Pressure injury risk assessment and prescription of preventative interventions using a structured tool versus clinical judgement: An interrater agreement study
Authors: Fulbrook Paul , Lovegrove Josephine , Ven Saroeun , Miles Sandra J. 
Published: March 2024

AbstractAimTo assess agreement of pressure injury risk level and differences in preventative intervention prescription between nurses using a structured risk assessment tool compared with clinical judgement.DesignInterrater agreement study.MethodsData were collected from November 2019 to December 2022. Paired nurse‐assessors were allocated randomly to independently assess pressure injury risk using a structured tool (incorporating the Waterlow Score), or clinical judgement; then prescribe preventative interventions. Assessments were conducted on 150 acute patient participants in a general tertiary hospital. Agreement of risk level was analysed using absolute agreement proportions, weighted kappa and prevalence‐adjusted and bias‐adjusted kappa.ResultsNinety‐four nurse assessors participated. Absolute agreement of not‐at‐risk versus at‐risk‐any‐level was substantial, but absolute agreement of risk‐level was only fair. Clinical judgement assessors tended to underestimate risk. Where risk level was agreed, prescribed intervention frequencies were similar, although structured tool assessors prescribed more interventions mandated by standard care, while clinical judgement assessors prescribed more additional/optional interventions. Structured tool assessors prescribed more interventions targeted at lower‐risk patients, whereas assessors using clinical judgement prescribed more interventions targeted at higher‐risk patients.ConclusionThere were clear differences in pressure injury risk‐level assessment between nurses using the two methods, with important differences in intervention prescription frequencies found. Further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk, with emphasis on the impact of risk assessments on subsequent preventative intervention implementation.ImpactThe results of this study are important for clinical practice as they demonstrate the influence of using a structured pressure injury risk assessment tool compared to clinical judgement. Whilst further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk and prescribe interventions, our findings do not support a change in practice that would exclude the use of a structured pressure injury risk assessment tool.Reporting MethodThis study adhered to the GRRAS reporting guideline.Patient/Public ContributionNo patient or public involvement in this study.Implications for the profession and/or patient careEducators and researchers can use the findings to guide teaching about pressure injury risk assessment and preventative intervention and to direct future studies. For clinical nurses and patients, a change in clinical practice that would exclude the use of a structured risk assessment tool is not recommended and further work is needed to validate the role of clinical judgement to assess risk and its impact on preventative intervention.