D221 Final Paper: Practice Improvement Plan for Pressure Injury Prevention

Grace J.
November 11, 2025November 11, 2025
BSN, D221, Western Governors University

Student Name

Western Governors University

D221 Organizational Systems and Healthcare Transformation

Prof. Name

Date

D221 Practice Improvement Plan Proposal

Situation (S)

Healthcare-Related Situation

Implementing structured and evidence-based turning protocols for immobile hospitalized patients is a critical component of nursing care and patient safety. Without appropriate repositioning and monitoring, patients are at increased risk for developing pressure injuries, which can cause severe discomfort, infections, and extended hospitalizations. These complications not only delay recovery but also lead to complex discharge planning and potential hospital readmissions. Consequently, unmanaged pressure injuries diminish patient outcomes, strain healthcare resources, and reduce the overall efficiency of hospital operations.

Background (B)

A2a: Data

Hospital-acquired pressure injuries (HAPIs) are recognized as a vital quality indicator within U.S. healthcare systems, reflecting the standard of nursing care and patient safety (Tervo-Heikkinen et al., 2023). More than 2.5 million Americans experience pressure ulcers each year, resulting in pain, increased infection risk, and additional healthcare costs. In response, the Agency for Healthcare Research and Quality (AHRQ) developed the Pressure Injury Prevention Toolkit in 2012 to guide healthcare professionals in implementing effective prevention practices. The toolkit emphasizes multidisciplinary collaboration, regular skin assessments, patient repositioning schedules, and staff education on risk management. Through these strategies, healthcare providers can promote patient safety, minimize complications, and optimize healing outcomes.

A2b: Patient Safety Standards

The Joint Commission’s National Patient Safety Goal (NPSG.14.01.01) identifies pressure injury prevention as a key safety initiative. Adhering to these clinical standards enables early recognition and proactive intervention for at-risk patients. Utilizing validated assessment tools—such as the Braden Scale—helps healthcare professionals evaluate skin integrity and risk levels. Preventive measures include maintaining clean and dry skin, minimizing friction and shear, and adhering to scheduled patient repositioning. Such protocols improve tissue tolerance, reduce injury risk, and align with best-practice nursing standards for quality care.

Assess (A)

A3: Impact

Pressure injuries create a significant financial and operational burden on healthcare systems. Hospitals face escalating costs related to specialized wound dressings, advanced support surfaces, extended nursing hours, and antibiotic treatments. Beyond financial strain, these cases can compromise patient satisfaction scores and overall care quality metrics. The increased workload associated with pressure injury management can also heighten nurse fatigue, stress, and job dissatisfaction—further impacting organizational efficiency.

A3a: Value

Preventing pressure injuries provides measurable benefits for both patients and healthcare institutions. Patients experience faster recovery times, reduced pain, and improved comfort. For healthcare teams, consistent prevention reduces documentation demands, frees up clinical time, and enhances workflow efficiency. Preventive care also demonstrates a commitment to patient-centered nursing, supporting both ethical and professional responsibilities in clinical practice.

Evidence-Based Practice Change

A4a: High-Reliability Organization

Integrating a structured pressure injury prevention protocol supports the goal of establishing a high-reliability organization (HRO). HROs emphasize consistency, accountability, and the anticipation of potential risks to minimize patient harm (Khan & Jonusas, 2019). Standardizing repositioning schedules and utilizing validated assessment tools across departments ensures that all patients receive equitable, evidence-based care. Studies have shown that repositioning immobile patients every two hours significantly reduces the occurrence of pressure injuries. Aligning with the recommendations of AHRQ and the Joint Commission promotes a culture of safety and organizational resilience.

A4b: Barriers

Two prevalent barriers to protocol implementation include:

Scheduling Conflicts: High patient-to-nurse ratios and unpredictable unit demands often disrupt regular repositioning schedules.
Patient Non-Compliance: Some patients may decline repositioning due to discomfort, fatigue, or misunderstanding the importance of prevention efforts.

A4c: Interventions

To address these barriers effectively, targeted interventions can be implemented. Assigning dedicated “turn teams” or staff members responsible solely for patient repositioning ensures accountability and consistency. In addition, involving patients in decision-making about their repositioning schedule can enhance their sense of control and cooperation. Education on the benefits of repositioning, supported by visual aids or bedside communication tools, further increases compliance and awareness.

A4d: Shared Decision-Making

Collaborative decision-making among nurses, physicians, and wound care specialists is vital for successful implementation. Establishing shared goals for skin integrity fosters mutual accountability and clear communication. A team-based nursing model, as opposed to task-focused care, encourages shared responsibility and eliminates confusion regarding assigned duties. This cooperative framework enhances patient outcomes through consistent, coordinated interventions.

A4e: Outcome Measures

Evaluation of the intervention’s effectiveness should involve measurable outcome metrics. Hospitals can track the rate of new pressure injury cases before and after implementing turning schedules. Audit tools and electronic health record (EHR) documentation can monitor compliance with repositioning frequency. Collecting qualitative feedback from nursing staff about challenges and workflow barriers allows for ongoing process improvement and adaptation.

A4f: Care Delivery Model and Impact

Transitioning from a task-oriented model to a team-based care delivery approach offers a more sustainable strategy for pressure injury prevention. Within this model:

Nurse Managers oversee compliance and documentation accuracy.
Charge Nurses coordinate schedules and monitor workflow.
Nursing Staff execute repositioning and provide feedback.

This structured approach enhances interprofessional collaboration, ensures accountability, and promotes communication between departments. Ultimately, it results in better patient outcomes, increased staff engagement, and improved hospital performance metrics.

Summary Table: Barriers and Interventions for Turning Schedule Implementation

Barrier	Intervention
Schedule conflicts on unit	Assign and train designated staff for consistent patient repositioning.
Patient refusal to comply	Engage patients in care planning and provide education to encourage cooperation.

References

Agency for Healthcare Research and Quality. (2017). Pressure injury prevention in hospitals training program. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/index.html

Khan, M., & Jonusas, E. (2019). Turn teams: How do you prevent pressure injuries? MEDSURG Nursing, 28(4), 257–261.