Table of Contents Abstract....................................................................................................................1 Chapter One: ...........................................................................................................2

1.1 Identifying research issue of interest:..............................................................2 1.2 Literature Review: ...........................................................................................2 1.3 Research question: .......................................................................................10 1.4 Aims and Objectives:.....................................................................................10

Chapter Two: .........................................................................................................11

2.1 Design / Proposed Method:...........................................................................11 2.2 Population / Sample: .....................................................................................12 2.3 Data Collection: .............................................................................................14 2.4 Rigour and Trustworthiness of study:............................................................15 2.5 Data Analysis: ...............................................................................................16 2.6 Pilot study: .....................................................................................................17 2.7 Ethical Considerations:..................................................................................18

Chapter Three:.......................................................................................................20

3.1 Proposed Outcome of the Study ...................................................................20 3.2 Time Scale.....................................................................................................20 3.3 Budget ...........................................................................................................21

Appendices:

Appendix I: Letter to the Director of Nursing Appendix II: Letter to the Ethical Committees Appendix III: Letter of Invitation Appendix IV: Consent Form Appendix V: Notice of Invitation / Information Appendix VI: Letter to the Clinical Nurse Manager Appendix VII: Interview Structure / Schedule Appendix VIII: Time Scale Appendix IX: Budget

References Bibliography

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Abstract Topic: Exploring nurses’ experiences of rehydration methods used in a paediatric hospital setting within Ireland. Background: There are two main types of rehydration practices used in children’s emergency departments (ED); oral rehydration therapy (ORT) and intravenous rehydration therapy (IVT). The recommendations regarding rehydration in children are to use ORT as a first line treatment for mild to moderate rehydration. However, despite this, many staff favour the use of IVT. The literature highlights barriers identified relating to rehydration practices including signs and symptoms of dehydration, parental preference and cost, which influence decisions as to which method of rehydration is appropriate. Aim of Research Study: The aim of this study is to explore nurses’ experiences of rehydration methods used in paediatric hospital settings within Ireland and to discover if they have recommendations for future practice. Research Question: What are nurses’ experiences of rehydration methods used in practice within Ireland? Method: Qualitative research is the approach chosen for this study. Within qualitative research, a descriptive approach will be used to conduct this study. Sample: The sample will be selected from registered children’s nurses working within the ED. It is proposed 15 to 25 nurses with a minimum of six months clinical experience in the ED will be selected through purposive sampling. Data Collection and Data Analysis: Semi-structured interviews will be used as a method of data collection. The interviews will be audio recorded and transcribed verbatim post interview. It is proposed data analysis and data collection will occur simultaneously. Colaizzi’s framework (1978) for descriptive analysis as cited by Polit & Beck (2010) is the data analysis approach selected for this study. Results / Findings: Through the use of member checking, the author proposes to validate the research findings. It is intended the findings will highlight nurses’ experiences of rehydration practices and identify any perceived barriers which need to be overcome. Recommendations for further research and clinical practice will be illustrated in the findings.

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CHAPTER ONE

1.1 Identifying research issue of interest:

The topic chosen to research is rehydration practices in terms of comparing oral

rehydration therapy (ORT) and intravenous rehydration therapy (IVT), and to

discover nurses’ experiences of same. Dehydration is a common reason for

children to present to the ED. There are recommended guidelines, including the

NICE guidelines and local hospital policies in situ which aim to provide

standardised optimum care. However, despite these indicators and the

recommendations to use ORT first for children who present to the ED with mild to

moderate dehydration; this practice is not always carried out. From the literature

and clinical experience, the author found that many staff choose to use IVT as a

first line treatment.

1.2 Literature Review:

The focus for this literature review is to explore rehydration practices in children’s

ED, whilst determining current practices used in hospitals and comparing ORT

with IVT to establish best practice. In some instances naso-gastric rehydration

(NGT) may also be indicated for use (Ozuah et al. 2002). Dehydration is a

common reason for children to present to the ED (Diggins 2008). The primary

cause of dehydration is diarrhoea and vomiting as a result of gastroenteritis (NICE

2009).

A universal search of CINAHL, EMBASE and PUBMED databases was conducted

in addition to a manual search of individual journals e.g. Paediatric Nursing. The

keywords used in the search were: rehydration, oral rehydration therapy,

intravenous rehydration therapy, dehydration, nursing and gastroenteritis.

Numerous articles were located through a comprehensive search; however the

articles are not restricted to the last ten years due to the lack of research articles

available surrounding this topic. The majority of the studies were based in the

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U.S.A., Canada and Australia. No relevant studies have been conducted in

Ireland. The author contacted paediatric hospitals in Ireland, the Health Service

Executive, Department of Health and Children and the Central Statistics Office to

obtain statistics and relevant research information, however there were no

available resources.

This literature review solely focuses on mild to moderate dehydration, secondary

to acute gastroenteritis. Recommended first-line treatment for this is ORT (Atherly-

John et al. 2002). However there is conflict between recommendations, guidelines

and practice which is evident in both the literature and clinical practice. The two

principal themes emerging from the literature were barriers to practice including

rehydration times and the advantages and disadvantages associated with

rehydration methods.

Barriers to Rehydration Practice

Rehydration methods used in Irish hospital settings are mainly ORT and IVT. ORT

involves administering a rehydration solution orally e.g. dioralyte, using between

50 to 100ml/kg over four hours. Standard practice is to administer this at a rate of

5mls every 5minutes (Canavan & Arant 2009). The NICE guidelines (2009) do not

recommend fruit juices or fizzy drinks due to the inadequate electrolyte

concentration and these can exacerbate symptoms.

Barriers to rehydration practice are interspersed throughout the literature. Seven

studies highlighted barriers associated with rehydration practices including those

by Atherly-John et al. (2002), Ozuah et al. (2002) and Spandorfer et al. (2005).

These studies were conducted in the USA, Canada and Australia and consisted

mainly of randomised controlled trials and some studies used surveys as the

methodology. The focus of these studies primarily compared rehydration practices

among children who were mild to moderately dehydrated and one of the main

issues emerging from these were barriers to practice including length of time taken

for rehydration and time spent in the ED.

Atherly-John et al. (2002) used a randomised controlled trial, in an urban

paediatric ED in the U.S.A. The study compared ORT with IVT for treating

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moderate dehydration as a result of acute gastroenteritis in children aged between

3 months and 17 years. From an original selection of 269 children; only 34 were

eligible to participate and were randomly allocated to either ORT (18) or IVT (16).

When using ORT the length of ED stay was significantly shorter at 225 minutes,

compared with IVT which took 358 minutes. ORT also required less staff time

(35.8 minutes) in comparison to IVT (65 minutes).

The small sample size used in this study may be considered a limitation, as it may

not be an accurate representation of a wider population. Procter and Allan (2006,

p. 180) state within a research study smaller sample sizes may be unable to

“achieve the power required to obtain a significant outcome”.

Spandorfer et al. (2005) carried out a similar study to Atherly-John et al. (2002)

with a larger number of participants and obtained parallel results. Spandorfer et al.

(2005) compared ORT with IVT in children aged 8 weeks to 3 years, in an urban

paediatric hospital in Philadelphia. The criteria required to be eligible for the study

meant that out of 335 patients who were assessed for participation only 73 were

suitable. Similarly to Atherly-John et al. (2002) a randomised controlled clinical trial

was the method used. Nelson et al. (2006, p. 245) supports the use of randomised

controlled trials as a research method and identified a strength of these as

“reducing the possibility of selection bias”. In addition to a shorter time required to

begin treatment with ORT; 19.9 minutes compared to 41.2 minutes for IVT, ORT

required less staff time, effort and overall care. A higher hospitalisation rate was

experienced with IVT at 48.7% of patients hospitalised, in comparison to only

30.6% of the ORT group.

Similarly, Mackenzie & Barnes (1991) carried out a randomised controlled trial in a

teaching hospital in Australia to compare ORT and IVT in children aged 3 to 36

months and assigned 52 children to receive each treatment. Prior to the initiation

of the study ethical approval was sought and granted. Haigh (2008) emphasises

the importance of ethical approval in all studies. Vomiting has been noted as a

major barrier to rehydration practice; and in this study 52% of children receiving

ORT in comparison to 22% receiving IVT suffered from vomiting. Despite initial

rehydration working quicker in the IVT group; after 24 hours children in both

groups experienced the same level of rehydration. A major limitation noted by

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Mackenzie & Barnes (1991, p. 395) to their study was that “it could not be a

double blind trial”. Smith (2008) highlights preventing experimental bias as a main

benefit to using a double blind trial. The results of these studies are reinforced with

a study conducted by Bender & Ozuah in an urban ED in America in 2004. In this

study, it was found IVT took a significantly longer time for successful rehydration

than ORT.

In a study, conducted by Ozuah et al. (2002), a survey was distributed among a

random selection of ED doctors and compared ORT, IVT and NGT. From an initial

selection of 240 doctors, 176 participated. Of these participants, 65 were familiar

with the practice parameters published by the American Academy of Pediatrics

(1996) which promotes using ORT as an immediate treatment of mild to moderate

dehydration. NGT was excluded from the findings due to its limited use within the

study (<1% of participants reported using NGT for rehydration). The results

highlighted that 70.5% of staff always used ORT, compared to 1.8% always using

IVT for mild dehydration treatment with children under two years of age. A major

limitation to surveys includes relying on self report data and the opinions

represented in the findings may not be a true representation of all staff (Ozuah et

al. (2002).

Barriers to practice illustrated by Ozuah et al. (2002) included the child refusing to

drink or take fluids orally. In this situation, 96% of staff favour the use of IVT and

only 0.6% would use ORT. Vomiting being a primary symptom favoured the use of

IVT and 85% of staff would use IVT with only 2% choosing ORT. These results

were supported with a study conducted by Cohen Reis et al. (1994) which found

30% of staff surveyed would withhold ORT if the child was vomiting. Staff favour

the use of ORT (59%) compared to IVT (8%) if diarrhoea was a primary symptom.

Not passing urine has a significant influence on rehydration methods, as 35% of

staff would choose IVT compared with only 7% choosing ORT. Waiting times and

busy ED had an influence on practice; 22% of staff would use IVT in contrast to

15% using ORT. The desire of staff to minimise pain among children and decrease

treatment costs were significant reasons for choosing ORT.

Conners et al. (2000) also used a staff survey to highlight barriers to practice, in

the U.S.A. and Canada. This study illustrated a significant underuse of ORT and

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reasons documented for this included the perception that IVT was quicker and

ORT required longer treatment and staff time and additional staff input. There was

also a belief among participants (41.7%) that parents expected IVT to be used as

first line treatment and parental concern surrounding dehydration influenced

rehydration practices. Ozuah et al. (2002) found 31% of ED staff were more likely

to choose IVT compared to 9% using ORT due to parental concerns.

As illustrated from the literature, many barriers to rehydration practice are evident

including vomiting and diarrhoea as major symptoms, waiting times and busy

hospitals, economic cost and parental concerns. In practice, as a conclusion from

these studies, rehydration time is shorter when using ORT. ORT reduces ED stay

and staff time associated with treatment and decreases the volume of hospital

admissions compared to IVT. Barriers to practice must be addressed and

explained in order to bridge the gap between guidelines, recommendations and

practice and to establish why ORT remains underused in practice. In order to

establish best practice and to provide holistic care the advantages and

disadvantages associated with each treatment need to be considered.

Advantages and Disadvantages relating to Rehydration Practice Advantages and disadvantages associated with rehydration practices are

documented widely in the literature as illustrated by authors including Nager &

Wang (2002), Ozuah et al. (2002), Ip et al. (2005) and Lee & Haden (2007). Older

research studies conducted by Sharifi et al. (1985) and Gremse (1995) also

highlighted advantages and disadvantages associated with rehydration methods.

Nager & Wang (2002) researched rehydration practices among children aged

between 3 and 36 months in a paediatric hospital in Los Angeles. The sample size

was 90 patients; 44 assigned to IVT and 46 to NGT. When inserting NG tubes and

IV cannulas, discomfort was experienced. A second attempt was needed to insert

the NG tube in two children due to bleeding on insertion and pulling out the tube.

However 13 participants had problems with the insertion of an IV line and 27

additional attempts were required to obtain access, which caused undue stress

and pain on the child.

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A study of 24 patients aged 2 to 19 months conducted by Gremse (1995) in the

U.S.A. supported these findings. The length of stay and hospitalisation costs

decreased in patients receiving NGT in comparison to IVT. Those patients

receiving IVT experienced more complications e.g. infiltration at the IV site, and IV

cannulae were found to be harder to insert than NG tubes.

Spandorfer et al. (2005) advocate the use of ORT as it avoids the painful and

difficult procedure of intravenous catheterisation. In their study, approximately half

of the participants (19 out of 37) had an IV cannula inserted successfully on the

first attempt; 7 needed an additional attempt in order to obtain intravenous access

and 10 children required multiple attempts (between 3 and 8), and even after

multiple attempts at cannulation, one child was unable to be cannulated. This

individual was treated using ORT and later discharged home. These results

echoed those of Nager & Wang (2002) that IVT appeared more painful and

distressing for the child. Ozuah et al. (2002) also found ORT to be effective, safe,

cheaper and less painful than IVT. Larson and Melnyk (2000) support these

findings and favour the use of ORT.

Advantages associated with ORT included less complications associated with use

and minimised pain as illustrated by Ip et al. (2005), Crellin (2008) and Lee &

Haden (2007). In Hong Kong, Ip et al. (2005) obtained 413 medical records of

children aged between 1 and 60 months, and examined the rehydration practices

used. In this study 241 children received IVT. Within these 241 children electrolyte

imbalances were present in 14 children and hospital stay length was longer with

IVT. The results from this study demonstrated IVT is more costly and has more

complications associated with use.

Crellin (2008) endorse these findings and advocates the use of ORT as it

minimises the electrolyte imbalances occurring with IVT use. A randomized

prospective trial conducted by Sharifi et al. (1985) included 470 children aged 1 to

18 months old and highlighted complications associated with use. Significantly

more electrolyte disturbances were experienced in the IVT group, including

hyponatraemia and hypokalaemia. In the IVT group 29 patients experienced

electrolyte disturbances in comparison to only 14 receiving ORT. Other

complications included phlebitis at the cannula site and abdominal distension as a

8

result of ORT. When using ORT, blood tests are not routinely carried out. With IVT

blood tests are needed to assess electrolyte levels, leading to increased costs and

can initiate trauma in the patient while obtaining samples (Mackenzie & Barnes

1991). Overall ORT causes less physical and emotional pain.

An audit focusing on rehydration methods was carried out in Melbourne by Lee &

Haden (2007) and recruited a sample of 17 children aged 3 months to 3 years.

NGT raised many issues including nasal bleeding and displacement of the NG

tubes. Disadvantages with IVT included “painful IV access causing physical and

emotional distress” and “risks of extravasation if fluids leak into the subcutaneous

and risk of infection” (2007, p. 113).

Although IVT is predominantly used as a first-line treatment, ORT would be as

effective and should be adopted as the primary treatment (Diggins 2008). As a

result of these studies, the findings emphasise the benefits of ORT and imply ORT

should be the initial treatment choice for mild to moderate dehydration, due to it

being less traumatic and less invasive for the child, easier to administer and less

costly (Bellemare et al. 2004).

Conclusion

The main themes emerging from the literature were (1) barriers to rehydration

practice and (2) advantages and disadvantages associated with each method.

Based on the literature ORT is superior to IVT and should be implemented as first

line treatment for mild to moderately dehydrated children. When using ORT,

shorter lengths of ED stay were endured and the children were rehydrated quicker

than those treated with IVT. The hospital admission rates were lower with ORT.

However, ORT remains underused in hospital settings worldwide. Parental

preference, cost and symptoms associated with treatment were barriers to practice

identified within the literature. These were viewed as deterrents to the use of ORT.

The fundamental advantages associated with ORT are less complications and the

avoidance of painful IV cannulation which causes stress to both the child and

parents.

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Overall, when considering the wealth of literature, ORT should be the initial

rehydration choice for children who are mild to moderately dehydrated. However,

despite this, ORT remains underused in practice today (Santosham 2002). Nurses

have a fundamental role in advocating and explaining the benefits of ORT to

patients and families whilst incorporating ORT into their practice (Larson & Melnyk

2000). ORT should be incorporated into all rehydration practices, as it reduces

morbidity and mortality associated with diarrheal illness (Ulrickson 2005). In

practice IVT is used unnecessarily, when the same results can be achieved

through a less painful method of ORT.

Worldwide, there remains a gap between recommended guidelines and current

practice. Additional research is necessary to further identify why staff favour IVT

over ORT and why ORT is not being used when indicated. Further education

among staff is needed to ensure they understand the benefits of ORT. Bender et

al. (2004) support this and emphasise the importance of staff becoming informed

of best practice in order to increase the uptake of ORT. The advantages

associated with ORT must be promoted to increase ORT use and change current

practice and behaviours, in order to coincide with published recommendations

including NICE guidelines (2009). Nurses’ experiences and views surrounding this

topic will be beneficial in order to assist with the understanding of this.

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1.3 Research question:

The research question would focus on the area of exploring nurses’ experiences of

rehydration methods used in practice within Ireland, and identify if they believe any

recommendations might improve rehydration practices in the future.

What are nurses’ experiences of rehydration methods used in practice within

Ireland?

1.4 Aims and Objectives:

Aim: The aim of this research study is to explore the experiences of nurses

regarding rehydration methods used within a paediatric hospital setting in Ireland.

The objectives are:

• To understand nurses experiences and opinions about rehydration

methods within hospitals.

• To discover nurses perceptions about how well and effective rehydration is

carried out in the ED.

• To ascertain if nurses believe there is a problem with rehydration

procedures in hospitals in Ireland.

• To determine if nurses perceive the barriers to practice identified from the

literature are actual barriers in practice.

• To find out if nurses have recommendations for future rehydration

practices.

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CHAPTER 2:

2.1 Design / Proposed Method:

This chapter focuses on the research methodology and design selected for this

proposed study, which incorporates the overall structure of the study and the

techniques used for data collection and analysis (Polit & Beck 2010). Bowling

(2002) highlights the importance of choosing the appropriate research method.

There are two approaches used in research, qualitative and quantitative research.

Qualitative research aims to help understand social phenomena in a natural rather

than an experimental setting while emphasising the experiences, attitudes, and

views of the participants rather than providing quantified answers to a question

(Nieswiadomy 2008). Qualitative research obtains data usually in the form of

words, based on observations and interviews, rather than numbers which is the

basis for quantitative research (Fawcett & Garity 2009).

Qualitative research focuses on obtaining deep and meaningful information from

small groups which fulfil certain criteria set out by the researcher (McCarthy &

O’Sullivan 2008) and has the ability to assist with guiding future nursing practice

(Barroso 2010). In contrast to this, quantitative research uses numerical data to

obtain information about the environment and surroundings. It is used to test

theories and examine relationships between variables (Burns & Grove 2011).

According to Macnee & McCabe (2008) quantitative research is unable to consider

the individuality of human experience and for this reason the author believes a

qualitative approach is more suited to the proposed study.

A qualitative approach appears to be more suitable to explore the research

question within this study; as the main focus is on establishing the experiences of

nurses. Parahoo (2006) identifies the benefit of qualitative research in exploring

professional experiences, behaviours and practice and to contribute to the

fundamentals of core nursing and health concepts.

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There are different research designs within qualitative research which include

phenomenology, grounded theory, exploratory, and descriptive (Burns & Grove

2011). In this study, a descriptive qualitative approach will be used to explore the

research question as this is well suited to the study of human experiences and will

aim to gain an understanding of nurses’ experiences of rehydration practices.

2.2 Population / Sample:

The population is the entire group of people the researcher wishes to obtain

knowledge from. A selection of these individuals is taken from this population and

is known as the ‘sample’ (Gerrish & Lacey 2006). The sample will provide the

information and data for the study. According to Parahoo (2006, p. 260) non-

probability samples can be useful with qualitative research as “the purpose of

qualitative research is to contribute to an understanding of phenomena” and the

sample can be ‘chosen’ to best provide the required data for the study.

Within qualitative research, the main types of sampling include convenience,

purposive, cluster, volunteer, random and snowball (Bloom & Trice 2007). As the

author intends to specifically target nurses working within children’s ED, purposive

sampling will be used, as the sample is chosen deliberately, “on the basis that

those selected can provide the necessary data” for the study (Parahoo 2006, p.

268). This allows the researcher to pick a selected group of individuals most

appropriate to answer the questions and select the specific information sources

required to gain insight into the research study (Burns & Grove 2011). As this

research is self-funded with limited time available for the study, this sample

technique and size allows for easy access and is cost effective.

The researcher will approach a gatekeeper; an individual who enables the

researcher access to the setting and research participants (Gerrish & Lacey 2006)

for example, a manager within a healthcare facility. Permission will be sought from

the Director of Nursing within the hospital (See Appendix I), asking permission to

conduct the study. Prior to this, ethical approval will be sought from the ethics

committee within the Faculty of Health Science in the college and further ethical

approval will be sought from the hospital site (See Appendix II). An invitation will

be sent to the nurses working in the ED (See Appendix III), including consent form

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(Appendix IV) and return stamped addressed envelopes to the researcher. A

notice of information will be posted in the staff room (See Appendix V). Contact

information of the author will be made available for further information. A letter of

permission will be subsequently sent to the ED Clinical Nurse Manager (See

Appendix VI) and the author will use this individual as the gatekeeper.

Inclusion criteria which involve characteristics the individual must have to

participate and exclusion criteria which are attributes which will exclude people

from the study (Bloom & Trice 2007) will be established. The sampling criteria for

this study includes the participants must be (1) registered children’s nurses with

An Bord Altranais (2) working in a children’s ED (3) with a minimum of six months

experience.

Qualitative research focuses on the quality of information obtained rather than the

quantity and size of the sample (Huberman & Miles 2002). There is little guidance

regarding exact sample sizes for qualitative research in the literature, as sample

size is influenced by the available resources and the feasibility of acquiring the

sample (Procter & Allan 2006). According to Burns & Grove (2011, p. 318) a small

sample size can be adequate for a qualitative study, “when the quality of the data

is high, with a rich content” and for this reason the author requires a sample of

between 15 and 25 staff members for interviewing. It is proposed that these

participants will achieve saturation of information, whereby “additional sampling

provides no new information, only redundancy of previously collected data” (Burns

& Grove 2011, p. 317).

The author recognises this is a small sample size however Bowling (2002, p. 380)

advocates the use of a small sample size when using qualitative interviews, as the

focus is on quality of the information rather than quantity and the data aims to

“provide rich insights in order to understand social phenomena rather than

statistical information”. This sample size reduces time constraints of the

interviewing process and the transcribing of the interviews (Parahoo 2006).

Barroso (2010) supports the use of smaller sample sizes for qualitative research

(under 30 participants) due to the large quantities of written text which will need to

be analysed by the researcher. Consequently, the author feels this sample size is

appropriate to the proposed study. However, to confirm this sample size is large

14

enough to represent this population, the expertise of a statistician will be engaged

and their opinion will be sought.

2.3 Data Collection:

The author proposes to use semi-structured interviews as a method of data

collection (Polit & Beck 2010), as with qualitative research the data collected are

usually words. Semi-structured interviews allow for a fixed set of questions but

with no fixed responses (Burns & Grove 2011) and allows participants to expand

on points made in the conversation. Semi-structured interviews allow for flexibility

that the researcher had not anticipated when preparing the interviews (Tod 2006).

Interviews are more appropriate to use in this instance, as there is no previous

research surrounding nurses’ experiences of rehydration and therefore a

questionnaire would be inappropriate at this moment in time as the researcher

does not know if there are issues or problems relating to rehydration practices and

nurses’ experiences. Qualitative research needs to be conducted before

quantitative research to assess if there is a problem in Ireland with rehydration

practices.

The author aims to use face-to-face interviews rather than telephone interviews,

as they are more personal and it is easier to explore participants experiences face-

to-face (Macnee & McCabe 2008). Burns & Grove (2011, p. 540) define interviews

as “structured or unstructured oral communication between the researcher and the

subject, during which information is obtained for a study”. The interview will last for

between 60 and 90 minutes and will follow an interview schedule (Tod 2006) (See

Appendix VII). The interview will follow the pattern of an opening introduction,

guiding questions and a final, closing statement; which will remain the same for

each interview to ensure consistency. The questions which will be used for the

interview have emerged from the literature review conducted prior to the

commencement of this research study, and will be pilot tested to see if the

questions will answer the research question. Through the use of individual

interviews, the author seeks to understand personal attitudes and beliefs

surrounding the topic (Jackson et al. 2008).

Burns & Grove (2011) advocate the use of a natural setting or location for a

descriptive study. A comfortable, private room, free from interruptions will be used

15

for the duration of the interviews, for example a seminar room in the hospital. The

participants will be reassured that confidentiality will be maintained at all times.

Participants will be given the opportunity to choose a pseudonym in order to

ensure confidentiality. It is important for the interviewer to build up a good rapport

with the participant and build a trusting relationship in order to make the participant

feel comfortable and enable them to express their views honestly (Jackson et al.

2008).

2.4 Rigour and Trustworthiness of study:

Rigour relates to establishing the trustworthiness of the data and study (Lacey

2006). When assessing qualitative research studies and the robustness of the

study, Lincoln & Guba (1985) as cited by LoBiondo-Wood & Haber (2010)

produced a set of criteria to use focusing on the credibility, dependability,

transferability and confirmability of a study.

Credibility focuses on the truth and value relating to the findings of the study and

the representation of these (Topping 2006). Through the use of semi-structured

interviewing techniques, tape recordings of the interviews and transcriptions of

these verbatim this will increase the accuracy of the descriptions of participants’

experiences and therefore will increase the credibility of the findings (Streubert &

Carpenter 2010). Dependability relates to the reliability of data over time and

different conditions and refers to the detail and information provided by the study

to allow others to replicate the methods of the researcher and reach the same

conclusions (Streubert & Carpenter 2010). Parahoo (2006, p. 410) define

transferability or fittingness of a study as “the extent to which the findings of a

qualitative study can be of use to other populations or settings similar to those in

the study”. Topping (2006, p. 169) identify the confirmability of a study establishes

that “data, findings and interpretation are clearly linked” and the participants along

with other research professionals support and agree with the researcher’s

interpretation of the findings. The author proposes to use these criteria as a guide

to ensure trustworthiness and robustness of the study.

The author intends to use member checking as a method of ensuring rigour and

establishing the credibility of the data obtained. As outlined by Polit & Beck (2010,

16

p. 499) “in a member check, researchers provide feedback to study participants

about emerging interpretations, and obtain participants' reactions”. However, a

limitation regarding member checks as highlighted by Polit & Beck (2010) is that

participants might not disagree with the researchers’ interpretations of the

interview, as they feel inferior and less knowledgeable, and the researcher must

be aware of this when relaying information.

In order to ensure the study is conducted in a rigorous manner, Bowling (2002)

highlights; the researcher should aim to avoid using bias throughout the process,

aim to reduce any sources of error which may present and the research should be

carried out in a systematic way relating to design, data collection, analysis and

interpretation. Accurate records must be kept of all interviews and interactions with

participants, as the careful recording of data is crucial to the study. Rigour is

attained through strict attention to detail, adhering to procedures and through

consistency and accuracy throughout the research process (Burns & Grove 2011),

each of which the researcher will consider at all times.

2.5 Data Analysis:

According to Burns & Grove (2011) data collection and data analysis occur

simultaneously in qualitative research, as the emerging results may require further

data collection. The researcher is concurrently gathering, managing and

interpreting data. Accurate transcribing of audiotaped interviews as soon as

possible after the interview is essential before data analysis can occur (Polit &

Beck 2010). This can be time-consuming, as Bowling (2002) emphasises for one

hour of recording it may take up to four hours to transcribe verbatim. The author

believes this validates the use of the chosen small sample size.

The storage of data will be done in an organised, secure manner and will be

disposed of confidentially and appropriately when necessary. Hand written

information will be typed into a word document for electronic secure storage with

correct dates, locations and identities in the form of pseudonyms.

Colaizzi’s framework (1978) for descriptive analysis as cited by Polit & Beck

(2010) will be used for data analysis. The aim of this is to establish common

17

patterns and trends relating to the nurses’ experiences. There are certain stages

involved in this process, as highlighted by Holloway & Wheeler (2002) and Polit &

Beck (2010).

• The researcher will listen to each of the interviews, transcribe them

verbatim and gain a broad understanding of same.

• Significant statements will be extracted and meanings formulated from

these.

• These meanings will be organised into clusters of themes and grouped

together, while ensuring these statements are original and not changed to

fit into a theme.

• The results will be integrated into an exhaustive description; which ensures

the participants views are described accurately and appropriately.

According to Holloway & Wheeler (2002, p. 286) exhaustive description is

“writing that aims to capture and describe the intensity and depth of the

participants’ experiences”.

• The themes of the research study will emerge from linking the patterns

found within the exhaustive description and will be discussed further.

• The researcher will provide the participants with a copy of the findings in

order to validate the results and ensure rigour.

2.6 Pilot study:

Gerrish & Lacey (2006, p. 538) highlight the function of a pilot study as “a

preliminary study carried out before the full research, to test out data collection

instruments and other procedures”. The pilot study will check out the feasibility of

the main study, highlight any problems or issues which may arise and will be

conducted a few weeks before the actual study is set to be carried out (Burns &

Grove 2011). The author will conduct a small number of pilot interviews, of

approximately 10% of the estimated sample size (e.g. 2 ED nurses), which will test

the interview schedule, determine if any equipment required e.g. tape recorder

works efficiently and to estimate the length of time the interviews will take (Gerrish

& Lacey 2006). The participants used in the pilot study must have the same

characteristics as those of the main study.

18

The pilot study will also assess the location for interview is easily accessible for

participants, discreet and appropriate (Fawcett & Garity 2009). The data collected

from this pilot study will not be included in the research findings, however the

outcome will be considered before commencement of the main study. When

analysing this data, the researcher will listen to the interviews to determine if the

participants understand the questions, if they supplied the data necessary to

answer the research question and will enable further adjustments to be made to

the interview schedule as necessary (Polit & Beck 2010).

2.7 Ethical Considerations:

Written ethical approval will be obtained from the college and hospital research

ethics committee prior to the commencement of the study. Ethical approval is

necessary for the protection of the participants and their rights. Informed written

consent will be obtained from each participant before the study, after they have

received adequate information, briefing and understand what participation in the

study entails (Bowling 2002). Participants will be informed of their right to voluntary

participation and the right to withdraw from the study at any time, without incurring

a penalty, which protects their right to self-determination (Burns & Grove 2011). All

information obtained within the study will be treated as confidential and stored

securely (Parahoo 2006).

Basic human rights, including the right to privacy and dignity, right to anonymity

and confidentiality, right to fair treatment and right to protection from discomfort

and harm (LoBiondo-Wood & Haber 2010) will be protected throughout the

research process. Within qualitative research total anonymity is not possible, as

the interviewer will be aware of the participant (Burns & Grove 2011). The

individual will be given an opportunity to adopt a pseudonym in order to maintain

anonymity for the duration of the rest of the process in order to protect subjects

and records (Zanotti & Cowman 2008). Confidentiality will be maintained at all

times by not disclosing the information shared to any other parties, without

consent and by avoiding attributing information in the findings which would identify

the participants (Parahoo 2006).

19

Beauchamp & Childress (2008) identify ethical principles; confidentiality, respect

for autonomy, non-maleficence, beneficence and justice which the author strives

to protect throughout the study. Autonomy relates to the individual choosing their

own course of action and the researcher will ensure all information, risks and

benefits associated with the study and consent forms are fully explained and

understood by each participant (Haigh 2008). Non-maleficence relates to

protecting the participants from harm including the appropriate storage of data in a

confidential manner. Beneficence involves the promotion of good for others (Haigh

2008), and the hope is that this research study will provide an overall benefit to the

wider population. Justice and fairness will be upheld through the equal opportunity

for all eligible participants regardless of nationality, language and age.

20

CHAPTER THREE

3.1 Proposed Outcome of the Study

The author proposes to report the findings of this research study when it is

completed and complete a research report (Gerrish & Lacey 2006). The lack of

research available regarding nurses’ experiences of rehydration practices

highlighted the need for further investigation into this aspect of care. There is little

research conducted into nurses’ experiences and there is a lack of resources and

information available from Irish hospitals. The author expects this research study

to provide an insight into nurses’ experiences regarding rehydration practices,

allow them to express their opinions and provide recommendations for practice

which may prove beneficial to future clinical practice. The author anticipates the

results from this study will highlight any issues arising from practice and it is hoped

that these issues will encourage further research into the area surrounding

rehydration practices in order to provide holistic, optimum care (LoBiondo-Wood &

Haber 2010). The study will contribute to developing rehydration practice and the

findings will assist policy makers to create best practice guidelines for the future.

3.2 Time Scale

The author proposes to carry out this research study over an eighteen month

period, incorporating the literature review through the entire research process until

the publication of the findings. A Gantt chart is a detailed time-scale which outlines

the steps in this research proposal (Lacey 2006) (See Appendix VIII) and outlines

the time-frame required for this study.

21

3.3 Budget

A resources budget has been devised for this research proposal (See Appendix

IX). It includes research staff salaries, data collection and processing costs and

administrative overheads (Bond & Gerrish 2006). A budget is necessary when

applying for funding for the research study and allows the researcher to use

available resources (Zanotti & Cowman 2008).

22

Appendices

23

Appendix I: Letter to the Director of Nursing A. N. OTHER

1 Main Street Town

Co. Dublin. Director of Nursing XXX Hospital XXXXX. <<DATE>> Re: Research Study: An exploration of nurses’ experiences of rehydration methods used in a paediatric hospital setting in Ireland. Dear Sir/Madam, I am currently undertaking a BSc in Integrated Children’s and General Nursing at Trinity College Dublin. As part of the degree programme I am required to complete a research study. I have chosen to undertake a descriptive qualitative study exploring children’s nurse’s experiences of rehydration practices in the Emergency Department. I am seeking to interview between 15 and 25 nurses regarding their experiences surrounding this topic. I hope to interview Registered Children’s Nurses only with a minimum of six months experience in the clinical area. The interview schedule is anticipated to take between 60 and 90 minutes in a seminar room at XXXX hospital. Subject to agreement and permission, I intend to use a gatekeeper e.g. the clinical nurse manager in the Emergency Department, and will make contact with them to approach participants, request permission for posting a notice of invitation (See enclosed for a copy of this notice) and to arrange suitable times for interviews. Participants will be informed that participation is strictly voluntary, with the right to withdraw at any time available to each participant without consequences. Through the use of pseudonyms and appropriate secure data storage, an assurance of confidentiality and anonymity will be given. I hope that by exploring nurses’ experiences of rehydration practices, this will lead to increased knowledge which will subsequently improve the quality of patient care and create the opportunity for positive changes within nursing practice. The findings will assist policy makers to create best practice guidelines. If you require any additional information or if you wish to see a copy of my research proposal, please contact me at xxxx@xxxxx.ie. Thank you for your time and consideration. I look forward to hearing from you. Yours Faithfully, XXXXXX

24

Appendix II: Letter to the Ethical Committees

A. N. OTHER 1 Main Street Town

Co. Dublin. Ethical Committee XXXXXXX Co. Dublin <<DATE>> Re: Research Study: An exploration of nurses’ experiences of rehydration methods used in a paediatric hospital setting in Ireland. Dear Sir/Madam, I am currently undertaking a BSc in Integrated Children’s and General Nursing at Trinity College Dublin. As part of the degree programme I am required to complete a research study. I am proposing to conduct a qualitative descriptive study exploring children’s nurse’s experiences of rehydration practices in the emergency department. I am writing to request approval from the ethical committee to conduct this study at XXX hospital. It is intended to interview between 15 and 25 nurses regarding their experiences surrounding this topic. I hope to interview Registered Children’s Nurses only with a minimum of six months experience in the clinical area. Participants will be informed that participation is strictly voluntary, with the right to withdraw at any time available to each participant without consequences. Through the use of pseudonyms and appropriate secure data storage, an assurance of confidentiality and anonymity will be given. I hope that by exploring nurses’ experiences of rehydration practices, this will lead to increased knowledge which will subsequently improve the quality of patient care and create the opportunity for positive changes within nursing practice. I would be grateful if the ethics committee would consider this research study and hopefully contemplate granting approval for this study to be undertaken. Please find enclosed a copy of the research proposal and participant information leaflet. Informed written consent will be obtained before and after each interview and the intention is to provide the participant with a hard copy of the findings in order to confirm this is an accurate representation of their experiences. If you require any additional information please do not hesitate to contact me at xxxx@xxxxx.ie. Thank you for your time and consideration. I look forward to hearing from you. Yours Sincerely, XXXXXX

25

Appendix III: Letter of Invitation A. N. OTHER

1 Main Street Town

Co. Dublin. Staff Nurse XXX XXX Hospital XXXXX. <<DATE>> Re: Research Study: An exploration of nurses’ experiences of rehydration methods used in a paediatric hospital setting in Ireland. Dear Staff Nurse, I am currently undertaking a BSc in Integrated Children’s and General Nursing at Trinity College Dublin. As part of the degree programme I am required to complete a research study. I have chosen to undertake a descriptive qualitative study exploring children’s nurse’s experiences of rehydration practices in the emergency department. I intend to interview between 15 and 25 nurses regarding their experiences surrounding this topic. I hope to interview Registered Children’s Nurses only with a minimum of six months experience in the clinical area. I hope you will agree to participate in this study. The interview schedule is anticipated to take between 60 and 90 minutes in a seminar room at XXXX hospital. Participation in this study is strictly voluntary and you have the right to withdraw at any time without consequences. Through the use of pseudonyms and appropriate secure data storage, I can assure confidentiality and anonymity. I hope by carrying out this study it will lead to increased knowledge which will subsequently improve the quality of patient care and create the opportunity for positive changes within nursing practice. The findings will assist policy makers to create best practice guidelines. Thank you for taking the time to read this letter and for your consideration. If you have any questions or require any additional information, please contact me at 08XXXXXXXX or email me at xxxx@xxxxx.ie. Should you wish to take part in the study please complete the enclosed form and return it to me in the stamped envelope by XX/XX/2011. Yours Sincerely, XXXXXX

26

Appendix IV: Consent Form Re: Research Study: An exploration of nurses’ experiences of rehydration methods used in a paediatric hospital setting within Ireland. I am an Integrated Children’s and General Nursing student at Trinity College Dublin and am completing a descriptive qualitative research study exploring Children’s Nurses’ experiences of rehydration practices in the Emergency Department. This study aims to provide information which will enable nurses’ in the future to improve rehydration practices and in doing so, improving patient care. The hope is that by exploring nurses’ experiences of rehydration practices, this will lead to improving the quality of patient care and create the opportunity for positive changes within nursing practice. The study has received ethical approval from the college Ethics Committee and the Hospital’s Ethics Board. Participation involves completing an interview which will take approximately between 60 and 90 minutes. All information obtained will be treated confidentially and no individuals shall be named throughout the process. The study data will not be linked with any names or personal details, and will be stored in a secure place and not shared with any other persons without your permission. Participants have the right to withdraw from the study at any time throughout the process, without penalty. If you require any additional information or have any further questions relating to the study please contact me at 08XXXXXXXX or email me at xxxx@xxxxx.ie. I have read this consent form, fully understand and voluntarily consent to participate in this study Participants Signature Date

27

Appendix V: Notice of Invitation / Information Re: Research Study: An exploration of nurses’ experiences of rehydration methods used in a paediatric hospital setting within Ireland. I am currently undertaking a BSc in Integrated Children’s and General Nursing at Trinity College Dublin. As part of the degree programme I am required to complete a research study. I have chosen to undertake a study to explore Children’s Nurses’ experiences of rehydration practices in the emergency department. There is controversy surrounding the use of oral and intravenous rehydration therapy within Emergency Departments. I feel that valuable information can be obtained from nurses’ experiences surrounding this topic in order to improve patient care and establish best practice. As you are dealing with this issue on a regular basis I am interested in your views on this area and appreciate your opinions. I hope to interview registered children’s nurses only, male or female, with a minimum of six months experience in the children’s Emergency Department. The interview will last 60 – 90 minutes. All information obtained will be strictly confidential. If you are interested in participating please contact me at xxxx@xxxxx.ie. Please respond by the XX/XX/2011. I look forward to hearing from you. XXXXXX

28

Appendix VI: Letter to the Clinical Nurse Manager A. N. OTHER

1 Main Street Town

Co. Dublin. Clinical Nurse Manager XXX Hospital XXXXX. <<DATE>> Re: Research Study: An exploration of nurses’ experiences of rehydration methods used in a paediatric hospital setting within Ireland. Dear Clinical Nurse Manager, I am currently undertaking a BSc in Integrated Children’s and General Nursing at Trinity College Dublin. As part of the degree programme I am required to complete a research study. I have chosen to undertake a descriptive qualitative study exploring children’s nurse’s experiences of rehydration practices in the Emergency Department. I hope to interview between 15 and 25 nurses regarding their experiences surrounding this topic. I hope to interview Registered Children’s Nurses only with a minimum of six months experience in the clinical area. The interview is expected to last 60 - 90 minutes in a seminar room at XXXX hospital. I would be grateful for your permission and assistance in facilitating interviews with the nurses while they are on duty. I have already received permission from the Director of Nursing to conduct this research study in the hospital. I hope that by exploring nurses’ experiences of rehydration practices, this will lead to improving the quality of patient care and create the opportunity for positive changes within nursing practice. If you require any additional information please contact me at xxxx@xxxxx.ie. Thank you for your time and consideration. I look forward to hearing from you. Yours Sincerely, XXXXXX

29

Appendix VII: Interview Structure / Schedule Title: An exploration of nurses’ experiences of rehydration methods used in a paediatric hospital setting within Ireland. Date: 5th March 2010 Venue: Seminar Room, Level 3, XXX Hospital Time: 10.00-11.30 a.m. Introduction: (5-10 minutes) The interviewer will discuss the purpose of the study with the interviewee, which is the exploration of Children’s Nurses’ experiences of rehydration methods (oral versus intravenous rehydration therapy) used in a children’s Emergency Department in Ireland. Preliminary Questions: (5 minutes) The interviewer will introduce themselves and ask the interviewee general questions about themselves. An ice-breaker question or two will assist with settling them in and relax the participant for example, a question relating to the weather. Conduct of interview / Main questions: (60 minutes; 10 minutes per question and an extra 10 minutes if necessary) 1. What are recommended current rehydration best practices in Ireland?

- What are the rehydration practices being used in the ED which they work in; oral or intravenous rehydration therapy?

2. Do you believe nurses aware of current rehydration practice in Ireland; yes or no?

-If they are aware, are they doing it? And if not, why? 3. Why, in your opinion, is intravenous therapy primarily used in the ED? 4. Do you experience any barriers to oral rehydration therapy and intravenous rehydration therapy in practice? -If yes, can you elaborate please and tell me about these barriers. 5. Do nurses have a role in promoting rehydration practices? -If so, what is it? Is there anything else you wish to add? Conclusion: (5 minutes) This entails a debriefing session, asking the participant if there is anything else they would like to add and asking are they happy with the interview. The interviewer can answer any questions in this section and ensure the participant understands the purpose of the study and what will happen with the findings. Thank you for your time and participation. (*all times are approximate, to be used as a guideline, as some sections will not take the allocated times.)

30

Appendix VIII: Time Scale

Month J F M A M J J A S O N D J F M A M J Literature Review

> > >

Research Question and Design

> >

Ethical Approval

> > >

Access and Sampling

> > >

Creating Interview Schedule

> >

Pilot Study > > Data Collection

> > > >

Data Analysis > > > > > Prepare Findings Reports

> > > >

Dissemination of Results

> >

31

Appendix IX: Budget Items / Resources Calculations Estimated Total

Cost (€)

Researcher’s Salary

20,000

20,000

Statistician

1,000

1,000

Postal Charges

60 x 50c

30

Travel Costs – Petrol

Approx €15/week

150

Equipment Tape Recorder

Tapes & Batteries

100 50

150

Stationary Paper

Envelopes Notebooks

Pens Extra

5 packets x 2

100 x .10 10 x 5

25 x .20 25

100

Computer Laptop

1000

1000

Photocopying

Printing Binding

30 50

5 x 4

100

Refreshments

Tea, Coffee, Water,

Biscuits

50

Total Estimated Cost

22,580

32

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