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Int J Nurs Stud. 2009 Oct;46(10):1307-12. doi: 10.1016/j.ijnurstu.2009.03.014. Epub 2009 Apr 29.

An interrater reliability study of the assessment of pressure ulcer risk using the Braden scale and the classification of pressure ulcers in a home care setting.

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Centre for Humanities and Health Sciences, Department of Nursing Science, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany.



Measurement error can seriously affect the validity of pressure ulcer risk assessment and of pressure ulcer classification.


Determination of interrater reliability and agreement of pressure ulcer risk and pressure ulcers using the Braden scale and the EPUAP system.


Duplicate assessments by trained nurses during two nationwide pressure ulcer prevalence surveys in the years 2007 and 2008 in The Netherlands in the home care setting.


Home care clients which participated in 2007 (n=352) and 2008 (n=339) in the pressure ulcer prevalence surveys.


The Braden scale was used to assess pressure ulcer risk. Skin examination was conducted to detect pressure related tissue damages and to classify them according to the EPUAP.


In 2007 and 2008, Intraclass Correlation Coefficients for Braden scale sum scores were 0.90 (95% CI: 0.88-0.92) and 0.88 (95% CI: 0.85-0.91) respectively, and corresponding Standard Errors of Measurement were 1.00 and 0.98. 95% limits of agreement were -2.8 to 2.8 and -2.7 to 2.7 respectively. The items "moisture", "sensory perception" and "nutrition" contained largest amounts of measurement error. Proportions of agreement for the classification of pressure ulcers were 96% and interrater reliability was 0.81 and 0.79. Most disagreements were observed for the classification of grade 1 pressure ulcers.


The standardized study procedure applied in the annual nationwide pressure ulcer prevalence surveys leads to reliable and reproducible results regarding pressure ulcer risk and pressure ulcer prevalence in the home care setting. Researchers and practitioners should be careful when drawing inferences from single pressure ulcer risk factors included in the Braden scale. Descriptions of the items "moisture", "sensory perception" and "nutrition" should be made more clearly and unambiguous.

[Indexed for MEDLINE]

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