Unavoidable Pressure Injuries: An Ethnonursing Study

In an effort to improve patient safety and quality care in the acute care setting, there has been an increased focus on the prevention of adverse events believed to be avoidable. Hospital-acquired pressure injuries (HAPI) have been listed as one of those adverse events.  However, there are patient conditions and clinical situations in which a pressure injury (PI) can be deemed unavoidable.  Unavoidable means the HAPI developed even though the provider had: evaluated the patient’s risk factors; defined and implemented PI interventions; monitored and evaluated the impact of the interventions; and revised the approaches when appropriate.  Despite these guidelines, PI prevention and documentation has been inconsistent, making it difficult to identify a HAPI as unavoidable.  There is a lack of research exploring the acute care nurses’ perspective of implementing and documenting PI prevention.   

PI prevention information was collected using an ethnographic qualitative method. Data collection took place in a Midwest USA medical center over a seven month period and included 23 participants:  7 acute care medical-surgical nurses who had provided direct care to a patient who developed a HAPI and 16 multidisciplinary health care members who had knowledge of PI prevention.  A systematic, rigorous, and in-depth qualitative analysis was completed using the Leininger Data Analysis Guide.  

Four themes emerged from the data regarding the culture of care of adults experiencing a HAPI:  incomplete skin assessments were influenced by priority setting and kinship relationships; an inability to implement PI prevention interventions was influenced by economical staffing; diverse documentation regimes were influenced by care rationing practices and technical factors; and diverse multidisciplinary collaborative PI injury prevention efforts were influenced by silo social structures.  

The findings of this study not only have implications for nursing practice, administration, and education, but are vitally important in the identification of a HAPI as avoidable or unavoidable.