Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 1 | 12 ORIGINAL RESEARCH Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers Wejdan Y. Younis1, Maysoon S. Abdalrahim1, Ruqayya S. Zeilani1, Randa Albusoul1, Dalyal Alosaimi2, Ayman M. Hamdan-Mansour1 1 School of Nursing, The University of Jordan, Amman, Jordan; 2 College of Nursing, King Saud University, Riyadh, Kingdom of Saudi Arabia. Corresponding author: Wejdan Y. Younis; Address: School of Nursing, University of Jordan, Amman 11962, Jordan; Email: W_younes@ju.edu.jo Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 2 | 12 Abstract Aims: One of the vital roles of nurses is to perform pressure ulcer risk assessment that enables them to appropriately assess and track healing progress of wound and pressure ulcers among pa- tients. Our aim was to assess the feasibility and clinical utility of the Bates-Jensen Wound As- sessment Tool (BWAT) among nurses caring of patients with pressure ulcer. Methods: A descriptive cross-sectional design used to collect data from 177 registered nurses caring of patients who developed or have a risk of developing pressure ulcers working in three hospitals in Jordan. Results: The mean feasibility score of the BWAT was 28.3 out of 36 (SD=3.4) with a median score of 29. Most of nurses reported that the BWAT was easy to use on a scale of 1-4 (best) (M=3.40/4, SD=0.62) and can successfully assess wound characteristics (M=3.40/4, SD=0.59). The mean utility score of the BWAT was 21.3 out of 28 (SD=2.7) with a median of 21. Nurses had a perception that using the BWAT enhances care of patients with wounds (M=3.36/4, SD=0.61) and makes communication easier between nurses and physicians. Conclusion: This study provided evidence that support the use of the Bates-Jensen Wound As- sessment Tool for patients with pressure ulcer. Nurses perceived BWAT as easy to use, under- standable, and relevant for assessing patients with pressure ulcers. Keywords: Bates-Jensen Wound Assessment Tool, clinical utility, feasibility, wound assessment. Funding statement: This work was supported by supported and funded by The Deanship of Sci- entific Research at The University of Jordan, Amman, Jordan [number1953/2017/19]. Conflicts of interest: The authors declare no potential conflicts of interest with respect to the re- search, authorship and publication of this study. Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 3 | 12 Introduction Pressure ulcer (PU) is a damage to an area of skin which covers a bony prominence (1). Pressure ulcers may cause several bio-psy- chosocial complications that include depres- sion, pain, and infection of muscles and bones (2). Such complications of PU might lead to more serious forms of poor quality of life, morbidity, and mortality (3,4). The liter- ature is showing that PU is affecting 6% to 10% of patents in the acute care settings caus- ing wide range of significant problems such as pain, delayed recovery, and poor healthcare outcomes (5). Globally, PU is al- most affecting 2.1 million people in acute care facilities and the cost of treatment may exceed $26.8 billion (6,7). The critical influ- ence of PU on the patient's biopsychosocial wellbeing is alarming nurses and other healthcare professionals to be attentive to in- tervene appropriately through assessing and minimizing its negative consequences. Therefore, nurses caring of patients at risk of PU need to be equipped with knowledge and skills that best enable them to detect and man- age PU. A systematic review of the literature showed that PUs are considered predictable, and the prevention of such events is consid- ered as a quality indicator (7). In particular, the increased number of older people and their high vulnerability to PU due to longer periods of hospitalization did make manage- ment of PU a priority and indicator of quality of care (8,9). Therefore, nurses, have a pri- mary responsibility in maintaining proper skin integrity and preventing skin injury and ulcer complications (10). One of the vital roles of nurses is to perform PU risk assess- ment that enables them to appropriately inter- vene to prevent PU and manage it effectively (10-12). This would suggest that feasibility of using the PU risk assessment has to be ad- dressed as priority. Feasibility is defined as the ease with which the clinicians can apply the tool in the clinical setting, while clinical utility is the ability to use the results of the tool in a useful or informative manner in clin- ical settings (10,13,14). One proposed tool that can be used and assist nurses working in medical-surgical units is Bates-Jensen Wound Assessment Tool (BWAT) (15). Alt- hough the tool is proposed for nurses and other healthcare professionals and strong ev- idence reported to support the usefulness of the tool, few studies have been conducted, globally, to assess the feasibility and clinical utility of the BWAT (15). The purpose of this study is to assess the feasibility and clinical utility of the Bates-Jensen Wound Assess- ment Tool (BWAT) in the experience of nurses caring of patients with pressure ulcer. Ethical Consideration: approval to use The Feasibility and Clinical Utility tool was ob- tained from the original author. Ethical ap- proval obtained from IRB of XYZ University (approval number 1953/2019/19). Methods A descriptive cross-sectional design was used to assess the feasibility and clinical utility of the BWAT among nurses caring of patients. Data are collected using a self-administered questionnaire. A liaison has been assigned to invite nurses to participate in the study. Those who expressed interest in participation were directed to the research team who was available to address purpose and significance of the study and ensure voluntary participa- tion. After having all their questions an- swered, the package including a cover letter that indicated returning the survey is consid- ered as consenting to participate in the study. The package also included a booklet about the technique of wound assessment using the BWAT. Nurses were directed where to return Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 4 | 12 the survey in the given sealed envelope to en- sure anonymity and confidentiality. Sample and setting A convenience sampling technique was used to recruit nurses from three major hospitals in Jordan representing the three healthcare sec- tors: governmental, educational, and military hospitals. Inclusion criteria: 1) has at least three month of experience to ensure knowledge regarding protocol and guidelines of practice, and 2) caring for patients who de- veloped or are at risk of developing PU in the selected hospitals. No exclusion criteria have been indicated. Using G*Power computer software program version 3.0.10, using exact test a medium effect size of 0.20 was deter- mined, a significance level of α = 0.05 was set, and at a power of 0.80. The yielded sam- ple was 177 participants. The tools employed are: − The Bates-Jensen Wound Assessment Tool (BWAT) has been developed in 1990 and revised in 2001. It aims to monitor the healing process of pressure ulcers (15,16). The BWAT contains 13 items that facilitate nurses’ role in evalu- ating wound characteristics such as the depth, size, edges, undermining, necrotic tissue type and amount, exudates, granu- lation tissue, epithelialization, peripheral tissue indurations, peripheral tissue edema, and skin color surrounding the wound. Each item in the BWAT is graded on a scale from 1 to 5, where a score of 1 indicates improvement toward healing, and a score of 5 indicates lack of healing or wound deterioration. The total scores range from 13 to 65 (15,16). The BWAT has reasonable reliability and va- lidity, with sensitivity of 61%, a Cronbach’s alpha of 0.90, positive pre- dictive value of 65%, and specificity of 52% (15). − The Feasibility and Clinical Utility (FCU) tool has been developed to test Bates-Jensen Wound Assessment Tool feasibility and clinical utility (Appendix A) (17). This tool consists of 16 ques- tions with two subscales. The first sub- scale measures the feasibility and com- prises nine questions while the second subscale measures the clinical utility and comprises seven questions. Nurses are asked to make their responses on a 4- pointscale ranging from of 1-4 (1=not relevant, 2=somewhat relevant, 3=quite relevant, 4=highly relevant). The tools have good reliability and validity with Cronbach's Alpha of 0.88. In addition, the questionnaire included a profile for socio-demographic data regarding in- cluding age, gender, and years of experi- ences (see Table 1). The association between the sample charac- teristics and feasibility and utility scores was tested using T-test or one-way ANOVA for variables with three categories or more. A value of P≤0.05 was considered statistically significant. Results Nurses' characteristics A total of 200 registered nurses expressed their interest, 177 nurses which filled and re- turned the survey represented the final sam- ple of the study with a response rate of 88.5%. The mean age of nurses was 31.8+6.4 ranging from 21 to 50 years. The majority of the nurses were females (n=111, 62.7%), having a bachelor degree (n=165, 93.2%) and were working as a registered nurses (n=137, Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 5 | 12 77.4%). The mean years of experience was 9.5+6.0, and the majority of them were from the military hospital (n=117, 66.1%), see Ta- ble 1. Table 1. Characteristics of the Participants (N= 177) Characteristics Frequency Percentage Gender Male Female 66 111 37.3 % 62.7 % Educational level Bachelor degree Master degree 165 12 93.2 % 06.8 % Position in nursing Staff nurse In charge nurse Supervisor 137 21 19 77.4 % 11.9 % 10.7 % Hospital sector Governmental Military University affiliated 22 117 38 12.4 % 66.1 % 21.5 % Already using BWAT* in the hospital No Yes 59 118 33.3 % 66.7 % Nurses experience** Surgical conditions Acute conditions Medical conditions Critical conditions Oncology patients Palliative conditions 70 48 116 84 78 65 39.5 % 27.1 % 65.5 % 7.5 % 44.1 % 36.7 % * BWAT: Bates-Jensen Wound Assessment Tool; ** More than one option acceptable. Feasibility of the Bates-Jensen Wound As- sessment Tool The mean feasibility score of the BWAT (see Table 2) was 28.3 +3.4 out of 36.0 with a me- dian score of 29, and range of 17-35. The in- terquartile range (IQR) classification system was utilized to categorize the feasibility scores into three categories; low (25th IQR), moderate (50th IQR), and high (75th IQR). Accordingly, the results revealed that 32.2% (n=57) of the nurses fell in the low category, 41.8% (n=74) in the moderate category, and 26.0% (n=46) in the high category. Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 6 | 12 Table 2. Classification of the Feasibility and Clinical Utility of the BWAT Category Classification Range Frequency (%) Feasibility of BWAT* Low Moderate High (28 and below) (29-30) (31 and above) 57 (32.2%) 74 (41.8%) 46 (26.0%) Clinical Utility of BWAT* Low Moderate High (20 and below) (21-23) (24 and above) 60 (33.9%) 72 (40.7%) 45 (25.4%) *BWAT: Bates-Jensen Wound Assessment Tool Regarding feasibility, most nurses (>70%) reported that the BWAT was easy to use in- dicated by the 4-point scale (M=3.40+0.62), and can successfully assess wound character- istics (M=3.40+.59). Nurses reported that they received sufficient training on using BWAT (M=3.30+0.65), and can easily un- derstood the tool's directions (M=3.35+0.56). The responses that had low mean scores less than 3.0 were, eventually, reported for the items that have structured negatively and those are: “I use the BWAT just because it is required by the hospital administration” (M=2.37+.80) and “Using the BWAT takes too much time from my work” (M=2.32+.69). Clinical Utility of the Bate-Jensen Wound Assessment Tool The mean utility score of the BWAT (see Ta- ble 2) was 21.3+2.71 out of 28 with a median of 21, and range of 11-28. The Interquartile classification system was utilized to catego- rize the utility scores into three categories; low (25th IQR), moderate (50th IQR), and high (75th IQR). The analysis showed that 33.9% (n=60) of nurses fell in the low cate- gory, 40.7% (n=72) in the moderate category, and 25.4% (n=45) in the high category. Nurses reported that using the BWAT in their daily practice will enhance the nursing care of patients with wounds (M=3.36+.61). Ac- cording to the nurses, the BWAT makes com- munication of a patient’s wound healing pro- cess easier for both nurses (M=3.26+0.57) and physicians (M=3.31+0.59). Most nurses (>60%) reported that they will recommend using the BWAT for wound assessment (M=3.28+0.63). The lowest mean item score was for the item “the tool is not connected to wound management guidelines in most of the hospitals” (M=2.68+0.98). In addition, a rel- atively low score was reported also to “the physician asks nurses frequently about the BWAT scores for patients with ulcer before managing wound (M=2.78+.86). Differences in Feasibility and Clinical Util- ity of the BWAT related to Sample Charac- teristics The results (see Table 3) indicated that there is a significant difference in feasibility and clinical utility mean scores between the mili- tary hospital and other hospitals (private and governmental). Nurses from the military hos- pital had higher mean scores in both feasibil- ity and clinical utility (28.5±2.7, 22±2.7; re- spectively). Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 7 | 12 Table 3. Association between Sample Characteristics and the BWAT Feasibility and Clini- cal Utility Variable Feasibility M ± SD P Utility M ± SD P Gender Male (n = 66) 28.4±3.90 .751 21.4 ± 2.81 .621 Female (n = 115) 28.2 ± 3.31 21.2 ± 3.10 Educational level BSC (n = 171) 28.2 ± 3.41 .672 21.4 ± 2.90 .045 MSN (n = 10) 28.7 ± 4.61 19.5 ± 2.90 Hospital sector Governmental (n = 21) 26.6 ± 2.11 20.7 ± 2.01 Military (n = 117) 28.5 ± 2.70 < .001 22.0 ± 2.01 .022 Teaching (n = 38) 26.4 ± 5.31 20.7 ± 4.10 Nursing position Staff nurse (n = 142) 27.7 ± 3.40 .301 21.0 ± 2.41 .501 In-charge nurse (n = 21) 28.5 ± 3.20 21.8 ± 2.60 Supervisor (n = 18) 28.5 ± 3.20 28.5 ± 3.20 Caring for medical condi- tions No (n = 61) 27.6 ± 3.21 .091 21.5± 2.90 .401 Yes (n = 120) 28.6 ± 3.51 21.1 ± 2.90 Caring for acute condi- tions No (n = 133) 28.1 ± 3.41 .240 21.3 ± 2.90 .991 Yes (n = 48) 28.8 ± 3.61 21.3 ± 3.01 Caring for critical condi- tions No ( n= 97) 27.4 ± 3.20 < .001 21.0 ± 3.10 .181 Yes (n =84) 29.3 ± 3.41 21.6 ± 2.81 Caring for surgical condi- tions No (n = 111) 28.2 ± 3.20 .921 21.2 ± 2.80 .821 Yes (n= 70) 28.3 ± 3.71 21.3 ± 3.20 Caring for the condition with cancer No (n =103) 27.4 ± 3.20 < .001 21.4 ± 3.00 .521 Yes (n= 78) 29.4 ± 3.41 21.1 ± 2.90 Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 8 | 12 Caring for palliative pa- tients No (n = 116) 27.6 ± 3.30 < .001 21.4 ± 2.90 .520 Yes (n = 65) 29.5 ± 3.41 21.1 ± 3.00 Previous educational pro- gram on wound assess- ment No (n = 106) 28.6 ± 3.30 .160 21 ± 2.90 .220 Yes (n = 75) 27.8 ± 3.61 21.6 ± 2.91 Previous use of assessment tools No (n = 59) 26 ± 4.10 <.001 19.8 ± 3.30 .003 Yes (n = 117) 29.4 ± 2.51 21.9 ± 2.50 Besides, higher mean scores of feasibility and clinical utility were reported among nurses that used the tool previously (had an experi- ence in using the tool at other settings and with other patients: 29.4±2.5 and 21.9±2.5). The work experience affected participants’ perception of utility and feasibility of BWAT; nurses who provided care for pallia- tive or cancer patients, and for critical pa- tients had significantly higher mean feasibil- ity scores than other nurses (29.5±3.4; 29.4±3.4; 29.3±3.4). However, there was no significant difference in clinical utility mean scores among nurses in relation to work ex- perience. Nurses with graduate level of edu- cation had higher mean scores on the BWAT clinical utility than nurses with undergradu- ate level. Nurses' age and their years of expe- rience in nursing were positively correlated with feasibility and clinical utility of BWAT (p-value <0.001). Discussion Positive healing progress of pressure ulcer is a core indicator for quality of nursing care. Therefore, nurses who assume the responsi- bility to assess and manage care for pressure ulcers need to be equipped with knowledge and skills to improve quality. In particular, nurses working in general wards - such as medical and surgical ones - caring for pa- tients occupied to bed are challenged with high load of work and simultaneously strug- gle to keep high quality of nursing care (21). In our study, we found on the one hand that a considerable number of nurses indicated low levels of perception of feasibility and clinical utility of BWAT although were using the tool competently. Such findings partially disagree with previous reports who reported good fea- sibility and utility of BWAT among health staff (7,18,19) whereas in our study about one third of nurses are categorized at low level. One explanation could be related to the nurs- es' belief that using BWAT is only for the purpose of adherence to hospitals' protocol rather than their clinical and scientific judg- ment and practice. Nurses were using the BWAT just to get satisfactory reports from their supervisors which may influence the core principle of safe and quality nursing practices. Such findings support previous studies that nurses found to perform BWAT to get management appraisals rather than for its clinical and quality importance for pa- tients and care outcomes (20). Moreover, Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 9 | 12 nurses were not well-oriented about such ad- vanced measure as they described BWAT as easy to understand, while their scores on the items of the scale do not reflect such percep- tion. This is one limitation of this study as we have used a self-reported format of data, while using an observational approach through assessing direct skills and outcomes would have revealed more informative re- sults. One significant contribution of this study is, however, that nurses considered BWAT as a helpful tool for documentation which en- hances the feasibility and utility of BWAT in different health care settings. Nurses reported that using BWAT made the communication of the patient’s wound healing progress eas- ier between and among nurses and physicians which sustains what Triantafyllouet al. (7) re- ported that BWAT helped the nurses to estab- lish meaningful communication and accurate tracking of wound healing process for both nurses and physicians (7). Most nurses advo- cated using the BWAT for wound assess- ment; however, they asserted also that BWAT has not been integrated into the hos- pitals’ policies which may also explain the low to moderate scores of feasibility and util- ity. Another significant contribution is re- lated to the effect of training and years of ex- perience in nursing on the willingness to use BWAT. We have found that nurses with more years of experience and those who re- ceived training on wound assessment and management did have higher scores of feasi- bility and clinical utility of BWAT. This in- dicates that nursing training is required and the notion that nurses should rely on their self-training and education is not valid. Those with better training are capable to provide higher levels of quality of nursing care. Conclusions This study found that BWAT is a sufficiently valid and reliable tool used to assess and monitor progress of PU among patients in different clinical settings. The study shows also that nurses have only a low to moderate perception of feasibility and clinical utility of the BWAT tool in PU assessment and moni- toring. Therefore, qualified training is needed to ensure nurses' competency to use the tool. Furthermore, policies need to be revised to ensure integrating BWAT into protocols, and a monitoring system should be created to en- sure nurses' adherence to use BWAT. Con- ducting a longitudinal observational study with larger sample size would reveal more in- formative results regarding competency and willingness of nurses to use BWAT and its outcome on patients' skin integrity. References 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Ad- visory Panel and Pan Pacific Pres/sure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haes- ler (Ed.). EPUAP / NPUAP / PPPIA; 2019. 2. McGinnis E, Briggs M, Collinson M, Wilson L, Dealey C, Brown J, et al. 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DOI: 10.11576/seejph- 5084 P a g e 11 | 12 © 2022 Younis et al; This is an Open Access article distributed under the terms of the Creative Commons Attribu- tion License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and repro- duction in any medium, provided the original work is properly cited. the Bates-Jensen wound assessment tool for the Brazilian culture. Texto Contexto Enfer 2015;24;826-33. 19. Shukla U, Kumar A, Anushapreethi S, Singh SP. Evaluation of the effi- cacy of hyperbaric oxygen therapy in the management of diabetic ulcer us- ing Bates-Jensen wound assessment tool. Anesth Essays Res 2020;14:335. 20. Hamdan A, Hamdan-Mansour A. Community versus Hospital Ac- quired Pressure Injuries: An Assess- ment of Predisposing Risk Factors. Malaysian J Med Health Sci 2020;16:170-6. 21. Christopher K. A Double Bind of Relational Care: Nurses’ Narratives of Caregiving at Work and at Home. Gender Issues 2021;1-16. _____________________________________________________________________________________________ Younis WY, Abdalrahim MS, Zeilani RS, Albusoul R, Alosaimi D, Hamdan-Mansour AM. Feasibility and clinical utility of Bates-Jensen wound assessment tool among nurses caring of patients having pressure ulcers (Original research). SEEJPH 2022, posted: 10 January 2022. DOI: 10.11576/seejph- 5084 P a g e 12 | 12 Appendix A: BWAT Feasibility and Clinical Utility Questionnaire Question 1 2 3 4 Strongly not Agree Not Agree Agree Strongly Agree Feasibility 1. I understand the BWAT directions. 2. I found the BWAT is easy to use. 3. The BWAT can successfully assess level of pain for mechanically ventilated patients. 4. I received sufficient training about the use of BWAT. 5. Using the BWAT takes too much time from my work. 6. The BWAT rating scores accurately reflect patients’ pain level. 7. The BWAT measurement is quick to use. 8. The score of BWAT is easy to document. 9. I use the BWAT just because it is required by the hospital administration. Clinical utility 10 The use of BWAT makes communication of pa- tients’ pain easy with other nurses. 11 The use of BWAT makes communication of pa- tients’ pain easy with physicians in the ICU. 12 I recommend the use of BWAT in assessing MV pa- tients’ pain. 13 Using the BWAT will enhance caring of MV pa- tients. 14 The BWAT scores are often used to manage MV pa- tients’ pain in our ICU. 15 Physicians ask nurses frequently about the BWAT scores for MV patients before managing pain. 16 The BWAT is not connected to pain management guidelines and policy of pain management in our hospital. Appendix A: BWAT Feasibility and Clinical Utility Questionnaire