Running head: QUALITY IMPROVEMENT: HOSPITAL ACQUIRED PRESSURE ULCERS 1

Quality Improvement: Hospital Acquired Pressure Ulcers

Kylie Banks

NUR 4144 Professional Role Development Servant Leadership

October 10, 2017

I pledge Kylie Banks

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Quality Improvement: Hospital Acquired Pressure Ulcers

This semester during my immersion at the orthopaedic unit at St. Marys Hospital, I was

able to discuss the main quality improvements for the unit with the clinical leader. One of the

main quality improvements identified was the prevention of hospital acquired pressure ulcers.

The overall patient population of the unit primarily consists of orthopedic patients but often

times there are many general surgery patients on the unit as well. Preventing hospital acquired

pressure ulcers is especially important for postoperative patients who many not want to move

because they are in pain. Postoperative patients are more susceptible to pressure ulcers because

they have bony prominences, may not be receiving adequate nutrition, and have issues with

mobility. When patients stay in the same spot for long periods of time, it causes continuous

pressure on the skin which leads to skin breakdown. According to Lyder and Ayello, Pressure

ulcers develop when capillaries supplying the skin and subcutaneous tissues are compressed

enough to impede perfusion, leading ultimately to tissue necrosis (2008). Pressure ulcers require

extensive treatment, require patients to stay in the hospital longer, and can cause an overall

decline in patient health. Treating pressure ulcers are also very costly and require multiple

disciplines to work together to prevent further deterioration. Before September 2016, the

orthopaedic unit at St. Marys had two hospital acquired pressure ulcers. Over the past year the

unit manager and staff have worked hard to prevent further hospital acquired pressure ulcers

from occurring. Nurse managers who apply the four domains of leadership and the five

exemplary practices of leadership improve the nursing practice and have better patient outcomes.

The four domains of servant leadership are the heart, head, hands, and habits. The

internal domains include the motivations of your heart and the head involves leadership and

overall perspective of the leader (2005, p. 31). The external domains of leadership include the
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hands which includes the behaviors and beliefs. The final domain a servant leader is the habits of

a servant leader and they define the leaders character. By applying these four domains to

preventing hospital acquired pressure ulcers, the nurse manager can improve quality patient care.

With preventing hospital acquired pressure ulcers it is important that the nurse manager is

motivated to make changes to promote optimum patient outcomes. By using the heart domain the

leader is motivated to improve and prevent pressure ulcers in the hospital environment. The

nurse manager needs to be willing to grow and seek out opportunities to prevent pressure ulcers

and promote quality patient care. For example, researching and identifying evidenced based

practice ideas on how other hospitals and units have successfully prevented pressure ulcers. The

nurse manager has to be able to think outside of the box and try new things. The head domain

involves identifying the nurse managers beliefs and values on preventing hospital acquired

pressure ulcers. A nurse manager in this situation values quality patient care and reducing

debilitating pressure ulcers and believes that nurses can make a tremendous impact on patient

outcomes. The managers beliefs and values affect the success of the quality improvement

project. If he or she does not believe in the importance of preventing pressure ulcers it can cause

the project to fail. The hands domain involves creating a plan for change and implementation.

This includes actions like implementing a skin tear risk assessment, daily skin monitoring, using

the Braden scale, and the Pressure Ulcer Prediction, daily dual nurse skin checks, Prevention and

Treatment Pathway (Primaris). By using these tools, the nurse manager is analyzing which

patients are most at risk and providing quick action to prevent pressure ulcers. The habits of a

servant leader involve the internal self-reflective side that allows us to stay on task and not be

consumed by our busy day-to-day lives. There are five main habits that help alleviate this

negative aspect of life which are solitude, prayer, study and application of Scripture, accepting
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and responding to Gods love, and being involved in supportive relationships (Blanchard &

Hodges, 2005, p. 154). As a nurse manager implementing changes to prevent pressure ulcers, it

is important to implement one of the five habits to stay grounded and not overwhelmed with

lifes daily responsibilities. In particular, solitude and silence allow reform of the innermost

attitudes toward people and events. It takes the world off of our shoulders and interrupts our

habit of constantly managing things, of being in control or thinking we are (2005, p. 45). It is

especially important for a nurse manager who has a lot on their plate to take time to reflect and

re-center himself or herself in order to successfully improve the overall project.

The five exemplary practices of leadership are guidelines that help leaders reach their full

potential. Model the way is the first step in becoming an exemplary leader. A nurse manager who

is modeling the way has identified their values, displays consistency, acts as a positive example

for others to follow, and speaks on behave of others in the overall community (Ellcessor). A

nurse manager who wants to prevent pressure ulcers will help do dual skin check and act as a

resource for any nurse who has concerns about patients who are at risk for potential pressure

ulcers. The next step, inspire a shared vision, involves the nurse manager to identify his or her

dream behind the project. For example, preventing hospital acquired pressure ulcers and

improving patient outcomes would be a dream that promotes a better future. The nurse manager

would also want other staff members to be apart of this dream and be encouraged to work

together towards improved patient outcomes. Another practice of leadership is challenging the

process. This involves the nurse manager implementing new ideas and using trial and error to

provide the best results for the project. In this stage the nurse manager is looking at how well

daily skin assessments are helping to identify and prevent possible pressure ulcers. The manager

may identify that there needs to be more frequent skin checks throughout shifts instead of one
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per shift. Enabling others to act is another step in exemplary leadership. It is important that the

nurse manager gets other members of staff involved in the project and fosters collaboration

within the team. This includes supporting and strengthening team members and providing them

with necessary resources. The last stage of an exemplary leader is encouraging the heart. A nurse

manager who is encourages the heart recognizes the teams contributions and reinforces positive

performance. This includes providing a team luncheon to reward them for all of their hard work

and celebrate their accomplishments.

Nurses are essential in initiating the necessary steps to prevent of hospital acquired

pressure ulcers. However, many clinicians believe that pressure ulcer development is not simply

the fault of the nursing care, but rather a failure of the entire heath care system, hence, a

breakdown in the cooperation and skill of the entire health care team (nurses, physicians,

physical therapists, dietitians, etc.) (2008). Preventing pressure ulcers must be a team effort in

order to provide the best outcomes for patients. There are several ways to prevent hospital

acquired pressure ulcers which include patient education on nutrition, increase movement,

identifying patients who are more at risk, and assessing patient skin daily. Risk factors for

hospital acquired pressure ulcers are older age of 70 years or older, smoking history, low body

mass index, impaired mobility, altered mental status (i.e., confusion), urinary and fecal

incontinence, malnutrition, physical restraints, malignancy, history of pressure ulcers, and white

race (2008). Nurses who identify these risk factors can implement preventative measures like

frequent turning if the patient is immobile, using pillows to alleviate pressure on bony

prominences, keeping patients clean and dry if they are known to be incontinent, increased

nutrition support if they have a low body mass index, performing dual skin checks by two

registered nurses, daily skin checks each shift, and putting the patient on a pressure reduction
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mattress. Overall, research has shown that using the AHRQ guidelines and the Braden scale on

pressure ulcer prediction and prevention can lead to decreased incidence of pressure ulcers

(2008). Using these preventative guidelines in the healthcare systems will prevent hospital

acquired pressure ulcers from occurring and greatly improve patient outcomes.

Initiating the necessary steps to prevent hospital acquired pressure ulcers is essential in

improving patient outcomes. A research study performed by Gunningberg and his colleagues

displayed a reduction in pressure ulcers by performing systematic risk assessments upon

admission, accurately staging pressure ulcers, using pressure-reducing mattresses, and continuing

education of staff. Thus, the use of comprehensive prevention programs can significantly reduce

the incidence of pressure ulcers in long-term care (2008). By using programs like the Braden

Scale and the AHRQ prevention guidelines to identify patients at risk hospitals have greatly

decreased the amount of pressure ulcers. For patients in the hospital this means that they may be

able to heal at a faster rate from their primary diagnoses be able to perform their activities of

daily living sooner, and be discharge from the hospital without a lasting complication like a

pressure ulcer.

In conclusion, nurse managers who implement quality improvement projects based on

preventing hospital acquired pressure ulcers improve patient outcomes and support nursing staff

in providing the best care possible. The four domains of servant leadership are essential for a

nurse manager to display when developing a quality improvement project. The heart, head,

hands, and habits allow the nurse manager to focus fully on the project and provide the best

results. A nurse manager who displays the five exemplary practices of leadership is more

equipped to implement new ideas, initiate staff involvement, and provide quality results. Overall,
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this quality improvement project displays improvement in the nursing practice and provides the

best patient outcomes by preventing hospital acquired pressure ulcers.

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References

Blanchard, K. & Hodges, P. (2005). Lead like Jesus. Nashville, TN: Thomas Nelson.

Ellcessor, NUR 4144: Servant Leadership The Five Practices of Exemplary Leadership

Lyder, C. H. & Ayello, E. A. (2008). Pressure ulcers: A patient safety issue. Agency For

Healthcare Research and Quality.

Primaris Healthcare Business Solutions. (2008). Gauging pressure ulcers: A nursing guide to

prevention and treatment. p. 1-60.