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Standing on the Shoulders of Giants: A Tribute to Barbara Braden
Everyone who had the honor and pleasure of working with Barbara Braden experienced her thoughtfulness, kindness, and generosity of spirit. She readily shared everything she knew to improve patient care. Since learning that Barbara was ill, I have been asking myself the question, “What makes the contributions of one person to health care so unique that almost everyone knows their name, every patient benefits from their work, and millions of wound and skin care specialists stand on their shoulders?” I have found the answers to each part of that question.
When Barbara Braden started her work, chronic wounds in general, and pressure sores (as they were called in the 1980s) in particular, were usually not an important topic of conversation or research. There were pressure sore risk assessment scales, such as the Waterlow and Gosnell scales,1,2 but they were not widely implemented. Research on the effects of extrinsic and intrinsic variables on skin and wound healing had been conducted, but the gap between research and practice was wide and the rate of pressure sores was high. Working with nursing homes and seeing the urgent need to address the problem, Barbara and Dr. Nancy Bergstrom applied for a National Institutes of Health grant to explore the relationship between nutrition and pressure ulcer development.3 The work that followed answers my question about how one person can make contributions so unique that almost everyone knows their name. Simply put, Barbara did the hard work, and she did it right.
The Braden scale was built on a solid foundation – a conceptual framework of the research available at that time4 regarding reduced mobility, activity, and sensory perception, which affect pressure and extrinsic (moisture, shear, and friction), intrinsic (nutrition, age, arteriolar pressure), and hypothetical (interstitial fluid flow, emotional stress, smoking, and skin temperature) variables that affect tissue tolerance.4 Dozens of subsequent studies helped refine the scale and test its validity and reliability when used by a variety of health care providers.
Interest in, and the need for, a valid and reliable risk assessment scale increased in step with both the realization that health care professionals should provide evidence-based care and the first clinical practice guidelines developed by the (then) Agency for Health Care Policy and Research. Their research not only identified pressure sores as a common and important concern, it also acknowledged this as a top area of non–evidence-based care and recommended use of the Braden scale.5 Of course, there were controversies about evidence-based practice versus “the way we have always done it,” and updates were needed; however, in wound care nursing, the guidance documents and the Braden scale were generally adopted and the evidence for using a formal risk assessment instrument kept growing.6 Wound care nurses embraced the use of the Braden scale because of the research behind it and because Barbara embraced us and helped when she could. And that is the answer to the second part of my question about how every patient can benefit from one person’s work.
Barbara never lost touch with the day-to-day work of nurses across the continuum and concerns about how to reduce the burdens of, among other things, paperwork. She listened and shared her insights and work generously without any ulterior or profit-seeking motives. She studied the predictive validity of cut-off scores in various practice settings and at different times following admission to help nurses optimize their time and implement appropriate prevention strategies based on the best available evidence.7 She understood that we all shared a common purpose – improving patient care. This is a task that is never done.
Hundreds of researchers have built on Barbara’s work, but much remains to be done and explored. Recent research is starting to show that one of the hypothetical variables in the original framework, smoking, may not be that hypothetical after all (see the article by Wu et al8 in this issue). Although Barbara was unable to establish a clear relationship between stress (cortisol levels) and pressure injury risk, there is no doubt that someone will revisit and examine that question.9 That brings me to my third answer and another explanation for the enduring legacy of Barbara Braden. Researchers and clinicians alike stand on her shoulders not just to improve patient care, but also to keep finding more answers to the questions that remain. Barbara did the right thing for every patient under our care – and she did the right thing right. For that, we all owe it to her to continue doing the same.
REFERENCES
1. Waterlow J. Pressure sores: a risk assessment card. Nurs Times 1985;81(48):49–55.
2. Gosnell DJ. An assessment tool to identify pressure sores. Nurs Res.1973;22(1):55–59.
3. Harley C. From humble beginnings: the development of an internationally recognized scale. Wound Care Canada. 2007;5(1):34–38.
4. Braden B, Bergstrom N. A conceptual schema for the study of the etiology of pressure sores. Rehab Nurs 1987;12(1):8–12,16
5. Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, Number 3. AHCPR Publication No.92-0047. Rockville, MD. Agency for Health Care Policy and Research. Public Health Service. U.S. Department of Health and Human Services; May 1992.
6. van Rijswijk L, Braden BJ. Pressure ulcer patient and wound assessment: an AHCPR clinical practice guideline update. Ostomy Wound Manage. 1999;45(suppl 1A):56S–67S.
7. Braden B, Bergstrom N. Risk assessment and risk-based programs of prevention in various settings. Ostomy Wound Manage. 1996;42(suppl 10A):6S–12S.
8. Wu B-B, Gu D-Z, Yu J-N et al. Relationship between smoking and pressure injury risk: a systematic review and meta-analysis. Wound Manage Prev. 2021;9:34–46.
9. Braden BJ. The relationship between stress and pressure sore formation. Ostomy Wound Manage. 1998;44(suppl 3A):26S–37S.
The opinions and statements expressed herein are specific to the respective authors and not necessarily those of Wound Management & Prevention or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.
