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Top nurse warns risk assessment tools are not backed by evidence

The director of the national nursing research unit has called into question the worth of clinical risk assessment tools routinely relied on by thousands of frontline nurses.

Risk assessment tools, such as the ones used to predict a patient’s risk of falls, malnutrition and pressure ulcers, have been widely used by nurses in clinical practice for years.

Such tools are also now forming the basis of indicators, or metrics, being introduced to measure the quality of nursing care across the health service in areas such as pressure ulcer prevention and falls.

But Professor Peter Griffiths has told Nursing Times there is “no clear evidence” that many of the tools currently used accurately predict risk and help improve clinical outcomes.

Professor Griffiths, who contributed to research on metrics that fed into the next stage review, cited the Waterlow score – a numerical system used for 25 years to assess pressure ulcer risk – as an example of a particularly ineffective risk assessment tool.

“The Waterlow score was designed to raise awareness of pressure ulcers and hugely over-predicts risk. It is fine if it is being used to focus efforts and attention in this area, but it is not fine if it is being used as a clinical risk assessment tool to target intervention strategies,” he said.

Reducing the number of pressure ulcers has been highlighted by the chief nursing officer for England, Dame Christine Beasley, as one of eight “high impact actions” that should be implemented by nurses to improve patient care and reduce NHS costs (news, page 1, 17 November)

And, as Nursing Times revealed last week, the Department of Health is considering linking the amount hospital trusts get paid to how well they perform in clinical areas such as reducing pressure ulcers (news, page 1, 1 December).

But Heart of England Foundation Trust chief nurse Mandie Sunderland, who helped pioneer the introduction of nursing quality indicators in the North West, suggested that while not perfect, the current risk scores were the best available.

She said they were a useful first step - and it was necessary to work with what was available unless better tools were developed.

“A fundamental issue for improving care in areas such as pressure ulcers and falls is to first assess if a patient is at risk. We have adopted risk assessment tools [as part of nursing metrics] to help nurses identify patient needs, and signpost them to who needs further care,” she said.

United Lincolnshire Hospital Trust’s lead nurse in tissue viability Mark Collier acknowledged that such risk assessments had “not been researched enough to be specifically used as absolute measures of quality”.

“Tools should be used as a baseline, but they also need to be reused when it is clinically indicated or in line with NICE guidance. It must not be just a paper filling exercise,” he said.

“There is definitely an argument for doing an analysis of what we already have and developing amalgamated tools, or generic templates, that can be tailored to patient groups,” he added.

A spokesperson for the Department of Health said it is up to local organisations to consider which tools they want to use as part of ongoing risk assessment, but that the DH “would always expect trusts to evaluate against the best evidence in terms of which tools they use.”

She added that the Department of Health is working with strategic health authorities and service providers to develop measurement methodology and definitions for pressure ulcers, and further guidance and materials to support nursing staff in implementing the chief nursing officer’s high impact interventions will be available next year.

Readers' comments (12)

  • Thank you Professor Griffiths for challenging the use of such tools. I once made the mistake of asking Ms Waterlow for validty, relaibiltiy and specificty evidence and was shot down in flames, being told that it had been 'tested extensively in a single organisation' and therefore was valid, reliable and specific.

    For too long staff have relied on these tools. I see the same problems ahead with the use of electronic BP machines etc - does anyone regularly calibrate them and do they know how to take such measurements manually?

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  • If we depend too much on these tools then it reduces everything down to a tick box/join the dots exercise; providing all of the boxes are ticked and the dots joined in the right order then the patients must be alright because the tools say they are, mustn't they?

    It's like saying "the barometer in my hall says that it is 'sunny' outside, so I won't bother with wearing a coat when I go out. " despite the fact it is the middle of January with a temperature of -1 degrees Celsius outside and 15 cm of frozen snow on the ground. The barometer is calibrated for Summer and not Winter air pressures. The barometer is only a tool, like the risk assessment tools, it does not remove the responsibility of the user to use their own eyes and judgement.

    The risk assessment tools cited in this article are based on probability not certainty , in the same way that a car insurance company assesses the relative risk of a 19 year old male driver with 18 months experience compared with a 40 year old female driver with twent years experience. The insurance company uses accident statistics as their evidence in providing a quote and the tools cited
    should have similar statistical evidence to support their implementation.

    My personal grouse is the Malnutrition Screening Tool, because it uses the word Malnutrition and then equates that with underweight or weight loss, not recognising that obesity is also a sign of malnutrition ( mal means bad ). Perhaps it's because it is easier to 'treat' underweight than it is overweight whilst a person is in hospital.

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  • Im glad someone has spoken out about these
    'TOOLS' Tools are implements you work with i dont think many nurses know how to work with them and neither does the person(s) who invented them
    observation and communication is the best way to assess any patient whatever the problem

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  • It has been recognised for decades that the 'Waterlow' scoring tool was an over anxious auntie - but it at least suggests staff focus on a prevention plan before a sore develops.
    I agree about the MUST scoring tool - it looks only at underweight/malnutrition - for this reason we reject its use in our hospital.
    The issue regarding electronic BP machines is massive. Some staff do not know how to record a manual BP - dont know the cuff size alters the reading and would never think to check a altered reading manually to ensure it is not the machine rather than the patient. We have some work to do!

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  • I would like to comment on the electronic BP machines.

    No two machines give a reading near enough and do the students know how to use the manual and confident about it?

    The answer is NO.

    So, in an emergency when the electric BP IS NOT WORKING, what do we do?

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  • its not just the students who do not know how to take a manual BP - we have a generation of registered nurses who have never used anything other than electronic BP machines
    In answer to your question of - so what do we do in an emergency - well us oldies would become useful for a change - as we can take BPs manually

    but joking aside - this is a serious issue that someone needs to address

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  • I disagree with the above statement that "Students don’t know how to record a manual BP".

    I am now in my third year of training and nine out of tens times I record a BP manually when equipment is available this is what we are taught in university!! I am able to carryout this skill with confidence and if ever feel unsure I will ask a qualified member of staff to check. Some clinical areas don’t even have sphygmomanometer therefore automatic BP machines are our only option.

    As for the use of assessment tools I feel some nurses rely on theses to much. Tools should be used as a guide; the nurse should use their clinical judgement when assessing patients holistically.

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  • I would also like to comment on the above statement about students not being able to measure and record a manual BP, I feel that is a huge generalisation, and as a student nurse, am confident and able in carrying out this task.

    Similar generalisations can be made about qualified nurses, i myself have witnessed many qualified members of staff who haven't been able to take a manual BP.

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  • I am concerned about the tension between student nurses and nurses who have a lot of experience.

    It would be great if we could break down some of the barriers and bring together experience with fresh ideas for the sake of patients.

    Assessment tools are like a SAT NAV- you still need to be able to drive.

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  • what happened to clinical nursing observations?

    As BP has been mentioned, I have witnessed quite a few qualified nurses and doctors in hospital and in practices of many years who do not apply the cuff of a sphygmomanometer correctly or measure BP properly. I think they just do it as a routine gesture to show they are doing something but this is of little help to the patient.

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  • Tiger Girl

    There is a wider philosophical point here, about assuming that simply because it appears that something has been measured, the measurement must 'be right, and useful'.

    You need to have some method of making assessments, but you should always be willing to consider if the method you are using is any good, or poor.

    It is a bit like assuming that because something has been written down in a textbook, it must be right: if it is clearly wrong, then it is wrong !

    But it is complicated, because establishing new accepted consensus opinions about what would be better, is slow and tricky - and everyone using different metrics, is in itself problematic.

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  • The fact that nurses are having to gain their degrees now as a matter of course can only be a help in these matters. It seems to me that a thorough and truly understood knowledge of A&P and in depth learning can help nurses make sound, clinical judgements about why the tools they are using may not be accurate. If a nurse can understand the results he or she is reading, couple this with all other systemic indicators and holistic assessment of their patient then far better patient outcomes will emerge. Far fewer actions, 'obs' or tick boxes will be done for the sake of them and this can only be a good thing.

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