Bachelor in Science Nursing

(Bsc)(Cur)

Research Proposal

An exploration of the knowledge and experiences of

Mental Health Nurses in the screening for metabolic syndrome among

people with Serious Mental Illness.

Research Proposal submitted to University of Dublin Trinity College,

in partial fulfillment of the requirements for the Bachelor in Science

(Nursing) (B.sc. (Cur.))

Wednesday 10th

March 2010

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DECLARATION:

I hereby declare that this Research Proposal which I now submit for assessment is entirely

my own work and has not been submitted an exercise for assessment at this or any other

University.

Signed: _______________________

Print Name: _____________________________

Date: _____________________

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ACKNOWLEDGEMENTS

I would like to extend my gratitude to my facilitator for her academic guidance and

understanding during this project. I would also like to thank the research module leader and

my personal tutor for their support and assistance. Finally I would also like to thank my

fellow classmates for being part of a great learning environment throughout this course and

my family for their understanding for the duration of this degree.

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Table of Contents Declaration ...................................................................................................................................... 2

Acknowledements ........................................................................................................................... 3

Table of Contents ............................................................................................................................ 4

Abstract; .......................................................................................................................................... 6

Chapter One .................................................................................................................................. 7

1.1 Identifying the area of interest ............................................................................................... 7

1.2 Literature Review- Introduction ............................................................................................. 8

1.2.1 Metabolic Syndrome and SMI. .............................................................................................. 8

1.2.2 Screening Methods ................................................................................................................. 9

1.2.3 Current screening practice ................................................................................................... 11

1.2.4 MHN‟s knowledge and practices of MetS. .......................................................................... 12

1.2.5 Conclusion ........................................................................................................................... 13

1.3 Research Question: .............................................................................................................. 14

1.4 Aim: ..................................................................................................................................... 14

1.5 Objectives: ........................................................................................................................... 14

Chapter Two ................................................................................................................................ 15

2.1 Design/proposed methodology: ........................................................................................... 15

2.2 Population/Sample ............................................................................................................... 16

2.2.1 Sampling Criteria ................................................................................................................. 17

2.2.2 Access to research site and participant recruitment ............................................................. 17

2.3 Data Collection .................................................................................................................... 18

2.3.1 Semi-structured interviews. ................................................................................................. 18

2.3.2 The Interview ....................................................................................................................... 18

2.4 Rigor and Trustworthiness ................................................................................................... 19

2.4.1 Credibility ............................................................................................................................ 20

2.4.2 Dependability ....................................................................................................................... 20

2.4.3 Confirmability ...................................................................................................................... 20

2.4.4 Transferability ...................................................................................................................... 20

2.5 Data Analysis ....................................................................................................................... 21

2.6 Pilot study ............................................................................................................................ 22

2.7 Ethical considerations .......................................................................................................... 22

2.7.1 Informed consent.................................................................................................................. 22

2.7.2 Protection of participants ..................................................................................................... 23

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2.7.3 Confidentiality and Anonymity ........................................................................................... 23

Chapter 3 ..................................................................................................................................... 24

3.1 Proposed Outcomes of Study. ............................................................................................... 24

3.1.2Limitations ............................................................................................................................ 24

3.1.3Research Dissemination ........................................................................................................ 25

3.2 Resources: ............................................................................................................................. 25

3.3 Gantt Chart ............................................................................................................................ 26

Appendix 1 World Health Organization (1999) Metabolic Syndrome definition....................... 27

Appendix 2. International Diabetes Federation(2005) Metabolic Syndrome definition .............. 28

Appendix 3 Inclusion and exclusion criteria ............................................................................... 29

Appendix 4 Letter to the Director of Nursing. ............................................................................ 30

Appendix 5 Letter to Gatekeeper/CNM III. ................................................................................ 32

Appendix 6 Information Leaflet ................................................................................................. 34

Appendix 7 Invitation to participate ........................................................................................... 37

Appendix 8 Letter to TCD research Ethics committee ............................................................... 38

Appendix 9 Letter to health service research ethics committee .................................................. 40

Appendix 10 Consent Form .......................................................................................................... 42

Appendix 11 Interview guide ........................................................................................................ 43

Appendix 12 Colaizzi‟s (1978) seven step framework. ................................................................ 44

References. ........................................................................................................................................

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Abstract;

Historically people with serious mental illness(SMI) have suffered higher rates of physical

illness and premature mortality compared to the general population leading to some authors

describing it as a „life shortening disease‟ (Allebeck, 1989). Metabolic Syndrome (MetS)

comprises a cluster of metabolic abnormalities that increase the risk of cardiovascular disease

and has been identified as a significant pathological threat to people with SMI with prevalence

rates in these populations exceeding general population rates.

High rates of MetS in people with SMI have been attributed to unhealthy lifestyles; iatrogenic

effects of medication and genetic predisposition with international consensus groups calling for

comprehensive screening of these populations. Current practice does not reflect these

recommendations although specific screening tools have been developed ranging from simple

cost effective measures to more systematic tools. Mental health nurses (MHN‟s) have been

identified as a group that are in an ideal position to help tackle this emerging pathological threat.

The literature however suggests that MHN‟S may have a lack of knowledge and confidence in

the assessment and interpretation of MetS parameters and also a desire for further training in this

area. However there is little known about MHN‟s current practices in screening for MetS.

The purpose of this study is to explore the knowledge and experiences of MHN‟s working in an

acute unit in the screening for MetS among people with SMI. The method employed for this

study will be a qualitative descriptive approach utilising a purposive sample of 10 nurses

working in an acute in-patient unit. Data collection will be through semi-structured interview

supported by an interview schedule. Participants responses will be audio-taped, transcribed

verbatim and analysed using Collaizzi‟s (1978) framework. The final report will comprise

themes and sub-themes that have emerged from the data reflecting the totality of the participants

experiences.

It is envisaged that the findings of this study can provide insight into current practices of

screening for MetS. This can lead to recommendations for the development of local policies and

specific screening methods and the provision of further training if deemed necessary.

Dissemination of findings will be aimed at local, national and international forums with eventual

publication in peer reviewed nursing journals.

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Chapter 1

1.1 Identifying the area of interest

The first broad definition of Metabolic Syndrome(MetS) was by the World Health Organisation

(1999)(Appendix 1), with the latest from the International Diabetes Federation (IDF)(2005)

(Appendix 2). Although these organisations differ in MetS diagnostic criteria Alberti et al,

(2005) states they are congruent on the core components of MetS: obesity, hypertension,

dyslipidemia and insulin resistance. This insulin resistance increases the risk of developing

cardiovascular disease(CVD) and type 2 Diabetes Mellitus(DM) both of which greatly

contribute to the premature mortality of people with serious mental illness(SMI) (Meyer and

Stahl, 2009).

As a result international consensus groups have developed guidelines for the screening of MetS

(Barnett et al,2004;Clark,2004;Lambert and Chapman,2004;Marder et al,2004 and

DeNayer,2005) among people with SMI. Minimum screening should then incorporate body mass

index(BMI), waist circumference at the level of the umbilicus, blood pressure(BP), fasting

plasma glucose(FPG), and a fasting lipid profile, results of which will indicate diagnostic criteria

for MetS(Cohn and Sernyak, 2006).

The rationale for this research proposal was borne out of the researchers interest in the scale of

premature mortality among people with SMI. This interest originates from 12 years of working

in a rehabilitative training centre in Dublin. Over this time the author noticed high levels of poor

physical health among clients attending the centre and also premature deaths particularly of a

cardiovascular nature. On commencing this proposal the author examined the area further and

discovered that a lot of the literature has noted stark excess mortality among people with SMI in

comparison to the general population (Brown, 1997;Harris and Barraclough, 1998;Saha et al,

2007). Furthermore while mortality rates decline among western populations they have remained

static among groups with SMI and in some categories increased thereby widening the differential

mortality gap (Saha et al, 2007).

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This area of study was extremely broad and in aiming to focus clearly the concept of Metabolic

Syndrome (MetS) was identified as a contemporary physical health priority for Service Users

and Mental Health Nurses(MHN‟s). Therefore the researcher has chosen the Screening for MetS

as the topic for this research proposal.

1.2 Literature Review- Introduction

This literature review will critically and objectively analyse screening practices for MetS among

people with SMI within contemporary MH services. This author will attempt to briefly elucidate

the relationship between SMI and MetS and then fracture the review under themes of; Screening

methods; Current practice; and MHN‟s knowledge and practices of MetS.

The search strategy involved key words; Syndrome x, Metabolic Syndrome, insulin resistance

syndrome, mental health, psychiatric, weight gain, obesity, medication, antipsychotic, and

screening. Internurse, Cinahl, Web of knowledge and Proquest databases were searched from

1997 to 2010. Explicit arrangements of key words incorporating „screening‟ revealed few

definite studies however one article was identified and the ancestry approach uncovered further

articles. Grey literature was discovered following contact with an Irish author and manual

searching revealed further papers.

The literature is heavily influenced by consensus, review and commentary with this author

having difficulty sourcing actual research studies. Sources of literature stem primarily from

Australian, European and American authors and predominant research designs encapsulate

outcome/evaluative research utilising quantitative methodologies. Almost all the literature was

focused on prevalence, prevention and management of MetS with little discovered about nursing

practice, knowledge or roles. The studies found in relation to nurses input were often embedded

in larger studies of prevalence as illustrated in the last theme.

1.2.1 Metabolic Syndrome and SMI.

Serious mental illness although a term commonly used is one that has broad subjective meaning

depending on the context in which it is used. Cahill and Jackson (2008) define SMI as “any DSM

[diagnostic and statistical manual] mental disorder leading to substantial functional impairment”.

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Throughout the literature however and in the context of physical co-morbidity SMI primarily

refers to schizophrenia, bipolar or schizo-affective disorder (Ohlsen et al, 2005; White et al,

2009).

The association between SMI and high prevalence rates of MetS have been attributable in the

literature primarily to lifestyle factors, genetic predisposition and iatrogenic effects of

Medication. Lifestyle factors have been identified as excessive smoking, lack of exercise and

poor diets of people with SMI (Brown et al 1999), (McCreadie 2003) with this latter McCreadie

study reporting 10 year risk of coronary heart disease over 40% greater than the general

population. The indirect iatrogenic effects of antipsychotic (AP) medication have also been

proposed as contributory factors in the exacerbation of MetS (Jones and Jones, 2008; Jarboe,

2007). The non industry funded Clinical Antipsychotic Trials of Intervention Effectiveness

(CATIE) identified a link between atypical antipsychotics and the development and exacerbation

of MetS(McEvoy et al, 2005). Finally genetic predisposition has also been proposed as a factor

hypothesising a link between the effects of stress on the hypothalamic–pituitary–adrenal axis and

the development of abnormal glucose metabolism and visceral obesity (Thakore, 2004).

The importance and consequence for mental health services is that rates of MetS in populations

with SMI surpass general population rates. An Irish study by O‟Brien et al (2007) found that

40.7% of people with SMI fulfilled criteria for MetS in comparison to 20.7% of the general

population while internationally Hausswolff-Juhlin et al, (2009) found rates of 27% in the

general population rising to approximately 40–60% in an overall SMI population. These high

rates of MetS have led to the development of specific screening methods.

1.2.2 Screening Methods

Tirupati and Chua (2007) in an Australian quantitative study proposed BMI as a simple

screening measure for MetS. This study applied IDF criteria for MetS with a convenience sample

of 202 people with schizophrenia with results indicating a high prevalence of MetS at 69.3%.

Similarly Straker et al, (2005) aimed to identify cost effective screening for MetS. A sample of

89 patients in an acute unit was assessed using a National Cholesterol Education Program

(NCEP) (2001) definition of MetS with rates of 29.2% identified. On examination of the five

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NCEP defining criteria these authors identified elevated fasting glucose (EFG) as having the

greatest specificity. This is the ability of a screening tool to correctly recognise non cases(Polit

and Beck, 2008) of which in this study 60 of 63 non cases were correctly identified. They further

identified abdominal obesity as having the highest sensitivity correctly identifying 23 of 26 cases

of MetS. The authors conclude that combining EFG and abdominal obesity provides the highest

positive predictive value in detecting MetS.

Compared to the Tirupati and Chua(2007) study the Straker et al,(2005) study is limited in its

small sample size however employed equal gender distribution and used a multiracial sample

thus increasing its external validity. Conversely Tirupati and Chua selected a convenience

sample of primarily Caucasian males from a single rehabilitative centre. The Receiver Operating

Characteristic analysis utilised by Tirupati and Chua is described as an appropriate and valid test

instrument to develop and refine a screening instrument(Polit and Beck, 2008) thereby increasing

the strength of this study. Conversely the Straker study incorporated treatment and demographic

variables in their analyses however inclusion of these potentially confounding variables was not

apparent in the study by Tirupati and Chua. This perhaps challenges the weight these authors

place on BMI as a comprehensive screening tool.

A more systematic screening approach is proposed by Brunero and Lamont(2009) who devised a

Metabolic Syndrome Screening tool (MSST) incorporating IDF (2005) criteria for MetS. This

tool assessed the prevalence of MetS in a convenience sample of 73 people attending an

outpatient clozapine clinic and identified 61.6% as meeting criteria for MetS. The authors used

data from this study and controlled with results of an audit of screening for MetS in what they

term an opportunistic sample of 72 patients drawn from five clinical regions. The results of the

clinical audit revealed no records of waist circumference or BMI and no records of MetS

diagnosis under any defining criteria. The authors conclude that the use of the MSST is a

systematic and effective means of detecting MetS in consumers with SMI.

There is little evidence that the aforementioned MSST was tested for validity or reliability while

its time or cost effectiveness is also not apparent whereby Polit and Beck (2008) state this is a

critical constituent in the design of evaluative research. While the authors aim was to generalise

their findings to consumers with SMI not all people with SMI are prescribed clozapine therefore

findings solely from a clozapine clinic cannot be entirely representative of broad SMI

populations. Furthermore the MSST was not controlled against alternative screening methods but

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simply to existing practices which as the next theme illustrates is virtually non-existent thereby

of little comparative value.

1.2.3 Current screening practice

Despite influential recommendations for screening the reality in practice is that screening rates

are suboptimal(Barnes et al, 2007). An audit standard based on a review of seven leading

consensus statements on MetS was developed by Barnes et al, (2007). A self selected sample of

1966 participants within 48 multidisciplinary assertive outreach teams (AOT) was studied. This

large sample strengthens the representativeness of this study however Parahoo (1997) states the

self selected strategy is a weak form of sampling. Data was collected from case notes and

revealed recorded measurements of Obesity in 17%, BP in 26% of people, plasma lipids in 22%

and FPG in 28%. Case notes indicated a diagnosis of hypertension in 6%, diabetes in 6 %, and

also dyslipidemia in 6% of cases. The authors then compared results of these case note findings

against specific studies into these conditions in similar populations. Results indicated that for

every case of diabetes recorded, another went undiagnosed, for every case of hypertension, four

went undiagnosed and for each case of dyslipidemia seven may not have been detected.

In conjunction with the aforementioned audit Barnes et al, (2007) used a questionnaire to

ascertain the views of each AOT regarding obstacles to screening and one factor that emerged

was of conflicting responsibility between primary and secondary care. Cahill and Jackson (2008)

state the primary responsibility for monitoring the physical health of people with SMI lies with

primary care however as Phelan et al,(2001) state GP practice is often reactive and incongruent

with people who are reluctant or unable to seek help.

A study by Roberts et al, (2007) examined the prevalence of routine health checks in primary

care of people with schizophrenia in comparison to a control group of asthma patients. Method

was by case matched case notes review. Results indicated that people with a diagnosis of

schizophrenia were less likely to have blood pressure checks, 55.9% compared to Asthma 71%,

weight recorded, 39.5% compared to Asthma 46.4%, and cholesterol, 12.3% compared to

Asthma 21.8%. People with schizophrenia were also less likely to have these standard health

checks in comparison to the general population albeit to a lesser extent. The study was limited as

only 17% of targeted practices responded which the authors state may be indicative of potentially

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poorer practices among the non responding General Practitioners. These results increase the

hypothesis that people with SMI have less routine health checks than control groups and the

general population

1.2.4 MHN‟s knowledge and practices of MetS.

A lack of confidence in assessing physical health needs was highlighted in a training needs

analysis (TNA) of 168 Community Mental Health nurses by Nash (2005). This study found that

despite 71% of this sample stating they were currently providing physical health care over 96%

expressed a need for training in physical health care skills. In a further TNA this time of 138 in-

patient and CommunityMHN‟s diabetes care skills 86% reported a need for further training in

Diabetes care (Nash, 2009). Interestingly when asked if this care should be given by General

Nurses in mental health settings 71% indicated they did not wish to abdicate this responsibility

outside of their discipline but instead would prefer to receive further training to provide this care

themselves. As physical assessment skills are essential in order to screen for MetS this study has

highlighted an important area of training for MHN‟s in order to detect MetS.

This area of training need is again highlighted by a lack of knowledge of MetS shown in a study

by Ludwick and Oosthuizen (2009) in which only 18% of healthcare workers were aware that

clients with SMI were at increased risk of metabolic illness and only 9% knew that the same

population group had increased risk for CVD. Surprisingly76% of healthcare workers believed

that patients with SMI were monitored for metabolic disorders as often as the rest of the

population. The aforementioned survey of healthcare workers can be viewed tentatively as it was

a small sample (n=22) size with a vague description of the type of healthcare worker identified.

The sample was drawn from a single clinic with practices and services potentially very different

in other settings. These limitations diminish the generalisability of these findings to other

settings. Furthermore the survey of healthcare workers knowledge was embedded in a larger

study of prevalence of monitoring for MetS and as such was not the primary focus of the study.

Closer to home, in a small qualitative Irish study, McDonald(2008) explored the views and

practices of Community Mental Health Nurses(CMHNs) in relation to metabolic syndrome.

Three themes emerged from the data which were „concerns‟, „CMHN practices‟ and „barriers

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to care‟. Although concerned about the physical health of service users the participants stated

they were unable to expand their practice due to large caseloads and lack of resources.

Regarding current practices of screening the results indicated that screening was haphazard

and inconsistent as McDonald(2008:48) reported screening is not performed routinely, nil

protocols are in place and as one respondent states “is a hit and miss effort”. Barriers to

screening of MetS are described as a lack of collaboration between primary and secondary

care and the possibility that service users needs are falling between these services. This is

reinforced in the literature by Cohn & Serynak 2006 who suggests there is a debate regarding

responsibility for the detection, prevention and management of Metabolic Syndrome.

This study indicated that participants were aware of the various components of MetS however

were not familiar with the actual term itself. The author states that the CMHN‟s had a broad

understanding of the syndrome however the participants actual responses „physical condition as a

result of treatments used ( P3)‟ and „a certain correlation between medication and increased

weight and diabetes (P7)‟ indicates a more one dimensional view of MetS as entirely

iatrogenically linked.

This study of 7 CMHN‟s was conducted by a novice researcher with self reported inexperience

with the process and the interviews therefore the findings should be examined with caution. It

was published as a Masters dissertation as such is grey literature and was not subject to peer

review

1.2.5 Conclusion

This literature review has revealed that high rates of MetS in people with SMI have been

attributed predominantly to unhealthy lifestyles; iatrogenic effects of medication and genetic

predisposition. International consensus groups have called for screening of these population

groups based on several prominent definitions. Current practice does not reflect these

recommendations however specific screening tools have ranged from simple cost effective

analysis of BMI (Tirupati and Chua, 2007) to more systematic tools such as the MSST developed

by Brunero and Lamont, (2009). The final theme addressing Nurses knowledge and practices

revealed a lack of knowledge and confidence in the assessment and interpretation of MetS

parameters and also a desire for further training in this area.

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As stated the literature is predominantly quantitative in nature and a distinct gap is a qualitative

exploration of MHN‟s knowledge and experiences of screening for MetS in order to ascertain

nurse‟s current role in this emerging pathological threat. This can in turn inform the depth and

breadth of training that may be required in order to help nurses play a pivotal role in the

detection and prevention of MetS. Therefore this author proposes to explore and in consequence

describe Irish MHN‟s knowledge and experiences of screening for metabolic syndrome among

people with SMI.

1.3 Research Question:

What are the experiences of Mental Health Nurses working in an acute unit in the screening for

metabolic syndrome among people with SMI?

1.4 Aim:

The exploration of the knowledge and experiences of Mental Health Nurses working in an acute

unit in the screening for metabolic syndrome among people with SMI.

1.5 Objectives:

To explore and describe Mental Health nurses knowledge of Metabolic Syndrome as a cluster of

risk factors in the physical health of people with SMI.

To explore and describe mental health nurses experiences of screening for Metabolic Syndrome

among people with SMI.

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CHAPTER TWO

2.1 Design/proposed methodology:

In order to meet the aims and objectives of the proposed study this researchers primary task is to

decide on an appropriate research design/ methodology. The chosen design will direct the selection of

a population, procedures for sampling, methods of measurement and plans for data collection and

analysis(Burns and Grove 2007). Within nursing research there are two broad paradigms namely

qualitative and quantitative, which although distinctive in philosophical characteristics can also

compliment each other as they generate different types of knowledge to inform evidence based

nursing practice.

Quantitative research stems from the logical positivist philosophy and is an objective, rigorous and

systematic process for generating information with the emphasis on collecting measurable data and

statistics (Vivar et al, 2007). Although often afforded considerable stature as a method of inquiry Polit

and Beck (2008) state that many of the intriguing, moral and ethical issues linked to healthcare cannot

be examined entirely through scientific examination.

Qualitative research has been described as evolving in response to the inadequacy of purely

quantitative enquiry (Bogdan and Biklen, 1982). It is rooted in the naturalistic interpretive philosophy

and aims to elicit meaning, discovery and understanding of human experience. Naturalistic

researchers emphasise the complexity of humans, their ability to shape their own existence and the

idea that truth is a composite of realities (Polit and Beck 2008).

According to Houser (2008) the demands of the research question should dictate the design

employed. This study proposes to explore MHN‟s knowledge and experiences of screening

for MetS among people with SMI. Qualitative research as a subjective, interactive approach

can help to describe and promote our understanding of human experiences (Burns and Grove,

2009). Therefore this study will be framed by this qualitative design as it aims to explore and

describe the knowledge and lived experiences of MHN‟s in the screening of MetS among

people with SMI.

Three prominent approaches exist within qualitative research which are phenomenology,

grounded theory and ethnography each of which carries their own distinct methodological

framework. Initially an ethnographic approach was considered as the researcher regarded

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MHN‟s experiences of screening for MetS to be strongly influenced by their primary focus

on mental health, the culture of the in-patient unit; and their role and autonomous decision

making ability within the wider MDT. However novice researchers may only have a naive

understanding of specific philosophical approaches and often do not have the skill or

competence to conduct this research with misunderstood findings resulting in „sloppy

science‟ (Streubert-Speziale and Carpenter 2007; Houser,2008).

Remaining cognisant of this researcher‟s limitations an exploratory qualitative descriptive

design is proposed. Sandelowski (2000) states that qualitative descriptive is the method of

choice when straight description of phenomena is desired and an independently valuable

methodological approach. She further states that tones and textures of the aforementioned

specific approaches may resonate within a straight descriptive study. This approach affords

the novice researcher the freedom to explore and describe phenomena without being

constrained by a specific qualitative methods niche. Furthermore the exploratory nature of

this study aims to develop the body of knowledge of this particular phenomenon of interest

thus broadening the evidence base to support practice.

2.2 Population/Sample

A sample is a subset of a population from which data can potentially be collected

(Parahoo,2006) of which there are two main types; Probability and Non Probability sampling.

Probability sampling often known as random sampling is primarily used in quantitative

research and refers to the fact that every element (member) of the population has an equal

chance of being selected for a study (Burns and Grove, 2009).

Within Non-Probability sampling there are three primary sampling methods employed in

qualitative research which are, Purposive, Snowball, and Convenience sampling (Polit and

Beck, 2008). The goal of the sampling strategy in qualitative research is credibility where the

researcher must utilise judgement in purposively selecting participants who can best inform

the study (Houser, 2008). In addition (Holloway and Wheeler 2002) also identify

homogenous sampling as selection of a particular group of people who share similar

characteristics or circumstances such as occupation. Therefore the researcher proposes to use

purposive sampling of a homogenous group which will allow the researcher to select

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participants that are most likely to yield a thick and exhaustive description of the

phenomenon of interest whom in this case will be: MHN‟s working in an acute Mental

Health in-patient unit.

2.2.1Sampling Criteria

Because of the in depth nature of the data uncovered and the detailed analysis required

qualitative research usually employs small sample sizes (Cormack, 2000). Qualitative

research designs must satisfy the sampling principle of adequacy or saturation which is

achieved when the researcher “concludes that the responses are repetitive and no new

information is being generated” (Houser, 2008:225). For practical planning purposes however

the researcher proposes to select 10 participants who meet the inclusion criteria (Appendix 3).

2.2.2 Access to research site and participant recruitment

The researcher proposes to recruit participants from an acute in-patient mental health service

in Dublin. The researcher will write a letter (Appendix 4) to the Director of Nursing seeking

permission to gain access to the mental health service in question. If permission is granted the

researcher will then write a further letter (Appendix 5) to the Clinical Nurse manager III

(CNM III) whom has been identified as the gatekeeper seeking permission to gain access to

staff and distribute information. Gatekeepers co-ordinate admission to a site and influence

those who work in that setting therefore negotiation is an integral part of the research process

(Roach (2009). The researcher will remain cognisant of this in the compilation of the

aforementioned letters and employ professionalism and sensitivity in communicating with the

CNM III. A participant information leaflet (Appendix 6) and letter of invitation (Appendix 7)

will be enclosed for distribution to potential participants. The researcher will seek ethical

approval from the Faculty of Health Sciences Research Ethics Committee in Trinity College

Dublin(Appendix 8) and a further correspondence will be made to the relevant health services

research ethics committee(Appendix 9).

Once permission has been granted from all relevant parties the CNM III will be asked to

distribute the participant information to staff who meet the inclusion criteria. The information

leaflet will explain the purpose of the study and briefly, the proposed requirements of

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participants. Contact details for the researcher will be supplied and interested staff will be

encouraged to make contact directly. The researcher will arrange a brief one to one meeting

with interested staff where a detailed description of the interview format and process will be

given. Potential participants will then be given one week to consider the information before

making an informed decision at which stage the researcher will invite them to sign a consent

form (Appendix 10).

2.3 Data Collection

Burns and Grove (2007) state that the interview is most often the data collection method of

choice in a qualitative inquiry. These can range from totally unstructured interviews whereby

content is controlled by the participant to a structured format in which the researcher guides

the interview with the aid of an interview protocol and schedule of questions. Despite this

structure the interview will be more than a mechanistic formal exercise but a dynamic

interaction with the aim of elucidating the importance of a persons experience and the

subjective data thereby generated (Houser, 2008).

2.3.1 Semi-structured interviews.

In order to elicit the knowledge and experience of MHN‟s in the screening practices for MetS

the researcher proposes to use a semi-structured interview. The structure in question will be

in the shape of an interview guide comprising of broad open ended statements and questions

(Appendix 11). Within these broad questions the researcher will also have prompts that can

aid with refocusing the interview in the event of what Field and Morse (1985) termed „Dross‟

or issues arising that are unrelated to the topic in hand.

2.3.2 The Interview

The interview location will be in a place free of distractions such as noise, visual stimuli and

interruptions and allow interviewees to comprehend the question Cormac (2000). This

location should be convenient for the participants and if acceptable the researcher proposes to

use a small room (to enhance the acoustics) in the hospital environment yet away from the

potential distractions of the unit. The interview strategy will be to phrase the questions

carefully using open ended words such as „how‟ „what‟ or „why‟. These questions will be

19

without double meaning and clear and logical. Questions will be posed sequentially allowing

the participant to feel at ease and introducing more depth of questioning as the interview

progresses (Polit and Beck, 2008).

It is envisaged the interview will last between 45 and 90 minutes and this will become more

apparent following the pilot study. The researcher proposes to audiotape recordings using a

digital voice recorder placed unobtrusively but within sufficient proximity to clearly record

the participant‟s responses. The recorder will be a Panasonic RR-QR230 which can record up

to 45 hours of data and is password protected for additional security. This allows interviewers

to turn transient data into permanent data which can be analysed in more detail over a longer

period of time (Cormack, 2000). Spare batteries, note pads and pens and refreshments will

also be available.

At the end of the interview any clarification sought will be given and the participant will also

be asked if they need an explanation of anything that arose during the interview. This can

ensure a „positive closure‟ to the process (Polit and Beck, 2008). Observations will be written

in field notes immediately following the interview so as not to disturb the actual interview

process and also to ensure the integrity of the data. A reflective journal will be maintained to

record this researcher‟s insights and personal reflections on the interviews.

This researcher recognises personal limitations in interviewing techniques and will attend a

two day workshop on qualitative interviewing in order to better develop these skills. Despite

this inexperience the researcher will utilise good interpersonal skills such as active listening,

maintaining appropriate eye contact and remaining open to all responses. This will help to

build trust and develop rapport with the participants and also serve to put them at ease during

the process.

2.4 Rigor and Trustworthiness

Methodological rigor can be assured by having a transparent audit trail of raw data collection

and analysis; consistent evidence of reflexivity; demonstrating saturation; and using vivid,

thick descriptions of the phenomenon. (Barreca Wilkins, 2008). Lincoln and Guba (1985)

identified four measures of rigour to assess trustworthiness in qualitative studies which are;

Credibility, dependability, confirmability, and transferability.

20

2.4.1 Credibility

Credibility refers to authenticity and how true the data reflects the participant‟s experiences

of the phenomenon under study (Vivar et al, 2007). Strategies identified to achieve credibility

include prolonged engagement with the participants, peer debriefing, and member checking.

Within this study „member checking‟ will be the primary means of achieving credibility. This

researcher specifically chose Collaizzi‟s (1978) framework to enhance credibility. Within this

framework verbatim transcripts will be provided to the participants throughout the process for

validation and an exhaustive description will be given at the end for further validation as to

the accuracy of the information recorded.

2.4.2 Dependability

This criterion is met once researchers have demonstrated credibility of a study and refers to

the stability of the data and whether the findings were likely to be replicated in the same

context with the same participants over time (Polit and Beck, 2008). The researcher proposes

to initiate an inquiry audit whereby an external auditor will examine the data collection

process and all decisions made in the transformation of data into concise schema (Burns and

Grove, 2008).

2.4.3 Confirmability

Confirmability is related to the aforementioned inquiry audit and is achieved through

reflexive and objective reporting of the participant‟s responses. This researcher will leave an

audit trail which is a seamless recording of all decisions made that can illustrate the evidence

and thought processes that led to the conclusions (Streubert-Speziale and Carpenter, 2007).

This audit trail can then be examined to assess whether the information gathered is

representative of the conclusions reached.

2.4.4 Transferability

21

This relates to the extent that the findings of the study can be transferred to other settings or

groups (Polit and Hungler, 1999). The judgement as to the transferability however rests with

the potential users of the findings and not the researcher. The responsibility of the researcher

is to give a clear and distinct description of the research context, culture, and process

(Graneheim and Lundman, 2004). This researcher proposes to achieve this by providing a

rich and thick description of participants responses interspersed with relevant quotations that

accurately reflect the experiences of MHN‟s.

2.5 Data Analysis

Qualitative data analysis occurs in three stages: description, analysis and

interpretation.(Burns and Grove, 2008).With qualitative research traditions however analysis

often occurs simultaneously with data collection and is referred to as constant comparison

(Houser, 2008). Challenges associated with Qualitative data analysis are; a lack of cogent

rules and procedures for analysis, sheer volume of data to be organised and interpreted, and

the reduction of this data for reporting purposes whilst maintaining the richness and value of

the data (Polit and Beck, 2008).

This researcher will follow Colaizzi‟s (1978) 7 step framework for data analysis (Appendix

12). Within these framework participants descriptions of their knowledge and experiences

will be collected. Following a return to the original transcripts significant statements will be

extracted. The meanings of these statements will be interpreted and information will be

organised into themes. An exhaustive description of these experiences will then be compiled.

Finally the researcher will feedback this description to participants to ensure they validly

reflect the totality of MHN‟s experiences (Polit and Beck, 2008).

Streubert-Speziale and Carpenter(2007) states that qualitative data analysis requires

considerable levels of reading, intuiting, analysing, and reporting of discoveries. To assist in

this process the researcher proposes to use computer assisted qualitative data analysis

software (CAQDAS). The program in question is Nvivo8 which can help researchers find

patterns in the data and can also assist in classifying, sorting and arranging thousands of

pieces of information(Polit and Beck,2008; QSR International.com, 2010). This software also

enables data to be imported directly from the digital audio recorder for immediate analysis.

22

2.6 Pilot study

A pilot study is a smaller version of the proposed study with the aim of refining the research

methodology (Burns and Grove, 2008). This pilot can test the feasibility of the study design,

the data collection techniques, logistical issues and can also provide an opportunity to analyse

the data (Cormack, 2000; Burns and Grove, 2008). Furthermore the pilot study can serve to

give the novice researcher experience with the data collection instruments and also valuable

interviewing experience. Repetitive or unclear questions can be identified and an assessment

of the potential duration of the interview can also be ascertained. The researcher proposes to

use two colleagues who meet the inclusion criteria to provide feedback on the

appropriateness of the interview guide. All responses will be recorded, analysed and returned

for validation as planned for the main study. This interview will take place in a room

available from 2 to 4 pm adjacent to these colleagues unit following a short 5 hour shift. The

data obtained in the pilot will not be used in the main study due to the potential for what

Teijlingen and Hundley (2001) call „contamination‟ in which methodological flaws evident in

the pilot may pollute the main study.

2.7 Ethical considerations

Failure to identify and address ethical issues can place the conduct and the findings of a study

in jeopardy (Oberle and Allen, 2006). This researcher will be guided by the basic ethical

principles set out in the Belmont report (1979) which are: Respect for persons; Beneficence;

and Justice. Furthermore the personal nature of qualitative inquiry requires the researcher to

pay close scrutiny to several considerations such as informed consent, protection of

participants, confidentiality, and anonymity (Vivar et al, 2007).

2.7.1 Informed consent

Informed consent is defined as “a process of information exchange in which participants are

provided understandable information needed to make a participation decision” (Houser,

2008). However Allbutt and Masters (2009) argue that in qualitative research, the term

„informed consent‟ is something of a misnomer as participants are unable to predict with

certainty what they will be asked at the interview or what information will be divulged.

23

Therefore this researcher proposes to use process consent whereby consent is obtained at the

beginning of the process but also informally at further critical points of data collection

leading to dissemination of results (Keogh and Doyle, 2009).

The 4 elements necessary for informed consent are: disclosure of essential information to the

participant; participants understanding of this information; capacity to give consent; and

voluntarily providing consent to participate (Burns and Grove, 2007). With these four

elements in place this researcher will ask the participant to read and sign a consent form at

the beginning of the process. Participants will furthermore be reminded of their right to

withdraw at any stage without prejudice.

2.7.2 Protection of participants

The researcher has a responsibility to ensure that participants in this study are free from harm

at all stages of the process. Although MHN‟S are not a vulnerable group as such and the topic

does not strike obvious emotional chords this is a presumption and the researcher will

endeavour to protect participants from any financial, physical, emotional, or social stress.

2.7.3 Confidentiality and Anonymity

Confidentiality relates to the researchers management of personal information shared by the

participants while anonymity exists when the participant cannot be linked with their

individual responses (Burns and Grove, 2007). Participants names will be replaced by code

numbers which will be used throughout the study and all other personal details will not be

disclosed to third parties. Within qualitative reports individuals may inadvertently be

identified through the use of long quotations. In order to prevent this, the researcher will

remove any of these identifying quotations and will also ask the participant at the stage of

member checking to further identify any information that may disclose their involvement in

the study.

All data, notes, and sundry information obtained in the study whether written or digital will

be encrypted, password protected and stored securely in a locked premises controlled solely

by the researcher. This data will be stored for 5 years post study completion as recommended

by Trinity College Faculty of health sciences research ethics committee (2009). However this

24

data must be fully anonymised and any information that can identify specific participants will

be retained only for the duration of the study and then immediately shredded or deleted.

Chapter 3

3.1 Proposed Outcomes of Study.

This study proposes to explore the knowledge and experiences of Mental Health Nurses

working in an acute unit in the screening for metabolic syndrome among people with SMI.

The researcher proposes to meet with the aims and objectives of the study. All steps in this

research process will be documented from the initial design to dissemination of results. The

collected data will be analysed and summarised succinctly. The final report will provide a

vivid and thick description of MHN‟s knowledge and experiences of screening for MetS

among people with SMI. Implications for nursing practice will be discussed and included in

the final report. It is envisaged that the findings of this study will indirectly increase

awareness of MetS among MHN‟s and allow them to reflect on their physical health care

practices among people with SMI. More directly it is anticipated that findings of this study

can lead to recommendations for:

1. Clearly identified further training for MHN‟s in this area.

2. The development of local policies and protocols for screening of MetS.

3. The development of specific screening methods at local level.

4. Rigorous further research in this area possibly examining variables that influence the

screening for MetS among people with SMI.

3.1.2 Limitations

The primary limitation of this study is the researcher‟s inexperience with the process.

However potential methodological errors will be lessened by training in qualitative research

methods prior to the study and adherence to the qualitative descriptive method. The single

site nature of this study and the small sample size will mean that findings cannot be directly

generalisable however the rich and thick description of findings will allow readers to draw

their own inferences from the study.

25

3.1.3Research Dissemination

The design and findings of this study will be presented in textual format and submitted for

publication in national and international nursing journals. The researcher will also aim to

make a presentation of the findings to colleagues at in-service training seminars. Furthermore

the researcher will aim to present a brief summary of findings to the local multidisciplinary

team with invitations extended to linked primary care and service user representatives.

Finally the researcher will aim to make presentations of the study at national nursing

conferences.

3.2 Resources:

The following is a breakdown of proposed expenses for this study:

Expenses

Cost in Euros

Researchers salary

€33,950.00

Digital audio recorder/Batteries

€180.00

Phone and internet charges

€400.00

Library services

€100.00

Photocopying/ stationery and binding costs

€100.00

Postage

€50.00

Printer cartridges

€210.00

Petrol

€100.00

Training

€230.00

Nvivo8 computer software

€240.00

Refreshments

€80.00

Miscellaneous

€150.00

Total cost

€35,790.00

26

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