CLINICAL SCHOLARSHIP

The Skin Safety Model: Reconceptualizing Skin Vulnerability

in Older Patients
Jill L. Campbell, BAppSc (Nursing), RN, Grad. Dip (Wound Care)1 , Fiona M. Coyer, PhD, MSc (Nursing), RN,
PGCEA2 , & Sonya R. Osborne, PhD, RN3
1 Phi Delta-at-large, Doctoral student, School of Nursing, Queensland University of Technology, and Clinical Nurse, Skin Integrity Service, Royal Brisbane
and Women’s Hospital, Herston, Queensland, Australia
2 Phi Delta-at-large, Professor of Nursing, School of Nursing, Queensland University of Technology, Royal Brisbane and Women’s Hospital, Metro-North
Hospital Health Service, Herston, Queensland, Australia
3 School of Nursing, Senior lecturer, Queensland University of Technology, Kelvin Grove; Joint appointment Royal Brisbane and Women’s Hospital,
Metro-North Hospital Health Service, Herston, Queensland, Australia

Key words Abstract

Acute care, incontinence-associated dermatitis,
older adult, pressure ulcer, skin safety Purpose: To develop a unique skin safety model (SSM) that offers a new and
unified perspective on the diverse yet interconnected antecedents that con-
Correspondence tribute to a spectrum of potential iatrogenic skin injuries in older hospitalized
Jill L. Campbell, Royal Brisbane and Women’s adults.
Hospital, Butterfield St, Herston,
Organizing Construct: Discussion paper.
Queensland, 4029. Australia.
Methods: A literature search of electronic databases was conducted for pub-
E-mail: Jill.campbell@hdr.qut.edu.au
lished articles written in English addressing skin integrity and iatrogenic skin
Accepted: October 5, 2015 injury in elderly hospital patients between 1960 and 2014.
Findings: There is a multiplicity of literature outlining the etiology, preven-
doi: 10.1111/jnu.12176 tion, and management of specific iatrogenic skin injuries. Complex and inter-
related factors contribute to iatrogenic skin injury in the older adult, including
multiple comorbidities, factors influencing healthcare delivery, and acute sit-
uational stressors. A range of injuries can result when these factors are com-
plicated by skin irritants, pressure, shear, or friction; however, despite skin
injuries sharing multiple antecedents, no unified overarching skin safety con-
ceptual model has been published.
Conclusions: The SSM presented in this article offers a new, unified frame-
work that encompasses the spectrum of antecedents to skin vulnerability as
well as the spectrum of iatrogenic skin injuries that may be sustained by older
acute care patients. Current skin integrity frameworks address prevention and
management of specific skin injuries. In contrast, the SSM recognizes the com-
plex interplay of patient and system factors that may result in a range of iatro-
genic skin injuries. Skin safety is reconceptualized into a single model that has
the potential for application at the individual patient level, as well as health-
care systems and governance levels.
Clinical Relevance: Skin safety is concerned with keeping skin safe from
any iatrogenic skin injury, and remains an ongoing challenge for healthcare
providers. A conceptual framework that encompasses all of the factors that
may contribute to a range of iatrogenic skin injuries is essential, and guides
the clinician in maintaining skin integrity in the vulnerable older patient.

Skin is the largest organ in the human body and is older) are particularly vulnerable to skin integrity threats
vulnerable to a multitude of threats. Within the acute and subsequent skin injury (Carville, 2012). While the
care setting, older patients (those 65 years of age and impact of pressure ulcers (PUs) in the acute setting is

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Table 1. Skin Injuries—Definitions and Significance of the Problem

Term Definition Significance of the problem

Pressure ulcer A localized injury to the skin and/or underlying tissue, 6.3%–16.6% in acute care, with stage 1 and 2 pressure
usually over a bony prominence, resulting from ulcers making up the majority of lesions (50%–55%;
sustained pressure (including pressure associated National Pressure Ulcer Advisory Panel et al., 2014).
with shear; National Pressure Ulcer Advisory Panel
et al., 2014).
Incontinence-associated Skin damage associated with exposure to urine or Prevalence data for general acute care is limited. Two
dermatitis stool. It is a type of irritant dermatitis found in studies in acute care range from 3.9% to 10% of
patients with urinary/and or fecal incontinence overall samples, and from 20% to 42% of incontinent
(Beeckman et al., 2015). patients in the samples (Campbell, Coyer, &
Osborne, 2014; Junkin & Selekof, 2007).
Intertriginous dermatitis (ITD) An inflammatory dermatitis of opposing skin surfaces One hospital study of 1,162 female patients reported
caused by moisture, commonly found in the 11.2% had ITD beneath the breasts (McMahon,
inframammary, axillary, and inguinal skin folds (Black 1991). A survey of 100 obese individuals found 63%
et al., 2011). had more than one skin problem (Brown,
Wimpenny, & Maughan, 2004).
Periwound dermatitis Maceration of periwound skin caused by excess wound No prevalence data for this condition has been
exudate. In some cases, it may extend beyond 4 cm published.
from the wound edge (Colwell et al., 2011).
Peristomal dermatitis Inflammation and erosion of the skin related to There is a wide range reported (10%–70%) due to
moisture that begins at the stoma/skin junction and variable definitions and assessment of peristomal
can extend outward in a radius (Colwell et al., 2011). skin conditions (Colwell et al., 2011).
Skin tear A wound caused by shear, friction, and/or blunt force, Studies conducted in Western Australian hospitals
resulting in separation of skin layers. A skin tear can between 2007 and 2011 found skin tear prevalence
be partial thickness (separation of the epidermis from to range from 8% to 10%, with the majority of skin
the dermis) or full thickness (separation of both tears being hospital acquired (Carville, Leslie,
epidermis and dermis from underlying structures; Osseiran-Moisson, Newall, & Lewin, 2014).
LeBlanc & Baranoski, 2011).
Medical adhesive–related Erythema and/or other manifestation of cutaneous Prevalence data are scarce. Skin stripping in the
skin injury abnormality (including, but not limited to, vesicle, pediatric setting ranges from 8% to 17%, with
bulla, erosion, or tear) that persists 30 min or more prevalence of tension blisters ranging from 6% to
after removal of the adhesive (Aydin, Donaldson, 41% in an adult orthopedic setting (McNichol et al.,
Stotts, Fridman, & Brown, 2015). 2013).

well understood, there are a range of potential iatrogenic For several decades, PU prevention has been the
skin injuries that are often regarded as an inevitable primary focus of maintaining skin integrity. Moreover,
part of aging yet remain underappreciated, underre- the terms pressure ulcer prevention and maintaining skin
ported, and somewhat invisible within this setting. integrity have, to some extent, become interchangeable.
Beyond PUs, other iatrogenic skin injuries include skin However, like PUs, the prevalence of these other skin
tears, medical adhesive–related skin injury (MARSI), injuries is significant (see Table 1), yet unlike PUs, their
incontinence-associated dermatitis (IAD), peristomal or impact in the acute care setting is underappreciated.
periwound moisture-associated skin damage (MASD), These iatrogenic skin injuries have the potential to
and intertriginous dermatitis (ITD; Table 1). Skin in- impact on morbidity, mortality, cost, and burden of care,
tegrity threats in older individuals arise from interactions in addition to causing pain, disfigurement, or disability.
between skin changes associated with aging; presence Importantly, any skin injury sustained in the delivery of
of multiple comorbidities; polypharmacy; changes in health care should be classified as an adverse event. Fur-
mobility, continence, and cognition; as well as the risks ther, research is emerging that strategies to prevent one
of acute illness and subsequent hospitalization. Main- iatrogenic injury can have positive effects on preventing
taining skin integrity in the older acute care patient is an other skin injuries (Coyer et al., 2015).
ever-present challenge for healthcare providers. These Historically, despite shared risk factors, skin injury
challenges are compounded by shrinking financial and prevention and management programs address a single
clinical resources, a rapidly aging population, and the skin injury (e.g., PU). For individuals, underappreciation
expectation that patients remain safe from harm. of the complexity and scope of skin integrity risks can

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result in adverse skin integrity outcomes. For healthcare jury, medical adhesive-related skin injury, patient safety,
providers, this singular approach to skin injury preven- and quality improvement, combined with additional
tion and management can result in fragmented, dupli- key words conceptual, framework, model, theoretical,
cated, inconsistent care that often takes place in silos. guideline, and consensus statement. Meta-analyses and
In response to the range of potential iatrogenic skin in- systematic reviews (Level I), randomized controlled trials
juries, a multitude of injury-specific conceptual frame- (Level II), pseudo-randomized controlled trials (Level III-
works have been published (Beeckman et al., 2015; 1), and comparative studies with or without concurrent
Black et al., 2011; LeBlanc & Baranoski, 2011; McNichol, controls (Levels III-2 and III-3) exploring risk factors,
Lund, Rosen, & Gray, 2013). However, to our knowledge, etiology, prevention, treatment, or management of skin
there is no framework that represents a unified, holistic injury of any type regardless of outcomes were included
paradigm for maintaining skin integrity. This gap repre- using the National Health and Medical Research Council
sents an opportunity for an innovative paradigm shift. (NHMRC) hierarchy of evidence (NHMRC, 2000). The
This article presents a framework that views skin as a search also included searches of websites of relevant
complex organ, vulnerable to a multitude of threats and national and international organizations, government
injuries. These diverse yet interrelated injuries can result websites, and conference proceedings. A hand search of
from complex interactions between patient and systems reference lists of relevant articles was undertaken.
factors as well as acute situational stressors. The frame-
work draws together important concepts into a single Results
unified paradigm, highlighting the interconnection of the
The search results yielded 2,980 records, and after
spectrum of skin frailty antecedents and resultant skin in-
excluding duplicates, 2,851 titles were screened. Two in-
juries. This article argues that the imperative to prevent
dependent reviewers evaluated 179 potentially relevant
the diverse range of iatrogenic skin injuries in older hos-
abstracts, with 21 papers meeting the criteria for inclusion
pitalized patients warrants a new skin safety conceptual
in this review. Papers included presented a conceptual
framework.
framework, theory, model, consensus, guideline, or po-
sition statement related to skin integrity, iatrogenic skin
Aim injury, pressure sore, PU, pressure injury, bedsore, de-
cubitus ulcer, moisture lesion, perineal dermatitis, IAD,
The aim of this article is to develop a unique skin safety
MASD, ITD, skin tear, peristomal skin injury, periwound
model (SSM) that offers a new and unified perspective
skin injury, or MARSI. Papers were excluded if they
on the diverse yet interconnected antecedents that con-
tested the effectiveness of a single intervention. A nar-
tribute to a spectrum of potential iatrogenic skin injuries
rative synthesis was undertaken.
in older hospitalized adults.

Narrative Synthesis of the Literature

Methods
Skin integrity risk is defined by the international
A review of the literature was conducted to identify nursing diagnosis group NANDA-I (Herdman, 2012) as
current frameworks, consensus documents, guidelines, a “patient being at risk for alteration in epidermis and/or
or position statements in the area of maintaining skin in- dermis” (p. 437), and classifies skin integrity risk in
tegrity. Electronic databases including PubMed/Medline, the domain of safety or protection. Despite this broad
Cumulative Index to Nursing and Allied Health Liter- definition, maintaining skin integrity has become a sur-
ature, PsycINFO, and Web of Science and Cochrane rogate term in the literature for PU prevention. However,
Library were searched for literature published between beyond PUs, older patients can be at risk for a range of
1960 and December 2014. The year 1960 was chosen to iatrogenic skin injuries. Prevention of hospital-acquired
capture seminal papers addressing PU etiology published pressure ulcers (HAPUs) has shaped policy, funding,
in that decade. The search strategy was limited to hu- and research agendas internationally, and has been the
man subjects and those published in English-speaking primary activity in maintaining skin integrity in the acute
countries. The search was conducted using the follow- care setting. Multiple conceptual frameworks (Braden
ing key words: skin integrity, skin injury, skin safety, & Bergstrom, 1987; Coleman et al., 2014; DeFloor,
iatrogenic skin injury, pressure sore, pressure ulcer, pres- 1999; National Pressure Ulcer Advisory Panel, European
sure injury, bedsore, decubitus ulcer, moisture lesion, Pressure Ulcer Advisory Panel, & Pan Pacific Pressure
perineal dermatitis, incontinence-associated dermatitis, Injury Alliance, 2014) have been published that address
moisture-associated skin damage, intertriginous dermati- PU risk factors and etiology. However, publication of a
tis, skin tear, peri-stomal skin injury, peri-wound skin in- range of consensus documents has resulted in increased

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appreciation of other iatrogenic skin injuries (Beeckman individual tissue tolerance and the influence of the type,
et al., 2015; Black et al., 2011; LeBlanc & Baranoski, intensity, and duration of an external force acting on
2011; McNichol et al., 2013). These injuries include the body. In addition to recognizing the influence of
IAD (Beeckman et al., 2015), ITD, peristomal or peri- tissue tolerance and external forces acting on the body,
wound MASD (Black et al., 2011), skin tears (LeBlanc & Defloor’s model (DeFloor, 1999) includes nursing and
Baranoski, 2011), and MARSI (McNichol et al., 2013; see medical interventions as determinants of both pressure
Table 1). and shear, and ultimately PU development. The recent
A compelling argument in support of an integrated conceptual model proposed by Garcı́a-Fernández et al.
skin safety paradigm is an appreciation of the multiple (2014) moves beyond considering only PU etiology to
contributing factors that many iatrogenic skin injuries identify shared risk factors common to PUs and other
share. A recent narrative synthesis of 54 published stud- dependence lesions, suggesting a growing appreciation of
ies, with more than 34,000 participants, was conducted shared antecedents of iatrogenic skin injury.
by Coleman and colleagues (2013) to identify PU risk fac- Consensus documents dealing with skin injuries other
tors. The most common PU risk factors identified were than PUs reveal several common themes regarding skin
in the domains of mobility and activity, perfusion, PU injury contributing factors and etiology (Brown & Sears,
status, skin moisture, age, hematological measures, and 1993; Coleman et al., 2014; Doughty, 2012; LeBlanc
general health status. They concluded that a complex & Baranoski, 2011). Firstly, the response to potentially
interplay of factors, rather than a single risk factor, in- harmful forces acting on skin is highly influenced by tis-
creased the probability of PU development. It is notewor- sue tolerance and is unique to each individual. Secondly,
thy that these PU risk factors are also cited as risk factors that impaired tissue tolerance is a key etiological factor
for other iatrogenic skin injuries, such as skin tears or IAD for any iatrogenic skin injury, not just PUs. Tissue toler-
(Beeckman et al., 2015; LeBlanc & Baranoski, 2014). ance is a construct that varies slightly between authors,
However, apart from the work of Garcı́a-Fernández, but is consistently linked with an individual’s advancing
Agreda, Verdú, and Pancorbo-Hidalgo (2014), propos- age, preexisting health status and comorbidities, nutri-
ing the mechanism for dependence-related lesions, and tion, medications, perfusion, oxygenation, mobility, and
the work of Campbell (2009), recognizing the associa- sensory perception. Finally, elements that threaten skin
tion between PU and frailty, there is a general paucity of integrity in vulnerable individuals are pressure, shear,
research exploring shared and synergistic factors con- friction, moisture, and trauma.
tributing to iatrogenic skin injury in older adults. PU prevention strategies are well documented in the
While iatrogenic skin injuries share multiple contribut- literature, and include nursing and medical interventions
ing factors, prevention and management of these skin (such as skin assessment, repositioning and appropriate
injuries is commonly undertaken in silos. This siloed equipment selection; National Pressure Ulcer Advisory
approach can result in fragmented, duplicated, or incon- Panel et al., 2014). The impact of healthcare interven-
sistent care, as well as a multitude of conceptual frame- tions on skin integrity outcomes is largely underappreci-
works and consensus documents addressing individual ated in PU or other skin integrity conceptual frameworks.
skin integrity outcomes (Brown & Sears, 1993; Coleman Defloor’s (1999) insightful inclusion of the influence of
et al., 2014; Doughty et al., 2012; LeBlanc & Baranoski, healthcare systems factors (such as medical and nurs-
2011). To our knowledge, there is no overarching skin ing interventions) as PU risk factors demonstrates a com-
integrity framework recognizing shared risk factors and prehensive framework that moves beyond physiological
acknowledging a variety of potential outcomes. and biomechanical causes of PU and recognizes broader
In the past three decades, several conceptual frame- threats to skin integrity.
works have been published that deal specifically with Recognition of healthcare systems and processes as a
PU etiology. A seminal paper by Braden and Bergstrom potential component of a risk profile is echoed in the
(1987) identified tissue tolerance and pressure as critical quality health outcomes model proposed by Mitchell,
determinants of PU development. Subsequently, the term Ferketich, and Jennings (1998). This model proposed the
tissue tolerance has been used throughout PU literature existence of dynamic feedback between patients, health-
to denote the ability of the skin and supporting structures care interventions, and the system in which care was
to endure the effects of pressure without adverse seque- provided. Further, they asserted that patient character-
lae (Benoit & Mion, 2012; Coleman et al., 2014; DeFloor, istics directly affected the intervention outcome. Their
1999; National Pressure Ulcer Advisory Panel et al., model highlights the need for consideration of the in-
2014). Further, a central concept in these frameworks fluence of organizational or system factors on outcomes,
is the recognition that risk for PU development results and that interventions should be evaluated within the
from an interplay between multiple factors, including context of interactions and feedback between the patient

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Figure 1. Skin safety model.

and the system (Mitchell et al., 1998). While not specifi- potential to change according to a specific situation, in-
cally dealing with PU or skin integrity, Mitchell and col- teraction with other domains, or the passage of time. The
leagues’ model (Mitchell et al., 1998) supports Defloor’s relationship between the potential contributing factors
contention that systems and process elements (i.e., nurs- and exacerbating elements domains is represented by a
ing and medical interventions) should be considered in plus symbol to indicate the cumulative or magnifying ef-
care delivery and subsequent patient outcomes. fect of the first domain on the second. The relationship
Overall, there is agreement in the literature that iatro- between the exacerbating elements and potential skin
genic skin injuries result from complex, multifactorial, injuries domains is represented by an arrow, indicating
and interconnected threats. It is clear from the literature the potential range of consequences (i.e., skin injuries)
review that the phenomenon of skin safety or iatrogenic that flow from interaction between the previous two do-
skin injury as a holistic concept is not represented. mains. An arrow represents the direct relationship be-
The term skin safety used in this article denotes the tween the potential skin injury and the final domain,
protection from possible alteration or injury to the epi- the range of potential outcomes as experienced by an
dermis or dermis in the older patient resulting from the individual.
interplay between multiple and complex threats to skin
integrity. While there is a significant body of literature Patient Factors
regarding PU etiology, prevention, and management,
Patient factors in the SSM are determinants situ-
and, similarly, a growing body of research addressing
ated within the domain of potential contributing fac-
other discrete iatrogenic skin injuries, a gap remains in
tors to skin injury. The determinants constituting pa-
the conceptualization of skin vulnerability to injury as an
tient factors are advanced age, multiple comorbidities,
overarching phenomenon.
mobility limitations, poor nutrition, incontinence, factors
affecting perfusion and oxygenation, polypharmacy, and
A Model for Skin Safety
alterations in sensation and cognition. Aging is associated
In a single model, the SSM (Figure 1) guides clinicians with the presence of accumulating chronic illnesses, mul-
in the recognition and consideration of diverse yet in- timorbidity, and geriatric syndromes (Inouye, Studenski,
terrelated contributing factors in the etiology of a range Tinetti, & Kuchel, 2007; Lakhan et al., 2011). The term
of iatrogenic skin injuries and subsequent outcomes. The geriatric syndrome’s refers to multifactorial health con-
model consists of four domains or constructs: (a) poten- ditions that result from accumulated effects in multiple
tial contributing factors to skin injury, (b) exacerbating systems, and describes conditions in older people that
elements, (c) potential skin injury, and (d) potential out- are not categorized as discrete diseases, including incon-
comes of skin injury. Within each domain is a subset of tinence, falls, PUs, delirium, and functional decline (In-
determinants, which can be considered as dynamic or ouye et al., 2007). Multiple comorbidities add cost and
on a continuum. There are a myriad of combinations of complexity to health care due to disease interactions and
these determinants, with varying severity, relevance, or the resultant complexity of the required care (Greene,
impact for each individual. The determinants have the Dasso, Ho, & Genaidy, 2014). It is clear that the presence

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of multiple disease states and geriatric syndromes influ- The structure and process by which nursing care is
ences all body systems, including skin. delivered within the hospital system can influence skin
integrity outcomes. Missed nursing care is seen as a sys-
tems error of omission (Kalisch, Landstrom, & Hinshaw,
System Factors
2009) and may include missing scheduled reposition-
Systems factors are determinants also situated within ing, not undertaking a skin inspection, inappropriate
the domain of potential contributing factors to skin management of incontinence, or missed feeding. These
injury. A system is defined as a set of things working aspects of care all have a direct role in maintaining skin
together as parts of a mechanism or an interconnecting integrity; therefore, if any or all of these aspects of care
network to form a complex whole (Fowler, Fowler, are delayed, incomplete, or even omitted, skin injury
& Crystal, 2011). The system represented in the SSM may result (Kalisch et al., 2009). Predictors of missed care
denotes the organized agency where care of the patient in a recent study (Blackman et al., 2014) include nursing
happens, specifically the hospital (McClellan et al., 2014; resource allocation, workload intensity, and workload
Mitchell et al., 1998). The domain of the system of care is predictability. It can be seen that the structure and pro-
conceptualized in the SSM as comprising both structural cess by which nurses are able to provide care has a direct
and process elements (Mitchell et al., 1998). Structural impact on PU risk and subsequent outcomes, and war-
elements of the system can include clinical governance, rants consideration in the broader skin safety paradigm.
safety culture, funding models, leadership, staffing, and
skill mix (Mitchell et al., 1998; Youngberg, 2013). A
Situational Stressors
process is defined as a series of actions or steps taken in
order to achieve a particular end (Fowler et al., 2011). A situational stressor is a further determinant in the
Process elements represented in the SSM refer to direct domain of potential contributing factors to skin injury.
and indirect interventions and activities by which care A situational stressor is conceptualized in the SSM as an
is delivered (Mitchell et al., 1998; Youngberg, 2013). acute event, illness, or trauma requiring a hospital admis-
The process elements in the SSM refer to interventions sion for an older individual. A situational stressor may be
and activities that influence skin integrity outcomes, a fall resulting in trauma, an acute infection, or an exacer-
for example, skin assessment, documentation, bed rest, bation of a preexisting condition. Increases in an individ-
mobilization, fasting, medication administration, use ual’s vulnerability to stressors such as infection, injury,
of mechanical barriers (such as restraints or bed rails), surgery, or hospitalization can result in significant and
or tethers (such as catheters, drains, or intravenous sometimes fatal declines in health (Fried et al., 2001). The
lines; Bry, Buescher, & Sandrik, 2012; Montalvo, 2007; combination of multiple patient factors interacting with
Youngberg, 2013). Ultimately, structural and process the complex hospital system, compounded by an individ-
elements of the system interact to affect patient out- ual’s lack of capacity to respond to these stressors, can po-
comes (Mitchell et al., 1998), in this case skin integrity tentially lead to a multiplicity of adverse events, including
outcomes. iatrogenic skin injury.
The means by which a hospital receives its funding
is integral to the system of care and has a profound
Exacerbating Elements
influence on its structures and processes. Traditionally,
many healthcare systems have been provider or supply The next domain in the SSM is exacerbating elements,
driven, whereby separate elements of care are remu- conceptualized by the determinants pressure, shear,
nerated (McClellan et al., 2014). The goal of provider- friction, or the presence of irritants on the skin. Exposure
or supply-driven funding models is to improve patient to one or a combination of these determinants can result
access to service and outcomes (Solomon, 2014). An in skin injury. These skin integrity threats have been well
example of the use of funding systems being used as defined and conceptualized in the literature (Beeckman
leverage to influence skin integrity outcomes is seen in et al., 2015; Gefen, 2014; Gray, 2007; National Pressure
the reduction of reimbursement for treatment of HAPUs, Ulcer Advisory Panel et al., 2014; Oomens, Bader,
or the introduction of financial incentives for HAPU Loerakker, & Baaijens, 2015; Shaked & Gefen, 2013).
prevention. It can be argued that funding disincentives
for specific aspects of skin safety (i.e., PU prevention)
Potential Skin Injuries
may foster a narrow focus on a specific activity (to
avoid financial penalty), while opportunities to provide The fourth domain in the SSM is potential iatrogenic
broader overarching skin safety programs are potentially skin injuries, with the determinants being PU, skin tears,
overlooked (McClellan et al., 2014). IAD, ITD, and MARSI. These injuries are the result of the

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interactions and convergence of the domains of potential gets and performance indicators), delivering fragmented
contributing factors and exacerbating elements. For in- care, rather than being a fully integrated process or con-
stance, an older person who is able to mobilize at home, tinuum of care (Shortell & Singer, 2008). The impact of
but falls frequently, may be vulnerable to skin tears as a the multifactorial complexity and individuality of the pa-
result. However, if a situational stressor is experienced tient can be easily lost in the specialty silo (Denham,
(e.g., acute diarrhea requiring hospital admission), the 2009; Inouye et al., 2007). Multiple narrow condition-
same individual is likely to be at increased risk for PU and focused care paradigms, with attendant narrow solutions,
IAD, as well as concomitant skin tear. Due to the multiple and the potential for duplication and inconsistency, are
shared contributing factors, older patients can be simul- neither sustainable nor desirable in the modern health-
taneously at risk for a range of different skin injuries. care environment. Improving care delivery and systems
requires initiatives that address multiple problems across
a continuum of care.
Potential Outcomes of a Skin Injury
Vulnerability to iatrogenic skin injury in the older
Potential outcome of a skin injury constitutes the final acute care patient results from the convergence of mul-
domain of the SSM. Regardless of etiology, disruption to tiple complex factors. An appreciation of the complexity
skin integrity can impact on well-being and predispose and diversity of all of these factors can create the circum-
an individual to infection, pain, and increased morbidity stances whereby genuine holistic care can be planned and
and mortality, with the attendant increase in the demand delivered, with the overall goal of care being skin safety
on healthcare services (Carville, 2012). The experience of and the prevention of iatrogenic skin injury. The SSM en-
a skin injury is highly individual, can change over time, compasses this complexity and offers a theoretical foun-
and can impinge on all domains of well-being (physi- dation for innovative skin injury prevention in the acute
cal, mental, social, and spiritual/cultural) (Augustin et al., care environment.
2012). The inclusion of potential outcomes of skin injury
in the SSM is unique. Rather than limiting the framework
Conclusions
to identifying the skin injury, recognition of the patient’s
experience of iatrogenic skin injury is fundamental for Maintaining skin integrity in the older hospitalized
delivery of holistic person-centered care. adult is a priority for healthcare providers. Diverse
antecedents interact synergistically to cause a range of
possible iatrogenic skin injuries. These injuries have
Shifting the Paradigm From Prevention
implications for patients and the healthcare system alike,
to Skin Safety
including pain and suffering, as well as increased cost
The SSM proposes a paradigm shift away from specific and length of hospital stay. This article has presented a
skin injury prevention towards a holistic patient-centered model formulated from a review of the literature for con-
goal of maintaining skin integrity. Patient individuality ceptualizing skin safety in a unified way. The SSM moves
in the context of multiple and shared risk factors is a beyond physiology and biomechanics to encompass and
central premise of the SSM, allowing numerous skin reconceptualize varied and complex factors that can
integrity outcomes to be accommodated in a single converge, interact, and ultimately lead to skin injury in
integrated framework. The SSM recognizes that dy- older patients. However, the SSM is not a risk assessment
namic and individual interactions between skin injury tool; rather, it is a framework to guide clinicians and
antecedents may result in different outcomes for each healthcare providers in the recognition and consideration
individual. Managing multiple individual risks separately of the complexity of skin injury etiology. Further testing
may result in competing risk assessments, care pathways, and validation of the SSM is required. Opportunities for
systems demands, and priorities, ultimately resulting further research include the development and validation
in fragmented or duplicated care. The SSM provides a of an integrated skin safety risk assessment tool. Re-
single integrated framework to facilitate skin integrity search and quality activities, such as PU prevalence and
management at the individual patient level. incidence studies in the acute care setting, could be ex-
Contemporary patient care is based on traditional panded to encompass data collection on any concurrent
biomedical models of disease that have a linear focus iatrogenic skin injury, rather than simply determining
on etiology, pathological processes, and ultimately spe- PU status. Reframing quality indicators to include an
cific clinical outcomes (Chiarelli, Bower, Wilson, Attia, & organization’s response to skin risk rather than PU
Sibbritt, 2005). This specialized care delivery can result management and prevention may result in improved
in the perception of the hospital being a series of depart- overall patient outcomes, as well as improved system
ments or silos (with each concerned with their own bud- efficiencies. The paradigm shift from focus on specific

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skin injury prevention to an appreciation of overarching MASD part 2: Incontinence-associated dermatitis and
skin integrity vulnerability in the older adult patient is intertriginous dermatitis: A consensus. Journal of Wound,
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