Community nurses’ judgement for the management of venous leg ulceration: A judgement analysis

Abstract

BackgroundNurses caring for the large numbers of people with leg ulceration play a key role in promoting quality in health via their diagnostic and treatment clinical judgements. In the UK, audit evidence suggests that the quality of these judgements is often sub optimal. Misdiagnosis and incorrect treatment choices are likely to affect healing rates, patients’ quality of life, patient safety and healthcare costs. ObjectivesTo explore the diagnostic judgements and treatment choices of UK community nurses managing venous leg ulceration. DesignA judgement analysis based on Brunswik's psychological Lens Model theory. SettingUK community and primary care nursing services. Participants18 community generalist nurses working in district (home) nursing teams and general practitioner services and 18 community tissue viability specialist nurses. MethodsDuring 2011 and 2012, 36 nurses made diagnostic judgements and treatment choices in response to 110 clinical scenarios. Scenarios were generated from real patient cases and presented online using text and wound photographs. The consensus judgements of a panel of nurses with advanced knowledge of leg ulceration judged the same scenarios and provided a standard against which to compare the participants. Correlations and logistic regression models were constructed to generate various indices of judgement and decision “performance”: accuracy (Ra), consistency (Rs) and information use (G) and uncertainty (Re). ResultsTaking uncertainty into account, nurses could theoretically have achieved a diagnostic level of accuracy of 0.63 but the nurses only achieved an accuracy of 0.48. For the treatment judgement (whether applying high compression was warranted) nurses could have achieved an accuracy of 0.88 but achieved only an accuracy of 0.49. This may have been due to the nurses giving insufficient weight to the diagnostic cues of medical history and appearance of the leg and ulcer and insufficient weight to the treatment cues of type of leg ulcer and pain. ConclusionClinical judgements and decisions made by nurses managing leg ulceration are complex and uncertain and some of the variability in judgements and choices can be explained by the ways in which nurses process the information and handle the uncertainties, present in clinical encounters.