the Study setting

This study was conducted at a university hospital located in Irbid, the largest city in the north of The Hashemite Kingdom of Jordan (HKJ), and the second largest city in the whole Kingdom (DOS, 2011). The location allows the hospital to provide primary, secondary and tertiary health care services to more than 1 million inhabitants of Irbid and three other governorates in particular, and to the wider Jordanian population in general.

It is a specialised referral medical centre with 683 beds in several wards, a number which can be expanded to 800 in emergency situations. Usually, it receives advanced cases that cannot be treated at other nearby hospitals, or which would need specialist therapeutic and diagnostic procedures (KAUH, 2011).

This university affiliated hospital contains one Paediatric Intensive Care Unit (PICU) with 12 beds for children aged from 1 month up to 14 years old, which treats medical, surgical and cardiac intensive cases. It also contains one General Intensive Care Unit (GICU) with 12 beds for children aged from 14 up to 18 years old, one General Intermediate Care Unit (GIMU) with 10 beds for neurosurgical patients) which both admit children, and finally one Neonatal Intensive Care Unit (NICU), which include 24 beds, for babies from birth up to 1 month old (KAUH, 2011).

For this research work, the hospital was chosen conveniently, however, many reasons could justify that. This hospital is the largest in the north, and has many specialist paediatric units, including a neonatal ICU, paediatric and general ICUs, medical and surgical paediatric wards including orthopaedic and oncology wards, cardiac and neurosurgical ICUs and intermediate care units.

The nature of the incidence study and the need to collect risk factors, in addition to the description of the risk assessment scales, necessitated choosing a hospital which

98

contained as many critical care wards as possible which could be included in the study, so as to attain a larger sample size and thus generate more reliable data.

The use of the computerised record system (MEDICOM) greatly assisted in establishing and recording much of the required data. The system eased the researcher’s access to each child’s current and previous medical records, laboratory test results, and some demographical characteristics throughout the study period.

This study was carried out in one hospital only because it was necessary that the children who took part were assessed frequently, and, due to the absence of an assessment team, the researcher would not have been able to assess children in two different locations. The choice to work individually without the support of a team or other nurses was made for the following reasons:

- It was important to gather reliable data and, if assessments were being performed by a number of different nurses or investigators, the data may not be comparable. Also, the subjective grading of PUs may affect the reliability of the findings.

- There is a lack of information regarding PU in children among Jordanian nurses since pressure ulcers are still thought to be an adult only problem. The researcher needed to establish baseline data to convince Jordanian health care personnel that PU exists in paediatrics, before any training or teaching sessions could be held.

- Because it is a phenomenon which has only recently been brought to light in Jordan, nurses lacked the motivation to participate in collecting data regarding PUs, especially ICU nurses who preferred to spend their time and effort focusing on what they deemed to be more serious physiological issues, such as airway clearance, respiratory support and so on.

- There was a lack of time and resources available to conduct training sessions for the nurses or researchers who would have been required.

99

In addition to the reasons already given, no previous study regarding paediatric PU prevalence and incidence had ever been conducted in Jordan which meant that any large, representative hospital would have been suitable for the study.

3.4.1 Jordan and its healthcare system

Before detailing further the dimensions of the research sample and procedures, a brief description of the country where the research was conducted is provided.

Jordan is a small country located in the Middle East; its formal name is the Hashemite Kingdom of Jordan. Excluding the coastal border on the Aqaba Gulf, land borders Jordan in all directions (Figure 3.1). Neighbouring countries are Iraq, Syria, Palestine and Saudi Arabia, with which Jordan shares its longest border. The total area is 92.300 km², of which land makes up 99.6% (91.971 km²), and the remaining 329 km² is represented by the Aqaba Gulf and the Dead Sea, which is the lowest point on Earth (Central Intelligence Agency (CIA), 2009).

The last estimation made by the department of statistics (DOS) revealed that the total population was 6,181,000 (DOS, 2011). Islam is the official religion of the country and Arabic is the official language, but English is widely used in certain sectors, such as trade, education, health, and government and banking.

 The healthcare system:

The Jordanian healthcare system is one of the leaders in the region, and has a good reputation in the Middle East (Library of Congress, 2006). According to the Ministry of Health (MOH) in Jordan, the government spent about 7.2% of gross domestic product (GDP) in 2008 on healthcare (MOH, 2008), which is close to the international average of 9.3% (Library of Congress, 2006).

The total number of hospitals, either public or private, in Jordan is 103. The public sector has three divisions. The first is the Ministry of Health (MOH), which runs 30 hospitals comprising 38.7% of the total number of Jordanian hospital beds. The second is the military’s Royal Medical Services which operates 11 hospitals, and represents 19% of the total number of beds, while the third is made up of two university affiliated

100

hospitals, which manage 9.2% of Jordanian hospital beds. In addition, the private sector runs 60 hospitals, which contain 33.1% of the total number of beds (MOH, 2008).

Figure 3.1: Jordan Map