The history of the development of the PUP algorithm via systematic review and face validation were described in an earlier publication.10 The current study provided content validation data and an overview of strengths and areas of challenge. The rating scores (average score 3.72 out of 4) and CVI (0.94 out of 1) of the PUP algorithm for use in adults were strong, suggesting the components were appropriate to the purpose of the instrument. Only 1 practice recommendation, the recommendation to use medical-grade sheepskin for patients with activity/mobility limitations and/or high risk for friction or shear, received a low score. This recommendation also received a low appropriateness score in the earlier face validation study.10 Ironically, this was one of a handful of recommendations based on the results of several high-quality studies and an overall A strength of recommendation based on several, mostly Australian, studies. Study participants were concerned about this recommendation because most practitioners in the US are not familiar with medical-grade sheepskin and may have used synthetic sheepskins only. Because the literature-based quality of the research underlying this recommendation is good (A-strength level of evidence) and the algorithm can be used in other countries, the recommendation was not removed but included in smaller print and with an “if available” footnote.
By design, algorithms are ideal for specifying appropriate management strategies, communicating complex series of conditional statements, and helping the transfer of research into clinical practice, but they are not exhaustive.9 The qualitative comment results of this and other content validation studies16 suggest a constant tension between clinician’s need for easy-to-follow, simple directions and more details and guidance. On the one hand, study participants were pleased with the easy-to-follow steps and were interested in algorithm pocket guides, yet for a number of action steps they would have liked more details.
Following a careful review of all quantitative and qualitative results, several minor algorithm modifications were made. Specifically, concerns about information flow, design, and colors centered mainly on the admission assessment regarding current or recent history of limited mobility that was preceded by “Not at risk and intact skin.” The latter was removed because it did not provide any actionable information and caused confusion (see Figure 1). This also facilitated a change in the color of the decision step/point that makes it easier to identify as part of an admission assessment decision point.
Nineteen participants indicated an admission assessment should be conducted within 24 hours and not, as originally stated, “usually within 24 hours.” The original algorithm version did not have any time designation because time recommendations in the literature and face validation study participant opinions varied; hence, the “usually within 24 hours” recommendation.10 However, because participants in the current study were less ambiguous about this statement and a risk assessment “at admission” has been shown to reduce the incidence of PUs17 and is now commonly recommended in all health care facilities,18,19 the word usually was removed during the final algorithm revision.
Concerns about the timing of education were addressed by moving that step to the top left corner as a visual reminder that education about risk and skin assessment should precede all processes. Finally, the colors were standardized and box shapes edited to match current standards9,20 (see Figure 1).
With respect to the need for more details and directions (eg, type of moisturizer or high-quality foam or need to obtain a dietary consult), it is important to note the algorithm is generic. Although the information contained within the algorithm cannot be changed without compromising validity, facilities interested in incorporating more specific evidence-based recommendations are encouraged to review the published evidence upon which the recommendations are based for further refinement to suit their protocols of care.10
After completing a case study using ethnographic methods to examine decision-making in nursing, Rycroft-Malone et al21 reported tension exists between the standardization demanded of evidence-based practice and individualizing decision-making. The authors suggested the use of protocols and guidelines may be dependent on incorporating nurses’ decision-making processes into the context of the work environment. Thus, giving nursing staff the opportunity to individualize specific evidence-based intervention recommendations (such as types of high-density foam and protective barrier creams) may facilitate adoption of this algorithm and help standardize care.
Study participant verbal comments were generally positive, especially regarding the focus on and organization of modifiable risk factors. These comments echo the results of a recent consensus study22 to construct a theoretical model for identifying the etiological factors of PUs. The authors concluded the local approach to risk reduction should be determined by production mechanism (eg, those that address pressure, friction, shear, and moisture) and modifiable etiological factors (less-than-optimal nutritional status).
Because the decision points were based on best available evidence10 and the content validation ratings by stakeholders supported their appropriateness, the algorithm is, to the authors’ knowledge, the first algorithm targeting PUP in adults that is strongly evidence-based. Only the Association for the Advancement of Wound Care23 PU clinical practice guideline, which includes PUP recommendations, has been formally content-validated. In addition, qualitative comments were generally supportive and positive. The few negative comments were used to tweak the structure of the algorithm to support its best usage.