Qualitative in Preoperative Nursing - Research Proposal Example

Qualitative Research in Preoperative Nursing Screening patient for elective joint surgery replacement in patient over 65 years old. Research Problem In the recent era of the medical science the total hip replacement and total knee replacement are regarded as a technique, which is aimed at improving the hip and knee joints which are mostly damaged by the arthritis or by injury (Erdogan, Cakmak, Erdogan, & Arslan, 2010). These surgeries are performed to provide relief to a patient with long term relief problem and improve his quality of life. This study aims to evaluate the screening and admission process for elective joint surgery replacement in patients over 65 years old and develop a theory for the overall experience and process for the patients of these surgeries. Patients’ views and perceptions regarding their joint surgery and perceived benefits of the screening process can be helpful in their surgery. The study will try to make an in-depth assessment of the various levels of risks and mental preparations which are adhered to with this kind of innovative treatment. There are certain levels of screening processes and preparatory processes that are required to be maintained by both the patient and the physician. The study with the help of a secondary survey will try to evaluate the mental and physical impacts of the screening process as well as the surgery process prior to the operation and even after completion of it. Background In the previous studies, there are various factors mentioned that can damage socket joint of the human hip and knee joints like injuries, chronic illnesses, normal process of degradation, arthritis and traumatic injuries (Erdogan et al. 2010). The healing process and treatment becomes challenging with the growing age of patient or special condition of health like treatment of a diabetic patient. Australian Orthopedic Association National Joint Replacement Registry (2009) joint replacement surgeries in patient over 65 had been 65.6% of the total older patients going for joint replacement surgery in 2007 and it has increased to 72.9% in 2008. This consists of 5.8% of hip replacement and 8.5% for knee replacement cases alone. Therefore, the screening processes including Anesthesia Screening are important to prevent complications of patients as a result of co-mobility, particularly patients over 65 years of age. There are number of screening procedures followed before the actual surgery process. Hip fractures especially in case of older patients are associated with impaired mobility along with excess morbidity and mortality. The typical sites of the injuries are femoral neck and the intertrochanteric and subtrochanteric regions (Hopley & Stengel, 2010). Displaced and unstable fracture areas show the early indications of surgical interventions. There are evidences that show that a randomized controlled trial displaced femoral neck fractures are mostly treated with primary Anthroplasty (Hopley & Stengel, 2010). It should be noted that prior to the actual surgery screening procedures are followed. The first step is necessary medical evaluations where the orthopedic surgeon will examine the physical condition of the patient that includes general health history. Recommendation for admission form (RFA) is completed and sent to the hospital in the case surgery is required and both patient and surgeon agree for that. After prioritising patient category, the patient will be contacted by hospital staff to arrange an appointment date for screening (ACT Health, 2010). Various tests are conducted during the screening process the lab testing, urine analysis, ECG, X-ray tests of the area and chest X-ray. Additional testing may be required depending up on the condition of patient and co morbidities of the patient. Before the actual surgery, the patients are also required to follow certain rules to make the process easer for both the parties. During the screening process, patient is informed and educated about the surgical process and treatment. Before surgery, patient is given two surgical sponges to use on the night before the surgery and on the surgery day. It is very important for the elderly patients. It should be ensured that there is no infection or irritation present in the skin before the surgery takes place. The other important factor is related to the donation of the blood. Blood is required during the surgical process. In most of the cases, patient is told to do it by themselves but for elderly patients the help of other parties are also considered. The screening procedure also includes vital sign observation, weight evaluation, dental evaluation, general health issues, history of anesthetic, urinary evaluation and also social planning as this process has tremendous social impact especially as far as the family is concerned. This is a complicated process for the patient and with the growing age the procedure becomes complex. The interest for the research comes from the thought and general curiosity of what joint patients think about joint replacement and how screening process is important and necessary for preoperative patients. Literature review It is evident from the previous studies that arthritis and musculoskeletal problems are highly affecting the various communities and can be regarded as a major burden for the population in Australia (Begg, Vos, Barker, Stevenson, Stanly, & Lupaz, 2007). These healths related problems were declared as the national health priority in the year 2002 (Australian Institute of Health and Welfare [AIHW], 2005; 2008). It is estimated that over six million of the Australian population have serious musculoskeletal condition in the year 2004-05 (AIHW, 2008). Interestingly, the rate of hospitalization of the disease is not too high. This can indicate towards the lack of proper screening and intervention for the problems. The impact of arthritis and other related problems can be avoided by prevention in the early stage. The most effective preventive cure measure todate is the joint replacement (Erdogan et al. 2010). It is the most cost effective intervention for osteoarthritis and has the capability of restoring the patient to almost normal functioning (Oduwole, Molony, Walls, Bashir, & Mullah, 2010). In New South Wales from the year 2006 to 2007, the rate of hospital operations for knee and hip replacements were 283.3 per 100,000 individuals in the population. This figure reflects a 31.1 % increase from the year 1998. Falls are identified as the major cause of such fractures but however only 4% of the hospitals in New South Wales have identified osteoporosis as co-morbidity (NSW department of health, 2008). Becker (2010) points out the fact that current decade were described as the Bone and Joint decade by the United Nation and the World Health Organization for promoting the awareness about musculoskeletal diseases. The rapid increase in the disease like the osteoarthritis is considered to have a major impact on the overall public health. The estimated number of people who will be diagnosed by osteoarthritis will increase by at least 40% in the coming twenty five years. Aging of the world population is a major factor which is fueling the growth of this disease. Wylde, Blom, Whitehouse, Taylor, Pattison and Bannister (2009) studied patient-reported outcomes after the total hip replacement and compared to the mid-term results and compared the functional outcomes obtained in the mid-term with the total knee replacement and the total hip replacement. They conducted a cross-sectional postal audit survey of the patients who have undergone joint replacement at any hospital. The target population was the people who had undergone any of such surgery five to eight years back. The participants were asked to complete an Oxford hip score and a knee score depending on their functional abilities and comfort parameters. It was found that the median oxford knee score, which came around twenty six, was significantly worse than that of the median oxford hip score of nineteen. The conclusion of the study was that the total hip replacement patients enjoys better functional outcome as compared to total knee replacement patients, after five to eight years of operation. Hopley and Stengel (2000) conducted a comparative study among the total hip arthroplasty process and the hemiarthroplasty process. The condition was applied to the case of displaced intravascular hip fractures especially for the elderly patients. The objective of the study was to determine whether the total hip arthroplasty is associated with the lower reoperation rates, mortality and complication as compared to the hemiarthroplasty process (Hopley & Stengel, 2000). The project was designed on the basis of systematic reviews and meta-analysis of the randomized trials along with questionnaire trials and cohort studies. The secondary data sources for this project include Medline, Embase, Cochrane register of the control trials and the published databases (Hopley & Stengel, 2000). The target group for the study included patients with femoral neck fractures who are being treated with either of total hip replacement or hemiarthroplasty process. The measures like the relative risks, the aggregate risks of the two procedures. They used random affect models and the analyses were stratified for the experimental design. There was a two way sensitivity analysis conducted in order to track down the influence of the various parameters associated with the study (Hopley & Stengel, 2000). In total 3821 reference materials were analyzed for this purpose out which 202 were full text articles. A meta-analysis of 14 studies revealed that there is lower risk of reoperation in total hip replacement when compared to hemiarthroplasty (Hopley & Stengel, 2000). Thus it can be concluded from the study that in a single stage the total hip arthroplasty can make lower chances of reoperation and better outcomes as far functionality of the patient are concerned, when compared to hemiarthroplasty in elderly patients. Frankel, Eachus, Pearson, Greenwood and Chan (2010) studied the population requirement for the hip-replacement surgery. It was basically a cross-sectional study conducted on a selected population of England. The researchers considered a stratified random sample of about twenty eight thousand and eighty individuals all above the age of thirty five years and from more than forty general practice centers (Frankel et al. 2010). The prevalent diseases were identified by the researchers with the help of a two stage process. First of them was a self-reporting screening process and then followed by a subsequent clinical examination (Frankel et al. 2010). The incident diseases in were estimated directly at the point of relevance with the help of statistical modeling. All the requirements for the total hip replacement surgery were evaluated on the basis of the degree of pain and the loss of functional abilities (Frankel et al. 2010). The adjustments were made on the evidence of the treatment preference of the patients. The results of the study reveal that three thousand one hundred and sixty nine cases of hip pain were in their screening questionnaire only two thousand and eighteen members where invited for the examination and only 1405 out of them actually attended (Frankel et al. 2010). The prevalence of the self reported hip pain was 107 per 1000 in the case of men and 173 per 1000 in the case of women. The prevalence which seriously required surgical intervention was 15·2 (12·7–17·8) per 1000 for the individuals aged between 35 and 85. The result also indicated that there are requirement for above forty six thousand patients who expresses preferences and also suitable for the surgery (Frankel et al. 2010). Oduwole et al. (2010) in their study analyzed the factor of increasing financial burden for the revision total knee arthroplasty. Like the total hip replacement the knee replacement surgery is a major operation and the researchers in this case reviewed the financial data of the patients who underwent a revision total knee arthroplasty in the institute from the year 1997 to 2006 (Oduwole et al. 2010). The aim of the study was to determine the major differences between the cost factors in the aseptic and septic cases. By determining the cost incurring factors they want to eradicate them so that the financial burdens are less on the patients who are revising their total knee replacement surgery (Oduwole et al. 2010).The study sample contained 117 female patients and 62 male patients. One of the significant findings of the study reveals that the median age of the patients decreased from 73 years between 1997 and 2001 to 70 years between the years 2002 and 2006. The mean ASA values also dropped from 3to 2 between the periods. But still the researchers found out that the total cost involving total knee arthroplasty is increasing and in case of most of the patients the cost component increases due to the infection that they incur. The study finds out that the cost of the implants has increased by thirty to thirty two percent which is again dependent on the selection of the implants (Oduwole et al. 2010). The conceptual framework is based on the fact that the number of reported cases of the hip and joint pains and number of patient coming for the screening process are different. Clients coming for screening process have different level of information and knowledge. How they are informed about the screening process, is there any additional information provided to them which changes their level of knowledge, perceptions and experience of the problem and screening process. There is lack of awareness of the problems that can be result of hip and joint pains (Frankel et al 1999, Hopley and Stengel, 2010). Therefore a study is needed to understand the overall process that a patient experience in the cases of reported need of arthroplasty requirements. This is clear from the previous studies that there is a gap in understanding the overall screening process and no theory exists for describing the same. It is evident that no hypothesis can be tested for the screening process in the given scenario. Use of Grounded Theory in Healthcare According to Noone (2004), “Grounded theory is an inductive, qualitative method useful in generating substantive theory when seeking the perspective of the individual(s) experiencing the phenomenon (Glaser & Strauss, 1967; Strauss & Corbin, 1998) or to update knowledge on a known phenomenon (Stern, 1980).” Noone (2004) has explained this theory to have a deductive approach. This study is based on inquiry which is conducted through the symbolic interaction process. This helps in understanding “how people define reality or events in everyday settings and how they act as a result” (Chenitz & Swanson, 1986 as cited by Noone, 2004) Grounded theory approach is particularly useful for the studies in healthcare sector (Noonem 2004). This helps in identifying ‘themes, subthemes and categories”. Data collected from the qualitative research is organized in these themes and theory is developed (Otr/l Luis de Leon Arabit, 2008). According to Polit and Beck (2008), “In depth interviews and observations are the most common data source in grounded theory studies but existing documents and other data sources may also be used.” Polit and Beck (2008) have listed number of studies using the grounded theory study like Levy (2006 as cited by Polit and Beck, 2008) developed a, “substantive theory of process by which midwives in the United Kingdom facilitate informed decision making by pregnant women.” Polit and Beck (2008) stressed on the need of modifying the research in order to ‘accommodate different dimensions’. The example of the same has been the study of Beck (2007 as cited by Polit and Back, 2008: 231) in the study of postpartum depression. Conceptual Framework It is evident that there have been no significant developments in studying the overall customer experience from the screening process to after actual hip and knee replacement surgery. Therefore grounded theory can be used in such circumstances. Grounded theory can be used for this case. “Grounded theory is an analytical approach to which theories are allowed to emerge from data, as opposed to previously formulated hypotheses which are tested against data” (Glaser, Strauss, 1967 as cited in Holliman 2009). It is evident that Grounded theory is used in the health care studies (Noone, 2004; Begg et al, 2007; Chronister et al, 2008; Otr/l Luis de Leon Arabit; 2008; Polit and Beck, 2008; Wylde et al 2009). It is clear from the literature review and research problem that Grounded theory is the most suitable for this study. This is clear that two types of data is collected in the Grounded Theory study (Polit and Beeck, 2008; Holliman, 2009). These are as follows: In-dept interviews Observations In-dept Interviews for the Study: This is clear from literature review that the information needs to be selected from two different respondent groups i.e. hospital staff interacting with patients and patients. Patients would provide information regarding their views for joint surgery replacement and at the same time hospital staff would provide information on the kinds of queries they receive and kind of information they share with patients and how both the group perceives elective joint surgery replacement. In-dept interviews will be conducted with twenty patients of age group sixty five years. Same number of interviews will be conducted with the hospital staff of the concerned departments. This report will cover all the major orthopedic hospitals within the region. Diagnosis of the problems in the clinic will be observed in this process. Researcher would contact each respondent with a set of questions to be asked and briefly inform regarding the research and take their consent for participation in the research process. Data will be recorded in a recording machine to analyze it later. Researcher will take permission from hospital authorities for research process, data collection from staffs and patients and observation. Procedure for data collection According to the feedback of patients a medical intervention will be made with the help of local orthopedic surgeons. This will be followed by an observation regarding how many patients who actually reporting back pain are actually advised in the favor of the total hip arthroplasty. Then from that selected section of individuals another screening mechanism will be conducted in order to determine the individual is fit for that particular test. Statistical modeling will be used to measuring the percentage of incident diseases observed among the selected patient group. The requirement of the actual hip and knee replacement surgery will be estimated. This will be done on the basis of the pain from which the individual is suffering and loss in the functional ability of an individual. The total process will take about twelve months before the entire screening process is completed and the patients are successfully undergone the treatment facility. The respondents for interviews would be selected on the basis of their age profile. Only people of 65 years or more will be considered for the interviews. These people should coming for the medical interventions for hip and joint problems. Data Analysis and presentation This will be the stage of initial data gathering that will help in collecting data for determining open coding. This will be followed by selecting sample for different situations. The main subjects are the patients undergoing surgical treatment and the medical staff interacting with them on regular basis. Axial coding will allow understanding the plot of the research. Once the data is collected, selective coding will be done. This selective coding will help in arranging the common themes together in the plot and develop the theory of the study. This group of data will be presented in tabular and graphical forms. Reference: ACT health. (2010). Waiting time and elective patient management policy:Managing elective patients and waiting lists in ACT public hospital. Retrieved August5, 2010, from http://www.health.act.gov.au/c/health?a=dlpubpoldoc&document=793 Australian Institute of Health and Welfare. Arthritis and musculoskeletal conditions in Australia, 2005: with focus on osteoarthritis, rheumatoid arthritis and osteopolosis. AIHW Cat. No. PHE67. Canberra: AIHW, 2005. Retrieved August 14, 2010, from http://www.aihw.gov.au/publications/phe/amca05/amca05.pdf Australian Institute of Health and Welfare. Australia’s health 2008. Cat. no. AUS 99. Canberra: AIHW, 2008. Retrieved August 5, 2010, from http://www.aihw.gov.au/publications/ aus/ah08/ah08.pdf Begg S, Vos T, Barker B, Stevenson C, Stanly L, Lupaz D A. (2007). The burden of disease and injury in Australia, 2003. Retrieved August 13, 2010, from http://www.aihw.gov.au/publications/hwe/bodaiia03/bodaiia03.pdf Chronister, J. A., Chan, F., Da Silva Cardoso, E., Lynch, R. T., & Rosenthal, D. A. (2008). The Evidence-Based Practice Movement in Healthcare: Implications for Rehabilitation. The Journal of Rehabilitation, 74(2), 6+. Retrieved September 8, 2010, from Questia database: http://www.questia.com/PM.qst?a=o&d=5028337207 Erdogan, H., Cakmak, G., Erdogan, A., & Arslan, H. (2010). Brucella meltensis infection in total knee arthroplasty: a case report. Knee Surg Sports Traumatol Arthrosc, 18(7), 908–910. Frankel, S., Eachus, J., Pearson, N., Greenwood, R., Chan, P., Peters, T., Donovan, J., Smith, G., & Dieppe, P. (1999) Population requirement for primary hip-replacement surgery: a cross-sectional study. The Lancet, 353(9161), 1304-1309. Holliman, R. (2009). Defining evaluation terminology. Retrieved August 19, 2010, from http://isotope.open.ac.uk/?q=node/148 Hopley, C., & Stengel, D. (2010). Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: systematic review. BMJ, 340:c2332. DOI: 10.1136/bmj.c2332 Noone, J. (2004). Finding the Best Fit: a Grounded Theory of Contraceptive Decision Making in Women. Nursing Forum, 39(4), 13+. Retrieved September 8, 2010, from Questia database: http://www.questia.com/PM.qst?a=o&d=5035520672 NSW department of health. (2008). Arthritis and Musculoskeletal condition. Retrieved August 13, 2010, from http://www.health.nsw.gov.au/publichealth/ chorep/bod/bod_joint_cathos.asp Oduwole, K. O., Molony, D. C., Walls, R. J., Bashir, S. P., & Mullah, K. J. (2010) . Increasing financial burden of revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 18:945–948. DOI: 10.1007/s00167-010-1074 Otr/l Luis de Leon Arabit, B. B. (2008). Coping Strategies of Latino Women Caring for a Spouse Recovering from a Stroke: a Grounded Theory. Journal of Theory Construction & Testing, 12(2), 42+. Retrieved September 8, 2010, from Questia database: http://www.questia.com/PM.qst?a=o&d=5037481571 Polit, D F and C T Beck (2008) Nursing research: generating and assessing evidence for nursing practice, Lippincott Williams & Wilkins available at Google Books Wylde, V., Blom, A. W., Whitehouse, S. L., Taylor, A. H., Pattison, G. T., & Bannister, G. C. (2009). Patient-reported outcomes after total hip and knee replacement: comparison of mid-term results. Journal of Arthroplasty, 24(2), 210-216. Read More