N4325 Nursing ResearchSubmit by the due date and time listed.docx

N4325 Nursing Research
Submit by the due date and time listed in your syllabus.
Name:
Date:
Overview
This assignment will allow you to create an evidence-based
practice project that includes the development of a PICO
question and follows the initial steps of the Iowa Model. You
will share your findings using an APA formatted paper.
Submitting your assignment
· Save this document to your desktop as a Word document.
· Open the document from your desktop and review the
assignment instructions and grading rubric.
· Create a separate Word document for your paper.
· Return to Blackboard and upload your paper and your nursing
research article that was approved by your instructor to the
dropbox in Module Four. Please note:if you forget to upload
your nursing quantitative research article, a 5 point penalty will
be applied to your paper.
Grading Rubric
Use this rubric to guide your work the assignment. Points are
awarded for each section based on content and clarity of
expression.
Accomplished
(Maximum points awarded)
Proficient
(Points awarded based on content)

Needs Improvement
(Minimum points awarded)
Initial PICO question completed / nursing research article
selected.
Research article is a quantitative article, nursing focused, and is
5 years or less from current publication date.
Please note: if you forget to upload your nursing quantitative
research article, a 5 point penalty will be applied to your paper
5 – 4 points
Research article is a quantitative article that is nursing focused
but is greater than 5 years old.
3 - 2 points
Research article is not nursing focused or is a qualitative
article, systematic review, meta-synthesis, meta-analysis, meta-
summary, integrative review, clinical information article or
“how-to” article.
No article uploaded.
0 points
Opening Paragraph
(Paragraph #1)
Introduction statement(s) present.
PICO question with all elements present.
Statement of importance with two facts such as costs,
morbidity, mortality, safety, or other related statistics with
citation and is 5 years or less from current publication date.
10 – 9 points
No introduction statement(s).
PICO statement is incomplete.
Statement of importance incomplete or missing.
Citation is incomplete or missing.

8 – 3 points
No introduction statement(s).
PICO statement grossly incomplete or missing.
Statement of importance missing.
No citation
2 - 0 points
Summary paragraph for your nursing quantitative research
article.
(Paragraph #2)
Three facts clearly identified from quantitative nursing research
article and is 5 years or less from current publication date.
Facts clearly tied to PICO question.
Facts connected to your nursing practice.
10 - 9 points
Less than three facts clearly identified from quantitative nursing
research article.
Facts not clearly tied to PICO question.
Facts not clearly connected to your nursing practice.
8 - 3 points
No facts clearly identified from the article.
No attempt to connect facts from the article back to the PICO
question.
No attempt to connect facts from the article back to your
nursing practice.
2 - 0 points
Reliability paragraph for your nursing quantitative research
article.

(Paragraph #3)
Definition of reliability offered with citation.
Discussion of reliability clearly connected to data collection or
measurement methods with examples from the student’s
research article. Hint: This information is covered in Chapter
10.
10 - 9 points
Vague or no definition of reliability.
Minimal reference to data collection or measurement methods in
discussion of reliability with no reference to specific
information from the student’s article.
8 - 3 points
Vague statements about reliability made with no discussion of
data collection or measurement methods offered.
2 - 0 points
Validity paragraph for your nursing quantitative research
article.
(Paragraph #4)
Definition of validity offered with citation.
Discussion of validity clearly connected to research design, data
collection, or measurement methods with examples from the
student’s research article. Hint: This information is covered in
Chapter 8 and 10.
10 - 9 points
Vague or no definition of validity.
Minimal reference to research design, data collection, or
measurement methods in discussion of validity with no
reference to specific information from the student’s article.

8 - 3 points
Vague statements about validity made with no discussion of
data collection or measurement methods offered.
2 - 0 points
Two additional strengths or weaknesses from your nursing
quantitative research article.
(Paragraph #5)
Two strengths or two weaknesses or one strength and one
weakness are specifically identified from your nursing
quantitative research article.
The student choices for strengths / weaknesses must focus on
the methods used by the authors for sampling, measurement, or
data collection with examples from the student’s research
article.
10 - 9 points
Only one strength / or weakness explained well with second
strength / weakness only identified.
Strengths / weaknesses not based on sample, measurement
methods, or data collection.
8 - 3 points
Strength / weaknesses identified are not based on these three
critique skills.
No strengths / weaknesses identified.
2 - 0 points
Clinical practice guideline summary.
(Paragraph #6)
Name and specific website of the clinical practice guideline

identified. Guideline is the most recent version or published
within the past five years.
Three facts clearly identified that were found within the
guideline.
10 - 9 points
Name or website of the clinical practice guideline not clearly
identified.
Fewer than three facts clearly identified that were found within
the guideline.
Facts vaguely tied to PICO question.
Facts vaguely connected to your nursing practice.
8 - 3 points
Name or website of the clinical practice guideline not stated.
No clearly identified facts from the guideline.
Facts not tied to PICO question or nursing practice.
2 - 0 points
“Fourth resource” summary.
(Paragraph #7)
Three facts clearly identified from the fourth resource which is
5 years or less from current publication date.
10 - 9 points
Less than three facts clearly identified from the fourth resource.

Facts not clearly tied to PICO question.
Facts not clearly connected your nursing practice.
8 - 3 points
No facts clearly identified from the fourth resource.
No attempt to connect facts from the fourth resource back to the
PICO question.
No attempt to connect facts from the fourth resource back to
your nursing practice.
2 - 0 points
Closing Paragraph(s)
(Paragraph #8 and #9, if needed)
PICO question is restated.
A summary of what was learned is present.
Recommendations for practice are offered.
10 - 9 points
Missing one or more of the following elements:
PICO question.
A summary of what was learned.
Recommendations for practice.
8 - 3 points
No PICO question.
Poor or no attempt to summarize information from the
resources.

No / vague recommendations for practice are offered.
2 - 0 points
APA Style and Formatting
APA formatting for this paper will follow the guidelines for
general formatting, in text-citations, margins, headings (if
desired) alignment and line spacing, font type and size,
paragraph indentation, page headers, and the reference page as
explained in the 2nd edition of APA the Easy Way or the 6th
edition of the APA Manual.
Helpful Hints:
· Do not use 1st person in a formal paper.
· Do not use direct quotes, instead summarize and paraphrase
what you are reading. Multiple quotes will receive multiple
point deductions.
· Please do not forget to use the approved CONHI cover page.
The first time an APA error is discovered, it will be pointed out
to you and a point will be deducted from your paper. Maximum
number of points deducted for APA errors: 15 points
Instructions for Completing Your Assignment
· Step one:Using the topic you chose for Module 2 Searching
for a Quantitative Nursing article, identify a nursing clinical
practice question that you would like to explore.
· Step two: Complete the readings from Module Four. Use the
readings from Module Four to put your nursing clinical practice
question into a PICO format.
· Step three: Search for a nursing quantitative research article
(or two) that relates to your PICO question using Academic
Search Complete, CINHAL, Pubmed, Google Scholar, or any
other database that contains nursing research articles. Please

note: you may be able to use the article that you submitted in
Module Two to meet this requirement.
· The article you will find must meet the following mandatory
requirements:
· It must be based on the topic list attached here.
· It must be from a nursing research journal or have a nurse as
an author.
· It must be no more than 5 years old from the current
publication year.
· It must include implications and / or interventions that are
applicable to nursing practice.
· It may not be a qualitative article, systematic review, meta-
synthesis, meta-analysis, meta-summary, integrative review or a
retrospective / quality improvement study. For more information
on how to recognize these types of article see Grove, Gray, and
Burns (2015) pp. 22-24.
· It may not be a clinical information article or “how-to” article.
· Step four: If you have questions about your PICO question
formatting or the nursing quantitative research article that you
found, post them to the Q & A discussion board for feedback
from your peers / instructor.
· Self-check: if you choose the wrong type of nursing
quantitative research article for your paper (the one that you
will be using to write paragraph 2, 3, 4, & 5) the best grade you
could make is a 55. Yikes!!! Please make sure that you have
selected a nursing quantitative research article that meets the
criteria for this assignment and ask for help if you are not sure.
Please note: you may be able to use the article that you
submitted in Module Two to meet this requirement.

· Step Five: Collecting More Evidence (Do the research)
· Find a resource published within the past 5 years that provides
you with at least two facts (ex. costs, morbidity, mortality,
safety, or other related statistics) for why your clinical problem
is important. (The internet is a great place to get this
information…just don’t forget to cite this information and add it
to your reference page).
· Find a clinical practice guideline at
http://www.guideline.gov/browse/by-topic.aspx that relates to
your question. It must have information that relates to the role
of the nurse. Guideline is the most recent version or published
within the past five years.
· Find a clinical “how-to” article, a nursing professional
practice website, a systematic literature review, a meta-analysis,
or a manufacturer’s website published within the past 5 years
that relates to your practice question.
· Hint: Did you notice that you will be finding a total of four
different sources of information for your PICO question?
· Step Six: Write up your findings in APA format and submit
them to Blackboard by the due date and time listed in your
syllabus. Here’s how to write up your findings:
· Start with a UTA CONHI approved cover page.
· Paragraph #1: This is your opening paragraph. Start with an
introduction statement. What is your PICO question? Describe
why was it important (share the dollars, morbidity / mortality,
statistics, safety stats you found with citation)?
· Paragraph #2: What did your nursing quantitative research
article add to your knowledge on this topic? Share at least three
facts that you found within the article in this paragraph that is
relevant to your PICO question and your practice as a nurse.

· Paragraph #3: Critique the reliability of the nursing
quantitative research article you used. Go back to what you
learned in your article critique about measurement methods and
data collection in Module 3 to make sure you are being
thorough in your assessment. Be specific, so that your
instructor, if reading the article, can find them too.
· Paragraph #4: Critique the validity of the nursing quantitative
research article you used. Go back to what you learned in your
article critique about research design, measurement methods,
and data collection to make sure you are being thorough in your
assessment. Be specific, so that your instructor, if reading the
article, can find them too.
· Paragraph #5: Using the skills you have learned in your
critique of a research article, describe two strengths or two
weaknesses (or one strength and one weakness) that you found
as you read this article. Go back to what you learned in your
article critique about sampling methods, measurement methods,
and data collection to make sure you are being thorough in your
assessment. Be specific, so that your instructor, if reading the
article, can find them too.
· Paragraph #6: What is the name and website of the clinical
practice guideline that you found? Share at least three facts
that you found within the guideline that is relevant to the PICO
question and your practice as a nurse and cite the guideline
appropriately.
· Paragraph #7: Identify the fourth resource you found (clinical
“how-to” article, a nursing professional practice website, a
systematic literature review, a meta-analysis, or a
manufacturer’s website) that relates to your practice question.
Share at least three facts that you found within this source that
is relevant to the PICO question and your practice as a nurse,
and cite appropriately.

· Paragraph #8 (and #9 if needed): re-state your PICO question
and briefly summarize what you have learned through your
search. What would you recommend, if anything, as a change in
practice for nurses? Why? Remember, this is your closing
paragraph(s).
· Note to students about writing up your findings:
· This is a formal APA paper. Look at the Rubric for more APA
information for this paper.
· Don’t forget to use your APA resources that were reviewed in
Module Two!
· Don’t forget to use the Module Four discussion board for
additional questions about your paper.
· Turn your paper and article that you used for paragraphs
2,3,4,& 5 in to the drop box under the Assignments Tab in
Module Four at the due date and time listed in your syllabus.
· Possible points for this assignment: 100 points
Module 4: Evidence Based Practice Project: Finding the
Evidence
PAGE

©2015 UTA School of Nursing
Page 1 of 6
PICO(T) Worksheet
First, identify each element of your PICO on the line below,
then take a look at the templates below to help you formulate a
PICO(T) question.
P: Population/disease ( i.e. age, gender, ethnicity, with a certain
disorder)
P:
_____________________________________________________
_______________
I: Intervention or Variable of Interest (exposure to a disease,
risk behavior, prognostic factor) Note: Not every question will
have an intervention (as in a meaning question – see below).
I:
_____________________________________________________
_______________
C: Comparison: (could be a placebo or "business as usual" as in
no disease, absence of risk factor). Note: This is not used in a
meaning question – see below.
C:
_____________________________________________________
_______________
O: Outcome: (risk of disease, accuracy of a diagnosis, rate of
occurrence of adverse outcome)
O:
_____________________________________________________
_______________
T: Time: The time it takes to demonstrate an outcome (e.g. the

time it takes for the intervention to achieve an outcome or how
long participants are observed). This is an optional “add-on” for
a PICO question.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~
For PICO questions about a nursing intervention/therapy:
In _______(P), what is the effect of _______(I) on ______(O)
compared with _______(C) within ________ (T)?
For PICO etiology questions:
Are ____ (P) who have _______ (I) at ___
(increased/decreased) risk for/of_______ (O) compared with
______ (P) with/without ______ (C) over _____ (T)?
For PICO questions involving prevention:
For ________ (P) does the use of ______ (I) reduce the future
risk of ________ (O) compared with _________ (C)?
For PICO questions that predict:
Does __________ (I) influence ________ (O) in patients who
have _______ (P) over ______ (T)?
For PICO questions that want to know more about the meaning
of…..
How do ________ (P) diagnosed with _______ (I) perceive
______ (O) during _____ (T)?
Based on Melnyk B., & Fineout-Overholt E. (2010). Evidence-
based practice in nursing & healthcare. New York: Lippincott
Williams & Wilkins.
O RI GI N A L A RT I CL E

Under pressure: prevent ing pressure ulcers in crit ically ill
infant s
Christine A. Schindler, Theresa A. Mikhailov, Susan E. Cashin,
Shelly Malin, Melissa Christensen,
and Jill M. Winters
Christine A. Schindler, PhD, RN, CPNP-AC, is Acute Care
Pediatric Nurse Practitioner; Theresa A. Mikhailov, MD, PhD,
is Associate Professor, Division of
Critical Care, Medical College of Wisconsin, Milwaukee; Susan
E. Cashin PhD, is Associate Professor, University of Wisconsin-
Milwaukee, Milwaukee,
Wisconsin; Shelly Malin, PhD, RN, NEA-BC, is Professor,
Mennonite College of Nursing at Illinois State University,
Normal, Illinois; Melissa Christensen, BS,
CCRC, is Clinical Research Coordinator, Medical College of
Wisconsin, Milwaukee; and Jill M. Winters, PhD, RN, is Dean
and Professor, Columbia College of
Nursing, Glendale, Wisconsin, USA
Search terms
Pediatric, pressure ulcer, prevention.
Author contact
[email protected], with a copy to the Editor:
[email protected]
Acknow ledgement
No external or intramural funding was received.
We appreciate the fabulous hard work of
Children’s Hospital of WI PUPteam in improving
skin care in the PICU; also to Thomas B. Rice for
his support to this project.
Conflict of Interest: The authors report no actual
or potential conflicts of interest.

First Received January 3, 2013; Final Revision
received June 10, 2013; Accepted for
publication June 11, 2013.
doi: 10.1111/jspn.12043
Abstract
Purpose. To determine whether a pressure ulcer prevention
bundle was
associated with a significant reduction in pressure ulcer
development in
infants in the pediatric intensive care unit.
Design and Methods. Quasi-experimental design involving 399
infants
0 to 3 months of age at a large tertiary care medical center.
Results. The implementation of the care bundle was associated
with a
significant drop in pressure ulcer incidence from 18.8 to 6.8%.
Practice Im plications. Pressure ulcers can be prevented in the
most
vulnerable patients with the consistent implementation of
evidence-
based interventions and system supports to assist nurses with
the change in
practice.
Pressure ulcer development is a significant hospital-
acquired injury that has far-reaching consequences
for infants who develop pressure ulcers as a result of
hospitalization. Pressure ulcers are localized areas of
tissue destruction that develop when soft tissue is
compressed between a bony prominence and an
external surface for a prolonged period of time
(National Pressure Ulcer Advisory Panel, 2007).
When there is local tissue destruction and necrosis,
infants experience ulcer-related pain and are at

profound risk for developing systemic infection, as
well as secondary scarring or alopecia at the site
of the ulcer (Curley, Quigley, & Lin, 2003; Gershan
& Esterly, 1993; McCord, McElvain, Sachdeva,
Schwartz, & Jefferson, 2004). The estimated cost of
managing a single full-thickness pressure ulcer in
the adult population is as high as $70,000, and the
total cost for treatment of pressure ulcers in the
United States is estimated at $11 billion per year
(Reddy, Gill, & Rochon, 2006). The adverse health
outcomes and high financial costs associated with
this condition have led the Institute for Healthcare
Improvement and the Joint Commission to identify
pressure ulcer prevention as a priority area for
patient safety (McCannon, Hackbarth, & Griffin,
2007; The Joint Commission, 2007).
The incidence of pediatric pressure ulcer develop-
ment in the critical care population has been
reported to be as high as 10.2–27% (Curley et al.,
2003; McCord et al., 2004; Reddy et al., 2006;
Schindler et al., 2011). Attempts have been made to
adapt information learned from adult studies to fit
characteristics of the neonatal and pediatric popula-
tions in an effort to decrease pressure ulcer develop-
ment in these populations (Razmus, Lewis, &
Wilson, 2008). Infants are a vulnerable population,
especially those less than 2 years of age who tend
to be at higher risk of developing pressure ulcers
bs_bs_banner
Journal for Specialists in Pediatric Nursing
329Journal for Specialists in Pediatric Nursing 18 (2013) 329–

341
© 2013, Wiley Periodicals, Inc.
(McCord et al., 2004; Schindler et al., 2007, 2011).
Neonates (ages 0 to 3 months) are especially vulner-
able (Gershan & Esterly, 1993; McLane, Krouskop,
McCord, & Fraley, 2002; Willock & Maylor, 2004).
Infants face special challenges in the critical care
environment because the epidermal layer in infants
is thinner and functionally immature compared
with toddlers and older children, placing them at
high risk for excesswater loss and higher permeabil-
ity to chemicals (Curley &Maloney-Harmon, 2001;
Lund, 1999; Lund et al., 2001). This is problematic
because one of the skin’s primary functions is to
provide a barrier to the outside environment. Given
the increased permeability of the skin, infants are
more vulnerable to the harsh chemicals used in the
hospital; understanding these developmental differ-
ences iskey to providingoptimal skin care for hospi-
talized infants.
The aim of this study was to evaluate the effect of
implementing a pressure ulcer prevention bundle
on the incidence of pressure ulcer development in a
high-risk subset of patients (infants 0 to 3 months
of age) in the Pediatric Intensive Care Unit (PICU)
at a large tertiary care children’s medical center.
Investigators previously conducted a multisite study
exploring nursing interventions associated with
lower pressure ulcer incidence in the PICU popula-
tion (Schindler et al., 2011). Results from this study
were used to design the Pressure Ulcer Prevention
Program (PUPP) which was implemented in this

PICU. The components of the PUPP included: (a)
assuring patients were maintained on the correct
support surface in order to decrease tissue interface
pressure, (b) frequent turning, (c) incontinence
management, (d) appropriate nutrition, and (e)
education. The hypothesis was that a significant
reduction in pressure ulcer incidence would be
evident in the group receiving the PUPP bundle
when compared with the standard care group.
M ETHODS
Subjects
In an earlier study, investigators from this hospital
conducted a large multisite study exploring nursing
interventions associated with lower pressure ulcer
incidence in the PICU population (Schindler et al.,
2011). The overall incidence ofpressure ulcer devel-
opment in infants 0–3 months of age was 18.8%. In
an effort to reduce this high incidence, this prospec-
tive, quasi-experimental study was conducted to
determine the effect of the PUPP bundle on pressure
ulcer development. There were 149 infants ages 0–3
months in the control group (Table 2). These infants
were cared for in the PICU between April 24, 2006,
and December 31, 2006. Infants from 0–3 monthsof
age admitted to the PICU between August 1, 2009,
and December 31,2009,were enrolled in the experi-
mental arm of this study. No infants were excluded
from enrolling in this study because the intention
was to gain an understanding of the efficacy of the
PUPP bundle in reducing pressure ulcer incidence
regardless of diagnosis, gender, risk of mortality, or
length of PICU stay.

Design
The PICU at a large tertiary care center was selected
as the site for data collection. The hospitalwasa 294-
bed free-standing children’s hospital with a 72-bed
PICU. In 2009, the hospital had 2,751 admissions to
the PICU, and 372 of those admissions were infants
between the agesof0 and 3 months. Apower analy-
sis to determine adequate sample size for t-tests,
which guided enrollment, was completed prior to
the start of the study. Although all infants admitted
to the PICU received the intervention, data were
only collected on the first 250 infants during the
study time frame. Protection of human subjects was
approved by the institutional review board of the
participating hospital, and a waiver of parental
consent was obtained.
The infants in the controlgroup were part ofa pre-
vious study conducted to determine the incidence of
pressure ulcer development in the PICU. During this
study, the nurses received education about the
Braden Q risk assessment scale and pressure ulcer
staging, but they did not receive any education
about skin care or pressure ulcer prevention in hos-
pitalized children. The Braden Q scale is a modifica-
tion ofthe adult Braden Scale used to quantify risk of
pressure ulcer development that was developed and
tested in the pediatricpopulation (Quigley &Curley,
1996). There are seven discrete categories, and each
category includes a risk factor and concept descrip-
tor. The minimum score for each item is “1” (more
risk), and the maximum score is “4” (less risk), with
potential scores ranging from 7–28. The subcatego-
ries include mobility, activity, sensory perception,

moisture, friction and shear, nutrition, and tissue
oxygenation and perfusion (Quigley & Curley,
1996). The infants in the control group received
standard skin care. Standard care included the use of
standard infant warmer mattresses that were not
pressure relief/pressure redistribution mattresses.
Under Pressure: Preventing Pressure Ulcers in Critically Ill
Infants C. A. Schindler et al.
330 Journal for Specialists in Pediatric Nursing 18 (2013) 329–
341
There was no set standard for bathing, use of barrier
creams, or moisturizing of infants. Nurses used their
own nursing judgment to address these components
of care. The standard nutrition consult occurred if
the infant was on total parenteral nutrition, receiv-
ing tube feeds, or on the fourth day of their PICU
admission. Infantswere turned or were repositioned
every 4 hr. There were no skin care champions or
unit-based skin resources at the time of the data col-
lection for the control group.
The Institute for Healthcare Improvement (IHI)
defined a bundle as a grouping of several scientifi-
cally grounded elements, essential for improving
clinical outcomes. Ideally, the bundle should be a set
of three to five evidence-based practices, or precau-
tionary steps, that when used together, may result in
significant improvement (Institute for Healthcare
Improvement, 2011). The intervention in the study
was a skin care bundle that included five compo-

nents: (a) ensuring patients were on the correct
support surface to decrease tissue interface pressure,
(b) frequent turning, (c) incontinence management,
(d) appropriate nutrition, and (e) education. In
order to relieve pressure, particularly over bony
prominences, it was essential to place infants on a
pressure relieving surface. Infants in this study were
placed on a Delta-202 Warmer Overlay (29″¥ 23.75″
¥ 2.25″). Thisparticular overlay was found to reduce
the occipital interface pressure in infants less than 2
years of age (McLane et al., 2002; Turnage-Carrier,
McLane, & Gregurich, 2008). Another strategy to
limit pressure over bony prominences was frequent
turning. Repositioning was used to reduce or elimi-
nate pressure in order to maintain circulation to
areas of the body at risk for pressure ulcer develop-
ment (Lund et al., 2001). Gel-filled pillows were
used by nurses to assist with positioningand padding
bony prominences (McLane et al., 2002; Reddy
et al., 2006). The third component of the interven-
tion was to improve moisture and incontinence
management. Wet skin has been associated with
development of rashes, is softer, and tends to break
down more easily. In addition, fecal incontinence is
a risk factor for pressure ulcer development, as stool
contains bacteria and enzymes that are caustic to
the skin (Wound Ostomy and Continence Nurses
Society, 2003). In order to ameliorate the risk of
incontinence contributing to pressure ulcer devel-
opment, zinc-based barrier cream was used with
each diaper change. Although the goal was to keep
the patient dry, it was important to keep the skin
moisturized. Bathing was minimized, and when the
infants were bathed, mild, non-alkaline cleansing
agents were gently used to minimize dryness of the

skin. Finally, any child who scored a “1” (defined as
very poor nutrition, which includes nothing by
mouth statusor maintained on clear liquidsfor more
than 5 days or serum albumin < 2.5 mg/L), or “2”
(defined as inadequate nutrition with liquid diet or
total parenteral nutrition, which provides inad-
equate calories and minerals or serum albumin <
30 mg/L) in the nutrition subcategory of the Braden
Q received nutrition consultation by a registered
dietician. The registered dietician would complete a
nutritional assessment as well as make recommen-
dations for improving the infant’s nutritional intake
and would share the recommendations with the
interdisciplinary team. Once the consultation was
made, the registered dietician continued to follow
the child until nutrition goals were met.
In the intervention group, nursing staff partici-
pated in an online educational module about the
Braden Q pressure ulcer risk assessment, pressure
ulcer identification and grading, aswell aseducation
on the components of the PUPP intervention. The
education module was an interactive online tutorial
developed by the investigators and placed on an
online educational platform. The online education
took approximately 60 min, and nurses were com-
pensated by the hospital for their time. The online
platform automatically generated a report of those
nurses who completed the education that was for-
warded to the unit supervisors. The supervisors
would follow up with any nurses who had not com-
pleted the education to assure that it wascompleted.
New nurses received in-person education asa part of
their orientation. Pediatric risk assessments were
completed every 24 hr, as assessing risk provides
caregivers the opportunity to re-evaluate the child’s

risk; the child’s condition can change rapidly in the
intensive care setting (Ayello &Braden, 2001).
A pressure ulcer prevention order set was placed
in the computerized provider order entry system to
facilitate compliance with the bundle. Additionally,
skin care champions, who were registered nurses in
the PICU, were identified in order to facilitate com-
pliance with the bundle and provide additional
supports on the unit. Two day-shift nurses and two
night-shift nurses were recruited from each of
the three ICUs to serve as skin care champions. Skin
care champions received additional education
regarding the PUPP bundle, participated in monthly
skin champions’ meetings, and maintained e-mail
contact with the principal investigator throughout
the duration of the study. During the monthly meet-
ings, the skin care champions received education on
C. A. Schindler et al. Under Pressure: Preventing Pressure
Ulcers in Critically Ill Infants
341
the science related to the prevention strategies and
on the available skin care products, reviewed any
pressure ulcers identified in the previous month,
and planned what would be the focus of staff educa-
tion for the month. Each skin care champion was
assigned six bed spaces for which they were respon-
sible for conducting weekly skin rounds. Rounding
on the patients included reviewing the Braden Q

score for the patient and if the score was � 21, the
skin care champion would do a full skin assessment
with the bedside nurse caringfor the child. Aspart of
the assessment, the skin care champion reviewed
the preventive measures to assure they were imple-
mented. If during the assessment, a pressure ulcer
was identified, the skin care champion implemented
an appropriate treatment plan and discussed the
plan with the bedside nurse and, if necessary, the
medical team. The skin care champions received
reimbursement for the time they spent at the
monthly meeting (2 hr/month) as well as for the
time they spent conducting skin care rounds (2 hr/
week). While they worked in the unit on their
regularly scheduled shifts they served as skin care
resources for the unit.
Another important study partnership wascollabo-
ration between the principal investigator and the
unit-based Advanced Practice Nurses (APNs). APNs
were given a weekly list of patients who developed
pressure ulcers, and then they conducted a root
cause analysis (Figure 1) on all Stage 3 and Stage 4
pressure ulcers to determine if there were any iden-
tifiable factors that could have contributed to the
development of pressure ulcers, including but not
limited to breaks in the PUPP bundle. There was one
APN for every 24 ICU beds. Each root cause analysis
took approximately 30 min to complete through a
combination of chart review, discussion with the
primary nurses, and patient assessment. The root
cause analyses revealed several common character-
istics of the patients who developed pressure ulcers.
These characteristics included use of high-dose ino-
tropes, the use of cooling mattresses, and intubated
infants who were believed to be under-sedated,

which made the nurses reluctant to move them. The
results of the root cause analyses were shared at the
monthly skin care champions’ meeting so that
the skin care champions would be more aware of
infants who had one of the identified risk factors.
Data collection
The investigators utilized two methods of data
collection for the study. The VPS© (Virtual PICU
Systems) is a clinicaldatabase dedicated to standard-
ized data sharing and benchmarking among PICUs.
Data abstracted from the VPS for this study included
age, race, length of stay, primary and secondary
diagnoses, use ofextracorporealmembrane oxygen-
ation (ECMO), use ofnon-invasive positive pressure
ventilation (NIPPV), use of conventional ventila-
tion, oscillatory ventilation, previous cardiac or res-
piratory arrest, and Pediatric Index of Mortality 2
(PIM2) score. The PIM 2 is a risk of mortality tool
that uses 10 physiologic indicators and diagnoses
collected at admission to calculate risk of death of
groups of patients admitted to the PICU (Slater,
Shann, &Pearson, 2003). The principal investigator
also developed an instrument to collect additional
study data from participants, including use of vaso-
active infusions, Braden Q subcategory scores, loca-
tion, and grade of pressure ulcer, application of
lotion, use of a specialty mattress, frequency of
turning, and documentation of the skin care initia-
tive. To compile the complete data set, study data
were entered into an Access database and linked
with the VPS database by VPS ID number.
Data analysis

Descriptive statistics were used to analyze demo-
graphic data and describe the sample. Data were
analyzed using PASW Statistics for Windows 18.0
(SPSS Inc., 2010). To meet the necessary assump-
tions for subsequent testing, range, mean, variance,
and standard deviation were determined for all data
sets. An independent t-test was used to compare
differences in participants between groups.
Main outcome measures
There were 149 patients enrolled in the control arm
of the study, and 250 patients enrolled in the experi-
mental arm (see Table 1). Demographic characteris-
tics were compared using t-tests, whereby study
(experimental) meanswere compared to population
(control) means. The PIM 2 risk of mortality scores
were not significantly different between the control
group1 and experimental group2 (M1 = 7.2% vs.
M2 = 6%, t(249) = - 1.64, p = .10). Although the
overall risk of mortality was not significantly differ-
ent between the groups, there were some significant
differences in the types of mechanical support
provided for the infants. The control group1 had a
higher percentage of patients requiring mecha-
nical ventilation than the experimental group2
(M1 = 54.4% vs. M2 = 44.4%, t(249) = - 1713.60,
341

PRESSURE ULCER RCA
PATIENT NAME
MRN/VISIT NUMBER
DOB
GENDER
SCM SIGNIFICANT EVENTS
COMPLETED
DATE FILLING OUT FORM
PRESSURE ULCER PRESENT ON
ADMISSION
DATE /TIME PRESSURE ULCER
RECOGNIZED
PRESSURE ULCER DESCRIPTION
PER PUSH FORM
ADMITTING DIAGNOSIS:
UNDERLYING DIAGNOSIS:
WAS THE PATIENT TRANSPORTED VIA
EMS?
PATIENT LOCATION
BACKGROUND DATA

Figure 1 Pressure Ulcer Root Cause Analysis (RCA) Tool.
341
HOW OFTEN IS IT DOCUMENTED THAT
THE PATIENT IS BEING REPOSITIONED?
MIN
ORDERED
UNDERSTOOD “DO
NOT TURN” AS DO
NOT MOVE, TILT,
OR REPOSITION
DID THE RN
INVESTIGATE THE
“DO NOT TURN”
ORDER
WAS THE PATIENT NOT REPOSITIONED
DUE TO A PROCEDURE/INTERVENTION AT
THE BEDSIDE?
DID THE RN INDICATE THAT FINDING HELP
TO REPOSITON WAS A FACTOR?

DID THE RN INDICATE THAT TIME WAS A
FACTOR THAT IMPACTED TURNING?
ACTIVITY LEVEL ORDERED
ACTIVITY LEVEL DOCUMENTED
SENSORY PERCEPTION
COMMUNICATE PAIN
MOISTURE
MOISTURE BARRIER
CREAM
FREQUENT STOOLING
SHEILD WIPES
DIAPHORETIC
DRAINAGE
LINEN/DRESSINGS
CHANGED

FEBRILE
BRADEN Q
WAS THERE A BRADEN Q ON ADMISSION?
IS THERE A CURRENT BRADEN Q?
IS THERE A BRADEN Q IN THE PAST 24
HOURS?
IS THERE A DAILY BRADEN Q?
WHAT FACTORS ARE IMPEDING MOBILITY?
SEDATION SCORE SBS MODIFIED RAMSEY
DID THE PATIENT/PARENT REFUSE
REPOSITIONING?
ARE ASSIST DEVICES BEING UTILIZED
DURING TRANSFER/ REPOSITIONING/ X-
RAY?
Figure 1 Continued
341

FRICTION/SHEAR PATIENT AGITATED/ITCHING
LEADING TO
REQUIRES FULL SUPPORT FOR
REPOSITIONING
UTILIZING REPOSITIONING AIDS
NUTRITION DIET ORDERED
Albumin level
TISSUE PERFUSION/OXYGENATION
DATE/TIME INITIATED
IMPAIRED CIRCULATION TO AFFECTED
O2 SATURATION _______
HAS THERE BEEN A RECENT CHANGE IN
PATIENT CONDITION THAT WOULD IMPACT THE
BRADEN Q OR A DECOMPENSATION OF
CLINICAL STATUS?
CAN IT BE REMOVED?
POLICIES/PROCEDURES
BATHING
DOCUMENTATION DAILY DOCUMENTATION
REGARDING THE
PRESSURE ULCER
SUNRISE AAF INDICATED TO ORDER SCM PU
PREVENTION

SCM PU ORDER SET IMPLEMENTED
IS THE ORDER SET BEING FOLLOWED
IS THE ORDER SET INDIVIDUALIZED
IS THE RN AWARE OF THE CURRENT SKIN CARE
POLICY?
Figure 1 Continued
341
p < .001), while the experimental1 group had a
higher percentage of patients requiring NIPPV than
the control group2(M1 =12% vs. M2 =6.7%, t(249) =
- 319.52, p < .001) and ECMO (M1 = 4.4% vs. M2 =
1.3%, t(249) = - 96.64, p < .001). The two groups
differed in other significant ways. The experimental
group1 was younger at admission when compared
with the control group2 (M1 =37.2 days vs. M2 =41.5
days, t(249) = - 2.43, p = .02), and the experimental
group1 had a longer length of stay in the PICU when
compared with the control group2 (M=18.6 days vs.
M= 6.2 days, t(249) = 5.42, p < .001).
PRINCIPAL RESULTS

There were 28 patients (18.8%) who developed
pressure ulcers in the controlgroup (see Table 2) and
17 patients (6.8%) who developed pressure ulcers in
the experimental group (see Table 2). Incidence
of pressure ulcer development in the control and
DAILY SKIN INTEGRITY ASSESSMENT
CORRECT ASSESSMENT/RISK EVALUATION
ANY SKIN-RELATED CONSULTS
HAS THE PATIENT BEEN TO THE OR?
DATE
PROCEDURE
LENGTH OF PROCEDURE
BED/SURFACE
SURFACE
USE
LAYERS OF LINEN = 1 CHUX AND 1 FLAT SHEET
MONITORING EQUIPMENT A CONTRIBUTING
FACTOR
TUBES/LINES A CONTRIBUTING FACTOR
TRACTION
C-COLLAR

CAST
DEVICES IN USE
IS THERE A PILLOW BEING USED WHILE ON A
PRESSURE REDUCING SURFACE?
GEL PADS UNDER PRESSURE POINTS
HEEL PROTECTORS UTILIZED
DOES THE RN HAVE AN INSIGHT AS TO THE
ETIOLOGY OF THE PRESSURE SORE
DEVELOPMENT?
INSIGHT
EQUIPMENT
Figure 1 Continued
341
experimental groups was compared using chi-
square test for nonparametric data and independent
t-tests for parametric data. Pressure ulcer develop-
ment in the control group1 was significantly higher
than in the experimental group2 (M1 = 18.8% vs.
M2 = 6.8%, t (397) = 3.72, p < .001). Demographic

characteristics for the infants who developed pres-
sure ulcers were compared using t-tests utilizing
population means for the control group. There was
not a significant difference in PIM 2 risk ofmortality
scoresbetween the two groups (M1 =12.2%, vs. M2 =
8.3%, t(16) =1.32,p=.21).Although the overall risk
of mortality was not significantly different between
the groups, there were some significant differences
in the types of mechanical support provided for the
infants. The experimental arm1 had a significantly
higher percentage of patients requiring NIPPV than
the controlgroup2 (M1 =41.2% vs.M2 =7.1%, t(16) =
- 54.36, p < .001), as well as a significantly higher
percentage ofpatients requiring ECMO (M1 =29.4%
vs. M2 = 0%, t(16) = 2.58, p = .02). In addition, par-
ticipants in the experimental arm1 of the study were
significantly younger at admission than the partici-
pants in the control group2 (M1 = 18.8 days vs. M2 =
38.3 days, t(16) = - 3.44, p = .001) and had a signifi-
cantly longer length of stay (M1 = 82.5 days vs. M2 =
12.9 days, t(16) = 4.20, p = .001). A difference in
mechanical ventilation impact could not be exam-
ined, asallexperimentalparticipantswho developed
pressure ulcers received mechanical ventilation
(SD= 0).
Of the 17 experimental participants who devel-
oped pressure ulcers, 13 (76.4%) developed one
pressure ulcer, two (11.8%) participants developed
two pressure ulcers, and two (11.8%) participants
developed three pressure ulcers in a range of loca-
tions(see Table 3).PIM 2 risk ofmortality and length
of stay were evaluated using independent t-tests to
determine any relationship with pressure ulcer
development.Participantswho developed a pressure

Table 1. Characteristics of Control and
Experim ental Groups
Characteristic
Control
(n =149)
Experim ental
(n =250) p-value
Gendera
Male 89 (59.7%) 138 (55.2%) > .05
Female 60 (40.2%) 112 (44.8%) > .05
Age in days at admissionb (Mean � SD) 41.5 (� 30.1) 37.2 (�
27.9) < .05
Race/Ethnicitya
African American 12 (8.1%) 31 (12.4%) > .05
American Indian 0 6 (2.4%)
Asian/Indian/Pacific Islander 0 8 (3.2%)
Caucasian 92 (61.7%) 152 (60.8%) > .05
Hispanic 16 (10.7%) 33 (13.2%) > .05
Other/Mixed Race 29 (19.5%) 7 (2.8%) < .05
Unspecified 0 13 (5.2%)
PIM 2 risk of mortalityb (mean � SD) 7.2 (� 15.0) 6.0 (� 11.5)
.1
Length of stayb (mean � SD) 6.2 days (� 10.1) 18.6 days (�
36.0) < .001
Primary reason for admissiona
Cardiovascular 90 (60.4%) 156 (62.4%) > .05
Gastrointestinal 0 10 (4.0%)

Genetic 0 5 (2.0%)
Infectious 0 11 (4.4%)
Injury/Poisoning 6 (4.0%) 7 (2.8%) > .05
Metabolic 0 1 (.4%)
Neurologic 8 (5.4%) 7 (2.8%) > .05
Newborn/Perinatal 0 8 (3.2%)
Renal/Genitourinary 0 2 (.8%)
Respiratory 20 (13.4%) 40 (16%) > .05
Rheumatologic 0 1 (.4%)
Other 25 (16.8%) 2 (.8%) < .05
Use of noninvasive positive pressure
ventilationa (NIPPV)
10 (6.7%) 30 (12.0%) < .001
Use of mechanical ventilationa (MV) 81 (54.4%) 111 (44.4%) <
.001
Use of extracorporeal membrane
oxygenationa (ECMO)
2 (1.3%) 11 (4.4%) < .001
Note:PIM 2 = Pediatric Index of Mortality 2, achi-square test,
bindependent t-test.
341
ulcer had significantly higher risk ofmortality when

compared with participants who did not develop a
pressure ulcer (M=12.2%, SD=12.19 vs. M=5.6%,
SD=11.31, t(248) =- 2.32, p= .02). In addition, par-
ticipants who developed a pressure ulcer had a sig-
nificantly longer length ofstay when compared with
infantswhodidnotdevelopapressureulcer (M=82.5
days,SD=68.38vs.M=13.9days,SD=27.34, t(248)=
- 8.63, p < .001). Correlations also were explored
between incidence of pressure ulcers and length of
stay, PIM 2 risk of mortality scores, Braden Q mean
score, and frequency of turning to determine any
relationships. The only significant finding was that
length of stay and Braden Q mean score were nega-
tively correlated, r(15) = - .63, p = .007), reflecting
the relationship between longer length of stay and
increased risk ofdevelopinga pressure ulcer.
Nutrition consultation for infants deemed as high
risk for developing pressure ulcers was a part of the
PUPP bundle. Infants who did develop a pressure
ulcer1 received a nutrition consultation significantly
more often than those infantswho did not develop a
pressure ulcer2, indicating a lower nutritional score
necessitating nutritional consultation (M1 = 64.7,
SD=49.60 vs. M2 =27.5, SD=44.73, t(248) = - 3.29,
Table 2. Characteristics of Patients with
Pressure Ulcer Developm ent by Group
Characteristic
Control
(n =28)
Experim ental
(n =17) p-value

Gendera
Male 16 (57.1%) 11 (64.7%) > .05
Female 12 (42.9%) 6 (35.3%) > .05
Age in days at admissionb (Mean � SD) 38.3 (� 32.8) 18.8 (�
23.3) .001
Race/Ethnicitya
African American 2 (7.1%) 1 (5.9%) > .05
American Indian 0 0
Asian/Indian/Pacific Islander 0 0
Caucasian 19 (67.9%) 14 (82.3%) > .05
Hispanic 3 (10.7%) 2 (11.8%) > .05
Other/Mixed Race 4 (14.3%) 0
Unspecified 0 0
PIM 2 risk of mortalityb (mean � SD) 8.3 (� 10.6) 12.2 (�
12.2) .21
Length of stayb (mean � SD) 12.9 days (� 19.9) 82.5 days (�
68.4) .001
Primary reason for admissiona
Cardiovascular 19 (67.9%) 15 (88.2%) > .05
Genetic 0 1 (5.9%)
Injury/Poisoning 0 1 (5.9%)
Neurologic 2 (7.1%) 0
Respiratory 4 (14.3%) 0
Other 3 (10.7%) 0
Use of noninvasiveb positive pressure
ventilationa (NIPPV)
2 (7.1%) 7 (41.2%) < .001
Use of mechanical ventilationa (MV) 20 (71.4%) 17 (100%)

Use of extracorporeal membrane
oxygenationa (ECMO)
0 (0%) 5 (29.4%) .02
Note:PIM 2 = Pediatric Index of Mortality 2, achi-square test,
bindependent t-test.
Table 3. Experim ental Group Pressure Ulcer Location and
Stage (n =17)
Location Stage
Abdomen Stage 1
Ankle Stage 2
Foot Stage 2
Not staged
Head Stage 3
Not staged
Hip Stage 1
Naris Stage 1
Stage 2
Stage 2
Stage 2
Stage 2
Neck Stage 2
Stage 2
Not staged
Not staged
Occiput Stage 1
Stage 2

Stage 2
Sacrum Stage 2
Stage 2
Other Stage 2
Stage 2
Note:Several patients had more than one pressure ulcer.
341
p = .001). Turning every 2 hr was also part of the
PUPP bundle. Prior to comparing how frequently
the infants in the control and experimental groups
were turned, one outlier was removed from the
group ofparticipantswho did not develop a pressure
ulcer. The outlier record indicated that the partici-
pant was turned every 27 hr, even though the
length of stay in the PICU was less than 1 day. The
infants in the standard care group were supposed to
be turned every 4 hr, while the infants in the experi-
mental group were supposed to be turned every
2 hr. Neither group met this mark as the mean in
both groups was turning every 5.8 hr. An indepen-
dent t-test was used to compare mean turning time,
and there was no difference in frequency of turning
between the two groups (M1 = 5.8 hr, SD = 3.12 vs.
M2 = 5.8 hr, SD= 2.00, t(243) = - .03, p = .97).

Mean Braden Q scores were calculated for each
child in the experimental group, and an indepen-
dent t-test wasused to compare groups to determine
any differencesbetween participantswho developed
pressure ulcersand participantswho did not develop
pressure ulcers. Participants who developed pres-
sure ulcers1 had significantly lower mean Braden
Q scores than participants who did not develop
pressure ulcers2 (M1 = 18.7, SD = 3.38 vs. M2 = 21.9,
SD= 3.03, t(227) = 4.10, p < .001).
DISCUSSION
Despite a significant reduction in pressure ulcer
development in the 0- to 3-month-old population
in the PICU, pressure ulcer development remains a
significant clinical problem in critically ill infants,
with an incidence in the experimental group of
6.8%. In this study, effective nursing care with tar-
geted interventions reduced the incidence of pres-
sure ulcers in critically ill infants, yet it remains
unclear why the incidence was unable to reach 0%.
Possible explanations include deviations in pre-
scribed nursing care, suboptimal effectiveness of the
intervention itself, or presence of a heavy disease
burden with secondary skin failure making total
eradication of pressure ulcers extremely difficult. It
also may be a combination of any or all of the
above proposed explanations. It is clear that study
participants who developed pressure ulcers were
extremely young, stayed in the PICU for extended
periods of time, and had heavy disease burdens
with the need for invasive mechanical support. In
this study, the PUPP bundle appeared to be associ-
ated with improved outcomes.

Although the PIM 2 risk of mortality was not sta-
tistically different between infants who developed
pressure ulcers in the control and experimental
groups, infants in the experimental arm required
more mechanical support during their PICU stays.
The PIM 2 risk of mortality score was calculated on
the first day ofadmission, but it was not reflective of
the actual PICU course. Although the PIM 2 is one
metric of severity of illness, it is possible that infants
in the experimental arm had much more unstable
PICU courses, as more of them needed ECMO
support, NIPPV support, and all of them required
mechanicalventilation during their PICUadmission.
Increased length of stay has been associated with an
increased risk of pressure ulcer development in the
literature and in this study (Curley et al., 2003;
McCord et al., 2004; Schindler et al., 2007, 2011).
This pattern raises questions about whether patients
can be identified early as potentially having a
long PICU stay, as well as whether early targeted
interventions could help decrease pressure ulcer
development in infants who have extended PICU
stays. Overall, findings from this study were statisti-
cally and clinically significant, indicating that the
PUPP bundle was associated with a decrease in pres-
sure ulcer incidence. Although this finding is impor-
tant, this sample was small. Replication is indicated
to support generalizability of these findings.
Pressure ulcers represent a serious iatrogenic
injury in the acute care setting and have been iden-
tified as a nursing research priority. Although there
have been several published studies on skin integ-
rity, pressure ulcer development, and pressure ulcer
prevention strategies in the adult population, the

science related to pediatric pressure ulcers is still a
developing area of inquiry. In order to protect the
vulnerable pediatric population, it is important to
continue to refine the levelofnurses’understanding
with respect to physiologic indices of pressure ulcer
development and the most effective evidence-based
interventions. Only with stringent testing of these
strategies will nurses be able to employ the most
sophisticated evidence-based approaches when
caring for their smallest, most vulnerable patients.
How might this information affect
nursing practice?
The incidence of pressure ulcers can be decreased
in the most vulnerable patients with the consistent
implementation of evidence-based interventions
341
and system supports for the nursing staff to imple-
ment the change in practice. Nursesbringexpertise
and high level care to their patients in an increas-
ingly complex practice environment. They are
regularly challenged with changes to their practice
and need to keep current to continually bring the
most expert care to their patients. In a fast-paced,
ever-evolvingpractice environment, it is important
to identify effective strategies to implement prac-

tice change. Thisstudy underscores the importance
of system supports when implementing a change
in practice. The use of novel dedicated skin
care champions coupled with system-based
improvement yielded dramatic improvement in
pressure ulcer development in a very vulnerable
population. Although the intervention itself was
important, the skin care champions reinforced the
practice change and the implementation of
the intervention into daily practice. The skin care
champions not only provided peer-to-peer educa-
tion about the intervention but also provided rapid
cycle feedback, which helped the nurses to connect
the change in practice to improved patient out-
comescreatingbuy in and sustainability in practice
changes. We recommend that a carefully planned
approach to practice change be included with the
introduction of any new education for nurses.
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