This is an original excerpt written by our team to show structure, depth and referencing. It is modelled on the course named above but is not a university document. Use samples as a study guide and follow your school's academic integrity policy.
Trigger
In the nursing home in this project, every resident at risk of pressure injuries is turned every 2 hours around the clock, including at night. Nursing assistants report that the schedule is hard to keep with current staffing, and residents complain of being woken repeatedly. The director of nursing asked whether the evidence supports a different schedule. The facility and its figures are illustrative.
The framework
The Iowa Model of Evidence-Based Practice is a widely used framework for implementing evidence-based practice. Its 2017 revision, based on feedback from 431 users and validated by 299 participants at a national conference, expanded the steps for piloting, implementation, patient engagement and sustaining change (Iowa Model Collaborative, 2017). The project follows its steps.
Step 1: Identify the trigger and state the purpose
Purpose: to determine whether repositioning frequency for residents on high-density foam mattresses can be based on assessed risk while keeping pressure injury rates low.
Step 2: Is this topic a priority?
Yes. Pressure injuries are a quality measure for nursing homes, staff workload is a recognized problem, and residents' sleep is a quality-of-life concern.
Step 3: Form a team
The team includes the director of nursing, two charge nurses, three nursing assistants from different shifts, the wound care nurse, a resident council representative and the DNP student as project lead.
Step 4: Assemble, appraise and synthesize the evidence
The key study is the Turning for Ulcer ReductioN (TURN) trial, a multisite randomized trial in 20 US and 7 Canadian nursing homes using high-density foam mattresses. It enrolled 942 residents aged 65 or older at moderate (Braden 13–14) or high (Braden 10–12) risk and randomly assigned them to repositioning every 2, 3 or 4 hours for 3 weeks. Only 2.0% developed pressure injuries, all superficial, and incidence didn't differ significantly by schedule (2.5%, 0.6% and 3.1%) or between moderate- and high-risk residents. The authors concluded that consistently turning residents every 2, 3 or 4 hours, with regular skin checks, gave similar results on these mattresses (Bergstrom et al., 2013).
Step 5: Is there sufficient evidence?
Yes, for the specific conditions studied: residents at moderate or high risk, on high-density foam mattresses, with consistent repositioning and skin monitoring. The trial was short (3 weeks), so the pilot must monitor outcomes over a longer period, and residents at very high risk (Braden 9 or below) or with existing injuries will stay on the current protocol.
Step 6: Design and pilot the practice change
| Element | Plan |
|---|---|
| Population | Residents with Braden scores of 10 to 14, on high-density foam mattresses, without existing pressure injuries |
| Change | Repositioning every 4 hours overnight, with the schedule individualized and documented; daytime repositioning and mobility continue |
| Safety checks | Full skin inspection each shift; Braden reassessment weekly and with any change in condition |
| Pilot | One 40-bed unit for 12 weeks |
| Engagement | Residents and families informed and asked about their preferences for night care |
Step 7: Evaluate the pilot
- Outcome: facility-acquired pressure injuries of any stage per 1,000 resident-days.
- Process: percentage of scheduled repositioning completed and documented; skin checks completed.
- Resident-centered: residents' reports of sleep quality.
- Balancing: falls at night.
Step 8: Is the change appropriate for adoption?
The team will decide after 12 weeks. The change will be adopted if pressure injury rates are no higher than baseline, documentation compliance is at least 90% and no safety concerns arise.
Step 9: Integrate, sustain and disseminate
If adopted, the change will be written into policy, added to orientation, and monitored monthly through the quality committee. Results will be shared with staff and residents and presented at a regional long-term care conference.
References
Bergstrom, N., Horn, S. D., Rapp, M. P., Stern, A., Barrett, R., & Watkiss, M. (2013). Turning for Ulcer ReductioN: A multisite randomized clinical trial in nursing homes. Journal of the American Geriatrics Society, 61(10), 1705–1713. https://doi.org/10.1111/jgs.12440
Iowa Model Collaborative. (2017). Iowa Model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175–182. https://doi.org/10.1111/wvn.12223
