Compare methods used in each Qualitative articles relating to pressure ulcer and write a summary of.

Compare methods used in each Qualitative articles relating to pressure ulcer and write a summary of comparison in around 500-600 words See attached of 3 articles to be used. plagiarism free J Wound Ostomy Continence Nurs. 2014;41(6):528-534. Published by Lippincott Williams & Wilkins WOUND CARE 528 J WOCN ■ November/December 2014 Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™ Patient Perceptions of the Role of Nutrition for Pressure Ulcer Prevention in Hospital An Interpretive Study Shelley Roberts ■ Ben Desbrow ■ Wendy Chaboyer ■ ABSTRACT PURPOSE: The aims of this study were to explore (a) patients’ perceptions of the role of nutrition in pressure ulcer prevention; and (b) patients’ experiences with dieticians in the hospital setting. DESIGN: Interpretive qualitative study. SUBJECTS AND SETTING: The sample comprised 13 females and 7 males. Their mean age was 61.3 ± 12.6 years (mean ± SD), and their average hospital length of stay was 7.4 ± 13.0 days. The research setting was a public health hospital in Australia. METHODS: In this interpretive study, adult medical patients at risk of pressure ulcers due to restricted mobility participated in a 20 to 30 minute interview using a semi-structured interview guide. Interview questions were grouped into 2 domains; perceptions on the role of nutrition for pressure ulcer prevention; and experiences with dieticians. Recorded interviews were transcribed and analyzed using content analysis. RESULTS: Within the fi rst domain, ‘patient knowledge of nutrition in pressure ulcer prevention,’ there were varying patient understandings of the role of nutrition for prevention of pressure ulcers. This is refl ected in 5 themes: (1) recognizing the role of diet in pressure ulcer prevention; (2) promoting skin health with good nutrition; (3) understanding the relationship between nutrition and health; (4) lacking insight into the role of nutrition in pressure ulcer prevention; and (5) acknowledging other risk factors for pressure ulcers. Within the second domain, patients described their experiences with and perceptions on dieticians. Two themes emerged, which expressed differing opinions around the role and reputation of dieticians; they were receptive of dietician input; and displaying ambivalence towards dieticians’ advice. CONCLUSIONS: Hospital patients at risk for pressure ulcer development have variable knowledge of the preventive role of nutrition. Patients had differing perceptions ■ Introduction Pressure ulcers (PUs) are associated with signifi cant costs to both patients and the health care system. 1,2 Issues such as pain, discomfort, decreased mobility and independence, wound exudate, odor, social isolation, and poor body image have been described by individuals who have experienced PUs. 3 In the hospital setting, PUs are associated with an increased risk of complications and lengthy healing times, resulting in longer length of stay (LOS) and higher hospital costs. 1-7 In the Australian public hospital setting, PUs increase LOS of acute admissions by a median of 4.3 days, 8 and a recent study estimated the total cost of PU in Australian public and private hospitals in 2010–11 was US$1.64 billion ( ±US$1.05 billion). 9 In the United Kingdom, the estimated annual cost of treating PU to healing time in hospital and long-term care settings was £1.4 billion to 2.1 billion in 1999 to 2000. 10 Clearly, the Shelley Roberts, MNutrDiet, PhD candidate, Centre for Health Practice Innovation, and School of Public Health, Griffi th University, Gold Coast, Queensland, Australia. Ben Desbrow, PhD, Associate Professor, Centre for Health Practice Innovation, Griffi th Health Institute, and School of Public Health, Griffi th University, Gold Coast, Queensland, Australia. Wendy Chaboyer, PhD, Director, NHMRC Centre for Research Excellence in Nursing, Griffi th Health Institute and Centre for Health Practice Innovation, Griffi th University, Gold Coast, Queensland, Australia. The authors declare no confl icts of interest. Correspondence: Shelley Roberts, MNutrDiet, School of Public Health, Gold Coast Campus, Griffi th University, QLD 4222, Australia ( s.roberts@griffi th.edu.au ). DOI: 10.1097/WON.0000000000000072 of the importance and value of information provided by dieticians. KEY WORDS: nutrition , patient knowledge , pressure ulcer , prevention Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 528 WOCN-D-13-00098_LR 528 10/31/14 12:29 AM 0/31/14 12:29 AM J WOCN ■ Volume 41/Number 6 Roberts et al 529 strong predictor of PU in the clinical setting. 4,6,20 Participants were eligible for inclusion if they could provide consent (aged ≥ 18 years, cognitively intact), had a hospital LOS of 3 or more days, and met the criteria for reduced mobility. The study sample was selected using a maximum variation purposive sampling technique (ie, a mix of men and women, younger and older patients, patients with and without experience with PU). 21 Data Collection Individual patient interviews were conducted on the ward, in a quiet area, and at a time convenient for the patient. The interviews lasted 15 to 30 minutes. Using a semistructured interview guide, patients were asked about their perceptions of the role nutrition played in PUP and their experiences with and opinions about the role of dieticians. Three nutrition-related questions were asked. They were based on literature review and current clinical practice guidelines, which suggest that nutritional intervention and education are important components of PUP. Prompts were used to gain additional information as required. Individual interviews were conducted by a research assistant with experience in qualitative data collection. Interviews were recorded with a handheld digital recording device and transcribed for analysis. Data Analysis Interview transcripts were analyzed using inductive content analysis, which provides a systematic and objective means to make valid inferences from verbal data to describe and quantify phenomena. 22-24 This technique takes into account meanings, intentions, consequences, and the context in which data were collected. 20 Because the interview questions encompassed 2 domains (knowledge of nutrition in PUP and experience with dieticians), data from each interview were analyzed in relation to these domains. To become familiar with the data, transcripts were read and reread, and notes were taken by 2 of the authors. For each domain, codes were developed from the verbatim statements of participants, which were then grouped into subthemes identifi ed from the data. Subthemes were then classifi ed into themes within each domain. Frequent discussion among the research team was undertaken to ensure that the codes accurately refl ected the data, and that the themes and subthemes adequately encompassed the data. Trustworthiness of fi ndings in qualitative data analysis is often considered in relation to credibility, dependability, and transferability. 25 We used purposive sampling which ensured a broad representation of patients, and regular meetings with the research team ensured codes, subthemes and themes accurately refl ected the data for transferability and credibility. A code book and memos were written to document the analytic process, including decisions about emerging subthemes and themes, providing an audit trail of the analysis. patient burden and hospital costs associated with PU in the clinical setting are signifi cant, and preferably avoided through effective pressure ulcer prevention (PUP). Historically, risk factors such as pressure, moisture, shearing forces, and friction have been a primary focus for PUP. 11-13 In addition, research suggests that malnutrition is an important risk factor for PU development. Malnutrition is associated with an odds ratio of 2.6 (95% confi dence interval: 1.8-3.5; P ■ Methods This interpretive qualitative interview study is part of a larger, multisite, mixed-methods study conducted across 4 medical wards in 2 metropolitan hospitals in Southeast Queensland, Australia. Both hospitals have established PUP programs, and preventive strategies have been implemented into regular clinical practice. Ethical approval for study procedures was obtained through Queensland Health (reference number HREC/11/QTHS/111) and Griffi th University (reference number NRS/40/11/HREC). All participants signed a consent form prior to data collection. The sample comprised adult medical patients who received care in 4 inpatient medical units who had reduced mobility (ie, bed-bound, wheelchair-bound, or requiring a mobility aid or physical assistance) and were therefore deemed at risk for PU development. Reduced mobility was chosen as an inclusion criterion to identify patients at risk of PU because it is a widely recognized risk factor and Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 529 WOCN-D-13-00098_LR 529 10/31/14 12:29 AM 0/31/14 12:29 AM 530 Roberts et al J WOCN ■ November/December 2014 ■ Results The sample comprised 13 women and 7 men. Participants mean age was 61.3 ± 12.6 years (mean ± SD, range 24-80 years), and their mean hospital LOS was 7.4 ± 13.0 days (range 3-62 days). After 16 interviews, no new information was emerging; however, 4 more interviews were completed to ensure data saturation. Within each domain, a number of themes emerged. A summary of the domains, themes, and subthemes is provided in Table 1 . Domain 1: Patient Knowledge of Nutrition in PUP The fi rst domain had 5 themes that expressed respondents’ perceptions of the role of nutrition for preventing PUs. Consistent with inductive approaches to qualitative analysis, we did not identify an overarching theme, nor was any theme prioritized over the others as each provided a unique perspective. In addition, we refrained from counting frequencies of emerging themes. The fi rst theme was “recognizing the role of diet for PUP.” Participants acknowledged that nutrition as important for prevention of PUs. Nevertheless, while most patients thought that nutrition played a role in prevention, they were unsure exactly what that role was. As respondent 1 stated, “I’m not a dietician and I’m not a medical expert, but I would suggest that nutrition is very, very important.” Some patients stated that consuming a poor diet will result in a higher likelihood of developing a PU. Other patients described a good diet as being a protective factor for PU, and weight loss (in the buttocks area) was described as a factor that may increase the risk of PU. “The good food is building you up all the time, and you may even be putting on weight. And it’s usually when someone loses a lot of weight in their bottom area that these things happen quicker. The skin comes apart quicker. Whereas with well-padded bottoms, it takes a while to happen.” Losing weight if overweight or obese was also described as a measure for PUP and healing. One participant postulated that consuming “heavy foods” in hospital would lead to patients feeling full and heavy, encouraging them to stay in bed rather than resuming mobility. Another participant, unsure of the role that nutrition played in PUP, supposed that nutrition affects your blood, and if your “blood’s out” (ie, blood test results abnormal), you may be more likely to develop PU. On the whole, this theme refl ects patients’ recognition that nutrition plays a role in PUP, but the description of that role was ambiguous. The second theme, “promoting skin health with good nutrition,” portrays how patients linked skin health and nutrition, even if they did not fully understand the mechanisms behind this relationship. Some participants made general statements that nutrition was related to skin health, while others said that poor nutrition would cause skin to break down more easily. Several participants mentioned dietary protein as an important factor for skin integrity. Protein was also mentioned as important for wound healing and prevention of infection. One patient thought that fl uid intake would play a role in PUP; however, they were unsure of its exact role. Although respondents did not articulate the exact relationship between nutrition and skin health, they appeared to have a broad understanding of this notion. One respondent noted, “I should assume that if you weren’t eating properly, and aren’t getting the right nutrition, of course your skin’s going to break down twice as much.” Another observed, “You need vitamins and minerals and proteins in the right ratio so that your skin, your body tissue maintain its intactness, because if it doesn’t maintain intactness, then you’re prone to infection.” The third theme, “understanding the relationship between nutrition and health” describes the perception that nutrition was important for health in general and would be expected to play a role in PUP. As one respondent articulated, “I know nutrition is important for all areas of health, and so it would have a part to play with pressure sore prevention.” The fourth theme “lacking insight into the role of nutrition and PUP” depicts the lack of understanding or knowledge of a relationship between nutrition and PUP expressed by some participants. Some respondents stated that they had “no idea” how nutrition and PUP may be related, and others reported that they had not given this potential connection much thought before. One respondent related, “I’ve got no idea, really. No, none whatsoever.” Another observed, “I don’t think nutrition plays a role in bed sores…. I don’t think it’s to do with nutrition. I wouldn’t have thought so anyway.” The fi nal theme in the knowledge of nutrition and PUP domain was “acknowledging other risk factors for PU.” Within this theme, patients described other risk factors they considered to be of importance for PUP; they were skin health, age, pressure, shear and friction, and comorbid conditions. Skin health and integrity were mentioned most frequently, but no link was made between skin health and nutrition. Keeping skin healthy was described as an important way to prevent PUs, and patients mentioned delicate or thin skin as being associated with vulnerability to PU development. Age was identifi ed as a factor affecting skin health and integrity. Participants noted that aging is linked to more fragile skin that is prone to skin tears. The combination of older age and medications such as warfarin was linked to fi ne skin that bruises, tears, and bleeds easily. Participants also acknowledged that older patients should be monitored for PU because they are at high risk. Pressure on the body associated with lying/sleeping positions and prolonged time spent in bed were described as factors involved in the development of PU. Several participants stated that “…heels rubbing on the bed” acted as a risk factor for PU development. Finally, patients expressed the belief that various illnesses were Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 530 WOCN-D-13-00098_LR 530 10/31/14 12:29 AM 0/31/14 12:29 AM J WOCN ■ Volume 41/Number 6 Roberts et al 531 TABLE 1. Description of Domains, Themes, and Subthemes Domain Theme Subtheme Patient knowledge of nutrition in PUP Recognizing the role of diet in PUP • Nutrition probably plays a role in PUP • Poor diet/weight loss (especially in the buttocks) is a risk factor for PU • Good diet/weight gain (when underweight) is a protective factor for PU • “Heavy food” may reduce mobility • If overweight, losing weight is important for PUP and healing Promoting skin health with good nutrition • Nutrition plays a role as it is related to skin health • Poor nutrition would cause skin to break down more easily • Protein, vitamins, and minerals maintain skin/tissue integrity and prevent infection • High protein diet for skin integrity and healing • Fluid intake may play a role (unsure what) Understanding the relationship between nutrition and health • Nutrition is important for all areas of health, so it would have a role in PUP • Nutrition plays a role as it is the well-being of the body • Better nutrition results in better health and circulation • If you have a healthy body, you won’t get PU as bad Lacking insight into the role of nutrition in PUP • Unsure how nutrition and PUP may be related • Has not thought about nutrition as a factor in PUP • Doesn’t think nutrition has a role Acknowledging other risk factors for PU • Main issue is skin integrity • Pressure, positioning, and medical conditions are important risk factors for PU • Friction/shear as a risk factor • Skin health is important • Age and medications affect skin health • Older patients are at risk Patient feedback on dieticians Receptive of dietician input • Feels lucky to be seen by the dietician • Appreciates nutritional information provided • Dieticians are happy and bright Displaying ambivalence toward dieticians’ advice • Patients do not think they need to see a dietician • Already knows how to eat • Dietician appointment did not meet expectations • Patient felt disempowered • Confl icting advice from dietician and specialist • Did not gain any new knowledge from dietician • Did not like prescribed diet Abbreviations: PU, pressure ulcer; PUP, pressure ulcer prevention. important in PU development. As one participant noted, “I think it’s to do with the patient, what’s wrong with them, and the way they lie.” Another stated, “Well the main reason [for developing a PU] is pressure on the body from the bed and the angles you sleep.” A third respondent observed, “I tend to think it’s more if the skin’s thinish and delicate.” Domain 2: Patient Feedback on Dieticians The second domain “patient feedback on dieticians” comprised 2 themes, describing patients’ experiences with and perceptions of dieticians. These included (1) receptive of dietician input and (2) displaying ambivalence toward dieticians’ advice. The theme “receptive of dietician input” describes positive experiences during interactions with dieticians. These participants expressed willingness to participate in nutritional education and gratitude toward dietetic input. They tended to describe dieticians as happy and bright and felt appreciative of the information and services they provided. As one respondent noted, “I’m lucky enough to have been referred, to a dietician.” Similarly, another stated, “It had just so much information; leafl ets and talking to the nutritionist, it was lovely.” In contrast to theme 1, the theme “displaying ambivalence towards dieticians’ advice” refl ects confl icting views of the value of dietetic advice. Some participants expressed the opinion that they did not need to see a dietician, Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 531 WOCN-D-13-00098_LR 531 10/31/14 12:29 AM 0/31/14 12:29 AM 532 Roberts et al J WOCN ■ November/December 2014 defi ned as an individual’s capacity to obtain, process, and understand information and services needed to make appropriate health decisions. 26 Health literacy in the hospital setting is especially important since education must be delivered in a setting of an acute illness. A study based in the United States found that 81% of English-speaking patients over 60 years of age lacked adequate health literacy to make informed decisions about their health care. 27 Researchers have also reported that patient education materials and consent forms in hospital are often above patients’ reading levels, rendering their comprehension even more challenging. 28-31 We recommend consideration of patients’ education, literacy levels, and prior knowledge of nutrition when planning education for acutely ill persons at risk for PU development. Participants in this study expressed differing perceptions of the importance and value of information provided by dieticians. Some patients expressed their gratitude toward dietetic input in the hospital setting, but others deemed it unnecessary. These fi ndings suggest that the role and importance of dieticians are unclear to patients in the hospital setting, and this lack of knowledge may affect patients’ responsiveness to PUP programs that include nutrition education. Interventions such as educational interventions related to nutrition and PUP must be compatible with individuals’ values, beliefs, and current needs, and they must be perceived as feasible and benefi cial. 32 This observation is refl ected in previous studies exploring staff perceptions on the role of clinical dieticians. 33,34 A study conducted at a public hospital in Queensland, Australia, used thematic analysis to explore staff perceptions around nutrition care. 33 They found that the role of the dietician was unclear to nursing and allied health staff such as pharmacists, speech pathologists, physiotherapists, and occupational therapists. The health care providers also expressed mixed views on whose responsibility it was to identify and provide nutritional care to malnourished patients. 33 Similarly, a cross-sectional survey of 237 internal medicine physicians and clinical dieticians in Michigan found that most responses to questions around the role and responsibilities of dieticians differed between professions. 34 If the role of dieticians is unclear among clinicians involved in PUP and wound care, it is not surprising that patients lack an adequate understanding of how consultation with a dietician may provide benefi t for prevention of PU development. Even though evidence supporting the effectiveness of dietary counseling in PUP or management of malnutrition in hospitals is lacking, 35 nutrition education may be an important component of PUP programs. This is refl ected in international PUP guidelines, which suggest that patient education is an important aspect of PUP. 36,37 Additional research is needed to determine the effectiveness of patient and nutritional education on PUP. Some participants displayed a lack of confi dence in dieticians, and they suggested they did not learn anything new from the dietician, disliked the prescribed dietary primarily because they already knew how and what to eat to keep healthy. Some stated that the need to consult with a dietician never crossed their minds, while others stated that meeting with a dietician was necessary only if diagnosed with a disease that required a special diet. One respondent described the need for a dietician, “…only if I needed it. Well, if I had any sort of diseases or sicknesses that needed, um, to be on certain diets, I’d be interested then. But for, like, everyday life I’ve got a fair idea what’s good for me and what isn’t, you know. So not really, no.” Another patient reported that an appointment with a dietician did not meet her expectations; she further stated that she left this appointment feeling disempowered. This participant also discussed receiving confl icting advice between the dietician and her diabetes specialist. “She (dietician) was telling me things that were in opposition to what my specialists were telling me. (Specialist): ‘You need to lose weight’. (Dietician): ‘No, you won’t be losing weight. When you’re diabetic you put weight on’.” Other participants thought that they did not learn anything new from their dietician as compared to nutritional information gained from everyday life. As one participant opined, “Well, she [dietician] didn’t provide me with anything I didn’t already know. I was quite bored.” Some stated they did not like the diet they were prescribed, or disliked restrictions on certain foods, resulting in discontinuation of their prescribed diet. ■ Discussion This study is the fi rst to our knowledge to explore awareness of the role of nutrition for PUP among patients at risk for PU development. Participants were patients at 2 Australian hospitals where both PUP and patient education were important parts of clinical practice, and it was initially postulated that their knowledge of the importance of nutrition in PUP would be adequate. Instead, we found variable levels of understanding of the role of nutrition in PUP. Some respondents had a personal history of PU or had experience through family members. These experiences may have infl uenced their perceptions around nutrition for PUP and the importance of dieticians. Nevertheless, study fi ndings suggest that patients had inadequate knowledge of nutrition and PUP despite welldeveloped programs that include consultation with a dietician and appropriate counseling. We, therefore, recommend additional education focusing on PUP that includes the role of nutrition for all patients deemed at risk for PU development. Based on the variable levels of knowledge expressed by study respondents, we also recommend individual assessment to determine patients’ level of knowledge and motivation to be involved in their care. Research suggests that basic literacy levels in adults may not be suffi cient to understand oral or written information regarding their medical condition and health care. 25 Health literacy is Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 532 WOCN-D-13-00098_LR 532 10/31/14 12:29 AM 0/31/14 12:29 AM J WOCN ■ Volume 41/Number 6 Roberts et al 533 Owing to the compromised nutrition seen in many persons at risk for PU development, we believe that selected patients will benefi t from nutritional education aimed at PUP that is tailored to suit their literacy levels. A better understanding of the role of dieticians within the clinical setting may improve patient participation in their nutritional care and associated outcomes. ■ ACKNOWLEDGMENT This research received funding from the Area of Strategic Investment Health and Chronic Diseases, Griffith University. Author contributions: Shelley Roberts: Conception and design of the study; collection, analysis, and interpretation of data; drafting and revision of manuscript; and approval of fi nal version of manuscript. Wendy Chaboyer and Ben Desbrow: Conception and design of the study; analysis and interpretation of data; drafting and revision of manuscript; and approval of the fi nal version of the manuscript. ■ References 1. Allman RM . Current concepts—geriatrics—pressure ulcers among the elderly . N Engl J Med. 1989 ; 320 ( 13 ): 850-853 . 2. Allman RM . Outcomes in prospective studies and clinical trials . Adv Wound Care. 1995 ; 8 : 61 . 3. Fox C . Living with a pressure ulcer: a descriptive study of patients’ experiences . British Journal of Community Nursing. 2002 ; 10 : 12-14 . 4. Allman RM . Pressure ulcer prevalence, incidence, risk factors, and impact . Clin Geriatr Med. 1997 ; 13 ( 3 ): 421-436 . 5. Allman RM , Laprade CA , Noel LB , et al. Pressure sores among hospitalized patients . Ann Int Med. 1986 ; 105 ( 3 ): 337-342 . 6. Grey JE , Enoch S , Harding KG . ABC of wound healing—pressure ulcers . Br Med J. 2006 ; 332 ( 7539 ): 472-475 . 7. Stratton RJ , Green CJ , Elia M . 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While dieticians are experts in nutritional care, recent research suggests that general practitioners are the most recognized health care professional providing nutritional care to patients with chronic disease in Australia, followed by dieticians. 34 Although this study was based in the primary care setting, it highlights the importance of a consistent approach to the information provided by all health care professionals providing care for an individual patient. Clinical Implications Three main recommendations arise from this study. We found that patients at risk of PU development expressed varying levels of knowledge of the role of nutrition in PUP, and require tailored education in this area, taking into account their health literacy. We hypothesize that tailored education may raise patients’ knowledge of nutrition and PU development and increase their participation in their nutritional care. We also recommend clarifi cation of the role of dieticians in the clinical setting, as patients appear to lack an understanding of the potential health gains to be made from dietetic input and nutritional care in hospital. A better understanding of this role and its importance in PUP may increase patients’ responsiveness to dietetic input and participation in their nutritional care. ■ Limitations Interview questions were asked after each patient had participated in an observational study targeting the patients’ role in PUP. As patients knew their oral intake was being monitored, their awareness of a potential role of nutrition in PUP may have been increased, infl uencing results of this study. Participant’s clinical conditions may have in- fl uenced their responses. We sought to minimize this potentially confounding influence by ensuring that interviews were conducted when patients felt well enough to participate, ensuring that patients remained comfortable during the interview, and informing participants that the interview may be ceased at any time if they felt tired or distressed. Another potential limitation is that analysis occurred several months after data collection; therefore, member checking was not possible as patients had been discharged from hospital. Selection bias is a consideration in any research. In qualitative research, purposive sampling is used to achieve variation in the experiences being explored and in this study, recruitment occurred until data saturation was reached. 21 It is always possible that some views were not represented in our sample. ■ Conclusions Findings from this study suggest that patients at risk of PUs have confl icting views on the role of nutrition in PUP. 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Washington, DC : European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel ; 2009 . 16. Dupertuis YM , Kossovsky MP , Kyle UG , Raguso CA , Genton L , Pichard C . Food intake in 1707 hospitalised patients: a prospective comprehensive hospital survey . Clin Nutr. 2003 ; 22 ( 2 ): 115-123 . 17. Mudge AM , Ross LJ , Young AM , Isenring EA , Banks MD . Helping understand nutritional gaps in the elderly (HUNGER): A prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients . Clin Nutr. 2011 ; 30 ( 3 ): 320-325 . 18. Thibault R , Chikhi M , Clerc A , et al. Assessment of food intake in hospitalised patients: a 10-year comparative study of a prospective hospital survey . Clin Nutr. 2011 ; 30 ( 3 ): 289-296 . 19. Bours GJ , Halfens RJ , Abu-Saad HH , Grol RT . Prevalence, prevention, and treatment of pressure ulcers: descriptive study in 89 institutions in the Netherlands . Res Nurs Health. 2002 ; 25 ( 2 ): 99-110 . 20. Lindgren M , Unosson M , Fredrikson M , Ek A . Immobility—a major risk factor for development of pressure ulcers among adult hospitalized patients: a prospective study . Scand J Caring Sci. 2004 ; 18 ( 1 ): 57-64 . 21. Sandelowski M . Sample size in qualitative research . Res Nurs Health. 1995 ; 18 ( 2 ): 179-183 . 22. Downe-Wamboldt B . Content analysis: method, applications, and issues . Health Care Women Int. 1992 ; 13 ( 3 ): 313-321 . 23. Elo S , Kyngas H . The qualitative content analysis process . J Adv Nurs. 2008 ; 62 ( 1 ): 107-115 . 24. Graneheim UH , Lundman B . Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness . Nurs Educ Today. 2004 ; 24 ( 2 ): 105-112 . 25. Parker R , Baker D , Williams M , Nurss J . The test of functional health literacy in adults . J Gen Int Med. 1995 ; 10 ( 10 ): 537-541 . 26. Institute of Medicine . Health Literacy: A Prescription to End Confusion. 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DOI: 10.1097/WON.0000000000000100 Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 534 WOCN-D-13-00098_LR 534 10/31/14 12:29 AM 0/31/14 12:29 AM International Journal of Nursing Studies 44 (2007) 1109–1119 Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study Kajsa Helena Funkessona,, Els-Marie Anba¨ckena , Anna-Christina Ekb a Department of Social and Welfare Studies, Linko¨ping University, Sweden b Department of Medicine and Care division of Nursing Science, Faculty of Health Sciences, Linko¨ping University, Sweden Received 16 September 2005; received in revised form 21 February 2006; accepted 27 April 2006 Abstract Background: Nurses’ clinical reasoning is of great importance for the delivery of safe and efficient care. Pressure ulcer prevention allows a variety of aspects within nursing to be viewed. Objective: The aim of this study was to describe both the process and the content of nurses’ reasoning during care planning at different nursing homes, using pressure ulcer prevention as an example. Design: A qualitative research design was chosen. Settings: Seven different nursing homes within one community were included. Participants: Eleven registered nurses were interviewed. Method: The methods used were think-aloud technique, protocol analysis and qualitative content analysis. Client simulation illustrating transition was used. The case used for care planning was in three parts covering the transition from hospital until 3 weeks in the nursing home. Result: Most nurses in this study conducted direct and indirect reasoning in a wide range of areas in connection with pressure ulcer prevention. The reasoning focused different parts of the nursing process depending on part of the case. Complex assertations as well as strategies aiming to reduce cognitive strain were rare. Nurses involved in direct nursing care held a broader reasoning than consultant nurses. Both explanations and actions based on older ideas and traditions occurred. Conclusions: Reasoning concerning pressure ulcer prevention while care planning was dominated by routine thinking. Knowing the person over a period of time made a more complex reasoning possible. The nurses’ experience, knowledge together with how close to the elderly the nurses work seem to be important factors that affect the content of reasoning. r 2006 Elsevier Ltd. All rights reserved. Keywords: Clinical reasoning; Elderly care; Nursing homes; Patient care planning; Protocol analysis What is already known about the topic? Nurses use different types of cognitive operators and strategies when they reason. The context is of importance for the reasoning process A variety of aspects differ between novices and experts in their reasoning process What this paper adds Reasoning concerning pressure ulcer prevention while care planning seems to be dominated by routine thinking. ARTICLE IN PRESS www.elsevier.com/locate/ijnurstu 0020-7489/$ – see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.04.016 Corresponding author. Tel.: +46 11 363511; fax: +46 11 125448. E-mail address: kajsa.funkesson@isv.liu.se (Kajsa H. Funkesson). Knowing the person over a period of time seems to make a more complex reasoning possible. The content of reasoning seems to be affected by how close to the person the RNs work. 1. Introduction Elderly people in Sweden moving to community care residences and in particular those of the nursing home kind, most often have a complex medical history with several diagnoses, which creates a great need of nursing care (The Swedish Board of Health and Welfare, 2001). The role among registered nurses working in nursing homes in Sweden varies. On an organisational level, most registered nurses at community care residences have two roles, one with the main responsibility for the nursing care and care planning for a limited number of residents and one with a consultative role for the care of a larger number of residents. The way the nurses perform the roles differs, at some community care residences nurses hardly ever participate in the care of the persons for whom they are principally responsible, at others they do. In both cases, they are the only staff with medical competence assessing the needs of the person. Considering this, the ability to reason and to use science and reliable experience in the reasoning process is of utmost importance, especially in connection with care planning and the delivery of safe and efficient care when acute problems occur for the client (Higgs and Jones, 2000; Higgs et al., 2001). So far not much is known about the reasoning process in relation to care planning for elderly persons living in community care residences The aim of this study was to describe nurses’ reasoning process during care planning for an elderly person who has just moved to a nursing home, as well as the content of the reasoning in relation to pressure ulcer prevention during different phases of care planning. 2. The reasoning process The reasoning process that takes place while making judgments about a person’s situation can be viewed from many different perspectives. Having to do with context and aim, it can be named critical thinking, reflective reasoning, diagnostic reasoning, decisionmaking, etc. In medicine and related areas, it is often called clinical reasoning. Fowler (1997) describes clinical reasoning as a process where multiple possibilities are processed while making judgments about a client’s situation, with the purpose of achieving a desired outcome. Simmons et al. (2003) characterise this process as recursive, where both inductive and deductive cognitive skills are used. Clinical reasoning can also be described simply as a process where knowledge and experience are applied to clinical situations, in order to develop a solution (Noll et al., 2001). Nurses’ reasoning is, to a great extent, dependant on the context in which it takes place (Crow et al., 1995; Thompson, 1999), which makes every situation unique. It is mainly about judging a person’s situation, seeing the needs and problems, making priorities and decisions about patient care (Junnola et al., 2002). In this paper, clinical reasoning is seen as a cognitive process, where both theoretical knowledge and personal experience are used in a unique care situation aiming to achieve a desired outcome for the person in focus. Greenwood (1998) differentiates between reasoning terminating in conclusions and in actions. The first is called theoretical reasoning, the second practical. When nurses lack clinical experience to handle a situation they need to reason theoretically. It is also important that the theory used is evidence based and contextually relevant (Higgs et al., 2001). In a study by Fowler (1997), six cognitive operators were found in the nurses’ reasoning; describing, explaining, evaluating, connecting, planning and judging. The purpose of these operators was to understand the situation and to produce judgements about incoming cues. Fowler (1997) also found six strategies in the reasoning; cue logic, framing, hypothesising, testing, reflective comparison and prototypical case reasoning. These were used to reduce cognitive strain, helping the nurse to manage the situation. Evidence from this study suggests that the context in which the reasoning takes place influences the use of cognitive operators and strategies. Within the last 25 years, several studies have been conducted with the aim of exploring the reasoning process in nursing. For example, Benner (1984, 1996), and Greenwood and King (1995) studied this process within expert and novice nurses and Simmons et al. (2003) within experienced nurses. It has also been explored in different contexts (Carr, 2004; McCarthy, 2003) and areas in nursing, of which one is care planning (Fowler, 1997; Grobe et al., 1991). However, studies have stated the importance of context and experience on the reasoning process but not on the way nurses perform their work. The way nurses reason and make decisions has been explored, either by the use of simulated cases, such as written scenarios (Fonteyn et al., 1993; Ritter, 2003) and computer simulations (Junnola et al., 2002), or by studies within real practise situations (Fonteyn and Fisher, 1995; Greenwood et al., 2000). 3. The study 3.1. Participants and contexts This study was conducted in one community in Sweden. To enable differences in the way registered ARTICLE IN PRESS 1110 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 nurses (RNs) perform their role to be represented in the study, all community care residences of the nursing home model, a total of eight, were included. Participating RNs should have more than 1 year of experience from working at the nursing home in question. All RNs who fulfilled the inclusion criteria were invited to participate but a maximum of two RNs from the same nursing home were allowed to be included. The invitation along with written information in which they were told that the study was about a care planning situation, was presented to the RNs by the head of the nursing home. A total of 11 female RNs from seven nursing homes gave their written informed consent. All were included. Six of the participating RNs, who came from four nursing homes, hardly ever participated in the nursing care (‘‘consultant nurses’’). Five of the participating RNs, coming from three nursing homes, worked closer to the residents and the nursing staff. These RNs participated in the care of those they were primarily responsible for on a regular basis (‘‘care nurses’’). The participants’ experience from working at nursing homes ranged from one and a half years to 15 years. Five had a nursing qualification older than 15 years. Three had a degree at bachelor level and one at master. Both groups, ‘‘consultant nurses’’ and ‘‘care nurses’’, had approximately the same distribution of personal data, such as age, nursing experience and level of nursing education. 3.2. Method The methods chosen were verbal protocol (VP) and protocol analysis (PA) also called think-aloud (TA) technique (Ericsson and Simon, 1984, 1993). This technique views the flow of information in our mind while reasoning and seeks to reveal the mental processes which take place during a problem solving task and has been well described by Ericsson and Simon (1984, 1993). Since the beginning of the 1980s, the think aloud technique has been used by nursing researchers to reveal nurses’ reasoning process (Benner, 1984; Greenwood and King, 1995; Simmons et al., 2003). Protocol analyses in four steps were chosen to analyse the incoming data (Ericsson and Simon,1993; Fonteyn and Fisher,1995). Investigation of the content of the reasoning was conducted by means of a qualitative content analysis (Mayring, 2000; Morgan, 1993). 3.3. Procedure Client simulation in terms of a written case was used as a mean for reasoning. This enabled a standardisation of the case and reasoning situation, which was considered important due to the aim and because of the different working situations at the nursing homes. The simulated case was based upon an authentic case about an 85-year-old woman who suffered a stroke resulting in severe problems within the physiological, psychological, social and spiritual areas. The simulation enabled the reasoning to be followed over a period of time. The presentation was structured according to a model called VIPS (Ehrenberg et al., 1996) well known to the participants. The VIPS model used in this study is a model for documentation of nursing care based upon the nursing process which has been adapted to documentation in nursing homes (Ehrenberg and Ehnfors, 1999a). It includes nursing history, status, diagnoses, goals, outcome and a nursing discharge note (Ehrenberg et al., 1996). The presentation given to the participants included nursing history together with a nursing discharge note plus two nursing statuses. All TA interviews were performed individually at the nursing home, in a secluded room without any disturbance. After permission from the participants, the interviews were audiotaped. Information was given about the TA technique as well as the difference between thinking aloud and talking aloud. This was followed by a short practise session. The participants were informed that the task was about care planning for a person who was moving into ‘‘their’’ nursing home after a period of hospital care and that they had the role of nurse responsible for the person. They were also told that the case was to be presented in three parts, starting 1 day before arrival and ending 3 weeks later. Preceding each part, the investigator made a short introduction. Just before starting, they were reminded to think aloud and express everything that passed through their minds while care planning. If more than a moment of silence occurred during the interview, the investigator reminded them again. This was to assure that all thoughts were verbalized and that a minimum of time was left for reconstructions. The actual TA interviews varied between 60 and 90 min in time. The study was approved by the Research Ethics Committee of the Faculty of Health Sciences, Linko¨ping University (Registration number: 02-385). 3.4. Data analyses The interviews were transcribed verbatim into VPs. The first step of the PA, general analysis, focused on getting a broad sense of meaning and to capture that of interest for the aim of this study. Pressure ulcer prevention was chosen as an example because in this context this is of special importance, since hospitalised immobile persons in general (Lindgren et al., 2004) and the elderly in particular runs an increased risk of developing pressure ulcers (Margolis et al., 2002). Pressure ulcer prevention also serves as an indicator of the quality of care provided (Stephan-Haynes, 2004; Wipke-Tevis et al., 2004) and it allows a variety of important aspects within nursing to be viewed such as ARTICLE IN PRESS Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1111 nutrition, activity, wellbeing, etc. Parts that directly, or indirectly, referred to pressure ulcer prevention or the treatment of first degree of pressure ulcers were marked. Indirect parts were those of importance for the prevention of pressure ulcers but not spoken of as such, as in this example ‘‘ydry skin is easily rectified with a softening cream.’’ The procedure capturing parts of interest for the study were repeated twice on two different occasions. Marked parts were coded as directly or indirectly connected to the topic. The second step, referred phrase analysis, aimed to identify what the participants concentrated on during the interviews. Nouns and noun phrases used while reasoning were marked and coded as a concept. Each concept was given a preliminary definition which was refined as the analyses proceeded. Finally, they were sorted with help of the nursing process. To give a picture of the flow of the reasoning process in relation to the nursing process, each phrase was numbered in order of appearance. The numbered phrases were plotted on a graph, one for each participant. At the third step, assertional analysis, the VPs were further examined to establish the aim or purpose of each phrase in the reasoning process. In focus for the analysis were the different types of relationship formed between concepts found in the referred phrase analysis. With this in mind, each phrase in the VPs was coded. The assertions found in this process were gradually refined throughout the analysis. To enhance the validity of coding the phrases, this part of the procedure was repeated with some time in between. In cases where codes did not match, a re-examination of the phrase was performed. The fourth step of PA, script analysis, aimed to make conclusions concerning the respondents’ reasoning process. The coded VPs were now seen as a whole. The texts were coded once again this time using the cognitive operators and strategies found by Fowler (1997) as a reference frame. This procedure was repeated in the same way as in the last phase. It was intended that data not fitting into this frame would be analysed separately but no such data were found. The content analysis started with a reduction of text. In order to get a general view of what was said about pressure ulcer prevention the reduced VPs were read through again. To get a picture of how and when the nurses reasoned about pressure ulcer prevention, the indirect and direct reasoning were analysed. This was followed by making notes in the margin, underlining significant concepts, sorting text units into different content areas. As a starting point for these areas, the keywords from the VIPS model in the case were used. Text that did not fit into these areas was analysed separately. This resulted in one additional content area named ‘‘nursing care management.’’ Finally the whole text was read through again to make sure that the text units were well connected to their context. In order to visualise the content, for the two groups in the three parts of the case, the occurrence of direct and indirect reasoning within the different content areas was put together. A second researcher studied the content of the verbal protocols and followed the different steps of the analyses thoroughly. Differences of opinion were discussed, enabling codes etc to be refined continuously. The results of the analyses were carefully discussed throughout the whole process. On the whole however there was a high correspondence between the two researchers. 4. Findings The general analyses of the PA showed that most nurses in this study had an extensive reasoning as a whole, of which the main part directly or indirectly connected to prevention of pressure ulcer. The ‘‘referred phrase analyses’’ showed that all participants reasoned within assessing, planning, implementation and evaluation of the nursing process. Within these phases 16 different concepts, were found (Table 1). The six most frequently used where sign, valuation, general action, nursing action, paramedic action and goal. On an individual level, the reasoning differed greatly but looking at the participants as a whole and to the three parts of the case, the reasoning showed certain patterns, (Table 2). Planning was a phase focused on most throughout all three parts of the care planning but before arrival this was the main focus. The day after arrival, the reasoning focused on assessing almost as much as planning and the different actions were more often a result of the assessment, with nursing ethics as an important component in the reasoning. By now, all 11 participants had some reasoning connected to pressure ulcer prevention. The reasoning 3 weeks after arrival was the most comprehensive. In addition to assessing and planning, all participants, in one way or other, reasoned about how to follow up the results. As shown in Table 2, the analysis reveals some differences between ‘‘care nurses’’ and ‘‘consultant nurses’’ in their average use of concepts within the ‘‘implementation phase’’ and ‘‘evaluation phase’’. Focusing on the flow of reasoning, it was found that reasoning leading to an action was most often preceded by reasoning that went back and forth between different phases. Another finding was that abnormal cues led to a greater focus on the assessing phase. At the ‘‘assertional analysis’’ three different kinds of assertions were found in the reasoning. These were ‘‘implicational’’, tending to suggest or imply something, ‘‘significative’’, having a special meaning and ‘‘causal’’ focusing on cause and effect. The two most frequently used were implicational and significative. Causal assertions were rare. The ARTICLE IN PRESS 1112 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 ‘‘script analysis’’ where the use of cognitive operators and strategies in the nurses reasoning were analysed showed that cognitive strategies were infrequently used. Instead, the reasoning was dominated by the use of operators. However the operator ‘‘connecting’’, where the RNs consider possible relationships among cues, was rare. The findings of these two last steps of the PA analysis were true for both ‘‘consultant’’ and ‘‘care nurses’’. Looking at the content of the reasoning, the result shows certain differences between the participants on a group level (Table 3). On the whole, the ‘‘care nurses’’ held a broader reasoning. ‘‘Activity’’ was the only content area within which the ‘‘consultant nurses’’ reasoned the most. The content area elimination showed the biggest difference. Most of the ‘‘consultant nurses’’ did not focus on this aspect at all, or said that this aspect was taken care of by the nursing assistants. All ‘‘care nurses’’, on the other hand, reasoned about avoiding incontinence in a way that could, indirectly, help to prevent pressure ulcers. The importance of good hygiene was highlighted by several nurses in this group but only ARTICLE IN PRESS Table 1 Concepts derived from the referred phrase analyses Concept Definition Examples from the VPs Time (occurs in all phases) Chronological reference ‘‘yheavily overweight before she became ill’’ ‘‘ybut only three weeks have passed’’ Assessment phase Sign Identification of objective information about health status ‘‘ydry skin that easily becomes bruised’’ ‘‘ysleeps a lot even during the day’’ Valuation Identifying the value of something ‘‘Dry skin is easily rectified with the help of some moisturising cream and it is very important to rub it in after washing’’ Nursing ethics A guideline for the nursing care given at the nursing home, or for the nurse in particular ‘‘Turning the patient repeatedly at night time interrupts sleep and a good night’s sleep is valuable’’ Prerequisite Identifying circumstances needed for the trustworthiness of the reasoning ‘‘It might not be totally wrong to lose a few kilos but she must not do it too quickly either’’ Assumption A starting point for reasoning that is not taken for granted. ‘‘It takes time for older people to recover’’ Conclusion A judgement reached from evaluating signs and/or facts ‘‘y 1000 ml glucose is not at all enough to provide nourishment’’ Planning phase General action An action that is indirectly tied to the person in focus for the nursing given, for example making phone calls, taking contacts, reporting, documenting ‘‘ I ought to speak to the doctor about this’’ ‘‘I can contact the hospital and discuss it with the nurse’’ Routine An action taken on regular basis or as a rule ‘‘In cases like this the person gets an anti-decubitus mattress as a rule’’ Nursing action An action nurses decide about and have the responsibility for. It can be specific or general. ‘‘ywe have nutritious drinks and nutritional supplements here, so we can offer these to her’’ Paramedic action An action decided upon by an occupational therapist or a physiotherapist ‘‘ywe have to ask an occupational therapist about one of those fancy mattresses’’ Treatment Medical prescription ‘‘yI suppose we must have a discussion with the doctor about inserting a feeding tubey’’ Goal Description of an endpoint, which one aims to reach ‘‘We have to be careful when we turn her over and hold her so we do not harm the skin’’ Implementation phase Procedure Description of how to do or perform a task ‘‘We shall look at different criteria, inspect the skin, how they eat, if they are heavy or thin, how they can move about y’’ Making priorities Pointing out the importance of a task ‘‘At first we have to relieve the pressure from the skin’’ Evaluation phase Following-up Description of how to evaluate the result or what to evaluate ‘‘y in this case I would weigh the lady once a weeky’’ The part of the citation written in italics is the part in focus for the specific concept. Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1113 one respondent associated this directly to an increased risk of developing pressure ulcersy Urine and faeces incontinence, the use of a diaperythen it is about preserving her skin and preventing pressure ulcers and such. Another difference between the two groups was that none of the ‘‘consultant nurses’’ connected nutrition directly to pressure ulcer prevention. The indirect reasoning was mainly about keeping the person well nourished to promote well-being and rehabilitation but the fact that she was overweight also led to reasoningy She weighed far too much before she got illy now she has probably lost a few pounds as she has only had some nourishment intravenously y I have to take a closer look into this when I see hery it’s not about putting an old person on a diet, on the contrary she has to be well nourished to recover. In a few cases, the participants connected her overweight to an increased risk of pressure ulcer development and later when the person had lost 7 kg the views about this differed, was it good or bad? she has lost seven kilosy but maybe it’s okay. Earlier she was really big, immobile and heavy so it might not be all bad. It’s easier for her and for us when she weighs less. A majority of the participants made a direct connection between the person’s immobility and the risk of pressure ulcers in their reasoning implementing a special mattress. A few participants made this connection already before they had ‘‘met’’ her, one expressed it like this. There is a big risk of pressure ulcers here, her fragile skin, she’s incontinent and she is mostly in bed y.maybe she will need an antidecubitus mattress immediately. On the whole this was the most common preventive action taken. Among those who did not reason directly about the risk of pressure ulcer in connection to ‘‘activity’’, most reasoned in a general way about how to mobilise and the need for a repositioning schedule during the day, as well as at nighty We will have to assess how often we need to turn her at night, maybe not so often if it’s possible. She needs to sleep at night. ARTICLE IN PRESS Table 2 Occurrence of reasoning in connection with derived concepts and the different phases in the nursing process Concept Before arrival (n ¼ 10) The day after (n ¼ 11) Three weeks later (n ¼ 11) Time 3 5 4 Assessment phase 54a (52b ,56c )% 64a (58b ,70c )% 76a (75b ,76c )% Sign 10 11 11 Valuation 7 10 11 Nursing ethics 1 7 7 Prerequisite 6 1 3 Assumption 6 8 8 Conclusion 6 5 10 Planning phase 62a (58b ,66c )% 65a (63b ,66c )% 69a (66b ,73c )% General action 10 11 9 Routine 3 2 1 Nursing action 10 11 11 Paramedic action 8 6 9 Treatment 3 6 6 Goal 7 7 10 Implementation phase 55a (50b ,60c )% 55a (50b ,60c )% 59a (50b ,70c )% Procedure 5 7 6 Making priorities 7 5 7 Evaluation phase 9a (16b , 0c )% 45a (66b ,20c )% 100a (100b ,100c )% Following-up 1 5 11 a The average use of the concepts belonging to the specific phase based on all the 11 VPs. b The ‘‘consultant nurses’’ average use of the concepts belonging to the specific phase. c The ‘‘care nurses’’ average use of the concepts belonging to the specific phase. 1114 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 The significance of a comfortable wheelchair was also something many respondents highlighted from the very start but first when persistent discolouration of the skin over the sacrum occurred, began reasoning about the use of a pressure ulcer prevention cushion. Consulting an occupational therapist was part of many participants reasoning. In connection with the content area ‘‘skin’’, all respondents identified the risk of pressure ulcer development though four respondents did not make any direct reasoning until persistent discolouration was a fact. yoh I seey her bottom has become red. Then we can’t have her on her back at all, only turn her from side to sidey Early in the care-planning process, before or just after the person’s arrival, many participants focused on the need for skin care in their reasoning. Preparing the bed with extra pillows, rotation device etc was part of the reasoning, as was having a moisturising cream for her dry skin at hand in the room but also how to instruct the staff about the care needed. The RN, at the only nursing homes where they performed a structured pressure ulcer risk assessment on arrival, reasoned like thisy We check different criteria, such as skin, how they eat if they are heavy or skinny, how mobile they are. In my opinion Ebba runs a severe risk of developing pressure ulcers and that we have to prevent. When persistent discolouration had occurred, many of the participants reasoned that an explanation could be her malnutrition. Other explanations were also given, such as insufficient peripheral circulation and lack of turning routines. Most of the participants stressed the importance of regular turning from side to side but the view on massaging the discoloured part of the body differed from being totally avoided to being one of the most important actions to take. How the participants interpreted the discolouration also differed, some looked at it as first grade pressure ulcer and others as an increased risk of skin damage. The reasoning in connection with the person’s wellbeing and ability to communicate was not very extensive and only indirect reasoning in connection to pressure ulcer prevention was found. The importance of communicating with the person in the process of care planning was highlighted by some, as well as the importance of listening to what she has to say during their everyday worky She has slurred speech, so we will have to let her finish what she has to say and show her that we understand, that we have the time to stay and listenythis aspect is important for me to emphasise when I meet the staff. The fact that the person easily cried, that she was tired and apathetic led some participants to reason about the importance of well-being for her recovery and rehabilitation. Several interpreted her status as probable depression, important to deal with. Some stressed the importance of keeping her free from pain. The reasoning around well-being was also about how things link to each othery ythe tiredness probably arises from her not getting enough nourishment. We will have to see that she sleeps properly gradually activating her more and more but her tiredness is also due to her illnessy The content area of ‘‘nursing care management’’ concerning information, supervising and care planning ARTICLE IN PRESS Table 3 Number of respondents that directly (D) or indirectly (I) focused on the prevention of pressure ulcers in the three different parts of the case, seen in each group Content area Consultant nurses (n ¼ 6) Care nurses (n ¼ 5) Part 1a D/I Part 2b D/I Part 3c D/I Part 1a D/I Part 2b D/I Part 3c D/I Communication —/2 —/3 —/2 —/3 —/4 —/4 Breathing/circulation — 2/— — — 2/1 2/1 Nutrition —/3 —/3 —/5 1/3 1/3 —/5 Elimination —/1 —/2 —/1 1/2 1/3 —/2 Skin 1/1 2/2 6/— 2/2 2/3 5/— Activity 2/2 3/3 4/1 1/3 1/3 2/3 Wellbeing — —/1 —/2 —/1 —/1 —/2 Nursing care management 1/2 3/— —/1 2/2 —/2 3/— a Before arrival. b The day after arrival. c Three weeks after arrival. Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1115 emerged in several participants’ reasoning. In this case, both direct and indirect reasoning in connection with pressure ulcer prevention was found. One participant not only involved the staff in this but also the person herself and her daughter. Some reasoned about the importance of documentation in a way that can, indirectly, prevent pressure ulcer developmenty We usually document important things like this in her nursing journal such as the regular use of moisturising cream to keep her skin smooth. Then everyone knows. 5. Discussion 5.1. Method As the purpose of this study was to reveal both the thinking process and to reach an understanding of the content, TA together with PA and qualitative content analyses was chosen. Methods like grounded theory (Edwards et al., 2004) and phenomenography (Baker, 1997) as well as quantitative methods (Brynes and West, 2000), also used to explore clinical reasoning, were not seen as alternatives since none of these methods capture the flow of thinking. The data collected in this study by the use of TA during the simulated care-planning situation was very rich. In order to minimise the risk of influencing the thinking process and its content, the nurses were unaware of the focus on pressure ulcer prevention during the TA interview. None of the participants had any major problem with thinking aloud and talking aloud was rare. As the participants had very little problem with the flow of information and thought process the interviewer only rarely had to remind them to go on thinking aloud. In no other way did the interviewer prompt the participants. All this considered the risk for reconstruction was minimal. Almost all participants said that this was a very typical case, making it easy for them to imagine the person, which strengthens the trustworthiness of the study. Due to this, together with the fact that the case is authentic and standardised, comparisons between nurses and groups of nurses is made possible. Still there are limitations that must be considered to using a simulated case, such as reduction of task complexity due to the lack of influence of the senses, time and context. The standardisation itself also limits the cue seeking process. However, real practise situations cannot be standardized and are ethically more complex which can make it impossible to think aloud during the nursing task. In such cases, ‘‘think afters’’ or retrospective interviews have to be used, imposing a greater risk for reconstruction of the reasoning (Fonteyn et al., 1993; Greenwood, 1998). In order to obtain a description of nurses’ reasoning process during care planning, PA was chosen. A lot of time was spent in finding the deeper meaning of each step of the PA in order to avoid the unintentional influence of earlier studies’ findings enabling comparisons. The hardest step to get a grip on was the third, assertional analysis. The different kinds of assertions found however correspond well with assertions found by Fonteyn et al. (1993) and to some extent with Simmons et al. (2003). The causal assertion was the easiest to discover despite the fact that it was rare and it is the only one identified in this study as well as in the other two. As the purpose of the content analysis was to obtain a more detailed description of the content (Morgan, 1993) the analysis was not further abstracted into themes and categories. The result shows that taking pressure ulcer prevention as an example when analysing the interviews, enabled a variety of content areas to be viewed as intended. 5.2. Findings As clinical reasoning is about applying knowledge and experiences to solve a clinical situation, it is hardly surprising that the results of this study show that both process and content of the clinical reasoning during care planning are, to a great extent, individual. Besides personal qualities and characteristics, many factors differ between the individual participants, such as previous working experiences, content of education, academic level, etc. On a group level the reasoning did not differ much between RNs who work close to the elderly at the nursing homes, ‘‘care nurses’’ or more as consultants, ‘‘consultant nurses’’. The only differences shown were in the use of concepts. This study however is too small to say whether these differences are due to coincidence or to the way they perform their work. However seen as a whole there are certain patterns to be found. One general finding was that there were no clear limits between the different phases of the nursing process and neither did the reasoning keep to one phase at a time, instead it had a tendency to go back and forth. This result corresponds well with earlier studies (Fowler, 1997; Grobe et al., 1991; McCarthy, 2003) and might to some extent explain the problems in nursing documentation such as concordance between nursing records in nursing homes and actual nursing care shown in the study by Ehrenberg and Ehnfors (2001). This study, as well as that of McCarthy (2003) and Ehrenberg and Ehnfors (1999b), also indicates that nurses seldom use reasoning in order to achieve nursing diagnoses. Routine thinking among the RNs in this study is indicated by the rare use of the most complex assertion, the causal, as well as by the lack of strategies aiming to reduce cognitive strain. On the other hand, the fact that the reasoning increased over time, especially in ARTICLE IN PRESS 1116 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 connection with assessing and evaluation of the person’s needs, points towards an increasing complexity of the reasoning, the better the nurses know the person. This study also indicates that the content of reasoning is affected by how close to the elderly the RNs work. Nurses who, as part of their work, participated in the nursing care, ‘‘care nurses’’ reasoned to a greater extent in a holistic way focusing on more perspectives than consultant nurses did. The ‘‘consultant nurses’’ mostly have a larger number of residents to pay attention to, often without deeper knowledge about the person. It has been found in studies performed both in the community and in hospital settings that knowing the person is especially important for determining nursing care both ethically and technically. Furthermore, the continuity of care is of special importance in order to provide more than just physical aspects (Luker et al., 2000; Takamura and Kanada, 2003). Without personal knowledge about the person, the ‘‘consultant nurses’’ depend a lot on the information given through documentation and the nursing assistant calling for help. The fact that there are normally considerable shortcomings in the documentation in nursing homes (Ehrenberg and Ehnfors, 2001; Voutilainen et al., 2004) makes nursing documentation doubtful as a data source for pressure ulcer prevention and care planning. The documentation given in the simulated case to the participating RNs was richer and more complete than is normally the case, which was something most participants commented upon. Still the ‘‘consultant nurses’’ had a more limited reasoning, overlooking problems such as incontinence. This however correlates well with Gunningberg et al. (2001) who found that RNs seldom relate incontinence to the prevention of pressure ulcers. As RNs in Swedish nursing homes work more and more as consultants, this can affect the nursing care, endangering a holistic view of the residents, putting the residents at unnecessary risk. Though the correlation between nutritional status and pressure ulcer development is well documented (Christensson et al., 1999; Ek et al., 1991), only two nurses in this study made this correlation. This unawareness correlates well with findings made by Gunningberg et al. (2001). On a group level the ‘‘care nurses’’ had a greater focus on the person’s nutritional problems than the other group. The only area where the ‘‘consultant nurses’’ as a group had the most extensive reasoning and reasoned more often directly about pressure ulcer prevention was around the person’s activity. As immobility is shown to be the most important risk factor for pressure ulcer development (Lindgren et al., 2004), this awareness among RNs and all nursing staff is of great importance. The consciousness of the importance of skin care in relation to pressure ulcer prevention was high among most RNs in this study. However all except one lacked routines for identifying those at risk on admission or made a formal pressure ulcer risk assessment. In addition, the need for continuous skin inspections were recognised by very few. There was also some reasoning made and actions taken based on old ideas and tradition that were more or less in contradiction to evidence based practise and current guidelines, for example massaging discoloured skin, a result that correlates quite well with other studies (Buss et al., 2004; Gunningberg et al., 2001 Sharp et al., 2000;). This, together with the RNs’ tendency to think routinely with regard to pressure ulcer prevention, indicates a need for continuous further education in this area for RNs working at community care residences, such as nursing homes. The positive effect of staff education in reducing skin damage and pressure ulcers has been shown by Hunter et al.(2003) in a clinical trial at two nursing homes. On the whole, the focus on physical aspects was overwhelming in the RNs’ reasoning, even though quite a lot of information was given about other dimensions of the person’s well-being and ability to communicate. This, however, reflects quite well the current evidence-based guidelines concerning pressure ulcer prevention, where the importance of informing and educating the patient and involving the patient in the actions taken, are the only things highlighted, besides physical and technical aspects (Rycroft-Malone, 2001; Infomedica, 2004). 6. Conclusions and implications Reasoning concerning pressure ulcer prevention among the RNs in this study was dominated by routine thinking. However, getting to know the person over a period of time made a more complex reasoning possible. The RNs’ experiences, knowledge, together with how close to the elderly the RNs work, seem to be important factors that affect the content of reasoning. RNs who did not participate in the nursing care had a tendency to overlook certain areas of nursing in their reasoning when care planning, such as incontinence care. Reasoning based on old ideas and traditions, rather than on evidence where pressure ulcer prevention is concerned, reveals a need for continuous further education for RNs in this area. The way in which RNs perform their work at Swedish community care residences is changing, towards them only rarely participating directly in the nursing care. Thus, further studies in real practise situations, with the aim of exploring how this change affects the reasoning in care planning, the content of documentation and the care performed by the nursing staff would be of great interest. Acknowledgements We greatly acknowledge the support from Linko¨ping University as well as participating nurses. ARTICLE IN PRESS Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1117 References Baker, J.D., 1997. Phenomenography: an alternative approach to researching the clinical decision-making of nurses. Nursing Inquiry 4 (1), 41–47. Benner, P., 1984. From Novice to Expert: Excellence and Power in Clinical Practice. Addison-Wesley, Menlo Park, CA. Benner, P., Tanner, C.A., Chesla, C., 1996. Expertise in nursing practice. Springer, New York. Buss, I.C., Halfens, R.J.G., Huyer, A.-S.H., Kok, G., 2004. Pressure ulcer prevention in nursing homes: views and beliefs of enrolled nurses and other health care workers. 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A conceptual treadmill: the need for middle ground’ in clinical decision making theory. Journal of Advanced Nursing 30 (5), 1222–1229. Voutilainen, P., Isola, A., Muurinen, S., 2004. Nursing documentation in nursing homes—state of the art an implication for quality improvement. Scandinavian Journal of Caring Sciences 18, 72–81. Wipke-Tevis, D.D., Williams, D.A., Rantz, M.J., Popejoy, L.L., Madsen, R.W., Petrovski, G.F., Vogelmeiser, A.A., 2004. Nursing home quality and pressure ulcer prevention and management practices. Journal of American Geriatric Society 52 (4), 583–588. ARTICLE IN PRESS Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1119 International Journal of Nursing Studies 44 (2007) 1109–1119 Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study Kajsa Helena Funkessona,, Els-Marie Anba¨ckena , Anna-Christina Ekb a Department of Social and Welfare Studies, Linko¨ping University, Sweden b Department of Medicine and Care division of Nursing Science, Faculty of Health Sciences, Linko¨ping University, Sweden Received 16 September 2005; received in revised form 21 February 2006; accepted 27 April 2006 Abstract Background: Nurses’ clinical reasoning is of great importance for the delivery of safe and efficient care. Pressure ulcer prevention allows a variety of aspects within nursing to be viewed. Objective: The aim of this study was to describe both the process and the content of nurses’ reasoning during care planning at different nursing homes, using pressure ulcer prevention as an example. Design: A qualitative research design was chosen. Settings: Seven different nursing homes within one community were included. Participants: Eleven registered nurses were interviewed. Method: The methods used were think-aloud technique, protocol analysis and qualitative content analysis. Client simulation illustrating transition was used. The case used for care planning was in three parts covering the transition from hospital until 3 weeks in the nursing home. Result: Most nurses in this study conducted direct and indirect reasoning in a wide range of areas in connection with pressure ulcer prevention. The reasoning focused different parts of the nursing process depending on part of the case. Complex assertations as well as strategies aiming to reduce cognitive strain were rare. Nurses involved in direct nursing care held a broader reasoning than consultant nurses. Both explanations and actions based on older ideas and traditions occurred. Conclusions: Reasoning concerning pressure ulcer prevention while care planning was dominated by routine thinking. Knowing the person over a period of time made a more complex reasoning possible. The nurses’ experience, knowledge together with how close to the elderly the nurses work seem to be important factors that affect the content of reasoning. r 2006 Elsevier Ltd. All rights reserved. Keywords: Clinical reasoning; Elderly care; Nursing homes; Patient care planning; Protocol analysis What is already known about the topic? Nurses use different types of cognitive operators and strategies when they reason. The context is of importance for the reasoning process A variety of aspects differ between novices and experts in their reasoning process What this paper adds Reasoning concerning pressure ulcer prevention while care planning seems to be dominated by routine thinking. ARTICLE IN PRESS www.elsevier.com/locate/ijnurstu 0020-7489/$ – see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.04.016 Corresponding author. Tel.: +46 11 363511; fax: +46 11 125448. E-mail address: kajsa.funkesson@isv.liu.se (Kajsa H. Funkesson). Knowing the person over a period of time seems to make a more complex reasoning possible. The content of reasoning seems to be affected by how close to the person the RNs work. 1. Introduction Elderly people in Sweden moving to community care residences and in particular those of the nursing home kind, most often have a complex medical history with several diagnoses, which creates a great need of nursing care (The Swedish Board of Health and Welfare, 2001). The role among registered nurses working in nursing homes in Sweden varies. On an organisational level, most registered nurses at community care residences have two roles, one with the main responsibility for the nursing care and care planning for a limited number of residents and one with a consultative role for the care of a larger number of residents. The way the nurses perform the roles differs, at some community care residences nurses hardly ever participate in the care of the persons for whom they are principally responsible, at others they do. In both cases, they are the only staff with medical competence assessing the needs of the person. Considering this, the ability to reason and to use science and reliable experience in the reasoning process is of utmost importance, especially in connection with care planning and the delivery of safe and efficient care when acute problems occur for the client (Higgs and Jones, 2000; Higgs et al., 2001). So far not much is known about the reasoning process in relation to care planning for elderly persons living in community care residences The aim of this study was to describe nurses’ reasoning process during care planning for an elderly person who has just moved to a nursing home, as well as the content of the reasoning in relation to pressure ulcer prevention during different phases of care planning. 2. The reasoning process The reasoning process that takes place while making judgments about a person’s situation can be viewed from many different perspectives. Having to do with context and aim, it can be named critical thinking, reflective reasoning, diagnostic reasoning, decisionmaking, etc. In medicine and related areas, it is often called clinical reasoning. Fowler (1997) describes clinical reasoning as a process where multiple possibilities are processed while making judgments about a client’s situation, with the purpose of achieving a desired outcome. Simmons et al. (2003) characterise this process as recursive, where both inductive and deductive cognitive skills are used. Clinical reasoning can also be described simply as a process where knowledge and experience are applied to clinical situations, in order to develop a solution (Noll et al., 2001). Nurses’ reasoning is, to a great extent, dependant on the context in which it takes place (Crow et al., 1995; Thompson, 1999), which makes every situation unique. It is mainly about judging a person’s situation, seeing the needs and problems, making priorities and decisions about patient care (Junnola et al., 2002). In this paper, clinical reasoning is seen as a cognitive process, where both theoretical knowledge and personal experience are used in a unique care situation aiming to achieve a desired outcome for the person in focus. Greenwood (1998) differentiates between reasoning terminating in conclusions and in actions. The first is called theoretical reasoning, the second practical. When nurses lack clinical experience to handle a situation they need to reason theoretically. It is also important that the theory used is evidence based and contextually relevant (Higgs et al., 2001). In a study by Fowler (1997), six cognitive operators were found in the nurses’ reasoning; describing, explaining, evaluating, connecting, planning and judging. The purpose of these operators was to understand the situation and to produce judgements about incoming cues. Fowler (1997) also found six strategies in the reasoning; cue logic, framing, hypothesising, testing, reflective comparison and prototypical case reasoning. These were used to reduce cognitive strain, helping the nurse to manage the situation. Evidence from this study suggests that the context in which the reasoning takes place influences the use of cognitive operators and strategies. Within the last 25 years, several studies have been conducted with the aim of exploring the reasoning process in nursing. For example, Benner (1984, 1996), and Greenwood and King (1995) studied this process within expert and novice nurses and Simmons et al. (2003) within experienced nurses. It has also been explored in different contexts (Carr, 2004; McCarthy, 2003) and areas in nursing, of which one is care planning (Fowler, 1997; Grobe et al., 1991). However, studies have stated the importance of context and experience on the reasoning process but not on the way nurses perform their work. The way nurses reason and make decisions has been explored, either by the use of simulated cases, such as written scenarios (Fonteyn et al., 1993; Ritter, 2003) and computer simulations (Junnola et al., 2002), or by studies within real practise situations (Fonteyn and Fisher, 1995; Greenwood et al., 2000). 3. The study 3.1. Participants and contexts This study was conducted in one community in Sweden. To enable differences in the way registered ARTICLE IN PRESS 1110 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 nurses (RNs) perform their role to be represented in the study, all community care residences of the nursing home model, a total of eight, were included. Participating RNs should have more than 1 year of experience from working at the nursing home in question. All RNs who fulfilled the inclusion criteria were invited to participate but a maximum of two RNs from the same nursing home were allowed to be included. The invitation along with written information in which they were told that the study was about a care planning situation, was presented to the RNs by the head of the nursing home. A total of 11 female RNs from seven nursing homes gave their written informed consent. All were included. Six of the participating RNs, who came from four nursing homes, hardly ever participated in the nursing care (‘‘consultant nurses’’). Five of the participating RNs, coming from three nursing homes, worked closer to the residents and the nursing staff. These RNs participated in the care of those they were primarily responsible for on a regular basis (‘‘care nurses’’). The participants’ experience from working at nursing homes ranged from one and a half years to 15 years. Five had a nursing qualification older than 15 years. Three had a degree at bachelor level and one at master. Both groups, ‘‘consultant nurses’’ and ‘‘care nurses’’, had approximately the same distribution of personal data, such as age, nursing experience and level of nursing education. 3.2. Method The methods chosen were verbal protocol (VP) and protocol analysis (PA) also called think-aloud (TA) technique (Ericsson and Simon, 1984, 1993). This technique views the flow of information in our mind while reasoning and seeks to reveal the mental processes which take place during a problem solving task and has been well described by Ericsson and Simon (1984, 1993). Since the beginning of the 1980s, the think aloud technique has been used by nursing researchers to reveal nurses’ reasoning process (Benner, 1984; Greenwood and King, 1995; Simmons et al., 2003). Protocol analyses in four steps were chosen to analyse the incoming data (Ericsson and Simon,1993; Fonteyn and Fisher,1995). Investigation of the content of the reasoning was conducted by means of a qualitative content analysis (Mayring, 2000; Morgan, 1993). 3.3. Procedure Client simulation in terms of a written case was used as a mean for reasoning. This enabled a standardisation of the case and reasoning situation, which was considered important due to the aim and because of the different working situations at the nursing homes. The simulated case was based upon an authentic case about an 85-year-old woman who suffered a stroke resulting in severe problems within the physiological, psychological, social and spiritual areas. The simulation enabled the reasoning to be followed over a period of time. The presentation was structured according to a model called VIPS (Ehrenberg et al., 1996) well known to the participants. The VIPS model used in this study is a model for documentation of nursing care based upon the nursing process which has been adapted to documentation in nursing homes (Ehrenberg and Ehnfors, 1999a). It includes nursing history, status, diagnoses, goals, outcome and a nursing discharge note (Ehrenberg et al., 1996). The presentation given to the participants included nursing history together with a nursing discharge note plus two nursing statuses. All TA interviews were performed individually at the nursing home, in a secluded room without any disturbance. After permission from the participants, the interviews were audiotaped. Information was given about the TA technique as well as the difference between thinking aloud and talking aloud. This was followed by a short practise session. The participants were informed that the task was about care planning for a person who was moving into ‘‘their’’ nursing home after a period of hospital care and that they had the role of nurse responsible for the person. They were also told that the case was to be presented in three parts, starting 1 day before arrival and ending 3 weeks later. Preceding each part, the investigator made a short introduction. Just before starting, they were reminded to think aloud and express everything that passed through their minds while care planning. If more than a moment of silence occurred during the interview, the investigator reminded them again. This was to assure that all thoughts were verbalized and that a minimum of time was left for reconstructions. The actual TA interviews varied between 60 and 90 min in time. The study was approved by the Research Ethics Committee of the Faculty of Health Sciences, Linko¨ping University (Registration number: 02-385). 3.4. Data analyses The interviews were transcribed verbatim into VPs. The first step of the PA, general analysis, focused on getting a broad sense of meaning and to capture that of interest for the aim of this study. Pressure ulcer prevention was chosen as an example because in this context this is of special importance, since hospitalised immobile persons in general (Lindgren et al., 2004) and the elderly in particular runs an increased risk of developing pressure ulcers (Margolis et al., 2002). Pressure ulcer prevention also serves as an indicator of the quality of care provided (Stephan-Haynes, 2004; Wipke-Tevis et al., 2004) and it allows a variety of important aspects within nursing to be viewed such as ARTICLE IN PRESS Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1111 nutrition, activity, wellbeing, etc. Parts that directly, or indirectly, referred to pressure ulcer prevention or the treatment of first degree of pressure ulcers were marked. Indirect parts were those of importance for the prevention of pressure ulcers but not spoken of as such, as in this example ‘‘ydry skin is easily rectified with a softening cream.’’ The procedure capturing parts of interest for the study were repeated twice on two different occasions. Marked parts were coded as directly or indirectly connected to the topic. The second step, referred phrase analysis, aimed to identify what the participants concentrated on during the interviews. Nouns and noun phrases used while reasoning were marked and coded as a concept. Each concept was given a preliminary definition which was refined as the analyses proceeded. Finally, they were sorted with help of the nursing process. To give a picture of the flow of the reasoning process in relation to the nursing process, each phrase was numbered in order of appearance. The numbered phrases were plotted on a graph, one for each participant. At the third step, assertional analysis, the VPs were further examined to establish the aim or purpose of each phrase in the reasoning process. In focus for the analysis were the different types of relationship formed between concepts found in the referred phrase analysis. With this in mind, each phrase in the VPs was coded. The assertions found in this process were gradually refined throughout the analysis. To enhance the validity of coding the phrases, this part of the procedure was repeated with some time in between. In cases where codes did not match, a re-examination of the phrase was performed. The fourth step of PA, script analysis, aimed to make conclusions concerning the respondents’ reasoning process. The coded VPs were now seen as a whole. The texts were coded once again this time using the cognitive operators and strategies found by Fowler (1997) as a reference frame. This procedure was repeated in the same way as in the last phase. It was intended that data not fitting into this frame would be analysed separately but no such data were found. The content analysis started with a reduction of text. In order to get a general view of what was said about pressure ulcer prevention the reduced VPs were read through again. To get a picture of how and when the nurses reasoned about pressure ulcer prevention, the indirect and direct reasoning were analysed. This was followed by making notes in the margin, underlining significant concepts, sorting text units into different content areas. As a starting point for these areas, the keywords from the VIPS model in the case were used. Text that did not fit into these areas was analysed separately. This resulted in one additional content area named ‘‘nursing care management.’’ Finally the whole text was read through again to make sure that the text units were well connected to their context. In order to visualise the content, for the two groups in the three parts of the case, the occurrence of direct and indirect reasoning within the different content areas was put together. A second researcher studied the content of the verbal protocols and followed the different steps of the analyses thoroughly. Differences of opinion were discussed, enabling codes etc to be refined continuously. The results of the analyses were carefully discussed throughout the whole process. On the whole however there was a high correspondence between the two researchers. 4. Findings The general analyses of the PA showed that most nurses in this study had an extensive reasoning as a whole, of which the main part directly or indirectly connected to prevention of pressure ulcer. The ‘‘referred phrase analyses’’ showed that all participants reasoned within assessing, planning, implementation and evaluation of the nursing process. Within these phases 16 different concepts, were found (Table 1). The six most frequently used where sign, valuation, general action, nursing action, paramedic action and goal. On an individual level, the reasoning differed greatly but looking at the participants as a whole and to the three parts of the case, the reasoning showed certain patterns, (Table 2). Planning was a phase focused on most throughout all three parts of the care planning but before arrival this was the main focus. The day after arrival, the reasoning focused on assessing almost as much as planning and the different actions were more often a result of the assessment, with nursing ethics as an important component in the reasoning. By now, all 11 participants had some reasoning connected to pressure ulcer prevention. The reasoning 3 weeks after arrival was the most comprehensive. In addition to assessing and planning, all participants, in one way or other, reasoned about how to follow up the results. As shown in Table 2, the analysis reveals some differences between ‘‘care nurses’’ and ‘‘consultant nurses’’ in their average use of concepts within the ‘‘implementation phase’’ and ‘‘evaluation phase’’. Focusing on the flow of reasoning, it was found that reasoning leading to an action was most often preceded by reasoning that went back and forth between different phases. Another finding was that abnormal cues led to a greater focus on the assessing phase. At the ‘‘assertional analysis’’ three different kinds of assertions were found in the reasoning. These were ‘‘implicational’’, tending to suggest or imply something, ‘‘significative’’, having a special meaning and ‘‘causal’’ focusing on cause and effect. The two most frequently used were implicational and significative. Causal assertions were rare. The ARTICLE IN PRESS 1112 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 ‘‘script analysis’’ where the use of cognitive operators and strategies in the nurses reasoning were analysed showed that cognitive strategies were infrequently used. Instead, the reasoning was dominated by the use of operators. However the operator ‘‘connecting’’, where the RNs consider possible relationships among cues, was rare. The findings of these two last steps of the PA analysis were true for both ‘‘consultant’’ and ‘‘care nurses’’. Looking at the content of the reasoning, the result shows certain differences between the participants on a group level (Table 3). On the whole, the ‘‘care nurses’’ held a broader reasoning. ‘‘Activity’’ was the only content area within which the ‘‘consultant nurses’’ reasoned the most. The content area elimination showed the biggest difference. Most of the ‘‘consultant nurses’’ did not focus on this aspect at all, or said that this aspect was taken care of by the nursing assistants. All ‘‘care nurses’’, on the other hand, reasoned about avoiding incontinence in a way that could, indirectly, help to prevent pressure ulcers. The importance of good hygiene was highlighted by several nurses in this group but only ARTICLE IN PRESS Table 1 Concepts derived from the referred phrase analyses Concept Definition Examples from the VPs Time (occurs in all phases) Chronological reference ‘‘yheavily overweight before she became ill’’ ‘‘ybut only three weeks have passed’’ Assessment phase Sign Identification of objective information about health status ‘‘ydry skin that easily becomes bruised’’ ‘‘ysleeps a lot even during the day’’ Valuation Identifying the value of something ‘‘Dry skin is easily rectified with the help of some moisturising cream and it is very important to rub it in after washing’’ Nursing ethics A guideline for the nursing care given at the nursing home, or for the nurse in particular ‘‘Turning the patient repeatedly at night time interrupts sleep and a good night’s sleep is valuable’’ Prerequisite Identifying circumstances needed for the trustworthiness of the reasoning ‘‘It might not be totally wrong to lose a few kilos but she must not do it too quickly either’’ Assumption A starting point for reasoning that is not taken for granted. ‘‘It takes time for older people to recover’’ Conclusion A judgement reached from evaluating signs and/or facts ‘‘y 1000 ml glucose is not at all enough to provide nourishment’’ Planning phase General action An action that is indirectly tied to the person in focus for the nursing given, for example making phone calls, taking contacts, reporting, documenting ‘‘ I ought to speak to the doctor about this’’ ‘‘I can contact the hospital and discuss it with the nurse’’ Routine An action taken on regular basis or as a rule ‘‘In cases like this the person gets an anti-decubitus mattress as a rule’’ Nursing action An action nurses decide about and have the responsibility for. It can be specific or general. ‘‘ywe have nutritious drinks and nutritional supplements here, so we can offer these to her’’ Paramedic action An action decided upon by an occupational therapist or a physiotherapist ‘‘ywe have to ask an occupational therapist about one of those fancy mattresses’’ Treatment Medical prescription ‘‘yI suppose we must have a discussion with the doctor about inserting a feeding tubey’’ Goal Description of an endpoint, which one aims to reach ‘‘We have to be careful when we turn her over and hold her so we do not harm the skin’’ Implementation phase Procedure Description of how to do or perform a task ‘‘We shall look at different criteria, inspect the skin, how they eat, if they are heavy or thin, how they can move about y’’ Making priorities Pointing out the importance of a task ‘‘At first we have to relieve the pressure from the skin’’ Evaluation phase Following-up Description of how to evaluate the result or what to evaluate ‘‘y in this case I would weigh the lady once a weeky’’ The part of the citation written in italics is the part in focus for the specific concept. Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1113 one respondent associated this directly to an increased risk of developing pressure ulcersy Urine and faeces incontinence, the use of a diaperythen it is about preserving her skin and preventing pressure ulcers and such. Another difference between the two groups was that none of the ‘‘consultant nurses’’ connected nutrition directly to pressure ulcer prevention. The indirect reasoning was mainly about keeping the person well nourished to promote well-being and rehabilitation but the fact that she was overweight also led to reasoningy She weighed far too much before she got illy now she has probably lost a few pounds as she has only had some nourishment intravenously y I have to take a closer look into this when I see hery it’s not about putting an old person on a diet, on the contrary she has to be well nourished to recover. In a few cases, the participants connected her overweight to an increased risk of pressure ulcer development and later when the person had lost 7 kg the views about this differed, was it good or bad? she has lost seven kilosy but maybe it’s okay. Earlier she was really big, immobile and heavy so it might not be all bad. It’s easier for her and for us when she weighs less. A majority of the participants made a direct connection between the person’s immobility and the risk of pressure ulcers in their reasoning implementing a special mattress. A few participants made this connection already before they had ‘‘met’’ her, one expressed it like this. There is a big risk of pressure ulcers here, her fragile skin, she’s incontinent and she is mostly in bed y.maybe she will need an antidecubitus mattress immediately. On the whole this was the most common preventive action taken. Among those who did not reason directly about the risk of pressure ulcer in connection to ‘‘activity’’, most reasoned in a general way about how to mobilise and the need for a repositioning schedule during the day, as well as at nighty We will have to assess how often we need to turn her at night, maybe not so often if it’s possible. She needs to sleep at night. ARTICLE IN PRESS Table 2 Occurrence of reasoning in connection with derived concepts and the different phases in the nursing process Concept Before arrival (n ¼ 10) The day after (n ¼ 11) Three weeks later (n ¼ 11) Time 3 5 4 Assessment phase 54a (52b ,56c )% 64a (58b ,70c )% 76a (75b ,76c )% Sign 10 11 11 Valuation 7 10 11 Nursing ethics 1 7 7 Prerequisite 6 1 3 Assumption 6 8 8 Conclusion 6 5 10 Planning phase 62a (58b ,66c )% 65a (63b ,66c )% 69a (66b ,73c )% General action 10 11 9 Routine 3 2 1 Nursing action 10 11 11 Paramedic action 8 6 9 Treatment 3 6 6 Goal 7 7 10 Implementation phase 55a (50b ,60c )% 55a (50b ,60c )% 59a (50b ,70c )% Procedure 5 7 6 Making priorities 7 5 7 Evaluation phase 9a (16b , 0c )% 45a (66b ,20c )% 100a (100b ,100c )% Following-up 1 5 11 a The average use of the concepts belonging to the specific phase based on all the 11 VPs. b The ‘‘consultant nurses’’ average use of the concepts belonging to the specific phase. c The ‘‘care nurses’’ average use of the concepts belonging to the specific phase. 1114 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 The significance of a comfortable wheelchair was also something many respondents highlighted from the very start but first when persistent discolouration of the skin over the sacrum occurred, began reasoning about the use of a pressure ulcer prevention cushion. Consulting an occupational therapist was part of many participants reasoning. In connection with the content area ‘‘skin’’, all respondents identified the risk of pressure ulcer development though four respondents did not make any direct reasoning until persistent discolouration was a fact. yoh I seey her bottom has become red. Then we can’t have her on her back at all, only turn her from side to sidey Early in the care-planning process, before or just after the person’s arrival, many participants focused on the need for skin care in their reasoning. Preparing the bed with extra pillows, rotation device etc was part of the reasoning, as was having a moisturising cream for her dry skin at hand in the room but also how to instruct the staff about the care needed. The RN, at the only nursing homes where they performed a structured pressure ulcer risk assessment on arrival, reasoned like thisy We check different criteria, such as skin, how they eat if they are heavy or skinny, how mobile they are. In my opinion Ebba runs a severe risk of developing pressure ulcers and that we have to prevent. When persistent discolouration had occurred, many of the participants reasoned that an explanation could be her malnutrition. Other explanations were also given, such as insufficient peripheral circulation and lack of turning routines. Most of the participants stressed the importance of regular turning from side to side but the view on massaging the discoloured part of the body differed from being totally avoided to being one of the most important actions to take. How the participants interpreted the discolouration also differed, some looked at it as first grade pressure ulcer and others as an increased risk of skin damage. The reasoning in connection with the person’s wellbeing and ability to communicate was not very extensive and only indirect reasoning in connection to pressure ulcer prevention was found. The importance of communicating with the person in the process of care planning was highlighted by some, as well as the importance of listening to what she has to say during their everyday worky She has slurred speech, so we will have to let her finish what she has to say and show her that we understand, that we have the time to stay and listenythis aspect is important for me to emphasise when I meet the staff. The fact that the person easily cried, that she was tired and apathetic led some participants to reason about the importance of well-being for her recovery and rehabilitation. Several interpreted her status as probable depression, important to deal with. Some stressed the importance of keeping her free from pain. The reasoning around well-being was also about how things link to each othery ythe tiredness probably arises from her not getting enough nourishment. We will have to see that she sleeps properly gradually activating her more and more but her tiredness is also due to her illnessy The content area of ‘‘nursing care management’’ concerning information, supervising and care planning ARTICLE IN PRESS Table 3 Number of respondents that directly (D) or indirectly (I) focused on the prevention of pressure ulcers in the three different parts of the case, seen in each group Content area Consultant nurses (n ¼ 6) Care nurses (n ¼ 5) Part 1a D/I Part 2b D/I Part 3c D/I Part 1a D/I Part 2b D/I Part 3c D/I Communication —/2 —/3 —/2 —/3 —/4 —/4 Breathing/circulation — 2/— — — 2/1 2/1 Nutrition —/3 —/3 —/5 1/3 1/3 —/5 Elimination —/1 —/2 —/1 1/2 1/3 —/2 Skin 1/1 2/2 6/— 2/2 2/3 5/— Activity 2/2 3/3 4/1 1/3 1/3 2/3 Wellbeing — —/1 —/2 —/1 —/1 —/2 Nursing care management 1/2 3/— —/1 2/2 —/2 3/— a Before arrival. b The day after arrival. c Three weeks after arrival. Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1115 emerged in several participants’ reasoning. In this case, both direct and indirect reasoning in connection with pressure ulcer prevention was found. One participant not only involved the staff in this but also the person herself and her daughter. Some reasoned about the importance of documentation in a way that can, indirectly, prevent pressure ulcer developmenty We usually document important things like this in her nursing journal such as the regular use of moisturising cream to keep her skin smooth. Then everyone knows. 5. Discussion 5.1. Method As the purpose of this study was to reveal both the thinking process and to reach an understanding of the content, TA together with PA and qualitative content analyses was chosen. Methods like grounded theory (Edwards et al., 2004) and phenomenography (Baker, 1997) as well as quantitative methods (Brynes and West, 2000), also used to explore clinical reasoning, were not seen as alternatives since none of these methods capture the flow of thinking. The data collected in this study by the use of TA during the simulated care-planning situation was very rich. In order to minimise the risk of influencing the thinking process and its content, the nurses were unaware of the focus on pressure ulcer prevention during the TA interview. None of the participants had any major problem with thinking aloud and talking aloud was rare. As the participants had very little problem with the flow of information and thought process the interviewer only rarely had to remind them to go on thinking aloud. In no other way did the interviewer prompt the participants. All this considered the risk for reconstruction was minimal. Almost all participants said that this was a very typical case, making it easy for them to imagine the person, which strengthens the trustworthiness of the study. Due to this, together with the fact that the case is authentic and standardised, comparisons between nurses and groups of nurses is made possible. Still there are limitations that must be considered to using a simulated case, such as reduction of task complexity due to the lack of influence of the senses, time and context. The standardisation itself also limits the cue seeking process. However, real practise situations cannot be standardized and are ethically more complex which can make it impossible to think aloud during the nursing task. In such cases, ‘‘think afters’’ or retrospective interviews have to be used, imposing a greater risk for reconstruction of the reasoning (Fonteyn et al., 1993; Greenwood, 1998). In order to obtain a description of nurses’ reasoning process during care planning, PA was chosen. A lot of time was spent in finding the deeper meaning of each step of the PA in order to avoid the unintentional influence of earlier studies’ findings enabling comparisons. The hardest step to get a grip on was the third, assertional analysis. The different kinds of assertions found however correspond well with assertions found by Fonteyn et al. (1993) and to some extent with Simmons et al. (2003). The causal assertion was the easiest to discover despite the fact that it was rare and it is the only one identified in this study as well as in the other two. As the purpose of the content analysis was to obtain a more detailed description of the content (Morgan, 1993) the analysis was not further abstracted into themes and categories. The result shows that taking pressure ulcer prevention as an example when analysing the interviews, enabled a variety of content areas to be viewed as intended. 5.2. Findings As clinical reasoning is about applying knowledge and experiences to solve a clinical situation, it is hardly surprising that the results of this study show that both process and content of the clinical reasoning during care planning are, to a great extent, individual. Besides personal qualities and characteristics, many factors differ between the individual participants, such as previous working experiences, content of education, academic level, etc. On a group level the reasoning did not differ much between RNs who work close to the elderly at the nursing homes, ‘‘care nurses’’ or more as consultants, ‘‘consultant nurses’’. The only differences shown were in the use of concepts. This study however is too small to say whether these differences are due to coincidence or to the way they perform their work. However seen as a whole there are certain patterns to be found. One general finding was that there were no clear limits between the different phases of the nursing process and neither did the reasoning keep to one phase at a time, instead it had a tendency to go back and forth. This result corresponds well with earlier studies (Fowler, 1997; Grobe et al., 1991; McCarthy, 2003) and might to some extent explain the problems in nursing documentation such as concordance between nursing records in nursing homes and actual nursing care shown in the study by Ehrenberg and Ehnfors (2001). This study, as well as that of McCarthy (2003) and Ehrenberg and Ehnfors (1999b), also indicates that nurses seldom use reasoning in order to achieve nursing diagnoses. Routine thinking among the RNs in this study is indicated by the rare use of the most complex assertion, the causal, as well as by the lack of strategies aiming to reduce cognitive strain. On the other hand, the fact that the reasoning increased over time, especially in ARTICLE IN PRESS 1116 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 connection with assessing and evaluation of the person’s needs, points towards an increasing complexity of the reasoning, the better the nurses know the person. This study also indicates that the content of reasoning is affected by how close to the elderly the RNs work. Nurses who, as part of their work, participated in the nursing care, ‘‘care nurses’’ reasoned to a greater extent in a holistic way focusing on more perspectives than consultant nurses did. The ‘‘consultant nurses’’ mostly have a larger number of residents to pay attention to, often without deeper knowledge about the person. It has been found in studies performed both in the community and in hospital settings that knowing the person is especially important for determining nursing care both ethically and technically. Furthermore, the continuity of care is of special importance in order to provide more than just physical aspects (Luker et al., 2000; Takamura and Kanada, 2003). Without personal knowledge about the person, the ‘‘consultant nurses’’ depend a lot on the information given through documentation and the nursing assistant calling for help. The fact that there are normally considerable shortcomings in the documentation in nursing homes (Ehrenberg and Ehnfors, 2001; Voutilainen et al., 2004) makes nursing documentation doubtful as a data source for pressure ulcer prevention and care planning. The documentation given in the simulated case to the participating RNs was richer and more complete than is normally the case, which was something most participants commented upon. Still the ‘‘consultant nurses’’ had a more limited reasoning, overlooking problems such as incontinence. This however correlates well with Gunningberg et al. (2001) who found that RNs seldom relate incontinence to the prevention of pressure ulcers. As RNs in Swedish nursing homes work more and more as consultants, this can affect the nursing care, endangering a holistic view of the residents, putting the residents at unnecessary risk. Though the correlation between nutritional status and pressure ulcer development is well documented (Christensson et al., 1999; Ek et al., 1991), only two nurses in this study made this correlation. This unawareness correlates well with findings made by Gunningberg et al. (2001). On a group level the ‘‘care nurses’’ had a greater focus on the person’s nutritional problems than the other group. The only area where the ‘‘consultant nurses’’ as a group had the most extensive reasoning and reasoned more often directly about pressure ulcer prevention was around the person’s activity. As immobility is shown to be the most important risk factor for pressure ulcer development (Lindgren et al., 2004), this awareness among RNs and all nursing staff is of great importance. The consciousness of the importance of skin care in relation to pressure ulcer prevention was high among most RNs in this study. However all except one lacked routines for identifying those at risk on admission or made a formal pressure ulcer risk assessment. In addition, the need for continuous skin inspections were recognised by very few. There was also some reasoning made and actions taken based on old ideas and tradition that were more or less in contradiction to evidence based practise and current guidelines, for example massaging discoloured skin, a result that correlates quite well with other studies (Buss et al., 2004; Gunningberg et al., 2001 Sharp et al., 2000;). This, together with the RNs’ tendency to think routinely with regard to pressure ulcer prevention, indicates a need for continuous further education in this area for RNs working at community care residences, such as nursing homes. The positive effect of staff education in reducing skin damage and pressure ulcers has been shown by Hunter et al.(2003) in a clinical trial at two nursing homes. On the whole, the focus on physical aspects was overwhelming in the RNs’ reasoning, even though quite a lot of information was given about other dimensions of the person’s well-being and ability to communicate. This, however, reflects quite well the current evidence-based guidelines concerning pressure ulcer prevention, where the importance of informing and educating the patient and involving the patient in the actions taken, are the only things highlighted, besides physical and technical aspects (Rycroft-Malone, 2001; Infomedica, 2004). 6. Conclusions and implications Reasoning concerning pressure ulcer prevention among the RNs in this study was dominated by routine thinking. However, getting to know the person over a period of time made a more complex reasoning possible. The RNs’ experiences, knowledge, together with how close to the elderly the RNs work, seem to be important factors that affect the content of reasoning. RNs who did not participate in the nursing care had a tendency to overlook certain areas of nursing in their reasoning when care planning, such as incontinence care. Reasoning based on old ideas and traditions, rather than on evidence where pressure ulcer prevention is concerned, reveals a need for continuous further education for RNs in this area. The way in which RNs perform their work at Swedish community care residences is changing, towards them only rarely participating directly in the nursing care. Thus, further studies in real practise situations, with the aim of exploring how this change affects the reasoning in care planning, the content of documentation and the care performed by the nursing staff would be of great interest. Acknowledgements We greatly acknowledge the support from Linko¨ping University as well as participating nurses. ARTICLE IN PRESS Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1117 References Baker, J.D., 1997. Phenomenography: an alternative approach to researching the clinical decision-making of nurses. Nursing Inquiry 4 (1), 41–47. Benner, P., 1984. From Novice to Expert: Excellence and Power in Clinical Practice. Addison-Wesley, Menlo Park, CA. Benner, P., Tanner, C.A., Chesla, C., 1996. Expertise in nursing practice. Springer, New York. Buss, I.C., Halfens, R.J.G., Huyer, A.-S.H., Kok, G., 2004. Pressure ulcer prevention in nursing homes: views and beliefs of enrolled nurses and other health care workers. 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A conceptual treadmill: the need for middle ground’ in clinical decision making theory. Journal of Advanced Nursing 30 (5), 1222–1229. Voutilainen, P., Isola, A., Muurinen, S., 2004. Nursing documentation in nursing homes—state of the art an implication for quality improvement. Scandinavian Journal of Caring Sciences 18, 72–81. Wipke-Tevis, D.D., Williams, D.A., Rantz, M.J., Popejoy, L.L., Madsen, R.W., Petrovski, G.F., Vogelmeiser, A.A., 2004. Nursing home quality and pressure ulcer prevention and management practices. Journal of American Geriatric Society 52 (4), 583–588. ARTICLE IN PRESS Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1119 s 3 6 9 research j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 © 2 0 1 4 M A H e a l t h c a r e l t d Pressure ulcer risk assessment and prevention: What difference does a risk scale make? A comparison between Norway and Ireland l Objective: To explore similarities and differences in nurses’ views on risk assessment practices and preventive care activities in a context where patients' risk of developing pressure ulcers is assessed using clinical judgment (Norway) and a context where patients’ risk of developing pressure ulcers is assessed using a formal structured risk assessment combined with clinical judgement (Ireland). l Method: A descriptive, qualitative design was employed across two different care settings with a total of 14 health care workers, nine from Norway and five from Ireland. l Results: Regardless of whether risk assessment was undertaken using clinical judgment or formal structured risk assessment, identified risk factors, at risk patients and appropriate preventive initiatives discussed by participant were similar across care settings. Furthermore, risk assessment did not necessarily result in the planning and implementation of appropriate pressure ulcer prevention initiatives. Thus, in this instance, use of a formal risk assessment tool does not seem to make any difference to the planning, initiation and evaluation of pressure ulcer prevention strategies. l Conclusion: Regardless of the method of risk assessment, patients at risk of developing pressure ulcers are detected, suggesting that the practice of risk assessment should be re-evaluated. Moreover, appropriate preventive interventions were described. However, the missing link between risk assessment and documented care planning is of concern and barriers to appropriate pressure ulcer documentation should be explored further. l Declaration of interest: This work is partly funded by a research grant from the Norwegian Nurses Organisation (NNO) (Norsk Sykepleierforbund NSF) in 2012. The authors have no conflict of interest to declare. pressure ulcer; risk assessment; prevention; focus group; Norway; Ireland Within healthcare practice today, regardless of the clinical setting, the prevalence and incidence of pressure ulcers is considered to be a key quality indicator.1 Indeed, a recent publication from the European Parliament focusing on patient safety calls on the Member States to encourage healthcare providers to focus on pressure ulcers, which they highlight are a major but often hidden problem.2 Pressure ulcers pose a significant problem for individuals, with all components of the activity of daily living adversely affected.3 Worryingly, pain is one of the most common complaints, which is often suggested to be intractable and exacerbated by treatment and prevention strategies employed.3 For health services, pressure ulcers are expensive, occupying up to 4% of health budgets, with nursing time accounting for up to more than 90% of costs.4,5 Bearing in mind the significance of pressure ulcers for the individual3 and society as a whole,4 coupled with the knowledge that most pressure ulcers can be prevented6 establishment of focused prevention strategies is suggested to be the key to success.7 The focus for pressure ulcer prevention has been primarily on identifying those at risk of pressure ulcer development and following this up with implementation of appropriate pressure ulcer prevention strategies.8 For those settings using formal risk assessment, the mean percentage of patients assessed is 57.25%, varying from 24% to 100%.9 One of the concerns here is that there are a plethora of risk assessment tools in current use, yet none has been demonstrated to be 100% reliable and valid.10–12 In general, each tool is developed for certain patients, or as a result of a search of the literature. As patients vary considerably regarding age, health status and pressure ulcer risk, in addition to the fact that institutions can choose which scale to use, there is a possibility that risk tools are not always uniquely developed for those specific patients cared for within each clinical setting. This compounds the challenges for healthcare providers in being able to correctly identify those at risk. Potentially, this could mean that clinical staff do not trust the current formal structured risk assessment tools and therefore, consider use of alternate methods of assessment.9 Thus, arguments abound in the literaE. Johansen,1 assistant professor, Bsc, Msc, RN; Z. Moore,2 professor and head of the school of nursing and midwifery, PhD, MSc, FFNMRCSI, PG Dip, RGN; M. van Etten3 ; physiotherapist, seating & mobility consultant, H. Strapp,4 tissue viability clinical nurse specialist, RGN, RSCN, RNP, MSc, PG Dip; 1 Faculty of Health Sciences Buskerud and Vestfold University College Drammen, Norway; 2 Royal College of Surgeons in Ireland, Ireland; 3 Halden, Norway; 4 AMNCH, Dublin 25, Ireland Email: Edda.Johansen@ hbv.no 3 7 0 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d ture pertaining to whether clinical judgment is as effective as formal structured risk assessment, yet just two studies have explored this from a randomised controlled trial perspective.13,14 Neither study found any difference in pressure ulcer incidence whether patients were assessed using formal structured risk assessment or whether assessed using clinical judgment alone. However, in interpreting these studies, one needs to question the concept of “clinical judgment” and how it is developed. Clinical judgment is considered to be an outcome and is arrived at following the process of critical thinking and critical reasoning.15 In this context it is taken to mean the judgment by the healthcare professional of the patient’s risk status following assessment of the patient and the perception of the healthcare professional of the risk factors that the individual patient presents with. Prior knowledge and experience of use of formal, structured risk assessment tools will inevitably influence clinical judgment, as it is impossible to unlearn what has been learned during clinical use of such risk assessment tools.12 Thus, to determine clearly if clinical judgment alone is as good as, or better than, formal structured risk assessment, it is important that confounding variables, such as prior use of the risk assessment tool, are eliminated.16 This was not the case in the studies of Saleh et al.13 and Webster et al.14 Conversely, in Norway, the use of formal structured risk assessment as a component of pressure ulcer risk assessment has yet to be established.17 Thus, in general, staff has no experience and little knowledge of instruments such as Waterlow, Norton, Modified Norton or Braden. This means that in Norway, clinical judgment alone is being used as a means of assessing patients’ risk of pressure ulcer development. Further, this clinical judgment is, in most circumstances, not influenced by prior experience of risk assessment tools.17 Such a clinical setting provides an ideal medium to explore clinical risk assessment and prevention practices and compare these with a setting where formal structured risk assessment is commonplace. In terms of pressure ulcer prevention, an issue of concern is that, despite considerable investment in education and training, research has identified significant deficits in patients receiving fully appropriate interventions to combat risk.18–20 Indeed, an integrative review by Moore et al.9 found that the mean use of pressure redistribution devices was 60%, varying from 28% to 97.3%. Furthermore, the mean use of repositioning for pressure ulcer prevention was 19%, varying from 0% to 37%.9 Overall the mean recording of pressure ulcer presence or prevention strategies within the nursing notes was 46.4%, varying from 9% to 70%.9 It is clear, therefore, that there are significant challenges in achieving the goals of pressure ulcer prevention as outlined in best practice guidelines,8 and this has significant implications for patients themselves and for achievement of quality and safety standards.2 Questions are raised pertaining to the value of formal, structured risk assessment as compared to clinical judgment alone, in addition to how either of these risk assessment methods act as a precursor to risk intervention. Norway and Ireland were chosen as the settings for this current study as Ireland uses formal structured risk assessment and Norway does not. This provides an ideal opportunity to explore how nurses describe their risk assessments and preventive practices in the two care settings. Thus, the aim of this study was to compare pressure ulcer risk assessment practices and preventive care activities between Ireland and Norway as perceived and experienced by nurses in either country. Methods Study design A descriptive, qualitative design was employed to explore nurses’ views on pressure ulcer risk assessment and preventive practices across two different care settings within Norway and Ireland. A qualitative research approach was chosen as it is considered an appropriate design where limited knowledge exists on a phenomenon,21 as was the situation for this study. Setting and participants This study was carried out in Norway and Ireland with a total of 14 healthcare workers, nine from Norway and five from Ireland. In Norway, participants were recruited from a cohort of 19 wound care students, nurses and social educators working with patients in different healthcare sectors in different parts of Norway. As the first author (EJ) was closely connected to the course and the students informing the study, the recruitment of participants was handled by a department secretary through email correspondence. Seven nurses and two social educators working in hospitals, home care and nursing homes, aged 28–51 years, with 4 to 9 years of clinical experience volunteered and subsequently participated in the study. In Ireland, nurses from 7 clinical sites within an acute care hospital setting received an invitation to participate in the study. As only 3 staff nurses and 2 clinical nurse managers volunteered, they were all invited to participate in the study. The participants from Ireland were working in a variety of clinical settings, including surgery, acute medicine, orthopedics and acute care of the older person. These participants were aged between 25–54 years, with 2 to 30 years of service. All participants (Norway and Ireland) were female. 3 7 2 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d Data collection A semi-structured interview design was chosen as it ensured that specific topics were covered while also being open to any spontaneous information proffered by respondents.22 Two focus group interviews were carried out, one in November 2012 (Norway) and a second interview in April 2013 (Ireland). A focus group is a method of systematic questioning used for obtaining qualitative data from many people.23 Interaction between group members can contribute to rich information and conflicting viewpoints can further enhance the overall knowledge about a topic.24 Focus group interviewing was therefore chosen for this study as it had the potential to expose similarities and disparities in clinical practice, both within and across countries. The questions used to guide the interview process included: 1. Can you tell us your experiences with pressure ulcers?; 2. Can you tell us how you risk assess patients for pressure ulcer?; 3. Tell us what makes patients at risk of developing a pressure ulcer; 4. Tell us how you prevent pressure ulcers; 5. Tell us what you know about risk assessment scales; and 6. Are there any other issues regarding pressure ulcers you would like to tell us about? Because rich information can be gathered when informants describe their experiences through concrete stories, respondents were encouraged to give examples from clinical practice.24 In the focus group interviews, one researcher was leading the interview while others kept field notes. The researchers’ roles were clarified for the participants at the onset of the interviews. In Norway, the first author (EJ) conducted the interview while in Ireland HS conducted the interview with ZM clarifying questions and taking notes. The third author (MvE) participated in both interviews as an observer, making field notes on nonverbal cues, agreements or disagreements, interest or disinterest of the participants and group dynamics. As data analysis began when field notes were made, having the same observer in both settings increased the immediate opportunity to reflect on similarities and differences in practices within and across countries. At the beginning of the focus groups the participants were thanked for their participation and a meal was provided. The study purpose was reiterated and it was emphasised that all participants’ experiences and opinions were valuable and that no right or wrong answers existed. Written consent was received from the participants. The focus groups were audio taped and transcribed verbatim by EJ (Norwegian interview) and ZM (Irish interview). Data analysis The analysis of the interviews began in the focus group settings and continued while the researchers transcribed and became familiar with the material. In qualitative studies, researchers’ different viewpoints on the same findings might increase the understanding of complex phenomena.25 To enhance the study trustworthiness, the Irish transcript was analysed independently by three Englishspeaking researchers (EJ, MvE, ZM) and the Norwegian transcripts independently by the bilingual speakers (EJ and MvE). The individual interpretations and conclusions for each interview were discussed until consensus was reached. Field notes and the third author’s experiences (MvE) from the observer role were integrated in the analysis. The interpretations and conclusions made by the three English-speaking researchers on the English interview were verified by the fourth author (HS), whereas the bilingual researchers were responsible for analysis of the Norwegian interview. The overarching themes from the Norwegian interview were translated into English. This study followed the inductive content analyses process described by King and Horrocks.26 The analysis involved reading and re-reading of the transcripts and highlighting with a marker those sections of the transcripts that provided an understanding of pressure ulcer risk assessment and preventive care. The highlighted phrases were tabulated and what was of interest within the extracted transcripts was noted in the table. The next step involved the formulation of descriptive codes from the interview extracts without any interpretation or ideas on what lay behind. The table now had three sections; interview extracts, comments of what was of interest and descriptive codes. The next step of the analysis was to interpret the meaning of the descriptive codes, and group the codes that seemed to share some common meaning, thereby reducing the material further. The interview extracts were then viewed together with the descriptive codes resulting in a third step involving the development of the interpretative codes. This way of registering data made it possible to view the stages of the analysis while keeping the research questions in the forefront. The final step was to develop the overarching themes26 which involved looking across both sets of interviews to elicit similarities and differences across countries. Ethics The study was approved by the Norwegian Social Science Data Services and the Research Ethics Committee of the participating hospital in Ireland. Participation was voluntary and participants were guaranteed anonymity, and signed informed consent was collected in the interview settings. Written s j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 3 7 3 research © 2 0 1 4 M A H e a l t h c a r e l t d information, outlining the study and its aim, was sent by e-mail before to the interview to allow time to ask questions about the study and assess whether to participate or not. Results Risk assessment practice The focus groups confirmed that risk assessment practices varied across the two countries. Norwegian participants were generally unfamiliar with formal, structured risk assessment scales, leaving pressure ulcer risk assessment based solely on clinical judgment. However, one Norwegian participant mentioned that risk assessment scales had been discussed at her workplace: “Starting now to discuss one such risk assessment tool, the Braden scale, to assess patients who get to us from hospitals or home. We are at bit at the starting line yet but what we have thought about (pause), that’s what we have thought about (Braden scale)”. [Norway] Nurses in Ireland, on the other hand, routinely used a numeric risk assessment tool in combination with clinical judgment: “I don’t know what they do in other wards but I know in our ward, no matter what, we have to have a skin care plan on everybody so we assess their skin and Maelor score”. [Ireland] “I think everybody has a Maelor score when they are admitted, you know, or when they come to the ward, It’s part of the admission”. [Ireland] Overall, the Maelor score was undertaken in patients primarily on admission, after which the nurses relied on their clinical assessment of the patient and existing care plans for further monitoring of the patients risk status. However, one respondent suggested that accurate care planning was dependent on staffing levels, competence and time. Due to staff shortages, care plans were not always updated, leaving some nurses continuing to use the Maelor score to determine the patients risk status. Conversely, another participant suggested that they would never go back to reassess the patient’s Maelor score; furthermore, this participant felt that although the risk assessment highlighted the patient’s risk, it would have to be followed by a full patient assessment: “It just highlights it, then you go and assess the patient physically”. [Ireland] From the Irish data, it emerged that there was an expectation by others that risk assessment using the established formal risk assessment tool would be conducted on all patients. As such, nurses were asked to provide evidence of the risk assessment undertaken: “Over the last few months the XX consultants are asking how the patients’ skin is, we are not used to that”. [Ireland] The nurses expressed that being “checked” undermined their scope of practice: “Recently the XX consultant is giving step-bystep instructions on pressure ulcer prevention and it is demeaning to nursing”. [Ireland] Pressure ulcer risk In both countries, the main risk factors described for pressure ulcer development were immobility, poor skin, incontinence and nutritional state. Immobility was identified as being particularly important in both countries: “It has to be the mobilisation, how mobile is the patient”? [Ireland] “If you have a patient that is mobile which you come across, then you do not have to think so much about pressure ulcers”. [Norway] It became clear from the data that the risk factors considered important and the types of patients deemed to be at risk, as outlined by the participants, concurred across both countries. However, because some nurses in Ireland worked in orthopaedic wards, they also described post-operative immobilisation as a significant pressure ulcer risk factor. Further, the presence of comorbidities and diabetes were also considered important in Ireland. In Norway, a lack of pressure ulcer knowledge among patients was considered to place the individual at risk; however, this was not mentioned by the nurses in Ireland: “I think the knowledge patients themselves hold is too limited. They haven’t been told they mustn’t lie on the side where they have an ulcer”. [Norway] Overall, participants in both focus groups discussed risk factors for pressure ulcer development, freely. There was general consensus among the groups of the most pertinent factors to consider and 3 7 4 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d the interactions between the focus group members indicated that they were comfortable with this concept. Not surprisingly, the importance of overall risk scores being an indication of risk status emerged only in the data from Ireland. Pressure ulcer prevention The focus groups revealed that, independent of risk assessment practices across countries, skin assessment and care, pressure relief, turning, nutrition care and access to necessary equipment were important for preventive strategies. However, access to appropriate mattresses seemed to be easier in Ireland than in Norway. In Ireland, unlike Norway, the Maelor scoring and care planning was regarded as important for pressure ulcer prevention. In Ireland for instance, results of the risk assessment was used to request other interventions for the patient such as nutritional assessment: “Order [sic] a dietician if necessary – useful in this way”. [Ireland] The importance of involving other professions to get the necessary equipment was only mentioned in Norway: “Pressure relief, turning schedules and then get the physiotherapist on board to get necessary equipment”. [Norway] The data revealed that the participants discussed preventive strategies at the same time as they described risk and risk assessment, making assessments and planning of interventions into integrated activities. For instance, in the Irish transcript the importance of care plans was described concurrently while describing risk assessments and risk factors: “We skin assess/risk score and develop a care plan on everyone …everyone has a care plan”. [Ireland] This means that risk assessment was not seen as a separate entity to planning prevention strategies, thus, nurses may in fact be integrating both risk assessment and prevention planning into a single activity. Care planning In Ireland, standardised care plans were used, however, these were often referred to as a “tick-the-box” exercise: “But a lot of the time, the care plans are a ticking exercise for nurses to kind of cover themselves. I’m not convinced that it’s (the prevention) done as well as the care plan”. [Ireland] In Norway, respondents suggested that care plans for prevention were rare, however, care plans were developed when wounds were formed: “We are not so clever at prevention, but we are very good at treating wounds when they have originated”. [Norway] Interestingly the participants in Ireland also suggested that care planning differed, becoming more focused if the patient had an existing pressure ulcer: “The care plans are all right when they are done …we can’t 100% depend on the care plan. But the skin ones are done well, if someone has a dressing, the care plan is good”. [Ireland] Participants in Ireland indicated that they would be reminded by consultants if care plans were missing and that this made them very “care-plan oriented”. This also influenced the updating of care plans: “But we update them every week because it’s something we are supposed to do”. [Ireland] “The consultants would pick it up if they find that something is wrong, they will ask – show me where it is documented – so, you know, we are very care-plan orientated”. [Ireland] Despite this, the importance of care plans for practice was unclear in both countries: “We don’t use them for reports (handing over information to other staff members) as such”. [Ireland] “We do not manage to keep them alive [the care plans]”. [Norway] Thus, the focus group interviews revealed that care plans may be missing and furthermore, existing care plans might not be used, leading to a disparity between care planning and the care actually provided. Indeed, staff, time and competence were considered to be important for accurate care plan development and implementation: “We can’t 100% depend on the care plan, they are as good as our staff is” “…because it’s a time management issue”. [Ireland] s j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 3 7 5 research © 2 0 1 4 M A H e a l t h c a r e l t d Barriers to pressure ulcer prevention In both Norway and Ireland, the interview identified factors having a negative impact on pressure ulcer prevention, for instance a lack of staff: “When you need to reposition and in a way is relied on available staff to help, they are not always available”. [Norway] “If you are down carers or staff you don’t have the physical power to do it, because you have no one to help you, you are not getting as much emphasis on turning, it could be delayed”. [Ireland] In both countries, participants suggested that students and some staff lacked the necessary competence to prevent pressure ulcers. This was explained, in part, by a lack of focus on pressure ulcer prevention by educational institutions: “I know there was only one kind of lecture on skin care that was about it”. [Norway] “It tends to be the older nurses on the wards that focus on pressure area care because that was so drummed into us , it will always be a part of the way we nurse, but for the student nurse, it doesn’t seem to sort of focus really”. [Ireland] Thus, for some, their pressure ulcer competence was solely based on experiences from clinical practice and not from theoretical teaching around the topics. Equipment for pressure ulcer prevention The Norwegian participants described how pressure redistribution high-specification mattresses were not always available and that some of the base equipment for the beds was old and worn, lacking pressure redistribution properties. Conversely, the Irish respondents suggested that they had ready access to equipment, high specification mattresses and tissue viability services: “In the older days there were more pressure ulcers coming in because we hadn’t got the equipment like the special mattress and speciality like tissue viability”. [Ireland] In Ireland, participants suggested that results from the Maelor score justified the supply of additional high specification pressure redistribution mattresses. However, they felt that use of a high specification mattress could detract staff from considering other important aspects of pressure ulcer prevention: “When a mattress is ordered, then less focus is paid because staff says that the patient is ok now”. [Ireland] Or, on considering the suitability of the already existing equipment: “Overlays are ordered and people don’t know that the base mattress is very good and no additional equipment may be needed”. [Ireland] Overall, it is evident from the analysis of the data from the focus groups that there are differences in the approach to pressure ulcer prevention between countries. In Norway, risk assessment is undertaken using clinical judgement, whereas in Ireland formal risk assessment involves the combination of a specific risk assessment tool with clinical judgement. Despite this, risk factors for the development of pressure ulcers identified by both groups were similar, including the most appropriate interventions needed to reduce or eliminate this risk. Differences emerged pertaining to the use of documented care plans for pressure ulcer prevention, with those in Norway tending to focus less on preventive care planning. Discussion This study revealed that whether participants used a numeric risk assessment scale in combination with clinical assessments, or not, had little impact on what clinicians regarded to be risk factors, risk patients or relevant preventive initiatives. Identifying at-risk patients Participants from both countries identified patients at risk of pressure ulcer development to be those who were immobile, incontinent, with poor nutritional and skin status. Furthermore, across both countries, immobility was highlighted as the key risk factor. A recent systematic review by Coleman et al.27 and an integrative review by Moore et al.17 both note that activity and mobility were key risk factors for pressure ulcer development. Activity and mobility are included in many numeric risk assessment scales together with several other risk factors such as skin condition, nutritional status, level of consciousness, pain and incontinence.27 As risk scales are routinely used in Ireland, it is not surprising to find that at-risk patients fit the risk factors found in those scales. However, to find that Norwegian healthcare workers, who base their assessment on clinical assessments solely, correspond with the Irish respondents and also highlight 3 7 6 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d immobility as being important is noteworthy. Interestingly, in some of the risk assessment scales, age, nutrition and incontinence for instance, are weighed equally as important for pressure ulcer development as are mobility and activity.28 As pressure and shear most likely occur in immobilised or inactive patients, it is argued here that immobility is a key risk factor where other factors only become important if they lead to immobility, or in the presence of immobility, where they reduce the individuals’ tolerance to pressure and shear.29 It is therefore questioned how age, incontinence and nutritional status predisposes patients to pressure ulcers if they are not always primarily related to immobility and thus to exposure to unrelieved pressure and shear forces. Indeed, Moore et al.29 argue that there is a hierarchy of pressure ulcer risk, with pressure and shear being the causative factors and activity and mobility the key factors that expose the individual to pressure and shearing forces. This opinion was also found among respondents in this study where they argued that they were not concerned about pressure ulcers in mobile patients. In the presence of activity and mobility problems other risk factors might, however, play a role in how well the individual can tolerate immobility and as such decreases the time it takes for the person to develop a pressure ulcer. Interestingly, these additional risk factors, for instance incontinence, poor nutritional and skin status, were identified by healthcare workers regardless of whether risk scales were in use or not, indicating that clinical judgment is an important precursor to risk assessment. Immobility as a key risk factor is supported by Webster et al.14 who contend that risk scales should be replaced by an assessment of patients’ own ability to reposition and if they cannot reposition, then pressure ulcer prevention interventions should be provided immediately. This approach is supported by earlier work of Sharp and McLaws30 who argue that risk assessment should be simple and focus primarily on mobility as other risk factors included in numeric scales might not be accurately predictive of pressure ulcer risk. In a study by Sving et al.,31 a Modified Norton Score (MNS) was used together with clinical assessments to identify patients at risk. Nurses suggested that immobile patients were at risk and preventive initiatives were offered to patients who were clinically assessed to be immobile rather than through assessments made by the MNS.31 If a simple assessment based on patients’ mobility is sensitive enough to identify patients at risk and those not at risk, the use of extensive numeric scales could be replaced by the combination of clinical assessments and a simple non-numeric risk scale based on mobility. Such practice might avoid nurses’ restricted time being used inappropriately on timeconsuming scales.9 Indeed, assessment based on mobility could contribute to improved patient care by making sure that preventive initiatives are effectively offered to those actually at risk. However, it remains important to validate the precise role of immobility in a prospective manner, in order to place the role of immobility into an evidencebased context. Indeed, Webster et al.14 found no difference in pressure ulcer incidence among those assessed using Waterlow, Ramstadius or clinical judgment, meaning that none of the risk assessment practices seemed to specifically influence care delivery. It is important to note, that due to the risk of bias inherent in many of the current risk assessment validation studies as identified by Balzer and colleagues32 it is, as yet, unknown whether initial risk assessment based on immobility is accurate and reliable. However, as this current study found that even across care settings and countries, risk factors and patients at risk as cited by participants were similar, with mobility considered to be the key factor, it is suggested that the use of scale or no scale seemed to have little impact on who were regarded being atrisk patients. Therefore, it is argued that risk assessment could begin with an assessment of mobility and activity and proceed to more complete assessments if impairments are identified.9 Care plans – the missing link In this study, participants discussed that risk assessment did not necessary lead to care planning and provision of appropriate preventive interventions. A lack of connection between risk assessment, care plans and care provided was found in both countries, even though the participants were more careplan oriented in Ireland. Healthcare workers are legally required to register care plans relevant to patients’ needs and implementation of appropriate care plans are necessary to provide safe and consistent care.33,34 However, in this study, in Norway, care plans were more likely to be prepared when patients had developed a wound, possibly leaving preventive care to be reliant on individual staffs’ knowledge and interest. According to the participants a lack of time, staff competence and access to equipment hindered optimal documentation and care, a finding that is consistent with earlier studies.35 Indeed, the caring culture in individual wards has also been found to negatively affect preventive care.31 This finding is supported by earlier work of Moore and Price36 who found that over half of nurses surveyed felt that pressure ulcer prevention was a low priority within the clinical practice setting. Further, the barriers to carrying out pressure ulcer prevention cited are similar to those affecting pressure ulcer risk assessment.36 s j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 3 7 7 research © 2 0 1 4 M A H e a l t h c a r e l t d This study found that in Ireland, care plans were sometimes reported as a “tick-the-box” exercise partly carried out because the documentation was monitored and staff reminded if care plans were not in place. This lack of connection between risk assessment and documented care is evident across the literature where nurses’ documentation of pressure ulcer prevention was found to be erratic, lacking consistency and standardisation.9 In addition, participants in this study admitted that what was registered in the care plans did not necessary reflect the care provided, leaving a gap between actual practices and nursing documentation. It is important to note that as long as care plans for prevention are not recorded it is difficult to prove that care has ever been offered. The documentation practices reported by participants in this study make it impossible to conclude that appropriate preventative care is actually provided to at-risk patients. Thus, more attention is needed on documentation practice to ensure that it reflects the care provided9 and not least, that care plans for prevention rather than for treatment are recorded. From this study it is evident that regardless of risk assessment practices, patients are not necessary provided with appropriate care plans which are subsequently implemented and evaluated. A further investigation into how risk assessment can provide a precursor to structured preventive care is paramount as care planning and care provided are not necessarily influenced by risk assessment. Rather than continuously re-developing existing risk scales to improve practice and reduce pressure ulcer prevalence, it seems timely to investigate those obstacles that lead to the creation of a missing link between risk assessment and the care planned and provided. Preventive practice From this study it became clear that regardless of risk assessment practice, nurses knew which patients’ were at risk, however, several barriers hindered them from offering evidence-based care. Access to equipment was only a Norwegian issue. In Ireland, base hospital mattresses were of a good quality and risk scores were used to justify the requirement for additional pressure redistribution devices with staff reporting ready access to equipment. Conversely, in Norway, equipment was described as being old and worn and additional pressure redistribution devices were not always accessible when needed. The systematic review of McInnes et al.37 concludes that individuals at high risk of developing pressure ulcers should be nursed on higher-specification foam mattresses rather than standard hospital foam mattresses. It is clear from this study that within the Norwegian healthcare system, this evidence has yet to be integrated into clinical practice. If risk assessment is to lead to optimal preventive care, it is crucial that healthcare workers have access to appropriate equipment and other preventative strategies. Indeed, it is of limited value to have structured risk assessments and theoretically appropriate care plans in place if the necessary tools or staff competence and time for pressure ulcer prevention are not available. Therefore, it is argued that pressure ulcer prevention must become a key quality issue for clinical care leaders35 as the procurement of necessary equipment, competence and time may rely on these leaders’ priorities. Limitations As only two focus group interviews, with nine and five respondents respectively, were undertaken for this study, the findings should be interpreted with care. It is worthy of consideration also, that the findings may have been influenced by the wide range of care settings in which respondents were employed. Nonetheless, it is clear that additional research on the role of risk scales and clinical assessments in identifying patients at risk is needed, in addition to how risk assessment might successfully lead to preventive care planning and care delivery. Conclusion Regardless of whether clinical risk assessment was combined with a formal structured risk assessment tool or not, identified risk factors, at-risk patients and appropriate preventive initiatives discussed by participant were similar across care settings. Furthermore, risk assessment did not necessarily result in the planning and implementation of appropriate pressure ulcer prevention initiatives. It is clear from this study therefore, that use of a formal risk assessment tool does not necessarily make any difference to the identification of at-risk patients, planning, initiation and evaluation of pressure ulcer prevention strategies. This finding is not unique to the current study, rather has been borne out in a number of RCTs exploring this subject.13,14 A risk assessment tool is supposed to help clinicians to focus on particular areas of practice, in this instance pressure ulcer risk. However, as long as there is no evidence to prove that the extensive number of available numeric risk scales add valuable information to clinical risk assessments, it is argued that risk assessment possibly should focus on mobility and activity.9,30 For those patients found to have impaired activity or mobility, a thorough clinical assessment should be offered to make sure that appropriate preventive care plans and initiatives are supplied. With a missing link between risk assessment, care planning and preventive care provision, neither risk scales nor clinical risk assessment will necessarily lead to a reduction in pressure ulcer prevalence. 3 7 8 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d Relevance to clinical practice It is evident from this study that the use of numeric risk assessment scales and their implications for clinical practice should be further assessed because clinical judgment has an important part in pressure ulcer prevention. Regardless of whether clinical assessment is used alone or in combination with risk scales, patients at risk are detected. However, the missing link between risk assessment and documented care planning should be of concern to clinical practice and barriers to appropriate pressure ulcer documentation should be explored further. Likewise, the missing connection between developed care plans and the actual care delivered is particularly important to understand, as care plans seem to act as inactive records made for procedural confirmation rather than patient care. Therefore, clinical preventive practice might rely on nurses’ individual competence, consequently leading to irregular practice. Consequently, it might threaten patient safety both while being hospitalised and on discharge as insufficient documentation might lead to unsatisfactory follow up at the next care level. n References 1 Department of Health and Children. Building a culture of patient safety, report of the comission on patient safety and quality assurance Dublin: Stationary Office; 2008. Available from: http://www.dohc.ie/ publications/pdf/en_patientsafety. pdf [Accessed July 2014]. 2 Rossi, O. 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