This guidelines set out by the Nursing and

assignment is a case study about patient risk and safety in the context of
adult nursing care, specifically looking at a patient who is at risk of
pressure damage. The assignment will explore the nursing care and process of risk
assessment, patient safety and the cost to patient, nurse and the NHS.
Throughout the assignment the patient will be referred to as Wendy, in order to
protect the patient’s identity and maintain confidentiality, in accordance with
the guidelines set out by the Nursing and Midwifery Council (NMC, 2008). Wendy
was an elderly female who was admitted to hospital for dehydration. Wendy lived
alone in sheltered accommodation with carers four times daily. She had poor
mobility, was underweight, poor nutritional intake and a smoker. Wendy was
admitted to an assessment ward following admission through accident and
emergency where district nurses found her in bed, having not moved for several
days. Wendy was found to be at risk of pressure damage due to her physical
condition and co-morbidities. Pressure damage is one patient safety concern for
adult nurses, which encompasses the need for risk assessment, treatment and
prevention. It is poignant in adult nursing care to help identify those most at
risk, to be able to combat factors that contribute to the deterioration
pressure areas.


safety can be defined as the prevention of errors and adverse effects to anyone
receiving health care (WHO, 2010). As healthcare has developed and become more
effective it is also become more complex with the integrated uses of new
technologies, medicines and treatments. With an ever-aging population,
healthcare has become tailored to tackle patient with significant
co-morbidities, who require more difficult and advanced decisions, with
altering health care priorities (Reference, 2010). With longer stays in
hospital, the health protection agency makes reference to that nearly one in
ten patients in hospital experience an incident that places them at risk, with
around half of these being preventable (Reference, 2010), including those who
suffer hospital acquired pressure damage.


National Patient Safety Agency (NPSA) (2010) advocates a simplistic solution to
pressure damage as: observing skin areas, positional changes at regular
intervals, keeping areas moisture free and monitoring nutritional statuses. As
a registered professional, the NMC (2015) code of conduct states that
registrants should make referrals to appointed professionals when it is in the
best interest of someone you are caring for. 
Registered nurses must act to identify and minimise the risk to patients,
specifically to patients who are at risk of pressure damage. With increasing
litigation and pressure ulcers being increasingly viewed as patients
experiencing harm, pressure damage prevention has become a national priority
and of poignant importance. NHS policy initiatives and best practice statements
specifically outline prevention strategies, which reflect the registrants’ duty
of care and prevention of patient harm (NHS Quality Improvement Scotland (NHS
QIS, 2009).  Claims that 95% of pressure
ulcers are preventable, omit concerns about the lack of evidence that suggest
this, however it continues to be cited in several NHS policies such as … (Downie
et al 2013). If the statistic is found to be accurate and achievable in
practice, this raises potential legal and professional implications and could
question the clinician’s accountability.  


frequency of repeat inspections is viewed as a major factor in the prevention
of development or future decline of pressure ulcer (Reference, 2010) The
finding of non-blanching erythema should alert the nurse to the possibility of
pressure damage, through clinical experience, knowledge and application of
evidence based practice. Due to the multifactorial nature of pressure ulcers
health care practitioners need up to date education on identification and
classification, nutritional status, anatomy and physiology, application of risk
assessment tools and appropriate documentation.


ulcers are a key patient safety concern. The prevention of pressure ulcers
represents a marker of quality of care (Reference, 2010). Pressure ulcers are a
nurse-sensitive goal. Thus, nursing care has a major effect on pressure ulcer
development and prevention. Prevention of pressure ulcers often involves the
use of low technology, but vigilant care is required to address the most
consistently reported risk factors for development of pressure ulcers. The literature
suggested that not all pressure ulcers can be prevented, but the use of
comprehensive pressure ulcer programs can prevent the majority of pressure
ulcers. When the pressure ulcer develops, the goals of healing or preventing
deterioration and infection are paramount (Lyder, Courtney & Ayello,
Elizabeth, 2008).


as reported within Mid Staffordshire NHS Foundation Trust Public Inquiry,
Francis (2013) reported a decline in patient safety standards was associated
with inadequate staffing levels and skills, as well as a lack of effective
leadership and support. In one study key findings concluded that 92% of nurses
say they face time constrictions and that up to 96% say that spending more time
with individual patient who have a significant positive impact on their
patients’ lives (DeCola PR1, Riggins P., 2010)


the individual, pressure damage can cause pain, systemic illness, low
self-esteem, altered body image and increased length of hospital stay (Hibbs,
1991). Therefore with the up most important to patient safety and care
alongside the legal and professional implications of pressure damage and the
risks they impose, nursing staff utilise risk assessment tools to use in
conjunction with their clinical knowledge and experience. With regards to
Wendy, the nursing staff in hospital must identify those at risk or at further
development of pressure damage upon first contact (reference, 2010) and with
continued revaluation. The assessment tool used for Wendy was the Pressure Area
Risk Assessment Chart (Waterlow) as advocated by the trusts own policy. The chart
allows for a clinician to assess the risk of a patient/client developing a
pressure ulcer. The score should be identified and used in conjunction with the
clinician’s clinical experience and knowledge to indicate a risk that should be
followed with action (Reference, 2010).


In a
review of the Waterlow chart, the scoring of some patients were not found to
display high levels of reliability, and suffered from a lack of operational
definitions within risk categories. In line with other research studies, the
Waterlow scoring system was found to actually over-predict pressure sore
formation (Edwards, 2016). It is stated that this particular scoring system

may be
a predictor of ill health in elderly people (Reference, 2010)

ulcer risk-assessment scales play a primary role in the prevention and management
of pressure ulcers. Pressure risk-assessment tools have been described as the
backbone of any prevention and treatment policy (Waterlow,1991). Although there
are over 40 different assessment tools, the Waterlow pressure ulcer risk-assessment
tool is the tool that is most widely used in the UK. The National Institute for
Clinical Excellence (NICE, 2015) stated that in order to achieve clinical
governance strategies, risk management in the form of pressure ulcer risk
assessment will contribute to improved quality of patient care. Waterlow (1985)
believed that many of the intrinsic factors, such as pain, nutrition, reduced
cardiac output and anaesthesia, had been omitted from the Norton scale (Norton
et al, 1962) which had been developed for an elderly population. Consequently,
the Waterlow risk-assessment scale was developed in 1984 (Waterlow. 1985) as a comprehensive
tool to be used in conjunction with the nursing process.


major criticism of the Waterlow tool is that Waterlow herself performed most of
the observations during its development (Edwards, 1996). Dealey (1989) tested
the inter-rater reliability of the Waterlow tool. Student nurses from four
wards assessed the same five patients using the Waterlow tool and the Norton tool.
Results revealed only a 61% agreement on the Waterlow score and a 70% agreement
using the Norton score — yet, despite these results, the Waterlow tool has been
widely adopted.


despite the limitations outlined, the Waterlow tool is a useful and practical
way of systematically evaluating and revaluating individual patients “at-risk”
status. NICE (2014) recommend using a validated scale to support clinical
judgement (for example, the Braden scale, the Waterlow score or the Norton
risk-assessment scale) when assessing pressure ulcer risk. Waterlow is a
practical, simplistic tool designed using a fundamental practical understanding
of the causes of pressure ulcers, backed up by the study of the medical
textbooks relating to pressure ulcers, which were available in 1984. However, with
regard to ‘reliability’, this is an inappropriate word and should be replaced
by ‘effectiveness’. However, 


important thing is that practitioners do assess risk using their clinical
judgements and, crucially, act on the assessments. Formal risk assessment tools
may or may not have a place but the standard of care is defined by good clinical
judgement and appropriate intervention, not the use of a tool.


The NHS Safety Thermometer is a local improvement tool for measuring,
monitoring and analysing patient harms and ‘harm free’ care.
NHS Safety Thermometer is a local improvement tool for measuring, monitoring
and analysing ‘harm free’ care. A minimum of 0.125% of the value of all
healthcare services commissioned through the NHS Standard Contract should be
linked to the 2014/15 national Commissioning for Quality and Innovation (CQUIN)
goal of improvement against the NHS Safety Thermometer, particularly pressure
ulcers, where this applies. In
June 2016, 4.4% of reported patients had pressure ulcers, compared with 4.3% in
June 2015.


daily costs of treating a pressure ulcer are estimated to range from £43 to
£374. For ulcers without complications the daily cost ranges from between £43
to £57 (Bennett, Dealey and Posnett, 2012).  One in five patients in the acute health
sector in the UK will develop a pressure ulcer. This represents 4% of NHS
spending at an annual cost of £2 billion (National Education for Scotland (NES)


Pressure ulcer prevention has traditionally
been viewed as a nursing problem with very little input from other allied healthcare
professionals. Whilst it is now recognised that not one single professional should
hold all the solutions to prevention and treatment, it is clear that effective
collaborative working may not always been consistently applied (Reference,
2010). With regards to Wendy, the professionals involved in her care included nurses,
dieticians, physiotherapists and social workers. The
Nursing and Midwifery Council code of conduct recently reviewed the nurse’s
role and responsibilities to ensure that nurses ensure good nutritional care
for all their patients (Evans & Best, 2015). Nutrition plays a vital role in the
prevention and treatment of pressure damage, so all health care professionals involved
with patient care must be empowered to influence nutritional decisions. In hospital
settings, predominantly the nutritional recommendations rest solely with the dietitian, with many trusts lacking in nurse led
nutritional care (Tappenden, 2013). Many clinicians believe that pressure ulcer development is not
simply the fault of the nursing care, but rather a failure of the entire heath care
system hence, a breakdown in the cooperation and skill of the multidisciplinary
team (Reference, 2010). Historically pressure ulcer prevention has been
widely regarded as a nursing issue, despite this results from a study suggested
both occupational therapists and healthcare assistants have a more positive attitude
toward prevention strategies than nurses, dieticians and physiotherapists
(Reference, 2010). Wendy was underweight, which
affected her ability to be mobile. Pressure damage is directly linked to immobility,
with the need for regular turns and repositioning. The nurse looking after
Wendy referred her to the wards physiotherapist who was able to recommend techniques
and skills to equip both patient and the nurse to help improve the pressure
damage. Encouraging
regular, physical activity of moderate intensity is part of all healthcare
professional’s role in the prevention of disease (Pate et al, 1995)




As the delivery of healthcare evolves, the need for a more cohesive
network between nurses, pharmacists, physicians, social workers and other allied
healthcare professionals has become of paramount importance. In its simplest
form, interprofessional collaboration is the practice of approaching patient
care from a team-based perspective. According to the World Health Organization,
by implementing interprofessional collaboration and learning to work together
and respecting one another’s perspectives in healthcare, multiple disciplines
can work more effectively as a team to help improve patient outcomes
(Refernece, 2010). In the
late 1980s, the World Health Organization recognised that, if health
professionals were taught together in a multiprofessional educational setting
and learned to collaborate as a team during their student years, they were far
more likely to work effectively together in their professional lives in a
clinical setting (WHO, 1988). Interprofessional learning (IPL) was born.

working implies a shared learning experience with, from and about
each other and involves a reduction in
professional autonomy. All members of the multidisciplinary team to
prioritise ward rounds as a forum of MDT Meeting, instead of the historical
physician only ward rounds. This recommendation is inspired by a publication
from Royal College of Physicians and the Royal College of Nursing, Ward Rounds
in Medicine: Principles for Best Practice, which was published in October 2012.
It highlights the importance of ward round collaboration.

policy emphasises the need for effective collaborative working in the NHS to
provide optimal and safe patient care. The need for effective inter-
professional learning and team working was highlighted in the Victoria Climbie?
case (DH, 2003) and the Bristol and Alder Hey (DH, 2001) case before that.
These both illustrated how poor team working and communication between health
professionals can have a hugely negative impact.


nurses must be able to provide leadership in managing adult nursing care,
understand and coordinate interprofessional care when needed, and liaise with
specialist teams. They must be adaptable and flexible, and able to take the
lead in responding to the needs of people of all ages in a variety of
circumstances, including situations where immediate or urgent care is needed.


delivering health care, an effective teamwork can immediately and positively
affect patient safety and outcome. 

evolution in health care and a global demand for quality patient care
necessitate a parallel health care professional development with a great focus
on patient centred teamwork approach. 

can only be achieved by placing the patient in the centre of care and through
sharing a wide based culture of values and principles. This will help forming
and developing an effective team able to deliver exceptional care to the
patients. Aiming towards this goal, motivation of team members should be backed
by strategies and practical skills in order to achieve goals and overcome


characteristics underpinning effective interdisciplinary team work were
identified: positive leadership and management attributes; communication
strategies and structures; personal rewards, training and development;
appropriate resources and procedures; appropriate skill mix; supportive team
climate; individual characteristics that support interdisciplinary team work;
clarity of vision; quality and outcomes of care; and respecting and
understanding roles.