Digital Repository Masters Projects Spring 2025 Preventing Pressure Injuries in the Neonatal Intensive Care Unit Through Nursing Education Allison Struiksma Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Struiksma, A. 2025. Preventing Pressure Injuries in the Neonatal Intensive Care Unit Through Nursing Education. 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 Preventing Pressure Injuries in the Neonatal Intensive Care Unit Through Nursing Education Project Title by Allison Struiksma 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 4/26/25 Ogden, UT Date Allison Struiksma, BSN, RN, MSN Student 4/26/25 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. 04/26/2025 Date 1 Preventing Pressure Injuries in the Neonatal Intensive Care Unit Through Nursing Education Allison Struiksma, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: This project aimed to educate Neonatal Intensive Care Unit (NICU) nurses on skin assessment practices, pressure injury identification, and prevention to increase their confidence in identifying and preventing pressure injuries. Rationale/Background: Pressure injuries harm patients physically and financially. Critically ill NICU patients are at an increased risk of developing pressure injuries due to factors related to their diagnosis, skin maturity, level of illness, and immobility. Nurses report that current skin assessment and pressure injury prevention education is inadequate to effectively manage and prevent pressure injuries. Methods: A bedside reference tool and education were developed to educate NICU nurses on skin assessment and pressure injury prevention in NICU patients. NICU nurses utilized this reference tool with their patients during skin assessment. Pre-education and post-education surveys were given to each NICU nurse to identify if the education increased the nurses’ confidence to identify and prevent pressure injuries. Results: Evidence-based education on skin assessment and pressure injury prevention in NICU patients increases nurses’ confidence in identifying and preventing pressure injuries. NICU nurses reported an increased ability to identify and prevent pressure injuries after education on and utilization of the reference tool. Conclusions: NICU nurses have increased confidence in their ability to identify and prevent pressure injuries after implementing skin assessment and pressure injury prevention education in NICU patients. Keywords: education, NICU, nurses, pressure injury, prevention, and skin assessment 3 Preventing Pressure Injuries in the Neonatal Intensive Care Unit Through Nursing Education Caregivers across healthcare systems strive to reduce pressure injuries during patient stays to prevent hospital-acquired conditions (Fassino et al., 2023). In the Neonatal Intensive Care Unit (NICU), patients are often at a higher risk for developing pressure injuries, as they are critically ill and have skin immaturity. Pressure injuries occur more frequently in critically ill NICU patients who are unstable or awaiting surgery. NICU nurses have difficulty repositioning these patients during this critical time due to frequent vital sign decompensation during standard care. Pressure injuries are painful, costly for the patient and the hospital, and can lengthen hospital stay (Hu et al., 2021). Identifying evidence-based skin assessment practices to utilize on the most critically ill NICU patients is vital to preventing pressure injuries (Broom et al., 2019). Educating nurses on evidence-based skin assessment is a critical factor in enhancing nurses' confidence in identifying and preventing pressure injuries (Kurtgoz & Koc, 2024). This education is particularly significant in the NICU, where patients are at a heightened risk of developing pressure injuries. The lack of specialized education for detecting and preventing pressure injuries for NICU nurses directly impacts patient outcomes, including length of stay and quality of care (Hu et al., 2021). Education on evidence-based skin assessment practices and pressure injury prevention strategies tailored to the NICU population improves nurses' confidence in preventing and identifying pressure injuries. Statement of Problem Although healthcare organizations acknowledge that pressure injuries harm patients physically and financially, nurses report that their skin assessment and pressure injury prevention education is inadequate to maintain their confidence to effectively manage and prevent pressure 4 injuries (Kurtgoz & Koc, 2024). Because the first stage of preventing pressure injuries is a thorough skin assessment, nurses must receive additional education on skin assessment techniques for patients in specialized care settings to feel confident about preventing pressure injuries (Broom et al., 2019). There is a lack of formal training on skin assessment for nurses assigned to provide care in the NICU setting, which can lead to unrecognized skin breakdown and an increased rate of pressure injuries in NICU patients (Dineen et al., 2023). Nurses experience emotional distress when their patients develop a pressure injury (Kurtgoz & Koc, 2024). Further, patients who develop a pressure injury experience physical pain at the wound site, and parents experience financial distress from added treatment and lengthened hospital stays (Hu et al., 2021). Premature or critically ill NICU patients are at an increased risk of developing pressure injuries due to factors related to their diagnosis, skin maturity, level of illness, and immobility. Therefore, this project aims to educate NICU nurses on skin assessment practices and provide a reference tool for skin assessment and pressure injury identification to increase their confidence in identifying and preventing pressure injuries. Significance of the Project Educating NICU nurses on skin assessment and pressure injury prevention is essential to nursing engagement and improved patient safety (Broom et al., 2017). Nurses who apply specialized skin assessment education to their practice can prevent patients from developing pressure injuries that may result in additional healthcare costs, an increased length of stay, and physical pain or long-term skin damage (Hu et al., 2021). Furthermore, additional education on skin assessment can increase nurses' confidence in identifying and preventing pressure injuries, thus increasing their engagement in the patient care setting (Kurtgoz & Koc, 2024). This project 5 aims to fill the education gap on skin assessment and pressure injury prevention for NICU nurses and identify if additional education increases nurses' confidence to prevent pressure injuries. Educating nurses on pressure injury prevention and skin assessment can decrease the length of a hospital stay and associated costs by decreasing the rate of pressure injuries (Hu et al., 2021). Patients with pressure injuries stay in the hospital longer than patients without pressure injuries. During a lengthened hospital stay, treatment costs are also significantly higher for patients with pressure injuries than those with similar diagnoses (Hu et al., 2021). For example, the average cost of a hospital-acquired pressure injury in the United States is over ten thousand dollars, including the lengthened hospital stay and added treatment costs (Hu et al., 2021). Furthermore, in immunocompromised neonates, a breach in skin integrity also increases the patient's risk for a hospital-acquired infection, which can also increase hospital stay and healthcare costs (Kar et al., 2024). Pressure injuries can cause physical pain for NICU patients and emotional distress for the nurse (Kurtgoz & Koc, 2024). Severe pressure injuries may cause skin deformities and scarring (Dineen et al., 2023). The increased pain and discomfort in NICU patients can lead to higher use of narcotic medications to comfort the patient, which can increase developmental delays in neonates (Broom et al., 2019). Educating nurses on skin assessment and pressure injury prevention can significantly reduce NICU patients' pain and potential for long-term skin scarring, decreasing the need for narcotic medication use and its associated risks (Broom et al., 2019). The development of a patient's pressure injury can cause the nurse distress, as nurses often feel responsible for the deteriorating skin integrity of their patients (Kurtgoz & Koc, 2024). Formal skin assessment and pressure injury prevention training have improved nurse confidence, increased nurse engagement, and improved patient outcomes (Broom et al., 2017). 6 Review of the Literature Healthcare organizations aim to prevent hospital-acquired conditions, such as pressure injuries, during patient hospitalization (Fassino et al., 2023). In the NICU, patients are often at a higher risk for developing pressure injuries, as they are critically ill and have skin immaturity. A thorough skin assessment of NICU patients is essential to identify risks and early interventions in preventing pressure injuries (Razmus & Keep, 2022). This literature review aims to find current evidence to address the PICOT question: In NICU nurses (P), does education on skin assessment and pressure injury prevention (I) in the NICU population versus standard education (C) improve nurses’ confidence to assess and prevent pressure injuries (O) over two months (T)? Framework The Iowa Model of Evidence-Based Practice (EBP) is a quality improvement framework suited to making clinical practice changes with appropriate feedback loops throughout the process (Melnyk & Fineout-Overholt, 2024). The Iowa Model allows for issue identification, literature review, and intervention identification based on sufficient evidence or a need for more research (Melnyk & Fineout-Overholt, 2024). This framework allows for review at the end of the EBP process and along the way. The Iowa Model is an appropriate framework for identifying and evaluating skin assessment and pressure injury interventions by NICU nurses. The first step in the framework is to identify an issue that requires intervention, which is the need for more education on skin assessment and pressure injury prevention for NICU nurses. The next step is identifying a practice question, gathering an expert team, and reviewing the literature. After creating the PICOT question, the clinician will identify an expert team, which includes NICU clinical leaders. 7 The literature review will be reviewed for evidence-based interventions to prevent pressure injuries in pediatric, neonatal, and adult intensive care unit settings. After identifying sufficient evidence, the next step is to design and pilot the practice change by collecting baseline data, developing an implementation plan, and collecting post-pilot data (Melnyk & Fineout-Overholt, 2024). A pre-survey for NICU nurses will identify the current understanding of pressure injuries and education gaps. The expert team will develop education for nurses and a bedside resource to guide skin assessment when caring for NICU patients. A post-survey will determine the effectiveness of the education on nurse confidence. The last step of the Iowa Model is to sustain the practice change by evaluating the postsurvey to identify further education needs and provide continued education on pressure injuries. This step allows for continued evaluation of the practice change to ensure the intervention is appropriate and effective (Buckwalter et al., 2017). The potential impact of this project on patient outcomes is significant and should inspire and motivate all involved. Strengths and Limitations The strengths of the Iowa Model include continued feedback loops throughout the process. The feedback loops provide an opportunity to streamline the nonlinear nature of evidence-based practice quality improvement projects and encourage forward movement in the project (Melnyk & Fineout-Overholt, 2024). The frequent revisions encourage continued review for needed practice changes, address the sustainability of evidence-based practice, and improve patient outcomes (Buckwalter et al., 2017). Identifying evidence-based education for skin assessment and pressure injury prevention in NICU nurses will require frequent revisions and feedback from multiple disciplines, following the Iowa Model. The Iowa Model has also provided student and faculty program satisfaction when used in an academic setting (Lloyd et al., 8 2016). Limitations of the Iowa Model include the need for more specificity in the individual steps of the framework and complexity in the number of steps for those new to the evidencebased practice research process (Buckwalter et al., 2017). Analysis of Literature This literature review evaluated the PICOT question of whether additional skin assessment and pressure injury identification education would improve nurses' confidence in preventing pressure injuries in NICU patients. The themes identified in this literature search included implementing a standardized skin assessment tool, providing nursing education on skin assessment and pressure injury prevention, and utilizing equipment that relieves pressure for NICU patients. While the literature on pressure injuries in NICU patients is minimal, there is evidence that additional education on skin assessment increases the confidence of Intensive Care Unit (ICU) nurses in preventing pressure injuries. Some articles in this literature review refer to ICU nurses and NICU nurses. Search Strategies This literature search used multiple platforms, including Weber State University's Stewart Library's OneSearch and Advanced Search (which searches multiple databases), the Cumulated Index in Nursing and Allied Health Literature (CINAHL), and PubMed. The search was narrowed to articles from 2019 through 2024 so that all evidence reviewed was in the last five years. The search included keywords such as assessment tool, ICU, identify, newborn, neonatal, NICU, nurses, pressure injury, prevention, qualitative, quality improvement, quantitative, and skin assessment. Boolean operators combined keyword search terms in the listed databases, ensuring a more comprehensive search. Synthesis of the Literature 9 Evidence from the literature reveals three themes: 1) implementing a standardized skin assessment tool, 2) initial and continuing skin assessment and pressure injury prevention education, and 3) providing effective pressure reduction equipment for NICU patients to increase nurses’ confidence to assess skin and prevent pressure injuries. Standardized Skin Assessment Tools Several studies found that using a standardized skin assessment tool decreases pressure injury prevalence in ICUs. Fassino et al. (2023) performed a descriptive and retrospective observational study of 127 NICU patients with pressure injuries over six years. They found statistically significant evidence that implementing a standardized skin assessment decreased pressure injury in the postimplementation phase. Blazier et al. (2023) also studied electroencephalogram (EEG) related pressure injuries in 295 NICU patients. They found that implementing an evidence-based skin assessment tool evaluated by an expert team could eliminate pressure injuries in NICU patients undergoing an EEG. A specific skin risk assessment tool was identified in multiple studies to decrease pressure injuries in NICU patients. While these articles provided evidence in favor of implementing a skin assessment tool, Broom et al. (2019), Dineen et al. (2023), and Ahmadizadeh et al. (2024) studied a specific skin assessment tool called the Skin Risk Assessment and Management Tool (SRAMT) to identify if the tool improved skin assessment and pressure injury prevention in the NICU. Researchers found that the SRAMT tool can reduce the incidence of skin injuries and standardize skin assessment in NICU patients (Broom et al., 2017). Broom et al. (2019) compared two NICU-specific skin assessment tools, the SRAMT and the Braden-Q Scale (BQS), and found that the SRAMT tool correctly predicted 42% of the infants at risk for a skin injury compared to the BQS tool, with a 24% prediction (Broom et al., 10 2019). Dineen et al. (2023) implemented the use of the SRAMT tool in a NICU that previously did not have a skin risk assessment tool. This study evaluated the effectiveness of the SRAMT tool to decrease pressure injuries after providing nursing education on the tool and skin assessment. Ahmadizadeh et al. (2024) utilized the SRAMT tool for skin assessments of 265 newborns in the NICU over 28 days from the newborn’s birth. Out of 265 newborns, 191 newborns developed a skin injury. The study showed that newborns with a high-risk score had more injuries than others. There was a significant and direct correlation between NICU skin injuries and a high-risk score using the SRAMT tool throughout this study with a p=0.05 (Ahmadizadeh et al., 2024). Pressure Injury Education Several studies found that implementing education in addition to a standardized skin assessment tool was beneficial in promoting the nurses' ability to recognize and prevent pressure injuries (Fassino et al., 2023). Vazquez and Bell (2024) studied the impact of education on the Braden-Q Scale (BQS) tool use within 12 hours of admission and every subsequent 12 hours, revealing that thorough education on the BQS tool led to an 80% use of the BQS tool within 12 hours of admission (Vazquez & Bell, 2024). The education included huddle board reminders and a bedside resource guide on the BQS tool (Vazquez & Bell, 2024). Cummins et al. (2019) provided pressure injury education to 51 pediatric intensive care unit (PICU) nurses to learn if education would decrease the rate of pressure injuries in the PICU. Pre-education test scores averaged 61.6%. Post-education test scores increased to 79.5%. After the education and the posttest occurred, the PICU pressure injury incidence rate dropped from 8% to 3%. Utilization of education on pressure injury prevention and implementation of a standardized skin assessment tool effectively increase nurses’ confidence to prevent pressure 11 injuries when used in conjunction. Nie (2020) performed a quality improvement study of 40 pediatric and NICU nurses to identify if pressure injury prevention guidelines for adult patients are adaptable to the pediatric population. The author conducted quarterly surveys of the nurses and provided education on pressure injuries and a skin assessment tool. Evidence shows that this education increased nurses' confidence in recognizing pressure injuries in the pediatric population. Kurtogz and Koc (2024) surveyed nurses about pressure injuries. They identified a statistical significance that nurses who do not receive pressure injury education cannot recognize and prevent pressure injuries. 61.5% of nurses reported receiving no pressure injury-specific education, indicating that education would increase their confidence in identifying pressure injuries in the ICU. Dineen et al. (2023) identified that continual education is required to ensure staff understand pressure injury prevention techniques and continually use skin assessment tools. In addition to continued education, a yearly review of the education and a tool use audit were all needed to successfully implement skin assessment education (Dineen et al., 2023). In partial contrast, Razmus and Keep (2022) conducted a cross-sectional survey of 252 nurses from various NICU organizations on pressure injury prevention practices for neonates. They found that combining a skin assessment tool, education, moisture management, and pressure redistribution tools gave nurses confidence to evaluate and prevent pressure injuries. Kar et al. (2024) also conducted a study to implement multiple interventions to reduce pressure injuries. They found that a quality nursing education initiative, an evidence-based skin assessment tool, and a skin barrier application increased nurses’ ease in identifying and preventing pressure injuries. This study’s pressure injury rate dropped from 30 injuries per 1000 incidences to 0 injuries after the combination of interventions (Kar et al., 2024). These authors 12 found that there was more that goes into preventing pressure injuries than a skin assessment tool and education. Pressure Injury Reduction Equipment Several studies found that utilizing pressure injury reduction equipment decreases pressure injuries in NICU patients. Utilizing evidence-based equipment to redistribute pressure could prevent pressure injuries from life-saving equipment such as EEG electrodes (Blazier et al., 2023). Seventeen percent of patients with tracheostomies develop pressure injuries at their tracheostomy site during their hospital stay (Vahabzadeh-Hagh et al., 2024). However, evidence shows that patients who utilize a tracheostomy support system have a decreased rate of pressure injuries during their hospital stay (Vahabzadeh-Hagh et al., 2024). Nurses who use specific pressure-reducing equipment and repositioning contribute to preventing pressure injuries (Nie, 2020). Using a fluidized positioner decreases pressure injuries for ICU patients when combined with frequent repositioning and rotation (Sousa et al., 2020). For neonate patients, using a prototype air mattress decreases pressure on patients’ skin by nine to twenty-nine percent (Schluer et al., 2023). Fassino et al. (2023) suggest that pressure injuries can be reduced by identifying patients at a higher risk for pressure injuries because of their medical devices and utilizing evidence-based skin barriers (Fassino et al., 2023). This literature review did not identify any articles with evidence against specific pressure-reducing equipment and preventing pressure injuries. Summary of Literature Review Findings and Application to the Project Preventing pressure injuries in the NICU patient population is challenging, but some interventions have effectively protected the skin of fragile patients. Implementing an evidencebased skin assessment at least once daily has helped identify patients at high risk for pressure 13 injuries and catch potential pressure injuries before they worsen, significantly improving patient outcomes (Blazier et al., 2023). Caregiver dedication to education on skin assessment, identification of pressure injuries, and proper use of medical equipment on the skin decreases pressure injuries significantly (Nie, 2020). This project will use evidence from the literature to identify evidence-based education for the NICU population and educate NICU nurses on using a bedside reference tool to prevent pressure injuries. More research is needed to identify which education practices increase ICU nurses' confidence to properly care for their patient's skin. Project Plan and Implementation This MSN project aims to prevent pressure injuries in the NICU by educating NICU nurses on skin assessment and pressure injury prevention. The involvement of multidisciplinary stakeholders is necessary for the success of this education. Those stakeholders include the nurse manager, nurse educator, quality nurse shared leader, medical director, clinical nurse specialist, and bedside NICU nurses. Implementing education on standardized skin assessment and pressure injury prevention techniques will require specific deliverables to ensure a successful understanding of the education to provide the highest quality impact to the nurse and, ultimately, the patient. These deliverables will include (a) a pre-survey for NICU nurses to document a baseline of current education on assessing skin and identifying pressure injuries using a Likert scale, (b) an infographic reference tool that details both images and evidence-based descriptions on NICU skin assessment and pressure injury prevention techniques, (c) a PowerPoint presentation on the infographic during the NICU staff meeting, and (d), a post-survey for NICU nurses to evaluate if the infographic and the distribution of the education were effective in increasing nurses’ confidence to assess and prevent pressure injuries. This project will utilize the Iowa Model, 14 which outlines a method to evaluate a process and make changes (Buckwalter et al., 2017). Thus, the stakeholders will evaluate the post-survey data to determine if further education is needed. The project lead will present the post-survey data to hospital administration if the survey shows statistical significance in increased education from the pre-survey data. Plan and Implementation Process Implementation of this project will require a collaborative effort from the stakeholders and commitment to education from the bedside NICU nurses. The intended recipients of this project are the bedside NICU nurses in a Level IV NICU in a stand-alone Children’s Hospital. The project aims to increase the nurses’ confidence in assessing skin and preventing pressure injuries in NICU patients. The stakeholders will meet to review the evidence-based literature on skin assessment and pressure injury prevention in the NICU. Key stakeholders are presented with evidence-based literature on pressure injury prevention for the NICU population and the project deliverables to obtain approval. During this meeting, stakeholders will be encouraged to share their questions, identify potential barriers, and collaborate on the education. Once the project is approved, implementation begins. Implementation begins with a pre-survey of the bedside nurses to evaluate their current education on skin assessment and pressure injury prevention. The pre-survey is added to the weekly NICU newsletter to advertise the pre-survey. The newsletter article will be on the shift huddle board with a QR code link to the survey. The survey will be available to the bedside nurses for three weeks to allow all nurses to complete it. After the pre-survey data has been collected, the project lead presents the pressure injury education presentation and infographic to the bedside nurses via a PowerPoint during the 15 monthly NICU staff meeting and includes the education in the weekly NICU newsletter. The education presentation is also recorded and stored in an online platform that all bedside nurses can access. The project lead places the infographic in every patient’s bedside resource binder for the bedside nurse to utilize. The clinical nurse specialist ensures the infographic is available on the NICU document index on the organization’s intranet. A reminder about the new infographic and recorded educational PowerPoint presentation will be on the shift huddle board. Once all nurses are educated, they apply the education to their patient care throughout the following month. One month after the education is shared with the bedside nurses, the project lead writes a newsletter article for the weekly NICU newsletter to advertise the post-survey. A summary of this newsletter article will be on the shift huddle board, along with a QR code link to the survey. The stakeholders evaluate the post-survey results and identify whether the education improved the nurses’ confidence in assessing and preventing pressure injuries. Interdisciplinary Team Involving a team of various healthcare professionals from different disciplines in project development will strengthen the success of the interventions and outcomes. For this MSN project, the interdisciplinary team will include the project lead, nurse educator, quality nurse shared leader, medical director, clinical nurse specialist, and bedside NICU nurses. These stakeholders will collaborate and utilize their differing perspectives and experiences to meet project goals. Project Lead. The project lead is a registered nurse, an MSN student, and the nurse manager of the NICU. The project lead organizes stakeholder meetings, creates deliverables, and acts as a resource to bedside nurses during the month of education. The project lead facilitates 16 potential differences during stakeholder meetings and utilizes the various perspectives to create the best possible deliverables. The project lead collects pre- and post-survey results and organizes the data for the other stakeholders. The project lead has the overall responsibility for the project implementation. Nurse Educator. The nurse educator works with the project lead to develop the infographic and PowerPoint presentation for bedside nurses. The nurse educator works closely with the quality nurse shared leader to round with bedside nurses during the month of education and answer questions about the infographic and skin assessment guidelines. The nurse educator will identify other educational venues not determined by the project lead. Quality Nurse Shared Leader. The quality nurse shared leader provides perspective on bedside nurse skin assessment and management of pressure injuries, as the quality nurse shared leader reviews all NICU pressure injuries and works as a bedside nurse. The quality nurse shared leader works closely with the nurse educator during the month of education and answers questions about the infographic and skin assessment guidelines. The quality nurse shared leader uses the education provided during their bedside shifts and gives feedback to the stakeholders on any potential barriers to utilizing the education. Medical Director. The medical director of the NICU is a neonatologist who oversees all neonatologists in the NICU and guides clinical decision-making. The medical director ensures that bedside nurses are educated on the best practices for evaluating NICU patients’ skin and pressure injuries. The medical director informs the neonatologists about the additional education bedside nurses receive on skin assessment and pressure injury identification so that these physicians can discuss skin assessment during daily rounds to solidify the education for bedside nurses. 17 Clinical Nurse Specialist. The clinical nurse specialist (CNS) analyzes the evidencebased practice identified by the project lead for validity and relevance. The CNS ensures the infographic is published on the NICU’s document index on the organization’s intranet for easy access for bedside nurses. The CNS collaborates on areas for improvement or efficiency. Registered Nurses. The bedside nurses will provide data on their current level of education on skin assessment and pressure injury prevention before being provided additional education. The bedside nurses will commit to reviewing the infographic, watching the PowerPoint presentation, and implementing the education provided to their patients. After reviewing and implementing the education, the bedside nurses complete the post-survey to provide data on their confidence level in assessing skin and preventing pressure injuries. The bedside nurses will provide feedback on the education and offer ideas for improvement in future education. Description and Development of Project Deliverables Implementing education requires project deliverables to educate bedside nurses and evaluate if that education is adequate. The stakeholders utilize the reviewed evidence to help the project lead develop effective deliverables for the project. The project lead develops a presurvey, an infographic on assessing skin and preventing pressure injuries, a PowerPoint on the evidence and the infographic, and a post-survey. Pre-Survey. The bedsides nurses’ pre-survey questions evaluate their current understanding of skin assessment and pressure injury prevention (see Appendix A). The presurvey consists of seven questions using identifiers of NICU nurse experience and a Likert scale rating to evaluate bedside nurses. The use of a pre-survey before education and a post-survey 18 after education is effective in increasing nurses’ confidence to prevent pressure injuries and assess the effectiveness of the education (Cummins et al. (2019). Bedside Educational Infographic. The educational infographic on assessing skin and preventing pressure injuries for NICU nurses is placed at their patient’s bedside (see Appendix B). This infographic is concise and organized into separate sections on assessing skin and utilizing tools to prevent pressure injuries. Using an infographic readily available to bedside nurses can increase nurses’ understanding of the provided education and, thus, increase their confidence in preventing pressure injuries (Nie, 2020). Implementing a quality education initiative that is easy to read, simple to use, and evidence-based has increased nurses’ understanding of said education (Vazquez & Bell, 2024). Educational PowerPoint. The PowerPoint is for bedside nurses to learn why education is needed and presents education and evidence on skin assessment and preventing pressure injuries (see Appendix C). The PowerPoint includes a copy of the infographic so bedside nurses can learn about the tool before using it at the bedside on a patient. Providing education on an initiative ensures nurses understand how to implement the initiative and increases nurses’ ease in identifying and preventing pressure injuries (Kar et al., 2024). Post-Survey. The post-survey questions for the bedside nurses evaluate their understanding of assessing skin and preventing pressure injuries after receiving education via the infographic and PowerPoint (see Appendix D). The post-survey consists of seven questions using identifiers of NICU nurse experience and a Likert scale rating to evaluate bedside nurses. A post-survey after education, when a pre-survey was used before education, is an evidencebased way to evaluate if the provided education was effective and understood (Cummins et al. (2019). 19 Timeline The stakeholders meet during the first month of the project to review the evidence and determine gaps in current education. The project lead considers the expertise of all the stakeholders in developing the deliverables. After developing the deliverables, the project lead gathers the stakeholders for another meeting approximately one month after the first meeting. The stakeholders determine if the deliverables are accurate and ready to present to staff. The project lead makes any necessary changes based on feedback from the stakeholders. The project lead sends the pre-survey to all bedside nurses in the weekly newsletter and the shift huddle board approximately two weeks after finalizing the deliverables with the stakeholders. The pre-survey will be available to bedside nurses for 3 weeks. After the pre-survey closes, the project lead presents the infographic and evidence on why education is needed in a PowerPoint presentation to all bedside nurses during a monthly staff meeting. The project lead also records the PowerPoint presentation and uploads the recording to the shared online space for all bedside nurses to review if they cannot attend the monthly staff meeting. After the staff meeting, the project lead places the infographic at each patient’s bedside. Bedside nurses are encouraged to apply the education and infographic tool to patient care over two months. Two months after the education is presented to the bedside nurses, the project lead sends the post-survey to all bedside nurses in the weekly newsletter and the shift huddle board. The post-survey will be available to bedside nurses for 3 weeks. The project lead collects the postsurvey data and improves the infographic and education based on the feedback. The project timeline will take over 6 months (see Appendix E). The project lead will continue to evaluate the effectiveness of the education over time and consider collecting data on 20 pressure injury rates in the NICU. The project lead will utilize the Iowa Model to sustain the practice change over time and determine if further education on preventing pressure injuries is needed (Buckwalter et al., 2017). Project Evaluation Project evaluation is a necessary part of the quality improvement process (Haass & Guzman, 2019). It ensures that the project was implemented successfully and that the intended audience received the benefits of the outcome. Project evaluation also allows the stakeholders to examine prior assumptions and identify any additional interventions needed for the project’s success (Haass & Guzman, 2019). The post-survey initially evaluates this project for effectiveness (see Appendix D). Compared to the pre-survey, the post survey gathers data on how effective the education was in increasing nurses’ confidence to complete a skin assessment and prevent pressure injuries. This data will provide the first insight into whether the project’s interventions successfully generated the predicted outcome. The stakeholders will review the post-survey data to identify any barriers to the intervention affecting the project’s outcome. If barriers are identified, the project lead will consider changing the provided education or finding another intervention entirely. The project lead and stakeholders will continue to evaluate the effectiveness of the education on the outcome by seeking direct feedback from the nurses who participated in the education. This evaluation will occur during and after the project. After the education is implemented, the project lead and nurse educators will round with bedside nurses to ask about barriers to education and improvements needed to ensure nurses can effectively utilize the education. After the education is implemented and the nurses have completed the post-survey, the project lead and nurse educators will round monthly for six months to ask bedside nurses 21 about the continued use of the education and if any improvements are needed as the skin assessment and pressure injury prevention tools become a part of the NICU culture. Ethical Considerations Ethical considerations are vital to ensuring a project is valid, protective of the participants, and maintains integrity. Ethics provide researchers with a basis for understanding their responsibility to the rights and interests of their participants (Mirza et al., 2023). This project ensures ethical considerations are followed by maintaining the participant’s confidentiality, minimizing the patient’s risk, and ensuring key stakeholders are included in all steps of the process. The participants of this project are the bedside NICU nurses. The nurses were not required to participate in the pre-and post-surveys. The nurses who chose to complete the preand post-surveys were not required to disclose their personal information to participate. The only identifying information the nurses share in the survey is how many years they have been a NICU nurse within a specific range. This question helps the project lead identify if more education is needed for less or more experienced nurses. All survey questions are optional; the nurses can skip this question if they do not want to identify how many years they have worked in the NICU. There is a possibility of having over 250 nurse participants with varying degrees of experience, further inhibiting personal identification. Patient risk is minimized in this project as all education provided to bedside nurses is based on literature from the last five years to ensure only evidence-based practice is utilized in the nurse’s skin assessment and pressure injury prevention. The evidence used to create the education was reviewed by the key stakeholders, including the clinical nurse specialist and NICU medical director, to ensure the skin care education is valid and safe for NICU patients. 22 Key stakeholders were involved during every step of this project. They were provided multiple opportunities to share their opinions and ideas about the current evidence and project implementation. The project lead ensured each stakeholder could speak during meetings and held one-on-one meetings with each stakeholder during the deliverables build to ensure all voices were heard equally. Discussion Pressure injuries can cause pain, financial injury, and sometimes lifelong harm to neonates in the NICU, in addition to emotional damage to nurses (Hu et al., 2021). Evidencebased skin assessment and pressure injury prevention education can increase nurses’ confidence in preventing pressure injuries in the NICU (Razmus & Keep, 2022). Pressure injury prevention benefits NICU patients, nurses, and healthcare organizations (Fassino et al., 2023). The dissemination plans, significance to nursing practice, implications, and recommendations of this project are important components of the evidence displayed in this paper. Evidence-based Solutions for Dissemination After this project’s implementation, data from the pre-and post-surveys will be collected and shared in various ways. The project and its results will be shared with NICU nurses and providers in a NICU staff meeting and shared with hospital leadership in the healthcare organization through a PowerPoint presentation at the Administrative Council meeting. The project lead will present a poster highlighting the project’s aims, implementation plan, and results to the peers and faculty at the Annie Taylor Dee School of Nursing at Weber State University. The project lead will implement any feedback from those peers and faculty to the current project, as continuous improvement is a large part of the ongoing dissemination of this project utilizing the Iowa Model of EBP (Melnyk & Fineout-Overholt, 2024). 23 Significance to Advance Nursing Practice Implementing evidence-based education to NICU nurses on skin assessment and pressure injury prevention can decrease pain and length of hospital stay for NICU patients and limit the emotional damage nurses incur when their patient develops a pressure injury (Hu et al., 2021; Kurtgoz & Koc, 2024). This project addresses the lack of education on skin assessment and pressure injury prevention for NICU nurses and ensures evidence-based interventions are utilized to protect NICU patients’ skin. Educating nurses about skin assessment and pressure injury prevention will increase nurses’ confidence in preventing pressure injuries, protecting NICU patients from harm, and elevating NICU nursing practice (Fassino et al., 2023). Implications This project has multiple strengths, which are identified throughout this paper. Using the Iowa Model for EBP ensures the project’s success, as feedback is continuously requested and implemented to improve the project’s outcomes and increase nurses’ confidence to prevent pressure injuries (Buckwalter et al., 2017). The project’s deliverables were developed by the project lead and stakeholders based on evidence from the literature to ensure that the education and structure effectively educate nurses. The project is evaluated through a pre-and post-survey to ensure the nurses participating in the project are positively impacted by the education and use of the resource tool. This project will support nursing knowledge and the profession by increasing nurses’ confidence in preventing pressure injuries in NICU patients, elevating their current practice, and preventing harm (Hu et al., 2021). This project has potential limitations because it is only implemented at one Level IV NICU in a medium-sized city. Another limitation of this project is the effect of implementing the education in the infographic deliverable on patients who are so critically ill that they cannot be 24 repositioned. The project lead and stakeholders could consider reviewing evidence, implementing a skin assessment tool, and providing education to ensure nurses understand how to best assess high-risk patients for pressure injuries. This additional education may include interventions to prevent pressure injuries in immobile, critically ill ICU patients. Recommendations This project identified education initiatives to increase nurses’ confidence in skin assessment and pressure injury prevention for NICU patients. To evaluate the potential success of this project, the project lead should implement this project at NICUs of various sizes and levels. The project lead and stakeholders should consider implementing an evidence-based skin risk assessment tool, like the SRAMT tool, alongside this education to best assist nurses in their skin assessment and individualize pressure injury prevention based on the specific needs of the patient (Broom et al., 2017). Additional research should be conducted on effectively implementing a skin risk assessment tool in the NICU. This project could also be implemented amongst other disciplines in the NICU, including providers, unlicensed staff, respiratory therapists, and physical therapists. The project lead could work alongside leaders in other departments to individualize the education, based on evidence, for each discipline. Conclusions Implementing evidence-based education on skin assessment and pressure injury prevention has decreased pressure injuries in NICU patients and increased nurses’ confidence in their ability to prevent pressure injuries (Fassino et al., 2023). Advancing the nursing profession with effective education benefits patients, nurses, and healthcare organizations (Cummins et al., 2019). This project recommends that NICU nurses receive evidence-based education, as seen in 25 the project deliverables, on skin assessment and pressure injury prevention to decrease physical, emotional, and financial harm to patients, nurses, and healthcare organizations. 26 References Ahmadizadeh, L., Valizadeh, L., Farshi, M.R., Neshat, H., Abadi, M.A.J., Broom, M. (2024). The correlation between the risk score and skin injuries in neonatal intensive care units. Family Medicine & Primary Care Review, 26(1), 7-11. https://doi.org/10.5114/fmpcr.2024.134697 Blazier, L., Boyle, F., Cooper, K., Wing, S., & Stefanescu, B. (2023). Neonatal electroencephalogram electrode-related pressure injury prevention quality improvement study. Advances in Skin & Wound Care, 36(3), 1-8. https://doi.org/10.1097/01.ASW.0000918352.29253.9f Broom, M. Burton, W., Ehrlich, L., Dunk, A., & Abdel-Latif, M. (2017). Developing an Australian skin risk assessment and management tool for neonates. Wound Practice & Research, 25(1), 15-22. Broom, M., Dunk, A.M., & Mohamed, A-L. E. (2019). Predicting neonatal skin injury: the first step to reducing skin injuries in neonates. Health Services Insights, Sage Journals, 12. https://doi.org/10.1177/1178632919845630 Buckwalter, K.C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, AM., Rakel, B., Steelman, V., Tripp-Reimer, T., & Tucker, S. (2017). Iowa model of evidence-based practice: revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223 Cummins, K., Watters, R., & Leming-Lee, T. (2019). Reducing pressure injuries in the pediatric intensive care unit. Nursing Clinics of North America, 54(1), 127–140. https://doi.org/10.1016/j.cnur.2018.10.005 27 Dineen, F., Raghu, K., Harris, D., & Brown, B. (2023) Introducing a skin assessment tool in tertiary neonatal intensive care unit. Journal of Neonatal Nursing, 29(1), 212-216. https://doi.org/10.1016/j.jnn.2022.07.012 Fassino, B., Ferrario, S., Sorrentino, G., Adamini, I., Pesenti, N., Fumagalli, M., Mosca, F., & Plevani, L. (2023). Hospital-acquired skin lesions in the neonatal intensive care unit: A retrospective analysis of temporal trends and quality improvement strategies. Journal of Pediatric Nursing, 70, 40-46. https://doi.org/10.1016/j.pedn.2023.01.009 Haass, O. & Guzman, G. (2019). Understand project evaluation-a review and reconceptualization. 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Neonatal intensive care nursing pressure injury prevention practices: A descriptive survey. WCET Journal, 42(3), 42-43. https://doi.org/10.33235/wcet.42.3.42-47 Schluer, A-B., Muller, A.Y., Fromme, N.P., Camenzind, M., Riener, R., & Rossi, R.M. (2023). Use of a novel pressure distribution system for severely ill neonates: a clinical pilot study carried out by the PREPICare consortium. BMC Pediatrics, 23(1). https://doi.org/2200/10.1186/s12887-023-04252-2 Sousa, I., Kapp, S, & Santamaria, N. (2020). Positioning immobile critically ill patients who are at risk of pressure injuries using a purpose‐designed positioning device and usual care equipment: An observational feasibility study. International Wound Journal, 17(2), 10281038. https://doi.org/10.1111/iwj.13365 29 Vahabzadeh-Hagh, A.M., Lindenmuth, L., Feng, Z., Custodio, J.G., & Patel, S.H. (2024). A tracheostomy support device to reduce tracheostomy-related pressure injury. Respiratory Care, 69(7). https://doi.org/2200/10.4187/respcare.11160 Vazquez, M. & Bell, T. (2024). Implementing the Braden QD scale in the neonatal intensive care unit population. Journal of Neonatal Nursing, 30(2), 176-180. https://doi.org/10.1016/j.jnn.2023.11.007 30 Appendix A Pre-Survey 1. How many years have you worked in the NICU as a nurse (include all NICU RN experience)? a. Less than 1 year b. 1-2 years c. 2-3 years d. 3-5 years e. 5-10 years f. Greater than 10 years 2. I have cared for a patient in the NICU with a pressure injury. a. Yes b. No 3. With the education I have now, I feel confident in my skin assessment skills for NICU patients. a. Strongly Agree b. Agree c. Neither Agree nor Disagree d. Disagree e. Strongly Disagree 4. With the education I have now, I feel confident in preventing pressure injuries for NICU patients. a. Strongly Agree b. Agree c. Neither Agree nor Disagree d. Disagree e. Strongly Disagree 5. I feel confident in the actions I should take if I notice skin deterioration on my NICU patient. a. Strongly Agree b. Agree c. Neither Agree nor Disagree d. Disagree e. Strongly Disagree 6. I feel confident caring for the skin of unstable NICU patients who are preparing for surgery, have frequent vital sign decompensation during cares, and/or are prescribed sedation and paralytics. a. Strongly Agree b. Agree c. Neither Agree nor Disagree 31 d. Disagree e. Strongly Disagree 7. I understand the process for conducting a multidisciplinary skin assessment in the NICU. a. Strongly Agree b. Agree c. Neither Agree nor Disagree d. Disagree e. Strongly Disagree 32 Appendix B Bedside Educational Infographic 33 34 35 Appendix C Educational PowerPoint 36 37 38 39 Appendix D Post-Survey 1. How many years have you worked in the NICU as a nurse (include all NICU RN experience)? a. Less than 1 year b. 1-2 years c. 2-3 years d. 3-5 years e. 5-10 years f. Greater than 10 years 2. I have cared for a patient in the NICU with a pressure injury. a. Yes b. No 3. Additional education improves my confidence in my skin assessment skills for NICU patients. a. Strongly Agree b. Agree c. Neither Agree nor Disagree d. Disagree e. Strongly Disagree 4. Additional education improves my confidence in preventing pressure injuries for NICU patients. a. Strongly Agree b. Agree c. Neither Agree nor Disagree d. Disagree e. Strongly Disagree 5. I feel confident in the actions I should take if I notice skin deterioration on my NICU patient. a. Strongly Agree b. Agree c. Neither Agree nor Disagree d. Disagree e. Strongly Disagree 6. I feel confident caring for the skin of unstable NICU patients who are preparing for surgery, have frequent vital sign decompensation during cares, and/or are prescribed sedation and paralytics. a. Strongly Agree b. Agree c. Neither Agree nor Disagree 40 d. Disagree e. Strongly Disagree 7. I understand the process for conducting a multidisciplinary skin assessment in the NICU. a. Strongly Agree b. Agree c. Neither Agree nor Disagree d. Disagree e. Strongly Disagree 41 Appendix E Timeline