Pressure ulcers (PU) or bedsores are caused due to prolonged pressure on the skin and its underlying tissue. It is prevalent among people especially geriatric population as they are confined to the bed or wheelchair for long periods (Black et al., 2011). There are developments of discoloured patches that are warm, hard or spongy creating itchiness or pain in the affected area. PU differs in size and affects tissue layers from skin erythema to bone damage. The problem of PU is common being a medical complication among the older population. In Australia, prevalence of PU is between 3.4 to 5.4% in aged care homes as reported by Australian Wound Management Association (AWMA) (Care, 2011). This problem induces suffering and deterioration in quality of life with prolonged hospitalization among the patients and therefore, pressure ulcer prevention are important parameters (Lyder et al., 2012). Therefore, PUs among the aged care people is a clinical issue that have a significant effect on the quality of life with increasing care costs and long hospital stays.
Pressure ulcers and related injuries not only impose significant burden on the patient, but the entire healthcare system. It has severe negative impact on the patient and healthcare system like increased infection rates, pain, morbidity, mortality, increased hospital stays and financial costs (Coleman et al., 2014). The frequency and prevalence of PUs need to be reduced which is an essential component for patient safety and quality of care. It is evident that potential risk factors for PU need to be assessed early that may influence clinical practice for the PU prevention and improvement in quality of care. The prediction of risk of PUs is a nursing issue and requires immediate risk assessment. The prevention of PU development is the best way to reduce the burden of PU for the healthcare system being their core aim (Sullivan & Schoelles, 2013). The implementation of PU prevention guidelines can help to prevent PUs that target the risk factors related to PU development (Moore and Cowman, 2014). Concisely, the understanding and identification of risk factors in the PU development can aid in developing prevention interventions and better utilization of resources in clinical practice.
According to Coleman et al., (2013) three main factors contribute to PU development: perfusion alterations, mobility/activity and skin status. For the assessment of these risk factors, PU risk assessment tools are important component for the identification of patients at risk of developing PU. The checklist comprises of Braden Scale, Waterlow Scale and Norton Scale that are currently in use. These tools are valid, reliable, specific and sensitive by identifying the individuals at risk in a consistent manner. However, there is little information available regarding the reliability and validity of these tools and that acts as big challenge for the clinical setting. Evidence also suggests that specificity and sensitivity of risk assessment tools vary in different healthcare settings because of clinical judgment made on obtained risk assessment results (García-Fernández et al., 2014).
According to Šáteková & Žiaková, (2014) among the most frequently used PU risk assessment scales, Braden scale demonstrated optimal predictive validity. However, there is a need to examine other scales in respective clinical settings and comparison with foreign studies. On the other hand, another study conducted by Ang, Chang & Tay, (2014) showed that Braden scale showed moderate predictive validity with low predictive specificity for PU risk assessment. Therefore, further development and testing of risk assessment scales is important for identification of PU risk factors and prevention.
From the above discussion, it is clear that risk assessment is important at the time of admission and at periodic time intervals. According to Centres for Disease Control and Prevention (CDC), the healthcare professionals use these risk assessment tools being the best and effective approach for PU prevention (Centres for Disease Control and Prevention, 2012). Various tools are used for the risk assessment like Braden, Norton and Waterlow scale PU assessment help healthcare professionals to identify individuals who might develop PU. Therefore, the aim of this paper is to evaluate the effectiveness of Braden scale and Waterlow scale for the assessment of PUs through systematic search strategy, identification of barriers and strategies to implement the evidence in the clinical setting of Saudi Arabia.
In patients at risk for pressure ulcers, does Braden scale as compared to Waterlow scale prevent the incidence of pressure ulcers?
Methodology: For the alignment of the research question with the aim of the research that is proposed, a systematic literature review is beneficial. The current trends of PU prevention in different clinical settings are to be analysed based upon strong evidence and gather the best evidence from the systematic literature review. This method is aimed at identification, evaluation and summarization of the major findings so that best available information can be retrieved and help to draw the evidences into practice (Liamputtong & Serry, 2013). Relevant literature can be extracted from the vast pool of evidences and helpful in drawing conclusion for the implementation into practice. The summarization of the key findings and identification of the literature gaps along with future scope for research are the main aims of systematic literature strategy. For the present study, a systemic literature strategy was carried out for understanding the effectiveness of Braden scale as compared to Waterlow scale in the prevention of PUs among the patients at risk. The scientific design was important during the literature search and accordingly, appropriate sources were retrieved from the credible sources in a logical and systematic manner through appropriate search strategy (Maxwell, 2012).
Databases used: Appropriate search engines were used for carrying out the literature search reviews. Identification of databases is important as it provides ample of information on any subject matter. The electronic databases used for the present study were CINAHL, Google Scholar, Cochrane and Medline. These databases help to provide wide range of information regarding every subject and also have proper access to the full text articles that are authentic. These databases are reliable and provide up-to-date information covering many journals. The update information is important for the study and so, these databases provide up-to-date information.
Keywords/search terms- Keywords or search phrases are important for carrying out a systematic literature search. The commonly used words that are important phrases in the clinical research question are used in the search engines for the search. When the keywords are entered appropriately with maximum number, systematic literature review is considered successful. For the present study, the search items used are “pressure ulcer”, “pressure ulcer prevention”, “risk assessment”, “Braden scale”, “Waterlow scale”, “incidence of pressure ulcer”.
Boolean operators- Apart from the appropriate key search items, Boolean operators are also important in the search strategy. These logical items are used in conjunction with the key search words for the authentic and reliable search. The Boolean operators used make the search smooth and inclined towards correct direction. Only the relevant data was extracted from the search and the inappropriate items were eliminated from the search. OR and AND were used for the present study and applied for each database search method.
Selection process- This is the most important part of a systematic search strategy as it requires arduous research to include the articles that are relevant to the study and contains updated information (Smith et al., 2011). A selection criterion is selected for the present study through an inclusion and exclusion criteria adhering to the current selection criteria (Uman, 2011). For the present study, thorough examination was done which is defined as the inclusion criteria. The articles published after the year 2010 was included for the study. Full-text articles were only included for the study searching in every databases and around fifteen relevant articles were selected for the study. This was the first round of selection based on the article paper name and in the second round of screening, the abstract of the articles were read for relevancy. Finally, six relevant contemporary articles were included in the present research study. All the articles that were published in English were included from different countries. These articles have studied the effectiveness of the risk assessment tools; Braden scale and Waterlow scale for the risk assessment in patients at PU risk.
Data extraction- For extracting the relevant information, a critical analysis of the articles was done. The critical appraisal was done for the study that included a checklist like aim, research methods, findings, conclusion, discussion and limitations. It also included information like research gap limitation and scope for future studies.
Data analysis- For the data analysis, the articles were reviewed properly before the presentation of the findings. This kind of literature review gives an opportunity to assess the quality of study, efforts made in the research and in identifying the gaps, limitations and scope for future studies. Apart from the research findings, the arguments and contradictions that were presented in the paper were also highlighted. When these points are considered, it helps to give a deep insight on the research topic and provide scope for comparison between the literatures.
The paper by Cowan et al., (2012) was aimed at studying the PU predictive model that was identified in the acute care settings for the assessment of PU risk by Braden scale. The paper beautifully addressed the effective use of Braden scale in the risk assessment in acute care settings and addressed the clinical significance of the study. The literature review of the paper is comprehensive explaining the significant challenge faced by the healthcare system in PU prevention. The review has incorporated the essential elements like the specificity and sensitivity of Braden scale that is poorly reported by other studies (He, Liu & Chen, 2012). This study is relevant to the research question and it helps to bridge the gap that addresses PU risk assessment tool like Braden scale in acute care settings in long-term care. The study highlighted the importance of nutrition and required intervention in the prevention of PU. The method used for the study is case control study that is an epidemiological observational study highlighting the long latency of PU risk in long-term care in acute settings. However, this kind of study is subject to selection bias as in the study sample males were more than females. The sample data collection is described in a representative manner. The study did not address the absolute risk of PU and did not allow the scope for calculation of incidence of problem (Braden, 2012). The sample size is small to study the effectiveness of Braden scale as sampling errors affect the interpretation and precision of results. The validity of the instrument, Braden scale is discussed thoroughly explaining the reliability and specificity of this tool and its use in PU risk assessment. Voluntary response bias is a major drawback in case control study being a systematic error and it is difficult to identify the controls in the study (Brick, 2011). The findings of the paper showed that Braden scale and its subscores provided maximum specificity and sensitivity (sensitivity 65%, specificity 70%) along with Braden subscores (sensitivity 80%, specificity 76%). The overall performance of Braden scale for PU preventive interventions is not highlighted in the article and requires proper analysis in the future. The aggregated risk from combined factors also needs to be explored for future studies with an emphasis on each risk PU risk factor.
The paper by Gadd, (2012) studied the effectiveness of Braden scale, PU risk assessment tool for hospital acquired PU (HAPU). The study design is a literature review that was conducted to study the patients’ outcomes when this tool was used for HAPU assessment and discussed the implications of future practice. The background of the study explicitly explained addressing the issue of PU and foundation for patient safety. It also mentioned the wide use of Braden scale for individualized planning based on subscale scores. According to Cohen et al., (2012) reviews studied regarding the current use of this scale, concluded that Braden scale is the most robust, and provide reliable data when compared to other risk assessment tools. Gadd, (2012), does not explain this point in the article regarding reliability of Braden scale. The integrative literature review used for this study comprised of only English language articles searched through databases like MEDLINE, CINAHL and Cochrane Library. After reviewing 1825 articles, only one article comprising of integrative literature search was studied. This is the major drawback of this paper as the results are not sufficient and provide authenticity that can be generalized in a population. The selected paper is a cohort study of PU risk factors that specifically discussed the cumulative BS score to subscales. The paper by Cowen et al., (2012) did not address the above mentioned point that is highlighted in this paper. The paper has highlighted the implications for future practice where Braden subscale scores indicate need for individual interventions that is generally overlooked in patient-centred care. This paper mentioned that Braden scale is a reliable tool, however, further evaluation of individual Braden subscores based on clinical judgment is required that affect risk assessment and PU prevention.
The paper by Iranmanesh, Rafiei & Sabzevari, (2012) was a prospective descriptive study where the purpose was to determine the relationship between Braden scale and PU development. The study was significant as it studied that score obtained in Braden scale is inversely proportional to PU risk. The main finding of the paper is that it is a useful tool for the prediction of PU in trauma ICU patients. The paper also suggested other factors like age and consciousness level that also influences the PU development. The study highlighted that PU risk is high in Iran and nurses do not use any scale for the prediction of PU development and risk assessment. Concisely, the study conducted is good and results indicated that Braden scale is a good predictor for PU development among critically ill trauma patients in Iran. Based on the results obtained in the study, the most significant difference between patients with or without PU was found in sensory perception where they were able to responds meaningfully to pressure-related discomfort. Other scales Waterlow, Norton and Cubbin-Jackson scale were used in patients for high PU development risk for quality improvement in trauma ICUs (Chou et al., 2013). Mean
Braden score was 13·4 ± 3·5 as compared to Glasgow coma scale was 10·6 ± 3·7.
The paper by Tayyib, Coyer & Lewis, (2016) conducted a prospective cohort study design for identification and PU risk incidence in ICU settings in Saudi Arabia. Out of 84 participants, over 33 participants were identified with new PUs of 39.3% (U=537⋅5, z=1098⋅5, P=0.004). Lower Braden scale scores predicted the PU development higher as compared to other studies (Gadd, 2014). The data collection method is not proper as it is limited by time. The study required a longer period and did not give any data regarding the frequency of repositioning performed by nurses (Coleman et al., 2013). However, the study did not address the effectiveness of Braden scale as compared to other scales like Waterlow or any description of development of PU due to other factors like BMI or time of stay in emergency departments. The sample size was small with a retrospective design and stage I PU exclusion. Small sample size suggests low statistical power and false inferences about population (Button et al., 2013). This suggests a research gap for prospective longitudinal studies confirming the association between PU and those factors in ICUs. The study added information to the existing knowledge of PU incidence in Saudi Arabia that suggests future studies for implementation of evidence-based practice for PU prevention. The study strongly suggested that a comprehensive PU risk assessment and prevention is required in ICUs in Saudi Arabia (VanDenKerkhof et al., 2011).
The study conducted by Tescher et al., (2012) was to identify the risk factors in PU and enhancement of Braden scale use in the clinical settings. The study was a retrospective cohort analysis of electronic medical records of 12,566 patients in Mayo Clinic was analyzed. In this study, only iatrogenic stage 2 to 4 PUs were considered and excluded the stage 1 PU as the study by Tayyib, Coyer & Lewis, (2016). The sample size comprised of 416 patients who developed PU by using Braden scale that was found to be very predictive in PU development. This study also provides an opportunity for enhancement of Braden subscales for the prevention of PU specific for the patient. However, this study did not perform natural history study and data based on active clinical practice (Teague et al., 2011). The effectiveness of these interventions might have reduced the PU risk development. The factors like shear, friction or low nutrition status might have influenced the results. The sample comprises of only high-risk population and its impact in the general population and only at the time of admission, however, PUs are likely to develop with prolonged stay (Stern et al., 2011). The results showed that Braden scale subscales are more predictive than Braden scale and provide scope for future studies that nurses should use this scale for high alert risk assessment (P < .0001, C = 0.71) (C= 0.83).
Jaul & Menzel, (2014) also studied the use of Braden scale in the PU risk assessment and highlighted the incidence of PU as a major complication among elderly population. The study illustrated that there are severe complications associated with PU among the elderly. The literature review is beautifully presented highlighting the prevalence of PU, pathogenesis and prevention measures. The results of the study findings suggest that the use of Braden scale for the risk assessment is superior in specificity and sensitivity as compared to other risk assessment models like Waterlow and Norton scale. It is advantageous as it assess five risk factors; skin moisture, sensory perception, mobility, activity levels, shearing forces, friction and nutritional intake (Mallah, Nassar & Badr, 2015). Braden scale defines the risk level with maximum score of 23, 18 or less indicate risk and score below 12 indicate high-risk patients (Eberlein-Gonska et al., 2011). This study has not addressed the effectiveness of the scale in PU risk assessment that does not align with the research question and its aims.
The above evidence illustrates that clinical problem of PU is a major public health issue that require urgent risk assessment and prevention. The above reviewed evidence shows that PU is a clinical issue that is hampering patient safety within the healthcare settings and contribute to the burden of disease and increased financial costs. Various risk factors contribute to pressure ulcers and increase the risk for its development. There is a need to assess the risk at early stages to prevent the development of PU from the time of admission. The key implications of the above reviewed evidence are that there is a need for wide use of risk assessment tools for the prevention of PU and early PU risk identification. The findings also suggest that wide use of Braden scale for risk assessment is not possible as it differ according to clinical setting and varying healthcare systems. However, the findings of this systematic literature search are significant and could be incorporated in the clinical setting with development of appropriate interventions. The significant use of risk assessment scales would guide the clinical decisions regarding evaluate of patient’s risk for PU development.
In nursing practice, clinical judgment is important to evaluate the score obtained by the scales for identifying the risks for PU development (Mwebaza et al., 2013). For its incorporation into clinical setting, a good understanding, knowledge is the key to identify the specific problem of PU development guiding prevention strategies. The translation of the knowledge to clinical practice is not possible as there are various barriers witnessed in the clinical setting of Saudi Arabia (Bayoumi & Bassuni, 2016). The use of risk assessment tools, clinical judgment for evaluation of obtained scale scores and provision for pressure relieving devices are important for reducing the prevalence of PUs in the clinical settings. The above gathered evidence illustrates that risk assessment by the nurses is helpful for identifying patients who are at high risk. The above evidence depicts that Braden scale being the most widely used reliable tool for risk assessment. The implications of the evidences is that there is a requirement for incorporation of Braden scale use in the identification of PU risk in the clinical setting for ensuring patient safety.
For the implementation of Braden scale in the clinical setting in Saudi Arabia, many barriers are identified. The findings showed that research gap is identified between scientific evidence (best practice) and actual clinical practice. While reflecting on the implementation of this practice in the clinical setting, a good understanding of the problem along with identification of the barriers and effective strategies are required. For implementation of change, there is lack of awareness, agreement, self-efficacy, low expectancy, lack of motivation and external barriers beyond the control that hinder the implementation for change in Saudi Arabia (Jankowski & Nadzam, 2011). Bayoumi & Bassuni, (2016) studied the level of knowledge of Saudi Arabian nurses regarding PU prevention measures. There is high prevalence of PUs in Saudi Arabia with developing risk factors and nurses’ perceptions and knowledge regarding comprehensive skin assessment and evaluation of results obtained from risk assessment tools is important for the implementation of change in the clinical setting. Nurses have no conscious regarding the assessment of scores obtained from risk assessment scales and factors for PU development vary according to clinical settings where identified risk assessment tools may fail and there is a need for new scales.
Lack of knowledge and clinical judgment is the major barrier, as results generated by the risk assessment tools require critical thinking where nurses’ clinical judgment guides the identification of PU risk in patients categorizing them as mild, moderate, high or no risk patients for PU. The nurses’ clinical judgment for the determination of capacity of risk assessment scales for the prediction of PU development is important for reducing the prevalence and prevention of PUs (Sving et al., 2014).
Clinical judgment and accurate early skin assessment in pressure ulcers by the nurses are the most effective strategies to implement change in Saudi Arabia. Although, clinical judgment is important for evaluation o risk assessment scores, the specificity and sensitivity of the risk assessment scales is not easy to validate alone with clinical judgment. When the clinical judgment is used alone, it results in inadequate predictive capacity and so it is used in combination with validated risk assessment scales like Braden scales. In addition, Braden scale also need to be used in combination with its subscales as it provides more accurate and specific results. When they are used in combination, it provides more reliable and specific results in the identification of PU risk factors and in reducing incidence of PU in the clinical settings. A study conducted at Riyadh Military Hospital, Saudi Arabia demonstrated that Braden scale along with nurses’ clinical judgment is used for identification of PU development that showed significant results (Saleh, Anthony & Parboteeah, 2009). However, there were no significant results found when Braden scale was used alone for PU incidence reduction and so, it is suggested that the combination of Braden scale and clinical judgment of nurses can work together to improve health outcomes regarding PU development. This phenomenon suggests that decrease in PU prevalence may be an example of Hawthorn effect where increased awareness can benefit patient care. It depicts that there is little difference between clinical judgment and Braden scale in terms of dimensionality being the strongest predictors for PU risk assessment when used together (Pickham et al., 2016).
The skin assessment, nutritional status for the pressure ulcer prevention is important for the early detection of PU risk that can be helpful to understand the risk exposure. Early and accurate skin assessment is also important for reducing the PU development and prevalence. Comprehensive skin assessment is important where the skin is assessed for any abnormalities. The identification of any PU, assistance in risk stratification for patients with existing pressures is essential for identifying the risk for additional ulcers. The skin related factors or lesions that predispose to PU development also need to be assessed for the patients who stay in bed or wheelchairs for long hours in long-term care facilities. The assessment must include the five parameters: temperature, colour, and moisture level, turgidity and skin integrity for any open areas or rashes. Nurses should perform standardized procedure for skin assessment by checking the skin at the time of bathing, cleaning or repositioning (Engels et al., 2016).
Early risk assessment techniques need to be performed at equal intervals so that it identifies people who are at risk for PUs. Nutritional level is also important as declining nutrition can result in increased PU risk. Inadequate nutritional intake resulting in low body weight and skin breakdown can result in increased risk for PU development. This suggests that nurses should perform risk assessment using risk assessment tools like Braden scale to identify the patients at high risk for PU development. Therefore, the compliance of the nurses towards the validated risk management of pressure ulcer using Braden scale is important for the early detection and management of the PUs (Sving et al., 2012).
Conclusion
From the above systematic literature review, it can be concluded that although Braden scale is effective in the identification and assessment of risk for the PU detection and prevention, Braden subscales increases the effectively of the assessment. When compared to other scales like Waterlow, the evidences showed that Braden is a better reliable and effective tool with high sensitivity and specificity. Braden scale is widely used in the clinical settings and its subscale measures risk in six major categories: moisture, mobility, activity, sensory perception, nutrition, and shear/friction. The score ranges from six to 23 where low score indicate high risk for PU development and preventive interventions are developed accordingly. From the above findings, it is clear that Braden scale alone cannot predict PU risk and require subscale or comparison with other scales for the appropriate assessment of risk factors. Although, there is no single tool that can assess risk with 100% specificity and sensitivity. However, certain barriers are identified that involved clinical judgment of the nurses and their compliance towards routine skin assessment and identification of risk for PU prevention. The evidences gathered through systematic literature search suggest that among the risk assessment tools, Braden scale is widely used as compared to Waterlow or Norton scale. Among all, Braden suggested to have highest predictive validity and nurses should know, understand, adopt and implement evidence based PU risk assessment tools and standard PU protocols for prevention of PU. The evidences suggest that Braden scale cannot be used alone and need to be used along with nurses’ clinical judgment for evaluating the results obtained by scales.
Comprehensive skin assessment, moisture, nutritional status is also important for the identification of patients who are at risk and reduce PU risk and prevalence. It also has implications for future nursing practice where nurses have to be in position to provide early intervention for reduction in prevalence and prevention of PU. In Saudi Arabia, for the implementation of practice change in the clinical setting, there is a need for identification of barriers and develop interventions to overcome it. Appropriate risk assessment through use of risk assessment tools in the clinical setting is important for the early identification and assessment of patients who are at risk for developing PU. Patient repositioning, use of foam gels, nutritional assessment, adequate fluid intake, good skin care are some of the strategies can be helpful in the implementation of change in Saudi Arabia clinical settings and in prevention of PU and prevalence.
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First, you will need to complete an order form. It's not difficult but, in case there is anything you find not to be clear, you may always call us so that we can guide you through it. On the order form, you will need to include some basic information concerning your order: subject, topic, number of pages, etc. We also encourage our clients to upload any relevant information or sources that will help.
Complete the order form
Once we have all the information and instructions that we need, we select the most suitable writer for your assignment. While everything seems to be clear, the writer, who has complete knowledge of the subject, may need clarification from you. It is at that point that you would receive a call or email from us.
Writer’s assignment
As soon as the writer has finished, it will be delivered both to the website and to your email address so that you will not miss it. If your deadline is close at hand, we will place a call to you to make sure that you receive the paper on time.
Completing the order and download