on the definition of faecal incontinence.     3.1Research Instruments   The writer intends to use interview questionnaires to gather pertinent data.  This method will save time and effort in organising answers. The questionnaire will be distributed to nurses, General Practitioners and to those identified with faecal incontinence.  The questions are structured on the Likert format, with a five-point response scale; requiring the subject to indicate his or her degree of agreement or disagreement to a statement. In this type of questionnaire, the respondents are given five response choices, see table 1. These options will serve as the quantification of the participants' agreement or disagreement on each question.   Table 1   5     Strongly Agree     4   Agree   3     Uncertain   2     Disagree   1     Strongly Disagree     3.2 Interviews Interviews will be the primary tool in providing clarifications and verification of the result of the survey.  Semi-structured interviews will be carried out with the interviewees. Unlike structured interviews which are standardized and do not allow the interviewer to deviate from the questions (Saunders, Lewis, and Thornhill, 2003), this type of interview does not limit response of the interviewees. Open-ended questions will also be asked of the interviewees. Open questioning will help the researcher explore the topic and produce a fuller account. Interviews will also be conducted through face-to-face interaction.   3.3 Access and Sampling A vital part in sampling is to identify the target population to be researched, for example, members of the medical profession (Ball & Cox 2003). Proper sampling enables the researcher to come to conclusions or make generalisations about the population (Watson 1999). The sample must be really representative of the population to be studied and also, remain practical in terms of the research (Haber 1998, Watson 1999).  According to Polit & Hungler (1997) probability sampling, using random selection ensures fairness to participants.  This is also believed to minimise risk of bias in data collection. For the purpose of this study the writer propose to use simple random sampling to select GP practices, nurses and patients.   The first step for the nurse researcher wishing to gain access for a study is to approach those people who can help with the study (Benton & Cormack 1996). Letters will be sent to the selected GP surgeries and the teaching hospital selected (Appendix).   The research will be covering GPs, nurses and adults over the age of 60 diagnosed with faecal incontinence defined as any involuntary loss of faeces causing a social and or hygienic problem. The proposed research will be relevant to patients and health care providers within the community or hospital setting.  A total of 50 respondents from these settings will be randomly selected to make up the sample. The selected participants will be required to answer a survey questionnaire structure in Likert format. Data gathered from this research instrument will be computed for interpretation. Along with primary data, the researcher will also make use of secondary resources in the form of published articles and literature to support the survey results.   4.0 METHOD OF DATA COLLECTION AND PROCEDURE Parahoo & McKenna (1999) regard questionnaires, structured interviews and observations as the main method of data collection for quantitative research, therefore the data to be collected must be relevant, achievable and manageable within the  time and resources available. Polit & Hungler (1997 contends that interviews yield a higher response rate than questionnaires and that they obtain richer data.   An added advantage is that the researcher is able to clarify facts or interpretations. Watson (1999) concurs and stipulate that questionnaires allow the researcher to collect data from large population samples or from subjects who are geographically remote.  Postal questionnaires are an economically and expedient method of data collection for most researchers Polit & Hungler 1997) and offer the possibility of anonymity and lessen the risk of researcher bias.   There are disadvantages with postal questionnaires; these are poor response rates and the complications in making convincing generalisations from findings. In actual fact, Barker (1996) asserts that the self-selective nature of responses compels the researcher to query final conclusions. Grey (1998) contends that there is a problem inherent in all forms of verbal or written self report as the subject might respond in a way that makes a favourable impression, this is known as the Hawthorne effect.   The study will be using the descriptive form of research. This means that the data acquired on this paper will be first hand and will be based on the actual observations made by the researcher. (Creswell, 1994 p. 342) In this regard, both qualitative and quantitative data will be taken to ensure that the analysis will be well covered. The primary research instrument will be the researcher-made questionnaire given to randomly selected respondents. The secondary data will come from articles and journals tackling faecal Incontinence, quality of life, psychological issues of patients. The study procedure will be explained to the participants and reassurances given to them that their answers will be anonymous and that any answers given will be in confidence.  Primary data will consist of answers to the questionnaires, while secondary data will consist of the research done by the researcher including interviews held to compile pertinent information about the problem of the study. Quantitative and qualitative data will be analyzed.  Quantitative data will be sourced to the primary data gathered and will undergo compilation, frequencies, percentages and determination of relationships. Qualitative data will come from the open-ended questions in the questionnaire that will reflect the personal opinions of respondents not included in the selection, data will be significant when quantitative data is discovered to have deviations from the hypothesized variables.   5.0 RIGOUR The data to be gathered will be tallied by the researcher and will be encoded in the computer.  A hard copy will be printed to ensure that files are kept including the questionnaire responses of the sample.  Frequencies will be computed into percentages and will be presented through graphs, tables and textual arrangements.  The latter will clarify the graphs and tables.  The data will also undergo interpretation to determine the causal relationships of the predetermined independent and dependent variables.  Such data will form the heart of the findings of the study and will indicate the applicability of the research. The research study anticipates discovering a unified definition for faecal incontinence, thereby helping in the early assessment of FI.    6.0 ANALYSIS: PROCESS AND METHOD Hazard Munro (2001) contends that descriptive statistics should be used to illustrate data by summarising them into appreciable terms without distorting the information.  Watson (1999) asserts that the quantitative researcher use statistical analysis to determine whether results of a study accurately represents a phenomenon, or whether the results are not authentic.  To perform data analysis, the data must be in numerical form and variables in descriptive data are given values to facilitate such analysis.   The data in this study will be analysed using SPSS for Windows. Martin & Thompson (2000) support the use of SPSS, and depict it as the leading computer based statistical programme, used for a wide variety of statistical tests.  They, however warn that the skills and knowledge of the user are precipitating factors that can limit the usefulness of computer-based programmes. In order to analyze the data gathered from the questionnaire, the weighted mean for each question item will be computed. A weighted mean is the average wherein every quantity to be averaged has a corresponding weight; these weights represent the significance of each quantity to the average. To compute the weighted mean, each value will be multiplied by its weight which will then be added to obtain the total value. The total weight will also be computed by adding all the weights and the total value will be divided by the total weight.   The range and interpretation of the five-point scale are shown in Table two.   Table 2: The Five-point Likert Scale Scale Range Interpretation 1 4.50 – 5.00 Strongly Disagree 2 3.50 – 4.49 Disagree 3 2.50 – 3.49 Uncertain 4 1.50 – 2.49 Agree 5 0.00-1.49 Strongly Agree   Weighted mean will be used to measure the general response of the survey samples, whether they agree to a given statement or not. It is proposed that the result of the survey will be presented in tables and excerpts from the interview integrated, based on the analysis outcome. Relevant literature to support the findings will also be included.   After the collection of information from self-administered questionnaire, and related studies, the data will be collated.  The statistical analysis for the information from semi-structure questionnaire was conducted using Microsoft Excel where the data is tabulated, graphed, and evaluated.  The testing of the level of significance will be conducted using the Statistical Package for Social Sciences (SPSS) and tabulated in the Excel files.  The SPSS is the standard software for conducting statistical analysis. Percentage – to determine the magnitude of the responses to the questionnaire: Where:  n = number of responses                                                                 N = total number of respondents Weighted Mean: Where: f – weight given to each response x – Number of responses xt – total number of responses For evaluation purposes, the percentage analysis and mean analysis will be used.   7.0       ETHICAL CONSIDERATIONS It is important to consider ethical implications whilst conducting research, and many authors, including Parahoo & McKenna (1999) maintain that researchers must guarantee that study participants rights are not infringed and that they come to no harm.  Additionally, nurses must perform according to the Code of Professional Conduct (NMC 2004).  It is understood that research should be guided by the ethical principles of autonomy, beneficence, non-maleficence, and justice (Hyde & Treacy 1999).   7.1             Confidentiality Confidentiality is pivotal to the development of trust between study participants and the researcher.  This research intends to protect the anonymity and confidential status of the participants by adopting strategies to protect identity and to secure information given during the research process. Parahoo & McKenna (1999) caution that respondents might be reluctant to give their opinion if they think answers can be traced back to them. The researcher must guarantee not to reveal to others what has been learned from individual subjects. The writer intends to code data and data collection tools in such a way that a subjects identity could not be accidentally revealed, as recommended by Martin & Thompson (2000).   The chosen respondents for this proposed study will be given a waiver regarding confidentiality issues over their identity and the information they choose to disclose. The interview and questionnaire tools will be explained to the participants and reassurances made to them. 7.2             Minimising Harm – Non-maleficience Ethical approval will be sought from the Ethics Committee, thereby ensuring that basic principles are met (Robson 2000). Giving clear and concise information to the participants will minimise any potential for distress and by being clear about the researcher's role boundaries and ensure that appropriate information and support are available. 8.0 Anticipated study outcomes and relationship to practice The development of a universal definition for faecal incontinence and  valid and reliable tool to measure patient-rated outcomes including symptom severity and quality of life would enable standardisation of outcome measures with which to compare results of interventions, allowing the effectiveness of interventions to be genuinely compared and accurately assessed. Qualitative approach will highlight paucity of information on patients' views and the crudeness of current evaluation of symptoms and outcomes. By involving users, healthcare providers and qualitative researchers in the design of tool, the most relevant outcomes could be measured, including symptom severity and quality of life. Each group would bring different perspectives to the tool, ensuring that all relevant topics are covered and that the tool is useful to all groups. Thus, qualitative evidence suggests that mutual support groups improve quality of life for people with faecal incontinence. Evidence also suggests that people with faecal incontinence should benefit from improved access to healthcare options, that information about management and treatment options is scarce, and that the taboo surrounding faecal incontinence hinders help-seeking behaviour. Addressing these issues would allow patients to be involved in tailoring of individual care plans. There would provide community-based healthcare, involving healthcare professionals including continence specialist clinicians and clinical psychologists and would integrate with social care. It is currently hard to predict which people will benefit from surgical treatment for faecal incontinence. Developing an improved selection procedure would reduce unnecessary procedures, reducing costs and improving care pathways for people with faecal incontinence. Various research instruments will be used to gather the data needed for the research. Given that the research was primarily after qualitative data, the research instruments that will be used are geared towards this purpose. SUMMARY AND CONCLUSION Faecal incontinence is a common condition of the elderly which causes shame and embarrassment and this can lead to isolation from family and friends who find it difficult to cope with the situation. The failure to control stool not only causes psychological stress to individuals but to an ill patient it can also be a great source of infection thus adding and leading to complications. (NICE guidelines, 2007) Although academics argue that there is a need for a much clearer definition or description, they are still not able to come to general consensus as to whether such definition should include psychological as well as physical conditions of such patients. Still yet, a few appear to be of the opinion that this definition should include the above as well as the socio and economic impact on the patient's quality of life. As stated in this methodology part, the research will be undergoing basic stages. For the research design, the researcher will collect secondary data and develop such interviews as well as questionnaire. In this stage, the research instruments will be subject for approval and validation. During such information collection, the researcher will collate and summarize any relevant data as obtain through interviews and the questionnaire as well. The researcher will have to analyze desirable information and from there, the researcher may come up with findings and recommendations that shall be presented into chapters.