ATTITUDE of NURSES towards the USE of BRADEN SCALE in

INTENSIVE CARE UNITS and MEDICAL WARDS

JOEMER C. MARAVILLA, RN, BSN Philippine Council for Health Research and Development

Department of Health, PHILIPPINES

BACKGROUND 65 Thousand Mortalities out of 1 Million Patients

with Pressure Ulcer

United States of America:

0.4% to 38% in Acute Care

2.2% to 23.9% in Long Term Care; and

0% to 17% in Home Care Setting

- Islam et. al., 2010

Asia:

2.1% to 31.3% in ICU -Suriadi et al., 2007

Philippines:

In a tertiary hospital, 20% orthopaedic patients

-Molon & Estrella, 2011

-Agency for Healthcare Research Quality (AHRQ), 2008

BACKGROUND

6th Indicator: Prevalence of Pressure

-Montalvo, 2007

14th National Patient Safely Goal: Reduce the risk of

developing bed sores through comprehensive assessment -The Joint Commission [TJC], 2011

Aside from positioning, skin care, and health education,

pressure ulcer risk assessment is also important to prevent

the occurrence of pressure ulcer -Kallman & Suserud, 2009

BACKGROUND

BRADEN SCALE

33 systematic reviews suggested that this scale has good sensitivity in

predicting pressure ulcer risks

-Stotts & Gunningberg, 2007

Risk assessment scales were developed to help healthcare providers

ensure correct evaluation of their patients -Wann-Hansson & William, 2008

PROBLEM STATEMENT

Non-compliant with the clinical guidelines for pressure ulcer prevention -Wann-Hansson & William, 2008

Applied Braden Scale to 11.26% of total hospital-days

considering that Braden Scale was instructed to be employed to

all hospital-days

-Cho & Noh, 2010

Put low priority on pressure ulcer prevention -Athlin & Idvall, 2010; Samuriwo, 2010

PROBLEM STATEMENT Pressure ulcer is multi-factoral in nature. -Moore & Price, 2004

Negative attitude towards pressure ulcer prevention resulted to a

higher prevalence of pressure ulcer

-Ayello & Meaney, 2003

ATTITUDE

-Islam et. al., 2010

In ICUs…

Usually has higher incidence of pressure

Most are bed-ridden patients

Has small nurse-to-patient ratio

CLINICAL

EXPERIENCE ATTITUDE

PROBLEM STATEMENT

Investigating the relationship and difference of attitude

with the nurses’ clinical area determines the need for

motivational interventions and correcting

misconceptions in using the

Braden scale.

PURPOSE OF THE STUDY

Explored the relationship between the clinical area

of nurses and their attitude towards the use of

Braden Scale.

PURPOSE OF THE STUDY Moreover, this also investigated the:

1. Attitude of nurses towards the use of Braden Scale

2. Presence of significant relationship between the

nurses’ clinical area and their attitude on the use of

Braden Scale; and

3. Difference between the attitude towards the use of

Braden Scale of nurses working in intensive care units

and medical wards.

METHODOLOGY

Design Descriptive Correlational Design

Locale 650 Bed-Capacity Hospital in Bonifacio Global

City, Taguig (Medical Center A)

217 Bed-Capacity Hospital in Alabang, Muntinlupa

(Medical Center B)

METHODOLOGY

POPULATION AND SAMPLE

Sampling Method Purposive Sampling

Inclusion Criteria

Full time Staff Nurses

Experienced using the Braden

scale

Working in Intensive Care Units

or Medical Wards

METHODOLOGY

POPULATION AND SAMPLE

Sample Characteristics Demographics Frequency Percentage

Sample 71

Gender

Male

Female

15

56

21.13%

78.87%

Hospital

Medical Center A

Medical Center B

37

34

52.11%

47.89%

Clinical Area

Medical Ward

Intensive Care Unit

32

39

45.07%

54.93%

METHODOLOGY

Ethical Considerations Approval of the patient services office and chief nurses of each

locale was obtained.

Autonomy and anonymity of the respondents were observed.

Research Instrument Modified 11-item Survey Tool

developed by Moore and Price (2004)

Reliability Coefficient= 0.84

RESULTS

Attitude of Nurses towards the Use of Braden Scale

Item Strongly

Agree Agree Uncertain Disagree

Strongly

Disagree

Weighted

Mean

Verbal

Interpretation

1. All patients are at potential risk of developing pressure

ulcers.

26 24 0 15 6 3.7 PA

37% 34% 0% 21% 8%

2. For me, Braden Scale is time consuming. 1 12 14 33 11

3.6 PA 1% 17% 20% 46% 15%

3. In my opinion, several patients tend not to get pressure

ulcers nowadays.

2 16 12 33 8 3.4 NPNA

3% 23% 17% 46% 11%

4. I do not need to concern myself with Braden Scale in

my practice.

0 5 6 40 20 4.1 PA

0% 7% 8% 56% 28%

5. Pressure ulcer treatment is of greater priority than

pressure ulcer prevention.

2 2 0 14 53 4.6 VPA

3% 3% 0% 20% 75%

6. Continuous assessment of patients will give accurate

account of their pressure ulcer risk.

54 13 3 1 0 4.7 VPA

76% 18% 4% 1% 0%

7. Most pressure ulcers can be avoided. 38 23 4 6 0

4.3 PA 54% 32% 6% 8% 0%

8. I am less interested in pressure ulcer prevention than

other aspects of nursing care.

4 9 6 39 13 3.7 PA

6% 13% 8% 55% 18%

9. My clinical judgment is better than Braden scale

scoring.

0 14 26 23 8 3.1 NPNA

0% 20% 36% 32% 11%

10. In comparison with other areas of care, pressure ulcer

prevention is a low priority for me.

2 4 5 40 20 4.0 PA

3% 6% 7% 56% 28%

11. Braden Scale scoring should be regularly carried out

on all patients during their stay in hospital.

24 33 10 4 0 4.1 PA

34% 47% 14% 6% 0%

Overall Mean = 3.97 PA

*Legend: 4.6 – 5.0: Very Positive Attitude (VPA); 3.6 – 4.5: Positive Attitude (PA); 2.6 – 3.5: Neither Positive nor Negative

Attitude (NPNA); 1.6 – 2.5: Negative Attitude (NA);

1.0 – 1.5: Very Negative Attitude (NA)

Overall Mean=

3.97; Positive Attitude

Attitude of Nurses towards the Use of Braden Scale

Studies from other countries showed same findings (Moore & Price, 2004; Islam et. al., 2010; Kallman & Suserud, 2009; and Beckman et. al., 2011)

Thinking that the clinical judgment is better than Braden scale

leads nurses to seldom use Braden scale in their practice.

Kallman & Suserud (2009)… This impression may be related to their lack of knowledge and ‘insecurity’

to use the scale.

Infrequent use of Braden scale leads to this misconception

Attitude of Nurses towards the Use of Braden Scale

No sufficient evidence was produced to show that clinical

judgement can predict the risk of patient of developing pressure

ulcer (Pancorbo-Hidalgo, et al., 2006).

Braden scale assessment is immediately necessary to be able apply

appropriate preventive interventions especially to stage 1 pressure

ulcer.

Clinical Area and Attitude towards the Use of Braden Scale

Pearson

Chi-Square

(X2) Value

Degree of

Freedom

(df)

Critical Value

(CV) p-value Decision

9.1268 2 5.9915 0.010 Reject the Ho

The clinical area of nurses is significantly related to their attitude

towards the use of Braden scale.

Attitude of Nurses towards the Use of Braden Scale in ICU and Medical Wards

Attitude of nurses towards the use of Braden scale in Intensive Care

Units is significantly higher than those in Medical Wards.

Clinical Area Mean SD z P value CV Decision

Intensive

Care Units

4.03 0.52 1.669 0.0475 1.645 Reject the Ho

Medical Wards 3.88 0.38

Attitude of Nurses towards the Use of Braden Scale in ICU and Medical Wards

Nurses in ICU and medical wards may demonstrate different level of

attitude (Islam et. al., 2010).

Variation in compliance, strategies, and practice allows patients to

develop pressure ulcer (Lewin et. al., 2003).

Risk assessment through Braden scale shall be performed regularly to

all areas of a hospital not only to bed-ridden patients but also to

newly admitted patients and those with low to moderate mobility

problems.

CONCLUSIONS

Nurses’ work area depicts their attitude in carrying out

Braden Scale as a risk assessment tool to prevent their patients

from developing pressure ulcer.

While nurses from both clinical areas have positive attitude,

this tends to be greater in ICUs than in medical wards.

RECOMMENDATIONS

NURSING PRACTICE Motivational strategies to balance the quality and type of

patient care in intensive care units and medical wards.

Encouraging frequent and regular use of Braden scale to all

clinical areas increases their compliance to practice.

RECOMMENDATIONS

NURSING EDUCATION Integration of risk assessment to

the core competencies of nursing

students promotes positive attitude

towards their practice.

RECOMMENDATIONS

NURSING RESEARCH Parallel surveys and interviews are

encouraged to produce an in-depth information

about their attitude and behavior.

Analysis of the relationship between nurses’

attitude, barriers, and experience towards

Braden scale assessment is also suggested.

RECOMMENDATIONS

NURSING RESEARCH Random sampling, increasing the sample size and multi-

locality may improve the generalizability of study.

References

Agency for Healthcare Research and Quality. (2008, December 3). Pressure ulcers increasing among hospital patients. AHRQ News and

Numbers. Retrieved from http://www.ahrq.gov/news/nn/nn120308.htm.

Athlin, E., &Idvall, E. (2010). Factors of importance to the development of pressure ulcers in the care trajectory: Perceptions of hospital and

community care nurses. Journal of Clinical Nursing, 19(15), 2252-8. Retrieved from http://www.ebscohost.com.

Ayello, E., & Meaney, G. (2003). Replicating a survey of pressure ulcer content in nursing textbooks. Journal of Wound Ostomy and

Continence Nursing, 30, 266-271.

Beckman, D., Defloor, T., Schoonhover, L., &Vanderwee, K. (2011). Knowledge and attitudes of nurses on pressure ulcer prevention: A cross-

sectional multicenter study in Belgian hospitals. Worldview Evidence Based Nursing. doi: 10.1111/j.1741-6787.2011.00217.x.

Cho, I. & Noh, M. (2010). Braden scale: Evaluation of clinical usefulness in an intensive care unit. Journal of Advanced Nursing 66(2), 293–

302. doi: 10.1111/j.1365-2648.2009.05153.x.

Islam, S., Sae-Sia, W., Khupantavee, N. (2010). Knowledge, attitude, and practice on pressure ulcer prevention among nurses in Bangladesh.

Diseases-Palliative Care, Proceedings of the 2nd International Conference on Humanities and Social Sciences, Prince of Songkla University,

Thailand. Retrieved from http://sv.libarts.psu.ac.th/conference5/proceedings/Proceedings2/article/6pdf/011.pdf.

Kallman, U., & Suserud, B. (2009). Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and

treatment – a survey in a Swedish healthcare setting. Scandinavian Journal of Caring Sciences, 23(2), 334-341. doi:10.1111/j.1471-

6712.2008.00627.x

References

Lewin, G., Carville, K., Newall, N., Phillipson, M., Smith, J., & Prentice, J. (2003). Determining the effectiveness of implementing the AWMA

guidelines for the prediction and prevention of pressure ulcers in Silver Chain – a large home care agency. Stage 1: Baseline measurement.

Prim Intent, 11, 57–8, 60–7, 69–72.

Molon, J.N.D., & Estrella, E. P. (2011). Pressure ulcer incidence and risk factors among hospitalized orthopedic patients: Results of a

prospective cohort study. Ostomy Wound Management, 57(10), 64-69.

Montalvo, I. (2007). The national database of nursing quality indicators ™ (NDNQI®). Online Journal of Issues in Nursing, 12(3). doi:

10.3912/OJIN.Vol12No03Man02.

Moore, Z. & Price, P. (2004). Pressure ulcer prevention: Nurses’ knowledge, attitudes and behavior. Journal of Wound Care, 13(8), 330-334.

Pancorbo-Hidalgo, P.L., Garcia-Fernandez, F.P., Lopez-Medina, I.M. & Alvarez-Nieto,C. (2006). Risk assessment scale for pressure ulcer

prevention: A systematic review. Journal of Advanced Nursing, 54(1): 94-110. Retrieved from http://www.ebscohost.com.

Samuriwo, R. (2010). The impact of nurses’ values on the prevention of pressure ulcers. British Journal of Nursing, 19 (15), S4-S13. Retrieved

from http://www.ebscohost.com.

Stotts, N., &Gunningberg, L. (2007). Predicting pressure ulcer risk. American Journal of Nursing, 107(11), 40-48. doi:

10.1097/01.NAJ.0000298058.25564.8a

Suriadi, Sanada, H., Sugama, J., Kitagawa, A., Thigpen, B., Kinosita, S. et al. (2007). Risk factors in the development of pressure ulcers in an

intensive care unit in Pontianak, Indonesia. International Wound Journal, 4, 208-215.

References

The Joint Commission. (2011). 2011-2012 National Patient Safety Goals. Retrieved from

http://www.jointcommission.org/assets/1/18/2011-2012_npsg_presentation_final_8-4-11.pdf.

Wann-Hansson, C., Hagell, P., &Willman, A. (2008). Risk factors and prevention among patients with hospital-acquired and pre-existing

pressure ulcers in an acute care hospital. Journal of Clinical Nursing, 17, 1718-1727. doi:10.1111/j.1365-2702.2008.02286.x.

Thank you very much! Maraming Salamat!

ATTITUDE of NURSES towards the USE of BRADEN SCALE in

INTENSIVE CARE UNITS and MEDICAL WARDS

JOEMER C. MARAVILLA, RN, BSN Philippine Council for Health Research and Development

Department of Health, PHILIPPINES