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
-Agency for Healthcare Research Quality (AHRQ), 2008

Asia:
United States of America: 2.1% to 31.3% in ICU
 0.4% to 38% in Acute Care -Suriadi et al., 2007
 2.2% to 23.9% in Long Term Care; and
 0% to 17% in Home Care Setting
- Islam et. al., 2010

Philippines:
In a tertiary hospital, 20% orthopaedic patients
-Molon & Estrella, 2011
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
Risk assessment scales were developed to help healthcare providers
ensure correct evaluation of their patients
-Wann-Hansson & William, 2008

33 systematic reviews suggested that this scale has good sensitivity in

predicting pressure ulcer risks
-Stotts & Gunningberg, 2007
PROBLEM STATEMENT
Non-compliant with the clinical guidelines for pressure ulcer prevention
-Wann-Hansson & William, 2008

Put low priority on pressure ulcer prevention

-Athlin & Idvall, 2010; Samuriwo, 2010

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

ATTITUDE
Negative attitude towards pressure ulcer prevention resulted to a
higher prevalence of pressure ulcer
CLINICAL
ATTITUDE
-Ayello & Meaney, 2003
EXPERIENCE
-Islam et. al., 2010

In ICUs…
 Usually has higher incidence of pressure
 Most are bed-ridden patients
 Has small nurse-to-patient ratio
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 15 21.13%
Female 56 78.87%
Hospital
Medical Center A 37 52.11%
Medical Center B 34 47.89%
Clinical Area
Medical Ward 32 45.07%
Intensive Care Unit 39 54.93%
METHODOLOGY
Research Instrument
Modified 11-item Survey Tool
developed by Moore and Price (2004)
Reliability Coefficient= 0.84

Ethical Considerations
 Approval of the patient services office and chief nurses of each
locale was obtained.

 Autonomy and anonymity of the respondents were observed.

RESULTS
 Attitude of Nurses towards
the Use of Braden Scale
Strongly Strongly Weighted Verbal
Item Agree Uncertain Disagree
Agree Disagree Mean Interpretation
1. All patients are at potential risk of developing pressure 26 24 0 15 6
3.7 PA
ulcers. 37% 34% 0% 21% 8%

1 12 14 33 11
2. For me, Braden Scale is time consuming. 3.6 PA
1% 17% 20% 46% 15%

3. In my opinion, several patients tend not to get pressure 2 16 12 33 8

3.4 NPNA
ulcers nowadays. 3% 23% 17% 46% 11%

4. I do not need to concern myself with Braden Scale in 0 5 6 40 20

4.1 PA
my practice. 0% 7% 8% 56% 28%

5. Pressure ulcer treatment is of greater priority than 2 2 0 14 53

4.6 VPA
pressure ulcer prevention. 3% 3% 0% 20% 75%
6. Continuous assessment of patients will give accurate 54 13 3 1 0
4.7 VPA
account of their pressure ulcer risk. 76% 18% 4% 1% 0%
38 23 4 6 0
7. Most pressure ulcers can be avoided. 4.3 PA
54% 32% 6% 8% 0%

8. I am less interested in pressure ulcer prevention than 4 9 6 39 13

3.7 PA
other aspects of nursing care. 6% 13% 8% 55% 18%

9. My clinical judgment is better than Braden scale 0 14 26 23 8

3.1 NPNA
scoring. 0% 20% 36% 32% 11%
10. In comparison with other areas of care, pressure ulcer 2 4 5
Overall
40 20
Mean=
PA
3.97; Positive
4.0
prevention is a low priority for me. 3% 6% 7% 56% 28%
Attitude
11. Braden Scale scoring should be regularly carried out 24 33 10 4 0
4.1 PA
on all patients during their stay in hospital. 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)
 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 Degree of
Critical Value
Chi-Square Freedom p-value Decision
(CV)
(X2) Value (df)

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

Clinical Area Mean SD z P value CV Decision

Intensive 4.03 0.52 1.669 0.0475 1.645 Reject the Ho
Care Units

Medical Wards 3.88 0.38

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

Units is significantly higher than those in Medical Wards.
 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
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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.
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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:
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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
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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