The Issue of Urinary Incontinence in Women - Essay Example

?Critical appraisal of research reports Critical appraisal of research reports Critical appraisal of research reports Introduction Critical appraisalof research reports varied with the two main kinds of researches as they had different components. These two major varieties of research were used in the nursing care researches as in any other discipline. The analysis of data from interviews or pictures was found in the qualitative research and the analysis of statistics, in the quantitative research. The qualitative research was selected when not much information was available on the topic and the researcher required complete details. In the quantitative research, plenty of information was already available and features were classified, counted and statistical models constructed for the study. The qualitative research was subjective and usually related in the participant’s own words and the researcher was not aware of the information he was looking for. The researcher was well aware of what he was searching for in quantitative research and the study was well-designed before data was collected. Qualitative researches were recommended when new subjects were dealt with in research projects. When some amount of information became available in the later phases, quantitative research was done to quantify measures. The researcher was responsible for collection of data in qualitative research while tools were used in quantitative research. Subjective interpretation was made in qualitative research while more objective interpretation was made in quantitative research. The data in qualitative research was richer and had details while the data in quantitative research consisted of numbers and statistics. Nursing research could also be a mixture of both: two parts of a research could be found with a different type of research in each part. This paper has been written to critically analyze a qualitative and a quantitative research, both relating to urinary incontinence in women. Borello-France et al (2008) used a quantitative research to compare the results of post-intervention of pelvic muscle exercises in the follow-up period of an intervention study of the influence of exercises on urinary incontinence. Zeznock and Gilje (2009) conducted a qualitative phenomenological study to understand the lived experiences of Alaskan women who had urinary incontinence, when this topic had not been studied by other researchers. The differences have been noted through the paper. Borello-France, D. F., Downey, P. A., Zyczynski, H. M., & Rause, C. R. (2008). Continence and quality-of-life outcomes 6 months following an intensive pelvic-floor muscle exercise program for female stress urinary incontinence: A randomized trial comparing low- and high-frequency maintenance exercise. Physical Therapy, 88(12), 1545-1553. The report had not been from a peer –reviewed publication; however the research had been current. This descriptive post-intervention study had been written well and had been grammatically correct and in good language. The paper had been laid out in an organized manner. All the researchers had been experts in their own field. There had been a surgeon who had been actually performing pelvic reconstruction surgery, a nurse practitioner who had been caring for the concerned patients and two physical therapy experts who had been Professor and Associate Professor in Physical Therapy in two different Universities. The latter two had PhDs possibly contributing to the high level of the research and paper. The title was precise, clear and unambiguous even though the number of words used made it a long one. A clear overview of the study could be obtained. The report had been logically constructed and there was a steady flow of information with clear linkage. The abstract provided a succinct overview of the research. The purpose of the research study or objectives, the method of study, size of sample, measurements to be made, results, discussion and conclusions were found in the abstract. The purpose of the study had been to evaluate continence and quality of life outcomes following pelvic floor exercises and to determine whether the frequency of exercises had any influence on the outcome in women with incontinence. The abstract provided the interest for reading the whole paper. Though recommendations had not been specified, a hint that more research needed to be done was understood. The literature review had been organized logically and provided a critical review of the studies available on the subject of pelvic floor exercises in incontinence. The research problem was identified with clarity from the literature review and the researchers provided a good argument to indicate the significance of the problem. The relevance to nursing had not been discussed but the prevention of incontinence and nursing care for the incontinent were duties within the profession. The exercise adherence was a message that could be publicized and passed on by nurses. The researchers reviewed a fair number of literatures which supported this research. The literature was mostly not of recent origin; only 5 out of the total of the 37 references could be considered current. The review was written critically indicating strengths and limitations. All were primary sources and mostly empirical. Having current sources could have improved the literature review. The possibility of a dearth of literature on the topic could be a reason to be thought of for the limited literature or it could be that only the quoted literature had significant information. The matter in the literature began with the history of the introduction of the pelvic floor exercises in 1948 and narrowed down to the study planned. Keywords had not been noted before the literature review. The subject had been dealt with in some depth and breadth. The poor adherence to the exercises by incontinent women, the outcome in the management of urinary incontinence, the determination of variables influencing the exercise adherence, the adherence of exercises and continence during follow-ups, efficacy of continued exercise and continence and quality of life outcomes were the themes discussed. No conceptual framework had been identified. The studies that were mentioned were mostly randomized controlled studies and some reviews. Poor exercise adherence was a threat to the long-term success following management of urinary incontinences. This could be reduced by ensuring adherence through reducing the burden of exercises. The parameters of exercise then became important for leading to a successful outcome: type of exercise, number of repetitions and frequency of performance. Research then focused on improving the strength of the muscles involved in incontinence. These exercises were to be less frequent so that the women did not feel them to be a burden. Researchers in other muscle-strengthening exercises had already focused on the least amount of exercises which could still produce good outcomes. Researchers of urinary incontinence now thought of the same thing: to have fewer exercises to lessen the burden of women with incontinence without reducing the quality of outcomes. The gap was the relevance of the minimum-exercise-for-maximum-outcome theme for incontinence in women. The same researchers had taken up the challenge to close the gap and recently published a study for quality-of-life outcomes involving a supervised exercise program in women with incontinence. The present study was a follow-up at the 6th month and the intention was to measure the quality-of-life outcome 6 months after the supervised exercise program and also for comparison of the effectiveness of low-frequency and high frequency exercises on quality of life. The researchers hinted that future research could be done to confirm that low frequency exercises were sufficient to produce good quality outcomes in incontinence in women and produce a potential program of low frequency exercises. The aims and objectives were clearly presented again in the concluding part of the literature. The hypothesis was also identified and stated: low and high frequency exercises were equally effective in maintaining therapeutic gains. This theme was a reflection of the information in the literature review. The data found in the review were congruent to the data in the study. Sampling errors were not possible as the participants were all females with history of incontinence and having had an exercise program. Inclusion and exclusion criteria had guided the selection of the sample which was a probability sample of adequate size in the earlier study. Participation was solicited in this study from previous participants of the earlier study through advertisement. The confidentiality and autonomy were preserved. Ethical considerations had been followed with the approval having been obtained from the University of Pittsburgh and Duquesne University Institutional Review Boards and informed consent from the participants. The theoretical framework had not been specified here. The research design was a true experimental one with pretest-posttest comparisons of two groups of women who had participated in an earlier 9 -12 week randomized intervention trial to determine the effect of pelvic floor muscle exercises when assuming one of two positions: supine versus upright and supine. In this 6 month follow-up study, the pretest constituted the outcomes at post-intervention earlier following the previous study using 2 parametric and 3 non parametric variables in all the participants randomly. The present study was the post-test which constituted the comparison of two groups of ladies who were doing one of two exercise patterns during the 6 months; either low frequency or high frequency. This study was the comparison of the earlier post-intervention results with those of 6 months after the post-intervention; the parametric variables used being urine leaks per week and volume of urine lost during pad test. The non parametric variables were the Incontinence Impact Questionnaire score, the Brink score and the percentage of participants with urodynamic stress incontinence. Here the parametric variables were the change in urine leaks per week and change in the urine lost during the pad test. The non-parametric variables were the change in Incontinence Impact Questionnaire score, change in Brink score and the prevalence of Urodynamic stress incontinence number (%) of participants. Though mention was not made within the paper, the variables were relevant for nursing and the tools for measurement were appropriate. The purposive sample included 28 women who had been included in the earlier intervention study where inclusion criteria had been women of 38 to 70 years of age, pregnant, ambulatory with at least one recorded incidence of stress urinary incontinence, no urgency or urge urinary incontinence in 7 days. Exclusion criteria had been a medical history of pelvic cancer, endometriosis of a severe nature, Intra-uterine –device, pacemaker, neurologic disorders with incontinence, metabolic disorders with incontinence, previous incontinence surgeries, prior exercise programs with a regimen from the physician, nurse, physiotherapist or other health professionals. In the present study, 28 women whose median age was 52.8, mean parity was 2 and 60.7% were postmenopausal and were exercising for the past six months were the participants. In this study (post-test), two comparisons had been made: comparison of the outcomes at post-intervention and 6 months after post-intervention and comparison between the outcomes of high frequency and low frequency groups. Only 15 women had participated with full exercise adherence diaries of the six months for the second comparison. Seven had been assigned to the low-frequency exercise group and eight to the high-frequency exercise group. The bladder diary had a high reliability (r=0.86-0.91). The internal consistency, reproducibility, construct validity and sensitivity of the Incontinence Impact Questionnaire had been established earlier. The Inter-rater reliability, test-retest reliability and validity of the strength of the pelvic floor muscles had been earlier reported. The data analysis was appropriate as several checks had been done. Randomization had been checked with independent t tests. The differences in the groups had been determined by the Mann-Whitney U tests. Chi square analysis had been done for the women in the two exercise groups who experienced urine leakage. Data from the 2 groups had been collapsed. Paired t tests and the ANOVA had been used for the changes that occurred in the number of weekly urine leaks and urine loss in the pad test. The IIQ and Brink score changes had been analyzed with the Wilcoxon signed rank test and the Kruskal-Wallis one-way ANOVA. The McNemar test was used for the urodynamic test. Complete diaries only had been used for the comparison of exercise adherence. The results were appropriate for the study and could answer the hypothesis. The 3 tables provided were understandable and one could note the continuation of the previous study. The findings were insignificant in that the findings did not merit generalization due to the limited number of participants. The findings could be related back to the literature review. The hypothesis that low and high-frequency exercise would be equally effective in maintaining therapeutic gains over the 6-month follow-up period was supported. The strength mentioned was the adherence of women to the pelvic floor exercises on advice. The discussions fit with the data and were logical. Previous research findings had been discussed. Many limitations had been noted by the researchers. Some of them were the few number of completed adherence diaries, credibility of information from self-kept diaries, lack of insight into the aging process, menopausal changes or the effects of changing health on exercise adherence. Women with mixed urinary incontinence or severe incontinence had not been included. The lack of a control group was a big limitation. The conclusion was that exercise adherence produced a favorable outcome for women with stress urinary incontinence whichever frequency was maintained. The limitations did not allow a strong conclusion. Implications for nursing practice were evident though not elaborate. The vast scope of research was highlighted and future researchers could do well to read through this research paper for guidance. Zeznock, D. E., & Gilje, F. L. (2009). Living with urinary incontinence: Experiences of women from 'The Last Frontier.' Urologic Nursing, 29(3), 157-185. The report had appeared in a peer-reviewed journal, Urologic Nursing. This report had been well organized and avoided jargon in its language. The researchers had been highly qualified nurses. Two had been working in Universities and one had been working in the Alaska Native Medical Center. The responses of the native women could have been possible though this latter researcher. The title was short, accurate and clear. The abstract provided a clear overview of the study indicating the research problem, defining the sample, giving an idea of the method used, providing a hint of the findings and a few recommendations. The introduction had provided the phenomenon of interest specially highlighted and clearly identified. The research question and phenomenon of interest were consistent: the experiences of Alaskan women with urinary incontinence were to be investigated. This was to close the gap in the literature which had investigated the experiences of most American women leaving out the Alaskan women or the women of the Last Frontier. The significance of the study had been clearly identified and it had evidently served to enumerate the lived experiences of the women. The research design here was therefore phenomenology. This qualitative phenomenological study was thus justified for selection by the researchers. It had been selected for describing, interpreting and understanding the lived experiences of the Alaskan women with urinary incontinence which had constituted the aim of the study. The responses had been to a single question of their experiences of living with urinary incontinence. The literature review was sufficiently informative and contained qualitative studies that focused on women with incontinence. It was mainly done to focus on the concepts already identified in literature Seven qualitative studies mostly of recent origin and on the subject of women’s experiences with urinary incontinence had been reviewed and subtle themes extracted. As no study had focused on women of the Last Frontier, the researchers were justified in the selection of this study topic. The review helped the philosophical aspects of the study and fulfilled its objectives. The studies had evaluated the experiences of non-geriatric women, the strategies for management of incontinence, why women failed to seek professional help, self-care strategies, the plots in narrative analysis in women with ethnic diversity, the complexity of healthcare-seeking behaviors, the symptom management perspective, the mental stress involved and the inadequacy of information available to healthcare staff on women with incontinence. The theoretical framework adopted was the inductive approach in this theory-generating research. It provided an interaction with the participants and built an integrative relationship. This qualitative research had been concerned with the accumulation of multiple truths. Discovery and description by the researchers had been the aspects of investigation in phenomenology. The social context and the cultural diversity had significance. The view-point of the participants or an emic perspective was essential. Sampling was purposive ensuring richness of data collected and only Alaskan women with urinary incontinence were selected. Inclusion criteria were that women had to be above 18 years, have incontinence and be English-speaking. The publicity was provided at the clinics which these women attended. When they contacted the researchers, information about the program was shared. Informed consent had been obtained then. The interviews had been conducted in rural and urban settings over a period of four months for 17 women. Fourteen women had obtained care. They had been suffering for an average of 9.8 years and their average age was 57 years. All had symptoms of five types of incontinence. Though the sample size had been small, each could provide a wide area of information. The sampling method had been appropriate and the participants had been full of information which they were only willing to share with their new confidantes, the researchers. Ethical considerations were conformed to and the participants had provided informed consent after being apprised of the study methods and requirements. The autonomy and the confidentiality of the participants had been guaranteed. The participants had been protected from harm. The approval had been obtained from the University of Alaska Institutional Review Board in 2003. Ethical guidelines had been followed. Researchers honestly had put down on paper all that the interviewees said. Participants had been permitted to check the transcripts of their interviews and revise if necessary. All participants had been respected by the researchers. Data collection had been through several half to one hour long, in-depth, unstructured interviews. Plenty of information was obtained and the study had been stopped when the saturation of data occurred or when no new information could be gathered. The women had provided answers to the question: “What is your experience of living with urinary incontinence?” Each woman’s answer was audio-taped and transcribed without changing any words. Details about the setting, participant’s body language and messages perceived were recorded. Data analysis had been done by qualitative content analysis. The transcripts and audio-tapes were repeatedly examined to sieve out themes from the text. Condensation was the process adopted to separate the text into meaning units. The central idea in the meaning units were then correlated in a continuing process till the themes emerged. Twenty sub-themes were obtained which were then grouped into 6 main themes. The participants were allowed to check the themes. Fifteen did so and consented to the themes. Two did not due to visual impairment. Auditing of the results of data analysis by two experienced researchers in qualitative research methods raised the quality of the data analysis. This study could be described as rigorous based on the credibility of the procedural, documentation and ethical practices and the auditing of the results. The naturalistic process of accumulating information using several methods together also ensured the elimination of researcher bias. Credibility had been established by allowing the participants to read the transcripts and also the themes that had been derived. The transferability of the study findings was possible in other situations. The criterion of goodness could be conferred on this research due to its trustworthiness and authenticity. The participant data and the themes were tabulated and clearly presented. The themes were discussed in good detail and had been supported by the literature review. The discussion had many suggestions for future research. The implications for nursing practice were well delineated and the recommendations for nursing practice were discussed in detail. Nurses were to prevent and manage urinary incontinence in their practice. Continence care competencies were to be shared through education. There had been a suggestion that guidelines had not been followed by nurses in their practice where incontinence was concerned. Public awareness on the subject could be increased by nurses deigning to speak on the subject themselves and providing patient education. The education was to be on bladder health, urinary incontinence, the method of evaluation and management strategies. The suggestion that had been given by the Agency for Healthcare Research and Quality (AHRQ), that the nursing curricula needed to include the management of urinary incontinence, had not been taken in the right spirit. The suggestion, that all healthcare students including nurses needed to be educated for managing urinary incontinence, was a useful one. This study in general was an example that could be followed in any other phenomenological study and especially for the impacts of management of urinary incontinence. Conclusion Critical appraisal of research reports varied with the two main kinds of researches in the nursing discipline, the qualitative and quantitative, as they had different components. Differences existed between the two in aims, research design, methodology, data analysis, results and findings. While the qualitative elicited the actual words of the participants for evaluation, the quantitative aimed at deciding the statistics through numbers. In this paper, the subject of urinary incontinence had been researched in different manners. The qualitative research of Zeznock and Gilje (2009) elicited the distress faced by the Alaskan women in their own words which were audio-taped and transcribed. Much work was involved in evolving the themes for discussion and the effort took more than four months. The quantitative research of Borello-France et al (2008) was obviously done after sufficient information on the subject had already been studied in literature. This study was intended to find out how pelvic floor exercises, which was a management strategy for urinary incontinence, had affected the quality of life in a woman with incontinence after the care of this patient had already been started. The stress was on finding the frequency of exercise, high or low, that could help the woman maintain a steady adherence for a better quality of life. It could be understood that the subject of incontinence had been gone into in depth and efforts were on to discover the exercise frequency which was least stressful and could be adhered to by women comfortably so that the quality of their lives could be sustained. Read More