Using cognitive pre-testing methods in the development of a new evidenced-based pressure ulcer risk assessment instrument.

S Coleman,E A Nelson,J Keen,C Dealey,N Stubbs,E Mcginnis,J Nixon,L Wilson,D Muir

doi:10.1186/s12874-016-0257-5

Abstract

BackgroundVariation in development methods of Pressure Ulcer Risk Assessment Instruments has led to inconsistent inclusion of risk factors and concerns about content validity. A new evidenced-based Risk Assessment Instrument, the Pressure Ulcer Risk Primary Or Secondary Evaluation Tool - PURPOSE-T was developed as part of a National Institute for Health Research (NIHR) funded Pressure Ulcer Research Programme (PURPOSE: RP-PG-0407-10056). This paper reports the pre-test phase to assess and improve PURPOSE-T acceptability, usability and confirm content validity.MethodsA descriptive study incorporating cognitive pre-testing methods and integration of service user views was undertaken over 3 cycles comprising PURPOSE-T training, a focus group and one-to-one think-aloud interviews. Clinical nurses from 2 acute and 2 community NHS Trusts, were grouped according to job role. Focus group participants used 3 vignettes to complete PURPOSE-T assessments and then participated in the focus group. Think-aloud participants were interviewed during their completion of PURPOSE-T.After each pre-test cycle analysis was undertaken and adjustment/improvements made to PURPOSE-T in an iterative process. This incorporated the use of descriptive statistics for data completeness and decision rule compliance and directed content analysis for interview and focus group data. Data were collected April 2012-June 2012.ResultsThirty-four nurses participated in 3 pre-test cycles. Data from 3 focus groups, 12 think-aloud interviews incorporating 101 PURPOSE-T assessments led to changes to improve instrument content and design, flow and format, decision support and item-specific wording. Acceptability and usability were demonstrated by improved data completion and appropriate risk pathway allocation. The pre-test also confirmed content validity with clinical nurses.ConclusionsThe pre-test was an important step in the development of the preliminary PURPOSE-T and the methods used may have wider instrument development application. PURPOSE-T proposes a new approach to pressure ulcer risk assessment, incorporating a screening stage, the inclusion of skin status to distinguish between those who require primary prevention and those who require secondary prevention/treatment and the use of colour to support pathway allocation and decision making. Further clinical evaluation is planned to assess the reliability and validity of PURPOSE-T and it’s impact on care processes and patient outcomes.

Highlights

Variation in development methods of Pressure Ulcer Risk Assessment Instruments has led to inconsistent inclusion of risk factors and concerns about content validity
We must target care appropriately, which is achieved by assessing the patient for the presence of Pressure ulcer (PU) risk factors, a process known as risk assessment
One-to-one think-aloud interviews encourage participants to vocalise their thoughts or ‘think-aloud’ while they are concurrently undertaking a task [46], in this case completion of the PURPOSE-T. The use of both focus groups and one-to-one thinkaloud interviews was considered appropriate, as it was anticipated that the focus groups would allow more general usability issues to be identified e.g. relating to the implementation of PURPOSE-T, while the think-aloud interviews would allow more specific item issues to be identified e.g. difficulties in understanding the wording of items within PURPOSE-T [47, 48]

Summary

Introduction

Variation in development methods of Pressure Ulcer Risk Assessment Instruments has led to inconsistent inclusion of risk factors and concerns about content validity. Pressure ulcers (PUs) are defined as ‘localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear’ [1]. They have a negative effect on patients quality of life [2, 3] and are costly to health care organisations world wide [4,5,6,7]. Risk Assessment Instruments (RAIs) have been developed and are commonly used to systematically identify patients at risk, in preference to clinical ‘judgement’ of risk alone, despite the lack of evidence of their clinical effectiveness [1, 9, 10, 12, 13]

Methods

Results

Discussion

Conclusion