title: What patient characteristics guide nurses' clinical judgement on pressure ulcer risk? A mixed methods study.
abstract: BACKGROUND
  Nurses' clinical judgement plays a vital role in pressure ulcer risk assessment, but evidence is lacking which patient characteristics are important for nurses' perception of patients' risk exposure.
  
  
  OBJECTIVE
  To explore which patient characteristics nurses employ when assessing pressure ulcer risk without use of a risk assessment scale.
  
  
  METHODS
  Mixed methods design triangulating observational data from the control group of a quasi-experimental trial and data from semi-structured interviews with nurses.
  
  
  METHODS
  Two traumatological wards at a university hospital.
  
  
  METHODS
  Quantitative data: A consecutive sample of 106 patients matching the eligibility criteria (age ≥ 18 years, no pressure ulcers category ≥ 2 at admission and ≥ 5 days expected length of stay). Qualitative data: A purposive sample of 16 nurses.
  
  
  METHODS
  Quantitative data: Predictor variables for pressure ulcer risk were measured by study assistants at the bedside each second day. Concurrently, nurses documented their clinical judgement on patients' pressure ulcer risk by means of a 4-step global judgement scale. Bivariate correlations between predictor variables and nurses' risk estimates were established. Qualitative data: In interviews, nurses were asked to assess fictitious patients' pressure ulcer risk and to justify their risk estimates. Patient characteristics perceived as relevant for nurses' judements were thematically clustered. Triangulation: Firstly, predictors of nurses' risk estimates identified in bivariate analysis were cross-mapped with interview findings. Secondly, three models to predict nurses' risk estimates underwent multiple linear regression analysis.
  
  
  RESULTS
  Nurses consider multiple patient characteristics for pressure ulcer risk assessment, but regard some conditions more important than others. Triangulation showed that these are measures reflecting patients' exposure to pressure or overall care dependency. Qualitative data furthermore indicate that nurses are likely to trade off risk-enhancing conditions against conditions perceived to be protective. Here, patients' mental capabilities like willingness to engage in one owns care seem to be particularly important. Due to missing information on these variables in the quantitative data, they could not be incorporated into triangulation.
  
  
  CONCLUSIONS
  Nurses' clinical judgement draws on well-known aetiological factors, and tends to expand conditions covered by risk assessment scales. Patients' care dependency and self-care abilities seem to be core concepts for nurses' risk assessment.
authors.affiliation: Nursing Research Group, Institute for Social Medicine and Epidemiology, University of Lübeck, Germany. Electronic address: katrin.balzer@uksh.de.
authors.forename: K
authors.initials: K
authors.lastname: Balzer
authors.affiliation: Institute for Social Medicine and Epidemiology, University of Lübeck, Germany.
authors.forename: L
authors.initials: L
authors.lastname: Kremer
authors.affiliation: Nursing Research Group, Institute for Social Medicine and Epidemiology, University of Lübeck, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Junghans
authors.affiliation: Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands.
authors.forename: R J G
authors.initials: RJ
authors.lastname: Halfens
authors.affiliation: Department of Nursing Science, Centre for the Humanities and Health Sciences, Charité - Universitätsmedizin Berlin, Germany.
authors.forename: T
authors.initials: T
authors.lastname: Dassen
authors.affiliation: Clinical Research Center for Hair and Skin Science, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Kottner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009730:Nursing Assessment; D003668:Pressure Ulcer / Q000453:epidemiology / Q000451:nursing* / Q000517:prevention & control; D018570:Risk Assessment
keywords: Judgement; Nursing assessment; Pressure ulcer/nursing; Risk assessment; Triangulation