Abstract

Introduction
The pressure ulcer risk assessment tool plays a pivotal role guiding a patient’s care pathway and quality of care [1]. Especially when considering, clinicians’ actions not only impact patient treatment, they profoundly influence patterns of care and allocation of resources [2]. Therefore, assessment tools need to produce the same or similar results i.e. aresensitivity accurate when different clinicians assess the same patient [3] and direct preventative and management resources appropriately.

To meet the ever more complex clinical needs of patients, and the challenge of the zero pressure ulcer agenda [4], evaluation of the Trusts clinical, assessment, prevention and management strategies was undertaken. Using a qualitative human-factor focused approach, clinical practices associated with the Waterlow Pressure Ulcer Risk Assessment Tool [5] were explored.

Method
A purpose-designed questionnaire, hosted using an online survey administrator, was developed specifically for the evaluation. Experiences of Using the Waterlow Pressure Ulcer Risk Assessment Tool Questionnaire (EUWT-Q), comprised nine open and closed questions and invited free expression. Questions aimed to capture experiences and perceptions of clinical practice surrounding Waterlow use. A panel of Expert Healthcare Professionals employed within the Trust reviewed and piloted the EUWT-Q.

A purposive sample of 79 community care clinicians employed across the Trust in varying roles, and users of Waterlow within daily clinical practice, were contacted to take part in the evaluation. Data analysis adhered principles of a six-phase recursive thematic analysis [6] with the themes developed strongly linked to language, concepts, and relationships of meaning.

Results
Of the 79 clinicians contacted, 59 completed the EUWT-Q (response rate 74%). Predominantly, respondents were Community Nurses 64% (n=38) and experienced using Waterlow, with 42% (n=25) having more than 15-years’ experience.

Two interrelated key themes emerged: Decision-Making Confidence and Defensively Nursing. Which, to a large extent, overlap and when considered together, comprehensively reflect experiences and perceptions of clinical practice surrounding Waterlow use.

Decision-Making Confidence
Seemingly, clinician's feel little confidence that Waterlow adequately supports clinical decision-making. For some Waterlow was considered useful and “…positive for identifying the potential risk” (CN0560). However, sensitivity accuracy was criticised, and a stronger picture surrounding completion difficulties emerged. Confusion surrounding interpretation of ‘grey area’s’ [8] or ambiguously interpretable risk factors were widely perceived as problematic. As a result, clinicians had lost decision-making confidence and sought peer support surrounding interpretation of risk factors.

Clinicians also perceived the use of Waterlow to have evolved into one of constrained dictation, rather than part of an assessment process. Particularly surrounding, perceptions of a propensity for Waterlow, to over predict risk and trigger inappropriate or unnecessary equipment prescription. In turn, this impacted and influenced the socio-political working culture, eroding clinical decision-making confidence, and creating barriers surrounding the freedom/autonomy to act in accordance with one’s professional knowledgebase. Thus, established patterns of defensive nursing.

Defensively Nursing
Clinician’s narratives exposed incongruence between professional philosophy’s and actions. This revealed frustration, with the development of diminished confidence and professional disempowerment surrounding use of Waterlow.

A fearful, consciously led, move toward defensive, care strategies, where, "clinicians focus on the score rather than the needs of the patient" (NS1112) rather than, foremost, in the interest of the patient, had seemingly developed as a self-protective response to Trust imposed ramifications, should patients develop pressure ulcers. As such, a perception of pressure to prescribe pressure relieving equipment had developed. Therefore, more, and higher-grade equipment was being prescribed even when contradicting clinical judgement. Clinicians were aware their clinical strategies were counterintuitive and directly linked to defensive nursing. As such, there were outright requests to "please replace it as soon as possible" (NS1558).

It seems counter-intuitive that a defensive nursing strategy built on risk overestimation and over prescription of pressure relieving equipment has not resulted in the elimination of avoidable pressure ulcers. The solution to eradicating avoidable pressure ulcers is, therefore, more complex than one of more pressure preventative equipment. From an economic perspective, a propensity for risk over-prediction with some patients is a serious and expensive limitation. Particularly considering the working practices that have developed.

Conclusion
Findings indicate that clinicians do perceive the use of Waterlow as assisting identification of risk factors. However, the use of Waterlow has seemingly influenced costly working practices. Costly in terms of diminishing workforce confidence, and costly in terms of the funds potentially being allocated to forms of pressure ulcer management that are not necessarily appropriate at the time of prescription. As such, the findings are strongly relevant to clinical practice, highlighting there is potential for cost savings through improved allocation of resources and providing evidence to support quality improvement innovation.