J Wound Ostomy Continence Nurs. 2014;41(4):340-344. Published by Lippincott Williams & Wilkins


Reliability and Validity of a Turkish Language Version of the Bates-Jensen Wound Assessment Tool Azize Karahan ■ Ebru Kilicarslan Toruner ■ Aysun Ceylan ■ Aysel Abbasoglu ■ Agah Tekindal ■ Lale Buyukgonenc

■ ABSTRACT PURPOSE: The aim of this study was to evaluate content and construct validity of a Turkish language version of the Bates Wound Assessment Tool (BWAT) as well as its internal consistency and interrater reliability. SUBJECTS AND SETTING: The study was conducted in 13 intensive care units that included patients with pressure ulcers; the units were located in a university hospital in Central Anatolia, Turkey. The sample comprised 70 nurses and 20 patients who have stage II, III, and IV pressure ulcers. METHODS: Data were collected between January and April 2011. Content validity was measured using the Davis Technique. The BWAT was scored by 2 groups, nurses with expertise in wound care and staff nurses. An expert nurse and a ward nurse conducted pressure ulcer evaluation on the same patient consecutively in order to determine interrater reliability. We also measured internal consistency via the Cronbach α. RESULTS: The content validity agreement rate was 0.82. The interrater reliability of the instrument was 0.82; its internal consistency calculated via the Cronbach α was 0.85. CONCLUSION: The findings of this study support the Turkish language version of the BWAT as possessing content validity, interrater reliability and internal consistency. KEY WORDS: Bates wound assessment tool, reliability, wound assessment.

■ Introduction Pressure ulcers (PUs) are a clinically relevant source of morbidity.1 The incidence and prevalence of hospital-acquired PUs in Turkey are not known. However, Uzun and colleagues2 reported a 26.8% incidence in 186 critically ill patients over a 3-month period in intensive care units in a university hospital over a 3-month period. All were stage II and 46% were located on sacrum.2 Inan and Oztunc3 measured a 10.4% prevalence in 404 patients in the medicalsurgical and intensive care units in a university hospital; more than half occurred in critically ill patients. The

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majority of PUs were stage II (45.2%) and located on the sacrum (43.9%).3 Leblebici and associates4 reported a 1.6% prevalence rate in 22,843 patients. Most of the PUs in this study (59.2%) occurred in critically ill patients.4 Multiple factors may have contributed to the variability in these epidemiological studies; however, they concur that the occurrence of PU tends to be higher in critically ill patients. Although definitive evidence is lacking, expert opinion suggests that some PUs are unavoidable.5 When a hospital-acquired PU occurs, the focus on nursing care shifts from prevention to treatment. Multiple tools have been developed to assist nurses in monitoring wound status and progress toward wound healing. Among the more commonly used tools are the Pressure Ulcer Scale for Healing (PUSH) instrument and the Bates-Jensen Wound Assessment Tool (BWAT).6 Both the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) advise the use of validated tools such as PUSH and BWAT for wound care.7 The PUSH tool has some limitations in assessing wound characteristics when comparing with the BWAT. For instance, the character of exudate is not included in  Azize Karahan, PhD, RN, Assistant Professor, Health Services Nursing Department, Baskent University Health Sciences Faculty, Ankara, Turkey.  Ebru Kilicarslan Toruner, PhD, RN, Assistant Professor, Nursing Department, Gazi University Health Sciences Faculty, Ankara, Turkey.  Aysun Ceylan, RN, Head Nurse of Urology Unit, Baskent University Ankara Hospital, Ankara, Turkey.  Aysel Abbasoglu, MSN, RN, Lecturer, Nursing Department, Baskent University Health Sciences Faculty, Ankara, Turkey.  Agah Tekindal, Medical Specialist, Department of Biostatistics, Baskent University School of Medicine, Ankara, Turkey.  Lale Buyukgonenc, PhD, RN, Professor, Department of Nursing, Hitit University School of Health, Corum, Turkey. The authors have declared no conflict of interest. Correspondence: Ebru Kilicarslan Toruner, PhD, RN, Nursing Department, Gazi University Health Sciences Faculty, Ankara, Turkey ([email protected], [email protected]) DOI: 10.1097/WON.0000000000000036

Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™

Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.

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the PUSH as a characteristic of wound healing. Another difference in the use of the PUSH tool is its sensitivity to wound size; the largest wound size for the PUSH instrument is more than 24 cm while the largest size subscore on the BWAT is more than 80 cm.8 Besides providing an assessment of PU, the BWAT has been shown to be valid and reliable for assessment of different wound types.9,10 The purpose of this study was to measure test-retest reliability and internal consistency of a Turkish language version of the BWAT in order to aid nurses who are caring for patients with PUs. Study questions were as follows: (1) what is the content validity of the Turkish language BWAT, (2) what is the internal consistency of the Turkish language BWAT, and (3) what is the interrater reliability of the Turkish language BWAT?

■ Methods The study setting was Central Anatolia, Turkey. Data were collected between January and April 2011. The hospital’s capacity is 300 beds and 254 nurses were employed in the hospital at the time of data collection. Data were collected on 13 medical and surgical intensive care units, which had patients with PUs. We excluded pediatric wards, operating room, and outpatient clinics. Patients with stage II-IV PUs were included in the study, but not those with stage I ulcers since this category is not associated with skin breakdown. Study procedures were reviewed and approved by Baskent University Institutional Review Board and Ethics Committee, Turkey (No: KA 09/05). Informed consent was obtained from both nurse and patient participants.

Instrument The BWAT began its existence as the Pressure Sore Status Tool, in 1997.11 The renamed instrument was designed for use in wound with variable etiologies.6 The BWAT consists of 13 items that prompt the nurse to evaluate wound size, type and depth, amount of necrotic tissue, amount and characteristics of exudate, presence of granulation tissue, epithelialization, and periwound skin. Each item is graded on a scale of 1 to 5, where a score of 1 indicates progress toward healing while a score of 5 indicates absence of healing or wound deterioration. Cumulative BWAT scores vary from 13 to 65. The English language BWAT instrument has been reported to have a Cronbach α of 0.91 and an interrater reliability coefficient of 0.99.12 We searched the literature but found no study reporting the existence, validity, or reliability of a Turkish language version of the BWAT. We, therefore, translated the BWAT into Turkish via 2 experts who were competent in both languages, and familiar with both cultures. A third expert, who is competent in Turkish and English languages and did not see the original scale before, translated the scale back to English. All experts had been trained as health care providers. The original and Turkish translations of the scale were compared by the researchers and a

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final form of the Turkish version of the BWAT was prepared. The final version of the scale was sent to Bates Jensen, who developed the instrument. Two other forms were used to collect data for this study. An 11-item form queried nurses’ demographic characteristics and their understanding of the BWAT. In addition, a 13-item questionnaire was prepared that queried pertinent patient characteristics.

Validation of the BWAT Content validity of the BWAT was evaluated using the Davis technique. The instrument was sent to 10 health care professionals with expertise in wound care including 6 nursing faculty members, including 1 with expertise in child care, 1 practicing nurse with expertise in acute wound care, and 3 physicians (a general surgeon, burn care specialist, and plastic surgeon). They were asked to examine every item in the BWAT and rank items as “very appropriate,” “item needs to be put into an appropriate form,” “appropriate but needs minor changes,” or “not appropriate.” The experts were also asked to provide narrative comments if desired. Experts were asked to rate each item from 1 to 4 and a content validity index was calculated by dividing the total score of each item to total number of experts in this technique. The minimum index for each item to be declared as having content validity was greater than 0.80.13 This review led to revision of 8 of the 13 items.

Interrater Reliability Pressure ulcers were assessed by 2 expert nurses with knowledge of wound assessment. The Turkish version of the BWAT was initially completed by these nurses, along with additional items that provided demographic and pertinent clinical characteristics of patients with PUs. Following this evaluation, the BWAT was completed by ward nurses. During this process, precautions were taken to prevent interactions between ward nurses. Specifically, ward nurses entered the patient room one by one and any one patient was not evaluated more than 3 times per day. In addition, ward nurses were selected from different inpatient care units when evaluating the same patient.

Data Analysis All computations were performed using the Statistical Package for the Social Sciences (SPSS) statistical software package, version 17 (SPSS, Chicago, Illinois). The Davis technique was used to evaluate the experts’ opinions and recommendations about the tool’s content validity. Factor analysis; we completed the Kaiser-Mayer-Olkin (KMO) test and Bartlett’s Test of Sphericity. These tests were also used to measure the internal consistency of the BWAT. The BWAT was found to be homogeneous if the KMO test result was greater than 0.60 for factor analyses.14 The internal consistency of the BWAT was further evaluated via the Cronbach α. This statistical test evaluates internal consistency within an instrument; values vary from 0 to

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1.0. Higher values (approaching 1.0) indicate greater internal consistency.15 The Spearman rank correlation coefficient was calculated to determine the magnitude of relationships between items on the BWAT; it is based on calculation of a single item to cumulative score. Interrater reliability was also evaluated. The Goodness of Fit Model was used to examine the consistency between results of BWAT scores done by independent observers. Statistical differences between the observers’ results of scoring the BWAT were calculated via χ2 test; P values < .05 were deemed statistically significant. Statistical analyses used in the study are summarized in Table 1.

■ Results The target sample was 102 nurses employed in 13 inpatient units. Twenty-five nurses who had been employed less than 6 months in the hospital were excluded from participation because they remained in an orientation period. An additional 7 nurses declined to participate resulting in a final sample of 70 participants. The mean age of the nurse participants was 25.4 ± 2.8 (mean ± SD; range = 22-33 years). Most of the nurses were female (82.9%) and held a baccalaureate degree in nursing (98.5%). Nurses participated in the study worked mostly (64.3%) in intensive care units and 31.4% of the participants have worked as ward nurses for 1 to 2 years. Assessment by the expert nurses identified 20 patients with stage II, III, and IV PUs who agreed to participate in the study. In the study, 44.3% of the 20 PUs were stage II, 48.5% were stage III, and 7.1% were stage IV. The mean age of the patients was 70 ± 13.1 years (range, 38-91 years). The descriptive characteristics of nurses and patients are shown in Table 2.

Validity Following item revision, content validity agreement rate based on expert rating was 0.82. Factor analysis was then



Demographic Characteristics of Nurses and Patients Characteristics of Patients (n = 20)

Age, y



Reliability and validity of a Turkish language version of the Bates-Jensen Wound Assessment Tool.

The aim of this study was to evaluate content and construct validity of a Turkish language version of the Bates Wound Assessment Tool (BWAT) as well a...
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