Abstract

Background
Pressure ulcers, (also known as pressure damage) are a debilitating, chronic wound condition representing a significant health and treatment burden. Associated with continuous pain (Brigs et al., 2013), distressing symptoms and impaired psychological and social functioning (Gorecki et al., 2013), reducing the quality of life for patients and their carers (Rees et al., 2001). The use of a validated pressure ulcer risk assessment tool for prevention assessment and management of PU is National Institute for Clinical Excellence (NICE) recommendation (NICE, 2015).

Rationale
Review of pressure damage assessment, prevention and management strategies, within an Community Health Services NHS Trust, identified themes requiring transformation to meet ever more complex clinical needs of patients and the elimination of all avoidable pressure damage within its care.

Method
A sequentially staged, service evaluation, implementing a new and innovative approach to pressure damage risk assessment, prevention and management strategies was undertaken. In Stage-One, a purpose designed questionnaire assessed clinician’s perspectives surrounding current pressure damage assessment, prevention, and care management strategies. Stage-Two implemented the innovation and the Trust, became early adopters of Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE-T; 2013). In Stage-Three, PURPOSE-T was implemented during March 2016 for a four-week pilot period and nurse’s perceptions surrounding implementation of PURPOSE-T were obtained via a focus group.

Results
Thematic analysis (TA; Braun & Clarke, 2006) of Stage-One survey identified three key themes in the way clinician's made sense of pressure damage prevention, management and care management strategies; Confidence in Tool Supporting Clinical Decision Making, Defensively Nursing and Usability. The findings suggest, clinicians are dichotomised toward considerations of using Waterlow in their daily practice. Some, considered Waterlow a useful, but flawed tool. A larger group of narratives however, strongly voiced Waterlow inadequacy supporting clinical decision making. Confusion surrounding interpretation of ‘grey areas’ (Waterlow, 2005) or ambiguously interpretable risk factor identifiers were widely perceived as problematic, these narratives revealed deep frustration, lack of confidence and professional disempowerment, which were perceived as stemming from use of Waterlow. Clinicians also perceived use of Waterlow to have evolved into one of constrained dictation, rather than part of an assessment process. This was strongly voiced surrounding perceptions of a propensity for Waterlow to over predict risk and trigger inappropriate allocation of resources and clinical facing time. This seemingly had influencing a working culture where clinical judgement is (for some) overruled by Waterlow score outcome, resulting in a move toward a ‘nursing by numbers’ care approach. Suggesting the Trust may be wasting resources on more expensive forms of PU management than necessary. As such, many narratives directly requested Waterlow replacement.

In Stage-Two, PURPOSE-T was successfully integrated into SystmOne and effectively incorporated into clinical routine during the four-week pilot period. In Stage-Three Clinician satisfaction and support for PURPOSE-T, was strongly favourable. Focus group TA (Braun & Clarke, 2006), identified three themes surrounding implementation of PURPOSE-T: Comprehensiveness of Assessment, Improved Clinical Confidence and Acceptability. The screening stage was considered an important feature for improving patient care, improving allocation of resources and potentially saving the Trust costs through an improved PU risk identification. Risk factor descriptors were felt to be clear and unambiguous and improve risk factor interpretation. This resulted in clinicians perceiving there to be potential for greater consistency of risk factor identification between clinicians. PURPOSE-T was also considered as supporting well supporting clinicians to act in accordance with an own professional knowledgebase, rather than as response to an assessment score outcome. Difficulties were however, encountered with the colour coded assessment pathway guidance being functionally limited within SystmOne and usability concerns arose from a changed risk assessment format and process. Usability concerns were subsequently addressed and refined within the educational package developed to support implementation of PURPOSE-T.

Overall, PURPOSE-T was considered as encouraging a more thoughtful, approach to assessment, prevention and management of PU and improving congruency between clinical judgement and care pathway allocation.