Application for Minor Field Study - A project description for a participant observational study

Hand hygiene routines in home care of

malnourished children - a nursing perspective

AUTHOR Sofia Henriksson, Lovisa Jansson

PROGRAM/COURSE Bachelor of Science in Nursing,

Bachelor thesis in nursing

SPRING 2013

SCOPE 15 hec (higher education credits)

SUPERVISOR Kerstin Segesten, Professor emerita

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Innehållsförteckning 1. Introduction ......................................................................................................................................... 3

2. Background .......................................................................................................................................... 3

2.1. Malnutrition ................................................................................................................................. 3

2. 2. Home care ................................................................................................................................... 3

2. 3. The Scandinavian Children’s Mission .......................................................................................... 3

2. 4. Infections ..................................................................................................................................... 4

2. 5. Health care associated infections ................................................................................................ 4

2. 6. Hand hygiene ............................................................................................................................... 4

3. Aim....................................................................................................................................................... 5

3.1 Specific objectives ......................................................................................................................... 5

4. Method ................................................................................................................................................ 5

4.1. Research method ......................................................................................................................... 5

4.1.1. Preparation phase ................................................................................................................. 6

4.1.2. Field study phase ................................................................................................................... 6

4.1.3. Analysis and interpretative phase ......................................................................................... 8

4.1.4. Writing phase ........................................................................................................................ 9

4.2. Trustworthiness ............................................................................................................................ 9

4.3. Ethical considerations ................................................................................................................ 10

Schedule ................................................................................................................................................ 11

References ............................................................................................................................................. 12

Appendix 1 ............................................................................................................................................. 13

Appendix 2 ............................................................................................................................................. 14

Appendix 3 ............................................................................................................................................. 15

Appendix 4 ............................................................................................................................................. 16

Risk analysis ........................................................................................................................................... 17

Preliminary budget ................................................................................................................................ 18

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1. Introduction Statistics from the World Bank show that in year 2008, 20.7% of the children under the age of five

years in the Philippines suffer from malnutrition (World Health Organization, 2011a). There is a risk

of severe infections among malnourished children since malnourishment abates the immune system

and diminishes the resistance against infections (Björkman & Karlsson, 2006; The United Nations

Children’s Fund, 2009). Infections can be prevented by good hand hygiene (Ericson, Ericson, &

Robertsson, 2009). Health care-associated infections (HCAI) are a worldwide problem present in all

kinds of health care settings and effects hundreds of millions of patients every year. The prevalence

of HCAI shows to be much higher in low- and middle- income countries than in high income countries

but there is not much research done on the subject in low income countries. In low income countries

you find all the risk factors you find in high income countries but additionally you also find risk factors

as lack of basic hygiene, malnutrition, lack of trained staff, overcrowding and limited financial

support. Research proves that it is possible to reduce the HCAIs by 50 % or more by compliance to

World Health Organization (WHO) hygiene guidelines. Evidence shows that proper hand hygiene in

outpatient care and home care settings reduces the risk of spreading infections (World Health

Organization, 2011b).

Therefore we would like to study how nurses work regarding hand hygiene in home care settings in

Manila, the capital of the Philippines. The role of the nurses is important both in how they handle

their own hand hygiene but also in how they educate the parents of the importance of proper hand

hygiene. We hope, except from that we will learn about hand hygiene and its importance, that our

study also will remind nurses and caretakers about it.

2. Background

2.1. Malnutrition The risk of mortality is 5-20 times higher for children with severe acute malnutrition than for well-

nourished children. Severe acute malnutrition is a direct cause of death among children but it is also

an indirect cause since it increases the risk of death by infections like diarrhea and pneumonia. WHO

estimates that about 1 million children die from severe acute malnutrition every year (World Health

Organization, World Food Programme, United Nations System Standing Committee on Nutrition, &

The United Nations Children's Fund, 2007).

2. 2. Home care Previously the recommendations for treatment of children with severe acute malnutrition were

treatment in a health care facility. Thus most of these children were never brought to any health

center. Today evidence suggests that children with severe acute malnutrition but without medical

complications could be treated in their communities without attending a health care facility. This

community- based management creates the possibility of health workers to identify children with

severe acute malnutrition and offer them treatment at home. WHO, World Food Programme (WFP),

United Nations Standing Committee on Nutrition (UNSCN) and United Nations Children’s Fund

(UNICEF) are examples of organizations supporting this community-based management to prevent

and treat acute severe malnutrition (World Health Organization et al., 2007).

2. 3. The Scandinavian Children’s Mission The organization: Scandinavian Children’s Mission is working to discover malnutrition, treat

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malnourished children and teach parents about their children´s nutrient requirements. Their work is

guided by the recommendations described above about community-based management of severe

acute malnutrition (Skandinaviska Barnmissionen; World Health Organization et al., 2007).

2. 4. Infections A consequence from malnutrition is abated immune system which increases the risk of infections

(Björkman & Karlsson, 2006). Malnourished children suffer for example a greater risk of severe,

prolonged and more frequent episodes of diarrhea than well- nourished children. Diarrhea often

leads to decreased food intake, reduced nutritional absorption and higher nutritional requirements

which increases the risk of worse malnutrition (The United Nations Children’s Fund, 2009). This

creates a vicious circle which has to stop to save children’s lives.

2. 5. Health care associated infections Health care- associated infections are the most common unpleasant incident for patients in all kinds

of health care settings (World Health Organization, 2011b). The definition of Health care-associated

infection (HCAI) is “an infection occurring in a patient during the process of care in a hospital or other

health-care facility which was not present or incubating at the time of admission. This includes

infections acquired in the hospital, but appearing after discharge, and also occupational infections

among staff of the facility” according to WHO (2011b, p. 6). One of the most common cause of HCAI

is infection spread via the hands and clothes of the staff (Ericson et al., 2009). HCAI causes a great

deal of suffering for the patients’ and their families as high costs, a prolonged illness and hospital

stay, long-term disability and in some cases even deaths (Ericson et al., 2009; World Health

Organization, 2011b).

It is hard to say if infections in outpatients are due to the health care or if they are acquired in the

community, and there is little research done on the subject. Thus evidence shows that a good hand

hygiene in outpatient care and home care settings reduces the risk of spreading infections (World

Health Organization, 2012). All kinds of infections are caused by microorganisms. By reducing the

number of microorganisms in health care settings as much as possible, the number of HCAI will also

decrease. Compliance to hygiene routines among all health care professionals is the key to reduce

the number of microorganisms and contagions in health care (Ericson et al., 2009). Research shows a

poor adherence to hand hygiene routines health care workers worldwide (World Health

Organization, 2009). In the home care setting we will visit, nurses, health workers and parents are

involved in the care of the malnourished child. There is a risk that these caregivers transfer

microorganisms from their hands to the child and cause a serious infection.

2. 6. Hand hygiene It is possible to reduce and prevent HCAI by 50 % or more according to WHO (World Health

Organization, 2011b). The most important and the easiest way to prevent HCAI is hygiene routines

and the most important of all hygiene routines is to maintain good hand hygiene (Ericson et al., 2009;

World Health Organization, 2009).

Summing up the WHO’s hand hygiene guidelines it is important to wash hands with soap and water

when visibly dirty, when soiled with body fluids, after using the toilet or when exposed to spore-

forming pathogens. Alcohol based hand rub should be used before and after touching a patient,

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before and after using gloves, before clean or antiseptic work and after touching patients

surroundings (World Health Organization, 2009).

3. Aim As previously mentioned, health care-associated infections is the cause of wide spread suffering and

has become a global problem present in all forms of medical care (World Health Organization,

2011b). Proper hand hygiene is the single most effective method for preventing transmission (Ericson

et al., 2009; World Health Organization, 2011b). However the lack of knowledge and the insufficient

compliance with proper procedures are common throughout the healthcare field, especially in low-

income countries (World Health Organization, 2011b). Because the trend towards home care steadily

increases and because the increased susceptibility to infection associated with malnutrition (Ericson

et al., 2009; World Health Organization, 2011b), the aim of this thesis is to study and dissect the role

of nurses in ensuring and maintaining proper hand hygiene routines in home care settings in the

treatment of malnourished children.

3.1 Specific objectives o To assess nurses’ hand hygiene routines in home care settings.

o To assess how nurses coop with difficulties which arise when practicing good hand hygiene in

slum areas.

o To assess how nurses pay attention to hand hygiene routines of parents.

o To assess how nurses educate parents about the importance of proper hand hygiene, in

which ways and to what extent.

4. Method As a basis for this study we have chosen the ethnographic research tradition as method for the

purpose of investigating the role of nurses in ensuring and maintaining proper hand hygiene in the

treatment of malnourished children in home care settings. The method is based on the idea that

humans and their actions only can be understood in the context where they act (Pilhammar

Andersson, 2000). As ethnographic observations inherently make the researcher present in the

setting studied, the possibility for a close dissection of the area of interest in its natural environment

is created. Therefore this method is a suitable tool in our field study. Behavior and interactions can

be studied in complex environments consisting of multiple variables and actions as well as the

circumstances behind can be observed. The reality in full can be studied using ethnographic

observations (Pilhammar Andersson, 2000, 2006). This makes the method a given choice, as we strive

to capture all phenomena affecting nurses’ undertakings for ensuring proper hand hygiene in home

care settings as. We wish to see nurses’ actions, how the surrounding environment affects as well as

how nurses involve parents in the infection preventive work. Our aim is not to conclude what is right

and wrong but to obtain an understanding for how nurses’ reality actually appears in a holistic

perspective.

4.1. Research method By participant observation, which according to Pilhammar Andersson (2006) is the main research

strategy within the ethnographic research framework, we will conduct observations of nurses’ work

to promote proper hand hygiene as well as engage in informal interview sessions with the observed

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in order to obtain a heightened understanding of our observations. The ethnographic study can be

divided into four phases, preparation phase, field study phase, analysis and interpretations phase,

and writing phase (Pilhammar Andersson, 2006). This division has been the basis for planning our

method of the study.

4.1.1. Preparation phase

During this phase all preparations take place before one as a researcher arrives at the field, such as

obtaining permissions, reflection over the researcher’s role and ethical aspects (Pilhammar

Andersson, 2006). Except everything specified in this application, we will continue our literature

survey and familiarize ourselves further with the field of study. We will especially focus on the study

of cultural differences and similarities between Sweden and the Philippines as well as study the

country. We will also have continuous correspondence with Thord Dahl, who is our contact in the

field, and in that way keep ourselves updated about Manila, the Philippines and be as prepared as

possible before departure.

4.1.2. Field study phase

The field study phase is the phase when the researcher is out in the field conducting observations.

During this phase analysis also takes place when reflections over field notes drives the research

forward and preliminary analysis leads to focus upon more specific areas (Pilhammar Andersson,

2006, 2008). Collection of data using observations will be further subdivided into the three phases;

start, collection, and closure according to Merriam and Nilsson (1994).

Start

The start phase will consist of the first week in the field, where our aim is to establish good contact

and familiarize ourselves with the environment. This means we will introduce ourselves to the staff,

take part in and show respect in the participants and their routines, show interest for their work and

assist them, which is in line with advice given by Merriam and Nilsson (1994). We will inform all

participants about our study personally and everyone willingly to take part will sign a document

testifying that they have been informed about our study and that they at any time can withdraw

their participation, see Appendix 1 and 2, designed by means of Olsson and Sörensen (2011).

Collection

The researcher’s role can vary from full participation to passive observer, both which has its own

pros and cons as well as ethical problems (Merriam & Nilsson, 1994; Pilhammar Andersson, 2006;

Polit & Beck, 2006). Our role will mainly be participant-as-observer which means that participants will

be aware that we observe simultaneously as we act as members of the group. This approach enables

a from-within-perspective as well as the possibility to combine several collection techniques e.g.

photo and interviews. An inherent risk with this approach is that the researcher will come too close,

also known as “go native” (Merriam & Nilsson, 1994; Pilhammar Andersson, 2006). As observer it is

important to be able to switch from being close to observing at a distance and be aware of the fact

that factors such as emotions, understanding, values and expectations can have a an impact on

observations (Henriksson & Månsson, 1996; Polit & Beck, 2006). In order to prevent subjectivity, we

will set aside approximately one hour per day for pure observations with mobile positioning, which

means that we will follow a nurse throughout a given activity (Polit & Beck, 2006).

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Observations and field notes

During week two in the field, our observations begins and will be based on the compressed model by

Jeffrey and Troman (2004), which means that we will try to capture as much as possible. We will try

to visit all relevant places and seek contact with all nurses who will take part in the study. The first

week of observation will tend more towards observing the environment and all coming weeks will

focus upon the nurses’ work. An interpreter will be hired in order for us as observers to be able to

follow the conversation between nurse and parents.

Field notes will be written during observations. During the pure observations field notes will be

registered in a note book with hard cover to facilitate writing standing. The right hand column will

contain notes and the left hand side will contain own reflections. The foundation of participant

observations is that the researcher has an open mind and as few theoretical imaginations as possible

in the beginning of the observation. The knowledge is supposed to evolve with a simultaneously

interaction between data collection and analysis (Henriksson & Månsson, 1996). However it is

impossible to observe everything, therefore we will make use of a guided questionnaire, see

Appendix 3, which is a choice recommended by several authors and researchers, in order to get

started (Merriam & Nilsson, 1994; Polit & Beck, 2006). The guided questionnaire will also help us

organize information and record the data that should be found in the observations. The notes will

describe when an observation took place, what kind of activity it involved, what was being said, what

took place, as well as rhythm, tempo and atmosphere (Pilhammar Andersson, 2006).

Exact choice of words and formulations from the observed will be noted to the largest possible

extent. During participant observations notes will be taken in a smaller notebook in as close

proximity as possible to the observations by both observers. Keywords will be used while time for

thorough notes might be limited. Therefore our role as an observer will be less prominent and affect

natural interactions to a lesser extent (Merriam & Nilsson, 1994). The notes will be formed to a

narrative story and analyzed with the help of a template developed by Pilhammar Andersson (2006),

see table 1 in Appendix 4, as well as by qualitative content analysis (step 1-5) every afternoon when

observations still reside clear in mind, see template in table 2, Appendix 4. Reflections over daily

observations will be done between the observers and questions arising will form the basis for further

data collection

Informal conversations

As a complement to observations, informal conversations will be held continuously, either directly

during observations or in close contact. Informal conversations will also be used when questions

arise during analysis of data. In participant observations, it is common to complete with informal

conversations (Graneheim & Lundman, 2004; Pilhammar Andersson, 2006). The conversations will be

held with the purpose of sharing the participants experience of situations and therefore create a

possibility for deeper understanding. An interpreter will also be hired in order to aid in informal

conversations with parents.

Photo

Environmental photos will be taken with permission.

Sample

All collection of data will take place at Scandinavian Children´s Missions outreach program in Manila,

the Philippines. The sampling period will extend from 2013-03-11 to 2013-05-06. All nurses willing to

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participate in the study will be included, see also under ethical considerations. No other selection

criteria will be implemented. Therefore only the nature of Scandinavian Children´s Missions current

operations will control the focus of our observational sessions.

Ethnographical observations should be performed in an environment native to the participants

(Pilhammar Andersson, 2008), therefore the location is part of the selection criteria. Such a location

with relevance to our aim of investigation is Scandinavian Children´s Missions outreach program,

where nurses carry out home visits in different slum areas in order to identify malnourished children.

The choice of location is therefore strategic and a conscious choice (Pilhammar Andersson, 2006).

Ending

Our field studies are limited to eight weeks, which will affect our results. Despite this we hope to

achieve saturation of results, i.e. meaning that no new information will arise during the end-phase of

our study (Thorén-Jönsson, 2008). All participants will be informed when we cease our observations.

By making our leave in a tactful manner, we hope to prevent that any negative experiences or

emotions arise for the participants, e.g. feelings of exploitation or offence. Information regarding

time of publication of the report and where the report will be made available will be shared with

everyone involved including participants.

4.1.3. Analysis and interpretative phase

A continuous evaluation and analysis will take place during the field study phase with the use of a

template developed by Pilhammar Andersson (2006), see appendix 4, table 1. Our method of choice

is qualitative content analysis, which according to Graneheim and Lundman (2004) is applicable to

various texts and also for interpretation of observations studies. Our step-for-step model is

developed by Graneheim and Lundman (2004) and will be carried out in the following manner:

1. Field notes and reflections will be written daily in the form of a narrative text.

2. The whole material (unit of analysis) will be read through multiple times to achieve an

understanding of the big picture.

3. Meaning units will be identified.

4. The meaning units will be condensed.

5. The condensed meaning units will be abstracted and labelled with a code. When coding both

the big picture and context will be regarded. A discussion and interpretation session will be

held until consensus is reached.

6. All codes will be compared and sorted in different categories with respect to similarities and

differences. If necessary sub-categories might be employed if hierarchical relations are

discovered. The categories should among themselves be exclusive i.e. no data can fit two

categories.

7. The categories will further be divided into themes, with the purpose of obtaining unification

and a connecting thread throughout the results.

Step 1 – 5 will be carried out daily. The final analysis will take place when all data is collected and will

consist of step 6 – 7. When it comes to analysis and interpretative work in qualitative studies, the

process is seldom as linear as described above. The analysis and interpretative phase is a process

where one as a researcher moves back and forth between the steps mentioned (Graneheim &

Lundman, 2004), which will likely occur for us as well. Reflection is an important concept within the

ethnographic method, while the researchers themselves participates and therefore affects the study

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(Pilhammar Andersson, 2006). During the whole study we will reflect upon our own impact,

relationship to the field of study, and which decisions we make and why. Which data will be

reported? Why have this particular set of data been chosen? Are we missing anything? Our thoughts

and reflections will be written down and reported in the final report. The results will be put in

relation to previous research.

4.1.4. Writing phase

The results will be reported in themes and the bachelor thesis will be written according to the

guidelines given by the University of Gothenburg. In the results section we will include an

environmental description and all participants will be made anonymous. In the event of any citations

reflecting the opinions of several, this will be carefully reported with respect to anonymity.

4.2. Trustworthiness For observations as a method of data sampling to be classified as a scientific tool, some criteria must

be met. Except the fact that all observations must have a clear purpose, be carefully planned and all

information obtained to be systematically registered, the researcher also has to consider

trustworthiness. A common critique directed towards ethnographic studies is the cofounding

influence and effect the researchers themselves have upon the study. How the presence of an

observer interferes with the processes and events being observed. The participants can be anxious

about being observed and therefore a behavioral change might occur according to their ideas of

what is accepted and desirable. Critics also point at the fact that the nature of human perception is

both insufficient and subjective (Merriam & Nilsson, 1994).

However the fact that the researcher is a part of the surrounding world is also one of the strengths of

the method. The interactions that occur, not only affect the participants but also the researcher

(Pilhammar Andersson, 2006). When it comes to investigations that study meaning, context, and

significance, the human being is best fit for the task of collecting and analyzing data (Merriam &

Nilsson, 1994). In qualitative studies the concepts credibility, dependability, confirmability, and

transferability are used to account for trustworthiness. Therefore, in order to improve the quality of

this thesis, the method of choice has been analyzed with respect to the proposed criteria for

trustworthiness according to Polit and Beck (2006).

Credibility:

Our goal is to enhance credibility and reduce bias by employment of the triangulation concept. We

plan to make use of method triangulation while we will use both observation and informal interviews

as tools of investigation. Furthermore investigator triangulation will be applied as both of us are

going to observe, analyze and interpret. Concrete examples describing how observations have been

analyzed with respect to e.g. meaning units, codes, and categories will be illustrated in the report in

order for the reader to be able to assess credibility of analysis. Our role in the study will be described

as well as our actions and research choices, in order to make the basis of our interpretations clear.

Dependability:

The dependability of our study will be enhanced due to our two separate means of data sampling

and due to the fact that both observers will carry out analysis before results are merged.

Furthermore inquiry audit will be performed to some extent while our academic supervisor, Kerstin

Segesten, RN, PhD, and Professor will take part of some of the data and analysis.

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Confirmability:

By systematically reporting the methodology of this study the confirmability will increase. A detailed

decision trail enables external readers and other interested to follow the logic of our workflow and

possibly reproduce it.

Transferability:

By a detailed description of context, culture, and other characteristics the possibility for

generalizability will increase. The reader can then form his or her own opinion about the

transferability of the results to other contexts, which is also pointed out by Graneheim and Lundman

(2004).

4.3. Ethical considerations To study ethical aspects is of prime importance for every researcher independent of research field

(Olsson & Sörensen, 2011). Our ethnographical study will involve human beings, therefore ethical

considerations will be important both during the data sampling and the data publication (Merriam &

Nilsson, 1994). Our method has been developed in agreement with “Ethical guidelines for nursing

research in the Nordic countries”, adopted by The Nordic Nurses Federation (NNF) 1983, based on

the human rights stated in UNs declaration as well as in the Declaration of Helsinki, as well as the

paper “Forskningsetiska principer inom humanistisk-samhällsvetenskaplig forskning” (Northern

Nurses’ Federation, 2003; Vetenskapsrådet, 2002).

Permission:

Permissions have been granted by the Scandinavian Children´s Mission and their representatives in

Manila, the Philippines.

Information to participants and consent:

In order to assure that information regarding our study will reach all participants, we will personally

inform them during the first week of our field studies. The nurses will be informed that their

participation is voluntarily and that they at any time may withdraw from the study without stating

their reasons for doing so. Information will be given both orally and in written according to Olsson

and Sörensen (2011). Consent will be obtained in written from all nurses willingly to participate. The

consent emphasizes that despite their signature they have no obligations towards the study and may

withdraw their participation at any time. Since this study focuses on the nurses and their work, no

signatures will be collected from parents as we wish to downplay our role as researchers. However

we will ask the nurses to inform the parents that two students wish to attend and ask for their

permissions. If the parents for any reason will not be comfortable with us attending, we will wait

outside their house.

Confidentiality

While the location of our study will be revealed in our paper, it might be possible to find out more

about the participants. We will actively strive for the right to autonomy and integrity and therefore

state information in such a way participants will remain hard to identify. If any quotes will be

reported, they will reflect the opinion of several. All material will be treated with confidentiality and

be locked up. All sampled data will only be used for our report and for no other purposes.

Information about when our study will be made public as well as how participants can take part of it

will be given to the participants.

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Ethical dilemmas:

When conducting observational studies there is a risk participants feel inspected and discomforted

resulting in a change of behavior, deviating from normal (Polit & Beck, 2006). This is a bachelor thesis

on undergraduate level with the purpose of familiarizing ourselves with scientific work, therefore we

will try to downplay our role as two researchers. We will emphasize that we are two students who

wish to learn about nurses’ experiences and their knowledge regarding hand hygiene. The

foundational principles of ethics the principle of autonomy, the principle of goodness, the principle of

making no harm as well as the principle of justice, will guide our study (Olsson & Sörensen, 2011).

We will actively counteract any discomfort and risk of harm by trying to establish god relationships.

We will always show respect by being grateful and polite. Any questions we have will be raised in a

tactful manner and we will be sensitive for any language and cultural differences that might arise

according to the recommendations of Polit and Beck (2006). By making our leave in a tactful manner

we hope to prevent any negative emotions to arise among participants, e.g. feelings of insult or being

taken advantage of.

With participating observation there is always a risk that participants might share information they

wanted to keep secret (Merriam & Nilsson, 1994). This risk can be minimized by only publishing

information relevant to the study. There is also a risk we might witness something inappropriate

(Merriam & Nilsson, 1994). Our action plan is that we will try to intervene if someone is in direct

danger. According to basic principles researchers should try not have an influence on the research

result, therefore we will exclude such events from our observational material.

Schedule Arrival date to Manila: 11 Mars 2013

Departure date from Manila: 6 May 2013

Week 1:

Meet the staff and present ourselves

Inform about our study

Visit Children’s Missions different works in Manila

Week 2:

Observe the environment

Take part in the nurses work

Analyze data material

Week 3- 4:

Observe nurses and be an active part of the work

Analyze data material

Week 5-6:

Final analysis

Complement with questions to the nurses to make everything clear

Week 7-8:

Final analysis

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References Björkman, Eva fil mag, & Karlsson, Karin. (2006). Kliniskt vårdarbete för sjuksköterskor. Lund:

Studentlitteratur. Ericson, Elsy, Ericson, Thomas, & Robertsson, Jakob. (2009). Klinisk mikrobiologi: infektioner,

immunologi, vårdhygien. Stockholm: Liber. Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: concepts,

procedures and measures to achieve trustworthiness. Nurse Educ Today, 24(2), 105-112. doi: 10.1016/j.nedt.2003.10.001

Henriksson, Benny, & Månsson, Sven-Axel. (1996). Deltagande observation. In P.-G. Svensson & B. Starrin (Eds.), Kvalitativa studier i teori och praktik (pp. 11-51). Lund: Studentlitteratur.

Jeffrey, Bob, & Troman, Geoff. (2004). Time for ethnography. British Educational Research Journal, 30(4), 535-548. doi: 10.1080/0141192042000237220

Merriam, Sharan B., & Nilsson, Björn. (1994). Fallstudien som forskningsmetod. Lund: Studentlitteratur.

Northern Nurses’ Federation. (2003). Ethical guidelines for nursing research in the Nordic countries. Retrieved 25 September, 2012, from http://www.sykepleien.no/ikbViewer/Content/337889/SSNs%20etiske%20retningslinjer.pdf

Olsson, Henny, & Sörensen, Stefan. (2011). Forskningsprocessen: kvalitativa och kvantitativa perspektiv. Stockholm: Liber.

Pilhammar Andersson, Ewa. (2000). Ethnography; field studies of training and supervision in clinical care. In B. Fridlund & C. Hildingh (Eds.), Qualitative research methods in the service of health (pp. 195-212). Lund: Studentlitteratur.

Pilhammar Andersson, Ewa. (2006). Etnografi i det vårdpedagogiska fältet: en jakt efter ledtrådar / [Elektronisk resurs]. Stockholm: eLib [distributör].

Pilhammar Andersson, Ewa. (2008). Etnografi. In M. Granskär & B. Höglund-Nielsen (Eds.), Tillämpad kvalitativ forskning inom hälso- och sjukvård (pp. 41-55). Lund: Studentlitteratur.

Polit, Denise F., & Beck, Cheryl Tatano. (2006). Essentials of nursing research: methods, appraisal, and utilization. Philadelphia: Lippincott.

Skandinaviska Barnmissionen, .). Barnomsorg. Retrieved 25 September, 2012, from http://www.barnmissionen.se/barnomsorg/

The United Nations Children’s Fund, . World Health Organization. (2009). Diarrhoea: Why children are still dying and what can be done. Retrieved 25 September, 2012, from http://whqlibdoc.who.int/publications/2009/9789241598415_eng.pdf

Thorén-Jönsson, Anna-Lisa. (2008). Grounded theory. In M. Granskär & B. Höglund-Nielsen (Eds.), Tillämpad kvalitativ forskning inom hälso- och sjukvård (pp. 107-123). Lund: Studentlitteratur.

Vetenskapsrådet. (2002). Forskningsetiska principer inom humanistisk-samhällsvetenskaplig forskning.

World Health Organization. (2009). WHO Guidelines on Hand Hygiene in Health Care. from http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

World Health Organization. (2011a). Malnutrition prevalence, weight for age (% of children under 5). Retrieved 25 September, 2012, from http://data.worldbank.org/indicator/SH.STA.MALN.ZS

World Health Organization. (2011b). Report on the Burden of Endemic Health Care-Associated Infection Worldwide. from http://whqlibdoc.who.int/publications/2011/9789241501507_eng.pdf

World Health Organization. (2012). Hand Hygiene in Outpatient and Home-based Care and Long-term Care Facilities

World Health Organization, . , World Food Programme, . , United Nations System Standing Committee on Nutrition, & The United Nations Children's Fund, . (2007). COMMUNITY-BASED MANAGEMENT OF SEVERE ACUTE MALNUTRITION.

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Appendix 1

Information letter to nurses at Scandinavian Children’s Mission Dear Nurse,

We are two Swedish nurse students, Lovisa Jansson and Sofia Henriksson, in our last year of

education. In March to May 2013 we are going to complete our education with a bachelor thesis in

nursing. The thesis will be accomplished in Scandinavian Children’s Mission outreach program for

malnourished children and is approved by Bo Wallenberg, president of Scandinavian Children’s

Mission and Thord Dahl, local manager in Manila.

The aim of this thesis is to study and dissect the role of nurses in ensuring and maintaining proper

hand hygiene routines in home care settings in the treatment of malnourished children. We wish to

learn about nurses’ actions, how the surrounding environment affects as well as how nurses involve

parents in the infection preventive work. Our aim is not to conclude what is right and wrong but to

obtain an understanding for how nurses’ reality actually appears in a holistic perspective.

We want to take part in your daily work to see and learn as much as possible. Approximately one

hour per day we will set aside for pure observations, meaning that we will take a complete outside

perspective, observing, without taking part in any activities. We will take notes but be as tactful as

possible. We will also talk to you about what we have noticed for a better understanding.

During our first week at Scandinavian Children’s Mission you will have the opportunity to get to know

us and ask questions about our thesis before deciding whether or not to participate and sign a

consent form.

All material will be treated with confidentiality and be locked up. All sampled data will only be used

for our report and for no other purposes. Confidentiality will be considered, no names will be

published and situation described will not expose the identity of any member of the staff.

Information about when our study will be made public as well as how you can take part of it will be

given.

Participation in the study is voluntary and you are free to withdraw your participation at any time

without any explanation. There will be no demands on the participants. We would only like to take

part in and see how you work.

This study is conducted by Lovisa Jansson and Sofia Henriksson at the Sahlgrenska Academy,

University of Gothenburg. If you have any questions, please, feel free to contact us.

Kind regards,

Lovisa Jansson and Sofia Henriksson

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Appendix 2

Consent form

I have been informed orally and in written about the study and here by confirm I fully endorse my

participation in this study. I am aware that I may at any time withdraw my participation without

sanction.

Signature respondent: Date and city:

…………………………………………………………. ……………………………………………………

Signature researcher: Date and city:

…………………………………………………………. ……………………………………………………

Signature researcher: Date and city:

…………………………………………………………. ………………………………………………………

Responsible for the study:

Lovisa Jansson Sofia Henriksson

Jägaregatan 10 d Gibraltargatan 78, lgh 1532/1392 417 01 Göteborg 412 79 Göteborg

SWEDEN SWEDEN

Supervisor:

Kerstin Segesten, RN, PhD, Professor

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Appendix 3

Interaction observation

When:

Where:

Who:

Type of activity:

What is said: (By who, to whom, in what

way)

What is done:

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Appendix 4

Table 1: Template for observation reports

Place Person Observer Activity Refection

Narrative

Table 2: Analysis template for step 1-5 in the analysis and interpretative process

Narrative Meaning unit Condensed meaning unit

Codes

Table 3: Analysis template for step 6-7 in the analysis and interpretative process

Codes

Sub-categories Categories Theme

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Risk analysis We have earned admission from Scandinavian Children's Mission to visit their work in Manila and do

our study. The aim of the study is approved by Bo Wallenberg, president of Scandinavian Children’s

Mission and Thord Dahl, local manager in Manila. Thord Dahl is our contact in Manila. He is informed

about the method and thinks our study is practicable which decreases the risk of unpreventable

difficulties.

The limited period of time will be a difficulty, since eight weeks passes quickly doing an ethnographic

study. Jeffery and Truman (2004) point out an ethnographic research may be as short as a couple of

days. Their compressed time mode model is the one we are going to use. We are aware about the

short time and will try to stick to our schedule, meaning we will stop our observations in the fourth

week. Doing so we will have time to analyze our material and complete with questions that arise

before we leave.

Another probable risk is the great amount of data material that may occur. The ethnographic method

includes analyzing the data material on daily basis. Since the numbers of observations are not

definite from start, we have the possibility to adjust the design of the study if the amount of data

material becomes unmanageable.

Our study and method depends on nurses’ volunteering as participants in our observation. There is a

risk no nurses at Scandinavian Children's Mission would like to take part in our study. If this happens

we will ask all health workers, not only nurses to participate. If this is not possible we will do our

observation at Scandinavian Children's Missions primary health care service for children and their

clinic for malnourished children.

Another risk is that parents do not allow us to take part in and observe the nurses work in their

home. If this happens and we are not able to collect as much data as needed we will increase the

number of informal conversations with the nurses. This way we will be able to get the nurses picture

of hand hygiene even if we cannot observe the work ourselves. We could also change our method

from observations to interviews with nurses if difficulties to collect data from observations and

informal conversations occur.

If no nurses or health workers are willingly to take part in our study which is unlikely since the study is

approved by the organization, we will examine how the organization promotes proper hand hygiene.

For example by interviewing the local manager, looking through the organization guidelines and find

out how they educate members of the staff.

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Preliminary budget

SEK/person

Flight Ticket 8000

Accomodation 2500

Vaccination 6000

Travelling within Philippines 1200

Travelling within Sweden 2500

Visa 500

Interpreter 2000

Paper copies 200

Littarature 1000

Computer 3000

Camera 1000

Total sum 27700