Satisfaction With the Withdrawal Assessment Tool-1 (WAT-1)
Satisfaction With the Withdrawal Assessment Tool-1 (WAT-1)
For nurses to believe a withdrawal assessment tool is useful, it must demonstrate that it is reliable and valid within the setting where they work. In addition, the tool must make nurses feel it assists them in providing care to a child undergoing withdrawal. Finnegan and colleagues initiated the measurement of withdrawal in children by creating the Neonatal Abstinence Scale (NAS) (Finnegan, Karon, Connaughton, & Emich, 1975). The scale was developed for infants born to mothers who were drug-addicted, and specifically uses newborn reflexes as part of the assessment. The NAS has limited usefulness in the older infant and child with iatrogenic narcotic withdrawal be cause the Moro reflex disappears by three months of age. In an attempt to go beyond maternal addiction and to address iatrogenic withdrawal syndrome, the Opioid Benzodiazepine Withdrawal Score (OBWS) was developed. It was found to have a low sensitivity and multiple items (21) to score, and was difficult to maintain inter-rater reliability (Franck, Naughton, & Winter, 2004).
In 2008, a new scale was developed, the WAT-1, based on the preliminary work of the OBWS. The WAT-1 identified four categories of symptoms of withdrawal, including 1) gastrointestinal (GI), 2) wakefulness, 3) ability to calm, and 4) autonomic evidence of withdrawal. The tool was evaluated for the utility of each withdrawal symptom to determine duplication of similar items and redundant, non-specific, or difficult items were dropped. Construct validity was evaluated by examining the degree of peak WAT-1 scores with other indicators of withdrawal. The WAT-1 had a 0.872 sensitivity and a 0.880 specificity showing it was a useful tool to assess withdrawal. It consists of 11 items in four groups that explain 58% of the variability in assessment of withdrawal symptoms. The higher the score, the more withdrawal problems were noted (Franck et al., 2008).
The availability of a valid withdrawal assessment tool for children does not automatically translate into implementation and improved nursing practice. Nurses need to feel comfortable with assessing withdrawal and communicating their findings to be satisfied that a new tool improves patient care. There is a paucity of literature about assessment tool implementation considering the wealth of tools available to nurses, and little literature reports on nurses' satisfaction with these assessment tools. Reports found on implementation of assessment tools included those on nutrition screening, falls, quality of life for cancer and palliative care, and a cancer fatigue scale (Hagelin, Wengstrom, & Tishelman Furst, 2007; Hsu et al., 2004; Mullen, Berry, & Zierler, 2004; Quick & Fonteyn, 2005; Raja, Gibson, & Turner, 2008). The concepts identified in these reports included satisfaction with the specific tool, its usefulness to nursing practice, the education involved in implementation, the specific tool's advantage in communication, and difficulties in use, including noncompliance.
No reports of nurse satisfaction with WAT-1 were found. The closest relevant reports were a qualitative study on sedation and a survey on pediatric pain tools. Weir and O'Neill (2008) interviewed nurses about the implementation of a sedation assessment tool in an adult ICU. The themes reported were improved patient care in the form of shorter ventilation time and shorter length of stay, improved communication between patient and staff, and frustration with non-adherence to the use of the scale by the medical staff of this particular unit (Weir & O'Neill, 2008) Simons and Macdonald (2006) also studied the implementation of pediatric pain assessment tools throughout a children's hospital with a 12-question survey of the nursing staff. The staff view of the ease of use shifted toward "very easy" over a sixmonth implementation period, and there was an increase in the reported use of the pain assessment tools. The greatest difficulty identified was the extra work. These authors also reported a 45% discrepancy in the nursing report and actual documentation of pain (Simons & Macdonald, 2006). To determine if the WAT-1 is a useful tool to improve care, a survey of nurses' satisfaction with assessment, communication, and care of children undergoing withdrawal was conducted.
Review of the Literature
For nurses to believe a withdrawal assessment tool is useful, it must demonstrate that it is reliable and valid within the setting where they work. In addition, the tool must make nurses feel it assists them in providing care to a child undergoing withdrawal. Finnegan and colleagues initiated the measurement of withdrawal in children by creating the Neonatal Abstinence Scale (NAS) (Finnegan, Karon, Connaughton, & Emich, 1975). The scale was developed for infants born to mothers who were drug-addicted, and specifically uses newborn reflexes as part of the assessment. The NAS has limited usefulness in the older infant and child with iatrogenic narcotic withdrawal be cause the Moro reflex disappears by three months of age. In an attempt to go beyond maternal addiction and to address iatrogenic withdrawal syndrome, the Opioid Benzodiazepine Withdrawal Score (OBWS) was developed. It was found to have a low sensitivity and multiple items (21) to score, and was difficult to maintain inter-rater reliability (Franck, Naughton, & Winter, 2004).
In 2008, a new scale was developed, the WAT-1, based on the preliminary work of the OBWS. The WAT-1 identified four categories of symptoms of withdrawal, including 1) gastrointestinal (GI), 2) wakefulness, 3) ability to calm, and 4) autonomic evidence of withdrawal. The tool was evaluated for the utility of each withdrawal symptom to determine duplication of similar items and redundant, non-specific, or difficult items were dropped. Construct validity was evaluated by examining the degree of peak WAT-1 scores with other indicators of withdrawal. The WAT-1 had a 0.872 sensitivity and a 0.880 specificity showing it was a useful tool to assess withdrawal. It consists of 11 items in four groups that explain 58% of the variability in assessment of withdrawal symptoms. The higher the score, the more withdrawal problems were noted (Franck et al., 2008).
The availability of a valid withdrawal assessment tool for children does not automatically translate into implementation and improved nursing practice. Nurses need to feel comfortable with assessing withdrawal and communicating their findings to be satisfied that a new tool improves patient care. There is a paucity of literature about assessment tool implementation considering the wealth of tools available to nurses, and little literature reports on nurses' satisfaction with these assessment tools. Reports found on implementation of assessment tools included those on nutrition screening, falls, quality of life for cancer and palliative care, and a cancer fatigue scale (Hagelin, Wengstrom, & Tishelman Furst, 2007; Hsu et al., 2004; Mullen, Berry, & Zierler, 2004; Quick & Fonteyn, 2005; Raja, Gibson, & Turner, 2008). The concepts identified in these reports included satisfaction with the specific tool, its usefulness to nursing practice, the education involved in implementation, the specific tool's advantage in communication, and difficulties in use, including noncompliance.
No reports of nurse satisfaction with WAT-1 were found. The closest relevant reports were a qualitative study on sedation and a survey on pediatric pain tools. Weir and O'Neill (2008) interviewed nurses about the implementation of a sedation assessment tool in an adult ICU. The themes reported were improved patient care in the form of shorter ventilation time and shorter length of stay, improved communication between patient and staff, and frustration with non-adherence to the use of the scale by the medical staff of this particular unit (Weir & O'Neill, 2008) Simons and Macdonald (2006) also studied the implementation of pediatric pain assessment tools throughout a children's hospital with a 12-question survey of the nursing staff. The staff view of the ease of use shifted toward "very easy" over a sixmonth implementation period, and there was an increase in the reported use of the pain assessment tools. The greatest difficulty identified was the extra work. These authors also reported a 45% discrepancy in the nursing report and actual documentation of pain (Simons & Macdonald, 2006). To determine if the WAT-1 is a useful tool to improve care, a survey of nurses' satisfaction with assessment, communication, and care of children undergoing withdrawal was conducted.
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