W O U N D C A R E A N D P R E S S U R E U L C ER S

Assessing predictive validity of the modified Braden scale for prediction

of pressure ulcer risk of orthopaedic patients in an acute care setting
Wai Shan Chan, Samantha Mei Che Pang and Enid Wai Yung Kwong

Aims and objectives. To assess and compare the predictive validity of the modified Braden and Braden scales and to identify
which of the modified Braden subscales are predictive in assessing pressure ulcer risk among orthopaedic patients in an acute
care setting.
Background. Although the Braden scale has better predictive validity, literature has suggested that it can be used in conjunction
with other pressure ulcer risk calculators or that some other subscales be added. To increase the predictive power of the Braden
scale, a modified Braden scale by adding body build for height and skin type and excluding nutrition was developed.
Design. A prospective cohort study.
Method. A total of 197 subjects in a 106-bed orthopaedic department of an acute care hospital in Hong Kong were assessed for
their risk for pressure ulcer development by the modified Braden and Braden scales. Subsequently, daily skin assessment was
performed to detect pressure ulcers. Cases were closed when pressure ulcers were detected.
Results. Out of 197 subjects, 18 patients (9Æ1%) developed pressure ulcers. The area under the receiver operating characteristic
curve for the modified Braden scale was 0Æ736 and for the Braden scale was 0Æ648. The modified Braden cut-off score of 19
showed the best balance of sensitivity (89%) and specificity (62%). Sensory perception (Beta = 1Æ544, OR=0Æ214, p = 0Æ016),
body build for height (Beta = 0Æ755, OR = 0Æ470, p = 0Æ030) and skin type (Beta = 1Æ527, OR = 0Æ217, p = 0Æ002) were
significantly predictive of pressure ulcer development.
Conclusion. The modified Braden scale is more predictive of pressure ulcer development than the Braden scale.
Relevance to clinical practice. The modified Braden scale can be adopted for predicting pressure ulcer development among
orthopaedic patients in an acute care setting. Specific nursing interventions should be provided, with special attention paid to
orthopaedic patients with impaired sensory perception, poor skin type and abnormal body build for height.

Key words: acute care setting, Braden scale, modified Braden scale, orthopaedic patient, predictive validity, pressure ulcer

Accepted for publication: 29 October 2008

only reduces patients’ quality of life, but also carries

Introduction
Pressure ulcer is defined as ‘localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a result
of pressure, or pressure in combination with shear and/or
friction’ (National Pressure Ulcer Advisory Panel 2007). It not
underlying connotations of lowered efficiency in nursing care
(Seongsook et al. 2004) and constitutes a significant financial
burden on healthcare systems (Fogerty et al. 2008). The
incidence of pressure ulcers ranges from 0Æ4–38% in acute
care hospitals (Bolton 2007) and 66% of older patients with

Authors: Wai Shan ChanI, MSc, Clinical Associate, School of Correspondence: Wai Shan Chan, MSc, Clinical Associate, School of
Nursing, The Hong Kong Polytechnic University, Hung Hom. Nursing, The Hong Kong Polytechnic University, Hung Hom.
Kowloon. Hong Kong; Samantha Mei Che Pang, PhD, Professor Kowloon. Hong Kong. Telephone: (852) 2766 4950.
and Head, School of Nursing, The Hong Kong Polytechnic E-mail: hswsc@inet.polyu.edu.hk
University, Hung Hom. Kowloon. Hong Kong; Enid Wai Yung
Kwong, PhD, Assistant Professor, School of Nursing, The Hong
Kong Polytechnic University, Hung Hom. Kowloon. Hong Kong

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doi: 10.1111/j.1365-2702.2008.02757.x
WS Chan et al.
hip fracture have been found to develop pressure ulcers
(Maclean 2003). Many patients admitted to orthopaedic
units are older people, as ageing is a global health issue which
will result in older people comprising 17% of the global
population in 2050 compared with 7% in 2002 (Romanelli &
Michael 2006). Most of them are limited in their ability of
activity and mobility due to trauma injury, degeneration of
the skeletal system or chronic pain. Fortunately, it is
estimated that 95% of pressure ulcers may be prevented
(Gunningberg et al. 1999) and nursing care is believed to be a
primary method of preventing pressure ulcer development
(David et al. 1983, Flanagan 1993, Davis 1994, Pang &
Wong 1998). Therefore, accurate identification of at-risk
patient by a reliable and valid pressure ulcer risk calculator is
the first step to pressure ulcer prevention. Correct allocation
of resources, then, will achieve the goal of cost-effectiveness, a
key issue in health care (Frank 2001, Franks & Collier 2001).
Commonly used pressure ulcer risk calculators include the
Braden, Norton and Waterloo scales. Even though the Braden
scale has been found to be the most predictive (Pang & Wong
1998, Bergquist & Frantz 2001, Seongsook et al. 2004), most
studies (Halfens et al. 2000, Defloor & Grypdonck 2005 &
Kring 2007) have suggested that it can be enhanced and that
some subscales be added to strengthen its predictive validity
in pressure ulcer management. A modified Braden scale (Pang
& Wong 1998, Kwong et al. 2005) for more accurate
identification of at-risk patients has thus been developed. The
modified Braden scale has been found to be more predictive
of pressure ulcers than the Braden scale (Xue et al. 2004 &
Kwong et al. 2005) in hospitalised adult patients. It is worth
further assessing the predictive validity of the modified
Braden scale in different specialties to ascertain its power in
pressure ulcer prediction, so that it can be applied in different
units and settings. This study aimed to evaluate the predictive
validity of the modified Braden scale and compare the
predictive power of the Braden and modified Braden scales.
Further, it attempted to identify the modified Braden
subscales that are predictive of pressure ulcer development
among orthopaedic patients in an acute hospital in Hong
Kong. The study would provide valid information for
selection of a more powerful pressure ulcer prediction scale
in the O&T unit and knowledge of which subscales would
significantly contribute to pressure ulcer risk among ortho-
paedic patients to design specific nursing interventions to
eliminate and/or reduce them.
Braden scale
The Braden scale was first introduced by Braden and
Bergstrom 1987b and is one of the best-known and most
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widely used tools for evaluating pressure ulcer risk. With
proven validity and reliability, it now used widely in acute and
long-term care settings. This tool has been tested and trans-
lated into Japanese, Korean, Italian, Dutch, French, Portu-
guese (Bergstrom et al. 1998) and Chinese (Xue et al. 2004,
Kwong et al. 2005). It reflects a particular conceptualisation
of aetiological factors in pressure ulcer formation, including
the intensity and duration of pressure and the tolerance of the
skin and supporting structures for pressure. The intensity and
duration of pressure are related to sensory perception, mobility
and activity. Tissue tolerance for pressure is influenced by both
extrinsic and intrinsic factors. Extrinsic factors impinging on
the outer layers of the surface of the skin are related to skin
moisture, friction and shear. Intrinsic factors such as nutri-
tional status, age and low arteriolar pressure influence the
architectures and integrity of the skin and supporting struc-
tures, particularly collagen and elastin and diminish the ability
of soft tissues to absorb and tolerate mechanical load
(Bergstrom et al. 1987a). These factors constitute the six
Braden subscales: sensory perception, activity, mobility,
moisture, nutritional status and friction and shear. Five of
the six subscales are rated from 1 (most impaired) – 4 (least
impaired) and the subscale of friction/shear is rated from 1
(problem) – 3 (no problem). The total scores range from 6–23.
Lower total scores indicate a higher risk of developing pressure
ulcers (Bergstrom et al. 1987a).
The subscales of sensory perception, activity and mobility
are the primary factors affecting intense and prolonged
pressure. Sensory perception is an individual’s ability to
perceive pain or discomfort and to respond purposefully by
changing position or seeking assistance in changing position.
Mobility refers to an individual’s ability to change and
maintain or sustain body positions. Activity is the ability of
an individual to remove all pressure from skin areas not
adapted to weight bearing, which also enhances circulation
and influences metabolism. The subscales of moisture,
friction and shear are primary extrinsic factors influencing
tissue tolerance. Moisture is the exposure of an individual’s
skin to moisture, leading to maceration and rashes and thus
weakening the natural barrier of the epidermis. Friction
likewise weakens this barrier as a result of movement over a
rough surface and shearing results when outer layers of the
skin slide on rough or sticky surfaces, pulling and potentially
tearing underlying tissues. Nutrition reflects the usual food
and fluid intake of an individual (Bergstrom et al. 1987a).
The scale has much strength in that it is a user-friendly
instrument with detailed explanations of the factors comprising
the scale (Bergstrom et al. 1987a) and it is demonstrated to be
both valid and reliable in existing studies. Early studies found
that a cut-off score of 16 or less on the Braden scale identified
Wound care and pressure ulcers
83–100% of general medical, surgical and intensive care
patients in whom pressure ulcers developed. The percentage
of patients without pressure ulcers who were identified by the
Braden scale as being risk-free (specificity) was 64–90%
(Bergstrom et al. 1987a, Bergquist & Frantz 2001, Bergquist
2001). Research conducted in medical, surgical and orthopae-
dic units in acute care institutions reported that the Braden
scale had 60–81% sensitivity and 54–100% specificity for
stage I–IV pressure ulcers when using a cut-off score of 18. It
further demonstrated a high degree of inter-rater reliability
coefficients from 0Æ83–0Æ99 and agreement of 88–100% for
registered nurses (Braden & Maklebust 2005, Kring 2007).
The Braden cut-off score of 18 produced the best balance
between sensitivity (72–81%) and specificity (60–73%) in
various settings (Bergstrom et al. 1998, Pang & Wong 1998,
Schue & Langemo 1998, Lyder et al. 1999). Although
sensitivity and specificity varied slightly between studies, the
collective evidence indicated that a cut-off score of 18 for older
patients is more appropriate in long-term care and tertiary care
settings (Braden & Bergstrom 1987b, Pang & Wong 1998).
The Braden scale also demonstrated higher predictive power
than the Norton and Waterloo scales, indicated by sensitivity,
specificity, positive predictive values and percentage of correct
classification (Pang & Wong 1998, Lyder et al. 1999,
Bergquist & Frantz 2001). Recently, Pancorbo-Hidalgo
et al.’s (2006) systematic bibliographical review and Kring’s
(2007) meta-analysis found that the Braden scale is the best at
predicting pressure ulcer risk when compared with the Norton,
Waterloo and Gosnell scales. In a recent review, health
professionals in more than 11 published studies supported
the Braden scale as a reliable measurement of pressure ulcer
risk (Kring 2007). However, Schoonhoven et al. (2005)
criticised the Braden scale as not satisfactorily predicting
pressure ulcer development in patients admitted to hospital,
due to being based on clinical observation and pathophysio-
logical insights rather than adequate prospective or prognostic
research. Defloor and Grypdonck (2005) found that 80% of
patients were over-predicted to be at risk of pressure ulcer
development and that only 20% of them needed to receive
preventive treatment, which means that much needless work is
done and expensive material is wrongly allocated. Brown’s
(2004) review likewise found that 58–91% of patients were
over-predicted to be at risk of developing pressure ulcers by the
Braden scale, representing a waste of healthcare resources. In
addition, only the most recent studies provide the value of the
area under the ROC curve (AUC), which gauges the predictive
usefulness of the Braden scale finding ranges from a very low
value 0Æ55–0Æ74 (Pancorbo-Hidalgo et al. 2006).
Halfens et al. (2000) emphasised that the predictive
validity of the Braden scale could be enhanced; Defloor and
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1565–1573
Braden scale for prediction of pressure ulcer risk
Grypdonck (2005) also find that it had lower effectiveness
and suggest that it could better be used in conjunction with
other pressure ulcer calculators which should be based on the
causal and associated factors of pressure ulcer development.
Kring (2007) also suggests adding other items with potential
for further strengthening the scale’s predictive validity.
Modified Braden scale
Pang and Wong (1998) conducted a study to compare the
Braden, Norton and Waterloo scales (Waterloo 1985) in a
Hong Kong rehabilitation hospital. The Braden scale was
found to have higher predictive power than the other two
scales. Further analysis revealed that the moisture/inconti-
nence, mobility, activity and friction and shear subscales from
the Braden scale and the skin type and body build for height
subscales from the Waterloo scale were most strongly related
to pressure ulcer formation. Based on these findings, the
Braden scale was initially modified to include skin type and
body build for height subscales. In one study, the initial Braden
scale was translated to Chinese and further modified by
excluding the nutrition subscale because it was found to be the
least distinct factor for pressure ulcer development and was
not easy to measure subjects’ oral intake of protein based on
the brief description reported by the nurse assessors (Kwong
et al. 2005). The final modified Braden scale comprises seven
subscales of sensory perception, moisture, mobility, activity,
friction and shear, skin type and body build. As on the Braden
scale, all the subscales are rated from 1 (most impaired) – 4
(least impaired), except the friction and shear subscale, which
is rated from 1 (problem) – 3 (no problem). The total scores
range from 7–27. The higher scores indicate lower pressure
ulcer risk. Several previous studies have reported that the scale
demonstrates the best balance of sensitivity and specificity at
the cut-off points of 19 and 22 (sensitivity: 89%; specificity:
75–68%) among adult patients in acute care (Xue et al. 2004,
Kwong et al. 2005). It obtained 100% agreement among raters
in Kwong et al. study (2005). In these studies, the modified
scale was found to be more predictive of pressure ulcer
development than the Braden scale. Despite this, more studies
need to be conducted in various healthcare settings to
determine its predictive validity and confirm its comparatively
higher predictive power.
Method
Design and sample
This is a prospective cohort study of 197 patients from two
orthopaedic wards of an acute care hospital in Hong Kong.
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WS Chan et al.
They were Chinese, aged 18 or above, expected to stay in the
ward for five days or more following admission, not
ambulant and had no pressure ulcers detected on admission.
Measures
A patient characteristic form was used to record subjects’
age, gender, length of hospital stay, other medical problems,
whether or not they had undergone surgery and smoking
habits. The Braden and modified Braden scales with good
reliability and validity were used to assess subjects’ risk of
pressure ulcer development. The skin assessment form was
used to record subjects’ skin condition including the site and
stage of pressure ulcer development, categorising the lesions
according to National Pressure Ulcer Advisory Panel (2007)
criteria for staging pressure ulcers. A Stage I ulcer is intact
skin with non-blanchable redness of a localised area, usually
over a bony prominence. Darkly pigmented skin may not
have visible blanching and the area may be painful, firm, soft
and warmer or cooler compared with the adjacent tissue. It
is also considered reversible in that no irreparable tissue
damage has occurred. A Stage II ulcer is a partial thickness
loss of dermis presenting as a shallow open ulcer with a red
or pink wound bed, without slough. A Stage III ulcer is full
thickness skin loss. Subcutaneous fat may be visible but
bone, tendon or muscle are not exposed and slough may be
present but does not obscure the depth of tissue loss; it may
include undermining and tunneling. A Stage IV ulcer is full
thickness skin loss with exposed bone, tendon or muscle;
slough or eschar may be present on some parts of the wound
bed, often including undermining and tunneling (Black et al.
2007).
Data collection procedure
The data collection period was 13 months from May–August
2005 and from October 2007–June 2008. The researcher, an
experienced nurse trained to use the modified Braden scale,
screened all newly admitted patients who met the selection
criteria of our study. Having obtained informed verbal
consent from the subjects and written consent from the next
of kin of unconscious and cognitively impaired subjects, the
researcher collected subjects’ characteristic data and assessed
the subjects’ risk for pressure ulcer development using the
Braden and modified Braden scales. Subsequently, she
assessed the subjects’ skin condition daily to detect pressure
ulcers. As normal practice, the ward nurses performed
preventive nursing interventions without knowing the Braden
and modified Braden scores assigned to the subjects. When
pressure ulcers were detected, the researcher recorded the
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sites and stages of the pressure ulcer development. The case
was closed if either stage I or above pressure ulcers
developed; or if the subject was discharged or transferred
from the orthopaedic ward or died.
Data analysis
The data were analysed using the Statistical Package for
Social Science – SPSS 15Æ0 (SPSS INC., Chicago, IL, USA). The
skew value of ±3 and kurtosis value of ±3 (Garson 2008)
support the use of parametric tests in this study. The modified
Braden scale score has a skew value of 0Æ025 and a kurtosis
+0Æ426. All modified Braden subscale scores, except those of
sensory perception (skew value: 2Æ621 and kurtosis value
+6Æ451) and activity (skew value: +2Æ017 and kurtosis value
+3Æ181) have skew values of 1Æ245 – +0Æ358 and kurtosis
values of 0Æ456–+2Æ143. Therefore, the independent t-test
and logistic regression analysis were used to identify the
modified Braden subscales that were predictive of pressure
ulcer development. The independent t-test (age, length of
hospital stay) and Chi-square test (gender, medical problems,
surgery, smoking habit) were used to examine the differences
in patient characteristics between the subjects with and
without pressure ulcers. The receiver operating characteristic
(ROC) curve determined the predictive validity of the Braden
and modified Braden scales. The significance value was set at
p < 0Æ05.
Ethical consideration
Ethical approval was granted from the Joint Chinese
University of Hong Kong and New Territories East Cluster
Clinical Research Ethics Committee. Verbal informed con-
sent from the subjects and written consent from the next-of-
kin of unconscious or cognitively impaired patients were
obtained before commencement of the study. They were
assured that there would be no penalties if they withdrew
from the study at any time and that their rights to anonymity
and confidentiality would be protected.
Results
Subject characteristics
Of 197 subjects with a mean age of 79Æ4, 30 (15Æ2%) were
male and 167 (84Æ8%) were female. Twenty-three (11Æ7%)
subjects were current smokers. Apart from orthopaedic
diseases, 167 (84Æ8%) patients had at least one medical
problem. All subjects stayed an average of 10Æ8 days in the
wards (Table 1).
Wound care and pressure ulcers Braden scale for prediction of pressure ulcer risk

Table 1 Comparison of patient characteristics between subjects with and without pressure ulcers development

All subjects Subjects with pressure ulcer Subjects without pressure ulcers
n = 197 (100%) n = 18 (9Æ1%) n = 179 (90Æ9%) t-value Chi-square (v2) p-value

Gender
Male 30 (15Æ2%) 1 (5Æ6%) 29 (16Æ2%) – 0Æ231 0Æ203
Female 167 (84Æ8%) 17 (94Æ4%) 150 (83Æ8%)
Age
Mean (SD) 79Æ4 (10Æ88) 82Æ2 (7Æ35) 79Æ1 (11Æ15) 1Æ180 – 0Æ167
Range (35–98) (73–98) (35–97)
Other medical problems
Yes 167 (84Æ8%) 17 (94Æ4%) 150 (83Æ8%) – 0Æ231 0Æ203
No 30 (15Æ2%) 1 (5Æ6%) 29 (16Æ2%)
Surgery
Yes 150 (76Æ5%) 14 (77Æ8%) 136 (76Æ4%) – 0Æ896 0Æ580
No 46 (23Æ5%) 4 (22Æ2%) 42 (23Æ6%)
Smoking
Yes 23 (11Æ7%) 2 (11Æ1%) 21 (11Æ7%) – 0Æ938 0Æ648
No 174 (88Æ3%) 16 (88Æ9%) 158 (88Æ3%)
Length of hospital stay
Mean (SD) 10Æ75 (5Æ89) 15 (7Æ49) 10Æ32 (5Æ55) 3Æ291 – 0Æ032*
Range (5–53) (5–34) (5–53)

*p < 0Æ05.

Table 2 Site and stage of pressure ulcer Differences in patient characteristics between subjects
Total Stage I Stage II with and without pressure ulcers
Site (n = 18, 100%) (n = 4, 22Æ2%) (n = 14, 77Æ8%)
Except for length of hospital stay (t = 3Æ29, p = 0Æ032), the
Buttock 9 (50Æ1%) 1 (5Æ6%) 8 (44Æ5%) socio demographic characteristics did not significantly differ
Sacrum 6 (33Æ5%) 2 (11Æ2%) 4 (22Æ3%) between the subjects with and without pressure ulcers. The
Hip 1 (5Æ6%) 1 (5Æ6%) 0 subjects with longer hospitalisation tended to develop
Inner thigh 1 (5Æ6%) 0 1 (5Æ6%)
pressure ulcers (Table 1).
Ankle 1 (5Æ6%) 0 1 (5Æ6%)

AUC, area under the ROC curve.

Pressure ulcer incident
Eighteen patients (9Æ1%) developed pressure ulcers after an
average of 8Æ1 days of observation (range 1–9 days, SD:
4Æ873). Stage II pressure ulcers (n = 14, 77Æ8%) on the
buttock (n = 8, 44Æ5%) were the dominant stage and site of
pressure ulcers (Table 2).
Predictive validity of the Braden scale (BS) and the
modified Braden scale (MBS)
The areas under the ROC curve for the Braden and modified
Braden scales were 0Æ684 and 0Æ736 respectively. The Braden
cut-off score of 16 and modified Braden cut-off score of 19
yielded the best balance of these two scales’ sensitivity (BS:
67%, MBS: 89%) and specificity (BS: 64%, MBS: 62%)
(Table 3).

Table 3 Predictive validity of Braden and

Cut-off Sensitivity Specificity 95% CI
modified Braden scales
point AUC p (%) (%) (range)

Braden scale 16 0Æ684 0Æ39 67 64 0Æ509–0Æ786

17 72 41
18 89 21
Modified Braden scale 17 39 80
18 56 73
19 0Æ736 0Æ01* 89 62 0Æ632–0Æ841

*p £ 0Æ01.

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WS Chan et al.

Table 4 Modified Braden subscales in relation to presence and absence of pressure ulcer

All subjects Subjects with pressure Subjects without pressure

Subscales mean (SD) ulcer mean (SD) ulcer mean (SD) t-value p-value

Sensory perception 3Æ86 (0Æ378) 3Æ67 (0Æ594) 3Æ88 (0Æ346) 2Æ275 0Æ024
Moisture 3Æ28 (1Æ151) 2Æ83 (1Æ425) 3Æ32 (1Æ115) 1Æ733 0Æ085
Activity 1Æ45 (0Æ854) 1Æ39 (0Æ850) 1Æ46 (0Æ856) 0Æ327 0Æ744
Mobility 2Æ88 (0Æ517) 2Æ61 (0Æ778) 2Æ91 (0Æ477) 2Æ372 0Æ019
Friction and shear 2Æ25 (2Æ180) 1Æ89 (0Æ471) 2Æ29 (2Æ279) 0Æ744 0Æ458
Body build for height 3Æ25 (0Æ752) 2Æ83 (0Æ857) 3Æ29 (0Æ730) 2Æ491 0Æ014
Skin type 2Æ91 (0Æ664) 2Æ39 (0Æ698) 2Æ96 (0Æ639) 3Æ589 0Æ000
Nutrition 3Æ22 (0Æ768) 2Æ94 (0Æ802) 3Æ25 (0Æ761) 1Æ593 0Æ113

p < 0Æ05, p £ 0Æ001.

Table 5 Logistic regression analysis of the subscale items in the modified Braden and Braden scales

Subscales B Wald X2 Degree of freedom p Odd ratio 95% CI

Sensory perception 1Æ544 5Æ852 1 0Æ016* 0Æ214 0Æ061–0Æ746

Mobility 0Æ518 0Æ943 1 0Æ332 0Æ596 0Æ210–1Æ694
Body build for height 0Æ755 4Æ712 1 0Æ030* 0Æ470 0Æ238–0Æ929
Skin type 1Æ527 9Æ930 1 0Æ002* 0Æ217 0Æ084–0Æ561

p £ 0Æ05, p £ 0Æ01.

Modified Braden and Braden subscales in relation to

presence and absence of pressure ulcers
Among the modified Braden and Braden subscales, sensory
perception (t = 2Æ28, p = 0Æ024), mobility (t = 2Æ37,
p = 0Æ019), body build for height (t = 2Æ49, p = 0Æ014) and
skin type (t = 3Æ59, p = 0Æ000) were significantly different in
term of the presence and absence of pressure ulcers among
the subjects (Table 4).
Risk factors affecting pressure ulcer development
The significant subscales were included for the logistic
regression analysis. Sensory perception (Beta = 1Æ544,
OR = 0Æ214, p = 0Æ016), body build for height (Be-
ta = 0Æ755, OR = 0Æ471, p = 0Æ030) and skin type (Be-
ta = 1Æ527, OR = 0Æ217, p = 0Æ002) affected pressure ulcer
development. The subjects with poorer sensory perception
and abnormal body build/height and skin type were more
likely to develop pressure ulcers (Table 5).
Discussion
The pressure ulcer incidence of 9Æ1% in our sample is lower
than in other studies of orthopaedic patients in acute care
settings, in which 30% of patients with hip fractures
developed pressure ulcers postoperatively (Rademakers
et al. 2007). The findings in this study showed no significant
relationship between subjects’ characteristics and pressure
ulcer development except the length of hospital stay, which
supports Defloor and Grypdonck’s (2005) finding of no
relationship between pressure ulcer and age. The HCUP
(2005) study also found no difference in the patients
according to gender, age and medical diagnosis. Although
Gunningberg et al. (1999) suggested that smoking, age and
medical problem are causative factors for pressure ulcer
development and Russell et al. (2003) also reported that age
is a major contributor to pressure ulcer risk, these contention
are not supported in this study. However, length of hospital
stay showed a significant relationship in that the longer the
hospital stay, the higher the risk of pressure ulcer develop-
ment found in this study. This is supported by Fogerty et al.
(2008). The risk of developing postoperation complications
was higher if the operation was delayed and the length of
hospital stay longer. Rademakers et al. (2007) also showed
that the development of pressure ulcers is significantly related
to prolonged length of hospital stay.
The average age of our subjects with pressure ulcers was
82Æ2 and 14 (77Æ8%) of them had had surgery. These are the
possible reasons for the stage II pressure ulcers being much
more developed than the stage I pressure ulcers in our study.
Perneger et al. (1998) found that patient age and having had
surgery were the strongest risk factors for stage II or greater
ulcers. Stage II pressure ulcers are usually caused by friction
or shearing of the tissues, which appear more readily during

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Wound care and pressure ulcers
the turning or transferring of subjects. Orthopaedic patients,
particularly those in old age, tend to be immobile after an
operation, which may put them at high risk of friction and
shearing of the tissues, particularly when care providers
perform turning and transferring inappropriately.
The area under the ROC curve of the modified Braden
scale is 0Æ736, with 89% sensitivity and 62% specificity using
a cut-off score of 19. With respect to the predictive validity,
the modified Braden scale had the high sensitivity of 89%.
Kring (2007) says that a perfect measurement tool would
yield 100% sensitivity and 100% specificity, but no real-
world clinical instrument is able to achieve this level of
precision. Instead, those that achieve a sensitivity of 75% or
higher are considered reasonably robust in terms of their
predictive validity. The modified Braden scale in the study by
Kwong et al. (2005) demonstrated a higher specificity of 75%
and a positive predictive value of 7% among hospitalised
patients, which was higher than the Braden scale; therefore, it
is more effective in minimising unnecessary nursing interven-
tions. Xue et al.’s study (2004) also found that the modified
Braden scale was more effective in pressure ulcer risk
prediction and more suitable for use in clinical settings,
particularly where the incidence of pressure ulcer is high. The
area under the ROC curve of the modified Braden scale is
0Æ736 (95% CI, 0Æ632–0Æ841) and that of the Braden scale is
0Æ684 (95% CI, 0Æ509–0Æ786), indicating that the modified
Braden scale is more accurate at identifying patients who are
and those who are not at risk of developing pressure ulcers.
The sensitivity (67%) and specificity (64%) of the Braden
scale with a cut-off score of 16 had a better balance between
sensitivity and specificity compared with using cut-off scores
of 17 and 18 where the sensitivity was 72 and 89% and the
specificity 41 and 21% respectively. The cut-off score of 19 in
the modified Braden scale demonstrated higher predictive
validity, sensitivity (89%) and specificity (62%) than the
Braden scale whether the cut-off score was 16, 17 or 18.
Thus, in terms of sensitivity and specificity, the modified
Braden scale showed greater accuracy in identifying patients
who are and those who are not at risk of developing pressure
ulcers, supporting Kwong et al.’s study (2005) reporting that
the modified Braden scale with a cut-off score 19 is more
effective and can minimise unnecessary nursing interventions.
The sensitivity was of greater value than the specificity in
correctly identifying all patients really at risk of developing
pressure ulcers, as this is more desirable than wrongly
identifying patients as at risk and needlessly giving preventive
care (Defloor 2004). Higher specificity nevertheless helps to
cost-effectively and correctly allocate resources to patients at
risk of pressure ulcer development. Therefore, adopting the
modified Braden scale as a predictor of pressure ulcer
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1565–1573
Braden scale for prediction of pressure ulcer risk
development may help in the cost containment and allocation
of resources to patients at risk. Therefore, a modified Braden
scale with a cut-off score of 19 is suggested for use in
orthopaedic departments in an acute care setting.
In this study, the modified Braden subscale items of sensory
perception, body build for height and skin type were the risk
factors affecting pressure ulcer development, supporting
Halfens et al.’s (2000) contention that sensory perception
was the most important risk factor for pressure ulcer
development. Sensory perception is the ability to notice and
respond to discomfort caused by exposure to increased
pressure on the skin. Patients who lack sensory awareness
are more likely to remain in one position for a prolonged
period and therefore to sustain a pressure injury (Kring
2007). This also supports the findings of Defloor and
Grypdonck (2005) that the subscale of sensory perception
of the Braden scale and skin condition were significant
predictors of pressure ulcer lesions; diminished sensory
perception will increase the duration of pressure and shearing
force, which cause pressure ulcers. In addition, Kwong et al.
(2005) showed that skin type and body build for height were
very distinct in positive and negative pressure ulcer groups.
Low body weight has been shown to be a statistically
significant indicator of pressure ulcer development; it acts as
an extrinsic tissue factor as bony prominences become more
pronounced in the underweight person (Kring 2007). In
addition, obesity is also one of the causes of pressure ulcer
development because extra weight increases pressure on the
skin over the bone and joints (Wood 2005). With respect to
unhealthy skin, dehydrated skin that loses elasticity and
oedematous skin that has a poorer supply of oxygen are also
risk factors of pressure ulcer development (Potter & Perry
2001).
The findings show that the subscale of nutrition is not
significant in relation to pressure ulcer development
(p = 0Æ113), supporting Pang and Wong (1998), who found
it to be the least distinct subscale. Halfens et al. (2000) tested
and found that all factors of the original Braden scale were
related to the risk of developing pressure ulcer, with the
exception of nutrition. The measure of nutrition in the
Braden scale is of the intake of meals and not the nutritional
content, leading Halfens et al. (2000) to suggest reformulat-
ing the risk factor of nutrition in the Braden scale to enhance
its sensitivity and specificity. Body weight may also be
considered a proxy for nutritional condition and is included
in the prediction rule (Schoonhoven et al. 2005 that low body
mass index typically indicate poor nutrition (Kring 2007).
Kwong et al. (2005) also suggested deleting the subscale of
nutrition in the modified Braden scale due to the finding that
it is the least distinct subscale for predicting pressure ulcer
1571
WS Chan et al.
development and the difficulty of assessing this in Chinese
communities. As ‘one serving’ may have a well known
meaning or be an amount that is easily understood in western
countries, it is different in Chinese or Asian societies, such
that it may not be effective for nurses in clinical application.
By contrast, the subscales of body build for height and skin
type are comparatively easy to assess. The modified Braden
scale was found to have better predictive validity than the
Braden scale because of adding the distinct subscale items of
skin type and body build for height and deleting the subscale
of nutrition. In view of these findings, the modified Braden
scale with a cut-off score 19 seems to be more capable of
assessing pressure ulcer risk than the Braden scale in the
orthopaedic department in an acute care setting.
Conclusion
The modified Braden scale with a cut-off score of 19 showed
better predictive validity than the Braden scale in predicting
patients at risk and those not at risk of pressure ulcer
development in orthopaedic departments in an acute care
setting. Therefore, health care providers are recommended to
adopt the modified Braden scale with a cut-off point of 19 in
orthopaedic units for better prediction of pressure ulcer
development and more cost-effective pressure ulcer manage-
ment. In fact, various departments/units are encouraged to
conduct their own studies to determine the optimal cut-off
score based on their patient population and care settings,
because the recommended cut-off scores vary based on
different patient groups and different care settings (Kring
2007). Further, when determining the appropriate cut-off
scores, agencies must balance their need to accurately
identify those patients at risk with avoiding the over-
identification of risk for ulceration and instituting costly
but unnecessary prevention programmes (Kring 2007).
Furthermore, among the seven modified Braden subscales,
sensory perception, skin type and body build for height were
identified as being predictive of pressure ulcer development.
Nurses should thus design specific nursing interventions to
reduce and/or eliminate these three risk factors among
patients in orthopaedic units for better pressure ulcer
prevention. This study was limited to older patients in an
acute setting in a Chinese community; as such, it applies only
in this setting and further studies need to be conducted in
various healthcare settings and units to confirm its predictive
power. Therefore, it is highly recommended that the predic-
tive validity testing of the modified Braden scale can be
continued in different settings and that the distinct subscales
be identified and modified to further strengthen the validity
of the scale.
1572  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1565–1573
Acknowledgement
We would like to thank the Orthopaedic & Traumatology
department, Prince of Wales Hospital in Hong Kong for
allowing the study to be undertaken and Dr Anthony Wong,
a statistician of School of Nursing, the Hong Kong
Polytechnic University for his advice on data analysis of
our study.
Contributions
Study design: SMCP, WSC; data collection and analysis:
WSC, SMCP, E W Y K; manuscript preparation: WSC,
SMCP, EWYK.
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