A Descriptive Study to Measure the Reliability of Braden Scale Score Calculated by Clinical Nurses and Evaluate Its Predictive Value for Pressure Ulcer Risk among ICU Patients

The research study was done to measure the Reliability of Braden Scale Score Calculated by Clinical Nurses and evaluate its Predictive Value for PU Risk among ICU Patients. A descriptive research study design was adopted. The study was conducted at the ICUs of DY Patil Hospital, Navi Mumbai. Non probability purposive sampling technique was used. In this study samples were ICU patients (N=75) and clinical staff (N=36). The data was collected using observation and interview techniques. The data was tabulated and analyzed in terms of the study objectives. The data collection was done from ICU Patients and clinical staff. The study result shows the overall Interrater reliability conveyed by intra class correlation coefficient was 0.865 with 95% confidence interval (0.787, 0.915). Interrater reliability expressed by intra class correlation coefficient for individual item ranged from 0.013 that is 13.00% with 95% confidence interval (-0.090, 0.140) to 0.643 with 95% confidence interval (0.176, 0.821) with the lowest value being measure from ‘sensory perception’ and ‘moisture.’ Although the calculated Interrater reliability coefficients for total Braden score were moderate or high in some cases several clinical differences occurred between the two groups. Due to Interrater, reliability being very low in some cases like “sensory perception” and “moisture” it is doubtful that Original Research Article Gawade et al.; JPRI, 33(62B): 57-63, 2021; Article no.JPRI.81272 58 their assessments contribute to any valid results. The calculation of intra class correlation coefficients is the most appropriate Interrater reliability estimates.


INTRODUCTION
Intensive care units (ICUs) receive patients with single or multiple organ failure, who often require life support measures like mechanical ventilation, continuous sedation and vasoactive drugs, in addition to multiple types of devices, such as catheters, drains, probes and immobilizers. These measures significantly impair one of the most important mechanisms for the maintenance of skin integrity, that is bed mobility, making patients highly vulnerable to the development of pressure ulcers (PU) [1].
High-risk patients are elderly people, stroke patients, people with diabetes, individuals with dementia, persons who use wheel-chairs or are bed-bound and any patient with reduced mobility [2]. The use of appropriate preventive measures gets hampered when high-risk patients cannot be accurately, reliably, and timely detected with the Braden Scale (the most used risk scale, with the best predictive values) [3]. Treatment options to avoid progression of PU are well established, but the method to detect and avoid them before onset has not evolved in two decades [4].
Since ICU patients have peculiar characteristics and in view of the scarcity of Indian studies evaluating the performance of the Braden scale in general; the aim of the present study was to analyze the predictive validity of the Braden scale in critical care patients [1]. Further it is also important to know whether the nurses are rightly rating the Braden scale. The overall aims of this study were to examine the Inter-rater reliability (IRR) of the item and total scores of the Braden scale in a real-life clinical setting and to determine the predictive value of Braden scale in an acute care setting.

METHODS
This study was conducted in November 2020 in D.Y. Patil hospital in Navi Mumbai. This study used descriptive research design and quantitative approach.{Recast English} Observation and interview techniques were used. Braden scale is used to assess the risk of PU among the respondents. An observation checklist is used to collect data regarding respondent's demographic data (from the clinical record sheet), Braden Scale Score and Risk factors of Pressure ulcer.
The required permission was obtained from the hospital authorities and the researcher ensured that all rules and regulations were followed with regards to safety and confidentiality of the respondents. The researcher visited the three selected Non-Covid ICUs of the study setting. The researcher recruited all the patients present in the ICU as per the inclusion and exclusion criteria. The researcher recorded from the patients clinical file (the 1 st set of respondents) the biographic variables such as age, gender, caste, religion, ICU invasive procedures and invasive lines, diagnosis, co-morbidities, ICU stay, and any surgical intervention. During the given shift the researcher assessed the respondent's risk for pressure ulcer using the Braden scale after the clinical nurse (2 nd set of respondents) had assessed and recorded it. It was ensured that the time duration between the clinical nurse's assessment and that of the researcher was less than 15 minutes. Before the 1 st set of respondents were transferred out of the ICU, the researcher recorded the presence or absence of pressure ulcer.
The researcher ensured that biographic data of the given clinical nurses (2 nd set of respondents) was obtained using the interviewing techniques on the last day of interaction with them. In this study the biographic variables of the set of respondents were analyzed by using descriptive statistics namely frequency and percentage in the forms of graphs, tables. Interrater Reliability scores of Braden scale scores were calculated using intra class correlation coefficient between clinical staff (2 nd respondents) and researcher. The analysis was done using SPSS. The intraclass correlation coefficient was calculated for each subclass and overall score to know the interrater reliability. Braden scale scores was analyzed for predictive validity of Braden Scale using Cronbach's alpha.
In this study, there are 2 sets of respondents. 1 st set of respondents were 75 patients, all patients who were admitted in the selected ICUs till the attainment of the sample size. 2 nd set of respondents were all clinical nurses (n=36), working in these selected ICUs.  Total Clinical experience-Percentage wise distribution of the respondents according to their clinical experience showed that highest percentage 45% were having <1 year (n=16), 36% were having 2-3 years (n=13), 8% were having 4-5 years and 6-10 years (n=3) and 3% were above 10 years (n=1).

MAJOR FINDINGS OF THE STUDY
 Clinical experience in ICU-Percentage wise distribution of the respondents according to their clinical experience revealed that highest percentage 69% were having <1 years (n=25), 14% were having 4-5 years (n=5) and 11% were having 2-3 years (n=4), 3% were having 6-10 years and above 10 years (n=1).

Section-4 Validity Scores of Braden Scale
 The incidence of patients who developed pressure ulcers during the study period was 5.33% (n=4). All the respondents developed grade I pressure ulcers, highlighting the sacrum as the most frequently affected location. Further validity analysis was not done due to limited sample size developing pressure ulcer.
 Interpretation-According to the below Similarly, In the current study the Interrater reliability expressed by intra class correlation coefficient for individual items ranged from 0.013 that is 13.00% with 95% confidence interval (-0.090, 0.140) to 0.643 with 95% confidence interval (0.176, 0.821) with the lowest value being measure from 'sensory perception' and 'moisture.' In the study done by Jan Kottner [5] the interrater reliability by the intraclass correlation coefficient was expressed as ranging from 0.70 to 0.95. Chester H, Ho [6] in their study reported that the interrater reliability of total score was high which is 0.807. These studies correlated to the current study. According to the current study the inter-rater reliability is 0.871 which is evidently high, that is 87.1% with confidence interval (0.918, 0.796) for the Braden score calculated by researcher and clinical staff.
In the study done by Jan Kottner [5], the intraclass correlation coefficients for individual items ranged from 0.06 (95% CI -0.31 to 0.48) to 0.97 (95% CI 0.93-0.99) with the lowest values being measured for the items "sensory perception" and "nutrition".
In the study done by Neomi Arias Brunet Rogenski [7] lower agreement was observed between moisture and nutrition.
In the study by Chester H, Ho [6], it was reported that the interrater reliability of subscale was of lowest reliability (ICC-0.266) in friction and shear. Nicole Ricciioni [8] found in their study that Intra-class Correlation Coefficient for the Braden scale was 0.894, 95% confidence interval (CI) (0.823, 0.938), which is an excellent agreement.
The above studies report different intraclass correlation coefficients ranging from good, excellent and strong. The inter-rater intraclass correlation coefficient range for the lower agreement between the sensory perception, nutrition, moisture friction and shear.
The present study was done to measure the reliability of Braden Scale score calculated by Clinical nurses and evaluate its predictive value for pressure ulcer risk among ICU patients. In the current study, H1 stated that the Braden scale score calculated by clinical nurses and the researcher found low interrater reliability in sensory perception, and moisture amongst ICU patients. H1 is accepted because the inter-rater reliability between the clinical nurses and the researcher is low in "sensory perception and Moisture." H2 hypothesis is not analyzed, as only 5.33% of respondents developed grade 1 pressure ulcer; this sample being too low for any statistical analysis.

CONCLUSION
The present study was done to measure the reliability of Braden scale score calculated by clinical nurses and evaluate its predictive value for PU risk among ICU patients of selected hospitals of Navi Mumbai. On the basis of Braden scale score this study was conducted to verify and validate the reliability of Braden scales score calculated by clinical nurses in predicting PU. The study was conducted on a total of 75 respondents and 36 clinical nurses. In this study the interrater reliability scores of Braden scale score were calculated using intra class correlation coefficient between clinical nurse and researcher's assessment. The analysis is done using SPSS. The inter-rater reliability is high 0.871 that is 87.1% with confidence interval (0.918, 0.796) for the Braden score calculated by researcher and clinical nurse. In sensory the interrater reliability is poor that is 0.202 that is 20.2% with confidence interval (-0.153, 0.476) for the Braden subscale for sensory training. In moisture-The inter-rater reliability is very poor 0.013 that is 13.00% with confidence interval (-0.090, 0.140) for the Braden subscale for moisture. In these two subscales the clinical nurses and researcher scores were poor. And recordings by the clinical nurses lacked accuracy.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.