A Quasi-experimental Study to Assess the Effect of Technology-Assisted Training on Correct Endorsement of Pressure Ulcer Prevent

Abstract

The two-fold purpose of the Detroit Medical Center (DMC) Braden Scale Training Module is to teach nurses to use the Braden Scale to correctly assess pressure ulcer risk and to effectively plan risk-based prevention interventions.

A pre-test, post-test, two-group, quasi-experimental study was conducted to evaluate the effect of web-based DMC Braden Scale Training on staff nurses’ ability to correctly endorse the use or non-use of 10 commonly-used risk-based pressure ulcer preventive interventions for patients at different levels of risk for pressure ulceration. “Regular” or “new” users of the Braden Scale from three hospitals assessed 102 patients. On eight out of 10 preventive interventions, the percentages of correct endorsements were higher for patients at extreme levels of risk (generally not at risk or high/very high risk) than they were for patients at midlevels of risk. Correct endorsement of prevention interventions was unaffected by group membership. Training substantially improved ability to correctly endorse interventions, but for new user only. Importantly, patients at midlevels of risk may be more vulnerable to pressure ulceration than their risk assessments indicate simply because nurses have great difficulty determining which preventive interventions should be implemented for this group of patients. Alternative approaches to training are needed to ensure that regular users of the Braden Scale are adequately prepared to use risk-based information to effectively plan pressure ulcer prevention.

     The potential for pressure ulcer formation threatens patient safety across all care settings. Although pressure ulcers are more prevalent in long-term care settings, pressure ulcer incidence (the proportion of new ulcers acquired among persons at risk) has been found to be greater in acute care settings (0.4% to 38%) than in long-term care settings (2.2% to 23.9%).¹ Failure to prevent hospital-acquired pressure ulcers adds to patient pain and suffering,^2,3 increases hospital length of stay,⁴ increases care costs,^5-7 may contribute to premature mortality in some patients,8 and can have important and potentially costly legal implications for both hospitals and healthcare professionals.^9-11 Thus, it is not surprising that hospital executives,¹² regulatory agencies,¹³ third-party payors,² and healthcare practitioners^10,14,15 are giving greater attention to pressure ulcer prevention in acute care settings.

     Vigilance in preventing hospital-acquired pressure ulcers requires careful adherence to best-practice guidelines.^16-19 To date, best practice guidelines uniformly recommend early identification of at-risk hospitalized patients followed by early and aggressive implementation of preventive interventions. Typically, it is recommended that pressure ulcer risk assessment occur within 24 hours of admission to an acute care facility and then daily thereafter or when there has been a substantial change in the patient’s health status.^18,20 The National Quality Forum²¹ designated the practice of initial pressure ulcer risk assessment and regular pressure ulcer risk reassessment as safe practice for the nation’s health.

     The National Pressure Ulcer Advisory Panell recommends using knowledge of individual risk factors to direct implementation of specific pressure ulcer preventive interventions. There is general consensus1,^17,19,22,23 but no research to support that using a clinically validated risk assessment tool, such as the Braden Scale for Predicting Pressure Sore Risk® (Braden Scale), helps clinicians make better decisions about initiating preventive interventions. Nurses, perhaps more than any other group of healthcare professionals, are in a position to prevent pressure ulcers by bridging the gap between a patient’s individual risk factors and what is actually done to prevent pressure ulceration.²⁴ However, research suggests there is room for improvement in the areas of accurate pressure ulcer risk assessment,²⁵ knowledge of best-practice pressure ulcer prevention guidelines,²⁶ and knowledgeable implementation of pressure ulcer preventive interventions.^27-29

     The Institute of Medicine (IOM)³⁰ recommends strengthening the capabilities of the workforce as a safety defense against medical errors such as pressure ulcers. Education^15,29 in pressure ulcer risk assessment and best-practice prevention interventions is needed to help nurses minimize errors of planning and execution. Errors of planning occur when nurses do not know, on a case-by-case basis, which preventive interventions should be used to prevent pressure ulceration. Errors of execution can occur when the appropriate preventive interventions 1) are known but are not carried out in practice, 2) are carried out inconsistently, or 3) when interventions are not modified appropriately in response to changes in the patient’s level of risk for pressure ulceration.

     The authors’ research program primarily has focused on strengthening the capabilities of the nursing workforce in ways that might help nurses minimize errors in planning — first, by clarifying how to make reliable pressure ulcer risk assessments and second, by demonstrating how to use risk assessment data to guide selection of pressure ulcer preventive interventions Thus, one segment of the current research focused on determining whether teaching nurses how to use the Braden Scale for Predicting Pressure Sore Risk® affects their ability to make reliable Braden Scale pressure ulcer risk assessments. ^25,31,32 Another segment focused on trying to determine whether teaching nurses how to use the Braden Scale to reliably assess pressure ulcer risk and select risk-based pressure ulcer preventive interventions actually improves their ability to identify appropriate risk-based preventive interventions — ie, to minimize errors in planning.

     To date, the authors have used the Detroit Medical Center (DMC) Braden Scale Training Module repeatedly to teach nurses how to correctly use the Braden Scale to assess pressure ulcer risk and select risk-based prevention interventions.^25,31,32 This computer-based training module on the Braden scale includes: 1) didactic content related to pressure ulcer etiology, pressure ulcer risk assessment, and pressure ulcer prevention strategies; 2) testing content organized around five case study exemplars depicting patients at different levels of risk for pressure ulceration: generally not at risk, mild risk, moderate risk, high risk, and very high risk; and 3) testing content related to each case study exemplar that evaluates competency in both Braden Scale risk assessment as well as competency in selecting risk-based prevention interventions. Nurses using the DMC Braden Scale Training Module receive instruction in pressure ulcer risk-based prevention strategies while studying the didactic content. This instruction then is reinforced when completing testing for each case study exemplar. Fuller descriptions of the DMC Braden Scale Training Module, its development and testing as well as characteristics of the case study exemplars, have been reported elsewhere.^25,31,32

     In pre-experimental studies^25,32 involving registered nurses, it was reported that following web-based DMC Braden Scale training, 76% to 80% of the nurses were able to select appropriate risk-based preventive interventions when working with case study data only. However, it was not clear to what extent this same level of web-based Braden Scale training might reduce errors of planning in the clinical setting when nurses who differ on familiarity with the Braden Scale are asked to endorse the use or non-use of specific pressure ulcer preventive interventions based on their assessment of an actual patient’s level of risk on the Braden Scale. Therefore, the overarching purpose of this study was to evaluate, among two groups of nurses, the effect of DMC Braden Scale training on nurses’ ability to correctly endorse the use or non-use of preventive interventions for hospitalized patients.

     Accuracy (reliability) of the Braden Scale risk assessment can influence the decision to use or not use specific pressure ulcer preventive interventions. Therefore, a clear picture of the true affect of DMC Braden Scale training on nurses’ ability to correctly endorse use or non-use of preventive interventions cannot be obtained without controlling for the extraneous influence that comes from the accuracy (reliability or unreliability) of the Braden Scale risk assessment. The following specific aims reflect the need to control for this extraneous influence:

     1. Determine whether differences in the correct endorsement of pressure ulcer preventive interventions observed in the pretest period might be attributable to familiarity (regular user versus new users) with the Braden Scale after controlling for the reliability of Braden Scale risk assessments

     2. Evaluate the effect of web-based Braden Scale training on the correct endorsement of pressure ulcer preventive interventions among regular and new users of the Braden Scale after controlling for the reliability of the Braden Scale risk assessment

     3. Determine whether differences in the correct endorsement of pressure ulcer preventive interventions observed in the posttest period might be attributable to familiarity (regular user versus new users) with the Braden Scale after controlling for the reliability of Braden Scale risk assessments.

Methods

     Design. A pretest-posttest, two-group, quasi-experimental design was used to evaluate the effect of web-based DMC Braden Scale training on nurses’ endorsements of risk-based pressure ulcer preventive interventions. Two experimental groups comprised of staff registered nurses (RNs) who were regular or new users of the Braden Scale received the same intervention, web-based DMC Braden Scale training. The differential effects of this technology-assisted training were examined within and across both groups. The research design and planned analyses are shown in Figure 1.

     Sample and setting. Convenience samples of patients and nurses were recruited from three different Michigan hospitals designated Hospital A, Hospital B, and Hospital C. Hospitals A (580 beds) and B (685 beds) are large urban, teaching hospitals located in the city of Detroit. Hospital C (450 beds) is a suburban teaching hospital located in Saginaw. Nurses at Hospitals A and B are required to use the Braden Scale daily to assess pressure ulcer risk; they were designated regular users of the Braden Scale. Nurses at Hospital C are required to routinely assess patients for pressure ulcer risk but do not use the Braden Scale to assess patients’ pressure ulcer risk; therefore, the nurses working at Hospital C were designated new users of the Braden Scale.

     Intervention protocol. A web-based version of the DMC Braden Scale Training Module was used to teach nurses how to make correct Braden Scale risk assessments and select risk-based prevention interventions.      Instruments. Three paper-pencil tools were used for data collection: the Braden Scale for Predicting Pressure Sore Risk (Braden Scale), an Expert-Rater Intervention Checklist (ExIC), and an RN-Rater Intervention Checklist (RNIC) (see Figure 2). The Braden Scale is a clinically validated pressure ulcer risk assessment tool that has been available for research and practice since at least 1987.^33-35 The goal of the Braden Scale is to accurately identify persons at risk for pressure ulcers for the purpose of planning effective preventive interventions.³⁶ The tool consists of six subscales (sensory-perception, moisture, activity, mobility, nutrition, and friction-shear) that reflect two etiologic dimensions of pressure ulcer risk: prolonged exposure to pressure and decreased tissue tolerance. Five of the six subscales are rated on a 1 to 4 scale, with lower ratings indicating a lower functional status and, therefore, higher risk for pressure ulceration. The friction-shear subscale is rated on a 1 to 3 scale. Again, a lower rating on the friction-shear scale indicates a lower level of functioning and, therefore, a higher level of pressure ulcer risk. Ratings on the six subscales are summed to obtain a Braden Scale total score with a theoretical range of 6 (highest level of risk) to 23 (lowest level of pressure ulcer risk). It has been suggested^15,37 that Braden Scale total scores can be used to designate five distinct Braden Scale levels of risk: generally not at risk (Braden score = 19 to 23), mild risk (Braden score = 15 to 18), moderate risk (Braden score = 13 to 14), high risk (Braden score 10 to 12), and very high risk (Braden score ≤ 9). Since its inception, the Braden Scale has been used extensively in research and practice. At present, the Braden Scale is the pressure ulcer risk assessment tool used most commonly in acute care hospitals in the United States.¹⁵

     The ExIC is an author-developed list of 10 commonly used best-practice pressure ulcer prevention interventions (see Figure 2). Seven (numbers 1 through 7) of the listed interventions are recommended for use to minimize or eliminate exposure to intense or prolonged pressure (assessed using sensory-perception, mobility, and activity Braden subscales). Three of the listed interventions (numbers 8 through 10) are recommended for use to minimize threats from decreased tissue tolerance (assessed using moisture, nutrition, friction-shear Braden subscales). Support for the use of these preventive interventions can be found in pressure ulcer best-practice guidelines from the Wound Healing Society,¹⁸ the WOCN,¹⁹ and the Registered Nurses Association of Ontario (RNAO).¹⁷ Expert-raters used the ExIC to indicate, based on their assessment of a patient’s Braden Scale level of risk, which preventive interventions should be implemented for the patient as well as which interventions actually were implemented.

     The RNIC enumerates, in the same order of presentation, the 10 pressure ulcer preventive interventions shown on the ExIC (see Figure 2). Staff RN-raters use the RNIC to designate, based on their assessment of the same patient’s level of risk on the Braden Scale, which preventive interventions should be implemented. Staff RN-raters were not required to provide information about which interventions actually were implemented.

     Measurement. The outcome of interest for this study was correct endorsement of pressure ulcer prevention interventions. On a case-by-case basis, the expert-rater’s decision to use or not use a specific intervention was the standard used to determine whether a preventive intervention should or should not be used. Thus, correct endorsement was determined by comparing RN endorsements for the use or non-use of an intervention to the expert-rater’s endorsement for the same patient. The outcome, correct endorsement, was operationalized as two variables: simple correct endorsement and total correct endorsement (major dependent variable). Simple correct endorsement was measured by determining whether the decision made by the staff RN-rater regarding use or non-use of a specific intervention agreed or disagreed with the endorsement made by the expert-rater. Agreements were assigned a value of 1 and disagreements were assigned a value of 0. The variable total correct endorsements was measured by summing the number of agreements (for use or non-use) made on the 10 possible preventive interventions. Thus, the theoretical range for the variable total correct endorsements was 0 to 10.

     Other variables of interest included Braden Scale risk category and reliability of the Braden Scale risk assessment. Braden Scale risk category was determined by first summing expert-rater subscale scores across all six Braden subscales to obtain a Braden Scale total score. Then, three categories of risk were established as follows: generally not risk (Braden score ≥19), midlevels of risk (Braden score = 13 to 18), and high/very risk (Braden score ≤12). The covariate, reliability of the Braden Scale assessment, was measured as the unweighted kappa coefficient obtained from computing inter-rater reliability between dyads of RN Braden Scale risk assessments and expert-rater Braden Scale risk assessments made on the same patient. In total, kappa coefficients were computed for 378 RN-to-expert dyads.

     Study procedure. Expert-raters (N = 12) were advanced practice nurses (n = 5), WOC nurses (n = 3), or RNs who already were functioning as skin care specialists at their place of employment (n = 4; Hospital B only). The process used to train expert-raters in the use of the Braden Scale has been described elsewhere.^25,31 All experts were introduced to the ExIC and were given opportunities to discuss the use of specific interventions but received no additional training in the appropriate use of risk-based pressure ulcer prevention interventions.

     Once expert-raters were trained, pretest data collection was initiated by having both expert-raters and RN raters use the Braden Scale to assess pressure ulcer risk. Then, based on their independent risk assessments, wound care experts and staff RNs indicated on their respective interventions checklists (ExIC or RNIC) which preventive interventions should be implemented. Once pretest data collection was completed, RNs (N = 1,391) from all three sites participated in web-based DMC Braden Scale training on how to correctly use the Braden Scale and select appropriate risk-based prevention interventions. Then, posttest data were collected by again having both experts and trained RN raters use the Braden Scale to assess pressure ulcer risk and use an intervention checklist to select risk-based prevention interventions.

     During both the pretest and posttest data collection procedures, the site coordinator or an expert-rater recruited and consented patient participants using institutionally approved informed consent procedures. After enrollment, an expert-rater assessed the patient’s pressure ulcer risk using an unabridged version of the Braden Scale. Immediately after completing the Braden Scale pressure ulcer risk assessment, the expert-rater completed the ExIC using a check mark to indicate which preventive interventions should be implemented for the patient as well as which interventions actually were implemented. Then, the site coordinator recruited one to five RN-raters to conduct independent Braden Scale risk assessments on the same patient, again using an unabridged version of the Braden Scale to guide the assessment. Immediately after completing the Braden Scale risk assessment of the patient, RN-raters used the RNIC to indicate, by check mark, which preventive interventions should be implemented for the patient. All RNs completed their Braden Scale risk assessments and RNICs independently and within 24 hours of the expert-rater’s assessment of the same patient. All raters, expert and RN, were instructed not to discuss their risk assessment findings or their intervention recommendations with each other.

     Human subject concerns. This study was approved by Wayne State University Internal Review Board as well as the Human Subjects Internal Review Boards of each participating institution. Patients participating in the study gave written consent at Hospital B and Hospital C but were not required to do so at Hospital A. Nurses participating in the study were not required to sign a consent form. However, during both the pretest and posttest periods of data collection, nurses recruited to participate in the study were given a document informing them of the purpose of the study, their rights as research subjects, benefits and risk associated with participating in the study, and the projected time commitment needed to participate in the study.

     Data collection and analysis. Data collection for this study occurred over 15 months (November 2005 to February 2007). Data were analyzed using SPSS 11.5 software (SPSS Inc., Chicago, IL). When appropriate, ANCOVA was used to evaluate the effect of web-based Braden Scale training on total correct endorsements after controlling for the reliability of the Braden Scale risk assessment. Alternatives, such as simple regression analyses or independent samples t-tests, were used to make independent evaluations of the effects of the covariate (reliability of Braden Scale assessments) and web-based Braden Scale training on total correct endorsements when use of ANCOVA could not be reasonably supported due to violations of underlying assumptions.

     Preliminary analyses. Preliminary analyses were conducted to ensure that assumptions underlying ANCOVA were met before proceeding with ANCOVA. A reasonable application of ANCOVA requires meeting two important assumptions.³⁸ First, a linear correlation should exist between the covariate (kappa) and the dependent variable (total correct endorsements). In the aggregate, these two variables correlated significantly (r = .33, P <0.001) but an examination of scatterplots suggested that the linearity of the relationship could be improved. Therefore, a monotonic transformation of kappa values was made by adding 10 to each value. Then, a log₁₀ transformation was made to both the covariate (kappa+10) and the dependent variable (total correct decisions) before proceeding with ANCOVA. A second assumption underlying ANCOVA, the homogeneity of regression assumption, requires the covariate (log transformation of kappa) to relate to the dependent variable (log transformation of total correct decisions) in the same way in each group. This assumption was evaluated to determine whether the regression lines for each group differed significantly in their slopes and intercepts.

Results

     In total, 500 Braden Scale risk assessments were made on 102 patients. Incomplete or ambiguous information on four of the ExIC resulted in the loss of data for four patients, reducing the total number of records available for analysis to 476 (98 expert ratings and 378 RN ratings). Braden Scale total scores generated by expert-raters were used as the standard for organizing risk assessments into categories of risk. As shown in Table 1, 24% of the patients were classified as “generally not at risk” and 76% were deemed to be at either “midlevel risk” (38%) or “high/very high risk (38%).

     With the exception of interventions 6 and 10 (see Table 2), on eight out of the 10 preventive interventions assessed, the percentages of correct simple endorsements for use or non-use of an intervention were consistently higher for patients deemed to be at extreme levels of risk (generally not at risk or high/very high risk) than for patients at midlevels of risk. These results suggest that when patients were at midlevels of risk, RN-raters had greater difficulty agreeing with expert-raters about which preventive interventions should be used.

Specific aims.

     1. Determining whether differences in the correct endorsement of pressure ulcer preventive interventions (total correct) in the pretest period might be attributable to familiarity (new user versus regular user) with the Braden Scale after controlling for reliability of the Braden Scale risk assessments.

     Although ANCOVA might be used to address this specific aim, preliminary analyses showed that a component of the homogeneity of regression assumption underlying ANCOVA was not met because the intercept for the new user’s (n = 87) regression line did not differ significantly (F(1, 212) = 3.72, P = .055) from the intercept for the regular user’s (n = 128) regression line. In other words, in the pretest period, familiarity with the Braden Scale (being a regular user versus a new user) could be discounted as a predictor of variability in total correct endorsements of pressure ulcer preventive interventions. Thus, a simple regression analysis was warranted, which showed that the covariate, reliability of the Braden Scale assessment (kappa), was a statistically significant predictor (B = 2.74, t = 3.88, P <0.001) accounting for a small but significant (F(1,214) =15.03, P <0.001) amount of variance (7%) in total correct endorsements. Moreover, results of an independent samples t-test showed, on average, total correct endorsements were significantly greater (t216 = 2.94, P = 0.004) (M = 7.17; SD = 1.92 ) for nurses (n = 130) who made reliable (kappa >0.5) Braden Scale risk assessments than they were (M = 6.38, SD = 2.01) for nurses (n = 88) who made unreliable Braden Scale risk assessments (kappa <0.5)

 2. Evaluating the effect of web-based Braden Scale training on the correct endorsement of pressure ulcer preventive interventions after controlling for the reliability of Braden Scale risk assessments.

     Pre-analysis showed that the regression assumption underlying ANCOVA was violated because the intercept of the pretest regression line did not differ significantly from the intercept for the posttest regression line, indicating that, in the aggregate, web-based Braden Scale training could be discounted as a source of variability in total correct endorsements. Thus, in the aggregate, use of a simple regression model to relate the covariate, reliability of Braden Scale assessments to the outcome, total correct endorsements, was warranted. Results of this analysis showed that reliability of the Braden Scale risk assessment was a significant predictor (B = 3.74, t = 6.82, P <0.001) of and accounted for a significant (F (1,367) = 46.57, P<0.001) but small amount of variance (11%) in total correct endorsements.

     Although analysis of the aggregate data showed that web-based Braden Scale training did not affect total correct endorsements of pressure ulcer preventive interventions, this was not the case for all users. Data provided by new users of the Braden Scale met the regression assumptions and ANCOVA showed that, after controlling for the significant effects of reliable assessment, both reliability of the Braden Scale assessment (F(1,150) = 26.50, P <0.001) and web-based Braden Scale training (F(1,150) = 4.14, P = 0.044) were significant predictors of variability in the total correct endorsements.

     The use of ANCOVA to further analyze new user data within categories of risk (generally not at risk, midlevels of risk, high/very high risk) could not be justified because various regression line assumptions were violated. Therefore, independent samples t-tests were used to estimate the effect of web-based Braden scale training on total correct endorsement of preventive interventions among patients at different levels of risk. These analyses showed that web-based training had no statistically significant (t(32) = -.801, P = 0.429) effect on the average number of pretest (M = 7.52, SD = 1.39) to posttest (M = 7.87, SD = .99 ) total correct endorsements when patients were deemed to be generally not at risk (Braden score ≥19). In contrast, among patients at midlevels of risk (Braden score = 13 to 18), web-based Braden scale training had a statistically significant effect (t(62) = -2.74, P = 0.008) on increasing the average number of posttest total correct endorsements (M = 7.18, SD = 2.30) compared to the average number of pretest total correct endorsements (M = 5.78, SD = 1.78). Similarly, among patients deemed to be at high/very high risk, the average number of posttest total correct endorsements (M = 8.28, SD = 1.88) was significantly greater (t[55] = -2.14, P = 0.019) than the average number of pretest total correct endorsements (M = 6.97, SD = 2.15).

3. Determining whether differences in the correct endorsement of pressure ulcer preventive interventions in the posttest period might be attributable to familiarity (new user versus regular user) with the Braden Scale after controlling for reliability of the Braden Scale risk assessments.

     As happened with the pretest data, a component of the regression assumption underlying ANCOVA was not met because the intercept for the new user’s (n = 66) regression line did not differ significantly (F(2, 151) = .013, P = 0.91) from the intercept for the regular user’s (n = 88) regression line. Thus, in the posttest period, familiarity with the Braden Scale once again could be discounted as a predictor of variability in total correct endorsements of pressure ulcer preventive interventions. However, simple regression showed that the covariate reliability of the Braden Scale assessment (kappa), was a statistically significant predictor (B = 4.87, t = 5.69, P <0.001) accounting for a small but significant (F(1,152) = 32.37, P <0.001) amount of variance (17%) in total correct endorsements. Independent samples t-test showed, that on average, total correct endorsements where significantly greater (t157 = 2.58, P = 0.011) (M = 7.42; SD = 2.26) for nurses (n = 101) who made reliable (kappa ≥.5) Braden Scale risk assessments than they were (M = 6.43, SD = 2.41) for nurses (n = 56) who made unreliable Braden Scale risk assessments (kappa <0.5).

Discussion

     Results of this study suggest that clinically correct decisions about the selection of pressure ulcer preventive interventions to a great extent depend on the reliability of the pressure ulcer risk assessment. Specifically, the reliability of Braden Scale risk assessments was the only consistent predictor of correct selection of commonly used pressure ulcer preventive interventions across groups (new users versus regular users) and across and within occasions (pretest to posttest). These findings support the general consensus^17-19 that pressure ulcer risk assessment is the first step in pressure ulcer prevention. However, findings of this study suggest that modifying the consensus view to endorse reliable pressure ulcer risk assessment as the first step in pressure ulcer prevention may be warranted.

     Although technology-assisted Braden Scale training did not improve total correct endorsements among all participants, the data clearly indicate that nurses who made more reliable Braden Scale risk assessments did better at selecting correct preventive interventions than nurses who made less reliable Braden Scale risk assessments. However, the connection between these two components of pressure ulcer preventive care is not entirely clear. For example, the data do not explain whether this finding occurred because these nurses were more capable, conscientious, or some combination of both. Others³⁹ have argued that, once pressure ulcer risk is known, success in pressure ulcer prevention depends on the actions taken by the nursing staff — a particularly cogent argument when the focus is shifted to minimizing errors of execution. To date, the authors’ research program has focused on finding ways to minimize errors in planning pressure ulcer prevention.  

   In the current study, a simple regression model was used repeatedly to relate the reliability of Braden Scale assessments to the correct selection of pressure ulcer prevention interventions. In each regression analysis, the variance among total correct endorsements was small (7%, 11%, and 17%), suggesting that adding predictors to the model might be warranted. Thus, further research using a more comprehensive model that includes characteristics of nurses (eg, their basic education, years of experience, work ethic, and problem solving capabilities) might account for a greater amount of variance in total correct endorsements and also might shed some light on unanswered questions regarding nurses’ capabilities and conscientiousness.

     The fact that web-based Braden Scale training had a statistically significant effect on the total correct endorsements made by new users of the Braden Scale but no statistically significant effect on correct endorsements made by regular users of the Braden Scale is difficult to explain. In an earlier research report³¹ using data generated from this same study, it was noted that 1) regular users of the Braden Scale made less reliable Braden Scale risk assessments than new users and 2) the reliability of Braden Scale risk assessments among regular users seemed to be recalcitrant to improvement using web-based Braden Scale training. It was previously speculated²⁵ that the recalcitrance observed among regular users may be do to habituated practice; whereas, others⁴⁰ have suggested that observer drift away from the intended meaning of subscale descriptors may occur. These same two factors — habitated practice and observer drift — might play a role in selecting appropriate preventive interventions. For example, regular users may treat risk assessment and prevention intervention selection as orthogonal events rather than rely on the actual results of the Braden Scale risk assessment to direct selection of preventive interventions. Thus, regular users might formulate their own schema of risk for the patient, subsequently selecting preventive interventions based on some pre-established and personally preferred repertoire of preventive interventions regardless of risk assessment findings.

     The fact that web-based Braden Scale training had a statistically significant effect on new users’ total correct endorsement of pressure ulcer preventive interventions is somewhat encouraging, especially in light of previous findings. ^25,31,32 The importance of these statistically significant findings needs to be interpreted with caution because what appears to be a statistically significant effect of web-based Braden Scale training on total correct endorsements among patients at midlevel and high/very high levels of risk might virtually disappear if the true effects of reliable Braden Scale risk assessments could be factored out of the equation. Collectively, these findings suggest that technology-assisted Braden Scale training is an efficient and clinically relevant means of minimizing errors of planning in pressure ulcer prevention among new users.

     As noted in the results, when examining new users’ correct endorsements of preventive interventions within categories of risk, using ANCOVA to statistically control for the covariate, reliability of Braden Scale assessments, could not be justified when looking at the effects web-based training on the selection of preventive interventions. Nevertheless, the authors believe results of the independent t-tests showing pretest-to-posttest increases in total correct endorsements when patients were deemed to be at midlevels of risk and high/very high levels of risk should not be disregarded. These findings suggest an independent effect for web-based Braden Scale training on the correct endorsement of preventive interventions for patients at mid- and higher levels of pressure ulcer risk. If further research supports this finding, the clinical relevance of using technology-assisted Braden Scale training among new users of the Braden Scale is likely to have far-reaching implications for reducing errors in planning pressure ulcer prevention.

Implications for Practice

     Given the current findings, the authors believe if the documented Braden Scale risk assessment is unreliable, clinicians should critically re-evaluate the appropriateness of the preventive interventions in use. In addition, greater attention needs to be given to ensuring that patients at midlevels of risk for pressure ulceration receive appropriate and effective preventive interventions. In a prevalence study involving 440 hospitalized patients, Gawron⁴¹ noted that nurses had great difficulty identifying patients at moderate risk. Results of the current study, as well as those reported by Gawron, suggest that patients at midlevels of risk (eg, Braden scores ranging from 11 to 18) may be at great risk for “falling through the cracks” when it comes to receiving appropriate preventive interventions. Lastly, tracking the appropriateness of preventive interventions based on a patient’s known areas of risk also may be worthwhile.

Conclusion

     Results of a pretest-posttest, two-group, quasi-experimental study suggest that clinically correct decisions about the selection of pressure ulcer preventive interventions depend largely on the reliability of the pressure ulcer risk assessment. Web-based DMC Braden Scale training improves the accuracy of RN endorsements of prevention interventions, but for new users only. Importantly, nurses seem to have great difficulty determining which prevention interventions should be used when patients were at midlevels of risk on the Braden Scale. The extent to which Braden Scale training programs affect actual implementation of preventive interventions in practice (controlling for characteristics of nurses such as education, experience, and conscientiousness) warrants future study.

Ms. Maklebust is a Clinical Nurse, Specialist/Wound Care, and a Nurse Practitioner, Oncologic Surgery, Karmanos Cancer Center; and Adjunct Associate Clinical Professor, College of Nursing, Wayne State University, Detroit, MI. At the time of this study, Dr. Magnan was an Assistant Professor of Nursing, School of Nursing, Oakland University, Rochester, MI, and Associate Research Professor, College of Nursing, Wayne State University. He is now a Care Manager, St. Joseph Mercy Oakland, Pontiac, MI. Please address correspondence to: JoAnn Maklebust, MSN, APRN, BC, AOCN, FAAN, Karmanos Cancer Center, 4100 John R, Detroit, MI 48201; email: maklebus@karmanos.org.

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