title: Using cognitive pre-testing methods in the development of a new evidenced-based pressure ulcer risk assessment instrument.
abstract: Variation in development methods of Pressure Ulcer Risk Assessment Instruments has led to inconsistent inclusion of risk factors and concerns about content validity. A new evidenced-based Risk Assessment Instrument, the Pressure Ulcer Risk Primary Or Secondary Evaluation Tool - PURPOSE-T was developed as part of a National Institute for Health Research (NIHR) funded Pressure Ulcer Research Programme (PURPOSE: RP-PG-0407-10056). This paper reports the pre-test phase to assess and improve PURPOSE-T acceptability, usability and confirm content validity.
  
  
  
  A descriptive study incorporating cognitive pre-testing methods and integration of service user views was undertaken over 3 cycles comprising PURPOSE-T training, a focus group and one-to-one think-aloud interviews. Clinical nurses from 2 acute and 2 community NHS Trusts, were grouped according to job role. Focus group participants used 3 vignettes to complete PURPOSE-T assessments and then participated in the focus group. Think-aloud participants were interviewed during their completion of PURPOSE-T. After each pre-test cycle analysis was undertaken and adjustment/improvements made to PURPOSE-T in an iterative process. This incorporated the use of descriptive statistics for data completeness and decision rule compliance and directed content analysis for interview and focus group data. Data were collected April 2012-June 2012.
  
  
  
  Thirty-four nurses participated in 3 pre-test cycles. Data from 3 focus groups, 12 think-aloud interviews incorporating 101 PURPOSE-T assessments led to changes to improve instrument content and design, flow and format, decision support and item-specific wording. Acceptability and usability were demonstrated by improved data completion and appropriate risk pathway allocation. The pre-test also confirmed content validity with clinical nurses.
  
  
  
  The pre-test was an important step in the development of the preliminary PURPOSE-T and the methods used may have wider instrument development application. PURPOSE-T proposes a new approach to pressure ulcer risk assessment, incorporating a screening stage, the inclusion of skin status to distinguish between those who require primary prevention and those who require secondary prevention/treatment and the use of colour to support pathway allocation and decision making. Further clinical evaluation is planned to assess the reliability and validity of PURPOSE-T and it's impact on care processes and patient outcomes.
authors.affiliation: Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK. medscole@leeds.ac.uk.
authors.forename: S
authors.initials: S
authors.lastname: Coleman
authors.affiliation: Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
authors.forename: J
authors.initials: J
authors.lastname: Nixon
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
authors.forename: J
authors.initials: J
authors.lastname: Keen
authors.affiliation: Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
authors.forename: D
authors.initials: D
authors.lastname: Muir
authors.affiliation: Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.|Mid Yorkshire Hospital NHS Trust, Wakefield, UK.
authors.forename: L
authors.initials: L
authors.lastname: Wilson
authors.affiliation: Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.|Leeds Teaching Hospitals NHS Trust, Leeds, UK.
authors.forename: E
authors.initials: E
authors.lastname: McGinnis
authors.affiliation: Wound Prevention and Management Service, Leeds Community Healthcare NHS Trust, Leeds, UK.
authors.forename: N
authors.initials: N
authors.lastname: Stubbs
authors.affiliation: School of Health & Population Sciences, University of Birmingham, Birmingham, UK.
authors.forename: C
authors.initials: C
authors.lastname: Dealey
authors.affiliation: School of Healthcare, University of Leeds, Leeds, UK.
authors.forename: E A
authors.initials: EA
authors.lastname: Nelson
mesh_terms: D000328:Adult; D003071:Cognition; D019317:Evidence-Based Medicine / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D017144:Focus Groups; D006801:Humans; D008297:Male; D008875:Middle Aged; D024802:Nurse's Role; D003668:Pressure Ulcer / Q000175:diagnosis*; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods / Q000706:statistics & numerical data; D012307:Risk Factors; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: Cognitive pre-testing methods; Nursing; Patient and Public Involvement (PPI); Pressure ulcer; Risk assessment; Tissue viability