Complications of adapting pressure ulcer risk assessment scales

Abstract

This article challenges recommendations to adapt a pressure ulcer risk assessment scale (RAS) according to the clinical context. The transformation of the Cubbin and Jackson (1991) RAS is used to illustrate problems in scale development. When new factors are added to an existing scale, this can lead to unnecessary complexity. When words are changed by a person developing a scale this illustrates their differing beliefs and value judgements. Arbitrary scores for factors are misleading and in some cases mystifying, yet appear to be objective. This article suggests that the relationship between sub-scales and the whole scale have not been adequately accounted for -- they can't simply be added up arithmetically. The paradox of risk is debated, namely, that the more something is thought to be a risk, the less risky it becomes. RASs should be replaced by risk reduction scales linking a risk factor with its outcome following intervention.

A review of the Lowthian pressure sore prediction score for risk assessment in the orthopaedic setting

“…Gebhardt (2002b) explains that the overall risk score may be used in the selection of a mattress or special bed, or in recommending implementation of a position changing regimen. Maylor (1999) believes that risk assessment scales can be useful for a variety of reasons, communication being the most salient. He explains that nurses usually work in teams, and decisions taken by one nurse have implications for both the patient and colleagues.…”

“…The common strand in developing risk assessment scales, or adapting established ones, is the belief that proper identification of risk leads to the prevention of pressure damage (Maylor, 1999). Scott (2000) further adds that a risk assessment scale must fit the needs of a client group, and believes that some existing scales may lack factors important in identifying risk for particular settings.…”

“…Despite such views, Maylor (1999) explains that one criticism of the PSPS is that it is ambiguous, as the questions include room for doubt regarding absolute classification of a characteristic. He continues that concern has been expressed by some staff nurses wanting to believe that they could rely on the risk scale to come up with a categorical answer about the patient's risk level.…”

“…An example includes the Pressure Sore Prediction Score (PSPS) (Lowthian, 1987). As a result of risk assessment, Maylor (1999) believes that prevention can be targeted at those in need and scarce resources used to their best advantage. If scales are being used for such important decision making it seems reasonable to presume that those adopted have been validated.…”

“…The PSPS has recently come under criticism, that it is worded ambiguously, resulting in poor inter-rater reliability of the scale (Maylor, 1999). Such views have been supported within the clinical setting, with nursing staff stating that the scale design may be open to misinterpretation.…”