The Braden Scale for Predicting Pressure Sore Risk: Reflections after 25 Years

Abstract

In 1984, I developed The Braden Scale for Predicting Pressure Sore Risk as a screening tool for a research study. Together with Dr Nancy Bergstrom and other colleagues, we tested the Braden Scale in several settings, and the results of those tests were published in 1987.1,2 To my amazement, use of the Braden Scale disseminated rapidly! People from around the world began asking for permission to translate the Braden Scale into a variety of languages. Today, it has circulated to all continents and to more than 30 countries. Nurses who were concerned with wound care were crucial to the widespread acceptance of the Braden Scale. The 1987 publications coincided with the early stages of the evidence-based practice movement, and nurses were anxious for current and clinically relevant research to guide their practice. Thus, a validated risk assessment tool and the ability to examine the meaning of the statistical tests associated with predictive validity were important. At the first consensus conference held by the National Pressure Ulcer Advisory Panel (NPUAP), Doreen Norton sent a paper to be read to the attendees. Among other things, she said that she had not been concerned with prediction, but rather with assessment when she developed the Norton Scale. I shrugged at her words, wondering how one could validate such a tool without calculating predictive validity. During our first tests of predictive validity, few units had anything but a standard mattress—a very firm innerspring mattress. When we conducted the multisite study in the late 1980s and early 1990s,3 many types of support surfaces were being used, and the innerspring mattresses were slowly being replaced with foam mattresses. After the publication of the Agency for Health Care Policy and Research guidelines in 1993, formal programs of prevention began to emerge. Predictive validity, with many preventive interventions being implemented with the first ‘‘at-risk’’ score, became increasingly irrelevant. Based on the predictive value of a positive result in multiple studies,1–6 I had set levels of risk and developed some preventive protocols based both on level of risk and on some broad guidelines for managing nutrition, moisture, and friction and shear. But eventually, Doreen Norton’s message at the first NPUAP consensus conference began to resonate with me. I realized that this tool is first and foremost an assessment tool. Thus, I now recommend that nurses use the Braden Scale so that each subscale score serves as an initial appraisal of a patient’s specific problems and functional deficits, a flag for assessments that need to be explored further, and a guide to the types of interventions that may be required. The lower the subscale scores and total scores, the more ‘‘intense’’ the nursing interventions should become. I have also realized that, as an assessment tool, each functional deficit that is detected should be individually addressed, whether the risk score falls below 18. Although the Braden Scale has been found to have better predictive validity than nursing judgment,7 the best care is prescribed when The Braden Scale is used in conjunction with nursing judgment. Some patients will have high scores and still have risk factors that must be addressed, whereas others with low scores may be reasonably expected to recover so rapidly that those factors need not be addressed. Again, other patients will have additional risk factors and comorbidities not measured by the Braden Scale, and good nursing judgment would reveal the need for a higher intensity of preventive intervention. When risk assessment is supplemented with good nursing judgment, reliably implemented interventions that address factors influencing intensity and duration of pressure and tissue tolerance for pressure, and continuous quality improvement efforts, it is reasonable to expect that the incidence of full-thickness pressure ulcers will decrease.8,9