Date of Graduation

Fall 12-12-2025

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

MSN project

First Advisor

Josephine Juan, MSN, RN, CCRN

Abstract

Abstract

Objective: Hospital-acquired pressure injuries remain a patient safety concern despite standard practice of nurses’ prevention protocols (National Pressure Injury Advisory Panel, 2022). Barriers include: inconsistent two-hour repositioning, documentation burden, inadequate staffing, lack of visual cues of patient risk level, and inconsistent compliance with the overall comprehensive prevention bundle (Agency for Healthcare Research and Quality, 2023).

Aim: HAPIs occur within two adult medical-surgical and telemetry units at a tertiary hospital. In response, staff were surveyed on potential interventions, resulting in the production of a visual cuing system.

Methods: Pre- and post-surveys were conducted on the two medical-surgical units to assess staff knowledge of HAPI prevention methods. Specific unit needs were assessed to identify feasible interventions. Results were compared to determine the effectiveness of quality improvement measures.

Intervention: A two-week intervention distributed modified visual flyers featuring the Braden Score protocol during huddles on both units. The flyers outlined moderate- and high-risk criteria and reinforced two-hour repositioning. Floor-wide audits during the intervention assessed the flyers’ viability, compliance, and use.

Results: About 67% of staff nurses reported adopting the HAPI Prevention Tool flyer into their daily practice for its potential effectiveness in decreasing HAPIs and improving patient care.

Conclusion: Staff strongly supported the cuing tool. However, audits revealed inconsistent implementation and low-fidelity signage despite higher self-reported use, indicating a knowing–doing gap.

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