My chosen policy is the code for best practice standards for the use of urinary catheters (2009). The research evidence underpinning this policy consists of many research articles.

University Degree Subjects allied to Medicine

My chosen policy is the code for best practice standards for the use of urinary catheters (2009). The research evidence underpinning this policy consists of many research articles. The three articles I intend to analyse in this paper are, Wilde, M. (2003) ‘Life with an indwelling catheter: The dialectic of stigma and acceptance’. Godfrey, H (2007). ‘Living with a long-term urinary catheter: older people’s experiences’ and McConville, A. (2002) ‘Patients’ experiences of clean intermittent catheterisation.’ My analysis will attempt to scrutinize the trustworthiness, dependability, credibility, transferability and reflexivity of this research. To do so is imperative as authorities base their recommendations on this research and specific policies are implemented as a result. These same said policies can then, in theory, be used behind the implementation of further policies or laws. And, so, a re-enforcing cycle is established, whereby research lead to laws which lead to similar tax-funded research, which calls for more law. Arguably, this can lead to a self-sustaining cycle that can discourage contrary evidence and critical thinking about the data on which the laws rest. Fundamentally, these articles inform the delivery of care the service user receives. For that reason alone it is surely vital that all research articles be subject to thorough editorial process, relevant service user involvement and meticulous peer review.

The professional rationale behind my chosen policy stems from an interest in elderly medicine and a recognition of the extensive use of catheterisation that this population is subject to. Statistics point to the need for policy improvement or stronger adherence to catheter guidelines. Certainly, the high rate of hospital-acquired infection caused by indwelling catheters raises the question of catheter misuse. Up to 25% of hospitalized patients have a urinary catheter placed during their stay and the use of indwelling urinary catheters accounts for 80% of nosocomial urinary tract infections (UTIs) (Godfrey & Evans, 2000). Saint et al (2008) state that in 2002 UTIs accounted for 36% of all nosocomial infections and 13,000 deaths were attributed to hospital-acquired UTIs. Catheter policies and their recommendations are therefore of paramount importance as they can affect the service user’s experience immeasurably. From a personal perspective I have become increasingly aware of the emotional ramifications urinary catheterisation can have upon a patient. Catheterisation, examined as a clinical skill, requires a high level of technical precision and anatomical knowledge (Haberstitch, 2005). However, catheterisation; examined as an experience requires an even deeper level of understanding and empathy.

This policy was based on approximately sixty research articles. In keeping with the character of guidelines at the moment a significant proportion of the articles were quantitative in nature. According to Streubert & Carpenter (2011), guidelines are often based on positivist, quantitative data in accordance with the still prevalent biomedical paradigm. However, my interest was in people’s experiences, which called for research of a qualitative nature which was noticeably scarce by comparison. Ultimately, I was forced to compromise on two qualitative pieces and one piece of mixed methodology (quantitative and qualitative). Nevertheless, it was interesting to note the types of research the policy’s author pursued, as this would arguably influence the flavour of the finished policy. I endeavoured to keep the literature as recent as possible, also with mixed results; 2002, 2003 & 2007. As such, Godfrey’s (2007) work must therefore be given somewhat more credence than Wilde (2003) and McConville (2002) due solely to its comparable modernity.

The purpose and justification for all three studies was very similar, they all purported that the experience of living with a catheter had not been examined. However, Wilde (2003) and to a lesser degree Godfrey (2007), were more explicit, in terms of supporting their arguments with relevant literature. According to Thompson & Cullum et al (2001) the appraisal of literature is integral to producing evidence-based practice. Unfortunately McConville’s (2002, p.55) appraisal fails to convince as it’s more of a discursive glance, describing the literature as other ‘studies’ rather than providing any specifics. Consequently, her study’s credibility could be called into question. Wilde (2003) and Godfrey (2007) on the other hand point to prominent gaps in specific literature in relation to the lived experience of catheterisation. Godfrey (2007), for example, cites the audit completed by the Royal College of Physicians (2007), which determined a noticeable absence in users’ perspectives with regards to catheterisation. The purpose of all three studies did however seem relevant to the policy, as arguably any policy should cover, holistically, all aspects of a nursing process.

The samples used in all three studies were reasonably small in size, which is not uncommon with qualitative research. According to Kuper et al (2008) the sample should reflect the nature of the research question. Traditionally, quantitative researchers embrace markedly larger samples than their qualitative colleagues. In keeping with this convention, Godfrey (2007) purposefully sampled only 13 older people via a district nursing service. She theoretically sampled her second interviews later on in the process in order to explore any previous contrasting views. She felt theoretical saturation was reached after an 8-month period consisting of 20 interviews. Regrettably, she failed to address younger people and no ages of the ‘elderly people’ were provided. Moreover, only one of her participants was black. Wilde (2003) purposefully sampled 14 community dwelling individuals from a homecare agency. She too failed to recruit younger people but was keen to address this failing and recruited them from a private urological practice instead. All ages and gender were addressed by Wilde (2003) and she acknowledged in detail her failure to recruit anyone of ethnic diversity. Wilde (2003), like Godfrey (2007), also conducted face-to-face interviews, lasting approximately 1 hour each. She conducted her research over a 6-month period until she felt maximum saturation was achieved. McConville (2002) on the other hand, chose quite a large sample considering the qualitative nature of her research question. However, the first stage of her research was in the quantitative form of a questionnaire. Paradoxically, her sample was then arguably too small for a quantitative study, especially as the response rate to her questionnaires fell to 67% upon return. McConville (2002) also failed to mention any ages at all. She failed to state where she attained her sample from and very little information was given about the participants she chose, be it age, race or gender. The reader was left to assume that she followed a typical-case sampling method.

McConville’s (2002) open-ended questions on the postal questionnaire formed her qualitative data, whereas both Wilde (2003) and Godfrey (2007) conducted lengthy in-depth face-to-face interviews over a significant period of time. Wilde (2003) deliberately followed a hermeneutic phenomenology approach, which purposefully lends itself to illuminating the nature of experience (Maltby et al, 2010). Godfrey’s (2007) design was based on grounded theory where concepts and themes are analysed together to produce a holistic explanation alongside the emerging theory (Streubert & Carpenter, 2011). The latter two approaches are typical and advantageous to qualitative work of this kind. McConville (2002) however, chose a ...

This is a preview of the whole essay

Analysis of the data by Wilde (2002) and Godfrey (2007) both involved computer software; MARTIN and NVIVO 2.0 respectively. They both audio-taped the participants and used their words verbatim in the transcripts. Wilde (2002) unlike Godfrey (2007) and McConville (2003) incorporated the assistance of two transcribers to check over the transcripts and verify her findings thus reducing researcher bias and promoting credibility. Although Godfrey (2007) didn’t employ transcribers or member check she did attempt to enhance trustworthiness by utilising the four strategies recommended by Chivotti & Piran (2003) to enhance credibility. Godfrey (2007) also states that she enhanced her auditability by detailing the analytic process and that the transferability of the research was increased by specifying the sample, setting and theory generated. Wilde (2003) states she attempted to participate in the technique of member-checking, unfortunately she was faced with the twin obstacles of poor vision and lack of interest. However, she believes, the trustworthiness of her data can be confirmed by the reader, as they read through her analytical process. She also sought precision by aiming for detailed, interpretive description using Merleau Ponty’s existentials (1962) to analyse the scripts. Wilde (2003) felt her results advanced theoretical understandings and that they were also relevant to multiple situations and thus helped issues of transferability. Indeed, although clearly no research is faultless Wilde (2003) does attempt to cover all issues of trustworthiness, auditability, transferability, credibility et al in impressive minutiae. She is arguably the first to address any limitations her study encountered. Unfortunately, McConville (2002) can be placed at the other end of the research spectrum. We are left to presume (as she fails to address) that she interpreted the data herself. Her quantitative data is reported without pre, post or follow up.

Godfrey (2007) arguably paid the most consideration to the participants of her study with regards to informed consent. She purposefully made courteous, first visits to their homes to chat about the process. She also believed this initial visit enabled her to build a rapport with the participants which resulted in the data obtained from her interviews being more revealing and insightful in nature. Wilde (2003) on the other hand, obtained full consent on the day of the interview and McConville (2002) only used the completed return of her postal questionnaires as indication of informed consent. All researchers sought ethical approval for their studies from universities and review boards. Reflexivity is also an important factor in any research. The researcher is anything but a passive observer and their bias and social and political leanings and even their gender must be acknowledged. Godfrey’s (2007) belief in substantive theory and Wilde’s (2003) stringent following of Merleau-Ponty’s phenomenology and van Mansen’s (1990) methods certainly influence their exclusion of other worthwhile research methods and thinking. However the latter two researchers do acknowledge the limitations of their approaches and Wilde (2003, p.1192) even states that she thoroughly ‘...examined (her) own preunderstandings...’

It would however be expected that the findings produced by Wilde (2003) and Godfrey (2007) would be far superior to McConville (2002) and in some ways this is true. However, it would be incorrect to presuppose that McConville’s findings are of no worth. Indeed, although her credibility is poor, it is not incredulous to argue that her findings are illuminating. According to Dixon-Woods et al (2004) some of the most important qualities of qualitative work can be the most difficult to measure. For example, a study may be judged to have followed the most appropriate procedures but offer little insight into the phenomenon at hand. On the other hand, a second study may be flawed in terms of the transparency of methodological procedures and yet offer a compelling, vivid and insightful narrative. Certainly, McConville’s (2002) study is demonstrably flawed in terms of thoroughness of procedure. Yet she does paradoxically offers insightful and practical advice with regards to further education for healthcares and her emphasis on catheterisation education taking place in the community setting rather than hospital resolutely rings true. Her results can also be said to be generalisable and relevant to other areas of practice. Wilde (2003) and Godfrey’s (2007) recommendations are certainly no less useful and are also generalisable, however, they are not the ground breaking recommendations one might expect considering the thorough and meticulous nature of research. Nevertheless, both Wilde (2003) and Godfrey’s (2007) findings are undoubtedly more reliable and transferable as a result of their thoroughness, a claim McConville (2002) certainly cannot attempt to make.

The Royal College of Nursing (RCN) believes that service users can bring a rich range of personal skill, knowledge, experience and ability to the research arena regarding health provision and this can compliment the expertise of the researcher (RCN, 2007). The Department of Health’s (DofH) (2011a) White Paper, Liberating the NHS has carried through with this belief, stating that shared decision-making between service user and provider should become standard practice. The present maxim, ‘no decision about me without me’ is also in line with the emerging theory regarding the importance of service user involvement in research (DofH, 2011b, p.4). This theory goes beyond welcoming the service user’s opinion, to advocating research, led by service users themselves. Current government strategy and legislation is certainly pushing the use of service user led research; Creating a Patient-led NHS (DofH, 2005) and the Empowerment White Paper – Communities in Control (2008) being two such examples. However, as with any developing method of research, controversy follows close behind. Currently this theory is having trouble negotiating a path between being seen as a tokenistic exercise on the one hand and the only acceptable form of research on the other (McLaughlin, 2010).

The three pieces of research I analysed did consult the service user. Indeed, all three articles were very interested in their perspective. However, the participants in all the studies were researched upon. All three researchers chose what questions to ask and they decided what direction the study went in. However, current thinking would argue that they could have involved their participants in the research process as researchers themselves. Certainly, evidence-based practice produced from this kind of research would lend itself to the validity of any policy. For example, the researchers could have asked the participants to decide what questions to ask. These questions may well have been very different to those the researcher thought to ask themselves, thus producing a new perspective on the subject. Alternatively, the service user could have changed the research method entirely. For example, they may have decided that a catheter diary would be a more effective method of eliciting opinion.

Unfortunately, service users face numerous barriers when they attempt to play a role in or instigate research. For example, the participant may be housebound, have communication difficulties, venue inaccessibility may be a problem or it may be more ominous, such as government action making it impossible for them to take part (, 2011). The reasons behind these barriers are therefore varied. However, four overriding factors do seem to come to the forefront. These are; information shortage, cost of involvement, representativeness and researcher resistance. Information shortage was shown to be a key barrier by Rose (2001). Whilst researching the User’s Voice Project, Rose (2001) discovered low levels of service user involvement across the country linked strongly, she claimed, to lack of information. Rose (2001) found this to be especially relevant to the care planning process. Tait & Lester (2005) go on to state that not only can the information be difficult to access physically but when it is available, it is increasingly difficult to access cognitively as the service user may feel can feel blitzed by the jargon. The cost of training and organising service users can also be a considerable barrier. Moreover, access to funding can prove difficult. Funding needs to be available on all levels, at the highest level so that the overall research project is possible, as well as at lower levels so that immediate needs can be met for example, travel expenses and practicalities such as teas, coffees and snacks.. Recruitment is also not cost free and recruitment and training is time consuming. Training a researcher in advanced statistical analysis skills is certainly not a minor task. McLaughlin (2010) concurs adding that if researchers are poorly trained, the research will also be poor. Overall therefore, the whole process can lead to service users feeling exploited by the research process especially when financial recompense is meagre and the university systems are inflexible.

Representativeness also acts as an overt barrier. The representation of ethnic minorities is often poor according to Tait & Lester (2005) who argue that most groups who put themselves forward as researchers are unrepresentative of minority ethnic communities. They also state that these groups tend to be small, recently formed and poorly funded. This same argument has been levied regarding the poor representation of gender, geographical difference and those with disabilities. Somewhat surprisingly many representatives of service user groups are also told they are too articulate and not representative enough of their group (Tait & Lester, 2005). However, service users argue that it is natural for them to put forward their most articulate member to represent their views. They contend that service providers deliberately want to deal with inarticulate, less intelligent representatives, so that their plans are complied with. All of the latter inevitably forms a barrier, limiting the capacity for change.

Professional resistance also plays a crucial role in barring service user involvement. As aforementioned, there is still a noticeable section of academics who take a tokenistic approach to service user participation. According to Campbell (2001) there is a noticeable discrepancy between expressed support and the reality of practice. He states that there is a transparent caginess with regards to the equal transference of power between academic researchers and service user researchers. The Scottish Consortium for Learning Disability (SCLD) (2009, p.19) agrees stating that ‘it is important that professionals learn to ‘let go’ (of) some of their power for real service user involvement to happen.’

Some steps to overcome these barriers have been put into place and although there is arguably much still to do there are examples of service user initiatives visible. Beresford (2003) believes in the development of inclusive approaches to promote involvement. He suggests these approaches should reflect and take into account difference and diversity. He also states that user involvement in governance needs to be connected to the equalisation of access to funding to ensure that user researchers are not disadvantaged in terms of accessing funding. Furthermore, he states that equal access to research tools should be put into place as well as increasing the access to groups that are seldom heard about, such as drug users. The White Paper Communities in Control – Real People Real Power (2008) also offers more tangible steps towards credible service user involvement. For example, they advocate helping councils to promote citizen involvement by extending the ‘duty to involve’ for citizens. As a result citizens can have their say in local policies. The paper has also stated that it will make it compulsory for councils to respond to petitions. It also planned the introduction of an ‘Empowerment Fund’ of at least £7.5m by 2012 to help national third sector organisations. Further steps include evidence of participatory budgeting and deliberative forums from across the world. If they choose to do so, local government can then use these initiatives to empower communities and give local people increased power and influence over the decisions that impact on their everyday lives (Tew & Gell, 2004.).

The problem at present is that the steps to overcome these barriers seem to be very much trapped in the theory process and although there is some evidence of change, it exists, mostly static, in the form of words on paper (often White). According to Stickley (2006), the concept of the service user as the agent of control at the top rung of Arnstein’s (1969) ladder is, despite popular rhetoric, still illusory. Certainly, the INVOLVE () website in 2008 showed only 11 projects involving the service user. Of these, the majority focussed on the service user perspective as opposed to the service user as researcher, analyser or evaluator (Smith et al, 2008). It is therefore clear that there is still much to achieve if the service user is to be involved in research. There is also a noticeable need for analysis of the research literature underpinning current policies to be more thorough. Arguably, it is only when researchers choose credible, up-to-date literature which involves the service user that the end policy produced will be of the requisite good quality required.

Arnstein, S. (1969) A Ladder of Citizen Participation. Available at: (Accessed: 12 June 2011).

Beresford, P. (2003) ‘User involvement in research: Exploring the challenges’, Nursing Times Research, 8 (1), pp. 36-46.

Campbell, P. (2001) The role of users in psychiatric services in service development – influence not power’, Psychiatric Bulletin Journal, 25, pp. 87–88.

Chiovitti, R. F., Piran, N. (2003) ‘Rigour and grounded theory research’ Journal of Advanced Nursing, 44 (4), pp. 427-435.

Communities and Local Government (2008) ‘Communities in Control – Real People, Real Power’. Available at: (Accessed: 15 June 2011).

Department of Health (2005) ‘Creating a Patient-led NHS’. Available at: (Accessed 2 July 2011).

Department of Health (2011a&b) ‘Liberating the NHS: Legislative framework and next steps’ Available at: (Accessed 2 July 2011).

Dixon-Woods, M. & Shaw, R. & Smith, J. (2004) ‘The problem of appraising qualitative research, Quality Safety Health Care, 13, (2), pp. 223-225.

Gill, T. (1994) ‘A Critical Appraisal of the Quality of Quality-of-Life Measurements’, The Journal of the Medical American Association, 272, pp. 619-626.

Godfrey, H. (2007) ‘Living with a long-term urinary catheter: older people’s experiences’ Journal of Advanced Nursing, 62 (2), pp. 180-190.

Godfrey, H. & Evans, A. (2000) ‘Catheterization and urinary tract infections: microbiology’, British Journal of Nursing, 9 (11), pp. 682-690.

Haberstitch, N. (2005) ‘Use of prevalence survey of indwelling urinary catheters and assessment of risk factors to enhance compliance with CDC guideline in Japanese hospitals’, American Journal of Infection Control, 33 (5), pp. 172-177

Haigh, C. (2008) ‘Exploring the evidence base of patient involvement in the management of health care services’, Journal of Nursing Management. 16, pp. 452-462.

Kuper, A. & Lingard, L. (2008) ‘Critically appraising qualitative research’, British Medical Journal., pp.1-12 [Online]. Available at: (Accessed: 28 June 2011)

Maltby, J. Williams, G. McGarry, G. & Day, L. (2010) Research Methods for Nursing and Healthcare.1st edn. Essex; Pearson Education Ltd.

McConville, A. (2002) ‘Patients’ experiences of clean intermittent catheterisation.’ The Nursing Times, 98 (4), pp. 55-58.

McLaughlin, H. (2010) ‘Keeping Service User Involvement in Research Honest’, British Journal of Social Work, 40, pp. 1591-1608.

Merleau-Ponty, M. (1962) Phenomenology of perception. New York. Routledge.

National Institute for Health Research (2011) Involve: Supporting public involvement in NHS, public health and social care research. Available at: (Accessed: 23 May 2011)

Rose, D. (2001) Users’ Voices: The Perspectives of Mental Health Service Users on Community and Hospital Care. 1st edn. London: Sainsbury Centre.

Royal College of Nursing (2007) ‘User involvement in research by nurses. Available at: (Accessed: 16 June 2011)

Saint S, et al., (2008) "Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study." Clinical Infectious Diseases, 46, pp. 243-56.

Scottish Consortium for Learning Disability (SCLD) (2009) Effective Engagement in social Work education – a good practice guide on involving people who use services and carers. Available at: (Accessed: 12 June 2011).

Smith, E. & Ross, F. Donovan, S. Manthorpe, J. Brearley, S. Sitzia, J. & Beresford, P. (2008) ‘Service user involvement in nursing, midwifery and health visiting research: a review of evidence and practice,’ International Journal of Nursing Studies, 45 (2), pp.298-315

Stickley, T. (2006) ‘Should service user involvement be consigned to history? A critical realist perspective’. Journal of Psychiatric and Mental Health Nursing 13, pp.570-577.

Streubert, H. & Carpenter, D. (2011) Qualitative research in nursing. 5th edn. China; Lippincott Williams & Wilkins.

Tait L. & Lester, H. (2005) ‘Encouraging user involvement in mental health services’, Advances in Psychiatric Treatment, 11, pp. 168-175.

Tew, J..& Gell, C. (2004). ‘Learning from Experience; involving service users and carers in mental health education and training’, Mental Health in Higher Education, pp. 1-66.

Thompson, C. Cullum, N. McCaughan, D. Sheldon, T.A. Mulhall, A. & Thompson, D.R. (2001) ‘The accessibility of research-based knowledge for nurses in United Kingdom acute care settings’, Journal of Advanced Nursing, 36(1), pp.11–22.

Wilde, M. (2003) ‘Life with an indwelling catheter: The dialectic of stigma and acceptance’, Quality Health Research, 13 (9), p. 1189-1204.