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Background

Catheter associated urinary infections (CAUTI) are a common health condition in the United States especially among the elderly. CAUTI is not only painful but also potentially life threatening to catheterized patients. There are questions as to whether implementing an evidence-based practice protocol such as perineum care can significantly decrease the incidence of CAUTIs (Boltz, 2011).

Indwelling catheter has been a health problem since the mid-1930s. At present, the indwelling catheter is the most commonly utilized medical device in management of urinary incontinence. Common symptoms for CAUTI include fever, urgency, dysuria, frequency, suprapubic tenderness, along with a positive urine culture with less than two species of organisms (Meleis, 2011). The condition is associated with such patient experiences as poor mobility, urinary incontinence, lack of priorization as a result of nurse’s workload, as well as limited knowledge on the risks of indwelling urinary catheters and how perineum care practices can help (Doughty, 2006). 

According to nursing theorist Ernestine Wiedenbach, there are four main elements to clinical nursing: philosophy, a purpose, a practice and the art of clinical nursing. The nursing theorist conceptualizes the practice of nursing as identifying a patient’s need for help by observing the present behaviors and symptoms. This, according to Wiedenbach, is to be followed by exploring the meaning of those symptoms along with the patient, and then a determining the causes of discomfort (Meleis, 2011). Thereafter, the nurse has to determine the ability of the patient to resolve the discomfort, or if indeed the patient needs help from the nurse or any other healthcare professional(s).  In providing perineum care, the nurse is expected to exercise sound judgment following deliberative, practiced and identification of symptoms. It is important to know that patient’s perception of the condition should be considered by the nurse when providing competent perineum care (Doughty, 2006).  

Perineum care, also known as perennial care, refers to the cleaning of the perineum area (below the vagina and testicles in females and males respectively) and associated structures (Carter, 2007). Thus, when nurses talk of providing perineum care, they are in reference to the practice of cleaning the perineum and anus, the vulva (in women) as well the penis (in men). Perineum care is important for two main reasons: first, prevention of infection because the perennial area is often a perfect environment for harboring growth of microbes as it is warm, dark and moist. These microbes can, therefore, easily find their way into the urinary tract and infect it. Secondly, the perineum is also a delicate area with many folds of skin that can often trap such body excretions as feces, urine and menstrual blood, resulting in skin irritation and odor if not properly removed (Carter, 2007).

Research Question

The research question for this study would focus on whether perineum/meatle care of a catheterized patient can decrease catheter associated urinary tract infection (CAUTI). Therefore:

Can perineum care of a catheterized patient decrease catheter associated urinary tract infection (CAUTI)?

Objective:

The purpose of this nursing research would be to explore and describe the potential of perineum care to decrease catheter associated urinary infection (CAUTI) for a catheterized patient. The study will link the findings with the theory of nursing theorist Ernestine Wiedenbach.

Significance

The significance of the research will be added to our knowledge of this otherwise complex phenomenon. Contributing to efforts targeted at decreasing CAUTI in already catherized patients using the nursing theorist Ernestine Wiedenbach theory.

Research Design

This research proposal will describe how the research will add to the knowledge of whether perineum or meatle care of a catheterized patient can decrease catheter associated urinary tract infection (CAUTI). The research design favored in this nursing research design focusing on the effect of perineum/meatle care on reducing CAUTI is qualitative research. The framework of the research design would be in line with the hypotheses. The objective of the research would be to predict the effect of perineum care. The research tool would be direct observation while the focus of the research would be the outcome of decreased CAUTI. This research design shall enable the researcher to explore the cause and effect of the measure of perineum/meatle care on a broad patient group.

Urinary tract infections are currently estimated to account for 40 percent of all hospital-related infections, 80 percent of this linked with urinary effects. Premium care is taken to be among the most effective intervention to indwelling catheters. In research, this form of care, there would be an investigation into both the effect of the process as well as evidence for clinical significance. If clinical significance is established, it could prove instrumental in the clinical setting for reduction of CAUTI in patients.

Research Method

Preparing a research proposal involves a number of steps, including choosing the problem, determining the purpose of the research, formulating a research question, developing of framework, formulating hypotheses, selecting research design, and identifying a population and sample. The process of data collection follows these steps. According to Neiswiadomy (2012), the researcher must seek to answer the questions: who, when, what, and how. This research proposes the use of qualitative research method, utilizing the grounded theory approach. This method will establish the potential of perineum care for a catheterized patient to reduce urinary tract infection (Meleis, 2011).

Sample Selection

The sample for this study will be drawn from patients with established indwelling catheter on the sixth-floor medical-surgical unit of the hospital. This group is chosen in view of the increasing infections in patients with urinary catheters. The sample population represents all patients with established indwelling catheter from a 462-bed hospital. The sample population would be recruited upon reviewing their electronic medical records along with the database of patients with indwelling catheters at the hospital. It is estimated that between 35-40 patients will be selected for the study.

Procedure

The method of data collection would be through direct observation of patients with catheters. The observation would be unstructured as a description of the events would be done as they occur. The research would seek to establish the performance of perineum care for a specific population considering that the care is a nursing action administered physically to a patient. Perineum care would be described as done or not done. The observer of patients and administration of the perineum care would be a non-participant.

Data Analysis

The research proposes the use of the constant comparative method of data analysis. This means that data will be simultaneously gathered, coded and then analyzed, in a manner that would facilitate the generation of a theory. The simultaneous gathering, managing, and interpreting of data is necessary in such qualitative research because the resultant findings may warrant further data collection. The data to be analyzed would have been stored in an organized, secure manner. All handwritten information will have to be typed to a word document to facilitate that electronic storage with their correct dates, locations and identities in the form of pseudonyms

Reliability and Validity

The research will employ several strategies throughout the research to ensure that both data collection and interpretation are done accurately to reflect the phenomenon. Reliability and validity issues of this qualitative research will addressed as follows:

-          Avoid bias in data collection and analysis by raising awareness of individual preconceptions and bias. Relating  it to the topic making the researchers stay always be conscious of the risk of imposing them on the exercise.

-          Clearly describing  the process of data collection and data analysis.

-          Having other researchers separately code segments of data so as to confirm the categories established.

-          Approaching and asking a sample of participants to validate the description by going through to ascertain if it accurately captures their experience (Rhinehart et al., 2006).

Pilot Study

A pilot study shall be carried out prior to the full research so as to test out data collection tools and other procedures. It will check out the feasibility of the full research, highlight any issues or problems that could arise, and will be done a few weeks prior to the main study. The researcher  will carry out several pilot observations, approximately 10 percent of the estimated sample size, to test the observation schedule, determine the functionality of the required equipment, and estimate the duration of time the exercise will take(Carter, 2008). The participants to be used in the pilot study would need to have the same characteristics as those of the actual study.

This research proposes the use of the experimental design method, specifically the quasi-experimental design. Nieswiadomy (2012), defines quasi-experimental design as “that which there is either no comparison group or subjects are not randomly assigned to a group.” The goal of an experiment in a nursing research is to render a patient to a treatment in order to gauge the response (Rhinehart et al, 2006).. The experimental design shows the steps followed in testing the hypothesis and reaching a conclusion regarding variable relationship. Considering that there are other design groups that fit into the quasi-experimental design, this research proposal uses the non-equivalent control group design. The choice of non-equivalent design group is appropriate considering that the assignment is not random under this category(Long et al, 2012). This implies that the researchers would have to develop criteria for inclusion into a group before conducting the study. The design is also well placed is assisting the researcher to look at a  population together with a preventable health problem. The underlying assumption of this research is that the nursing care offered would integrate perineum care  for patients with indwelling catheters.

The pilot study will also seek to analyze the setting of the study. The data gathered from the pilot study will be part of the research findings in the main study, but its outcome would be assessed before undertaking the actual study. In analyzing this data, the researcher will assess to determine if the participants met the requirements and  the perineum care was present or not(Long et al, 2012). 

Ethical considerations

Written ethical approval for the proposed research will be obtained from the ethics committee of both the university and the hospital prior to undertaking the study. Ethical approval is needed to protect the participants and their rights. As such, informed written consent will be sought from each participant prior to study, after receiving sufficient information, briefing and comprehension on what their participation in the study would entail. Participants will be made aware of their right to voluntary participation along with their right to withdraw at any given time without facing penalties, thus protecting their right to self-determination. Also, all information gathered from the study will be treated as confidential as well as stored securely (Fink, 2012).

Throughout the research process, there will be protection of such human rights as privacy, dignity, anonymity, confidentiality, fair treatment and protection from harm and discomfort. Given that qualitative research cannot guarantee total anonymity because of the interviewer would be aware of the participant, each participant would be afforded an opportunity to take up a pseudonym so as to maintain anonymity for the rest of the research process to protect subjects and records (Jeong, 2010).

Confidentiality will also be maintained throughout by avoiding disclosure of any information shared with any other parties as well as by attribute information in the findings that could identify the participants. The study will also make sure to uphold justice and fairness by providing equal opportunity for all selected participants regardless of their nationality, language and age. In line with the requirements of the University, the gathered information will be kept in a secure place for a period of five years.

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