INTRODUCTION

Canada is a developed country located in the northern part of North America. In 1867, it became a self-governing state while retaining its tie with the British crown. When it comes to economic and technology, Canada is developing in parallel to its neighbour to the south, which is the United State of America. It is a member of the Commonwealth of Nations, with a democratic constitutional monarchy as their form of government. In the past years, Canada’s politics faces the challenges of reaching the population’s demands for quality improvement in education, social services, economic competitiveness and health care.

The health care system in Canada is funded publicly and delivered on a provincial or territorial basis, within a guidelines set by the federal government (Canadian Health Care, 2007). Every Canadian citizens are provided with preventative services and medical treatments from general practitioners at the same time having access to hospitalisation, dental surgery and other medical services. However, in the past few years Canada’s Healthcare System is facing controversy because of it’s soaring costs.

I


NCREASING COST OF UNIVERSAL HEALTH CARE IN CANADA

According to a latest study (Esmail N., Palacios M., 2013), conducted by the Fraser Institute with the title “

The Price of Public Health Care Insurance: 2013 Edition

”, the average Canadian household now pays approximately $7,860 in taxes for ‘health care insurance.’, which is 53.3% higher than of in 2003. Over the past decade the cost of healthcare in Canada doubled and is believe to exceed the $200 billion budget mark.

Canada’s health care costs continue to grow at a faster rate than the government’s revenue, largely driven by spending on prescription drugs. In the last five years, however, growth rates in pharmaceutical spending have been matched by hospital spending and overtaken by physician spending, mainly due to increased provider remuneration (Marchildon G., 2013).

In addition, this trend is also caused by what the health system spends on doctors, which rose by an average of 6.8 % every year. Of that value, 3.6% was caused by the increase in physician’s fees. Other driving factors for the increase in healthcare costs are population growth, aging population and increased health care demand.

Consequently, this rise in Canada’s universal health care costs is said to be the reason why the government has limited ability to provide other services such as education, transportation and pension benefits. Increased health care costs will results into higher labor costs, which might cause companies to hire lesser workers, produce less output, or raise their prices. The high expenditure for health causes the budget for other government programs and priorities be restricted.

EFFECT ON CANADA’S ECONOMY

The abrupt rise in health care costs and insurance can affect several parts of the economy. The rise in health care costs can cause job growth to slow down because it costs companies more money to add new employees. Wage increases have also slowed for current employees, since companies must spend more money on health care premiums. The public sector includes the federal, state and municipal governments. The public sector is dealing with costs rising more than revenues. This places a high degree of examination on discretionary health care spending. Companies are faced with rising health care spending often cut other expenses, such as reducing health care benefits, requiring employees to pay a larger share of their health care benefits, or reducing wage increases.

Furthermore, increasing health care costs can cause Canada’s goods and services to be less competitive in the international markets. If all other factors remain constant, the increasing health care costs will most likely be reflected in final product costs and depending on how rapidly costs rise in other countries; this may result in more expensive goods and services.

IMPACT ON NATIONAL AND INTERNATIONAL HEALTH CARE POLICY

The soaring cost of healthcare is a burden to a country in so many ways. For the community, this increase means that there is less money in their savings and triggering hard choices in balancing food, rent and needed care. For small companies, it will make it harder for them to add new employees, more difficult to maintain coverage for retiree and makes them not competitive globally. The effect of it in the local government is it will lead to higher medicare cost thus reducing funding on other priorities such as infrastructure, public safety and education.

The government’s activities to lessen the burden of high health care cost includes funding and facilitating data gathering and research to regulating prescription drugs and public health while continuing to support the national dimensions of medicare through large funding transfers to the provinces and territories. The governments collaborate through conferences, councils and working groups comprised of ministers and deputy ministers of health. Nongovernmental organizations at both federal and provincial levels influence policy direction and the management of public health care in Canada.

One of the policy is that only physicians are legally allowed to prescribe a full range of pharmaceutical therapies. However, in recent years, a number of provincial governments have changed their laws and regulations in order to permit some providers, including nurse practitioners, pharmacists and dentists, to have limited authority to prescribe pharmaceutical therapies within their respective scopes of practice.

Policy makers should develop funding strategies that will contain the cost of delivering health care and providing economic stimulus to increase provincial and territorial revenues or income, while maintaining the delivery of quality healthcare services to all Canadians.

POLICY INTERVENTION SOLUTIONS

EDUCATION AND TRAINING

In addressing the issue of expensive cost of healthcare, one of the possible solution is the population-wide health education about prevention and any other relevant information about health. The government can launch self-care programmes that would lessen the demand for consultation and hospitalisation. Self -care programmes includes the “patient as the expert” approach, home self-monitoring techniques and the use of latest gadgets and technology such as mobile phones, computers and telemedicines.

In general, these self-care programmes trains and empowers the people to be involved in their own care and be able to manage their own condition. It also includes interventions that imparts knowledge and skills to the people to participate in decision making, to monitor and control the disease and the change in behaviour thus decreasing the chance of seeking expensive medical services.

TAX BENEFITS AND PAYMENT TO CAREGIVER

In Canada’s Economic Action Plan (CEAC, nd), the government is committed to recognised the sacrifies that many citizens exerts to take care of their children, spouses, parents and other family members with health issue. In support of this objective, Budget 2011 introduced a new Family Caregiver Tax Credit to provide tax relief to those who care for an infirm dependent relative .This initiative provides tax relief to those who care for an infirm dependent relative, including, for the first time, spouses, common-law partners and minor children.

Same with direct payments from government, such as agriculture subsidies or social security benefits, tax benefits and payment are given directly to the citizen in exchange of accomplishing a desired behavior. As a result, tax credits permit individual discretion on spending rather than the government dictating spending priorities for each person.

The availability of tax credits is probably most beneficial to people with lower incomes,because low income families often cannot give up a salary to provide full-time care, nor do their jobs offer flexibility that would allow them to mix caretaking and working.

A tax credit for individuals is a simple concentration of funds from the whole economy onto a specific population segment, assuming the tax credit is paid for with general revenues. In this manner the government’s expenditure on universal healthcare is somewhat reduced. In addition to that, there is a lesser need for aged care facility, disability care or hospital care since caregiver can perform home care.

RESPITE CARE

Caring for a disabled or old family member can be challenging, potentially impacting caregivers’ health, mental health, work, social relationships, and quality of life. To alleviate caregiver stress, enable caregivers to better cope with the demands of caring for a loved one, and improve caregiver and care recipient outcomes, many interventions have been developed.

A short-term break for people and their carer/support person is called Respite Support. This short-term break is usually done away from home and overnight. Respite services are equipped to meet the needs of a disabled person while away from home and their usual support, and aim to create a positive experience for the person. Carer Support enables a usual caregiver to take a break from supporting a person by providing an alternative carer.

Moreover, respite care is a vital part of the overall support that families need to keep their family members with a disability or chronic illness at home. Respite care is temporary care to persons with disabilities or special health care needs, including individuals at risk of abuse or neglect, or in crisis situations.

Respite care can be an effective cost-saving measure that Canada’s government can venture more. In US, there is an estimated 50 million family caregivers nationwide that provide at least $375 billion in uncompensated services —an amount almost as high as Medicare spending and more than total spending for Medicaid, including both federal and state contributions and both medical and long-term care ($311 billion in 2005) (Gibson and Hauser, 2008).

BUSINESS REGULATIONS COMBINING WORK AND CAREGIVING

Caregiver can be defined as a person or individual who provides care or assistance to a member of the family in their home or the care recipient’s home who has a mental or physical disability, is chronically ill, old or who is on a palliative care. Caregiving is a difficult task but family members tend to naturally take care of their love ones and resort to medical institutions when the burden is too much. These caregivers might find it hard to balance their work and their family obligation.

The government can addressed this issue by mandating businesses to allow employees to take medical leave to take care of a disabled or sick relatives. After the medical leave, the employee should be restored of the original job or to an equivalent job. By doing this business regulations, there is less demand for health services, nursing homes, disability services thus helping the government saved the cost for healthcare.

REFERENCES

Canadian Health Care (2007), Introduction. Retrieved from:

http://www.canadian-healthcare.org/

Esmail N., Palacios M., (2013), The Price of Public Health Care Insurance: 2013 Edition, Fraser Institute.

Marchildon G. (2013), Health Systems in Transition: Canada Health System Review, University of Regina, Canada.

CEAC, (n.d.), Family Caregiver Tax Credit: Canada’s Economic Action Plan, Retrieved from:

http://actionplan.gc.ca/en/initiative/family-caregiver-tax-credit

Gibson, Hauser (2008), Valuing the Invaluable: A new look at the economic value of family-caregiving, Public Policy Institute, Washington.

Communication is the complex process of sending and receiving verbal information. The communication process plays a very important role in the profession of nursing. Daily the nurses have to deal with a huge number of patients of diverse background. Some belong to educated background and understands thing very well but some are not educated, and for them understanding and communicating with the medical staff is very difficult so it is the responsibility of the nurses to improve their skills to such an extent that communicating with people of all sorts become possible for them. The communication could be verbal or nonverbal like by the use of expressions or jesters etc. The discussion among the nurses and the patients is conducted usually in a very hectic atmosphere; both the patients and nurses are in an urgency as a result of which unwanted issues may arise. The directions are often delivered to the patients on the phones rather than face to face. In the cases of emergency the communication skills gain very high importance as the decision about the procedure has to be made immediately but sometimes the patient nurse interaction is delayed too much as a result of which serious consequences could be faced. In order to avoid the problems in communication some strategies have been discussed in this paper. One technique to attain this objective is by the use of strategies which are being used by other industries and have been very effective like team resource management. It is a training course which has been designed by the aviation business. It emphasizes on combined decision making and team oriented approaches. The most excellent patient care can be provided when the nurses are accessible at all times. By the use of equipments like background-assessment-recommendation (SBAR), it is guaranteed that the delivered messages are very clear and not ambiguous in any kind of stressful situation (Leonard, Graham & Bonacum, 2004). U-nursing is also very effective in improving the patient nurse communication. The SWOT analysis is also given in the proposal. The above mentioned plans could be implemented easily. Some are not time consuming like changing the behavior and attitude of the nurses however some of them needs time like installation of wireless equipments.

If the nurses lack the skills for good communication the above mentioned tasks becomes really difficult to handle. In order to deal with patients who have diverse cultural and ethnic backgrounds and having different levels of knowledge, communication becomes a big challenge to the health care providers. Health care providers especially the nurses have always been very keen to advance the communication skills so that they can progress to better patients care services. In nursing, a heavy amount of information has to be provided and received in a narrow time period. In order to do this perfectly and smoothly the communication settings, history experiences and individual opinion of the people must be considered very deeply. So the communication enhancements mentioned above will prove to be very successful. From this study we have come to know that when you move toward alteration with a patient-centered attitude, the finest decisions are obvious.

Table of Contents

Introduction

Communication means relocation of the information amongst the people. The nursing job involves continuous communication between the patients, their relatives and the nurses. The chances of miscommunication in this profession are very high which can lead to serious consequences. For nurses it is really important that they should be aware of key communicating process and the height to risks and problems that they can come across as a result of miss-communication. It is important to have clear communication with patients especially for those nurses who are involved in collection of patient history. They should be aware of the art of educating the patients giving them the needed emotional help (Munhill, 2007, p.452).

According to a report at Institute of Medicine, it has now been an established fact that secure and trustworthy relationship between a patient and the health care provider (especially nurse) depends upon healthy and good communication (Leonard, Graham & Bonacum, 2004; Viney et al., 2006). Usually the goal of the health care providers is to achieve more in a smaller amount time as a result of which their relations with patients suffer. In this proposal we are going to discuss about how communications between the patients and the nurses can be improved in order to have a healthy and fruitful relationship.

Analysis of change needed

Efficient communication between the patients and health care providers especially nurses is a very important area in the hospital management but it is hampered by different problems. The discussion with the patients is conducted usually in a very busy environment; both the patients and nurses are in a hurry as a result of which undesirable issues are raised. Communication with the patients is mostly carried out through answering machines instead of having a direct interaction. According to the leadership theory as presented by Fred Fiedler suggests that “effective group performance depended upon the proper match between a leader’s style of interacting with his or her followers and the degree to which situation allowed the leader to control and influence” (Robbins & Coulter, 2008, p. 493). It is often argued that in a hospital setting, in-charge nurse is often lacking required competencies in relation to communicating with patients that represent a barrier in efficient leadership. One of the prime reasons being their promotion from the clinical nurse thus they are apt at dealing with medical issues but ill equipped to be regarded as a good communicator with patients (Connelly et al., 2003, p.298). Their relationship should be “relationship oriented” instead of focusing solely on routine tasks.

Similarly “path-goal theory” as devised by Robert House also favours leader role to be more supportive, providing direction to relevant others (Robbins & Coulter, 2008, p.498). A study conducted in United States of America concluded that 90% of the faults in patient analysis result from poor communication between the patients and the health care providers. Different sort of parameters like lack of sleep or proper rest, long duty hours, other part time jobs, personal issues or family concerns may have serious effects on the ability of nurses to interact with the patients. Therefore the present challenge is to develop an environment which is comfortable for nurses so that they can easily perform their job.

One method to achieve this goal is by applying the strategies which have been adapted by industries working beyond provision of medical aid. Team resource management as constructed by aviation department could also bring desired outcomes. The strategy helps to direct all efforts towards equal participation in decision making, leading a team focused behavioral approach.

The best patient care can be provided when the nurses are can be easily contacted in case of any issue during patient’s stay at the hospital. By using different electronic gadgets like situation-background-assessment-recommendation (SBAR), such methods help to convey lucid messages between both nurses and patients to overcome the challenging situation (Leonard, Graham & Bonacum, 2004). It is stated that many nurses save around 20 to 40 minutes every day if they have immediate contact with the specialists. Most of the hospitals of the Unites States still use the old weird telephone systems which not only waste time but also may lead to miscommunication. A new communication technology like that of ‘Dalcon Alert’can provide a solution to this problem. It is a wireless technology and by the use of it the patients, nurses, staff and the physicians can stay in contact with each other all the time, while even on move. A study showed that 70 to 80 percent of time could be saved each day by the use of this technology. The technology also provides direct alerts to the nurses on their devices (Kohn, Corrigan & Donaldson, 2000). Another method is to employ the U-Nursing technique. By U – Nursing we mean that the nurses are available to all the organizations and institutes at all the time by using the facilities from information technology. The SWOT analysis about this nursing technique is given below (Murray, 2007, p.32).

SWOT Analysis:

Strengths:

User friendly and Less time consuming

Expert advice avail all the time

Infrastructure is very safe and secure

International quality standards maintained

Enhance the communication between the patients and the nurses

Weaknesses:

The setup costs are very high

Nurses are not yet very much trained to use this system

Lack of support and backup infrastructure

Opportunities:

Research studies will be facilitated

Technology development in nursing profession

If goes successful , could be applied to all the hospitals and has just one time setup costs

Holistic and Humanized

Threats:

System breakdowns by attack of viruses leading to data loss

High dependency on the information technology

Intellectual proprietary issues

Be short of leadership in nursing

Misuse of personal information of patients and loss of privacy

Ignorant patients may be misguided

Plan of Action

The plan of action for the above mentioned analysis is as follows:

First the working hours of the nurses would be discussed and adjusted accordingly so that they can work attentively and efficiently and this will be done immediately. The salary structure would be revised so that there would be no need for part time jobs.

Recognize any hindrances which may hamper the communication like can the patient converse in English easily or not? If not the nurse should arrange for an interpreter. If the hearing ability of the patient is not well, hearing aid should be provided.

Training courses for the nurses would be arranged regarding communication skills so that they can improve their communication with the patients and the physicians.

Infrastructure for the U-Nursing plan would be arranged. For this purpose letters would be written to higher authorities at the hospital or even the government level if required so that the funds could be provided. Once the approval is received for such plan then nurses would be trained for the use of such facilities.

In hospital equipment would be updated like the use of wireless technologies to be implemented so that the wastage of time could be prevented. The patients would be able to communicate with the nurses through wireless gadgets at all the times so that emergency situations can be dealt with ease and efficiency.

Evaluation strategy

The real time monitoring strategies about these new things will be applied. The amendment trials are fruitful when they are structured keeping in view the present situation and are visible with healthy results. They are made on the existing method of doing things, are visible and have positive outcomes (Greenhalgh et al., 2004; Rye & Kimberly, 2007). The study would be evaluated by noticing the change in the general attitude of nurses, their change in appearance and social dealings. The qualitative and quantitative data will be used. For the qualitative data general observations will be done on the communication changes between nurses and the patients and for the qualitative data questionnaires will be given to the patients and they will be asked about the improvement in the communication skills of the nurses. They will be asked about the benefits or demerits of the use of wireless technology implemented in the hospital. If the patients provide us with the positive feedback this will mean the change is a success.

Conclusion

The immediate problem and challenge in the health care industry is to manage and develop an environment which provides effective and transparent communication system between the patients and the health care workers especially nurses as they are the most frequent ones to come across with the patients. It is anticipated that the above mentioned changes will bring a positive and healthy change in the hospital environment and the communication skills of the nurses will be improved. Especially when the nurses will be trained accordingly the patients would definitely feel a positive change in the hospitals. It is wisely said that half of the illness of the patient is cleared out immediately when he is treated nicely by the health care provider.

The purpose of this study is to give a critical analysis of the Literature, and briefly enumerate the causes, treatment, prevention and the risk factors of Pressure Ulcers (PUs). The process leading to pressure ulcer formation and early detection of individuals who are at risk of developing it for prompt prevention are paramount in this study.

Methods: The methods adopted in this dissertation involved various strategies: selecting a review topic and searching the literatures to be used. Gathering, reading and analysing the literatures. It also involved critical examination of the various causes, treatment and preventive measures.

Furthermore, it is also intended to find out the various risk factors that could lead to its emergence. On this basis, a number of research articles was examined after which their literatures were critically analysed All the literature searches were undertaken online with the aid of computer and electronic databases. Computer databases are used because they offer access to varieties of information, which could not be obtained manually.

Findings and Conclusions: This study went further to find out the effect of age and nutrition on the persistence and spread of presure ulcer. Finally, having given a critical analysis of the literatures, it summarised the findings as well as the various ways to curtail the emergence as well as improving the wellbeing of the patients with essential pressure ulcer, ie, those who by reason of underlying health conditions such as diabetes and catheterized individuals, people with profound learning disability, who could not avoid staying in one position for too long.

CHAPTER ONE

INTRODUCTION

The impact of pressure ulcers on the quality of life of the people with learning disability cannot be overemphasised, as it can be devastating (Spilsbury et al. 2007; MEP Ltd, 2009; NHS for Scotland, 2009).

A pressure ulcer (PU) otherwise known as pressure sore, pressure damage, pressure injuries or bed sore (Spilsbury et al. 2007), is an area of the skin that has become abraded gradually due to a reduction or cessation of blood flowing through that part of the body. It is mainly as a result of continuous maintenance of same position when sitting or lying down for a long period of time, (RCN, 2005). It can also be described as a localised abrasion on the skin or the underlying tissue, in most cases over a bony prominence, due to the pressure or pressure in combination with deformation of the site; this can also be caused by friction. Based on the degree of damage, it can further be defined as partial-thickness of skin loss involving epidermis or dermis; mainly affecting the surface manifesting as a scratch, fluid-filled elevation of the skin or simply as a swollen crater (Lyder, 2010 & Guy, 2012). Furthermore, Pressure ulcer in some other cases can present as an erythematic or abnormal redness of the skin due to dilation of the blood vessels in the skin. (www.merckmanuals.com/home/heart_and_blood_vessel_disorders.html).

The reddened area remains as such for longer than 30 minutes after pressure is relieved (Barbanel, and Hagisawa, 2001).

In view of the fact that Pressure ulcer has been widely noted to reduce the quality of life in people with learning disability (Dorner et al, 2009), this topic is very important and relevant to a very large extent for Nurses and other carers involved with the treatment and management of PUs in individuals having learning disability.

Among the many reasons for choosing this particular topic are as follows: Having established that pressure ulcers are a major cause of morbidity, mortality and healthcare burden globally and that many of the cases are avoidable (Whittington et al, 2004); it follows that solutions need to be sought aimed at reducing it, if its prevalence.

Looking at PUs from the perspectives of treatment and management, it has been observed that both treatment and management are capital intensive, but it is also preventable (Soban et al; White-Chu, 2011). It is very important to concentrate more efforts at minimising the occurrence of PUs, rather than wasting resources on treatment, which might be counterproductive, especially in diabetic patients (European Pressure Ulcer Advisory Panel [EPUAP], 2005).

Pressure ulcers pose grave consequences on the wellbeing of people with profound learning disability, be that as it may, its treatment, prevention and management is a major priority within the clinical and policy agenda. It is very important that patients are educated on the impact of PUs on health and quality of life, at the same time; it is their right to make informed decision about their care and treatment in conjunction with the healthcare provider (Spilsbury et al, 2007; NICE clinical guideline, 2005).

In addition, the data generated could be used to estimate the total number of cases with PUs within a particular population (i.e. prevalence) and the rate at which new Pressure Ulcers are occurring in people in needing medical care. (Clark, 2007).

(Plaum et al, 2006), in their questionnaire research on Pressure ulcer discovered that it was possible for patients to have a combination of deficiency of sensory experience as well as memory loss. The above combination of health challenges tended to increase the probability of having PUs (Plaum et al, 2006).

This study will therefore discuss common risk factors for developing pressure ulcers in people with learning disability, its prevention and management (Guy H, 2012, Vanderwee et al, 2007).

This study will also find out effect on age, and nutrition on the persistence and spread of pressure ulcer. The findings will summarise the various ways to curtail the emergence as well as the ways to improve the wellbeing of the patients with pressure sores. According to the International guidelines on Pressure ulcer prevention, prevalence and Incidence (MEP Ltd, 2009: page 8); “the results of PUs prevalence and incidence studies could be used for enlightenment purposes, to reduce PUs occurrence, and therefore improve clinical practice”. It is very important to understand the consequences and pitfalls of the prevalence and incidence of PUs.

Lastly, it is essential for all healthcare practitioners, managers, payers and financiers involved in the development, implementation and assessment of PU prevention protocols (Fletcher et al, 2011).

The overall aim of this study a strategy geared towards the reduction of PUs as well as reducing the number of patients who have it. The need for identification and production of new antimicrobial agents that are selectively toxic, that is; being able to destroy the causative agent with little side effect on the host and broadly effective with a low propensity to induce resistance is very crucial (Bowler et al, 2001).

According to (Bowler et al, 2001); while it is true that microorganisms are known to be responsible for wound infections, there are widespread controversies relating to the exact mechanisms by which the microbes cause infection and also their significance in non-healing wounds that fail to exhibit clinical manifestation. (Robson, 1999); observed that the mass per unit volume of microorganisms is a critical factor in determining the probability of the wound healing. However, (Pallua et al, 1999) argued the fact that certain virulent microorganisms were isolated is evidential in delayed wound healing.

Nevertheless, others have reported that microorganisms “per se” play little or no role in wound healing or slow healing. (EWMA MEP Ltd, 2005), stated that; not all wounds become infected, being that, the susceptibility or resistivity of the host determines the chance of such a wound eventually becoming infected by bacterial pathogen. Although the role of Microbiology laboratory is incontrovertible, the necessity of carrying out wound culture and sensitivity testing must be critically considered in order to save in cost, labour, and avoid unnecessary disturbance to the patient, (Bowler et al 2001).

1.3 Mode of treatment: since pressure ulcer (PU) is a debilitating chronic wound that affects mostly individuals who are incapacitated as a result of age or an underlying illness (Lyder, 2003), or people with profound learning disability who spent longer time on a particular position, its treatment typically involves multiple treatment procedures simultaneously; such as support surface and dressings. Nutritional supplements are essential; since most individuals with learning disability have been known to have diet problems (Dorner et al, 2009). At successive stages of the treatment, different treatments are applied (Lyder, 2003).

CHAPTER TWO

METHODS

The methods adopted in this dissertation involved various strategies: Selecting a review topic and searching the literatures to be used. Gathering reading materials and analysing the literature followed by the review of references.

Having selected the topic the next step was identification of the appropriate and related information. This method was in agreement with (Hek and Langton 2000). In their study, they discovered and applied a particular orderly approach which was sequential and capable of generating reliable and beneficial information unlike the traditional review.

All the literature searches were undertaken online with the aid of computer and electronic databases. The reason for using computer databases is that they offer access to varieties of information, which cannot be obtained manually and sometimes quite recent. Keyword searches were the most common method of identifying literature (Ely and Scott, 2007). However, keywords which have to do with the review/assessment and management of pressure ulcers were used.

Databases of particular relevance to the selected topic, which are very useful for Nurses (Parahoo, 2006), aided the search for related journals which included: British Nursing Index Nursing Journals in English Language

CINAHL (Cumulative Index of Nursing and Allied Health Literature) and related publications. This according to (Polit and Beck, 2006), offers an important, reliable and up-to-date electronic databases for Nurses and other healthcare professionals. More importantly, CINAHL databases offer both staff and student Nurses the most recent and best available evidence-based clinical practice.

Medical Subject Headings or subject headings:

Pubmed/MEDLINE

Google scholar

The essence of using numerous databases was to harvest a large catalogue of research materials including those directly linked to the field of learning disability practice:

Journal of Learning Disabilities

Journal of Intellectual Disabilities.

Journals of wound care and management.

Generally, Journals are much more up-to-date than books which were probably written decades ago since information is dynamic and prone to changes. Therefore, maximum period of 10 years was placed on the age of the works and journals that were used in this work except in some rear cases where no recent materials were found in relation to the subject matter. The search strategy sought to identify all published and unpublished research investigating patient reports about the impact of PUs and PU interventions on HRQL. Data extraction involved the reading through each of the published articles and identifying their findings in the form of statements by the author supported by patient reported data, the extracted patient reported data produced (Gorecki et al 2009). Moreover, specialist Journals were also hand-searched.

The internet played a crucial role for web sites on pressure ulcer publications, as well as books from my local area and the university library.

Eligibility: Both exclusion and inclusion criteria were used for the primary and final selection for reporting the impact of PUs and interventions respectively on Health related quality of life (HRQL), including symptoms and patient evaluation of interventions. (Gorecki et al 2009).

Concept of Causation and common Epidemiological study designs.

Name: Confucius Aligo Allison Amba

Objective of this paper is to explain the concept of ‘Causation’ and explain of some common epidemiological study designs

Causation Definition

Causation is defined as the capability of one variable to influence another. The first variable may bring the second into existence or may cause the incidence of the second variable to fluctuate. “Causality is a genetic connection of phenomena through which one thing (the cause) under certain conditions gives rise to, causes something else (the effect)” (Alexander 1983)

¹

The concept of causation was first described by Plato he stated that “everything that becomes or changes must do so owing to some cause, for nothing can come to be without a cause” (Menno)

²

. The stoics stated that “cause is linked both to an exceptionless regularity and to necessity. They strictly hold to the view that each event has a cause” (Menno). A cause of disease is “an event, condition, characteristics or combination of these factors which plays an important role in producing the disease” (JLI Video Lecture note – 3

^rd

Lesson of Epidemiology).

Common Epidemiological study designs

The word epidemiology comes from the Greek word “epi, meaning on or upon, demos, meaning people, and logos, meaning study of”

³

the Epidemiology is the “study of the distribution of disease and determinants of health-related states or events in specified human population and the application of this study to the control of human health problem”(CDC)

³

. Epidemiology is “data-driven and relies on a systematic and unbiased approach to the collection, analysis and interpretation of data. It also draws on methods from other scientific fields including biostatistics and informatics, with biologic, economic, social and behavioral sciences” (CDC).

Epidemiological studies are conducted using human population to determine causal relation between factors that and individual or population is expose to and the health effect of the exposure. The epidemiological studies designs can be classified either as

observational or experimental

. (JLI Video Lecture note – 3

^rd

Lesson of Epidemiology).

Experimental study designs

Experimental studies can be randomized controlled, non-randomized control, field trail studies and community trials.

• 
  Randomized controlled trail (RCT),
  
  alternative name
  
  clinical trials
  
  (JLI lecture note – 3
  
  ^rd
  
  Lesson of Epidemiology) in this study “people are allocated at random to receive one of several clinical interventions”
  
  ⁴
  
  one of the group is a control which may be given a placebo or no intervention. This study is “quantitative, comparative, controlled experiments in which investigators study two or more interventions in a series of individuals who receive them in random order. The RCT is one of the simplest and most powerful tools in clinical research” (MedicineNet.com). This study is termed as “gold standard” (
  
  http://www.bmj.com/content/348/bmj.g4115
  
  ) that determines the effectiveness of treatment.

• 
  Non-randomized controlled trails
  
  this is a study in which is assigned to an intervention alternate and not random. Participants may be volunteers who accept to participate in the study.

• 
  Field trials
  
  are study design where the intervention strategies are assigned to healthy individuals within the community.

• 
  Community trials
  
  alternative name community interventions studies (JLI Video Lecture note – 3
  
  ^rd
  
  Lesson of Epidemiology) are mostly preventive; interventions are assigned to all community members in the study area. The advantages include easier changing the community social environment; interventions are tested in actual natural conditions and cheaper (Omar 2006)
  
  ⁵
  

Observational study designs

Observational studies can be either

descriptive or analytic studies

. Observational studies allows nature to take place; “the investigator measures but does not intervene”. (JLI Video Lecture note – 3

^rd

Lesson of Epidemiology).

Descriptive studies

Descriptive studies are studies that are design to describe occurrence of disease by time, place and person, while analytic studies are studies designed to examine etiology and causal association. “A descriptive study is limited to a description of the occurrence of a disease in a population and is often the first step in an epidemiological investigation”. (JLI Video Lecture note – 3

^rd

Lesson of Epidemiology).

Descriptive epidemiological study design describes the occurrence of disease or the determinants within a population. Descriptive epidemiological study generates hypothesis and answer the questions WHAT, WHO, WHERE & WHEN? The WHO refers to person and characteristic such as (age, sex, occupation), WHERE refers to place that is location (residence, work or hospital). WHEN refers to time (includes diagnosis, test and reporting), descriptive studies can be “geographical or ecological also known as ecological correlational studies examine population, can be used to demonstrate patterns of disease and associated factors in a population and unit of study are populations or groups”

⁶

. The advantage of ecological studies include use of routine collected health statistics, cheap and simple to conduct, generate hypothesis to examine at individual level; and the disadvantages includes lack of available data on confounding factors, difference between areas in measurement of exposure and difference in recording disease frequency (healthknowldge.org.uk, David AG., Kenneth FS., 2002

⁷

). The other major type of descriptive study is individual study “

individuals studies

are case reports, case-series report, cross-sectional studies and surveillance” (David AG., Kenneth FS., 2002).

Case-series report

this combine individual medicine information in one report or “appearance of several similar cases in a short period heralds an epidemic” (David AG., Kenneth FS., 2002).

Case report

this is an observation reported by a clinician. This mean lead to case-control studies to determine the association of the outcome to the exposure for example long term use of specific medication (David AG., Kenneth FS., 2002)

Cross-sectional studies

this is also referred to as prevalence study and is used to describe the health of a population, this can be study in small population with particular exposure for example employee in a factory (David AG., Kenneth FS., 2002)

Surveillance study

this can be done as active or passive ongoing collection, analysis and interpretation of health data. In order to determine control and preventive measure to any identified health condition (David AG., Kenneth FS., 2002).

Ecological study

also called co-relational studies “the unit of analysis is population or groups of people rather than individuals” (JLI Video Lecture note – 3

^rd

Lesson of Epidemiology). This study “look for associations between exposures and outcomes in population” (David AG., Kenneth FS., 2002). This type of study is simple to conduct, interpretation is often difficult and it’s difficult to link individual to exposure and effect. (JLI Video Lecture note – 3

^rd

Lesson of Epidemiology).

Analytical study design

Analytical epidemiological study design aims to gain understanding on the quality and the impact of the diseases determinants on the occurrence of disease. Analytical studies can cohort study, case control study and cross-sectional study

• 
  Cohort Study
  
  is the study that identify individuals based on their exposure status, this study consider two group of people expose and non- exposed in order to follow the disease outcome whether disease or non-disease, the “study participant are followed overtime-form weeks to years; and the study group share characteristics for example in birth cohort”
  
  ⁸
  
  . The advantage of this study include estimation of the risk, can look at multiple outcomes, can investigate the potential natural history of disease and the disadvantages include requires large population, not suitable for rare outcome or exposure, expensive and time consuming.

• 
  Case Control Study
  
  are retrospective they normal look back. In this study the cases have the condition and the controls are not, its looks back to identify the risk factors associate with the disease. in this study “the prevalence of exposure to a potential risk factor (s) is compared between cases and controls”
  
  ⁶
  

• 
  Cross-Sectional Study
  
  this study is used to determine the “prevalence of the outcome of interest for a given population”
  
  ⁹
  
  . This studies can assess multiple out come and risk factors, useful for public health planning and disease etiology, takes little time and not expensive, can estimate prevalence of outcome of interest. With this study prevalence-incidence bias may occur and difficult to make causal inference (Kate 2006).

• 
  Occupational epidemiological study
  
  this study designed select working people with particular jobs or exposure as the subjects for the study. Workers have high exposure to certain risk factors than the usual population, due to their risk exposure the probability of finding and effect is high if any true effects exist. However, the outcome of this study many not be generalized to the overall population and even worker with may have different risk from each other.

References

1. Alexander Spirkin (1983) Dialectical Materialism © 1983 by Progress Publishers available at
   
   https://www.marxists.org/reference/archive/spirkin/works/dialectical-materialism/intro01.html
   
   accessed on 2015/06/17
2. Menno Hulswit A Short History of Causation University of Nijmegen, The Netherlands available at
   
   http://see.library.utoronto.ca/SEED/Vol4-3/Hulswit.htm
   
   accessed on 2015/06/17
3. Centre for Disease Control and Prevention Principles of Epidemiology in Public Health Practice, Third Edition An Introduction to Applied Epidemiology and Biostatistics CDC 24/7: Saving Lives, Protecting People available at
   
   http://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section1.html
   
4. MedicineNet.com Definition of Randomized controlled trail available at
   
   http://www.medicinenet.com/script/main/art.asp?articlekey=39532
   
   access on 2015/06/16
5. Omar Kasule Islamic Medical Education Resources -04 0611-Randomized Design: Community Trials synopsis of lecture for MPH candidates at university Malaya on Friday November 3, 2006 available at
   
   http://omarkasule-04.tripod.com/id1033.html
   
6. Health Knowledge Education, CPD and Revalidation from Phast Introduction to study designs 1a – Epidemiology available at
   
   http://www.healthknowledge.org.uk/public-health-textbook/research-methods/1a-epidemiology
   
7. David AG.; and Kenneth FS (2002). Descriptive Studies: what they can and cannot do Epidemiological Series Lancet 2002; 359:145-49 available at
   
   http://www.m-publichealth.med.uni-muenchen.de/download/mph/mph_wintersemester_2012_2013/epidemiologie/epigrimesdescriptive.pdf
   
   accessed on 2015/06/18.
8. Institute for work & Health Research Excellence Advancing Employee health what researchers mean by — cohort study available at
   
   http://www.iwh.on.ca/wrmb/cohort-study accessed on 2015/06/16
   
9. Kate Ann Levin Study design III: Cross-sectional studies Evidence-Based Dentistry (2006) Dental Health Service Research Unit, University of Dundee, Scotland, UK. 7, 24-25.Doi:10.1038/sj.ebd.6400375 available at
   
   http://www.nature.com/ebd/journal/v7/n1/full/6400375a.html accessed on 2015/06/16