The 10 Strategic Points

Title of Project

1)
Title of Project

Impact the number of depression screenings and referrals to a child psychologist 

Background

Theoretical Foundation

Literature Synthesis

Practice Change Recommendation

2)
Background to Chosen Evidence-Based Intervention:

List the primary points for six sections.

i) Background of the practice problem/gap at the project site

One of the primary causes of disability worldwide, depression affects a sizable percentage of the population. Persistent feelings of sadness and guilt, changes in sleeping patterns (insomnia or oversleeping), changes in appetite, decreased mental and physical energy, unusual irritability, inability to enjoy once-enjoyed activities, difficulty working, and thoughts of death or suicide are all symptoms that can be associated with any type of depressive disorder. These “down” symptoms alone may indicate a unipolar depressive disorder like dysthymia or severe depression if they are present. A person may be diagnosed with bipolar illness if they experience alternating spells of depression and euphoria. Adolescents and young adults increasingly have difficulties with their mental health (Poppen et al., 2016). An individual’s mental health is something only they can fully comprehend, making it difficult for friends and loved ones to spot warning signs in time to intervene. Juvenile and young adult suicide is a major problem in today’s world. A lack of life experiences, self-confidence, and faith in one’s own skills contribute to the suicides of many young individuals.

ii) Significance of the practice problem/gap at the project site

Mental illness has been a problem that is affected the population for a long period and worryingly young people and adolescents are experiencing many effects that lead to some committing suicide. The stress that today’s youth encounter nowadays is the most significant of all these issues, especially the pressure they receive based on their academic expectations and poor communication about their troubles to their parents. There is also a gap in the schools in terms of students receiving counseling services because there are limited professional counselors that attend to student needs. Despite the fact that psychologists claim stress could be caused by anything, many young people find the rapid pace of modern life to be a significant source of anxiety. Many young individuals are inspired to take their own lives by the media’s glorified depiction of suicide (Poppen et al., 2016). The reality that suicide is always fatal seems to be lost on many young people. Young people, in other words, consider suicide an option for self-expression or as a means of making up for past misdeeds.

iii) Theoretical Foundations (choose one nursing theory and one evidence-based change model to be the foundation for the project):

The most likely reasons for people to take their own lives are outlined in Emile Durkheim’s theory of suicide. According to the theory, a person’s lack of social integration may be a contributing factor in their decision to take their own life after experiencing chronic depression. It is possible that individuals do not have adequate psychosocial assistance to help them deal with the difficulties of life (Poppen et al., 2016). There is limited psychological assistance in schools making it a significant cause of the burden of psychological issues that leads to chronic depression. These individuals have weak egos because they lack sufficient social networks in their immediate environment. It is society’s fault, according to Durkheim, because the regulations that restrict people’s actions are so lax. He is of the opinion that individuals’ actions are influenced by social problems such as the economic crisis, pressure from academic work for high school adolescents, and particularly when such people are unable to cope with their depression. Additionally, the notion indicates that an individual may choose to end their own life if they have the perception that the regulations that are in place restrict their freedom.

Evidence-Based Change Model

A wide number of approaches can be taken to bring about change in healthcare organizations. The data, assessment, and plan (DAP) project’s activities, which include community and adolescent education, community presentations to improve awareness of depression, and teaching positive coping strategies, will be efficiently implemented with the use of the PDSA model’s four steps: plan, do study, and act. During the “plan” phase of the DAP program, a group consisting of school nurses, parents, instructors, and students themselves will serve as the program’s leaders. After the planning stage comes to the “Do” stage, which is where the actual execution of the program takes place. The DAP program will include a variety of components, including public education, the promotion of healthy emotional expression among adolescents through the medium of painting, and the instruction of coping skills (Poppen et al., 2016). The “Study” step is where you’ll be doing any kind of analysis or assessment of the program. A few of the factors that are taken into consideration are the return on investment, any necessary adjustments, and the possibility of unfavorable repercussions. The final phase of the PDSA process is referred to as the “Act.” It includes conducting an in-depth analysis of the project’s goals and results.

iv) Create an annotated bibliography using the “Preparing Annotated Bibliographies (APA 7th)” located in the Student Success Center. https://www.gcumedia.com/lms-resources/student-success-center-content/documents/writing-center/preparing-annotated-bibliographies-apa7-mla8-turabian9.pdf utilizing the five (5) original research articles that support the evidence-based intervention. This will be the foundation of the Literature Synthesis you will have to do in DNP-820A.

Kroning, M., & Kroning, K. (2016). Teen Depression and Suicide: A Silent Crisis. Journal of Christian Nursing, 33(2), 78.

https://doi.org/10.1097/CNJ.0000000000000254

Kroning et al. discuss the hidden epidemic of adolescent depression. They discovered that over 11% of all teenagers and nearly a third of all high school students suffer from depression. About one-fifth of high school pupils (about 17%) have seriously considered suicide. Intriguingly, adolescent depression is rarely given the attention it deserves. The article describes the events leading up to the death of a 17-year-old girl and discusses the warning indicators of depression that could have been observed. Teen depression is a major public health problem. Many adults have witnessed kids’ melancholy and incorrectly assumed it was due to hormonal changes, defiance, or general adolescent irritability. When comparing causes of mortality among people aged 15–24, suicide is by far the most common worldwide. The article provides a detailed plan that can save the life of a depressed person and keep them from even considering suicide.

Best, P., Manktelow, R., & Taylor, B. (2014). Online communication, social media, and adolescent wellbeing: A systematic narrative review.
Children and Youth Services Review, 
41, 27-36

Researchers in this study used a narrative synthesis method and a valued appraisal instrument to read the articles and analyze the findings. The research aimed to answer the following question: “What are the positive and negative consequences of social media among youth?” (Best et al., 2014). Further, this study illustrates the beneficial and bad effects of social media use on adolescents’ mental health; this outcome aids me in my investigation of the relationship between adolescent use of the internet and their physical and mental well-being. Evidence from Best et al. (2014) shows that social media can have both beneficial and negative effects on adolescents’ mental health; however, the authors also suggest that further research is needed to strengthen the connection between social media and adolescents’ psychological well-being.

O’Reilly, M., Dogra, N., Hughes, J., Reilly, P., George, R., & Whiteman, N. (2018). Potential of social media in promoting mental health in adolescents. 
Health Promotion International, 1-11.

The study details the examination of three primary topics: the role of social media in the mental health of teenagers, the benefits and problems of social media and mental health, and the future directions for research on these topics. Further, this lends credence to the idea that social media can have both beneficial and detrimental effects on young people’s mental health. Finally, the study does a fantastic job of disaggregating responses by gender and age, resulting in a wide range of perspectives on the potential effects of social media. The concepts of social media opinion, mental health, and views for the future of social media in the context of health informed the design of the focus group.

Wang, X., Cai, L., Qian, J., & Peng, J. (2014). Social support moderates stress effects on depression. International Journal of Mental Health Systems, 8(1), 41. https://doi.org/10.1186/1752-4458-8-41

The paper explores how social support plays a role in mitigating depression and other stress-related outcomes. A survey of college students was administered to assess their levels of social support, stress, and depressive symptoms. In a regression study, it was discovered that social support mitigates the association between depression and stress. Undergraduate students who had high-stress levels were discovered to be having depression. The students who reported having social support from faculty and peers were in a different situation. Anxiety manifests itself mentally when the needs of the spirit exceed the capabilities of the body. It’s very uncommon for this to lead to additional feelings of negativity, despair, and anxiety, all of which can stunt a person’s ability to mature and flourish as a person. Individual and environmental variables both play a role in the development of depression.

Albert, P. R. (2015). Why is depression more prevalent in women? Journal of Psychiatry & Neuroscience: JPN, 40(4), 219–221.

https://doi.org/10.1503/jpn.150205

The article discusses how common depression is among women. Major depressive disorder is a serious health problem that affects many people. It is estimated that in 2010, depression disorders were the second-leading cause of burdens for Canadians with disabilities, after mobility impairments. When people are depressed, it often results in their own death by means of suicide or a stroke. Depression ranks as the third leading cause of death around the world because of all these deaths. Education and income, maltreatment, and other socioeconomic issues all have a role in exacerbating women’s already high suicide incidence.

v) Summary of the findings written in this section.

The adolescents that suffer from depression are contributed by multiple factors that include social issues, academics, lack of support, and the influence of social media. The limited resources for addressing mental health in high school result in cases of chronic depression. There is a need for screening to assist adolescent students in the preliminary stages and avoid cases of depression.

Problem Statement

3)
Problem Statement:

Depression is a huge problem among adolescents in high school and prior screening through schools having enough counsellors and creating awareness help in mitigating the risks and consequences.

PICOT to Evidence-Based Question

4)
PICOT Question Converts to Evidence-Based Question:

The purpose of this quantitative, quasi-experimental quality improvement project is to determine if or to what degree the translation of research by Anand et al. utilizing the Patient Health Questionnaire-9 (PHQ-9) will impact the number of depression screenings and referrals to a child psychologist when compared to current practice among adolescents at a high school setting in urban Texas over eight weeks.

Sample

Setting

Location

Inclusion and Exclusion Criteria

5)
Sample, Setting, Location

The sample size targeted is 15 participants and the study setting is the urban area of Texas. High school adolescents and counselors are the target participants.

Define Variables

6)
Define Variables:

i) Independent Variable (Intervention): Therapy/counseling and having enough counsellors.

ii) Dependent Variable (Measurable patient outcome): Depression

Project Design

7)
Project Design:

However, research findings do not have to be immediately integrated into clinical practice, the fundamental purpose of quality improvement programs is to improve patient care. To identify a problem, research must be undertaken, and quality enhancement entails gathering evidence that can be used to better the topic of interest.

Purpose Statement

8)
Purpose Statement:

The purpose of this quality improvement project is to determine if the implementation of therapy/counseling intervention would impact the mental health well-being among high school adolescents. The project was piloted over eight weeks in an urban setting within Texas state.

Data Collection Approach

9)
Data Collection Approach:

To gather and analyze demographic data, I plan to use an Excel spreadsheet. By consulting with healthcare professionals and conducting the survey with 15 participants, I will be able to collect valid and trustworthy data on patient outcomes. To ensure that the collected data can be replicated, the survey instrument employs a standardized, organized format. In the realm of data collecting and analysis, spreadsheets are widely regarded as among the most efficient and trustworthy tools available.

i) Describe the step-by-step process you will use to collect the data, explain where the data will come from, and how you will protect the data and participants.

I would first seek the approvals from necessary authorities and also get the consent from the target participants that is the counsellors and high school adolescents. The participants are 15 in number from Urban Texas.

High school adolescent patients in mental health care are given an evaluation questionnaire to fill out, with two weeks allotted to finish the process. The questionnaire itself takes only a few minutes to complete. To acquire this data, we have them fill out a questionnaire and record their responses in a spreadsheet. A copy of the encrypted data is subsequently uploaded to a remote server.

ii) Discuss potential ethical issues pertaining to your project. Ethical Considerations in Human Research Protection (i.e., confidentiality vs anonymity of the data, informed consent, and potential conflict of interest.)

Participants are needed to sign the informed consent form as soon as they agree to take part in the study, demonstrating their willingness to allow the data to be shared. The participants’ anonymity is protected by the confidentiality guarantees inherent in the informed consent process. The participant has the moral right to expect that their date would be kept private and discreet. There should be no potential conflict of interest between the researcher and the participant.

iii) Discuss how you will adhere to the principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, within the theoretical framework, clinical problem, and clinical questions.

I would analyze the Belmont report and make sure that all the requirements are adhered to in the research study.

Data Analysis Approach

10)
Data Analysis Approach:

Using a descriptive statistical method and demographic analysis, I would examine the provided descriptive data and demographic information. If I were to analyze the quantifiable patient outcomes, I would use the chi-square test. In this case, I would resort to the techniques employed by statisticians. A possible source of error in the data is that respondents provided false information, especially about demography. To deal with this difficulty, we can establish a range within which each given piece of data should lie to ensure that our results can be reproduced.

References

Albert, P. R. (2015). Why is depression more prevalent in women? Journal of Psychiatry & Neuroscience: JPN, 40(4), 219–221.

https://doi.org/10.1503/jpn.150205

Best, P., Manktelow, R., & Taylor, B. (2014). Online communication, social media, and adolescent wellbeing: A systematic narrative review.
Children and Youth Services Review, 
41, 27-36

Kroning, M., & Kroning, K. (2016). Teen Depression and Suicide: A Silent Crisis. Journal of Christian Nursing, 33(2), 78.

https://doi.org/10.1097/CNJ.0000000000000254

O’Reilly, M., Dogra, N., Hughes, J., Reilly, P., George, R., & Whiteman, N. (2018). Potential of social media in promoting mental health in adolescents. 
Health Promotion International, 1-11.

Poppen, M., Sinclair, J., Hirano, K., Lindstrom, L., & Unruh, D. (2016). Perceptions of Mental Health Concerns for Secondary Students with Disabilities during Transition to Adulthood. 
Education And Treatment Of Children, 
39(2), 221-246. https://doi.org/10.1353/etc.2016.0008

Wang, X., Cai, L., Qian, J., & Peng, J. (2014). Social support moderates stress effects on depression. International Journal of Mental Health Systems, 8(1), 41. https://doi.org/10.1186/1752-4458-8-41

The 10 Strategic Points

Title of Project

1)
The Use of Five-Layer Prophylactic Foam Dressings to Prevent Pressure Injuries.

Background

Theoretical Foundation

Literature Synthesis

Practice Change Recommendation

2)
Background to Chosen Evidence-Based Intervention:

i) Patients in the intensive care unit (ICU) have an increased risk for pressure injuries (PIs) due to a multitude of risk factors to include poor nutrition, hemodynamic instability, immobility, and many others (Webb-Anderson, et al., 2018).

ii) The Trauma Neuro Intensive Care Unit (TNICU) where this doctoral learner is employed is significantly impacted by a high number of hospital-acquired pressure injuries (HAPIs) and currently uses a standard approach to preventing them. Although risk assessment and standard interventions are utilized, there are no formal processes in place for this critically ill patient population when they are required to remain in the supine position for long periods of time. These patients often require multiple interventions such as magnetic resonance imaging (MRI) and multiple operative procedures, placing them at greater risk for sacral skin breakdown.

iii) Theoretical Foundations:

(1) Ida Jean Orlando Pelletier’s deliberative nursing process discipline theory will be the foundation of the DPI project. The framework of her theory contains three elements: patient behavior (risk assessment), nurse reaction, and what the nurse does to mitigate the problem (interventions) (1961).

(2) Kotter’s (1995) 8-step change model best aligns with the DPI project for decreasing the incidence of pressure injuries (PIs) among critically injured patients in a trauma neuro intensive care unit (TNICU). The facilitator will create a sense of urgency by sharing the rates and staging of the previous months PIs. By identifying the potential reimbursement and quality threats to the key stakeholders and engage with honest discussions, the organization will want to implement the new practice (Kotter, 1995). The second step involves the formation of a coalition. This will be the task of engaging the unit-based skin champions and asking for a commitment to the change in practice. Step three is to create a vision for change by incorporating the solution to the identified problem. The skin-champions and DPI facilitator will then communicate the vision to the frontline colleagues to create buy-in. Identification and removal of obstacles in step 5 will ensure success. In this step, early adopters will be encouraged and recognized and those that are resistant will be reeducated on the importance of the change. Short term wins will be celebrated such as decreased incidence of PIs. Step 7 includes building on the change and continuous improvement. In step 8, anchoring the changes into the unit culture will ensure standard work continues (Kotter, 1995).

iv) Annotated Bibliography:

Annotated Bibliography

Hahnel, E., Genedy, M.E., Tomova-Simitchieva, T., Hau, A., Stroux, A., Lechner, A., Richter, C., Akdeniz, M., Blume-Peytavi, U., Lober, N., & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high-risk intensive care unit patients: a randomized controlled parallel-group trial. The British Journal of Dermatology, 183, 256-264. https://pubmed.ncbi.nlm.nih.gov/31628863/. This randomized control trial sought out to determine if the use of silicone preventative dressings applied to the sacrum and heels among patients in intensive care units (ICU) from a tertiary hospital had reduced incidence of pressure injuries. A total of 475 patients were included in the study and divided into two groups. The results of the study revealed that patients with interventions had a cumulative pressure injury incidence of 2.8% whereas the control group was 10.5%. The results of this trial concluded that the use of silicone dressings is effective in the prevention of hospital-acquired pressure injuries in the ICU.

Padula, W. (2017). Effectiveness and value of prophylactic 5-layer foam sacral dressings to prevent hospital-acquired pressure injuries in acute care hospitals. Journal of Wound, Ostomy and Continence Nursing, 44(5), 413- 419. https://doi.org/10.1097/won.0000000000000358.

This observational cohort study examined the effectiveness of a five-layer prophylactic foam dressing to prevent pressure injuries among patients in acute care settings. Over a 5-year period, the use of the prophylactic 5-layer foam dressing decreased the rate of pressure injuries when combined with a prevention protocol. It was also identified that the cost of the dressing is well within a reasonable expense of $7 per dressing.

Riemenschneider, K.J., (2018). Prevention of pressure injuries in the operating room. Journal of Wound Ostomy Continence Nursing, 45(2), 141-145.

This study utilized a sample of 81 patients who underwent vascular surgery in an operating room at a level 1 trauma acute care setting in the Northeastern United States. The use of a five-layer silicone foam dressing was utilized on the intervention group which consisted of forty-four patients. Results revealed that 50% of patients in the pre-intervention group developed pressure injuries between the third and seventh postoperative days, whereas only one person (2%) developed a pressure injury in the intervention group. These findings add to the evidence that the use of silicone foam dressings decrease the incidence of pressure injuries when used in conjunction with standard interventions.

Stankiewicz, M., Gordon, J., Dulhunty, J. M., Brown, W., Pollock, H., & Barker-Gregory, N. (2019). A cluster-controlled clinical trial of two prophylactic silicone sacral dressings to prevent sacral pressure injuries in critically ill patients. Wound Practice & Research, 27(1), 21–26. https://doi-org.lopes.idm.oclc.org/10.33235/wpr.27.1.21- 26. This cluster-controlled randomized clinical trial compared the effectiveness between two prophylactic silicone sacral dressings among critically ill patients. This study did not show a statistical difference in the effectiveness of two different dressings, but it recorded a significant cost difference. With the use of the dressings on all patients, only 5/302 patients developed pressure injuries among both groups, revealing the use of the dressings are effective regardless of brand.

Strauss, R., Preston, A., Zalman, D.C., & Rao, A.D. (2019). Silicone foam dressing for prevention of sacral deep tissue injuries among cardiac surgery patients. Advances in Skin & Wound Care, 32(3), 139-142. This uncontrolled, quality improvement design evaluated the effectiveness of silicone foam dressings that were placed preoperatively. Pre- and post-interventions were assessed. Patients that had the dressing placed, were maintained for up to five days in the intensive care and step-down units after cardiac surgery. Pre-intervention patients revealed a sacral deep tissue pressure injury (DTPI) incidence rate of 2.33%. Zero patients in the intervention group developed sacral DTPI, concluding that the use of silicon foam dressings for prophylactic prevention of sacral DTPIs is effective on this high-risk patient population.

v) Practice Change Recommendation: Evidence suggests the use of a five-layer prophylactic foam dressing decreases the incidence of pressure injuries. The practice change recommendation will be placement of a five-layer silicone bordered foam on critically ill patients that are at increased risk for pressure injuries. The use of various shaped foams will be used and placed on bony prominences such as the sacrum and heels.

vi) Patients in the TNICU are critically injured and require multiple diagnostic tests and operating room procedures that require them to be placed in the supine position on a hard surface for long periods of time. Because of this, they are at increased risk for developing pressure injuries. Research has shown that the use of a five-layer prophylactic foam dressing has been linked to a decrease in the incidence of pressure injuries in the operating room as well as in the ICU. The practice change recommendation is to place a five-layer silicone foam dressing on bony prominences of patients in the TNICU to decrease the incidence of pressure injuries.

Problem Statement

3)
Problem Statement:

 It is not known if the implementation of a five-layer prophylactic silicone foam dressing placed on bony prominences would decrease the incidence of pressure injuries among patients in the trauma neuro ICU.

PICOT to Evidence-Based Question

4)
PICOT Question Converts to Evidence-Based Question:

(P) Among adult patients in a suburban, Pennsylvania Level I Trauma Neuro Intensive Care Unit (TNICU),
(I) how does the translation of Padula’s research on the use of a five-layer prophylactic foam dressing
(C) compared to current practice (
O) impact the rate of pressure injuries (
T) over a period of eight weeks?

Sample

Setting

Location

Inclusion and Exclusion Criteria

5)
Sample, Setting, Location

i) Sample and Sample Size: Adult patients in the TNICU who are at risk for skin breakdown. Estimated sample size will be 25-30 patients over an eight-week period that meet the inclusion criteria will be compared to the pre-intervention period and based on the sample size calculator. Potential bias will be related to the overall four-week census pre- and post-intervention and the acuity of the patient population.

ii) Setting: Inpatient, trauma neuro intensive care unit.

iii) Location: Suburban, Pennsylvania

iv) Inclusion Criteria

· Patients > 18 years old

· Admitted to the Trauma Neuro Intensive Care Unit

· Braden scale score < 18

· Bony prominences that do not have pre-existing, present on admission pressure injuries

v) Exclusion Criteria

· Patients < 18 years old

· Not admitted to the trauma neuro intensive care unit

· Braden scale score > 18

· Bony prominences with pre-existing, present on admission pressure injuries.

Define Variables

6)
Define Variables:

i) Independent Variable: Five-layer Foam Dressing

ii) Dependent Variable: pressure injury rates.

Project Design

7)
Project Design:

i) Quality Improvement projects are developed to improve practice or performance based on a determined goal. Implementation of a new product or process to improve patient care defines a quality improvement project (Hirshon, 2021). This DPI project is designed to improve outcomes of patients by utilizing a five-layer prophylactic foam dressing to prevent skin breakdown among critically injured trauma patients.

ii) Research is regulated and is designed to investigate and test new processes or interventions that can translate into new knowledge. Research utilizes a systematic approach and requires review through an institutional review board (IRB) prior to beginning the research. This is to ensure all federal ethical standards are met (Hirshon, 2021).

iii) In summary, quality improvement projects are intended to improve practice or patient outcomes. This DPI project utilizes primary research as a preface for implementing an intervention that is backed by primary research already conducted. It is meant to improve patient outcomes based on the intervention of a five-layer prophylactic foam dressing.

Purpose Statement

8)
Purpose Statement:

The purpose of this quality improvement project is to determine if the implementation of a five-layer prophylactic foam dressing would impact the development of pressure injuries among critically ill adult patients. The project will be piloted over an eight-week period in a suburban, Level 1, Pennsylvania trauma neuro intensive care unit.

Data Collection Approach

9)
Data Collection Approach:

i) An Excel spreadsheet will be used to gather patient demographic information from the electronic health record. Items include age, gender, mechanism of injury, Braden risk assessment, test/procedure, and length of time of the procedure.

ii) The organization’s quality report, Tableau will be accessed to obtain the measurable patient outcome. This system tracks rates of pressure injuries by unit. It tracks rates monthly. This system does not contain confidential patient identifiers; therefore, consent is not needed.

iii) There is no instrument for this project. The data source is the electronic health record and the Tableau system

iv) Describe the step -by-step process you will use to collect the data, explain where the data will come from, and how you will protect the data and participants.

1. Obtain comparative and implementation pressure injury rates from the Tableau system.

2. Obtain demographic data through a report located in the electronic health record.

3. Obtain usage report of the five-layer prophylactic foam dressings for the comparative and implementation period to determine usage.

4. All participant data will be protected, and identifiable information will not be included in the data that is gathered.

v) Potential ethical issues pertaining to this DPI project include a convenience sample of participants. All patients who meet the inclusion criteria will receive the same intervention with the intent of improved outcomes for all patients. All data will be stored appropriately on an encrypted password protected computer at the project site only accessible by the project manager and the mentor.

vi) Adherence to the principles of the Belmont Report falls under the realm of beneficence or doing good. The clinical question and theoretical framework are developed to improve patient outcomes with the intent to decrease hospital-acquired pressure injuries in critically injured trauma patients.

Data Analysis Approach

10)
Data Analysis Approach:

Data analysis will encompass the comparison of patients pre-and post-intervention. Participants’ descriptive information will not impact the DPI project. A chi-squared test will be used for the data analysis portion of the DPI project. This method will help to answer the question if utilization of the five-layer prophylactic foam dressing influences the incidence of pressure injuries when used on the same patient population of trauma patients. Intellectus statistics will be used utilizing the regression interface selecting the dependent and independent variables. Potential bias of pressure injuries will be mitigated with the use of the expert clinician WOCN dedicated to the TNICU.

References

Hahnel, E., Genedy, M.E., Tomova-Simitchieva, T., Hau, A., Stroux, A., Lechner, A., Richter, C., Akdeniz, M., Blume-Peytavi, U., Lober, N., & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high-risk intensive care unit patients: A randomized controlled parallel-group trial.
The British Journal of Dermatology, 183, 256-264. https://pubmed.ncbi.nlm.nih.gov/31628863/.

Hirshon, J.M. (2021). Quality improvement versus research: What is ethically and regulatorily right?
Annals of Emergency Medicine, 1-3. https://doi.org/10.1016/j.annemergmed.2021.03.038

Jean, I. (1961).
The dynamic nurse-patient relationship: Function, process, and principles. G. P. Putnam’s Sons

Kotter, J. (1995).
Leading change. Harvard Business Review Press.

Padula, W. (2017). Effectiveness and value of prophylactic 5-layer foam sacral dressings to prevent hospital-acquired pressure injuries in acute care hospitals.
Journal of Wound, Ostomy and Continence Nursing, 44(5), 413- 419. https://doi.org/10.1097/won.0000000000000358

Riemenschneider, K.J., (2018). Prevention of pressure injuries in the operating room.
Journal of Wound Ostomy Continence Nursing, 45(2), 141-145. https://doi.org/10.1097/won.0000000000000410

Stankiewicz, M., Gordon, J., Dulhunty, J. M., Brown, W., Pollock, H., & Barker-Gregory, N. (2019). A cluster-controlled clinical trial of two prophylactic silicone sacral dressings to prevent sacral pressure injuries in critically ill patients.
Wound Practice & Research, 27(1), 21–26. https://doi-org.lopes.idm.oclc.org/10.33235/wpr.27.1.21- 26

Strauss, R., Preston, A., Zalman, D.C., & Rao, A.D. (2019). Silicone foam dressing for prevention of sacral deep tissue injuries among cardiac surgery patients.
Advances in Skin & Wound Care, 32(3), 139-142. https://doi.org/10.1097/01.asw.0000553111.55505.84

Webb-Anderson, K., Daley, P., Isenor, C., McMullen, S., Kelly, E., & Bishop, L. (2018). Intensive care unit (ICU) pressure injury prevention: When ‘under pressure’, use evidence to inform action! 
The Canadian Journal of Critical Care Nursing, 29(2), 60-61