NURS FPX 6085 Assessment 2 Problem Statement (PICOT)
Student name
Capella University
NURS- FPX6085
Professor Name
Submission Date
NURS FPX 6085 Assessment 2 Problem Statement (PICOT)
A key ingredient for evidence-based clinical practice is the ability to create well-stated PICOT (Population, Intervention, Comparison, Outcome, Time) questions that will direct clinical inquiry and lead to action in clinical practice. The structured framework allows for the clinicians to be clear about clinical problems, and investigate solutions based on evidence, with systematic research and analysis. The systematic approach helps to keep clinical questions being asked specific and measurable, which helps to create more effective strategies for improved delivery of care, based on evidence. The main question in the PICOT question that guides the evaluation is:
Does implementation of a dedicated turn team for repositioning every 2 hours (I) in ICU patients at risk for development of pressure injuries (P) over 6 months (T) reduce the incidence of pressure injuries and severity of pressure injuries when compared to current practices (C) being used for repositioning?
The following PICOT question(s) are presented:
Isolation: single patient room and/or dedicated bathroom with extra bed space (if necessary) for the patient and their caregiver who may experience a pressure injury.
Communication: Nurse documentation and verbal communication with patient/caregiver and/or staff.
Result: Removal of restriction on the turn team, with a new dedicated team of nurses that takes and delivers a turn every 2 hours to each patient.
The participants in the experimental group received standard care. The experimental group was provided with standard nursing care and repositioning of the patient was performed by the nurse.
Intervention: A complete list of the interventions, which may include hospital meals, the inclusion of a specific food type in the diet, and/or more frequent or increased meal frequency.
Outcome: Pressure injury incidence rates and severity (may also include secondary outcome measures such as compliance with turning schedules, nurse satisfaction, or hospital-acquired pressure injury stages)
Time: Six-month period
Need Statement
The need to improve the quality and prevent pressure injuries in the ICU environment is still a major need. The cost of individual patient treatment is also significantly different, with AHRQ estimating that the cost of a pressure ulcer ranges between $20,900 and $151,700. The need for action is further highlighted by the fact that as much as 95% of pressure injuries can be prevented by consistently following the pressure injury prevention protocols, albeit two hour turn schedules are not routinely followed when left to bedside nurses to perform amongst many competing priorities. Having a dedicated team to provide re-positioning can be a systematic effort to guarantee consistent implementation of evidence based re-positioning practices and ultimately minimise avoidable harm and improve the outcomes of patients within an intensive care setting.
Assumptions
The analysis is based on the assumption that repositioning of patients in the ICU is not associated with any significant hemodynamic instability, that adequate training and staffing of a dedicated turn team can be done within the available resources and that existing documentation of pressure injuries is reflective of actual incidence of pressure injuries in the population. It is also assumed that the nurses at the bedsides will be able to work well as a team with the turn team and the intervention’s benefits are worth its implementation costs.
Population and Setting
The target population are adult (18 years old and older) critically ill patients that are sedated, on mechanical ventilation and/or have limited mobility and are at high risk for developing a pressure injury. The necessity to address the needs of the population is paramount as the patients are unable to move themselves, have several risk factors to consider such as hemodynamic instability, tissue hypoperfusion and prolonged lack of mobility. This hospital is set in a medical-surgical ICU, a place where patients’ acuity is greatest and patient-nurse staffing ratios often make it difficult to maintain the same nurse-to-patient ratio for effective implementation of repositioning. This is because ICUs have the highest pressure injury incidence of the hospital and implementing a dedicated turn team in this unit can show that it has a significant impact on patient outcomes and can be a model for the potential rollout of a dedicated turn team to other high-risk hospital wards in the hospital (Fulbrook et al., 2023).
Potential Challenges
Some of the challenges that come with this are making sure that there is enough staff to have a dedicated turn team at every shift, especially during night and weekend shifts; or having enough financial resources to run this. Staff reluctance to changing their workflows when bedside nurses might think the team is encroaching on patient care might impact on collaboration (Cheraghi et al., 2023). Planning patient repositioning schedules with other patient care activities, treatments and procedures can be logistically complex. In addition, in hemodynamically unstable patients, a different turning schedules might be necessary, and the turning schedules should be clearly communicated (Vyas et al., 2024).
Intervention Overview
The proposed intervention is to have a special turn team of trained nursing assistants or patient care technicians who will systematically turn all patients in the ICU every 2 h on a schedule (Asiri, 2023). The intervention is well suited to its target population – critically ill patients need to be moved at regular intervals and the intervention team can be relied upon to perform this task regardless of the other demands on bedside nurses. The intervention is exactly what is needed in the ICU as patients are often extremely sick, have complex needs and are not able to meet the standard of care for turning. The systematic approach directly targets the identified need, by systematically following evidence based pressure injury prevention guidelines. The team will use consistent documentation, communicate with bedside nurses on patient specific factors and use correct repositioning techniques, such as pressure-redistribution surfaces and positioning aids, to ensure the best integrity of skin and prevention of skin breakdown.
Weaknesses of the Intervention
The main drawback of the intervention is that it relies on having a stable staffing and thus is subject to budget constraints, turnover and scheduling issues that could impact the viability of the program. Several factors can cause a lack of communication between the turn team and bedside nurse, which can mean missed contraindications and/or inappropriate repositioning of hemodynamically unstable patients (Gillespie et al., 2020). There is also a high initial cost for intervention because of the need to train, equip and staff the intervention and it is not obvious that any intervention will be cost effective in the short term. Moreover, the team of dedicated nurses could also lead to a lack of participation in the entire process of a skin assessment and possibly pressure injury prevention, which may result in fragmented care.
Comparison of Approaches
An interprofessional solution is to use an integrated technology enhanced reposition system that features smart bed sensors, automated alert system and an interprofessional (IP) dashboard which can be accessed by ward nurses, doctors, wound care specialists and rehabilitation therapists. The strategy integrates interprofessional working as all staff are able to see real time information about patient positioning, pressure mapping and turning compliance and discuss this as a team during interdisciplinary rounds. The technology works for the target population at hand as it is objective and tracks high risk patients, and allows individual pressure redistribution schedules to be tailored for each patient. The alternative is easily combined with the already widespread use of advanced monitoring technology in the ICU and the routine of staff use of technology in workflows. The solution might focus on addressing the need through greater accountability and increased data-driven decision making, but may have a limited lifespan due to cost of implementation, technical issues, alert fatigue and the possibility of over-reliance on technology over clinical judgement and assessment.
Potential Interprofessional Communication and Collaboration Strategies
Interprofessional approaches include daily huddles between turn team members, bedside nurses, physical therapists and wound care specialists, and discussing high risk patients and making plans specific to each person to help prevent pressure ulcers. A complete shared charting system allows for timely information sharing on the topic of turn schedule, skin assessment and contraindications by all disciplines (Ghosh et al., 2024). Interprofessional education sessions regularly occur and help promote understanding of the part each team member has in the prevention of pressure injuries. Having a pressure injury prevention “champion” within a unit helps with coordination across disciplines and helps to address barrier issues in a timely fashion.
Weakness in Alternatives
One of the main drawbacks of the technology enhanced repositioning system is the large initial investment in smart beds, sensors and software development for the system, which can be expensive for some healthcare facilities. Problems with the technology itself, software issues, or issues with the technology’s sensors could endanger patient safety, and provide false assurance to staff. Alert fatigue is also a major issue, since an excessive number of alerts can cause clinicians to override and/or ignore alerts, negating the value of the alarms. Requires a large amount of staff training (across various disciplines) to ensure staff are utilising and interpreting data correctly. Also, excessive use of technology can lead to a lack of the necessary skills and judgement in assessing patients without technology.
Initial Outcome
The most important organizational change that occurs due to the team focused on turns is a quantifiable decline in the number of pressure injuries acquired in the hospital by patients in the intensive care unit (ICU) compared to the current rate to below national standards. The reduction in severity of pressure injuries – from Stage III and Stage IV – would prove effective pressure injury prevention and safety for the patient. Good adherence with the two-hour repositioning protocol would be reflected by near complete adherence to the protocol documented. If the cost-effectiveness and optimum use of resources is confirmed from reduced length of stay for the ICU due to complications relating to pressure injuries, that would support the cost-effectiveness of this strategy. Reduction in length of stay for the ICU as a result of complications related to pressure injuries would confirm cost-effectiveness and optimum use of resources. Improved nurse satisfaction scores for workload management and the patient safety culture could contribute to effective and safe practice change and interprofessional working.
The SMART objective of the project is as follows
Specific: Put in place a specific turn team within the medical/surgical ICU, to systematically shift at-risk patients every two hours.
Measurable: Decrease hospital acquired pressure injuries by 50%, from baseline, and have 95% compliance with 2 hour pressure injury turning as per EHR.
Realistic: Employ 4 full time staff to ensure 24/7 coverage and have consistent repositioning procedures and documentation forms; have a collaboration agreement with bedside nurses.
Relevant: tackle the critical need for continuous pressure injury prevention – adhere reliably to the evidence-based pressure injury repositioning practices, preventing patient harm and thus lowering healthcare costs.
Time bound: All team recruitment, training and implementation of protocols completed in 2 months and outcome measurement and data collection over the next 6 months.
Evaluation Criteria
The effectiveness of the intervention will be determined by recording a monthly pressure injury incidence rate, using a consistent pressure injury staging classification, and 2-hour repositioning compliance rate (using electronic documentation audit) as well as length of stay when compared to baseline. Other factors are nurse satisfaction scores related to workload and working with colleagues, cost benefits analysis of intervention costs versus benefits of treatment and performance against national quality and performance benchmarks. A quarterly data analysis will be conducted using statistical process control (SPC) charts that will be used to uncover trends and even improvement over the six-month implementation period.
Time Estimate
The development time for the intervention for the dedicated turn team takes about two months to complete the necessary preparatory work, such as budget approval, hiring staff, design of competence-based training curriculum, developing the intervention protocol and procurement of the equipment used. Considering hospital practice, the time period is realistic, but could be longer if the process is delayed by administration or budget considerations, which could take several weeks. Implementation timeframe is feasible and will meet quality improvement standards and observe PIR trends that will be meaningful over time (Roderman et al., 2024). Potential issues which may affect the timeframes are jobs that cannot be filled, as well as the delay of recruitment process; resistance to a change of processes which would require more people to be involved in the process; competing organizational needs that could result in the shift of resources and/or delays in the approvals process (Coombs et al., 2022).
Areas of Uncertainty in Implementation Timeline
Potential delays to these factors are significant, such as the unpredictable length of time in recruiting qualified staff during nursing shortages, the approval process on the hospital administrative committees varies, or equipment may not be installed or placed into existing electronics health record (EHR) systems. An unexpected patient acuity increase could lead to changes in the protocol which may lengthen the learning curve. Depending on the response of stakeholders, or changes in the management of nursing, further consensus building efforts may be required.
Literature Review
The frequency at which patients are being turned to minimize the risk of pressure injury (PI) in an intensive care unit (ICU) has been explored in several studies. Using cluster process control to reduce the incidence of pressure injuries was shown to be effective by Chen et al (2024) to achieve a significant reduction from baseline for patients receiving treatment for head and neck cancer (HNC) who were treated with the SSKIN framework. Ten studies were found to have been systematically reviewed by Asiri (2023) who found that repositioning frequencies varied greatly in the different studies with no clear consensus, although most clinical guidelines stated that the frequency of repositioning was every 2 hours. In this study, by combining viable high-density foam mattresses with cueing systems, the researchers found there were no pressure injury incidences in all repositioning intervals (2-hr, 3-hr, and 4-hr) and 4-hr intervals had 95% compliance compared to 80% for 2-hr intervals (Yap et al., 2022). Avsar, et al (2020) found that repositioning patients every 2-3 hrs, instead of less frequent repositioning, decreased the odds of developing a PRESSURE INJURY by 25%. Daigné et al (2022) conducted an individualized repositioning schedule using Braden scores in a French, ICU without increasing adverse events (AEs) as the proportion of patients with pressure injuries (PIs) stayed around 26-28%, despite the increase in repositioning from 3.3 to 4.3 times daily. In the area of dedicated turn team, it was demonstrated that new repositioning teams have improved the outcomes and compliance, which directly supports the proposed intervention of dedicated ICU turn team. Riley et al. (2023) revealed that the importance of SHP and the need for equipment standards were determined as a part of the stakeholder perspectives for sustainable programs for PW prevention. According to Berihu et al. (2020), the nurse to patient ratio, insufficient training and lack of universal guidelines were found to be significant barriers and require intervention for proper pressure ulcer prevention practice among Ethiopian nurses (82.2% had poor practice). In one California hospital, Singh et al. (2023) followed a standardized pressure injury prevention bundle for four years, with pressure injury prevention nurse certificants leading the way, and were able to achieve a sustained 4% reduction (and 90% reduction) in pressure injuries. A cluster randomized trial (CRT) was designed by Cortés et al. (2021), which involves two or four repositioning frequencies between different ICUs in Colombia, pressuting repositioning more frequently would be effective in lessening development of PUs. To conclude, patient repositioning monitoring devices were validated for patient repositioning movements by Minteer et al. (2020) who identified that devices could be objective and relied on with a 85% accuracy at capturing repositioning movement, thus providing support that patients repositioning monitoring devices are feasible.
Relevance, Currency, Sufficiency, and Trustworthiness of the Evidence
Interventions in the Intensive Care Unit (ICU) or hospital settings are to prevent pressure injuries. The currency is satisfactory, publications are from 2020-2024, which represents modernity of clinical practices. Seven studies were randomized controlled trials or systematic reviews, which can be considered as having high trustworthiness and methodological rigor. There is evidence from a variety of settings in multiple countries (United States, Ethiopia, Belgium, Spain, France, Colombia, China) with an increase in generalizability. Further studies focusing on how effective dedicated turn team is in the end, within the context of an ICU setting would add to the evidence base for the intervention.
Healthcare Policy that Impacts the Approach to Address an Identified Need
The way a dedicated turn team for pressure injury prevention is implemented in ICUs is shaped by implementation of several health policies. Because stage III and IV pressure injuries are a preventable HAC, which are counted as “HAC” measures in the Hospital-Acquired Condition Reduction Program (HACRP), this program provides fiscal incentive for hospitals to effectively implement pressure injury prevention strategies. Severe pressure injuries (SAPIs) are viewed as acts of Alasdair MacArthur’s who develop within the hospital as sentinel events that must be subjected to root cause analysis, thus a case for accountability and documentation within the organization and to be included in intervention design (Singh et al., 2023). Careful planning of staffing models, documentation processes and compliance monitoring processes must also be considered when crafting the turn team intervention, as this will be mandated by the policies. Moreover, the implementation of patient care assistant interventions will be influenced by hospital delegations policies, which may mean interventions will be either implemented by patient care assistants with the direct supervision of nursing staff or not at all, resulting in inefficiencies or unaffordability.
Missed Information
There is a lack of clarity on aspects of the implementation needs of the policies. The CMS Hospital-Acquired Condition Reduction Program has no clear guidance of what is acceptable for prevention interventions and no one knows if the introduction of dedicated turn teams complies with the program requirements when compared with other interventions that help prevent HACs. Although the Joint Commission’s sentinel event policy supersedes their policy for stage III and IV pressure injuries, what kind of preventive protocols is sufficient to meet regulatory requirements is not defined.
Conclusion
Use of a specialised turn team, who carry out systematic two hour repositioning in the critical care environment, is an evidence based intervention that aims to reduce the incidence of pressure injuries, and their severity, in the critically ill population. But, overcoming challenges of staffing, interprofessional collaboration and navigating the challenges of health care policies including CMS penalties and Joint Commission standards is required for success. Further research specifically designed to assess the dedicated turn team in the ICUs setting needs to be carried out to provide definitive guidelines and improve the allocation of resources in a sustainable program of PE prevention using the bundles of frequency and prevention.
References
Agency for Healthcare Research and Quality. (2024). Preventing pressure ulcers in hospitals. Ahrq.gov. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
Asiri, M. Y., Al Mutairi, T. S. J., Alanazi, H., & Al-Ghareeb, S. A. (2025). Assessing the cost-effectiveness of pressure injury prevention strategies in a quasi-experimental design. Advances in Skin & Wound Care, 38(8), 413–417. https://doi.org/10.1097/asw.0000000000000331
Asiri, S. (2023). Turning and repositioning frequency to prevent hospital-acquired pressure injuries among adult patients: Systematic review. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 60. https://doi.org/10.1177/00469580231215209
Avsar, P., Moore, Z., Patton, D., O’Connor, T., Budri, A. M., & Nuget, L. (2020). Repositioning for preventing pressure ulcers: A systematic review and meta-analysis. Journal of Wound Care, 29(9), 496–508. https://doi.org/10.12968/jowc.2020.29.9.496
Awoke, N., Tekalign, T., Arba, A., & Lenjebo, T. L. (2022). Pressure injury prevention practice and associated factors among nurses at Wolaita Sodo University Teaching and Referral Hospital, South Ethiopia: A cross-sectional study. BioMed Journal Open, 12(3), e047687. https://doi.org/10.1136/bmjopen-2020-047687
Berihu, H., Wubayehu, T., Teklu, T., Zeru, T., & Gerensea, H. (2020). Practice on pressure ulcer prevention among nurses in selected public hospitals, Tigray, Ethiopia. BioMed Central Research Notes, 13(1), 207. https://doi.org/10.1186/s13104-020-05049-7
Chen, M., Wang, F., Xie, X., Yang, X., Luo, Y., Zhuang, C., & Xie, B. (2024). Application of bundled process control in the prevention of pressure injury in patients with head and neck cancer. Public Library of Science One, 19(6), e0305190. https://doi.org/10.1371/journal.pone.0305190
Cheraghi, R., Ebrahimi, H., Kheibar, N., & Sahebihagh, M. H. (2023). Reasons for resistance to change in nursing: An integrative review. BioMed Central Nursing, 22(1), 1–9. https://doi.org/10.1186/s12912-023-01460-0
Choi, H., Tak, S. H., Song, Y. A., & Park, J. (2025). Nurses’ perspectives on the adoption of new smart technologies for patient care: Focus group interviews. BioMed Central Health Services Research, 25(1), 391. https://doi.org/10.1186/s12913-025-12578-z
CMS. (2024, September 10). Hospital acquired conditions. Cms.gov. https://www.cms.gov/medicare/quality/value-based-programs/hospital-acquired-conditions
Coombs, N. C., Campbell, D. G., & Caringi, J. (2022). A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access. BioMed Central Health Services Research, 22(1), 438. https://doi.org/10.1186/s12913-022-07829-2
Cortés, O. L., Galindo, M. H., Villar, J. C., Rojas, Y. A., Paipa, M. D. P., & Salazar, L. (2021). Frequency of repositioning for preventing pressure ulcers in patients hospitalized in ICU: Protocol of a cluster randomized controlled trial. BioMed Central Nursing, 20(1), 1–10. https://doi.org/10.1186/s12912-021-00616-0
Daigné, D., Blanchard, P.-Y., Allain, M.-C., Lambert, G., Rodriguez, S., Tessier, B., Blayau, C., Voiriot, G., Bérard, L., Rousseau, A., & Fartoukh, M. (2022). Feasibility of a repositioning schedule on pressure ulcer prevention in a French intensive care unit: A pre and post-intervention pilot study. Journal of Tissue Viability, 32(1), 20–25. https://doi.org/10.1016/j.jtv.2022.12.007
Ditlopo, P., Rispel, L. C., Bogaert, P. V., & Blaauw, D. (2024). The impact of the nurse practice environment, workload, and professional support on job outcomes and standards of care at primary health care clinics in South Africa: A structural equation model approach. International Journal of Nursing Studies Advances, 7, e100241. https://doi.org/10.1016/j.ijnsa.2024.100241
Fulbrook, P., Lovegrove, J., Hay, K., & Coyer, F. (2023). State‐wide prevalence of pressure injury in intensive care versus acute general patients: A five‐year analysis. Journal of Clinical Nursing, 32(15-16), 4947–4961. https://doi.org/10.1111/jocn.16687
Ghosh, Ms. P., Raj, Mr. P., N, Ms. V. M., R, Mr. P. S., Pereira, Dr. P., J, Dr. T. C., Ramesh, Dr. M., Syed, Dr. J., & Harsha. (2024). Advances in technology-driven strategies for preventing and managing bedsores: A comprehensive review. Archives of Gerontology and Geriatrics Plus, 1(3), e100029. https://doi.org/10.1016/j.aggp.2024.100029
Gillespie, B. M., Walker, R. M., Latimer, S. L., Thalib, L., Whitty, J. A., McInnes, E., & Chaboyer, W. P. (2020). Repositioning for pressure injury prevention in adults. Cochrane Database of Systematic Reviews, 6(6), 1–65. https://doi.org/10.1002/14651858.cd009958.pub3
Hosseini, M. S., Jahanshahlou, F., Akbarzadeh, M. A., Zarei, M., & Gharamaleki, Y. V. (2024). Formulating research questions for evidence-based studies. Journal of Medicine, Surgery, and Public Health, 2(2), 1–5. https://doi.org/10.1016/j.glmedi.2023.100046
Lin, S. P., Chang, C. W., Wu, C. Y., Chin, C. S., Lin, C. H., Shiu, S. I., Chen, Y. W., Yen, T. H., Chen, H. C., Lai, Y. H., Hou, S. C., Wu, M. J., & Chen, H. H. (2022). The effectiveness of multidisciplinary team huddles in healthcare hospital-based setting. Journal of Multidisciplinary Healthcare, 15(15), 2241–2247. https://doi.org/10.2147/JMDH.S384554
Michels, E. A. M., Gilbert, S., Koval, I., & Wekenborg, M. K. (2025). Alarm fatigue in healthcare: A scoping review of definitions, influencing factors, and mitigation strategies. BioMed Central Nursing, 24(1), 664. https://doi.org/10.1186/s12912-025-03369-2
Minteer, D. M., Simon, P., Taylor, D. P., Jia, W., Li, Y., Sun, M., & Rubin, J. P. (2020). Pressure ulcer monitoring platform—A prospective, human subject clinical study to validate patient repositioning monitoring device to prevent pressure ulcers. Advances in Wound Care, 9(1), 28–33. https://doi.org/10.1089/wound.2018.0934
Noie, A., Jackson, A. C., Taheri, M., Sayadi, L., & Bahramnezhad, F. (2024). Determining the frequency of pressure ulcers incidence and associated risk factors in critical care patients: A 3‐year retrospective study. International Wound Journal, 21(11), e70120. https://doi.org/10.1111/iwj.70120
Rahman, S. (2024). Operational disruption in healthcare associated with software functionality issue due to software security patching: A case report. Frontiers in Digital Health, 6, e1367431. https://doi.org/10.3389/fdgth.2024.1367431
Riley, B. H., Pittman, J., Otts, J. A. A., & Mulekar, M. S. (2023). Key stakeholders’ perspectives: A gap analysis of hospital-acquired pressure injuries. Journal of Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing, 56(2), 291–313. https://doi.org/10.1111/jnu.12940
Roderman, N., Wilcox, S., & Beal, A. (2024). Effectively addressing hospital-acquired pressure injuries with a multidisciplinary approach. HCA Healthcare Journal of Medicine, 5(5), 577–586. https://doi.org/10.36518/2689-0216.1922
Singh, C., Shoqirat, N., Thorpe, L., & Villaneuva, S. (2023). Sustainable pressure injury prevention. BioMed Journal Open Quality, 12(2), e002248. https://doi.org/10.1136/bmjoq-2022-002248
Vyas, V., Sankari, A., & Goyal, A. (2024, December 11). Acute pulmonary embolism. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560551/
Yap, T. L., Horn, S. D., Sharkey, P. D., Zheng, T., Bergstrom, N., Emeric, C. C., Sabol, V. K., Alderden, J., Yap, W., & Kennerly, S. M. (2022). Effect of varying repositioning frequency on pressure injury prevention in nursing home residents: TEAM-UP trial results. Advances in Skin & Wound Care, 35(6), 315–325. https://doi.org/10.1097/01.asw.0000817840.68588.04
FAQs NURS FPX 6085 Assessment 2
Q: What is the purpose of NURS FPX 6085 Assessment 2 Problem Statement (PICOT)?
The purpose of this assessment task is for learners to create an effective and precise PICOT statement related to a particular nursing issue.
Q: What does PICOT mean?
PICOT is an acronym for Population, Intervention, Comparison, Outcome, and Time.