The proposed research will help in the creation of awareness among the community members, particularly stakeholders in the mentioned research question, to enhance their capacity to prevent the unwanted outcomes. In particular, the PICOT question for the proposed research focuses on how family nurse practitioners can work with community-based organizations to promote the prevention of unwanted pregnancies and STDs among young adults in South Florida. The purpose of this research study is to provide a background to the two phenomena, i.e. unwanted pregnancy and STDs, and to propose a solution that will help healthcare practitioners to address those issues particularly among the young members of the society.
Various studies have presented information concerning pregnancy and STDs across the United States. For instance, the Guttmacher Institute (2019) presents descriptive statistics concerning the prevalence and outcomes of unwanted pregnancy in the United States. The information provided by the institute was obtained through a combination of methods, most prominently the collection of demographic data from different sources. The findings by the institute show that most of the unwanted pregnancies come earlier in life (more than 5% of women in the child-bearing age have unintended pregnancies each year). The pregnancies also result in significant emotional, social and financial constraints, which have driven most women with unwanted pregnancies to undertake abortions. A strength that can be associated with the study is its intense focus on statistical data. On the other hand, there is not clear distinction between the data collected from primary sources and the synthesis of data from other sources.
Finer and Zolna (2016) also described the prevalence rates of unintended pregnancies in the U.S from 2001 to 2011. The study was conducted with the objective of determining the trends in unintended pregnancies and how they have been addressed over the years. This was accomplished through a qualitative research approach based on an abstraction data collection approach in which data was collected from the results of past demographic surveys. The study showed that the rates of unintended pregnancies among young adults and older women had declined significantly over the years considered in the study. Only 45% of women had unintended pregnancies in 2008 compared to 51% in 2001; the rate continued to decline by up to 18% by 2011 (Finer & Zolna, 2016). The rates of abortion were more or less constant at around 40% of the unintended pregnancies. The study is characterized its strength which is its focus on unintended pregnancies and their outcomes. On the other hand, the study fails to show the connection between the unintended pregnancy and other sexual and reproductive health issues that may arise during reckless sexual behaviors.
Both men and women of reproductive age are at risk of unintended pregnancy. Hughey et al. (2017) carried out a qualitative study with the objective of finding out the population that was at risk of unintended pregnancy. The qualitative study was conducted using surveys administered to 500 men and women of Latino origin. The surveys were aimed at predicting the intentions to have children in the next year. A follow up survey a year later was used to determine the risk of unintended pregnancy. The authors found out that men were at 67% risk of unintended pregnancy while women had only a 59% risk. The large sample population presents an opportunity for data generalization, unlike other studies on the subject. On the other hand, the research findings could have been constrained due to focus on a single demographic group.
Part of the recommended action plan implementation for the proposed study was that family care nurses should be involved in counseling sessions for young adults in the general healthcare setting. Barbosa et al. (2015) conducted a qualitative study with the objective of understanding the perspectives of nurses on counseling about sexually transmitted infections. The study involved data collection through the focus group technique with nurses and physicians as the participants. The findings showed that while physicians and nurses find that counseling may be a good approach to the prevention of sexually transmitted diseases, they are limited by barriers to counseling continuation. The study by Barbosa et al. (2015) can be considered a strong source of evidence based practice information due to its focus on the population targeted by the proposed solution. However, it still poses a challenge to future research, which may need to find an evaluation metric for the efficiency of one-time counseling to the prevention of STDs and unintended pregnancies among young adults. The findings given by Barbosa et al. (2015) are corroborated by Boroumandfar et al. (2017). In the latter study, the authors aimed at determining the impacts of awareness creation towards behavior change among young adults. The study was based on the background that effective prevention of STDs required behavior change, towards the adoption of healthier sexual and reproductive health practices. This study therefore to some extent covers the gap left by Barbosa et al. (2015).
Boroumandfar et al. (2017) used a qualitative study methodology in which 32 participants were taken through a conventional content analysis approach. An empowerment program was run for vulnerable women to determine the level and impacts of awareness creation on STDs and reproductive health practices. The authors concluded that preventive programs for STDs and other sexual health related problems have to be divided into three stages namely, awareness of STDs, belief in being at risk, and the decision to engage in behavior change. The study provides a significant support to the proposed solution by providing sufficient information to promote self-care and reproductive health management. It is suitable for healthcare providers designing curricular for awareness creation and also for young adults who are at risk of sexual health related concerns. On the other hand, the data collection process did not consider the input of healthcare providers.
In a bid to promote sexual and reproductive health awareness and the prevention of sexually transmitted infections and unwanted pregnancy, it is essential to understand the factors that bar young adults from accessing reproductive health screening. A qualitative study conducted by Denison, Bromhead, Grainger, Dennison, and Jutel (2017), was aimed at determining the factors that prevent early detection of STDs among young adults. Through in-depth interviews in which 24 university students participated, the authors confirmed that underestimation of risk is one of the main barriers to early detection of STDs. While the study does not focus on the intervention measures for the prevention of unwanted pregnancies among the young adults, it provides a justification for the proposed solution, which is its main strength. Its main limitation on the other hand, is the focus on university students as the target population, as it constrains the applicability of the findings to bigger youth populations.
In an effort to improve the reproductive health quality and access to reproductive health services among youths, Atuyambe et al. (2015) conducted a study to find out what sexual health needs adolescents have and what their attitudes towards the existing services are. The study was based on a qualitative methodology in which data was collected through 20 focus group discussions. The findings showed that adolescents have a lot of sexual and reproductive health issues that result in sexuality related problems including unwanted pregnancies, sexually transmitted infections, and substance abuse among others. As the proposed solutions attempts to prevent unwanted pregnancy and sexually transmitted infections, reference to reproductive health is crucial, and Atuyambe et al. (2015) provides just the required context. The only limitation of this study is its dependence on the Ugandan youths as the study respondents. Cultural factors may result in different perceptions across different groups of youths, which could limit the generalizability of the findings to the South Florida context. Kim, Kim, and Kim (2018) also explained the awareness of sexual health issues, particularly among young men and women. The study used a qualitative design to collect data from 12 participants where were 20-28 years old. The conclusion drawn was that there was low awareness of sexual health issues, particularly of HPV. This lack of awareness is a justification for the proposed research. The only limitation for the study is the small sample population.
Similarly, Ngilangwa et al (2017) explored accessibility of sexual and reproductive health education by the youths. The authors opined that it was probable that lack of access to sexual and reproductive health information was the reason behind the wrong decisions made by youths, which resulted in outcomes such as unwanted pregnancies and sexually transmitted diseases. To prevent STIs and unwanted pregnancies therefore, healthcare providers should focus on giving the youths sufficient information on SRH. The study was based on a cross-sectional study design with 398 youths as participants. This study gives a well grounded description of the need for more diversified teaching approach to reach youths and adults of all ages with information on SRH. Its main limitation is the focus on Tanzania as the country of reference. Kuzma and Peters (2015) also refer to the vulnerability of youths in sexual health issues. The authors, through a qualitative methodology based on data extraction, conclude that the sexual and reproductive healthcare needs of youths should be met within the context of traditional healthcare settings.
Research Approach and Design
A qualitative research method has been proposed for the study. The qualitative method is used to describe life phenomena and to attach meanings to them. This method is also considered effective where the objective of the study is to gain insight into a phenomenon, to explore the degree of intensity of that phenomenon and to explain the inherent complexities in the said phenomenon (Korstjens & Moser, 2018). The qualitative research approach embodies different characteristics as explained by Rahman (2017) namely, it is based on soft science rather than hard science, it is subjective, it can induce deductive reasoning where the objective is to create a theory, it can be used as the basis of knowledge, meaning and/ or discovery, is unique to the situation and can be subject to individual interpretation. Each of these characteristic gives the qualitative approach a unique strength that makes it suitable for the present study. Barnham (2015) also describes qualitative approach as being more subjective and intepretivist.
The qualitative approach of choice for this study is the grounded theory design. According to Timonen, Folley, and Conlon (2018), the grounded theory design is often used by researchers aiming to explore a phenomenon in order to come up with a theory that can be used to explain it. The core principles of the approach include: taking the “grounded” aspect theory. This implies that the researcher should not be aiming at verifying existing information or hypotheses. Instead, they should be open to new ideas, and to expected unanticipated findings through the research inquiry. Secondly, GT research involves actively capturing and concurrently recording processes and phenomena that are related to the context under study (Mortell, Ahmad, and Abdullah, 2018). This implies that the researcher has to obtain information on processes and phenomena through various practices and to continuously and accurately record that information. For this reason, grounded theory works with several data collection methods, which can also be combined to achieve the intended objectives. The third principle is that the pursuit of theory through continuous engagement with data. In this context, the practice of grounded theory research is based on a large creative impetus in that connections between phenomena have to be developed through close consideration of available data (Timonen et al., 2018).
While using the grounded theory the key consideration will be that the objective of the study is to develop a plan that can be used by family nurse practitioners to help in preventing unwanted pregnancies and STDs among young adults. While doing this, the underlying knowledge will be that the unwanted pregnancies and STDs are the outcomes of poor sexual and reproductive health practices, which can be attributed to lack of awareness of risks. In line with the studies examined, explaining this phenomenon will not be based on any existing hypotheses. The data collection will be aimed at providing information that can help in somewhat developing a theory that can be used by practitioners to inform their practice of pre-infection counseling. While applying this design, the researcher will base his progress on the assumption that the grounded theory research does not always result in a fully fledged theory. Instead, the development of a conceptual framework of what nurses can do in a bid to prevent unwanted pregnancies and STDs among young adults in South Florida, and probably across the world, will be sufficient.
The decision to use the grounded theory approach and qualitative design methodology is based on various reasons. First, the objective of the study justifies the use of qualitative research approach in its grounded theory design. The proposed research will be aiming at developing methodologies or a framework that nursing professionals can use to prevent unwanted pregnancies and STDs among young adults. Secondly, this objective is supposed to be achieved without a prior existing theory or hypothesis. This implies that the data collection will go beyond the conventional hypothesis based methodologies and will instead combine different approaches. The extent of data on the phenomena under consideration has to be explored. For instance, data on the barriers to accessing quality healthcare will be collected even though it may seem to deviate from the initial research objective. The grounded theory approach provides the best opportunity to achieve these objectives. Furthermore, this research design provides an opportunity to explore first hand information from the stakeholders in the subject.
In addition to the justification, qualitative research in general, has several advantages that will be beneficial to the researcher in this study. One of the major advantages of the method is that it produces a link between the participants’ feelings, opinions and experiences. This is necessary in this study since this particular set of information will influence the choice of framework proposed for the prevention of unwanted pregnancies and STDs. On the other hand, the main disadvantage of the qualitative research approach is that it may not take into consideration contextual insensitivities, which can be a challenge in addressing (Rahman, 2017). The advantages however, are stronger than the disadvantages hence the choice of method.
The research will be targeting healthcare service providers and young adults who are at risk of STDs and unwanted pregnancies. The population of family nurse practitioners and youths across South Florida is large, and the choice of the sample population will determine the efficiency of the research outcomes. According to Etikan, Musa, and Alkassim (2016), the choice of the sample population determines the quality of information collected, which affects the credibility of the research and its validity. For this research a non-probability sampling approach will be used. Non-probability sampling is most commonly used in case studies and qualitative research, whereby the focus is on small sample populations that help in creating a link to a real-life phenomenon. A clear rationale has to be available for choosing specific participants to a qualitative research and leaving out others. As such, non-probability sampling maximizes the reliability of information by avoiding random, whole population sample selection.
One of the approaches of non-probability sampling that will be used in this study is the convenience sampling method. Convenience sampling is relatively inexpensive and easy to conduct hence it is mostly chosen where the population consists of individuals who have more or less the same characteristics (Taherdoost, 2016). In this study, a total of 35 participants will be selected. The sample population will consist of 25 healthcare providers, majority of whom have to be nurses and 10 young adult patients. The criteria for including the healthcare providers will be that they work within contexts that allow them to be in contact with young adult patients, and in which they are able to provide 5 minutes of counseling to patients. On the other hand, the patients were included based on the criterion that they were between 15 and 30 years of age. Patients who were undergoing prenatal and post natal care for unintended pregnancies were excluded to avoid producing feelings of discrimination in them.
Convenience sampling is often favored by students as well as other researchers due to its flexibility, ease and low cost. In most cases, this sampling method helps to overcome the challenges and limitations that are common in other research methods. According to Elfil and Negida (2017), one advantage of convenience sampling is that it allows researchers to enroll participants based on their accessibility and availability for participation. It is also the most widely used sampling approach in clinical research. On the other hand, convenience sampling embodies biasness in selection since the populations deemed unfit to provide reliable information are left out of the research (Etikan et al., 2016). This biasness may also result in failure to be representative of entire populations. The proximity of the subject also plays a crucial role in determining whether a subject can fit a particular objective.
While working with the subjects, it will be imperative to take into consideration certain ethical aspects of research. Kara and Pickering (2017) mentioned that in the contemporary times, the main focus in the discussion on ethical research has been on issues surrounding data collection. This is founded on the perception that participant well-being is of utmost importance in research design. For this reason, a variety of ethical concerns have been discussed in extensive literatures in a bid to direct ethical conduct during research activities. One of such concerns is on the subject of participant anonymity. In the healthcare environment and beyond there is exceptional need for participant identities to be kept confidential. Information on specific participant patients and healthcare providers can result in biasness in care delivery. Another commonly mentioned issue is that of informed consent. All participants have to be informed about the research, the rationale for their engagement and the implications of the information they provide for the research. Participants have to sign an informed consent form to indicate their willingness to participate in the study. Mooney-Somers and Olsen (2017) also points out the need for the researcher to protect the participants from harm. In clinical research, harm can be physical or emotional. To protect the participants therefore, Vohora (2018) points out that the researcher should commit to providing a safe environment for research participation and also protecting the participant confidentiality, whose violation can result in emotional harm, particularly to patients.
PDSA Change Model
While implementing the planned EBP process, the Plan-Do-Study-Act (PDSA) change model has been selected for use. The objective of the model is to enable fast modification in interventions to ensure that they work. The model allows practitioners and researchers to learn as quickly as possible about the suitability of a given intervention in a particular setting and to make the requisite adjustments fast enough to improve chances of sustaining the required improvements (Reed & Card, 2016). The model is contrary to controlled trials in that new learning can be introduced into the experimental process to foster continuous improvement. In a clinical environment, PDSA provides sufficient flexibility and adaptability, which are required in intervention works in complex social systems (Vordenberg et al., 2018). Since the intended output of the model is to improve learning and informed decision making, the success of the PDSA process does not necessarily imply the success of the project. As such, the model helps in developing research gains with or without achieving the research objectives.
The PDSA model has been confirmed suitable for the clinical setting since it provides an opportunity for healthcare providers such as nurses to lead change by conducting rapid small-scale tests on the desired initiatives (Reed & Card, 2016). The simplicity and practicality of the PDSA model is considered one of its key strengths in the clinical setting in that it can be used by anyone. It is for this reason that the proposed research has selected the model for application in this particular context (Reed & Card, 2016). For a grounded theory research such as the proposed EBP, the PDSA model provides a perfect opportunity to explore the available scenarios for eventual development of a working framework. However, there may be a barrier to the implementation of PDSA also emanating from its simplicity. The organizational environment has been mentioned extensively as the biggest barrier to the implementation of EBP results. In particular, challenges arising from management resistance to change form the greatest component of organizational barriers to implementation (Cidoncha-Moreno & Ruiz de Alegria-Fernandez de Retana, 2017). This can however be addressed through provision of sufficient information to all stakeholders, to promote informed decision making even among healthcare leaders. One of the ways to foster such as environment that supports EBP is through continuous training, utilization of seniority buy-in and critical reading training among others (Warren et al., 2016).
For the proposed project, the implementation of PDSA would begin with identification of the initial problem, the decision to introduce pre-attendance counseling by nurses and physicians and provision of the requisite resources. The planning process will entail identification of participant healthcare providers and date and time setting; the doing will involve issuance of the training materials to physician, pre and post service delivery survey of patients about their awareness of reproductive health issues and their commitment to the prevention of STDs and unwanted pregnancies. Thirdly, the studying step will involve an evaluation of the difference in perception before and after the pre-attendance counseling, while the acting stage will involve decision making as to whether to continue with the plans or not. Working plans would be approved for further tests while non-workable plans will be reviewed, revised, planned, done and seen reiteratively.
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