An Examination of how Nurses use the Waterlow Scale for Judgement and Decision Making in ...

460 Pages·2013·34.59 MB·English

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An Examination of how Nurses use the Waterlow Scale
for Judgement and Decision Making
in Continuing Care
A thesis submitted to the University of Stirling for the degree of Doctor of Philosophy
in the Faculty of Human Sciences
September 2005
Miss Susan Baxter
Department of Nursing and Midwifery
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ABSTRACT
Using an information processing approach, this study examines how nurses working in
the area of continuing care for older people in Scotland use the Waterlow scale to
inform their judgement and decision making in risk of pressure ulcers and plan of care.
While assessment tools are commonly used, a number of assumptions surround their
use for nurse practice and for patient care. To date, there appears to be no research
which actually examines how nurses use assessment tools to assess patient's needs and
plan care, despite the emphasis placed on evidence based practice. Assessment is a
fundamental activity when caring for an older person where multipathology and the
potential for health state deterioration are likely. This study consists of 3 parts. Part 1
identified the number and type of assessment tools that are routinely used within
continuing care settings using a postal survey, revealing that the Waterlow scale is the
most routinely used tool to assess pressure ulcer risk. Part 2 examined how continuing
care nurses assess pressure ulcer risk through the use of observation and interview. Part
3 involved a detailed examination of the cognitive processes used by nurses when
assessing pressure ulcer risk and planning care using simulation and a technique known
as `Think aloud'. The results of this study indicate there were no differences between
continuing care nurses working in either hospital wards or nursing homes in how the
assessment was carried out, as neither group based their assessment or plan of care
solely on the Waterlow scale. However, the Waterlow scale was found to be used
differently according to the nurses' experience with those with more than 2 years
experience, less likely to base their assessment of pressure ulcer risk or plan of care on
Waterlow derived information.
1
CONTENTS PAGE
Contents Page 2
List of Tables 9
List of Figures 12
Declaration 13
Copyright 14
Dedication 15
Acknowledgements 16
1. INTRODUCTION 17
1.1 Background to the Study 17
1.2 Overview of Study 21
1.3 Organisation of the Thesis 22
2. JUDGEMENT AND DECISION MAKING IN NURSE PRACTICE 23
2.1 Introduction 23
2.2 Literature Search Strategies 24
2.3 Approaches to the Study of Judgement and Decision Making: An Overview 25
2.3.1 Normative Approaches 25
2.3.2 Prescriptive Approaches 26
2.3.3 Descriptive Approaches 28
2.3.3.1 Social Judgement Theory 29
2.3.3.2 Information Processing Theory 31
2.4 Reasoning Strategies 33
2.4.1 Hypothetico-Deductive Reasoning 34
2.4.2 Heuristic Reasoning 42
2.4.2.1 Representativeness 43
2.4.2.2 Availability 44
2.4.2.3 Anchoring and Adjustment 45
2.4.3 Rule Based Reasoning 48
2.5 Factors which Influence the Processing of Information 49
2.5.1 Task Complexity 49
2
2.5.2 Experience and Knowledge
2.5.2.1 Performance
2.5.2.2 Accuracy
2.6 Information Use
2.6.1 Sources Information
of
2.6.2 Types Information Cues Used
of
2.7 Nursing Assessment
2.7.1 Assessment in Action
2.7.2 Nursing Assessment Tools
2.8 Summary
2.8.1 Research Aims
3. SURVEY OF CONTINUING CARE UNITS
3.1 Introduction
3.2 Research Design
3.2.1 Methods of Data Collection
3.2.1.1 Questionnaire Development
3.2.2 Sampling Frame
3.2.3 Ethics
3.3 Pilot Study
3.3.1 Sample
3.3.2 Procedure
3.3.3 Results
3.4 Main Study
3.4.1 Sample
3.4.2 Procedure
3.4.3 Analysis
3.5 Results
3.5.1 Questionnaire Response Rates
3.5.2 Sample Characteristics
3.5.3 Areas of Health Assessed and Assessment Tools Used
3.5.4 Choice of Areas of Assessment and Assessment Tools
3
97
3.6 Discussion
3.6.1 Continuing Care and Assessment Tool Users 97
3.6.2 Training in use of Assessment Tools 98
3.6.3 Areas of Health Assessed and Tools Used 99
3.7 Conclusion 101
4. PRESSURE ULCERS AND RISK ASSESSMENT TOOLS 103
4.1 Introduction 103
4.2 Pressure Ulcers: Why a Concern in Continuing Care? 103
4.3 Aetiology and Risk Factors 105
4.3.1 Aetiology of Pressure Ulcers 105
4.3.2 Risk Factors 107
4.4 Pressure Ulcer Risk Assessment Tools 117
4.4.1 The Norton Scale 118
4.4.2 The Waterlow Scale 119
4.4.3 The Braden Scale 120
4.4.4 A Comparison of Pressure Ulcer Risk Assessment Tools: Norton,
Waterlow Braden 121
and
4.5 Reliability and Validity of Pressure Ulcer Risk Assessment Tools 123
123
4.5.1 Reliability Studies
4.5.2 Validity Studies 126
132
4.6 Summary
133
4.7 Gaps in the Literature
5. OBSERVATION AND INTERVIEWS WITH NURSES
PERFORMING PRESSURE ULCER RISK ASSESSMENTS 135
135
5.1 Introduction
135
5.2 Research Design
5.2.1 Methods Data Collection 136
of
5.2.1.1 Unstructured Observations 137
138
5.2.1.2 Semi-Structured Interviews
138
5.3 Ensuring Methodological Rigour
140
5.4 Sample
4
5.5 Ethics 142
5.5.1 Informed Consent 142
143
5.5.2 Respect for Patients Dignity
143
5.6 Procedure
5.6.1 Negotiating, Access 143
5.6.2 Participant Recruitment 143
5.6.3 Data Collecting Process 144
145
5.7 Data Analysis
5.7.1 Analysis of Observation Data 146
5.7.1.2 Reliability and Validity 147
5.7.2 Analysis of Interview Data 148
5.7.2.1 Reliability and Validity 149
5.8 Results 150
5.8.1 Demographic Results 150
5.8.2 Observation Results 153
5.8.3 Interview Results 158
5.8.3.1 Information Gathering 159
5.8.3.1.1 Problem Framing 159
5.8.3.1.1.1. Matching the Score to the Patient 162
5.8.3.1.1.2 Tool Ambiguity 163
5.8.3.1.2 Knowledge of the Patient 166
168
5.8.3.1.2.1 Use Specific Risk Factors
of
170
5.8.3.1.2.2 Accounts for Risk Score
5.8.3.2 Continuous Assessment 171
172
5.8.3.2.1 Informal Assessment
5.8.3.3 Wider Assessment Process 173
5.8.3.3.1 Other Areas Assessed 174
5.9 Discussion 175
5.9.1 Assessment of Pressure Ulcer Risk with Patient Present or Absent 175
5.9.2 Sources of Information Used and their Order of Use 176
5.9.3 Role of the Waterlow Scale in the Assessment and Care Planning Process 178
5
5.9.4 Assessment of Pressure Ulcer Risk 179
5.10 Conclusion 182
6. USE OF SIMULATION AND THINK ALOUD TO EXAMINE THE
EFFECT THAT THE WATERLOW SCALE HAS ON NURSE
JUDGEMENT AND DECISION MAKING 184
6.1 Introduction 184
6.2 Methods 184
6.2.1 Think Aloud 184
6.2.2 Simulation 186
6.2.2.1 Developing the Simulated Patient Case 189
6.2.2.2 Actor Recruitment Preparation for Role 190
and
6.2.2.3 Consistency and Validity of the Simulation 191
6.3 Ethics 192
6.3.1 Informed Consent 193
6.4 Pilot Study 193
6.4.1 Sample 193
6.4.2 Procedure 194
6.4.2.1 Participant Recruitment 194
6.4.2.2 Data Collection Process 194
6.4.3 Results 196
6.5 Main Study 196
6.5.1 Sample 196
6.5.2 Procedure 197
6.5.2.1 Participant Recruitment 197
6.5.2.2 Data Collection Process 198
6.6 Data Analysis 199
6.6.1 Verbal Protocol Analysis 199
6.6.1.1 Reliability and Validity of the Cognitive Operators Identified 200
6.6.2 Statistical Analysis 201
6.7 Results 201
6.7.1 Demographic Results 201
6
6.7.2 Protocol Analysis 203
6.7.2.1 Cognitive Operators 203
6.7.2.2 Information Sources Used 204
6.7.2.3 Information Cues 205
6.7.2.3.1 Waterlow Cues 205
6.7.2.3.2 Other Cues 208
6.7.2.4 Care Interventions Recommended 210
6.7.3 Waterlow Scores 212
213
6.7.4 Patterns of Reasoning
6.7.5 Comparison of Experienced and Less Experienced Nurses 214
6.7.6 Protocol Analysis 215
6.7.6.1 Cognitive Operators 215
6.7.6.2 Information Sources 216
6.7.6.2.1 Waterlow Cues 216
6.7 6.2.2 Other Cues 219
6.7.6.3 Care Interventions Recommended 221
6.7.7 Waterlow Scores 223
6.7.7.1 Analysis of the Subscale Scores 224
6.8 Discussion 227
6.8.1 Information Sources Cues Used 227
and
6.8.2 Risk Scores 229
6.8.3 Care Recommendations 231
6.8.4 Reasoning Processes 233
6.9 Conclusion 235
7. STUDY DISCUSSION 237
7.1 Introduction 237
7.2 Overview Study Findins 237
of
7.2.1 How Many and What Type of Assessment Tools are Routinely
used by Nurses in the Areas of Continuing Care for Older People? 237
7.2.1.1 Number and Type of Assessment Tools 237
7.2.1.2 Use of In-house Developed Assessment Tools 239
7
7.2.1.3 Assessment Tool Users 240
7.2.1.4 Assessment Tool Training 241
7.2.1.5 Assessment Tool Users 243
7.2.2 How do Continuing Care Nurses Assess Pressure Ulcer Risk
and Plan Care? 244
7.2.2.1 Performing an Assessment of Pressure Ulcer Risk
in the Presence or Absence of the Patient 244
7.2.2.2 Use of Information Sources 245
7.2.2.3 Use of Information Cues 246
7.2.2.4 Risk Scores and Care Interventions Recommended 248
7.2.3 What Effect does the Waterlow Scale have on the Judgement and
Decision Making Process of Continuing Care Nurses? 249
7.2.3.1 Influences on Judgement and Decision Making 249
7.2.3.2 Reasoning Strategies 250
7.3 Methodological Critique 252
8. CONCLUSION 258
8.1 Conclusions and Implications for Policy 258
8.2 Recommendations for Future Research 264
REFERENCES 265
APPENDICES 296
8