Running head: LEADERSHIP QI PROJECT: PRESSURE ULCER PREVENTION 1

Leadership QI Project: Pressure Ulcer Prevention

Melissa Alfaro

Bon Secours Memorial College of Nursing

I pledge
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Leadership QI Project: Pressure Ulcer Prevention

In the United States alone, 2.5 million patients a year are suffering from a pressure ulcer.

The Agency for Health Care Research and Quality (AHRQ) estimates that each pressure ulcer

(PU) adds $43,180 in costs to a hospital stay. AHRQ quantifies the gravity of undue suffering

from PUs with a mortality rate of more than 60,000 patients per year (Preventing Pressure

Ulcers in Hospitals, 2014). Considering that PUs are never supposed to occur in the clinical

setting, it becomes stigmatized as a direct reflection on the quality of nursing care a patient

receives. With compounding morbidity and mortality rates in a place where patients seek

treatment and relief from illness, hospital leadership is responsible for promoting change in the

right direction. Using Blanchard and Hodges book, Lead Like Jesus (2008), this paper will

explore how to inspire change from a nurse managers perspective in reducing the occurrence of

PUs.

The Heart of the Leader

The heart of the leader, or the spiritual motivation of the leader, must be clarified. As

Blanchard and Hodges articulate in their book, the heart question that Jesus asks is, Are you a

servant leader or a self-serving leader? (2008, p. 31). The servant leader is one that puts the

needs of others before self, which nurses should strive to emulate. Some ways that a nurse

manager can promote the heart of a leader in her nurses is to ask them their feedback. Is turning

patients as important to a nurse managing many other critical aspects of their care? The nurse

manager may also question if nurses are equipped with the knowledge and appropriate

technology to prevent PUs.

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Samuriwo and Dowding (2014) suggest that nurses may deal with assessing patients for

PUs based on prior experience rather than evidence-based practices. Other factors affect nurses

judgment such as the overall health of the patient, the familys perception of the patients health

affect the urgency by which nurses react to preventing a pressure ulcer. With this knowledge, it

becomes apparent that using specific tools such as the Braden scale, and also, assessing patients

upon admittance for PUs should be part of the model of practice.

The Head of the Leader

To efficiently carry out any idea set forth, the head of a servant leader must lead by

setting the course and direction, and serve by empowering and supporting others in

implementation (Blanchard & Hodges, 2008, p. 84). A clear vision, therefore, is necessary in

implementing a change. Part of creating a clear vision involves getting buy-in from upper

management as well as staff. As a nurse manager, steps needed to achieve a clear vision is:

ensuring the resources and funds for patient safety are allocated, and that patient safety is a

concern for upper level management. On the floor, some ways that create a sense of shared

vision would be creating a system on the EHR which would refer patients at risk on the Braden

scale to higher supervision, and have that system alert the nurse.

The Hands of the Leader

With the hands of the leader, transformation begins with the inspiration that a leader

incites among the people around him, as Lead Like Jesus illustrates: above all, servant leaders

care about people and want them to flourish and succeed in their unique purpose and calling

(Blanchard & Hodges, 2008, p. 120). As an effective leader, one must act as a performance

coach. Performance coaching provides learners with the knowledge they need to progress into
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the mastery stage of a task. A successful leader-follower relationship must be established to

accomplish a goal. As a nurse manager, one must always be available to staff nurses to build

successful relationships. In the context of PU prevention, this means the nurse leader must be a

superior resource in preventing pressure ulcers. She must have the knowledge to assess PUs on

all types of patients. The prevention measures against them, be it specific patient positioning or

special devices, and the ability to communicate that knowledge effectively to her team are all

important as the head of a leader.

The Habits of a Leader

The habits of a leader define and form character, and are a cornerstone in maintaining the

vision as well as countering negative habits. Some habits as a nurse leader that I would like to

instill in my staff would include daily reflections on how the overall day went, and how the

quality of the day affected meeting our goals. I would also include daily huddles which would

emphasize the importance of monitoring our patients for PUs, and reiterating they can reach out

when needing help.

The Practices of Exemplary Servant Leadership

Modeling the way involves commanding respect by behaving as a servant leader. The

commitment to the goal of preventing PUs would have to be modeled by the nurse manager. That

means being proactive about the care of a patient when the signs of a PU forms, and involving

the right people in that care. Part of modeling the way involves allowing your staff to know that

it is a multidisciplinary job. We must involve team members of all disciplines to prevent PUs.

Having a dedicated team to reposition patients would be exponentially helpful in the prevention

of PUs.
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A way to inspire a shared vision would be to post the information for all people to see,

including family members of patients, patients and staff alike. Information about PUs, including

risk factors and prevention methods, could be posted as part of the welcome information during

admission.

To challenge the process, the nurse manager must allow an open forum for staff to give

feedback. We must know whether repositioning every 2 hours is too much to add to the laundry

list of nursing actions, and if assessments using the Braden score should happen more or less

frequently. That transaction between theory and practice will allow the nursing staff to achieve

the goals pertaining to PUs. Also, research outside of the hospital from evidence-based sources

can always be considered, and should evolve practice accordingly.

To enable others to act, a reiteration must be made of the fact that nurses do not carry the

burden of repositioning patients and calling for the right equipment. We must empower them

with the communication that is needed to prevent PUs. A way that could happen is to ensure the

efficacy of a referral system through the EHR, where the nurse can contact other specialties; for

example, a nurse can put in a referral to nurse specialized in wound care to help heal an existing

PU. Another example is having seamless communication within the EHR to the staff that is

dedicated to repositioning patients. Also, having equipment available and always evolving with

new technologies to help lift and reposition patients can be considered.

To encourage the heart, we must liberally give out recognition to the staff members who

go above and beyond, such as helping their fellow peers to assess the skin of a patient, or those

who have completed continued education on PUs. This would include rewards of some sort that

could be given out biannually to recognize those staff members who extended beyond their duty.
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Professional Practice Implications

One example of practice implications are the evolving practices that are evidence-based,

and transform the way nursing operates. By paying attention to minimizing patient distress by

preventing PUs, we are minimizing mortality and morbidity from a cause that is preventable,

decreasing their length of stay, and improving the quality of life for a patient. Thorpe identifies

the practice of preventing PUs had evolved into a prophylactically placing dressings on patients

who were at risk (2016). In a critical care unit, the nurse management had adopted a mindset of

pro-action versus reaction, where they applied sacral dressings to all patients regardless of the

grading on the PU prevention scale. This resulted in 301 PU-free days, and a reduction in

occurrence rate from 19.9 per 1000 patients to 0.84 per 1000 patients (Thorpe, 2016).

Nelson and Harris (2013) identifies the importance of education for nurses in the

identification of PUs. A project was implemented to decrease the incidence of PUs through

education. Education included skin product review, risk assessment tools, and unit protocols. By

investing in the prevention of PUs by educating their nurses, the morbidity of the patients

decreased and the quality of life increased. As for the hospital expenditures, it had a promising

return on investment, with no PUs noted at an audit three months after the educational program.

Outcomes Evaluation

The most obvious evaluation of outcome would be measured by the amount of hospital

acquired PUs documented. By using the tools and the education invested in decreasing the

incidence of PUs, it allows for a safer patient experience, and redirects health care to the goal set

forth. Specific interventions would have to be created by the feedback from the nurses.

Repositioning, clinical tools such as the Braden scale, and prophylaxis in preventing PUs are in
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place currently. Increased patient satisfaction would be another evaluation by the success of

preventing PUs.

Conclusion

For nurses in leadership positions, it is important to continually inspire and empower our

nurses to achieve the goal of safe and effective patient care. Nursing is a job that requires

excellent communication and skilled mastery of the sciences to take care of our patients.

Preventing pressure ulcers is no exception under that ideal. Using the heart, hands, head and

habits of a servant leader as well as the principles of servant leadership, eliminating the incidence

of pressure ulcers is attainable and realistic. By leading like Jesus, we are empowering those

around us to achieve to the highest of their ability.

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References

Blanchard, K. & Hodges, P. (2008). Lead like Jesus. Nashville, TN: Thomas Nelson.

Nelson, M., & Harris, R. (2013). Pressure ulcer alert! Nursing 2013, 43(11), 64-67.

Preventing pressure ulcers in hospitals. (2014). Agency for Healthcare Research and Quality.

Retrieved March 25 2014, from http://www.ahrq.gov/professionals/systems/hospital/

pressureulcertoolkit/index.html.

Samuriwo, R. & Dowding, D. (2013). Nurses pressure ulcer related judgments and clinical

practice: A systematic review. International Review of Nursing Studies, 51(12).

Thorpe, E. (2016). Prophylactic use of dressing for pressure ulcer prevention in the critical care

unit. British Journal of Nursing, 25(12).