130 Chapter 5 Process evaluation Process evaluations aim to provide a comprehensive understanding to guide policy and practice. These evaluations typically cover five key aspects: context, intervention, implementation, mechanism of impact, and outcomes. In this process evaluation, we concentrated on context: Examining how external factors, such as the reliability of the electronic patient documentation, affect the delivery and functioning of the interventions. Intervention: In which the intervention is described, including the causal assumptions about how the intervention will work. Implementation: Exploring the structures, resources, and processes involved in the delivery of the intervention. This includes evaluating the implementation strategy, such as conducting educational sessions, and assessing both the quantity in number of sessions and quality in for instance the topics covered of what is delivered. Table 1 Definitions, outcomes and data sources in this process evaluation based on the principles of Moore, Audrey [24] in the pilot study of implementing DRAAI Process evaluation domain Defined in this study as Context Context at baseline Current PU screening – Until May 2023 the Waterlow Risk Score was required twice weekly and during any clinical changes. Since then, nurses have been encouraged to use their clinical reasoning to assess PU risk, with the Braden Scale available as backup in cases of uncertainty. For at-risk patients a nursing care plan must be created. This plan includes selecting preventive measures, which are automatically integrated into the nurses' activity overview in the electronic patient record. Additionally, it prompts nurses to document observations related to PU risk in a dedicated section that becomes visible if a care plan is created. Medical beds – In May 2023, the hospital implemented pressure-reducing mattresses. Previously, patients at risk for PU were transferred to beds with an alternating surface. Now, transfers are only necessary for patients at high risk for developing PU. Nurse champions – Each ward has between one to seven nurse champions dedicated to PU prevention and wound care. Joint daily stand-ups – In the Covid-19 and pulmonary wards, all nurses participate in joint daily stand-ups. For internal medicine, the ward is divided into five zones, with one nurse from each zone attending the session. Computer-on-wheels – All nurses have access to mobile desktop devices during their shifts, allowing them to consult the electronic patient record or access DRAAI via a web link as needed. Complex intervention Daily risk predictions in three risk categories: low risk, at-risk or at high risk. The risk categories were shown in written text, by default only the at-risk and at highrisk patients are shown Stand-alone web application in which the risk predictions were available. Feedback on the follow-up of the predictions (in line with hospital protocol) with creating a nursing care plan for at-risk patients was incorporated. Causal assumptions of DRAAI were: 1) daily risk predictions will reduce the feeling of registration burden among nurses, 2) attention towards PU prevention will increase and 3) this may result in timely pressure ulcer prevention.
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