Thanks to Morris Magnan and JoAnn Maklebust for drawing attention to the reliability and precision of nurses' ratings of the Braden Scale for Predicting Pressure Sore Risk.^(C) We demonstrated in the mid-1980s that it is possible to achieve high levels of interrater reliability among research staff. These early studies of interrater reliability used a variety of statistics including the Pearson product moment correlation (a very generous assessment), percent agreement (a far more stringent assessment), and interclass correlation (for greater precision).1-3 Magnan and Maklebust are correct in assuming that the ability to produce an outcome during a clinical trial or a formal research project is very different from producing the same outcome during day-to-day practice. Participants in early studies were research staff or volunteers, who were intrigued by the research goals, received formal training, were evaluated, and in the end, were dedicated to doing their best to improve the prediction of pressure ulcers through risk assessment. Challenges are much different for nurses in clinical settings. Considering that the Braden Scale is used to some extent worldwide and it has been translated into many languages, the challenges to accuracy are compounded. Most nurses never received any training in the use of the Braden Scale, so it is not surprising that accuracy might suffer. Moving knowledge from idealized research settings to clinical settings is a special challenge. For this reason, the work of Magnan and Maklebust is important and is a good example of translational research. We are grateful to them for taking on this challenge. We need to know how to better teach nurses to use and maintain their accuracy, or we need to learn if there is a better way to phrase a subscale descriptor to be more understandable. We do not know which approach is most appropriate, but it is imperative that we take on the challenge of improving accuracy.

The significance of accurately predicting who is at risk has increased since the Centers for Medicare & Medicaid Services revised the inpatient prospective payment system and instituted medical severity to the diagnosis-related groups. In the updated system, hospitals will receive more funding if a stage III or stage IV pressure ulcer is present on admission, but they will not receive additional funding if the pressure ulcer is hospital acquired. A commentary by Krapfl and Mackey4 describes these changes in the inpatient prospective payment system and suggests that efforts to improve prevention, assessment, and documentation are important. A major focus in this commentary and those of other wound care experts is on documenting skin condition. Perhaps, it is also time to improve the assessment of risk so that care planning can be based on the assessed risk factors.

The goal of the Braden Scale is to accurately predict who will develop pressure ulcers for the purpose of planning effective preventive strategies. The nursing care plan for reducing pressure ulcer risk should be based on specific risk factors in the assessment tool. Accurate assessment is essential to moving ahead with pressure ulcer prevention. There have been a number of challenges to accurate assessment. Comments of clinical nurses, who have spoken with me informally after presentations in small local venues and large national conferences for the last 20 years, can be classified according to system threats and individual nurse issues. System threats to reliability include (1) lack of adequate training during orientation to the facility, (2) lack of adequate training during a nursing education program, (3) lack of a competency program to evaluate practitioner skills, (4) inadequate numbers of registered nurses in nursing facilities to complete the Braden Scale, (5) abridged versions of the Braden Scale that include only the headings of subscale scores (done to save space), (6) the sense that accurate rating isn't important since the score isn't used in formal care planning, abridgment by vendors of hospital information systems (done to save programming time, space, or to avoid licensing issues), and (7) lack of concern for decreasing the incidence of pressure ulcers rather than meeting regulatory requirements. Threats to accuracy at the nurse level may include (1) lack of clarity about scoring and little time to seek training, (2) lack of time to do thoughtful assessment, (3) lack of familiarity with patients/residents who are being assessed, (3) lack of clarity about the influence of clinical judgment on assessment, (4) preconceived ideas about the score a patient/resident should have so they can get more care, and (5) relying on subscale scores when the entire tool is not available.

The lack of reliability among nurses using the Braden Scale is only one symptom of a much larger issue, accuracy in documentation. Accuracy issues can be identified in relation to other problems as well. For instance, respiratory rates which are recorded for the most part as 16 in the hospital and 20 in nursing homes (how hard is this, we can all count). Patient repositioning is recorded as occurring every 2 hours when we know this doesn't happen. Data from a study by Bates-Jensen et al5 shows that turning occurred less frequently (3-5 hours) for many residents. Skin assessments often report normal skin when stage I and stage II ulcers are present. Wound assessments are only partially completed and wound care is not completely documented. The point is that lapses in accuracy of documentation diminish our professional integrity and obscure the value of our practice. The system pressures that require nurses to take or accept short cuts reduce the ability to provide better care. When we accurately document care and outcomes of care, we are able to demonstrate the value of professional wound care nurses. Congratulations to Magnum and Maklebust for helping us focus on improving the accuracy of clinical measures. Please join us in testing ways to move from assessment to care planning and outcome measurement.

Remember, Florence Nightingale was called the compassionate statistician. She used patient data to demonstrate that improving care resulted in reduced mortality. She was a member of the British statistical society. As a result, our discipline was born because data accurately demonstrated the value of nursing. Thanks for taking on the challenge of improving accuracy and improving outcomes.

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