Introduction

Data is the basic and the fundamental concept that this study focus on. Since there is no information can be acquired without availability of data (Ahsan and Shah, 2006). The data that we are talking about in this context is the clinical data, which is the data that gathered about patients in practice by clinicians (Millar et al., 2009). Pressure ulcer (PU) data is one of these data that collected by nurses in clinical settings, these involve all the elements of PU data, like; prevalence, incidence, risk assessment, ulcer grading, and prevention data.

Data is a concept being of high interest in the discipline of nursing informatics. (Graves and Corcoran, 1989) define nursing informatics as “a combination of computer science, information science and nursing science to assist in the management and processing of nursing data, information and knowledge, to support the practice of nursing and delivery of nursing care”. So, the nursing informatics as a speciality begins with the basic concept “data”, as the present research did.

Indeed, nursing informatics can be applied in four areas, that are summarised in the word “CARE”; clinical, administration, research and education areas (Hannah et al., 2006). In this study, the nursing informatics concepts chosen to be applied in a clinical oriented subject, which is PU. PU as one of the important clinical areas has been selected due to the importance of this problem, in term of its size and the costs of preventing and treating such problem, from one side, and due to limited numbers of previous works that relate the concept of nursing informatics to PU field, from other side. More specifically, this research has related the concept of nursing informatics on PU data. Nursing informatics deal with the data, that processed to support nursing care, and PU data is one of these data that should be processed to support the delivery of patient care.

In this thesis, the recording of PU data in recording systems, either paper or electronic was explored, and the uses of these data in these records were identified. As has been recommended, more researches are needed to realize what need to be recorded in the recording systems and how this will be used (Urquhart et al., 2009).

Personal motivations toward the research

The researcher’s interest in this subject arose from the importance of nursing informatics in nurse’s daily practice. The nursing informatics specialists have a special role in using the information technology (IT) to enhance the safety, effectiveness, and quality of health care (Murphy, 2010). It is acknowledged that all providers of healthcare assumed to be skilled in exercising the IT to make decisions that lead to better care (Saba and McCormick, 2006).

PU topic investigated due to its great importance. As a nurse used to work in clinical practice caring for PU patients, and observing the magnitude of the physical and psychological impacts of this problem on patients and their families life, the researcher decide to choose this area to be studied. Noticing many patients die because complications of this problem is an enough motivation to start digging in this area. First, to understand how PU data is recorded and used in practice, in effort to understand the difference between recording this data on paper and electronic record. Then, to realise the size of this problem in the researcher country “Jordan”, to make a reference data for health policy makers to adopt prevention programs in Jordan, there is no one in action yet.

Statement of the problem

PU is one of the health problems that are very common and prevalent, without accurate portrait of PU data, the problem will continue to grow. Nurses in clinical practice collect and record large volume of PU data every day. This data should be recorded and used appropriately in practice. Taken into considerations that recording and utilising of patient’s data is the fundamental role of any healthcare provider (Millar et al., 2009). Further, and in the second study, urgent identification of prevalence and prevention data in Jordan is necessary, especially that there is no previous works have been located. So, the primary focus of this study was on the problem of PU, identifying its size, the preventive measure provided to PU patients, and how its data recorded and utilised in practice.

Overall Research Aim

The overall research aim is “to explore how PU data are recorded and utilised in clinical settings”. This is the overall aim of the study, with many other secondary objectives for each study and method of the research, but all these objectives are come under the main aim of the study. The objectives of each method will be presented in the methodology chapter (chapter 3).

Definition of terms

From the general aim of the study, the reader can note that many terms have been used in formulating the aim. The following represent the operational definitions of each term presented in the study aim:

“PU data”: raw facts that related to PU concept, like prevalence, risk assessment, ulcer grading, and prevention data. For instance; a prevalence rate for a specific ward is 5%, Waterlow risk assessment score is 10, patient’s PU grade is 4, and patient repositioned on his bed every 2 hours. All these are clinical data related to the PU problem.

“PU Data recording”: recording and documenting of PU data that specified above into patient’s medical record, either this record held on paper or electronic format.

“PU Data utilization”: the uses of the collected and recorded PU data in practice, what they are make of this data, what they are benefit from it.

“Clinical settings”: the different care settings that usually collect, record and used patient’s clinical data, including PU data. Most commonly, it is composed from primary and secondary settings.

Background to the study problem

Scope of the problem

European Pressure Ulcer Advisory Panel (EPUAP), are group has been lunched to guide all Europe nations in preventing and treating PUs. They define PU as: “an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and or a combination of these” (EPUAP, 1998).

These ulcers, regardless of their basis, represent negative outcomes for patients; these negative outcomes may include pain (Reddy et al., 2003, Günes, 2008), longer hospital stays, where it can add about 7 days to a hospital admission (Anthony et al., 2004), decreased quality of life (Price, 1998, Neil and Munjas, 2000), and increased the spending of care provider time and costs (Alterescu, 1989, Clough, 1994, Severens et al., 2002a, Bennett et al., 2004). PUs have been regarded as the most physically debilitating complications in the twentieth century (Burdette-Taylor and Kass, 2002), and it is the third most costly problem after cancer and cardiovascular diseases in the Netherlands (Shahin et al., 2008).

In fact, there are many complications for PUs, including infection, sepsis, and osteomyelitis (Thomas, 2001). It has been found that more than half (51%) of long term care patients with PUs have Methicillin-Resistant Staphylococcus Aureus (MRSA) infection (Capitano et al., 2003). Furthermore, PUs are linked with two-fold rates of increased mortality, regardless of the origin of the ulcer (Brem and Lyder, 2004). This is consistent with Landi et al (Landi et al., 2007) study, who investigated the connection between PU and the risk of one year all reasons mortality in a community of very elder people, and found a significant difference between the PU group and non-PU group in mortality rate, 29% vs. 14% (p <0.001) respectively. After adjusting for all important variables between the groups, found that participants in PU group were more expectedly to die compared to non-PU group.

Size of the problem

The size of such problem can be measured using prevalence and incidence estimate in any healthcare setting (Davis, 1998). A plethora of literature related to the incidence and prevalence rates of PU are available. As example, in acute care the prevalence rate found to be between 14-17% in the USA (Whittington and Briones, 2004). A Canadian study report prevalence of 25.1% (Woodbury and Houghton, 2004), and across five European countries including the UK the prevalence was 18.1% (Vanderwee et al., 2007). Regarding the incidence, a systematic review revealed that in acute care settings in the USA and Canada, the incidence was ranged from 8.5% to 13.4%, and in the UK it was ranged from 2.2% up to 29% (Kaltenthaler et al., 2001). This suggests that this problem is substantial and widely common worldwide.

Cost of the problem

There are several studies predicting the cost of this problem, and frequently this cost is given to the prevention of new ulcer or managing existing one. In the UK, Bennett et al (Bennett et al., 2004) performed a study in the health and social care system in the UK to estimate the cost of treating PUs. They found that treating a PU varies from £1,064 (Grade 1) to £10,551 (Grade 4), and there is a relative relationship between PU grade and the costs, as one rises the other ascends. Complications occurred in sever stages since long time is needed to be healed. Anyway, the annual cost of treating PUs in the UK was £1.4-£2.1 billion, which represents around 4% of total NHS spending, and most of these costs were nurses’ time (Bennett et al., 2004).

In the US, 2.5 million PU patients approximately are treated every year in the US acute care settings, with a cost reached $11 billion (Sullivan, 2008). The cost of PUs problem in the Netherlands ranged from a low of $362 million to a high of $2.8 billion, which is approximately 1% of the total Dutch healthcare budget (Severens et al., 2002b). All these studies suggest that the cost of treating PU is high anywhere.

Significant of the study

The consequences, complications, magnitude and costs of treating such problem, clearly indicate the significance of the study, and justify the choosing of PU problem particularly. In fact, reliable PU data are needed to deal with this problem, especially that there is inaccuracy in recording PU data (Gunningberg et al., 2000, Gunningberg et al., 2001, Gunningberg and Ehrenberg, 2004), and this inaccuracy may come from the subjectivity and unreliability of detection and grading PU, specifically in the early stages of their formation (Benbow, 2004). One study reflect that, where one third of PUs cases were not documented by nurses, due to failure of the nurses in grading non-blanching erythema as a grade one (Chan et al., 2005). The problem of inconsistency in recording PU data cannot be defeated without accurate and complete recording systems, either electronic or paper system.

In general, it has been seen in several studies that the use of electronic recording systems of patient data was contributively lead to accurate and complete documentation that improve the quality of patient records (p <0.01), and eradicate the redundant paperwork that influence nurse’s time and contentment (Stengel et al., 2004). The majority (75%) of nurses in one study believed that computerising patient record could improve the quality of documentation, safety and patient care (Moody et al., 2004). This view was supported by (Mahler et al., 2003), where the completeness of patient record represented by high quality documentation was noticed in 20 documents assessed by two nurse experts at three appointed time slots in different wards.

Many profits have been allocated to the electronic health record (EHRs). It makes the clinical data available all the time, which facilitate timely decision making process (Wang et al., 2003). It can reduce the redundant unessential testing, improving the utilisation of radiology examinations, accurate capturing of patients payments and reducing the errors in bills, which reduce the costs and improve incomes (Wang et al., 2003).

In brief, it has been noted that EHR system could improve the quality of different type of clinical data. However, there are limited studies explore whether it improves PU data recording. Given the size of the problem of PUs, accurate identification of them is important. In this thesis, PU data recording and utilising was explored in both the paper and electronic format, highlighting the advantages and disadvantages of each recording system for PU data. Further, reliable data about PU in Jordan was obtained by the researcher.

Context of the study

To accomplish the research objectives, the current research has been conducted in two major settings, the UK and Jordan. For the purpose of simplification, each one presented in a separate study, due to different methodology used in each one. Although, the two studies were answered two questions, and they are two separate studies, they share the same theme of the thesis, “PU data”. Where study one in the UK explore how PU data recorded and utilised in clinical practice, and study two extended some aspects of PU data deeply, where prevalence, risk assessment and prevention data have been collected in Jordanian settings.

Study one combined QUAN and QUAL methods to answer the research questions, where a survey questionnaire and semi-structured interview have been performed. In study two a prevalence survey of Jordanian settings has been accomplished to answer the other research questions.

In the organisation of the thesis as will explained in section 1.5 and figure 1.1, a separation in the two studies will be exist in all chapters to make it easy to follow the research objectives, except in the literature review chapter, where merging of the two studies will be noted since this chapter discuss all elements of PU data and both studies were aiming this goal, and it was unfeasible to separate them.

Research Justifications and Rationales

Presence of two studies was justified by the concept that the two studies are inter-related, where both concerned the PU data. Study one explore how PU data recorded and utilised in the UK. In Jordan, no PU data have been collected before and no idea how these data recorded and used in practice. So, the second study was a continuation for the first, with a concentrating on some aspect of this data in different settings and population. However, absence of any study conducted before in Jordan about prevalence give other rational for conducting the second study in Jordan. Taking into consideration that conducting a prevalence survey is pointless without exploring the preventive measures (Phillips and Clark, 2010), the prevention data was decided to be collected as well.

Anyway, conducting the prevalence survey in Jordan was fortunately supported by the findings that obtained from the UK part as seen in the results chapter (chapter 4). Where it was clear especially from the QUAL phase of the UK study that the prevalence rate calculated could be based on nurse report of PU cases to TVN, or reviewing the recording system that based originally on nurses reports, and this in turn will exclude some underreported cases from the prevalence calculation, and express inaccurate prevalence data. This give a strong evidence that calculating a prevalence rate using a validated tool by examining each patient skin is more accurate in this regard. So, this gives an extra credit to Jordan prevalence survey, where the researcher himself examined each patient’s skin and calculated the prevalence.

Structure of the thesis

The content of this thesis is organised into six chapters. Figure 1.1 outlines the research process and the related chapters. Each chapter organised into several sections and sub-sections. At the beginning of each chapter there is a section called ‘Introduction’ which is provide an overview about each chapter and its content briefly, to give the reader an impression about the content and structure of the chapter before reading it. Similarly, at the end of each chapter, a summary presented to provide a summary and conclusion drawn from each chapter, to keep the reader oriented about each chapter. To avoid confusions, some terms used and have a specific indication, where the term “research” refer to the whole research and thesis, “study” refer to study one and two (UK and Jordan) that made up the thesis, “phase” refer to the QUAN and QUAL phases in the first study. The following present the content of each chapter:

Chapter one gives an overview of the thesis, identify the research problems, the reasons for undertaking the research, the research objectives and the significance of the study.

Chapter two reviews the existing literature regarding recording and utilising of clinical data in practice in general, then for PU data in particular. After that, a critical appraisal of all PU data elements have been undertaken, including prevalence, risk assessment, ulcer grading and prevention data. The theoretical basis underpinning the research has been presented and discussed in this chapter as well. In this chapter, the literature reviewed for the topic in general without separating the two studies, since both of them concerning the same topic that is the PU data. The first is about recording and utilising the data, and the second about the data itself.

Chapter three delineates the research methods used to collect data for analysis. This chapter organised into two main studies. The methods used in the UK settings and the method used in Jordanian settings, since both methods are different. Mixed methods have been used in the UK part, and prevalence survey used in Jordan. The Justification for each research strategy was explored for both study of the thesis.

Chapter four presenting the results of each part separately, where the UK part results presented into two phases, the QUAN results and the QUAL results. In Jordan, the prevalence survey findings presented in separate part.

Chapter five discussed the main findings in light with the research objectives and the existing literature. Reflection of the theoretical framework on the study findings has been discussed, in addition to the methodological consideration of the study. In this chapter, since the QUAN and QUAL phases of the UK study were answered the same research questions, the discussion of their findings were difficult to separate, so they are discussed in one section, and the prevalence survey in Jordan discussed in a separate section.

Finally, chapter six draws the conclusions that based on both studies together. The unique contribution of this research to knowledge has been set out. The chapter also discusses: the implications of the study’s findings at clinical, administrative and research levels; in addition to the limitations of each study.

Summary

This chapter identified the research problem and objective. The terms that have been used in this research were defined in line with the research aim. The background of PU problem has been clarified in term of size, cost, consequences and complications in order to understand the problem. The need for appropriate recording and using of PU data were highlighted in the research significance section. Moreover, the justification of conducting the research in two separate countries has been explained. The chapter present the context and structure of the thesis as well.

In the next chapter, a critical review of the literature will be offered in order to grant an understanding of the problem about recording and utilising PU data in practice, and all elements of PU data. Furthermore, the gaps present in the literature will be identified.