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

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.

PURPOSE T in Swedish hospital wards and nursing homes: A psychometric evaluation of a new pressure ulcer risk assessment instrument

“…To address conceptual, methodological and practical limitations, Coleman et al. (2013) in the UK developed the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T) using “golden standard” instrument development methods in a structured five‐phase approach: systematic review, consensus study (Coleman, Nelson, Keen, & Wilson, 2014), conceptual framework development (Coleman, Nixon, Keen, & Wilson, 2014), design and pretesting (Coleman et al., 2016) and clinical evaluation (Coleman, Smith, McGinnis, & Keen, 2018).…”

Clinical evaluation of a new pressure ulcer risk assessment instrument, the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T)

“…To address these conceptual, methodological and practical limitations we developed the Pressure Ulcer Risk Primary Or Secondary Evaluation Tool, PURPOSE‐T as part of a NIHR funded PU Programme Of Research (PURPOSE: RP‐PG‐0407‐10056). PURPOSE‐T development drew on principles of the MRC complex intervention framework (MRC, , ) and incorporated adapted “gold standard” instrument development methods (FDA DHHS, , Mokkink et al., , SAC, ; Steyerberg, ), in a structured five phase approach: Systematic review (Coleman et al., ) Consensus study (Coleman, Nelson, et al., ) Conceptual framework development (Coleman, Nixon, et al., ) Design and pre‐testing (Coleman et al., ) Clinical evaluation (Nixon et al., ) …”

“…The first four phases of this work were concerned with providing evidence of content validity which was indicated along with usability and acceptability in the phase iv) design and pre‐test (Coleman et al., ). This led to the development of the preliminary PURPOSE‐T for clinical evaluation.…”

The Belgian pressure ulcer risk assessment project: Is assessing mobility and skin status a more accurate, reliable, and feasible approach to assess pressure ulcer risk in hospitalised patients?

“…To address the limitations of the existing risk assessment tools and instruments, the PU Risk Primary or Secondary Evaluation Tool (PURPOSE-T) has been developed. 7 Based on PU risk evidence, expert consultations, and a thorough clinical evaluation, the following specific key risk factors were selected: immobility/inactivity and skin assessment. 8 Nevertheless, the implementation of PURPOSE-T in practice is still quite complex for the ward/community nurses because of a three-step assessment process that has to be followed per patient: screening, full assessment, and a final assessment decision.…”