Pedal Ulcers in Older Adults With Diabetes Mellitus

Introduction

The phenomenological type of qualitative research has been utilized in an attempt to answer the problem raised in this study. Phenomenology research has been selected because it is the only method in qualitative research, which can give information on life experiences. The impact of the experience of living under pressure ulcers on the health of the elderly diabetic patient will be investigated. The elderly with diabetes face higher risks of developing ulcers and are most likely wound failure due to the presence of co-morbidities such as peripheral vascular disease, foot deformity, and peripheral neuropathy (Sinacore & Mueller, 2000). The people who are living with pressure ulcers can also acknowledge the effects of pressure ulcers on physical, social and financial status of the patients through sharing of experiences. From the sharing, patients have been reported to indicate loss of independence and control due to pressure ulcers.

There is already existing knowledge on pressure ulcer and its prevalence and effects on the diabetic elderly. According to Ballinger & Findlay (2006), the complications of diabetes mellitus increase as people age, making the management of pressure ulcers associated with diabetes for this population a complex issue and a challenge for everyone involved in the care. Identifying the location of these ulcers and healing of this disease is of a chief importance in order to prevent infections and amputations, which is consequently of high priority (Sinacore & Mueller, 2000).

Objectives

The objectives of the study are to explore how pressure ulcers affect the quality of life of the elderly diabetic patients, find out if the therapeutic procedures being employed to alleviate the pressure ulcers satisfy the patients in terms of comfort and in facilitating performance of their expected activities of daily living. The study also seeks to establish and document with as much detail as possible the link between the experiences of the older diabetics and pressure ulcers.

The knowledge of possible complications is associated with pressure ulcers on elderly people with diabetes informed the formulation of the questions that this research seeks to answer. Since healing of pressure ulcers seems to be very slow and tedious for the elderly with diabetes, phenomenology study will excavate deeper into this problem. This will help in finding out the impact of all these in observing their life experiences, with the hope of using the knowledge as the initial structure to a new investigation and will serve as a platform on which a qualitative design is built (Denzin & Lincon, 2011). This will provide a rationale for the predictable boundaries and will make known the theoretical assumptions, biases, and preconceptions that will drive the decisions in the design.

Research Design

The objectives will lead with exploring the impact of pressure ulcers on the state of elderly people with diabetes. The conceptual basis of phenomenology study is based on reflections of the lived experience and the four existentials, namely lived times, lived space, lived other, and lived body. The study will be done through a systematic comprehensive process where the researcher hopes to conduct semi-structured interviews with the patients. The researcher will document what patient says at that particular time. The phenomenology research is guided by some philosophical and theoretical underpinnings. The philosophical concepts of ontology are used in phenomenology research. Ontology is a theory of knowledge, which is concerned with the nature of being and existence. The study will also be guided by the theory that the nature of being and existence has been changed significantly, and this can be attributed to the presence of the illness (Holloway & Wheeler, 2010). The researcher can learn the impact of pressure ulcers on elderly diabetic patients in their natural environment. The researcher would see how the patients conduct their daily lives and cope with the illness. Phenomenology method of research is best suited to learn, discover and account for some of the experiences of elderly patients with pressure ulcers.

The phenomenological approach requires viewing reality in multiple, constructed and interdependent way. This means that the whole cannot be cut down into quantifiable parts. Instead, the whole should be taken in for what it is, and not of what it is made. In addition, subjective perspective is acknowledged and accepted as truth. Subjective experience focuses on human beings and their way of interpreting and making sense of reality. The subjective experience demands that the participants’ opinions and views are highly recognized as truth, for they are the ones experiencing them, and the ones with the theorized knowledge about their experience.

The researcher will not approach participants as individual entities who exist, but will be viewed within the whole context of their lives. The researcher will interact with the participants normally in order to understand their experiences and perceptions through listening to them and observing them in their natural setting. The conceptual basis of phenomenology is based on reflections of the life experience and the four existential dimensions, namely lived times, lived space, lived other and lived body (Hollaway, 2005). An interpretive perspective will underpin the phenomenology methodology of research. According to Denzin & Lincon (2011), using interpretive approach can be applied to qualitative inquiry into human health and illness experiences for developing nursing knowledge. In this context, it is believed that interpretive description can be utilized to investigate the experience of the older diabetics with pressure ulcers for creating, from the observations and their experiences, ways to enhance their quality of life, even with same current conditions.

Developing clinical knowledge has significant nursing science applications that should follow specific principles such as having an analytic framework and specific sample selection. Data sources should be from the documentation of interviews and observations, data analysis, and rigor. By utilizing the interpretive descriptions that are of increasing complexity and interrelatedness will pave way for the foundation of nursing’s theoretical structure and its substantive body of knowledge to grow. To establish an analytical framework, the interpretive perspective will seek to locate, within the existing knowledge, the findings that can be utilized as the basis of thoughtful linkages to this study and to the work of others in the field (Denzin & Lincon, 2011)

Once an analytical framework for the study has been established, sample selection will take place. Sampling for this study is purposive, voluntary, and covers the total population sample. Sampling will be purposive because the researcher wants participants who will fulfill the needs of the study. For instance, the framework of this study states that pressure ulcers is a problem for the elderly with diabetes. The researcher will sample subjects among the elderly with diabetes who are currently suffering from pressure ulcers. The researcher will have to locate whether these subjects are in one place so that data collection and observation will be convenient to both parties. In this case, the researcher wants to document the lived experiences of the elderly diabetic patients aged 65 and above, in nursing homes and suffering from the anger of pressure ulcers.

An informed consent form will be distributed to all of the members of the participating group, and to the nursing home staff as well. Those who fit the criteria will be asked for consent to participate in the interviews and allow the researcher to observe them in doing their daily activities. Only those patients who volunteer to participate will be considered to participate in the study. The researcher will respect the rights of the patient to reject participation in these studies.

There is an argument that people who have experienced certain events are the best source of expert knowledge regarding these experiences (Denzin & Lincon (2011). However, this is not always the case as the subjects of study vary in a way that some subjects are articulate and detailed in telling their abstractions and analysis regarding a particular situation. On the other hand, others tend to be more concrete and comfortable with events than interpretations and storytelling. This is why phenomenology will be implemented so that the researcher will be able to witness directly lived experiences of the people.

Sources of data for this study will not only rely on semi-structured interviews but also on the researcher’s documented observation of what is happening at a given time. Data sources could be one-on-one interviews, group interviews, observation, and documents (Dew, 2007). Intensive interviewing and participant observation are, although notoriously time consuming and expensive, the most often used for qualitative research. Varied approaches and methods in data collection are possible through triangulation. In this process, the researcher would combine observation techniques and semi-structured interviews or just dialogues with the study population in documenting his observations of the patients.

The researcher will use a combination of closed and open-ended questions in the semi-structured interview. The questions will be centered on a fixed schedule of topics or questions to be addressed (Liamputtong, 2009). The interviewer must have the adequate intellect and knowledge about the topic to be discussed so that he or she is able to initiate a dialogue and engage participants in an intellectual yet comfortable discussion.

Some already pre-worded questions will be used to force respondents to structure their responses according to the researcher’s priorities and notions of what is relevant to the study (Axford, Greenwood, Minichiello &Sullivan, 2003). There are also interview guides, which will help the interviewer start the discussion and to keep it rolling once it hits a dead end. The guide will also lists all the possible questions to be asked, and themes or issues to be covered.

In employing semi-structured interviews, the researcher hopes to have important themes or issues to be covered and to be prepared for other themes or issues that they did not include but which the participants feel like discussing and which are an important part of the topic (Dew, 2007). This study will focus on issues regarding the effect of pressure ulcers on the daily lives of the older diabetics. Following are sample questions to be used during the interview: How does the presence of the pressure ulcer affects your life?’, ‘Do you feel any pain?’ ‘What do you think may cause the pain and how does it affect you?”.The interviewer will allow participants to discuss issues or themes that were not identified by the researcher (Dew, 2007).

Data collection will start with interviewing and observing a phenomenon through the participants’ point of views. The researcher aims at listing to the voices of the participants during the interviews, and observe them in their natural environment. Therefore, it must be accepted by the researcher that his or her subjects are autonomous people who will share information willingly, and thus, a balanced research relationship between the researcher and the participants will encourage disclosure, trust and awareness of potential ethical issues (Eisenhauer, Orb & Wynaden, 2000).

Limitations of the Study

The researcher is aware of the limitations of using an interview method in investigating the effects of pressure ulcers on elderly people with diabetes. Among the limitations are time constraints, fatigue, and getting the participants to open up. Even with well-planned interview, the interview process can be unpredictable depending on the availability of the participants. In the event that not everything is covered in the interview due to these limitations, Axford et al (2003) suggest use of silence, gestures, and repeating the last few words of the participants to avoid the researcher from putting words into the participants’ mouth. Observing participants is also useful as a source of data because what is said may differ from what is done (Dew, 2007). Participant observation has been described as a combination of two contradictory terms with confusing results, namely, a positivist tradition of observing a social field with the minimum interference and a contrary view in which observers have to participate in the social field to be able to gain shared meanings (Savage, 2000). In this study, the researcher will first observe the lived experiences of the study subjects for a week. After which the researcher will try to interact with them, asking them questions about their routine and the effects of their illness. In a sense, the researcher will move onto participatory observation.

Another useful source of rich information about elderly people with pressure ulcers due to diabetes is the nursing case reports and clinical papers. Patient’s medical records are often readily available, and can provide a strong backbone of support for qualitative nursing investigations. In case the data gathered or the anecdotal reports from the interviews and participatory observation documented do not match the ones reported in the medical record, the researcher should be able to explain the discrepancy and call for further analysis.

Ethical Considerations

Ethical considerations will be paramount in dealing with the participants. For example, the researcher will be ready to deal with sensitive topics and make a decision whether to continue with the interview or not if participants are getting distressed by opening up (Eisenhauer, et al., 2000). In making this decision, the researcher will be informed by the knowledge that there is a potential therapeutic benefit of participants’ reviving unpleasant memories which further stresses the need to seek ongoing consent (Eisenhauer, et al., 2000).

The researcher acknowledges that other benefits of qualitative interviews as outlined by Eisenhauer et al (2000) are catharsis, self-acknowledgment, and a sense of purpose, becoming self-aware, empowerment, healing, and providing a voice, among many others. It is important for the interviewer to stop the interview and search for possible solutions for the participants’ distress. This indicates their awareness of the participants’ vulnerability and their rights. It is a mandate in healthcare to protect the human rights of any individual and as such, any kind of research should be guided by some principles (Eisenhauer, et al., 2000). Autonomy, beneficence and justice are the three ethical principles that will guide the researcher in dilemmas that may arise during data gathering in this phenomenological qualitative research.

Autonomy is honored in researches by informing in advance the participant about the study, the right freely to decide whether to participate in the study, and the right to withdraw at any time without penalty, through giving an informed consent. Beneficence means doing good and preventing the participants from harm. To maintain this principle within the study, the use of pseudonyms is recommended because of the potential consequences of revealing relevant information. There should be confidentiality and anonymity. Finally, justice is a principle that refers to equal share and fairness. The researcher must avoid exploitation and abuse of participants (Eisenhauer, et al., 2000).

The contributions of participants will be acknowledged where the researcher will be careful not to further burden the already burdened vulnerable group of participants with new founded relationships that might cloud judgment and as such, the researcher will maintain professional boundaries at all times. The interviewer or the researcher has the moral obligation to refer his or her participants to counseling or ensure that they have regained control over the situation by talking. In addition, researchers are required by law to report anything that may be criminal to the courts (Eisenhauer, et al., 2000).

Data Analysis

Analyzing data in phenomenology is inductive rather than deductive. The inductive approach builds up an understanding of the world from the data (Dew, 2007). Analytic techniques such as the repeated immersion in the data, prior to beginning coding, classifying, or creating linkages, synthesizing, theorizing, and contextualizing rather than simply sorting and coding will be employed (Denzin & Lincon, 2011). The following principles of conceptualization, comprehension and the techniques will guide the researcher. Conceptualization of the study is based on the reflection of the lived experiences and the existential outlook. Comprehending is the task of learning everything about the particular setting of the experiences of participants in the study. The first condition in ensuring comprehension is the entrance of the researcher in the setting as a complete stranger. The second condition is the capability of the researcher to passively learn or absorb with concentrated effort everything that he or she observes and is relevant to the topic being investigated. The third condition is that the participants of the study should be willing to tolerate intrusion and must be able to share any information necessary with the researcher or interviewer (Cullum, Iglesias, Mason, Nelson, Nixon & Spilsbury, 2007).

Techniques that may be employed by the researcher include active inquiry, taking down notes as frequently as possible. The researcher should keep the literature and non-data knowledge of the topic separate from the data. Coding and analysis facilitate understanding, and Intra-participant analysis or line-by-line analysis of an interview are techniques that will be used. Synthesizing is the merging of all stories, experiences or cases to describe a typical, composite pattern of behavior or response. The process is governed by linking to descriptions of experiences in other stories. Sifting is a technique used to remove the stories or experiences that are not part of the commonality of entire gathered stories.

After data analysis, the researcher will come up with a theory or a final solution that provides the best comprehensive, coherent, and simplest model for linking diverse and unrelated facts about pressure ulcers for elderly people in a useful, pragmatic way. The last step in this phenomenology research is contextualization, which is the development of a theory applicable to other settings and to other populations to whom the research may be applied. A theory that will be formulated after this qualitative phenomenological research on the impact of pressure ulcers on elderly people with diabetes will be generalized and contextualized into different settings.

The researcher will be rigorous where rigor can be established by trustworthiness. Ascertaining trustworthiness in a study can be verified by auditing and following a decision trail that was made by the researcher. This decision trail will help the other researchers who would desire to replicate the study or to review the study by following the steps made by the previous researcher. There are several criteria in determining whether the study possesses rigour or not. This includes credibility, transferability, dependability and ability to be confirmed (Cullum, Iglesias, Mason, Nelson, Nixon & Spilsbury, 2007). A study is credible if there is prolonged involvement, persistent observation, triangulation, and member checks. The main goal of credibility is to be able to identify who are the participants and accurately describe them through the aforementioned characteristics (Ballinger & Findlay, 2006). Prolonged involvement is the act of spending sufficient time to learn more about the culture or the population being studied and observed to be able to build trust and establish relationship with them (Spilsbury et al, 2007). This study will ensure that this criterion is fulfilled by having the researcher spend a whole week living with the population subjects. The researcher thus will be able to document how the study population is experiencing their lives with pressure ulcers and diabetes. In addition, persistent observations involve conditions that are studied for a certain amount of time that will allow to select and which are the most relevant and representative for the issues being observed allowing an in-depth study on experiences (Spilsbury et al, 2007).

Transferability is another next criterion in establishing rigour in research. This means that if the results of this study can be transferred from just the sample population that was studied to the whole population, then more or less the ability to generalize the study will be established and, therefore, its transferability as well. However, in doing this phenomenological qualitative research, the results of the study is the attempt to understand the phenomena, or in this case the experiences of the sample population in dealing with pressure ulcers, and unlike quantitative research, which aims to find out the distribution of phenomena in a population for transferability to apply. The findings in this type of study will be considered idiosyncratic to a particular situation, which means that they are considered a representative of a particular group of people or a person in the particular context or setting, and not necessarily reflective of experiences of other people in other contexts or settings ( Spilsbury, et al, 2007).

Dependability is another criterion for establishing rigour and follows credibility. If a study is credible, then it is also dependable. Dependability can be checked by auditing the study. The critic and the other readers of the research can do this by following procedures of a checking process that will establish an audit trail linkages.

Lastly, confirm ability is established by linking data to their sources so that the reader will be able to verify that the conclusions and interpretations directly arise from the sources. To do this, the raw data will be given so as the analyzed data, the formation of the findings of the study, the process done, the early intentions and the development of the measures used are understood ( Spilsbury, et al, 2007).

Conclusion

This phenomenological qualitative research seeks to understand the effects of pressure ulcers on elderly people with diabetes. The researcher will use phenomenological qualitative research method to gain more understanding on how the elderly people with diabetes and pressure ulcers cope in real life situations. Involving elderly people with diabetes and pressure ulcers, living together in a controlled environment such as a nursing home will help the researcher get varied views on ways of coping with pressure ulcers. In cases where the participants are not able to give information due to various reasons, observation method and secondary data from the nursing records will supplement the interview. Ethical considerations will be of paramount importance in the whole research.

References

Axford, R., Greenwood, K., Minichiello, V., & Sullivan, G. (Eds.). (2003). Research methods for nursing and health sciences (2nd Ed.). Sydney: Addison Wesley.

Ballinger, C. & Findlay, L. (2006). Qualitative research for allied health professionals. challenging choices. West Sussex: John Wiley & Sons.

Cullum, N., Iglesias C., Mason, S., Nelson, A., Nixon, J. & Spilsbury, K. (2007). Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. Journal of Advanced Nursing, 57(5), 494-504.

Denzin, N. & Lincoln, Y. (2011). Sage handbook of qualitative research (4th ed.). Los Angeles: Sage.

Denzin, N. & Lincoln, Y. (2008). Strategies of qualitative inquiry (3rd ed.). Los Angeles: Sage Publications.

Dew, K. (2007). A health researcher’s guide to qualitative methodologies. Australian and New Zealand Journal of Public Health, 31, 433-437.

Eisenhauer, L., Orb, A. & Wynaden, D. (2000). Ethics in qualitative research. Journal of Nursing Scholarship, 33 (1), 93-96.

Holloway, I., & Wheeler, S. (2010). Qualitative research in nursing and healthcare (3rd ed.). Chichester, West Sussex: Wiley-Blackwell.

Hollaway, I. (2005). Qualitative research in health care. Berkshire: Open University Press.

Liamputtong, P. (2009). Qualitative research methods (3rd ed.). South Melbourne: Oxford University Press.

Mueller, M. & Sinacore, D. (2000). Pedal ulcers in older adults with diabetes mellitus. Top Geriatric Rehabilitation, 16, 11-23.

Savage, J. (2000). Participative observation: standing in the shoes of others? Qualitative Health Research, 10, 324-339.

An interview with an order person who has diabetic pressure ulcers

Analytical notes

Program

1. The interview will run from 10:00am to 11:00am
2. Objective- The Impact of the Experience of Living with Pressure Ulcers on the Health of the Elderly Diabetic Patients
3. Starting the interview-the process will start with set induction on the participant.
4. The interviewer will explain to the participant on the ethical measures in place throughout the interview. Such measures will include upholding high level of privacy, request for permission before any recording is done either on graphic or audio and guaranteeing security of the participant.
5. Questions to be answered: who are elderly diabetic patients?, what are the symptoms of the diabetes

Critique to the interview technique

There are several risks associated with interviews due to bias, manipulation as well as lack of enough control. It is therefore important to engage an interviewee who is reliable in compiling the required data. If this is not done, the research lacks important details. It is also important to rely on an interviewee who knows the interviewer in order to enhance control from both sides.

In the case where the participants has not lived with elderly diabetics, the response information would not be first hand as most of the answers would be based on knowledge gotten from books and these may not meet the need of the research.

Sometimes the interviewer may ask questions that guide the participant on the answers to give in order to arrive at the expectation of the researcher. This would mean that the results of the disease?, is the number of people suffering from diabetes increasing or decreasing on a global scale?, what is the leading cause of diabetes and what are the factors that generally accelerates the number of patients of diabetes?, what does pressure ulcers refer to, does pressure ulcers affect elderly diabetics?, what are the impacts of pressure ulcers on elderly diabetics? and what are the common experiences that elderly diabetics with pressure ulcers have to go though? What are the mitigation measures for this disease and how do pressure ulcers affect elderly diabetics:

1. Appreciation of the interviewee
2. Ending the interview at 11:00am

Important points noted during the interview

Elderly diabetes affects elderly people where the major cause is insufficient hormones to control the level of insulin in the body. This disease can be controlled and treated especially if interview would not be original as the answers are biased.

The outcomes of the research may also be manipulated by both parties. Conventionally, focus should be given only to the response by the interviewee in line with the research objectives. It is also possible for the interviewer to ask questions at the end of the interview that matches his or her expectations as opposed to over relying on the perception of the participant. The tone used by the interviewer may also influence the response by the participant depending on whether it is friendly or not. Such manipulation may also arise if both parties know each other. It is also possible to find that the participant indirectly controlling the questions posed by the interviewer by the way of how he or she responds to other questions. The participant may also not be willing to discuss some diagnosed early. There has been a general increase in the number of diabetic patients due to eating unhealthy and failure to exercise enough. When diabetes reaches an advanced level among elderly people it results to bedsores.

Pressure ulcers among elderly diabetics are caused by the following: lack of enough blood supply, lack of enough mobility by elderly diabetics and aged skin.

There are various effects of pressure ulcers on the elderly diabetics ad these include: financial constrains, psychological effects as well as effects on social interaction.

Families that nurse patients of pressure ulcers incur heavy medical bills and therefore experience financial constrain. These worsen if the families also have other dependants such as children or other expenses that have to be catered for. The psychological effects of pressure information even when the interviewer has given assurance about the ethical standard to be observed. This is because even after being assured of confidentiality, the participant may not be certain that that the promise would be upheld. That would lead to substandard findings of the research.

ulcers on elderly diabetics include stress and depression. This is because majority of these patients spend most of their times thinking about the disease and therefore they are not free as they are always engaged on their illness. In most of their times they do not interact with the rest members of the society. Elderly diabetics are also socially affected because the society sometimes fails to pay enough attention to them. Sometimes the society even associates them with HIV/AIDS. The participant made his final remarks and stated that more support is needed to overcome the challenges faced by elderly diabetics where they should be supported in order to live positively with the situation.