Evaluating the Feasibility and Predictive Validity of the Braden Scale for Pressure Injury Risk Assessment Among Nursing Staff in Public Hospitals, Addis Ababa, Ethiopia, 2021
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Date
2025-09-27
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Addis Ababa University
Abstract
Background: Pressure injuries (PIs) remain a significant global healthcare concern, affecting patients across various settings with differing levels of severity and prevalence. Patients admitted to healthcare facilities, particularly those in intensive care units (ICUs), are at increased risk of developing more severe and frequent PIs. Pressure injuries are extensively recognized as significant indicator of the quality care provided to hospitalized patients. Occurrence of PIs underscores the importance of the vital role of nurses in implementing effective prevention strategies. Various risk assessment tools, including the Braden scale, have been adopted in many countries to support PI prevention strategies. Howevere, despite the availability of these tools and established prevention protocols, the PIs prevalence rate continues to increase. Despit routine PI risk assessment with preventive measures are essential, these practices are neglected in most clinical setting. In Ethiopia, PI risk assessment tools such as the Braden Scale have not been generally reported or implemented in hospital practices. This gap is frequently linked with inadequate planning and inconsistent implementation of preventive measures, which may result from limited knowledge and skill related to PI risk assessment and management among nurses. Effective prevention depends on identifying at-risk patient accurately. International pressure injury prevention (IPIP) guidelines strongly recommend the use of validated risk assessment tools like the Braden Scale. Varying level of predictive ability of the Braden Scale is reported, while its applicability and effectiveness within the Ethiopian healthcare context remains unexamined. Moreover, despite evidences supporting efficacy of the PI prevention strategies, their implementation remains suboptimal worldwide, particularly in low-and-middle income countries (LMICs) where standardized guidelines and resources are often limited. In LMIC settings such as Ethiopia, nurses often do not have been taught or not have the requisite skills to assess PIs risk with validated instruments such as the Braden Scale. In addition, no study has used a theory based framework to examine the intentions and acceptance among nurses for implementing the Braden Scale.
Objective: This study aims to evaluate the feasibility of the Braden Scale by examining changes in nurses' knowledge and attitudes after receiving education through various delivery methods, to assess the effectiveness of the Braden scale in predicting pressure injuries among hospitalized patients, and to examine the relationship between the Theory of Planned Behavior and Nurses‘ xii readiness to implement and accept the Braden Scale for pressure injury risk assessment in Ethiopia. Methods: the study was conducted using quasi-experimental cluster, prospective and cross sectional study design in three public hospitals, Addis Ababa. The quasi-experimental cluster study was conducted on a sample of 159 nurses. The Participants were selected from units with patients often bedridden and more likely to develop a pressure injury during their hospital stay. Data was collected using structured self-administered questionnaires. A cross-sectional study design was utilized on 163 staff nurses enrolled from three public hospitals. The participants were full-time staff nurses working in units designated for critical patient care, including the ICU, Internal Medicine, Surgical, and Orthopedic unit. Data was collected using a structured self-administered questionnaire. A multiple regression analysis was employed to analyze the data. A Wilcoxon signed-rank test for pair t-test and one-way ANOVA and Kruskal-Wallis test for independent group test was used to analyze the data. With the prospective study 238 patients, from critical care units of the three selected public hospitals in Addis Ababa, Ethiopia. Participants enrolled using convenience sampling technique. The data collection was carried out using structured questionnaires. Data analyzed with Binary logistic regression and ROC analysis to assess variable relationships, evaluate the Braden Scale's predictive ability for pressure injuries development.
Results: Out of 145 nurse participants, 68.3% of nurses, were female, with a mean age of 29.4 + 4.9 years and 66.7% had no prior information about the Braden Scale. The overall mean scores change of the pre-to-post educational intervention for knowledge and attitude was statistically significant, with a large effect size, (d=1.95 and 0.81), respectively p < .001. The analyzed 229 participant were predominantly male (59.8%), with a median age of 39 years. The mean score on the Braden Scale was 13.2 ± 2.95on a scale of 6 – 23. Pressure injuries developed in 21.83% of participants. The Braden Scale score, age, and body temperature were significant predictors of pressure injury risk. A one-unit increase in the Braden Scale score reduced injury odds by 24.5%, while age and body temperature increased the odds by 2% and 2.27 times, respectively. ROC analysis revealed a sensitivity of 64% and specificity of 59.2% at a cut-off point of 13.5. The AUC value was 0.682 (95% CI: 0.611, 0.761), reflecting a statistically significant, yet insufficient capacity to predict the pressure injuries (p < 0.001). A total of145questionnaires xiii were completed by the nurses, resulting in a response rate of 89%. Four factors including Nurse‘s knowledge of the Braden Scale explained 56.7% of the variance in intention. Attitude, subjective norms, perceived behavioral control significantly predicted intention to use the Braden Scale, with β (95% CI) = (0.078 [0.032, 0.125], 0.390 [0.240, 0.539], and 0.302 [0.190, 0.414,p< .001]), respectively. Two factors, intention and perceived behavioral control explained 63.8% of variance in nurses‘ acceptance, with a β (95% CI) = (0.873 [0.697, 1.047] and 0.368 [0.220, 0.515], p< .001), respectively.
Conclusion and recommendation: This study has identified nurses attending a brief educational program are feasible and, as a result, are more knowledgeable, and have a more positive attitude about utilizing the Braden Scale, feasible for resulting significant change. Future research is needed on how educational programs such as the ones provided increase the acceptability and implementation of the Braden Scale in practice settings. In-service training for nurses, focusing on pressure injury risk assessments, is essential to update their knowledge, and improve patient outcomes; experts should also consider integrating a pressure injury risk assessment score in the nursing process format. This study also found the TPB beneficial for understanding nurses' intent to use the Braden Scale. Subjective norms strongly influenced intention, which in turn impacted acceptance. Strategies to improve utilization should focus on strengthening social support and increasing nurses' confidence in the effectiveness the Braden scale, while addressing and minimizing perceived barriers to its use. Future research should also examine external factors and organizational supports system that may affect implementation. The Braden Scale score, body temperature, and age are significant predictors of pressure injuries. However, the results indicate that the Braden Scale has limited predictive ability in identifying hospitalized patients at risk of developing pressure injuries. Further research with a larger sample size in specific clinical settings is needed to fully evaluate its effectiveness.
Key words: Braden Scale, Pressure Injury, nurse, knowledge, attitude, quasi-experimental, educational intervention, ROC analysis, AUC, Sensitivity, Specificity, and Theory of Planned Behavior