Pressure Injury Prevention

Introduction and Problem Statement
This scholarly project proposal examined a problem within a long-term care facility, specifically the development of pressure injuries among older patients. A significant health concern for older adults within the inpatient health care setting, specifically long-term care facilities, is the development of pressure injuries. These injuries can cause physical, psychological, social, and economic consequences, leading to patient suffering and reduced quality of life. More than 2.5 million American patients develop a pressure injury every year while hospitalized or in a healthcare facility (Padula & Delarmente, 2019). The result is mortality in 60,000 of these patients annually, representing a significant patient safety threat (National Pressure Injury Advisory Panel [NPIAP], 2021; Padula & Delarmente, 2019). There is reliable evidence that the elderly face disproportionate risks of both lengthy hospital stays and the development of pressure injuries (Van Gilder et al., 2017). Unfortunately, the situation is worsening, with a reported increase of 6 percent between 2014 and 2017, and a spike in incidence due to the COVID-19 pandemic (NPIAP, 2021).
Pressure injuries are a predictable result of immobility or bed rest during hospitalization, and these can complicate recovery as well as lead to acute health risks and problems. For nurses providing direct care to inpatients, pressure injuries, sores, and ulcers are an indicator of poor care quality and threats to patient safety. Pressure injuries burden the American healthcare system with overall costs of about $17.8 billion every year (Hajhosseini et al., 2020). The rates of these pressure injuries within this vulnerable population must be reduced. Therefore, evidence-based interventions are needed to reduce pressure injury rates. One intervention involves the implementation of a pressure injury prevention bundle. Compared to current practice, this bundle can significantly reduce pressure injuries in patients.
Background and Significance
Reducing the incidence of pressure injuries is of great clinical significance, especially since the research clearly shows the negative consequences of pressure injuries. Pressure injuries represent a public health concern for which the older population is most at risk, as age represents a critical risk variable (Cox et al., 2020). Older patients in long-term care facilities have an increased vulnerability to pressure injuries in comparison to their younger peers. One reason for this is that as a person ages, they are more likely to develop chronic illnesses and comorbidities. At the same time, they also lose the ability to fight off infections as their immune system also ages (Haynes, 2020). Due to this reduced immunity, they are much more susceptible to pressure injuries (Cox et al., 2020). Furthermore, long-term care facilities are a prime location for these pressure injuries to develop, as patients may have to be immobilized for extended periods; long-term care facilities also care for patients who are more at risk, such as those with impaired circulation, malnutrition, and altered states of consciousness (Kumta et al., 2018).
Therefore, by addressing pressure injuries and reducing their incidence within the long-term care facility setting, nursing practice can be advanced. Since the elderly represent a vulnerable population, it is imperative that interventions to reduce pressure injuries be targeted toward them. Not only are they more likely to develop these pressure injuries, but they are also more likely to have severe repercussions, including loss of life (Chung et al., 2022). Pressure injury prevention involves using a bundle, which represents a set of evidence-based interventions that enable facilities to reduce the incidence of pressure injuries they experience (Yilmazer & Tuzer, 2019). Furthermore, the bundle enables the staff to better comply with the clinical guidelines that should be followed to prevent these pressure injuries, thus improving the quality and continuity of patient-centered care (Yilmazer & Tuzer, 2019). By implementing a pressure injury prevention bundle within the long-term care facility, these risks can be significantly reduced, improving patient safety and care quality. These patients can then live longer and healthier lives, many times being released from the long-term care facility earlier, thus enjoying better prognoses and overall wellbeing.
Purpose
Aims and Objectives
The purpose of this project was to reduce the rate of pressure injuries in older patients (65 years of age and older) residing in a 120-bed long-term care facility. The aim was to prevent unnecessary patient suffering while ensuring that the facility was able to meet the established quality and safety benchmarks (Dalvand et al., 2018). This project had one key objective: to create an educational intervention for bedside nurses so they could increase their knowledge regarding ways to prevent pressure injuries in patients. The outlined goal was for nurses to score an average of 90% (minimum of 75%) on a survey that measured their knowledge of pressure injury prevention and management. Thus, it was anticipated that the project’s educational intervention would result in an increase in the knowledge of nurses working at the long-term care facility.
Synthesis
Introduction
It is generally known that the elderly is more susceptible to skin complications such as pressure injuries compared to their younger adult counterparts, as skin loses functional qualities as a person ages (De Bengy et al., 2022). Despite the consensus that pressure injury prevention is important for all patients and elderly patients in particular, few recent research studies provide insights in relation to the factors of importance for prevention and practice for this targeted group. There is considerable literature in relation to the economics of hospital-acquired injuries, as well as reports of pressure injury prevention bundle implementation in general adult populations and pediatric populations. In fact, there are many reliable and credible sources of information when reviewing the literature on pressure injuries and evidence-based practices for reducing these sores. Recent peer-reviewed journal articles were identified and examined through conducting a literature search online and perusing nursing databases.
Search Strategy
The intention of the search approach was the identification of the current level of evidence and status of the research question. Several databases were searched to collect articles published between 2017 and 2022 using the following search terms: “bundle”, “pressure injury bundle”, and “pressure ulcer”, and “elderly” in Google Scholar. Google Scholar is an aggregated database of scholarly articles that includes articles cross-referenced to CINAHL, Medline, and other popular nursing journal sources. The result was just four (n= 4) publications, with none of these reflecting a focus on geriatric patients. One was focused on the pediatric population (Kriesberg et al., 2018), while the other three were for a general adult population that included elderly patients (Halecka, 2020, Jones, 2021, Raynaldo, 2020).
Synthesis of Evidence
Biophysical Aspects Of Pressure Injuries In An Elderly Patient Population
Recent synthesis of studies relating to skin tissue, the elderly, and pressure injuries has established some background for understanding the biophysical characteristics of the skin which contribute to ulceration and poor patient outcomes. De Bengy et al. (2022) described the fragility of the skin of the elderly as a significant issue leading to greater risks of pressure injury. The issues were identified as a thinning epidermal layer with less-resistant networks of collagen and reduced elastin, flatter dermal-epidermal junction, and thinner hypodermis (Bengy et al., 2022). As a result of these functional issues, skin tissue itself is challenged by reduced structural resistance to damage under any pressure or force (Bengy et al., 2022). There is evidence of these impairments at the level of the molecule, which displays reduced processing ability in relation to the growth factor β and the correlated receptor, TGFβ receptor II (Bengy et al., 2022). These are needed for the continual reconstruction of the dermal extracellular matrix that creates skin and its protection (Bengy et al., 2022). A higher skin pH also results from these changes, and this can impair the enzymatic activity which serves to protect the skin from pathogens and damage (Bengy et al., 2022). Skin vessel vasodilation results from the low application of pressure due to impairment of the vasodilation response, cutting off blood flow and resulting in tissue damage even when the pressure on the skin is minimal (Bengy et al., 2022). As endothelial function decreases, vasodilation becomes impaired (Bengy et al., 2022).
Pressure Injury Prevention Bundle Modules
Various bundles have been developed and branded, such as the InSPiRE (patient skin integrity care bundle) program and INTACT (INTroducing A Care bundle To prevent pressure injury) (Luton et al., 2018). The most effective bundles include interspecialty components that include training/awareness, patient education, patient risk assessment, skin assessment, nutrition management, activity management, moisture and incontinence support, and support surface management (Yilmazer & Tuzer, 2022a). An international clinical trial found that five-layer silicone border dressings were both clinically effective and cost-effective in preventing predictable pressure injuries due to immobility (Padula et al., 2019b). Lavallée et al. (2019b) developed an evidenced-based pressure injury prevention bundle collaboratively with nurse specialists and nursing home care staff targeting nurse behaviors relating to the patient support surface, skin inspection, and regular turning and positioning. Padula et al. (2020) examined the cost-effectiveness of sub-epidermal moisture scanning, a practice requiring a device to identify areas of moisture accumulation in the skin, in the context of American hospital inpatients. They found annual cost-savings of $4,054 per patient admitted with an acute health diagnosis and reduced mortality of pressure injuries by 7 per 1,000 patients. The bundle for use in the study was determined after a more thorough review of the literature, which focused on the specifics of bundles. However, each of the components was addressed as part of the final pressure injury prevention bundle.
The Evidence For The Use Of Pressure Injury Prevention Bundles
In American hospitals, pressure injury prevention bundles have reduced pressure injury prevalence across hospital departments and units (Rivera et al., 2020). There have been spectacular achievements, including reductions in the incidence of pressure injuries to zero (Kimsey, 2019). The results have been similar across borders and cultures. Zhang, et al. (2021) reported on a PIP bundle intervention in a hospital setting in a multi-site study across 26 provinces in China over six months. The intervention resulted in a reduction of pressure injuries from 13.86 per thousand patient-days (PTPD) to 10.41 PTPD, and hospital-acquired preventable injuries by 29.5 percent. Al-Otaibi et al. (2019) also reported on a quality improvement project in a 144-bed hospital in Saudi Arabia involving prevention bundles, and in this intervention the rate of pressure injuries was reduced by 84 percent in just three months. Yilmazer and Tuzer (2022a) in Turkey similarly found that their eight component bundles reduced the incidence of stage 1 pressure injuries from 15.11 PTPD to 6.79 PTPD after implementation. A systematic analysis by Trisnaningtyas et al. (2021) of studies at the evidence level of II revealed that the incidence of pressure injury had decreased between 4 percent and 36 percent in developed countries where pressure injury prevention bundles had been deployed, with a slightly smaller range and effectiveness in developing nations. A hospital in England was able to reduce the incidence of pressure injuries in a nursing care home to zero during a nine-week quality improvement pressure injury prevention bundle project (Lavallée et al., 2019a).
Cost-Effectiveness Of Pressure Injury Prevention Bundles
The cost-effectiveness of pressure injury prevention bundles is often quantified in the abstract, in that the presence of high rates of hospital-acquired infections will result in lower values for reimbursement for Medicare/Medicaid programs (Luton et al., 2018). Despite these economic pressures to ensure low rates of hospital-acquired infections, pressure injuries have been increasing in recent years, particularly during the COVID pandemic (Padula et al, 2021). Researchers and analysts provide not only evidence of the cost-effectiveness of pressure injury prevention practices, but also propose that stricter measures and greater liability are borne by hospitals and care facilities with high rates of pressure injuries as an indicator of poor care quality (Padula et al, 2021). Singh (2021) proposed that even significant upfront costs in implementing prevention bundles that include physical support for specific areas result in savings within just a few years. Padula et al. (2019) further noted that even free or low-cost tools, such as the repeated use of the Braden scale to monitor pressure-injury risks, are cost-effective in terms of the use of nursing time. Yilmazer and Tuzer (2022) further reported that the bundle approach to pressure injury prevention eased, rather than increased, pressures on nursing time after implementation, indicating the cost and resource effectiveness of the approach.
Factors of Influence
There are several factors of influence associated with this project. For example, exceptional situations in the surrounding population or the organizational context can be detrimental to the study by distorting the results. Additionally, the skill level of nurses in terms of skin assessment and ulcer detection is an important factor that determines or limits success. The extent to which nurses are willing, self-motivated, and engaged in their participation is key to the successful implementation of a pressure injury prevention bundle program (Luton et al., 2018). Furthermore, ensuring that hospital management is aware of the cost-effectiveness and quality improvement potential of pressure injury prevention bundles can help to facilitate the budget and other approvals required for broad implementation (Luton et al., 2018). Finally, the factors relating to the elderly remain the subject of study, but poor cellular structure leading to vasodilation and damage even at low pressure is a characteristic of aging skin, creating greater risks.
Appraisal
Most studies agree that organized pressure injury prevention interventions can substantially decrease patients’ risks of developing these sores, while also improving patient safety within long-term care facilities (Chung et al., 2022; Wung Buh et al., 2021). Many different interventions can be used, from implementing a pressure injury prevention bundle to conducting hourly rounding and even improving patient education (Richardson et al., 2017). Overall, the recommendation is for nurses to be more proactive regarding implementing evidence-based solutions to improve patient outcomes.
The current state of evidence-based practice justifies the urgency of the pressure injury issue, clearly outlining the rationale for implementing a pressure injury prevention bundle. For example, a recent study shows that bundled interventions may be more effective in decreasing pressure injury rates when compared with isolated or individualized strategies (Gaspar et al., 2019). A bundle integrates several different evidence-based interventions. To reduce pressure injuries, these interventions primarily support using risk assessment, frequent repositioning, prophylactic dressings, and skin care (Gaspar et al., 2019). Many pressure injury prevention bundles have eight components: 1) risk assessment, 2) skin assessment, 3) skin care, 4) mobility/activity management, 5) nutritional management, 6) incontinence management, 7) education and training, and 8) utilization of support surfaces (Yilmazer & Tuzer, 2019). Each of these components has a strong evidence base, offering evidence-based solutions to the issue of pressure injuries. Apart from reducing pressure injuries, such bundles can promote patient wellbeing and improve their quality of life (Mao & Zhu, 2021).
Research also shows that nurses must consider all patients’ multifaceted needs when creating these care plans (Richardson et al., 2017). This includes not only physical needs such as medications and treatments, but also psychological and social needs. Hence, nurses must offer both encouragement and support, promoting a better rapport that enables them to develop a more effective therapeutic relationship (Richardson et al., 2017). In doing this, nurses can better meet their patients’ needs and ensure that patients will comply with their care plans, including any pressure injury prevention strategies that may be incorporated into these plans (Richardson et al., 2017). With the implementation of the pressure injury prevention bundle, nurses can ensure they are adhering to the most recent clinical guidelines in patient care, including those that address these other complex needs. Therefore, the bundle is a proven, effective framework that can be useful in reducing the rates of pressure injuries in older patients admitted to long-term care facilities.
Strengths and Weaknesses
Only the pediatric focused study was peer reviewed and published in a reputable journal, while the other three represented recent doctoral projects. Clearly, research relating to the pressure injury prevention approach for an elderly population is at an earlier stage of conceptual and exploratory level research as there were few clinical studies at a high level of evidence. Much of what was found was conjecture on causes of pressure injuries sustained by elderly patients. For example, Hajhosseini et al. (2020) noted that while pressure injuries occur across all age groups, recent increases in prevalence could be related to the aging of the population and the increased risk of increasing numbers of long-term care residents. While it was repeatedly found that the elderly was mentioned as a risk category, a comprehensive approach to the prevention of pressure injuries in the elderly was limited to just a few studies on nutritional aspects.
Gaps and Limitations
Gaps in the literature were noted in each area outlined in the PICOT question, including fewer studies regarding the use of prevention bundles in long-term care inpatient facilities (LTCF), on the implementation of the program through training and awareness of bedside nurses, concerning the most effective methods for the reduction of pressure injuries, innovations to dramatically improve pressure injuries incidence and outcomes, and relating to challenges of pressure injury prevention in an elderly inpatient population. The pressure injury prevention bundles exist in a variety of heterogeneous and non-comparable forms, and this fragmentation prevents the coordination of data and findings. It is such fragmentation and lack of a coherent framework that impair the goal of higher levels of evidence for practice (John Hopkins Medicine, 2020). Another gap concerns the approach to educating, engaging, and increasing efficacy in nurses delivering bedside care to hospitalized patients at risk of a hospital-acquired pressure injury.
Concepts and Theoretical Framework
The theoretical framework that was used for this project, specifically to implement the pressure injury prevention bundle, was Florence Nightingale’s environmental theory. Under this nursing theory, nursing is considered to be able to change the environment (Mughal & Ali, 2017). Hence, any potential environmental variables contributing to patients’ poor health must be identified and addressed, as this can significantly improve their overall health and wellbeing. For this project, the environmental factors may lead to pressure injuries or put the elderly at increased risk for developing them when they are in long-term care facilities. In this way, pressure injuries can be reduced, subsequently improving patients’ overall safety, care quality, and health outcomes. Nightingale’s theory strengthens the role of nurses in promoting patient safety and reducing the incidence of pressure injuries, as it emphasizes nurses’ contribution to patients’ recovery by changing the clinical environment.
Nightingale’s theory represents the theoretical framework guiding this project. The pressure injury prevention bundle represents a change in the patients’ environment, as current practice at the long-term care facility does not require nurses or other health care providers to use this type of intervention. Instead, although patients are assessed for their fall risk when they are first admitted, there are no ongoing assessments conducted. Furthermore, the facility does not have a bundle that outlines eight different components that need to be integrated into patient care. As Nightingale’s theory explains, these are environmental factors that are putting patients at increased risk for developing pressure injuries. Therefore, the environment within the facility was transformed through implementing the pressure injury prevention bundle.
Project Design
Organization
For this project, a nonrandomized clinical trial was used. The trial examined the implementation of a pressure injury prevention bundle for reducing pressure injuries among older patients in the long-term care facility. There was a pre-test/post-test format, as the pressure injury rate was examined both before and after the intervention was implemented. This study was quantitative, as the pressure injury rate represents a measurable and objective value.
Participants
Participants included all older patients admitted to the long-term care facility when the pressure injury prevention bundle was being implemented. Therefore, a convenience sample was used, which a type of non-probability is sampling where the sample is taken from a group who are easy to reach (Campbell et al., 2020). Inclusion criteria required that all participants be 65 years of age or older, while having been admitted to the long-term care facility for at least 24 hours. Exclusion criteria included any patients who already had a pressure injury when they were admitted. When patients were admitted to CCCC during the three-month period when the pilot study was being undertaken, they were automatically included in the study if they met the inclusion criteria. As they were cared for by the nurses who had received the pressure injury prevention education and training, the recruitment of participants took place during the admission process. It was expected that at least 100 patients would be admitted to CCC meeting the inclusion criteria, enabling them to participate in the pilot study.
Setting
The setting for this project was Cypress Cover Care Center (CCCC) Rehabilitation, which is a 120-bed long-term care facility located in North Florida, specifically Crystal River in Citrus County (CCCC, 2022). The facility has been operating for 35 years, providing many different services, including rehabilitative and post-acute, short- and long-term, skilled nursing, medical management and therapy (CCCC, 2022). Current practices at CCCC for the prevention of pressure injuries involve monitoring, repositioning, and similar standard approaches. The intervention approaches included the documentation of wound status and assessment with printers and cameras where a pressure wound is suspected or forming. The nursing home is rated five stars, with the comment “much above average” on the Medicare Compare Nursing Homes database (Medicare.gov, 2022). Quality indicators provided by the same dataset state that the percentage of “long-stay high-risk residents with pressure ulcers” is just 2.5 percent, far below the national average of 8.2 percent, and the state average of 9.1 percent (Medicare.gov, 2022). As a facility where many of the patients are elderly, recovering from acute health events, or in need of long-term care, many suffer from mobility issues or require bed rest, creating risks for pressure injuries.
Intervention
The intervention was the pressure injury prevention bundle by Yilmazer and Tuzer (2019). Nurses performed a patient risk assessment for pressure injuries, including a skin assessment; additional assessments included those to evaluate patients for mobility, nutrition, and incontinence (Yilmazer & Tuzer, 2019). Patients at risk of developing pressure injures were provided with skin care, while the management of detected conditions also commenced (Yilmazer & Tuzer, 2019). Nurses worked with their interdisciplinary colleagues to determine an optimal set of interventions for effective pressure injury prevention in these participants, with interventions documented in patient charts and electronic health records. This ensured that all nursing staff members were aware of the patient’s individualized pressure injury prevention care plan. The primary outcome measure was the pressure injury rate. No specific instrument or tool was necessary to calculate this measure, as the formula to determine pressure injury rate was instead employed. By measuring the pressure injury rate both before and after the intervention was implemented, these values were compared to determine if there were any changes.
The mechanism driving the intervention was the increased awareness, engagement, and skill level of healthcare professionals delivering bedside care. The independent variable was the intervention, and the dependent variable was the resulting prevalence rate. This was captured as the incident rate per thousand patient days (PTPD), and then expressed as the percentage of patients who experienced a pressure injury during the set term. Possible mediating variables included nurse skill level in the assessment of skin for pressure injuries and level of engagement with the practice implementation.
The nursing staff working at the nursing home received education and training on this pressure injury prevention bundle, representing an educational intervention (Wung Buh et al., 2021; Yilmazer & Tuzer, 2019). The nurses first completed a pre-implementation survey, assessing their current knowledge regarding pressure injury prevention. For the training and education, all nurses working at the facility were required to sign up for mandatory sessions. Before these sessions, the nurses received written information on the pressure injury prevention bundle, explaining the need for this quality improvement project at the nursing home. There were two four-hour training sessions that nurses had to complete, although they were offered online to make it easier for the nurses. Therefore, both written and online material were presented to the nurses, promoting optimal learning. The goal was for the nurses to complete their online training over the two-month period.
Implementation
The project focused on pressure injury prevention, which was implemented at Cypress Cove Care Center (CCCC). It involved providing training and education to clinical staff (specifically the nurses) working at the center, ensuring they had appropriate levels of knowledge about the pressure injury prevention bundle and its evidence-based strategies for preventing pressure injuries in patients. All participants had to be currently employed at CCCC, as the recruitment letter was sent to the facility asking for approval as well as volunteers to receive this education and training. Hence, the sample of participating nurses came from the CCCC.
The implementation of the project and intervention occurred between June 2023 and July 2023. For this teaching project, nurses working at CCC volunteered to receive this education and training intervention. To make it more convenient, two different meeting times were held: 1) 8 am to 12 pm and 2) 8pm to 12 am. This enabled nurses who were working both the morning and evening shifts to sign up for the times that were easier for them to attend. One meeting was held at the end of June 2023 while the second was held at the middle of July 2023, after which the intervention’s training and education was completed.
A nurse educator who volunteered to help in this project was responsible for creating the learning material for the training and education. She was involved in developing the course material for the four-hour training, producing written material for the nurses to learn and be tested on. Written handouts summarizing the training were printed out so they could be given to the participants as well. Before the session commenced, a short pre-implementation survey was handed out, with the participating nurses asked to complete it to the best of their ability. The volunteer nurse educator then conducted the training, using PowerPoints and a lecture format to provide the information to the participating nurses. There was a short 10-minute break at the halfway mark. After the session was complete, the nurse educator also handed out the post-implementation survey for the nurses to fill out.
Budget Plan
For the pressure injury prevention project, the total project budget is $32,570.00. When considering project expenses, salaries and wages take up the majority of the budget. There will be five registered nurses assessing patients for one hour twice weekly at $26.00 per hour, which will total $52.00 a week and $208.00 a month. They will be working for a total of two months, which will total $416.00 for all five nurses. There will also be two advanced registered nurse practitioners who will be diagnosing and treating participants for $150.00 a week or $600.00 a month. Again, this will continue for two months, totaling $1,200.00 in salaries for both ARNPs.
There will also be start-up costs, such as charts and boards that are needed for the project, as these will help in recording and tracking patient progress. It is estimated that charts will cost $200.00, while copies will be about $150.00. Miscellaneous costs will also be included in the budget ($200.00) for a total start-up cost of $550.00. There must also be a supply of support equipment for the patients to prevent pressure injuries. Hardware includes $150.00 along with $1,400.00 for two high-risk, reusable patient beds, which contain foam or fluidized positioners (estimated at $700.00 each). Two other patient beds will also be included in the equipment needed for the project (totaling $500.00). This yields a total capital cost of $2,050.00.
For operational costs, since the project will be implemented within the hospital’s department, electricity, water, sewage, and other utilities will already be paid for by the facility. However, there will be estimated operational costs for the project, including $11,250.00 for the advanced positioning and turning systems for the patients as well as $12,000.00 for non-reusable supplies per patient bed based on need. These include many single-use supplies like Z-Flex fluidized boots as well as sacral and border heel foam dressings. This budget assumes sufficient reusable supplies to provide for at least 15 patients, taking into account the average costs for non-reusable supplies per patient bed. Overall, this total is projected to be about $23,250.00. For the total project expenses, it is estimated to cost $32,570.00.
For the project revenue, donors will be expected to provide roughly $3,000.00, while the hospital and other private foundations may donate up to $33,500.00. This totals $38,000.00 in revenue, as the patient care will be free. When considering that the total estimated project expenses is $32,570.00, this yields a Total Program Benefit/Loss of $5,430.00. Hence, with the external and internal funding, there will be over five thousand extra dollars to cover any unexpected expenses that may arise.
Project Expenses
Salaries/Wages* Monthly Total
Registered Nurse 1
Registered Nurse 2
Registered Nurse 3
Registered Nurse 4
Registered Nurse 5
ARNP 6
ARNP 7

Total Salary Costs: $ 208.00
$ 208.00
$ 208.00
$ 208.00
$ 208.00
$ 600.00
$ 600.00

$ 2,240.00 $ 416.00
$ 416.00
$ 416.00
$ 416.00
$ 416.00
$ 1200.00
$ 1200.00

$ 4,480.00
TOTAL FOR BOTH: Total $ 6,720.00
Start Up Costs:

Total Start Up Costs
Charts
Copies
Miscellaneous
$ 200.00
$ 150.00
$ 200.00

Total $ 550.00

Capital Costs
Hardware
Equipment

Total Capital Costs Tool
High Risk Patient bed x2
For high-risk bed
For high-risk bed $ 150.00
$ 1,400.00
$ 300.00
$ 200.00

Total $ 2,050.00

Operational Costs

Advanced positioning and turning systems
Non-reusable supplies per patient bed based on need
$ 11,250.00

$ 12,000.00

Total Operational Costs Total $ 23,250.00
TOTAL PROJECT EXPENSES Total $ 32,570.00

Project Revenue**
Revenue Generation

Total Project Revenue
Charities
Facility
$ 3,000.00
$ 35,000.00

Total $ 38,000.00

Program Benefit/Loss
Total Revenue $ 38,000.00
Less Expenses $ 32,570.00
Total Program Benefit/Loss $ 5,430.00 (Positive)

Data Collection
Data were collected by the nurses working in the nursing home, as they were the ones implementing the pressure injury prevention bundle. This integrated the Braden Assessment, which is a scale nurses frequently use to screen patients for pressure injuries (Al Aboud & Manna, 2021). It evaluates six of the most common risks for developing pressure injuries, such as moisture, mobility, activity, sensory perception, nutrition, and friction/shear (Al Aboud & Manna, 2021; Coleman et al., 2018). For the participants enrolled in the study, they were assessed daily with the Braden Assessment, with the nurses examining their skin for any potential signs of pressure injuries. The data collected was each participant’s skin assessment results, which will be entered into the nursing home’s electronic health record system.
Other data were also collected, specifically in regard to the facility’s pressure injury rate. This required information from the electronic health record system to be evaluated, determining how many patients had developed pressure injuries while residing in the facility. As the pilot study commenced for a period of three months, the three months before the intervention was implemented was examined. This provided a baseline (pre-intervention), measuring the pressure injury rate. Additionally, in order to determine the intervention’s sustainability in the long-term, there was post-intervention data collected for three months after the pilot study ended. Overall, the data included nine months of pressure injury rates: three months pre-intervention, three months of the intervention, and three months post-intervention. Specifically, the number of patients who developed pressure injuries each month was measured. The data were collected by the lead researcher and the statistician, as they reviewed the facility’s electronic health records.
There were also data collected on the nurses, as they were the target population receiving the educational intervention. All participants completed a pre-implementation survey, which determined their current level of knowledge regarding preventing pressure injuries in patients. This enabled process variables to be evaluated, ensuring that the training and education the participants received within this project were sufficient. Specifically, after the participants finished the education and training, they also completed another similar survey. With both surveys available, the researcher was able to compare the two, determining if there was a difference in nurses’ knowledge regarding preventing pressure injuries. The intervention launch occurred between June 2023 and July 2023.
Data Collection Plan
The data were collected by the researcher in April and May, 2023. First, the data gathered pertained to the process variables, with the researcher examining the knowledge surveys that the participating nurses completed. Specifically, nurses were expected to improve upon their skills in pressure injury detection, assessment, and grading. This survey was taken at two different time points: 1) before the nurses took the education and training on the pressure injury prevention bundle, as well as 2) after completing the education and training at CCCC. The objective of this project was to reduce both the incidence of pressure injuries by 20% as well as the rate of incidence per 1,000 patient days (PTPD) (Gupta et al., 2020; Hubig et al., 2020). The Agency for Healthcare Research and Quality (AHRQ, 2017) explains that the pressure injury rate can be calculated through counting the number of patients who were admitted to a unit during a certain period. After finding this value, the number of patients who have a new pressure injury must be divided by this value (i.e., total number of admitted patients) (AHRQ, 2017). Hence, data were also collected on outcome variables, including how many patients developed pressure injuries at CCCC. Therefore, the pertinent data for both process and outcome variables were collected at CCCC.
Specifically, CCCC’s electronic health records were reviewed, as the facility kept meticulous records on patients. This required additional approval from the facility, as the patient histories and records had to be examined. However, no identifying information was reviewed, protecting the privacy of the patients. After gathering the pertinent information and appraising it, the researcher was able to determine previous pressure injury rates at CCC (before the intervention was implemented), while also examining these rates after implementing the project. With both sets of raw data, the researcher could then compare the two different time points, determining if there was any change in the rate of pressure injuries at CCC following the nurses receiving the education and training intervention.
Permissions
IRB approval was obtained before starting this project, with the researcher requesting approval from the university. Permission was also be obtained from Cypress Cove Rehabilitation to use this site. All ethical principles and standards for human research were upheld. When conducting research with human subjects, various ethical principles that must be followed include maintaining privacy and confidentiality (Nusbaum et al., 2017). Therefore, this study kept all participants’ information confidential, preventing any unauthorized access. All data was safely stored on an external hard drive that does not have access to the Internet, while it was also password protected. To promote participants’ privacy, their information was de-identified, using only their initials within the study. While the long-term care facility does have access to other sensitive information, such as patients’ addresses, dates of birth, and other health records, these were not be examined. Finally, as the participants were patients in the facility, informed consent was not required.
Data Analysis and Results
Evaluation
The evaluation phase began with the educational intervention for the nurses, where the evaluation method involved the use of the Pieper Pressure Ulcer Knowledge Test. This is a 72-item survey that measures knowledge regarding pressure injuries, specifically how to treat and manage them within clinical settings. The nurses took this survey two times: pre-testing (at baseline) and post-testing. To evaluate if the nurses’ knowledge levels increased after receiving the educational intervention, the pre-survey scores were compared to the post-survey scores. An improvement in scores indicates that the educational intervention and training was a success.
Another part of the evaluation involves the patient intervention, with the bedside nurses applying the pressure injury prevention bundle’s evidence-based strategies when caring for patients at the nursing home. The pressure injury rate for the long-term care facility was measured to evaluate the pressure injury prevention bundle. This was the primary outcome measure, measured as the number of older patients developing pressure injuries after being admitted to the long-term care facility. According to the Agency for Healthcare Research and Quality (AHRQ, 2017), this rate can be calculated by counting the number of patients admitted to a unit during a specific period. Then, the number of patients with a new pressure injury (of any stage) must be divided by the total number of admitted patients (AHRQ, 2017). The pressure injury rate before the intervention’s implementation can then be compared to the pressure injury rate after its implementation. The difference between pre- and post-intervention pressure injury rates represented a critical measure of success in the proposed activity. There was expected to be at least a 10% reduction in the pressure injury rate in the long-term care facility. Data analytical software was also used to evaluate the change between the pre- and post-test intervention.
Data Analysis
For the data analysis, the survey, patient data, and other collected data was summarized and organized, enabling the research questions to be answered. Specifically, a learning tool was employed for the five bedside nurses working at the long-term care/subacute facility, enabling them to learn about evidence-based strategies to reduce the risk of patients developing pressure injuries. The Pieper Pressure Ulcer Knowledge Test was employed to evaluate the nursing staff’s knowledge on pressure injury prevention, wound description, and staging, with a total of 72 items that nurses must answer (Agency for Healthcare Research and Quality, 2017b). This survey was conducted both pre- and post-intervention, enabling the nurses’ knowledge to be compared both before and after implementing the educational intervention. The findings from this survey were then analyzed using SPSS software, with both descriptive and inferential statistics calculated.
Additionally, data were analyzed from the pressure injury prevention intervention as well. Specifically, the pressure injury rates from both pre- and post-intervention for patients were determined. According to the Agency for Healthcare Research and Quality (2017a), the pressure injury rate is calculated by counting how many patients developed a new pressure injury during a specific period, then dividing that value by how many patients were admitted to the unit during that time. The data includes a total of nine months of pressure injury rates, with three months during pre-intervention, three months during the actual implementation of the intervention, and three months during post-intervention. Again, pressure injury rate data were analyzed using SPSS software – as with the survey data regarding nurses’ knowledge – with both descriptive and inferential statistics employed.
Results
In Table 1, the results of the nurse survey, both pre- and post-intervention, are depicted for the five nurse participants in the study. The values correspond to the percentage of nurses who answered the question correctly. As can be seen, the nurses scored an average of 70.8% during the pre-survey, when they took the Pieper Pressure Ulcer Knowledge Test before receiving the educational intervention. However, after receiving the education and training on pressure injuries, the post-survey score increased to an average of 98.1%, which represents a 27.3% increase in knowledge. Therefore, the results clearly indicate that the educational intervention was a success, leading to more than a quarter percent improvement (with more nurses answering the survey questions correctly).
Table 1
Results of DNP Project: Pieper Pressure Ulcer Knowledge Test
QUESTION Pre-Survey Post-Survey

1. Slough is yellow or cream-colored necrotic /devitalized tissue on a wound bed. 67 97
2. A pressure injury/ulcer is a sterile wound. 87 99
3. Foam dressings increase the pain in the wound. 72 98
4. Hot water and soap may dry the skin and increase the risk for pressure injury/ulcers. 82 99
5. Chair-bound persons should be fitted for a chair cushion. 65 96
6. A Stage 3 pressure injury/ulcer is a partial thickness skin loss involving the epidermis and/or dermis. 73 99
7. Hydrogel dressings should not be used on pressure injury/ulcers with granulation tissue. 52 97
8. A person confined to bed should be repositioned based on the individual’s risk factors and the support surface’s characteristics. 67 94
9. A pressure injury/ulcer scar will break down faster than unwounded skin. 63 95
10. Pressure injury/ulcers progress in a linear fashion from Stage 1 to 2 to 3 to 4. 45 93
11. Eschar is healthy tissue. 90 99
12. Skin that doesn’t blanch when pressed is a Stage 1 pressure injury/ulcer. 78 99
13. The goal of palliative care is wound healing. 85 98
14. A Stage 2 pressure injury/ulcer is a full thickness skin loss. 46 95
15. Dragging the patient up in bed increases friction. 95 100
16. Small position changes may need to be used for patients who cannot tolerate major shifts in body positioning. 84 99
17. Honey dressings can sting when initially placed in a wound. 63 97
18. An incontinent patient should have a toileting care plan. 98 100
19. A pressure redistribution surface manages tissue load and the climate against the skin. 79 98
20. A Stage 2 pressure injury/ulcer may have slough in its base. 57 96
21. If necrotic tissue is present and if bone can be seen or palpated, the ulcer is a Stage 4. 64 98
22. When possible, high-protein oral nutritional supplements should be used in addition to usual diet for patients at high risk for pressure injury/ulcers. 78 99
23. The home care setting has unique considerations for support surface selection. 61 97
24. When necrotic tissue is removed, an unstageable pressure injury/ulcer will be classified as a Stage 2 injury/ulcer. 54 98
25. Donut devices/ring cushions help to prevent pressure injury/ulcers. 86 99
26. A specialty bed should be used for all patients at high risk for pressure injury/ulcers. 83 99
27. Foam dressing may be used on areas at risk for shear injury. 92 99
28. Persons at risk for pressure injury/ulcers should be nutritionally assessed (i.e., weight, nutrition intake, blood work). 91 100
29. Biofilms may develop in any type of wound. 63 98
30. Critical care patients may need slow, gradual turning because of being hemodynamically unstable. 86 99
31. Blanching refers to whiteness when pressure is applied to a reddened area. 94 100
32. A blister on the heel is nothing to worry about. 54 99
33. Staff education alone may reduce the incidence of pressure injury/ulcers. 32 96
34. Early changes associated with pressure injury/ulcer development may be missed in persons with darker skin tones. 57 98
35. A footstool/footrest should not be used for an immobile patient whose feet do not reach the floor. 62 97
36. Deep tissue injury (DTI) may be difficult to detect in individuals with dark skin tones. 75 99
37. Bone, tendon, or muscle may be exposed in a Stage 3 pressure injury/ulcer. 87 98
38. Eschar is good for wound healing. 71 99
39. It may be difficult to distinguish between moisture associated skin damage and a pressure injury/ulcer. 85 98
40. Wounds that become chronic are frequently stalled in the inflammatory phase of healing. 65 99
41. Dry, adherent eschar on the heels should not be removed. 87 99
42. Deep tissue injury is a localized area of purple or maroon discolored intact skin or a blood-filled blister. 85 99
43. Massage of bony prominences is essential for quality skin care. 54 95
44. Poor posture in a wheelchair may be the cause of a pressure injury/ulcer. 89 100
45. For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals. 92 100
46. Patients who are spinal cord injured need knowledge about pressure injury/ulcer prevention and self-care. 89 99
47. In large and deep pressure injury/ulcers, the number of dressings used needs to be counted and documented so that all dressings are removed at the next dressing change. 86 98
48. A mucosal membrane pressure injury/ulcer is found on mucous membrane as the result of medical equipment used at that time on that location; this pressure injury is not staged. 79 98
49. Pressure injury/ulcers can occur around the ears in a person using oxygen by nasal cannula. 79 100
50. Persons, who are immobile and can be taught, should shift their weight every 30 minutes while sitting in a chair. 56 98
51. Stage 1 pressure injury/ulcers are intact skin with non-blanchable erythema over a bony prominence. 89 100
52. When the ulcer base is totally covered by slough, it cannot be staged. 37 96
53. Selection of a support surface should only consider the person’s level of pressure injury/ulcer risk. 48 98
54. Shear injury is not a concern for a patient using a lateral-rotation bed. 46 99
55. It is not necessary to have the patient with a spinal cord injury evaluated for seating. 54 98
56. To help prevent pressure injury/ulcers, the head of the bed should be elevated at a 45-degree angle or higher. 65 100
57. Urinary catheter tubing should be positioned under the leg. 57 98
58. Pressure injury/ulcers may be avoided in patients who are obese with use of properly sized equipment. 89 99
59. A dressing should keep the wound bed moist, but the surrounding skin dry. 73 98
60. Hydrocolloid and film dressings must be carefully removed from fragile skin. 65 99
61. Nurses should avoid turning a patient onto a reddened area. 56 96
62. Skin tears are classified as Stage 2 pressure injury/ulcers. 43 97
63. A Stage 3 pressure injury/ulcer may appear shallow if located on the ear, malleolus/ankle, or heel. 67 99
64. Hydrocolloid dressings should be used on an infected wound. 42 98
65. Pressure injury/ulcers are a lifelong concern for a person who is spinal cord injured. 59 97
66. Pressure injury/ulcers can be cleansed with water that is suitable for drinking. 89 99
67. Alginate dressings can be used for heavily draining pressure injury/ulcers or those with clinical evidence of infection. 76 99
68. Deep tissue injury will not progress to another injury/ulcer stage. 92 100
69. Film dressings absorb a lot of drainage. 57 98
70. Non-sting skin prep should be used around a wound to protect surrounding tissue from moisture. 54 97
71. A Stage 4 pressure injury/ulcer never has undermining. 65 96
72. Bacteria can develop permanent immunity to silver dressings. 89 99
    70.77777778 98.0972222 For Nurse 1, their pre-test score was 30/72 (missing 42 questions), giving them a score of 41.7%. However, their post-test score was 67/72 (only missing 5 questions), for a total score of 93.1%. This represented an improvement of 51.4%. For Nurse 1, their pre-test score was 27/72 (missing 45 questions), yielding a score of 37.5%. Again, they improved significantly on the pre-test score, with a 66/72 (missing 6 questions) for a score of 91.7%. Their improvement was 54.2%. For Nurse 3, their pre-test score was 33/72 (missing 39 questions) for a total score of 45.8%, while their post-test score was a 70/72 (only missing 2 questions) for a score of 97.2%. Again, this indicates an improvement of 51.4%. For Nurse 4, their pre-test score was 39/72 (missing 33 questions), for a score of 54.2%. However, their post-test score was 67/72 (only missing 5 questions), for a score of 93.1%, which indicates an improvement of 38.9%. Finally, for Nurse 5, their pre-test score was 50/72 (missing 22 questions), for a score of 69.4% (which is the highest of the five nurses). In their post-score, their score was 68/72 (only missing 4 questions), for a total score of 94.4%. Their improvement was 25%. See Table 2 for the results, including the average scores among all five nurse participants for the pre-test (49.7%) compared to the post-test (93.9%).
    Table 2
    Results of Participants’ Pieper Pressure Ulcer Knowledge Test Scores (pre- and post-test)
    Nurse 1 Nurse 2 Nurse 3 Nurse 4 Nurse 5 Average Score
    Pre-Test Score 41.70% 37.50% 45.80% 54.20% 69.40% 49.72%
    Post-Test Score 93.10% 91.70% 97.20% 93.10% 94.40% 93.90%

Sustainability
To support the sustainability of the project over time, training and education must be provided to the nurses utilizing this pressure injury prevention bundle, with yearly continuing education. They need to receive this to improve their knowledge and skills regarding managing and preventing pressure injuries. Subsequently, they can improve their compliance with the prevention bundle, enabling the pressure injury rate to continue to be decreased. Therefore, a requirement of nurses’ continued employment will be for them to participate in yearly training and education on the pressure injury prevention bundle. This will ensure that any newly hired nurses are aware of the pressure injury prevention bundle, while also allowing existing nurses to regularly review this intervention.

Relationship of Results
Framework
The theoretical framework employed for this DNP project was Florence Nightingale’s environmental theory. It argues that nursing can change the environment, as they identify and address any environmental variable that may contribute to the poor health of a patient (Mughal & Ali, 2017). As the focus of this DNP project was on preventing pressure injuries, there are environmental factors that put older adults at greater risk of developing these injuries, especially when residing in long-term care facilities. Therefore, by nurses making changes to the environment – such as implementing pressure injury prevention strategies –patients’ health and safety can be supported.
Additionally, Nightingale’s environmental theory guided this DNP project. By creating and establishing the pressure injury prevention bundle, a set of evidence-based best practices were compiled into an intervention plan, which was then implemented within the facility. The results of the project clearly show that through providing an educational intervention to the bedside nurses caring for these elderly patients, there was a decrease in the development of pressure injuries. Furthermore, this educational intervention increased the nurses’ knowledge deficits, which was a primary goal of the project.
Aims and Objectives
The project had a clear aim: reduce the risk of developing pressure injuries in older patients (65 years of age and older) admitted to a 120-bed long-term care/subacute facility in Citrus County, Florida. The first objective was to create an educational intervention for nurses working in these facilities, enabling them to learn about evidence-based methods for preventing pressure injuries. Specifically, the nurses involved were those at the bedside of patients, with the educational intervention focused on teaching them not only the etiology of pressure injuries, but how to manage them. The goal was for there to be an average of 90% (minimum of 75%) score on the survey, indicating an increase in nurses’ knowledge deficits following the implementation of the project.
Strengths and Limitations of Project
Strengths
Overall, the DNP project was a success. Many things went right with this project, including the results – as they met the project’s outlined aim and objectives. The bedside nurses at CCCC were able to significantly increase their knowledge regarding pressure injury prevention strategies, learning how to care for patients who had diagnosed pressure injuries while also implementing prevention strategies to help reduce the risk of these sores developing in patients/residents living in the facility.
One of the strengths of the project was that quantitative data were collected and analyzed. Specifically, the Pressure Ulcer Knowledge Test survey was conducted, which measured the objective knowledge of nurses both before and after receiving an educational intervention. Additionally, the pressure injury rate of patients also represents quantitative data. Research incorporating quantitative information requires researchers to utilize a systematic approach when examining observable events or occurrences, as these types of studies focus on collecting and analyzing objective or numerical information in an effort to prove or refute a hypothesis (Bloomfield & Fisher, 2019; Zyphur & Pierides, 2019). In comparison, qualitative data concentrates more on textual and subjective information, such as participants’ perspectives or experiences (Bloomfield & Fisher, 2019). Therefore, as this DNP project used quantitative data collection and analysis procedures, the findings are likely to have greater reliability, while also being more accurate compared to if qualitative data had been the focus (Zyphur & Pierides, 2019).
Limitations
Unfortunately, there were also limitations associated with this DNP project. Again, as it employed quantitative data, the findings may be narrower in concentration, as the focus was on more extensive trends (Puhl, 2020). While the project’s choice of methodology and research design may have offered objective findings on how an educational intervention can improve nursing knowledge – with this increase in knowledge subsequently reducing pressure injury development in patients the nurses care for – there were limited insights into how the nurses felt about this intervention. As Puhl (2020) explains, quantitative data collection and analysis may be preferred for larger sample sizes and many different data sets. Therefore, since there was no qualitative data examined, the researcher cannot make assumptions regarding how satisfied the nurses in the unit were with the educational intervention (or get feedback on how this intervention could have been improved for future applications).
Additionally, there were some issues identified with the implementation of the educational intervention. Specifically, it was more difficult than expected to get all bedside nurses signed up to take the intervention, which was required for them to learn the pressure injury prevention bundle that integrated several different, evidence-based strategies for preventing and managing pressure injuries in elderly patients. There were scheduling problems with some of the bedside nurses, causing this phase to take longer than projected.
Maintaining Success for the Project
The project will maintain its success by undergoing regular evaluation, ensuring that it continues to meet its objectives and goals. This will include reviewing the results from the nurses’ scores on the Pieper Pressure Ulcer Knowledge Test as well as the facility’s pressure injury rate. The goal is for nurses to maintain their knowledge and skills regarding preventing and caring for pressure injuries, which will subsequently reduce the pressure injury prevention rate. Nurses will be asked to complete a survey on their satisfaction with the educational intervention and pressure injury prevention bundle, providing feedback on the project. This feedback will be carefully reviewed, making any improvements to these interventions as needed to ensure they are effective in the long term.
Recommendations and Implications for Future Practice
Based on the limitations of the DNP project, it is recommended that future projects exploring this phenomenon utilize mixed methods research designs, as these combine both quantitative and qualitative data collection and analysis procedures. It is still necessary to gather quantitative data on the nurses’ survey scores (indicating knowledge on pressure injury prevention) as well as the facility’s pressure injury rate (suggesting that this nursing knowledge was successfully applied to reduce the risk of patients developing pressure injuries). Nonetheless, by integrating a qualitative element, the nurses’ satisfaction with the educational intervention could have been explored as well. This subjective, qualitative data would provide greater insights into how the nurses accepted (or did not accept) the need to engage in ongoing education and training, while also giving them opportunities to make suggestions for future training sessions. Therefore, future research projects may need to carefully assess what additional data may be gathered in order to increase the researcher’s understanding of this clinical practice issue.
Additionally, it is recommended that the pressure injury prevention bundle be implemented within the long-term care/subacute facility, as the educational intervention phase has been completed. The pilot study for this evidence-based bundle of strategies to prevent (or reduce) the risk of patients developing pressure injuries while residing in a long-term care facility setting is ready to be introduced. The researcher has already gathered and analyzed the data from the educational intervention’s implementation; now, the next step is to implement the pressure injury prevention bundle. In doing so, the application of this nursing knowledge can be investigated, determining if the nursing staff at the facility are able to successfully utilize these strategies with their patients (integrating the bundle and its evidence-based practices into nursing practice). Finally, it is recommended that the data collected from this last phase be analyzed using SPSS software as well, comparing pressure injury rates in the facility (both pre- and post-intervention).
There are also significant implications associated with this DNP project. For example, as the pre- and post-survey data analysis indicates, the nurses in the facility were able to increase their knowledge through the educational intervention. Their scores on the Pieper Pressure Ulcer Knowledge Test increased by over one quarter percentage points, which provides evidence in support of the effectiveness of the educational intervention. Hence, the Agency for Healthcare Research and Quality’s (2017b) tools and resources for teaching about preventing pressure injuries can be considered beneficial for nurses and nurse educators alike. In future research studies and/or DNP projects, these tools may also be employed, as they were developed through the use of the most recent, evidence-based best practices. Additionally, future research inquiries into preventing and/or reducing pressure injury rates in patients may also consider the implementation of a pressure injury prevention bundle, as it incorporates many different evidence-based strategies.
Furthermore, the findings of this DNP project can also be applied to future clinical practice. Advanced practice nurses, especially those that are DNP-prepared, must embody the role of change leaders. This refers to not only leading quality improvement initiatives within their workplaces, but also communicating with colleagues and management regarding ways to ensure continuous improvement. Pressure sores are one of the most common hospital-acquired injuries/infections that patients may develop, especially vulnerable populations like elderly adults, who are already suffering with reduced immune systems and other aging-related physical and/or mental/cognitive impairments. For those DNP-prepared nurses who work in long-term care facilities, pressure injuries are to be expected, unfortunately. However, based on this project and its findings, nursing staff can be adequately trained and educated, which can subsequently lead to reductions in these types of injuries. Therefore, within clinical practice, nurses can employ these pressure injury prevention strategies in an effort to reduce this risk, resulting in significant improvements in not only patient health outcomes, but also quality of care provided.
Contribution of Study to DNP Essentials
The American Association of Colleges of Nurses (2006) lists the DNP essentials for advanced nursing practice. Several of these essentials were met through the DNP project, especially Essential I: Scientific Underpinnings for Practice. The author engaged in scientific research, focusing on a common nursing practice issue (i.e., pressure injuries) and developing a quality improvement project to address this problem. Two other essentials met were Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes as well as Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health. Through this pressure injury prevention project, the author was able to improve the health of patients at their workplace, as the project helped to prevent illness and injury within the target population.
Dissemination Plan and Rationale
Dissemination is planned for three distinct audiences: the debriefing of participants, the broader nursing community, and publication for wide access. A one-page summary of the findings and conclusions and a conference poster will be prepared for the dissemination of research results. The debriefing of participants will include a presentation at the research site (CCCC) and the posting of the conference poster with research findings in a staff area. A webinar will be developed for dissemination at the nursing association level, which offers regular webinars on research and practice issues (American Association of Colleges of Nursing [AACN], 2022). The final report of the project will also either be submitted to a nursing research repository (Kesten & Hoover, 2022) or be submitted for publication in a nursing research journal. This will ensure that the results can be accessed by any researcher with an interest in the topic.
Additionally, the one-page summary of the findings/conclusions and the conference poster will also be presented to NKU, while the poster will be submitted at various nursing conferences in the area. This will ensure that the nursing community is aware of this project and its findings, enabling them to be more successfully disseminated. The Florida Nurses Association (FNA, 2021) holds an Annual Nursing Research & Evidence-Based Practice Conference, which enables nursing research along with evidence-based practice improvement projects to be disseminated throughout the state. To participate in the conference, a poster must be created on the project (FNA, 2021). There are numerous benefits to presenting this project at the conference, as it will promote collaboration and networking with other nurse researchers, obtaining feedback from nursing peers that may enhance future research work (FNA, 2021).
When considering publication submission, the final manuscript will be published in Elsevier’s Journal of Tissue Viability. This journal was chosen because its audience encompasses numerous health care providers, including those who treat and manage wounds such as pressure injuries (Patton, 2022). The journal is interprofessional, with providers from many different specialties in nursing and medicine. Additionally, the journal articles it publishes focus on health issues that are of concern to advanced practice nursing, with the journal being a center for research activity on a plethora of medical topics. Furthermore, the Journal of Tissue Viability only publishes certain studies, such as research and clinical studies, reviews, and case studies associated with tissue viability (Elsevier, 2022). Therefore, with the completion of the DNP project, the author will write a manuscript detailing the project, sending it to the journal for publication and, subsequently, dissemination.
With the Journal of Tissue Viability, there are specific written dissemination guidelines for authors. Specifically, authors are encouraged to first contact the editor of the journal before presenting their manuscripts, enabling the editor to ascertain if the research topic is relevant and able to be published (Elsevier, 2022). While there is no specified structure for the paper, it should be separated into sections that explain the methodology and results of the study, with an estimated word count of between 3,000 and 4,000 words (Elsevier, 2022). All manuscripts must also include a 200- to 250-word summary, while identifying five keywords (Elsevier, 2022). Authors must declare any competing interests, with ethical considerations outlined if the study used humans as participants (Elsevier, 2022). Furthermore, authors must employ consistent formatting within the manuscripts, although a specific format like APA is not required; however, DOIs should be included in all resources, if available (Elsevier, 2022).

References
Agency for Healthcare Research and Quality. (2017a). Module 5: How to measure pressure
injury rates and prevention practices. https://www.ahrq.gov/patient-safety/settings/ hospital/resource/pressureinjury/workshop/guide5.html
Agency for Healthcare Research and Quality. (2017b). Preventing Pressure Ulcers in Hospitals.
https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/ pu7a.html
Al Aboud, A. M., & Manna, B. (2021). Wound Pressure Injury Management. StatPearls
Publishing.
Al-Otaibi, Y. K., Al-Nowaiser, N., & Rahman, A. (2019). Reducing hospital-acquired pressure injuries. BMJ open quality, 8(1), e000464. https://doi.org/10.1136/bmjoq-2018-000464
American Association of Colleges of Nurses. (2006). The Essentials of Doctoral Education for Advanced Nursing Practice. https://www.aacnnursing.org/portals/42/publications/ dnpessentials.pdf
American Association of Colleges of Nursing. (2022). Featured Webinars. https://www.aacnnursing.org/Professional-Development/Online-Learning/Webinars
Bloomfield, J., & Fisher, M. J. (2019). Quantitative research design. Journal of the
Australasian Rehabilitation Nurses Association, 22(2), 27-30. https://search. informit.org/doi/10.3316/informit.738299924514584
Campbell, S., Greenwood, M., Prior, S., Shearer, T., Walkem, K., Young, S., Bywaters, D., &
Walker, K. (2020). Purposive sampling: complex or simple? Research case examples.
Journal of research in nursing : JRN, 25(8), 652–661. https://doi.org/10.1177/1744987 120927206
Chung, M. L., Widdel, M., Kirchhoff, J., Sellin, J., Jelali, M., Geiser, F., Mücke, M., & Conrad,
R. (2022). Risk factors for pressure injuries in adult patients: A narrative synthesis.
International Journal of Environmental Research and Public Health, 19(2), 761. https:// doi.org/10.3390/ijerph19020761
Coleman, S., Smith, I. L., McGinnis, E., Keen, J., Muir, D., Wilson, L., Stubbs, N., Dealey, C.,
Brown, S., Nelson, E. A., & Nixon, J. (2018). Clinical evaluation of a new pressure ulcer
risk assessment instrument, the Pressure Ulcer Risk Primary or Secondary Evaluation
Tool (PURPOSE T). Journal of advanced nursing, 74(2), 407–424. https://doi.org/ 10.1111/jan.13444
Cox, J., Schallom, M., & Jung, C. (2020). Identifying risk factors for pressure injury in adult
critical care patients. American Journal of Critical Care, 29(3), 204-213. https://doi.org/10.4037/ajcc2020243
Cypress Cove Care Center. (2022). About us. https://cypresscovecare.com/about-us/
Davland, S., Ebadi, A., & Gheshlagh, R.G. (2018). Nurses’ knowledge on pressure injury
prevention: A systematic review and meta-analysis based on the Pressure Ulcer Knowledge Assessment Tool. Clinical, Cosmetic and Investigational Dermatology, 11, 613-620. https://doi.org/10.2147/CCID.S186381
de Bengy, A. F., Lamartine, J., Sigaudo‐Roussel, D., & Fromy, B. (2022). Newborn and elderly skin: two fragile skins at higher risk of pressure injury. Biological Reviews, 97(3), 874-895. https://doi.org/10.1111/brv.12827
Elsevier. (2022). Guide for Authors. https://www.elsevier.com/journals/journal-of-tissue-viability/0965-206X/guide-for-authors
The Florida Nurses Association. (2021). 7th Annual Nursing Research & Evidence-Based
Practice Conference. https://www.floridanurse.org/page/ResearchConference-2021
Gaspar, S., Peralta, M., Marques, A., Budri, A., & de Matos, M.G. (2019). Effectiveness on
hospital-acquired pressure ulcers prevention: A systematic review. International Wound Journal, 16, 1087-1102. https://doi.org/10.1111/iwj.13147
Gupta, P., Shiju, S., Chacko, G., Thomas, M., Abas, A., Savarimuthu, I., Omari, E., Al-Balushi, S., Jessymol, P., Mathew, S., Quinto, M., McDonald, I., & Andrews, W. (2020). A quality improvement programme to reduce hospital-acquired pressure injuries. BMJ open quality, 9(3), e000905. https://doi.org/10.1136/bmjoq-2019-000905
Hajhosseini, B., Longaker, M. T., & Gurtner, G. C. (2020). Pressure injury. Annals of surgery,
271(4), 671-679. https://doi.org/10.1097/SLA.0000000000003567
Halecka, D. (2020). Development and Evaluation of a Clinical Nurse Specialist-Driven Pressure
Injury Prevention Bundle in a Community Hospital. Wilmington University (Delaware). https://www.proquest.com/openview/809c02019fba6ecd0629b9944da355d9/1?pq-origsite=gscholar&cbl=18750&diss=y
Haynes, L. (2020). Aging of the immune system: Research challenges to enhance the health
span of older adults. Frontiers in Aging, 1, 602108. https://doi.org/10.3389/fragi.2020. 602108
Hubig, L., Lack, N., & Mansmann, U. (2020). Statistical process monitoring to improve quality assurance of inpatient care. BMC health services research, 20(1), 1-14. https://doi.org/10.1186/s12913-019-4866-7
John Hopkins Medicine. (2020). Johns Hopkins Nursing Evidence-Based Practice Appendix C: Evidence Level and Quality Guide. https://www.hopkinsmedicine.org/evidence-based-practice/docs/appendi x_c_evidence_level_quality guide.pdf
Jones, D. (2021). Documenting Operating Room RNs’ Effectiveness to Prevent Hospital Acquired Pressure Injuries (HAPI) after a HAPI Workshop: A Qualitative Case Study (Doctoral dissertation, Northcentral University). https://www.proquest.com/openview/7d8a51b14789d3bd53497c8227d6c8ea/1?pq-origsite=gscholar&cbl=18750&diss=y
Kesten, K. S., & Hoover, S. N. (2022). Doctor of nursing practice scholarship dissemination through an open access repository. Journal of Professional Nursing, 41, 19-25. https://doi.org/10.1016/j.profnurs.2022.03.010
Kimsey, D. B. (2019). A change in focus: shifting from treatment to prevention of perioperative
pressure injuries. AORN journal, 110(4), 379-393. https://europepmc.org/article/med/
33048828
Kriesberg, C. P., Little, J. M., Mohr, L., & Kato, K. (2018). Reducing pressure injuries in a
pediatric cardiac care unit: a quality improvement project. Journal of Wound Ostomy &
Continence Nursing, 45(6), 497-502. https://doi.org/10.1097/WON.0000000000000477
Kumta, N., Coyer, F., & David, M. (2018). Perioperative factors and pressure ulcer
development in postoperative ICU patients: A retrospective review. Journal of Wound Care, 27(8), 475-485. https://doi.org/10.12968/jowc.2018.27.8.475
Lavallée, J. F., Gray, T. A., Dumville, J., & Cullum, N. (2019a). Preventing pressure ulcers in nursing homes using a care bundle: a feasibility study. Health & social care in the community, 27(4), e417-e427. https://doi.org/10.1111/hsc.12742
Lavallée, J. F., Gray, T. A., Dumville, J. C., & Cullum, N. (2019b). Preventing pressure injury in nursing homes: developing a care bundle using the Behaviour Change Wheel. BMJ open, 9(6), e026639.
Luton, A., Stewart, D., Steward-Scott, M., Mullen, J. … & Jones, A. (2018). Evidence-Based Skin Champion Program Reduces Pressure Injuries in a Pediatric Hospital. Journal of Nursing & Interprofessional Leadership in Quality & Safety, 2(1), 1-11. https://digitalcommons.library.tmc.edu/uthoustonjqualsafe/vol2/iss1/2
Medicare.gov. (2022). Cypress Cove Care Center. https://www.medicare.gov/care-compare/details/nursing-home/105437?city=Crystal%20River&state=FL&zipcode=
Moran, K., Burson, R, Critchett, J., & Olla, P., (2011). Exploring the cost and clinical outcomes
of integrating the registered nurse certified diabetes educator in the patient centered
medical home. The Diabetes Educator, 37 (6), 780-793.
Moran, D., Wu, A. W., Connors, C., Chappidi, M. R., Sreedhara, S. K., Selter, J. H., & Padula,
W. V. (2020). Cost-Benefit Analysis of a Support Program for Nursing Staff. Journal of
patient safety, 16(4), e250–e254.
Mughal, F.B. & Ali, B.H. (2017). Enhancing patient well-being: Applying environmental
theory in nursing practice. Annals of Nursing and Practice, 4(3), 1085. https://www.jscimedcentral.com/Nursing/nursing-4-1085.pdf
National Pressure Injury Advisory Panel. (2021). 2021 Fact Sheet: About Pressure
Injuries In US Healthcare. https://cdn.ymaws.com/npiap.com/resource/resmgr/ public_policy_files/npiap_word_fact_sheet_08mar2.pdf
Nusbaum, L., Douglas, B., Damus, K., Paasche-Orlow, M., & Estrella-Luna, N. (2017).
Communicating risks and benefits in informed consent for research: A qualitative
study. Global Qualitative Nursing Research, 4. https://doi.org/10.1177/2333393 617732017
Padula, W. V., & Delarmente, B. A. (2019). The national cost of hospital‐acquired pressure injuries in the United States. International wound journal, 16(3), 634-640. https://doi.org/10.1111/iwj.13071
Padula, W. V., Pronovost, P. J., Makic, M. B. F., Wald, H. L., Moran, D., Mishra, M. K., & Meltzer, D. O. (2019a). Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Quality & Safety, 28(2), 132-141. http://dx.doi.org/10.1136/bmjqs-2017-007505
Padula, W. V., Chen, Y. H., & Santamaria, N. (2019b). Five‐layer border dressings as part of a quality improvement bundle to prevent pressure injuries in US skilled nursing facilities and Australian nursing homes: a cost‐effectiveness analysis. International Wound Journal, 16(6), 1263-1272. http://dx.doi.org/10.1136/bmjopen-2018-026639
Padula, W. V., Malaviya, S., Hu, E., Creehan, S., Delmore, B., & Tierce, J. C. (2020). The cost-effectiveness of sub-epidermal moisture scanning to assess pressure injury risk in US health systems. Journal of Patient Safety and Risk Management, 25(4), 147-155. https://doi.org/10.1177%2F2516043520914215
Padula, W., Berke, C., & Bryant, R. (2021). A collaborative call for changes in reimbursement policies to achieve improvements in hospital safety related to pressure injuries. Journal of patient safety, 17(4), e268. https://doi.org/10.1097/pts.0000000000000854
Patton, D. (2022). Journal of Tissue Viability. Elsevier. https://www.journals.elsevier.com/ journal-of-tissue-viability
Puhl, R. M. (2020). What words should we use to talk about weight? A systematic review
of quantitative and qualitative studies examining preferences for weight‐related
terminology. Obesity Reviews, 21(6). https://doi.org/10.1111/obr.13008
Raynaldo, M. C. (2020). Implementing hospital-acquired pressure injury (HAPI) prevention program. University of St. Augustine for Health Science. http://hdl.handle.net/10755/20958
Richardson, A., Peart, J., Wright, S. E., & McCullagh, I. J. (2017). Reducing the incidence of
pressure ulcers in critical care units: A 4-year quality improvement. International Journal
for Quality in Health Care, 29(3), 433–439. https://doi.org/10.1093/intqhc/mzx040
Rivera, J., Donohoe, E., Deady-Rooney, M., Douglas, M., & Samaniego, N. (2020). Implementing a Pressure Injury Prevention Bundle to Decrease Hospital-Acquired Pressure Injuries in an Adult Critical Care Unit: An Evidence-Based, Pilot Initiative. Wound Management & Prevention, 66(10), 20-28. https://europepmc.org/article/med/33048828
Singh, C., Shoqirat, N., & Thorpe, L. (2021). The Cost of Pressure Injury Prevention. Nurse Leader. https://www.sciencedirect.com/science/article/pii/S1541461221002561#:~: text=https%3A//doi.org/10.1016/j.mnl.2021.11.003
Trisnaningtyas, W., Retnaningsih, R., & Rochana, N. (2021). Effects and Interventions of Pressure Injury Prevention Bundles of Care in Critically Ill Patients: A Systematic Review. Nurse Media Journal of Nursing, 11(2), 154-176. https://doi.org/10.14710/nmjn.v11i2.28881
Van Gilder, C., Lachenbruch, C., Algrim-Boyle, C., & Meyer, S. (2017). The international pressure ulcer prevalence™ survey: 2006-2015. Journal of Wound, Ostomy and Continence Nursing, 44(1), 20-28. https://doi.org/10.1097/WON.0000000000000292
Wung Buh, A., Mahmoud, H., Chen, W., McInnes, M., & Fergusson, D. A. (2021). Effects of
implementing Pressure Ulcer Prevention Practice Guidelines (PUPPG) in the prevention
of pressure ulcers among hospitalized elderly patients: A systematic review protocol. BMJ Open, 11(3), e043042. https://doi.org/10.1136/bmjopen-2020-043042
Yilmazer, T., & Tuzer, H. (2019). Pressure ulcer prevention care bundle: A cross-sectional,
content validation study. Wound Management & Prevention, 65(5), 33-39. https://doi.org/10.25270/wmp.2019.5.3339
Yilmazer, T., & Tuzer, H. (2022a). Effectiveness of a Pressure Injury Prevention Care Bundle; Prospective Interventional Study in Intensive Care Units. Journal of Wound, Ostomy & Continence Nursing, 49(3), 226–232. https://doi.org/10.1097/WON.0000000000000875
Yilmazer, T., & Tuzer, H. (2022b). The effect of a pressure ulcer prevention care bundle on nursing workload costs. Journal of Tissue Viability. https://doi.org/10.1016/j.jtv.2022.05.004
Zhang, X., Wu, Z., Zhao, B., Zhang, Q., & Li, Z. (2021). Implementing a pressure injury care bundle in Chinese intensive care units. Risk Management and Healthcare Policy, 14, 2435. https://doi.org/10.2147/RMHP.S292579
Zyphur, M. J., & Pierides, D. C. (2019). Statistics and probability have always been
value-laden: An historical ontology of quantitative research methods. Journal of
Business Ethics, 8, 1-18. https://doi.org/10.1007/s10551-019-04187-8