Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)




Catherine M. Clarey-Sanford

Loyola University Chicago


In an effort to improve patient safety and the quality of care in the acute care setting, there has been an increased focus on the prevention of adverse events believed to be avoidable. Hospital-acquired pressure ulcers (HAPU) have been listed as one of those adverse events, and hospitals are no longer reimbursed for related costs. However, there are patient conditions and clinical situations in which a pressure ulcer can be deemed unavoidable. In acute care, unavoidable means that the patient developed a pressure ulcer even though the provider had: evaluated the patient’s pressure ulcer risk factors; defined and implemented interventions that were consistent with recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Despite these guidelines, the implementation and documentation of pressure ulcer prevention has been inconsistent, making it difficult to identify a HAPU as unavoidable. There is a lack of research exploring the acute care nurses’ perspective of implementing and documenting pressure ulcer prevention interventions.

Using an ethnographic qualitative method, information was collected through observation, informal conversations, interviews, and field notes. Data collection took place in a regional medical center located in the mid-west of the United States over a seven month period and included 23 participants: 7 acute care medical-surgical nurses who had provided direct care to a patient who developed a HAPU and 16 multidisciplinary health care members who had knowledge of pressure ulcer prevention

interventions and documentation. A systematic, rigorous, and in-depth qualitative analysis was completed using the Leininger Data Analysis Guide. Four themes emerged from the data regarding the culture of care of adults experiencing a HAPU: incomplete skin assessments were influenced by priority setting and kinship relationships; an inability to implement pressure ulcer prevention interventions was influenced by economical staffing; diverse documentation regimes were influenced by care rationing practices and technical factors; and diverse multidisciplinary collaborative pressure ulcer prevention efforts were influenced by silo social structures. The findings of this study not only have implications for nursing practice, administration, and education, but are vitally important in the identification of a HAPU as avoidable or unavoidable.

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

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