Digital Repository Masters Projects Spring 2025 MSN Signature Project-Improving Skin Assessment Skills of Registered Nurses for All Skin Tones Brandon Crosby Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Crosby, B. 2025. MSN Signature Project-Improving Skin Assessment Skills of Registered Nurses for All Skin Tones Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP MSN Signature Project-Improving Skin Assessment Skills of Registered Nurses for All Skin Tones Project Title by Brandon Crosby Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY April 25th, 2025 Ogden, UT Date Brandon Crosby, BSN, RN, MSN student April 25th, 2025 Student Name, Credentials (electronic signature) Date JoAnn Tolman, DNP-L, MSN-Ed, RN, CNE 04/25/2025 MSN Project Faculty Date (electronic signature) Anne Kendrick, DNP, RN, CNE (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. 04/25/2025 Date 1 Improving Skin Assessment Skills of Registered Nurses for All Skin Tones Brandon Crosby, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: Pressure injury prevention in patients with darker skin tones requires a practical skin assessment. This project aims to expand nursing skin assessment education specific for darker skin tones and provide a resource tool to improve early detection and prevention of skin breakdown. Rationale/Background: The current literature in academia and clinical practice education is dominated by fair skin assessment concepts. The literature illustrates a universal gap between the early identification of pressure injuries in patients with darker skin tones. Data over the last 8 months at a level 1 trauma center showed pressure injury incidence was nearly three times higher in an ICU setting, with stage 2-4 pressure injuries occurring substantially higher in patients with darker skin tones. Methods: The Iowa Model for Evidence-Based Change and Excellence in Healthcare served as the foundation for this project. A pre-and post-survey was conducted to assess registered nurses' confidence and knowledge levels before and after the educational intervention. An infographic was created to illustrate the current evidence-based practices for conducting skin assessments across all skin tones. Additionally, a presentation and hands-on skills assessment highlighted the differences in various Braden Scales, providing essential foundational education. Results: Nurses report increased confidence in conducting skin assessments for all skin tones and in the early detection and prevention of pressure injuries. Conclusions: Sound foundational education utilizing clinical practice guidelines for assessing darker skin tones reduces the incidence of pressure injuries. Nursing education 3 that addresses pressure injuries in darker skin tones improves patient outcomes and reduces disparities. Keywords: Pressure injury, standardization, skin assessment, darker skin tones, continuing education, modified Braden scale. 4 Improving Skin Assessment Skills of Registered Nurses for All Skin Tones Given their highly preventable nature, skin integrity and pressure injury prevention are often viewed as a direct measure of an organization's quality of care. The potential for pressure injuries to prolong recovery and impact a patient's quality of life underscores the urgency and importance of skin assessments. According to Black et al. (2023), pressure injuries are nearly twice as likely to occur in black patients when compared to white patients, with stage 2-4 pressure injuries being nearly three times more likely to occur in Black patients than in White patients. This illustrates that current standardized skin assessments fall short, and that the early detection of pressure injuries is more challenging in individuals with dark skin tones. The average cost of treating a pressure injury is $43,000 and costs the United States $11.6 billion annually, with 60,000 patients dying annually from complications of a pressure injury (Francis, 2023). These staggering figures underscore the financial and human costs of this issue. As a preventable injury, there is no excuse for this loss of life. Pusey-Reid et al. (2023) state that nursing and physician education is lacking at an academic level and that clinical education for registered nurses does not fare much better. Registered nurses are vital to identifying pressure injuries through thorough skin assessments and scoring utilizing the Braden scale. Findings by Kennerly et al. (2022) and Wynn et al. (2024) show that the Braden score shows a moderate level of accuracy in predicting pressure injury risk, though consecutive scores are often not compared in clinical settings. Additionally, the history of a pressure injury is not accounted for in the score and is one of the most significant predictors of one occurring (Wynn et al., 2024). Additionally, high Braden Scale scores increase the risk of death (Tang et al., 2024). These findings underscore the importance of registered nurses being well-informed about the limitations of the Braden Scale, obtaining 5 proficiency in skin assessments, and understanding the additional variables that should be considered. Statement of Problem Despite a push toward patient-centered care and addressing disparities, nursing and medical institutions lack skin tone diversity teaching, widespread across much higher education. This highlights an urgent need to address a knowledge gap in skin integrity in diverse populations (Oozageer Gunowa et al., 2021). This knowledge gap is prevalent in intensive care and acute medical-surgical patients at a level-one trauma center in Salt Lake City, Utah. There is a lack of expanded education on skin assessment for darker skin tones in patients who are bedbound due to being hemodynamically unstable after traumatic events, resulting in an increased number of pressure injuries. The demographics of Utah’s population limit exposure to patients with darker skin tones. According to the United States Census Bureau (2021), 89% of Utah’s population identifies as White/Caucasian alone, meaning that nursing exposure to diverse skin tones is limited. Working in a less diverse area signals that nurses' confidence in assessing darker skin tones may not be as high as that of nurses who work in more diversely populated areas (Fletcher & Oozageer Gunowa, 2021). According to Francis (2023), healthcare professionals have become color-blind due to living in the modern era of total inclusivity and challenges clinicians to become color-aware, a concept that emphasizes the importance of recognizing and understanding the impact of skin tone on health outcomes to promote accurately addressing skin health and reducing disparities. This MSN project aims to reduce the knowledge gap regarding skin tone assessments by educating nurses on the value of the Braden score assessment, a widely used tool to predict the 6 risk of developing pressure ulcers, evaluating trends of the Braden score, and identifying other variables that contribute to poor skin integrity. Significance of the Project Acknowledging that diversity exists is essential to breaking down systematic racism (Fletcher & Oozageer Gunowa, 2021). Skin tone diversity is crucial in skin assessments as it can significantly impact the visibility of pressure injuries. The detection and prevention of pressure injuries are crucial to maintaining the quality of care a patient receives. These injuries can lead to long-lasting adverse effects post-discharge, including limb loss or diminished functionality. Taking a proactive approach to pressure injury prevention not only minimizes the need for unnecessary procedures to address these injuries but also decreases the likelihood of preventable deaths caused by complications associated with pressure injuries (Edsberg et al., 2022). Pressure injuries constitute healthcare-related patient harm, leading to increased healthcare expenditure and mistrust of the healthcare system (Fleming et al., 2022). Nurses are crucial in preventing pressure injuries (Sim et al., 2024). Nurses have an ethical and professional responsibility to care for all patients regardless of their demographic characteristics (Gaines, 2023). However, nurses need to possess the knowledge to be competent in skin assessments to fulfill this responsibility. The need for improved assessment skills is not just a requirement but a pressing urgency to uphold standards of equitable care and reduce preventable harm (Schumacher et al., 2023). Preventable harm to a patient can weigh heavily on the nurse who could have prevented it, leading to increased psychological stress (Panagioti et al., 2019). This project will close the gap in improving the assessment skills of registered nurses, thereby enhancing patient outcomes, reducing hospitalization stays and associated costs, alleviating psychological stress for both patients and nurses, and promoting evidence-based change in clinical practice. 7 Review of the Literature A panel of quality improvement experts at a hospital in Salt Lake City, Utah, reported a nearly 200% increase in pressure injuries among patients in the ICU and acute medical-surgical trauma unit from January 2024 to August 2024, compared to the incidence of pressure injuries in 2023. Internal surveys indicated that stage 2 to 4 pressure injuries were significantly higher in hemodynamically unstable patients with darker skin tones (M. Lacey, personal communication, August 11, 2024). A PICOT question guided the research on evidence-based practice: For nurses working on an acute medical-surgical floor or intensive care unit, does expanding skin assessment education and a resource tool specific to darker skin tones, compared to standard education, improve nurses’ confidence in early detection and prevention of skin breakdown over a two-month period? Framework The Iowa Model for Evidence-Based Practice and Excellence serves as a framework for enhancing skin assessment skills and boosting confidence among registered nurses (Cullen et al., 2022). This model involves several key steps: identifying a triggering issue and opportunity, assembling a team of experts, conducting research, synthesizing evidence, piloting practice changes, implementing those changes, evaluating the implementation process, and disseminating information (Cullen et al., 2020). In intensive care units and acute medical-surgical trauma units, patients often present with hemodynamic instability, complicating safe repositioning and requiring the use of multiple medical devices to address their acute needs. The potential risk of harming a hemodynamically unstable patient, combined with the presence of various medical devices, increases the likelihood of pressure injuries developing in these individuals. Additionally, limited exposure to a diverse patient population can pose challenges for registered 8 nurses in accurately identifying pressure injuries, especially in patients with darker skin tones. These challenges may stem from inadequate education or training in recognizing injuries across different skin types and highlight the need to review and synthesize existing literature to formulate targeted educational initiatives focused on skin assessments and the Braden scale, ultimately enhancing nurses’ proficiency in preventing pressure injuries in diverse populations. To create this educational program, a team comprising organizational and clinical experts, unit managers, clinical specialists, wound care professionals, quality improvement specialists, and skin champions was assembled to contribute insights into clinical practice, education, wound management, and treatment, all aligned with best practices for skin assessments and pressure injury prevention. The Iowa model is a well-established model that acts as a systematic framework for implementing education (Buckwalter et al., 2017) for registered nurses and evaluating their confidence levels before and after the program's implementation. Strengths and Limitations The strength of the Iowa Model, often used by registered nurses for quality improvement projects, is that it provides a straightforward, step-by-step process for integrating research into real-world practice (Hanrahan et al., 2019). It incorporates a pilot test of practice changes before implementing them on a larger scale. The Iowa Model also encourages ongoing monitoring and evaluation of interventions and outcomes to ensure the sustainability of quality improvement measures. The Iowa Model's limitation is that it requires strong support and leadership. Duff et al. (2020) identified several determinants of evidence-based practice, including practice changes conducted by bottom-up members of an organization. These require strong leadership support and the facilitation of project leaders to ensure the framework's success, which can be time- 9 consuming and tax resources. The determinants of evidence-based practice, highlighted by Duff et al. (2020), illustrate that practice changes depend on statistical quantitative studies and may disregard qualitative evidence or clinical expertise. Analysis of Literature This literature review aims to identify evidence that can enhance nursing practice, achieve practical outcomes, and improve patient care, while also boosting the confidence of registered nurses in conducting skin assessments for individuals of all skin tones. To foster an inclusive and patient-centered approach, the review will evaluate traditional assessment tools and techniques, alongside emerging evidence-based interventions and training methods. Additionally, it will underscore the significance of interdisciplinary collaboration and the necessity for both cultural and clinical competence. Search Strategies A literature search was conducted to identify current evidence using PubMed, National Library of Medicine, Google Scholar, and Weber State University Stewart Library OneSearch and Advanced Search to direct initial exploration. Only articles from 2019-2024 were included in this literature search to keep information current. The search included Boolean phrases in various combinations using these keywords: pressure injury AND/OR darker skin tones, modified Braden scale, skin assessment, tools, risk factors, clinical practice, registered nurse, and guidelines. Synthesis of the Literature Three themes were identified exploring literature surrounding the PICOT question: For nurses working on an acute medical-surgical floor or intensive care unit, does expanding skin assessment education and a resource tool specific for darker skin tones, compared to standard 10 education, improve nurses’ confidence in early detection and prevention of skin breakdown over two months? The first theme identified is that there is a gap in knowledge for treating patients with darker skin tones. The second theme identified is that appropriately considering the differences in skin tone can positively affect patient outcomes. The last theme found that the Braden scale, skin tone identification, and diagnostic tools are reliable, providing a solid foundation for education in practice and further research. Knowledge Gap Assessing Diverse Skin Tones In a study conducted by Oozageer Gunowa et al. (2021) that focused on nursing academics in the United Kingdom, significant evidence emerged highlighting a lack of diversity in the teaching and learning of skin tones concerning pressure injuries in individuals with darker skin. According to Black et al. (2023), pressure injuries are nearly twice as likely to occur in Black patients compared to their white counterparts, with stage 2-4 pressure injuries being almost three times more prevalent among Black patients. Additionally, a literature review by Francis (2023) further confirmed healthcare disparities affecting patients with darker skin tones, revealing that approximately 60,000 individuals die each year from complications related to pressure injuries. African Americans, in particular, experience higher mortality rates than any other ethnic group within this statistic. To combat these disparities, Francis urges healthcare professionals to adopt a color-aware approach in clinical settings, underscoring their vital role in addressing skin health across diverse populations. Research by Harvey et al. (2024) indicates that dermatology clinical trials inadequately represent minoritized patient groups. The lack of diversity in clinical trials and educational settings suggests that skin assessments should not be solely based on findings related to white skin, as this reinforces the notion of white skin as the standard (Dowley, 2023). These findings illustrate a pervasive issue across numerous 11 institutions, emphasizing the need to address the knowledge gap regarding skin integrity assessments in diverse populations (Oozageer Gunowa, 2020). Considering Differences in Skin Tone Considering differences in skin tones can positively affect patient outcomes. It ensures more accurate and timely diagnosis, a patient-centered care plan, and equitable care. When healthcare professionals are trained to recognize unique presentations of skin conditions and early signs of pressure injuries, rashes, or infections on darker skin tones, the risk of complications decreases (Chambers & Thompson, 2024). Pusey-Reid et al. (2023) identified a knowledge gap in skin integrity for clinical nurses and nursing students. They took a proactive approach to clinical practice guidelines in Boston by providing extensive resources on the differences in skin ailment presentation in varying skin tones, which proved highly effective. Additionally, Pattinson et al. (2021) stressed the importance of patient involvement in skin tone classification, leading to better patient outcomes and satisfaction. This approach allows healthcare professionals to educate patients on their skin composition, improving care quality. Konya et al. (2021) supported the idea that patient input is essential for patient satisfaction and outcomes regarding preventative care, such as bathing methods, ointments, lotions, and timing of exposing skin for skin assessments. Skin Tone Identification and Diagnostic Tools Skin tone assessment tools and classifications of skin tones need to be standardized, though many methods have been proven effective. A study by Fors et al. (2020) demonstrated that self-assessments of skin tone were consistent with findings from the Fitzpatrick Skin Phototype Classification (FSPC). The study involved a sample population (N=254) of both genders, aged 40 to 90 years, living in a rural area of Quito, Ecuador. The results indicated a 12 moderate level of reliability (Cronbach’s alpha = 0.51; r = 0.37) and a significant goodness-of-fit (p < 0.001), suggesting that both the FSPC assessments and self-assessments are statistically significant and could serve as cost-effective implementation measures. Further research conducted by Weir et al. (2024) aimed to validate skin assessments based on skin tone using a comprehensive approach, which included other scales like the Von Luschan Scale and the Melanin + Erythema Index (p < 0.001), as well as the Pantone scale (inter-rater reliability k = 0.454; intra-rater reliability k = 0.725). This extensive validation process establishes a strong foundation for the reliability of these assessment methods. Humphrey et al. (2021) also explored the link between cardiovascular health, skin perfusion, skin integrity, and skin appearance. They used diagnostic tools, computer-aided image analyses, and artificial intelligence (AI) to assess the topography and morphology of the skin, producing high-definition images that reveal details such as texture and temperature that cannot be seen with the naked eye. Chambers and Thompson (2024) employed sub-epidermal moisture (SEM) assessment technology and observed a 100% reduction in hospital-acquired pressure injuries (HAPIs) among all patients in a cardiac care unit, where the pre-implementation HAPI incidence stood at 8.9% (N=8 out of 90). Tang et al. (2024) identified that the Braden Scale, a widely used tool for evaluating the risk of pressure injuries in adults (Delmore & Ayello, 2023), was an independent predictor of mortality. Their findings revealed that Braden Scale scores of 15.5 or less significantly correlated with higher 30-day mortality rates (p < 0.001; hazard ratio: 2.08, 95% confidence interval: 1.71–2.53), emphasizing the critical importance of proficient skin assessment skills. It is important to note that a history of pressure injuries, which is one of the most significant predictors of future pressure injuries, is not included in standardized skin assessments (Wynn et al., 2024). 13 Lastly, the Braden Scale does not apply to all patient populations, as it is typically used for adults. In contrast, the Braden Scale QD is intended for pediatric patients and neonates with medical devices (Puspitasari et al., 2020). Confusion arises from the fact that a high Braden Scale score indicates a low risk, whereas high scores on the Braden Scale QD indicate a high risk for pressure injuries. Despite these differences, the proper use of the Braden Scale remains a reliable method for assessing the risk of pressure injuries across various patient demographics (Kennerly et al., 2022). Summary of Literature Review Findings and Application to the Project The existing literature on standardizing skin integrity assessments for all skin tones is limited. Despite growing awareness of the significance of accurate skin assessments for patients with darker skin tones, there are still notable knowledge gaps. These gaps can contribute to delayed diagnoses, potentially leading to poorer patient outcomes. Many registered nurses lack the necessary education, experience, and training to effectively assess darker skin tones and identify early signs of pressure injuries. This is often due to traditional assessment tools and clinical guidelines being predominantly based on research conducted on lighter skin tones. The findings from research support the need to incorporate education on proper skin tone assessments, as well as the anatomical and physiological differences in different skin tones. Recognizing subtle changes in skin color, temperature, and texture can indicate compromised skin, and understanding these differences can lead to earlier intervention, more suitable treatment plans, and significantly improved patient outcomes, which is promising for the future of patient care. Project Plan and Implementation 14 The initial steps of the project plan will focus on raising awareness about the prevalence of pressure injuries and the essential roles that healthcare workers, caregivers, and patients play in the prevention of these injuries. The aim is to inspire a vision for effective change, enhance confidence, reduce disparities, and improve patient outcomes. This will be achieved by empowering registered nurses in their skin assessments through educational seminars and training sessions. These sessions will provide comprehensive instruction on the Braden scale, address cultural considerations, encourage open communication with patients, incorporate touch in patient interactions, and utilize appropriate lighting and other diagnostic tools. Plan and Implementation Process Utilizing the Iowa Model for Evidence-Based Practice and Excellence framework, a notable trigger has been identified: the high prevalence of pressure injuries among hemodynamically unstable patients in the pediatric intensive care unit and acute medical-surgical unit of a level one trauma center, affecting a diverse range of skin tones. This situation presents a unique opportunity to enhance nurses’ confidence and competence in skin assessments. To address this issue, a team comprised of nurse leaders, physicians, wound care specialists, registered nurses, clinical nurse educators, physical therapists, and quality improvement leaders. The team conducted research, synthesized the evidence, and presented findings. Research indicates that the best practices for skin assessments include using touch, ensuring appropriate lighting, and maintaining open, transparent communication. These elements are essential for effective skin assessments across all skin tones, with the Braden scale identified as the most accurate measurement tool. Key stakeholders are informed of the evidence through a presentation and review of the deliverables to obtain buy-in for the project. The deliverables 15 include a) a pre-survey, b) an educational presentation for nurses, c) an infographic resource tool, and d) a post-survey. Once buy-in is obtained, implementation begins. The pre-survey will be distributed via email to assess the confidence levels of nurses in conducting skin assessments on darker skin tones, their current practices, and their approaches to reporting abnormal findings. This will help identify knowledge gaps through a self-assessment survey. The results will inform a plan for the formal education of registered nurses based on evidence-based findings. Nurses will participate in a one-hour in-person educational seminar that utilizes a PowerPoint presentation to emphasize key topics. Additionally, an introduction to a Canva infographic will be provided and displayed in patient areas to serve as an educational resource for nurses. Nurses apply education and the use of the infographic to their skin assessment over two months. At the end of two months, a post-survey will be emailed to each nurse to gather feedback concerning their confidence in skin assessments. Findings from the surveys are disseminated to key stakeholders for discussion and project improvement. Interdisciplinary Team Project Lead. The project lead is a registered nurse currently pursuing an MSN degree, responsible for conducting project research, establishing project goals, timelines, and deliverables, and securing necessary resources. This individual actively engages the interdisciplinary team to ensure their input and participation in the project while addressing barriers through effective communication and support. Registered Nurses. As the project's primary recipients, registered nurses are tasked with attending training sessions to learn best practices for skin assessment, implementing these newly acquired skills, and documenting and reporting their findings. They also provide feedback on the 16 educational program to enhance and refine its content and share strategies for further research and evidence-based interventions. Nurse Educators. These professionals assist in designing evidence-based educational materials and resource tools, playing a crucial role in measuring learning outcomes and assessing feedback to enhance future curricula for both formal and continuing education. Nurse Leaders. Nurse leaders support nursing staff by securing resources and time for education, ensuring that training programs are effectively integrated into clinical practice through regular reviews of assessment documentation, and promoting a culture of inclusivity and equality. Physicians. Physicians collaborate with interdisciplinary teams to deepen their understanding of pressure injuries. They engage registered nurses in bedside teaching and discussions with patients about the presentation and prevention of pressure injuries. They also verify registered nurses' findings and provide treatment protocols tailored to individual patient needs. Physical Therapists. Physical therapists work alongside registered nurses to teach proper body positioning, offloading techniques, and mobility strategies for critically injured and hemodynamically unstable patients. They also provide guidance on methods for inspecting pressure points and skin folds in patients with various injuries. Description and Development of Project Deliverables Pre-Survey. The pre-survey is used to determine nurses’ confidence in skin assessments and test knowledge prior to completing the required education. This gives the project a baseline to compare results at the completion of the project to determine the project's effectiveness (see Appendix A). 17 PowerPoint Presentation. The primary educational resource presented during this plan will focus on effective teaching strategies, particularly emphasizing statistical analysis as a means of data-driven decision-making to enhance educational outcomes. The presenter will share personal experiences designed to inspire participants to reconsider their current approaches, fostering a vision for and the necessity of change in practices. Additionally, the presentation will underscore the importance of professional development and articulate a primary goal of promoting inclusion and equality for all patients while addressing disparities in healthcare (see Appendix B). Infographic. The infographic will be featured during the educational seminar and displayed in patient areas to reinforce key learning concepts. It serves as a reference for utilizing appropriate lighting (Hanlon et al., 2022), incorporating touch to explore what the eye cannot see (Oliveira et al., 2023), and effectively communicating with patients about their pain, sensations, and expected versus unexpected findings. By employing these methods, nurses can foster a trusting relationship while empowering patients to take an active role in their assessments and reporting their findings (see Appendix C). Post-Survey. The post-survey will assess knowledge and confidence levels following the program's implementation. Additionally, it serves as a template for nurses to provide constructive feedback on how to improve the program and evaluate its value to nursing practice (see Appendix D). Timeline Creation Phase: 0-2 Months 1. Identify and engage stakeholders. 2. Establish a project team and assign roles. 18 3. Develop a communication plan and resources to ensure team compliance. 4. Conduct a unit or organizational assessment to identify potential gaps. 5. Review existing evidence regarding skin assessment for diverse skin tones. Development Phase: 2-4 Months 1. Development of learning materials and curriculum content. 2. Create training modules and learning aids based on evidence-based practice. Implementation Phase: 4-6 Months 1. Completion of the pre-survey. 2. Conduct in-person education for all allotted registered nurses. 3. Provide mentorship and real-time feedback to bedside nurses as they apply the education to patient care over two months. 4. Facilitate interdisciplinary collaboration. Evaluation Phase: 6+ Months 1. Completion of the post-survey. 2. Collect and analyze post-survey results and feedback. 3. Identify areas for improvement based on evaluation data. 4. Update training materials based on results. 5. Create a plan for ongoing education and new nurse orientation. Project Evaluation Project evaluation will concentrate on three key factors: Confidence scores from pre- and post-survey assessments, the identification and reporting of pressure injuries, and the quality of documentation. Pre-implementation surveys will be conducted to establish baseline confidence and knowledge levels among participants. A follow-up survey will be administered two months 19 after the educational intervention to evaluate changes in confidence, knowledge, and practices. Additionally, focus groups and interviews will be employed to gather further insights into participants' experiences and to identify any potential barriers. Data will be gathered through audits of patient electronic medical records (EMRs) and reviews of these records to evaluate the accuracy of Braden scale assessments, the validity of skin assessment findings, the timing of consultation orders placed, and the frequency and effectiveness of patient positioning. Quality improvement systems will incorporate both qualitative and quantitative reporting features, along with reviews by nursing educators and leaders, to assess the direct impact on patient care and outcomes before and after the intervention. The findings from these audits, paired with pre- and post-survey results, will undergo statistical analysis to evaluate changes in confidence intervals and determine the program's effectiveness. Further data analysis will help identify emerging trends in registered nurses' confidence in skin assessments and compliance in reporting and documentation for program customization. Ethical Considerations Several key considerations will be rigorously addressed to uphold ethical integrity throughout the project. This initiative aims to illustrate that traditional skin assessments and education, which predominantly focus on findings related to fair skin, fail to represent all diverse groups adequately. Ongoing education must recognize that fair skin should not be viewed as the standard norm. The program team will actively promote equality and inclusion by engaging registered nurses from diverse backgrounds and incorporating educational training that acknowledges the unique healthcare needs of individuals with darker skin tones. Data collection will be structured to minimize bias, emphasizing the importance of objective outcomes, with the 20 program surveys open to voluntary participation. The team will maintain privacy and confidentiality by securely storing data, redacting personal information, and restricting access to authorized personnel only. Findings will be reported accurately and comprehensively to encourage equitable and dignified care for patients while also fostering the professional growth of registered nurses. Discussion This project aimed to determine whether methods could be implemented to reduce pressure injuries in patients with darker skin tones by increasing registered nurses’ confidence in skin assessments. The research conducted explored the national prevalence of pressure injuries by patient demographic and the current best practices utilized. Findings indicate that although technological resources and various skin tone assessment tools are available to assist in evaluating patients with darker skin tones, enhancing confidence universally requires targeted educational interventions. These interventions should standardize practices regardless of skin tone by using the appropriate version of the Braden Scale, appropriate lighting for examinations (Hanlon et al., 2022) and employing tactile methods to detect subtle differences in temperature and texture (Oliveira et al., 2023). It is also essential to engage in effective communication to understand the patient’s perceived sensations, thereby empowering them to take an active role in their care. These findings align with research conducted by Black et al. (2023) and Fletcher & Oozageer Gunowa (2021), which underscores the necessity of addressing gaps in clinical assessment skills for patients with darker skin tones and the challenges in detecting early-stage pressure injuries. Evidence-based Solutions for Dissemination 21 Project findings will be disseminated through posters, presentations, and papers. This method ensures that findings reach diverse audiences, from frontline nurses to potential leadership and organizational policy members, increasing the likelihood that the project will be applied in real-world settings. Poster. The poster will distill key findings into a format that effectively engages the audience, promoting both learning and retention. It will include clear visuals with an emphasis on practical application, making it ideally suited for use in hospitals, clinics, conferences, or academic settings. Presentation. The presentation will utilize slides to display key data points, visuals, and actionable steps for implementation. The slides will be clear and concise, engaging the audience through storytelling and case studies concerning patients within the project's demographic, making the data relatable to healthcare professionals in clinical or academic settings. Paper. The paper will serve as a formal document for the quality improvement project and practical changes in nursing practice. It will provide a detailed account of scholarly findings for institutional use. Significance to Advance Nursing Practice This project directly advances nursing practice by addressing a critical gap in assessment skills. The findings highlight the importance of systematic changes in clinical practice and improved training in skin assessments for patients with darker skin tones (Black et al., 2023). By equipping nurses with the skills to increase their confidence in the early detection of pressure injuries, health equity can be promoted by reducing racial and ethnic disparities (Oozageer Gunowa, 2020). This project aligns with evidence-based practice by incorporating findings into continuous clinical nursing education. 22 Implications Integrating research findings into structured clinical education, assessing outcomes, and adapting training based on feedback from participants and stakeholders will ensure that evidence-based nursing practice remains dynamic in the ever-evolving healthcare landscape. This data-driven approach underscores the importance of continuous education and professional development to uphold high standards of care. Furthermore, the implementation of patientcentered training programs fosters inclusivity and contributes to reducing disparities. It is important to note that this project will primarily focus on standardized skin assessments without regard to skin tone. It will emphasize reporting abnormal findings related to texture, temperature, bilateral appearance, patient statements, and a thorough overview of various Braden Scales rather than using visual scales and specialized medical devices. This limitation is addressed by improving the foundational aspects of skin assessments and reporting across healthcare, ensuring that incorporating visual scales and devices is used to enhance practice rather than create dependency. Recommendations Recommendations for improvement include further exploration of visual scales that can reliably distinguish skin tones in conjunction with the Braden Scale, Braden Scale II (Ayello & Delmore, 2022), and the Braden QD scale, which are specifically designed for neonates and pediatric populations (Puspitasari et al., 2020). Obtaining evidence-based research and findings is challenging as updates to the Braden Scale II are relatively new. An additional challenge is that the Braden Scale used for adult populations does not include medical devices in its assessment risk score. Developing a universal assessment tool for all age groups, taking into 23 account medical devices and the history of pressure injuries, may help alleviate confusion in high-risk scoring, regardless of patient demographics. Conclusions Addressing disparities in skin assessment requires targeted education and systematic changes in nursing practice. The project demonstrated that standardizing skin assessment techniques, regardless of patient population, improves registered nurses’ confidence in assessing all patients, particularly those with darker skin tones. Hospitals and higher education institutions should implement similar practices to promote equitable patient care and reduce disparities in the detection of pressure injuries. 24 References Ayello, E. A., & Delmore, B. A. (2022). Risk assessment for pressure injuries. WCET Journal, 42(4). https://doi.org/10.33235/wcet.42.4.31-37 Black, J., Cox, J., Capasso, V., Bliss, D. Z., Delmore, B., Iyer, V., Massaro, J., Munro, C., Pittman, J., & Ayello, E. A. (2023). Current perspectives on pressure injuries in persons with dark skin tones from the national pressure injury advisory panel. Advances in Skin & Wound Care, 36(9). https://doi.org/10.1097/asw.0000000000000032 Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M., Rakel, B., Steelman, V., Tripp-Reimer, T., Tucker, S., & Authored on behalf of the Iowa Model Collaborative (2017). Iowa model of evidence-based practice: revisions and validation. Worldviews on evidence-based nursing, 14(3), 175–182. Chambers, C. L., & Thompson, J. (2024). Shedding New Light for nurses: enhancing pressure injury prevention across skin tones with sub‐epidermal moisture assessment technology. Journal of Advanced Nursing, 80(7). https://doi.org/10.1111/jan.16040 Delmore, B. A., & Ayello, E. A. (2023). Braden Scales for Pressure Injury Risk Assessment. Advances in Skin & Wound Care, 36(6), 332. https://doi.org/10.1097/01.ASW.0000931808.23779.44 Dowley, V. (2023). Assessing pressure ulcers in patients with darker skin tones. Oska. https://oska.uk.com/assessing-pressure-ulcers-in-patients-with-darker-skin-tones/ Duff, J., Cullen, L., Hanrahan, K., & Steelman, V. (2020). Determinants of an evidence-based Practice environment: an interpretive description. Implementation Science Communications, 1(1), 1–9. https://doi.org/10.1186/s43058-020-00070-0 25 Edsberg, L. E., Cox, J., Koloms, K., & VanGilder-Freese, C. A. (2022). Implementation of pressure injury prevention strategies in acute care. 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R., Jaleel, T., Heath, C. R., Kang, S., Vashi, N., Lester, J., Vasquez, R., Rodrigues, M., Elbuluk, N., Iltefat Hamzavi, Kwatra, S. G., Sundaram, H., Cobb, C., Brown, S. G., & Kohli, I. (2024). Integrating skin color assessments into clinical practice and research: A review of current approaches. Journal of the American Academy of Dermatology. https://doi.org/10.1016/j.jaad.2024.01.067 Humphrey, S., Manson Brown, S., Cross, S. J., & Mehta, R. (2021). Defining skin quality: clinical relevance, terminology, and assessment. Dermatologic Surgery, 47(7), 974-981. https://doi.org/10.1097/dss.0000000000003079 Kennerly, S. M., Sharkey, P. D., Horn, S. D., Alderden, J., & Yap, T. L. (2022). Nursing assessment of pressure injury risk with the Braden scale validated against sensor-based measurement of movement. Healthcare, 10(11), 2330. https://doi.org/10.3390/healthcare10112330 Konya, I., Nishiya, K., & Yano, R. (2021). Effectiveness of bed bath methods for skin integrity, skin cleanliness and comfort enhancement in adults: A systematic review. Nursing Open, 8(5), 2284-2300. https://doi.org/10.1002/nop2.836 Oliveira, R., Ferreira, J., Luís Filipe Azevedo, & Almeida, I. (2023). An Overview of Methods to Characterize Skin Type: Focus on Visual Rating Scales and Self-Report Instruments. Cosmetics, 10(1), 14–14. https://doi.org/10.3390/cosmetics10010014 27 Oozageer Gunowa, N. (2020) Embedding skin tone diversity into undergraduate nurse education. Through the lens of pressure injury. Journal of Clinical Nursing, 29(p.4358-4367) Oozageer Gunowa, N., Hutchinson, M., Brooke, J., Aveyard, H., & Jackson, D. (2021). Pressure injuries and skin tone diversity in undergraduate nurse education: qualitative perspectives from a mixed methods study. Journal of Advanced Nursing, 77(11). https://doi.org/10.1111/jan.14965 Panagioti, M., Khan, K., Keers, R. N., Abuzour, A., Phipps, D., Kontopantelis, E., Bower, P., Campbell, S., Haneef, R., Avery, A. J., & Ashcroft, D. M. (2019). Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ, 366(366). https://doi.org/10.1136/bmj.l4185 Pattinson, R., Trialonis-Suthakharan, N., Gupta, S., Henry, A., Lavallée, J., Otten, M., Pickles, T., Courtier, N., Austin, J., Janus, C., Augustin, M., & Bundy, C. (2021). Patient-reported outcome measures in dermatology: a systematic review. Acta Dermato Venereologica, 101(9), adv00559. https://doi.org/10.2340/00015555-3884 Pusey-Reid, E., Quinn, L., Samost, M. E., & Reidy, P. A. (2023). Skin assessment in patients with dark skin tone. American Journal of Nursing, 123(3), 36–43. https://doi.org/10.1097/01.naj.0000921800.61980.7e Puspitasari, J. D., Nurhaeni, N., & Waluyanti, F. T. (2020). Testing of Braden QD Scale for predicting pressure ulcer risk in the Pediatric Intensive Care Unit. Pediatric Reports. https://doi.org/10.4081/pr.2020.8694 Schumacher, D. J., Kinnear, B., Burk-Rafel, J., Santen, S. A., & Bullock, J. L. (2023). The next era of assessment: can ensuring high-quality, equitable patient care be the defining 28 characteristic? Academic Medicine: Journal of the Association of American Medical Colleges. https://pubmed.ncbi.nlm.nih.gov/38109659/ Sim, J., Wilson, V., & Tuqiri, K. (2024). The pressure injury prevalence and practice improvements (PIPPI) study: A multiple methods evaluation of pressure injury prevention practices in an acute‐care hospital. International Wound Journal, 21(10). https://doi.org/10.1111/iwj.70050 Tang, Y., Li, X., Cheng, H., Tan, S., Ling, Y., Ming, W., & Lyu, J. (2024). Braden score predicts 30‐day mortality risk in patients with ischaemic stroke in the ICU: A retrospective analysis based on the MIMIC‐IV database. Nursing in Critical Care. https://doi.org/10.1111/nicc.13125 United States Census Bureau. (2021). QuickFacts: Utah. Weir, V. R., Dempsey, K., Gichoya, J. W., Rotemberg, V., & Wong, A. I. (2024). A survey of skin tone assessment in prospective research. Npj Digital Medicine, 7(1). https://doi.org/10.1038/s41746-024-01176-8 Wynn, M.O., Goldstone, L., Gupta, R., Allport, J., & Robert. (2024). Improving pressure injury risk assessment using real‐world data from skilled nursing facilities: A cohort study. International Wound Journal, 21(7). https://doi.org/10.1111/iwj.70000 29 Appendix A Pre-Survey Assessing Knowledge of Skin Assessments for Darker Skin Tones Section 1: Demographics What is your primary role in nursing (Nurse manager, Charge Nurse, Nurse Educator, Executive Leader, Quality Improvement, Care Management, etc)? How many years do you have in healthcare? • • • • 0-3 4-7, 8-10, 10+ Have you received any formal training or education addressing skin assessments in individuals with darker skin tones? Yes or No Section 2: Knowledge Assessment What is the most common early sign of pressure injury in individuals with darker skin tones? • Redness • Non-blanchable erythema • Hyperpigmentation • Pale or ashen skin True or False: In darker skin tones, skin temperature and texture changes may indicate early skin breakdown. When assessing perfusion and for cyanosis in individuals with darker skin tones, which areas should be examined? (SATA) • Fingertips and palms • Lips and nail beds • Oral mucosa and conjunctiva • All of the above True or False: The appearance of blanching is a reliable method of assessing pressure-related skin changes in darker skin tones. Which of the following methods can enhance the skin assessment of skin conditions in individuals with darker skin tones? (SATA) • Using a well-lit environment 30 • • • • Palpitation to assess texture and temperature Strictly visual inspection Examining less pigmented areas such as lips, mucous membranes, and sclera Communication with patient/caregiver Section 3: Braden Scale Knowledge Which of the following are factors assessed in the Braden Scale? (SATA) Sensory perception • Moisture • Activity • Nutrition • Medication • Diagnosis • Friction and Shear • Medical devices • Patient placed in bed • Skin integrity True or False: A lower Braden Scale score indicates a higher risk for pressure injury. How frequently should a Braden Scale assessment be performed for patients at risk of pressure injuries? • Every 2 hours • Every 4 hours • Every 24 hours • Once per shift • Only when a pressure injury is suspected • On admission and at discharge Section 4: Confidence and Practice On a scale of 1 to 5 (1= Not confident, 5= Very confident), how confident are you in assessing skin conditions in individuals with darker skin tones? What challenges do you face when assessing skin conditions in individuals with darker skin tones? 31 Appendix B PowerPoint Presentation Enhancing Skin Assessment Skills in Darker Skin Tones BRANDON CROSBY RN, BSN, MSN STUDENT WEBER STATE UNIVERSITY Introduction Importance of accurate skin assessments Common challenges faced in clinical practice Objectives • Highlight unique considerations for darker skin tones • Address various Braden Scales and its limitations • Provide guidance on skin assessment, documentation, and reporting 32 Significance of Skin Assessments • Role of skin assessments in pressure injury • Impact on patient experience and outcomes (Fletcher & Oozageer Gunowa, 2021) • Statistics per defined demographics (Black et al., 2023) Statistics What patient demographic has the highest reported Stage 1 PI incidence? White, Non-Hispanic What patent demographic has the lowest incidence of PI staged 2-4? White, Non-Hispanic Demographics with the highest reported incidence of PI? Black 16.6%; White 8.4% Cost of treating a pressure injury? Single PI ranges from $500-$70,000, or $11 billion annually (Singh et al., 2021) 33 Education • How are skin assessments typically taught in higher-level educational institutions? • Various stages of a pressure injury? • What is normal? • Braden scale Braden Scale What are the six subscale factors? • Mobility • Activity • Sensory perception • Nutrition • Moisture • Friction and shear Is a high score or low score bad? 34 Braden Score Cont. • Total range: 6-23 • No risk: 19-13 • Mild risk: 15-18/risk for increased mortality begins (Tang et al., 2024) • Moderate risk: 13-14 • High risk: 10-12 • Severe Risk: 9 or less (Kennerly et al., 2022) Braden Scale Cont. Are the subscale factors universal for all skin tones? What are some limitations? What are other contributors to pressure injuries? 35 The Twist Braden QD The Braden QD pediatric-specific risk assessment, for premature infants to 21 years of age, incorporates medical devices and immobility in acute care environments. (Puspitasari et al., 2020) Notable Difference: A lower Braden QD score indicates a lower risk, whereas a low Braden Scale score indicates a higher risk. 36 An updated version of the adult Braden Scale is called Braden Scale II. This includes a new subscale category for the ability to change and control body position and potential cognitive impairments that could affect sensory perception. Did you know? Improvements in Practice • Touch (Oliveira et al., 2023) • Lighting (Hanlon et al., 2022) • Communication (Fletcher & Oozageer Gunowa, 2021) • Appropriate Braden Scale 37 Summary No patient is immune to pressure injuries, but many are at higher risk. Due to higher educational and clinical practice gaps,stage 1 pressure injuries are more challenging to detect in patients with darker skin tones, leading to a higher risk of more serious pressure injuries. Regardless of skin tone, all assessment techniques should be standardized. Use appropriate lighting, incorporate tactile elements, and involve the patient by asking questions and gathering subjective data through effective communication. The Braden Scale is used for adults. The older the patient, the higher the score is considered better. The Braden Scale QD is used for pediatrics. The younger the patient, the lower the score is better. Helpful mnemonic: • Questions? TLC (TOUCH, LIGHTING, COMMUNICATION) 38 References Black, J., Cox, J., Capasso, V., Bliss, D. Z., Delmore, B., Iyer, V., Massaro, J., Munro, C., Pittman, J., & Ayello, E. A. (2023). Current perspectives on pressure injuries in persons with dark skin tones from the national pressure injury advisory panel. Advances in Skin & Wound Care, 36(9). https://doi.org/10.1097/asw.0000000000000032 Fletcher, J., & Oozageer Gunowa, N. (2021). Skin assessment: Assessing skin on patients with darker skin tones in relation to PU prevention. Society of Tissue Viability. Retrieved August 18, 2024. https://societyoftissueviability.org/resources/skin -assessment-assessing-skin-on-patients-with-darkerskin-tones-in-relation-to-pu-prevention/ Hanlon, K. L., Wei, G., Correa -Selm, L., & Grichnik, J. M. (2022). Dermoscopy and skin imaging light sources: a comparison and review of spectral power distribution and color consistency. Journal of Biomedical Optics, 27(08). https://doi.org/10.1117/1.jbo.27.8.080902 Kennerly, S. M., Sharkey, P. D., Horn, S. D., Alderden, J., & Yap, T. L. (2022). Nursing assessment of pressure injury risk with the Braden scale validated against sensor -based measurement of movement. Healthcare, 10(11), 2330. Oliveira, R., Ferreira, J., Luís Filipe Azevedo, & Almeida, I. (2023). An Overview of Methods to Characterize Skin Type: Focus on Visual Rating Scales and Self -Report Instruments. Cosmetics, 10(1), 14–14. https://doi.org/10.3390/cosmetics10010014 Puspitasari, J. D., Nurhaeni, N., & Waluyanti, F. T. (2020). Testing of Braden QD Scale for predicting pressure ulcer risk in the Pediatric Intensive Care Unit. Pediatric Reports. https://doi.org/10.4081/pr.2020.8694 Singh, C., Shoqirat, N., & Thorpe, L. (2021). The cost of pressure injury prevention. Nurse Leader , 20(4). https://doi.org/10.1016/j.mnl.2021.11.003 Tang, Y., Li, X., Cheng, H., Tan, S., Ling, Y., Ming, W., & Lyu, J. (2024). Braden score predicts 30 -day mortality risk in patients with ischaemic stroke in the ICU: A retrospective analysis based on the MIMIC -IV database. Nursing in Critical Care . https://doi.org/10.1111/nicc.13125 39 Appendix C Infographic 40 Appendix D Post-Survey Post-Educational Survey: Skin Assessment of Darker Skin Tones Question 1-Strongly 2-Somewhat 3- Neutral 4- Somewhat Disagree Disagree Agree After completing the program, I am confident in assessing skin conditions in individuals with darker skin tones. After completing the skin assessment education and using the resource tool, my confidence in early detection and prevention of skin breakdown has improved I am confident in using the Braden Scale to assess patients at risk for pressure injuries. The content is relevant to my nursing practice. The teaching methods used in the program were engaging and benefited my learning. This program addresses my challenges when assessing skin conditions in individuals with darker skin tones. I am likely to recommend this program to colleagues. 5-Strongly Agree Feedback on the Educational Program (Open-Ended) What aspects of the program were the most helpful? What assessment methods will you incorporate into your practice? What improvements would you suggest? What barriers do you still encounter when assessing skin conditions in individuals with darker skin tones? What additional support or resources would help you further improve your practice? Thank you for completing this survey! Your feedback is valuable in improving future educational initiatives and addressing disparities in patient care. 41 Appendix E Timeline